Andrea’s Diary

I am setting out today for the UK. This next round of workshops will take in Northern Ireland (Belfast and Derry), Hemel Hempstead (just north of London), Nottingham, Burton on Trent, and Solihull (Birmingham). There is also a week in Spain, with two workshops scheduled, one near Alicante at the Acuario Birth Centre and another in Murcia, about 2 hours further south.

In the middle, I will have a few days with my good friends the Habananandas from Thailand, who spend part of each year in Bournemouth. We will be discussing how we can set up a training program for childbirth educators in Thailand, as part of the work of the Childbirth and Breastfeeding Foundation of Thailand’s work. Birth International will be consultants for this project.

There will also be a day out with my office manager in the UK, Fran Gallwey, to inspect the proposed site for our big conference on childbirth education next year. We will be checking out the facilities at Reading University, which are looking promising. This will be a landmark event for the UK, not only for Birth International, but also for childbirth education, as no-one has offered a program such as the one we have planned, which will ensure that all participants are able to attend 6 workshop sessions on specific educational topics over the two days. There sill also be Plenary Speakers (of note!) and a video evening, where all the new releases will be shown. During my visit to the UK, we will be finalising the program and speakers, so keep an eye on our Web site for the details, which we plan to have available in July.

OK, now to finish the packing…..

Midwifery students often have a hard time when they venture out into the hospital system to undertake the practical components of their education. They learn some exciting things in the University and then discover that the “real world” of practise is very different, creating confusion and in some cases, despondency.

A student contacted me today after she had attended one of my Active Birth workshops. During that program she learned about performing vaginal examinations while women were upright, rather than lying down on a bed. We had talked about the impact of performing this invasive procedure on women and the need to help them feel more in charge of the process and less vulnerable, on those occasions when it is really necessary to check the cervical dilatation.

The student had reflected on this, and changed her practice, receiving positive feedback from the women. Her hospital based clinical supervisor, however, had other ideas and challenged the validity of performing a vaginal exam in this way. She wanted the evidence before she would support this student and also challenged the occupational health and safety issues for the midwife of working like this.

Amazing but not surprising! As I pointed out to this student, it sounded like this midwife was very challenged by the student’s perceptive ideas and felt uncomfortable supporting her (she probably had never tried this technique herself). The crux of this matter is that it is the woman who is central here, not the student nor the supervising midwife. If the woman is happier off the bed, then the midwife must follow her lead and be of service to her in the most appropriate way. Yes, there could be issues for some midwives with bad backs etc, but as I demonstrated at the workshop, these concerns can easily be overcome if the midwife sits down on a low stool, or kneels on one knee. If this is beyond the midwife’s capabilities, then perhaps she should either abandon the procedure (a great idea!) or else find someone who is fitter for the job to take over.

People who feel threatened by new techniques often react by demanding “show me the evidence”. I suggested to the student that she ask her clinical supervisor to find the evidence that performing a vaginal examination on a recumbent woman does not cause distress, discomfort or anxiety. It is a technique that midwives have been undertaking for years, and is a basic skill that hardly needs evidence to support it - just practise!

Its been a quiet week for me - quite a change from my usual hectic pace and a nice lull before I head back to the UK next weekend. Midwifery issues also seem to be bubbling along and there have been few issues of note worthy of comment.

The childbirth education field has generated some discussion amongst some of us, however. I was asked recently by a pregnant woman on the phone for the name of an independent educator in her area. Several years ago this would have been an easy question to answer, as there was a network of educators in and around Sydney that provided community based classes. Over the past couple of years, this number has dwindled and now it is almost impossible to provide a contact for most part of Sydney.

The demise of the independent educator is an interesting phenomenon, caused no doubt by several underlying causes. One major reason for their move out of this area of interest has been the difficulty in attracting clients, which poses risks for the viability of their (very) small businesses.

Hospitals, who are routinely unable to provide enough classes for their own clientele, could refer to community based programs, but usually fail to do so. One likely reason may be that booking clerks in the maternity units and other involved hospital staff are unaware of the programs available elsewhere. Better communication, publicity and collaboration would solve this problem.

Another reason for lack of referral may be suspicion about the content of these programs, especially as many are perceived to be “anti hospital” in their message when really they are just advocating for consumer rights and informed choice. Some of the educators that I know have been active in the community are fairly “invisible” within wider maternity circles (for example, they don’t attend workshops or seminars where they could meet with midwives) and this may contribute to their isolation, and perhaps misunderstandings about their role.

Some hospitals have been reported as actively discouraging referrals to programs outside the hospital setting. This is nothing new, of course, as I can remember 20 years this was the case in the northern suburbs of Sydney (a very affluent area). These behaviours are usually instigated by the doctors, who want to restrict information given to parents so that awkward questions can be avoided and policies will not be challenged. There is a suggestion that in one area of Sydney the directive to not refer parents to “outside” classes has actually come from the Parenthood Education Department itself, perhaps because they resent the quality of the programs on offer elsewhere or again because of internal pressures from doctors.

Community based classes offer the best chance for parents to gain unbiased, comprehensive, consumer orientated in formation in an appropriate adult education setting where individual needs can be met. Setting up these programs takes initiative, perseverance, effective networking and good marketing. The rewards are there for the successful educator, but it takes time and energy and rarely offers enough financial reward to make it a viable career choice in itself.

I hope that the role of these educators can be preserved. In a similar way to that of home birth in relation to hospital birth, they keep birth education “honest”, maintaining high standards and offering real choice to expectant parents. Many of the childbirth groups that once flourished have now disappeared as a result of a lack of volunteers, the changing roles of women in our society and the perception that paid work is more necessary/fulfilling/valued by society. Many independent educators would have once aligned themselves with such groups, either as casual employees or in collaborative referral arrangements. Now, they are being forced to work on their own and they must make extra effort to stay in the loop - with parents, with maternity care workers and with hospital departments. Having spent many years in this role myself, working from home and loosely aligned with other educators across the city, I know that this work is important and very necessary. Parents have a right to an independent view and unbiased information.

An English journalist, living in Barcelona and writing for expats who live in Spain, has approached me for information regarding maternity care in Spain as she is writing an article for women who are expecting babies. She found my earlier comments in earlier Diary entries regarding the Acuario Birth Centre and the birth scene generally in Spain. She thought I could shed some light and provide tips for women planning to give birth in the Spanish hospital system.

I felt unable to give expats in Spain any real hope of having a birth experience similar to women in the UK - the system in Spain is so medicalised and the concepts of choice for women, informed consent for procedures and treatments and evidence based care seem to have been overlooked, from what I have been hearing from the midwives (obstetric nurses) who work in Spanish hospitals.

I was asked if it was worthwhile paying for private care if it could be afforded and I was emphatic in my “NO!”. There is overwhelming evidence , from every western country in the world, that hiring a private obstetrician is asking for unnecessary intervention in birth, frequently leading to caesarean section, high costs and worse outcomes for mothers and babies. The problem for women, however, is that in many countries there are few alternatives available. Midwifery care in hospital, home birth, water birth, birth centres, midwifery-led units are all rare, if they exist at all. Even though “midwives” may be working in hospital, because these institutions are so doctor-dominated and birth is so medically managed, midwives may have no experience of natural birth or confidence in managing labour without the trappings of a hospital labour ward or theatre.

The best suggestion I could offer this journalist was to encourage expat women from the UK that they find a way of returning home for the birth to seek midwifery care there. Although this might be expensive, inconvenient and difficult, the birth of a baby is too precious an experience to squander in a hospital where shaves, enemas, hourly vaginal examinations, drips, drugs, stirrups and routine episiotomy are all routinely performed, without question.

Meanwhile, I will be back in Spain in two weeks, to present two workshops for midwives. The first issue we will tackle will be “what is a natural birth like”" and to answer this I will start by showing them the beautiful video “Inner Strength”. I know from my previous visits that this will blow them away - they will probably never have seen women labouring like this and giving birth so ecstatically. Once they have an idea of what to aim for, we can start exploring ways they can help women achieve this magnificent outcome and how they can take on the role of midwife, rather than obstetric nurse. It will be a challenge for us all!

An English journalist, living in Barcelona and writing for expats who live in Spain, has approached me for information regarding maternity care in Spain as she is writing an article for women who are expecting babies. She found my earlier comments in earlier Diary entries regarding the Acuario Birth Centre and the birth scene generally in Spain. She thought I could shed some light and provide tips for women planning to give birth in the Spanish hospital system.

I felt unable to give expats in Spain any real hope of having a birth experience similar to women in the UK - the system in Spain is so medicalised and the concepts of choice for women, informed consent for procedures and treatments and evidence based care seem to have been overlooked, from what I have been hearing from the midwives (obstetric nurses) who work in Spanish hospitals.

I was asked if it was worthwhile paying for private care if it could be afforded and I was emphatic in my “NO!”. There is overwhelming evidence , from every western country in the world, that hiring a private obstetrician is asking for unnecessary intervention in birth, frequently leading to caesarean section, high costs and worse outcomes for mothers and babies. The problem for women, however, is that in many countries there are few alternatives available. Midwifery care in hospital, home birth, water birth, birth centres, midwifery-led units are all rare, if they exist at all. Even though “midwives” may be working in hospital, because these institutions are so doctor-dominated and birth is so medically managed, midwives may have no experience of natural birth or confidence in managing labour without the trappings of a hospital labour ward or theatre.

The best suggestion I could offer this journalist was to encourage expat women from the UK that they find a way of returning home for the birth to seek midwifery care there. Although this might be expensive, inconvenient and difficult, the birth of a baby is too precious an experience to squander in a hospital where shaves, enemas, hourly vaginal examinations, drips, drugs, stirrups and routine episiotomy are all routinely performed, without question.

Meanwhile, I will be back in Spain in two weeks, to present two workshops for midwives. The first issue we will tackle will be “what is a natural birth like”" and to answer this I will start by showing them the beautiful video “Inner Strength“. I know from my previous visits that this will blow them away - they will probably never have seen women labouring like this and giving birth so ecstatically. Once they have an idea of what to aim for, we can start exploring ways they can help women achieve this magnificent outcome and how they can take on the role of midwife, rather than obstetric nurse. It will be a challenge for us all!

There was a moment during yesterday’s workshop in Melbourne that we were able to reflect on the unique nature of Australia and Australians.

Some of the midwives in the group work in rural areas and they started sharing stories about they way they work with the GPs, who provide emergency back up for their maternity units. Most of the time the births are capably managed by the midwives, but when a problem occurs they call the local GP who comes to assist. Birth being unpredictable, these calls can interrupt the doctor at unexpected moments and we heard of occasions when one doctor turned up wearing pyjamas, another arrived in bike shorts and cyclists helmet, and another time when the doctor arrived wearing muddy Wellington boots and farm overalls.

One midwife, when she was new to the unit, asked a man sitting in the waiting room wearing trackie pants, a “Quicksilver” T- shirt and very old trainers, if he needed assistance. “No” he said, “I’m the anaesthetist”!

These midwives know to warn the labouring woman that the man who will becoming is the doctor - so they will be prepared for whatever he looks like. In an emergency, no-one is worried about sartorial elegance, just professional competence, but it must cause a few giggles when the crisis is over.

I couldn’t help thinking of the fanatical zeal with which some infection control and occupational health and safety people stalk the hospitals seeking our “transgressions”. I wonder what they would make of this casual, yet practical approach adopted in Australian rural areas!

Several people have asked me, via Diary feedback and emails, about the “towel trick” and the “pencil in the vagina” suggestion that Vicki Chan offered during the Midwifery Intensives tour, as ways of facilitating difficult births. These were just two among many suggestions that Vicki had compiled for working with OP labours, but they were some of the most intriguing.

The “towel trick” was a idea she had picked up from the Internet, and had used successfully during hard labours. It is a variation of a strategy that can be adapted in several ways for making it easier for the woman to push out her baby. The woman adopts a deep squat, holding the ends of a towel that has been rolled up into a loop. A partner or support person holds the towel in the middle, and as the woman pulls on the towel, the partner pulls back. I hope you can get the picture!

Variations would be to have the woman pull against a rope, a bar fixed to a wall, or even the end of the bed. The advantage of using a towel is that it can be done anywhere, being completely portable. As the woman bears down in this squatting position, with her upper body stabilised by pulling on the towel, her pelvis will tilt under, curving the birth canal. For some babies this change of drive angle may help them into the world.

The “pencil in the vagina” was an idea that Vicki suggested to encourage women to wiggle their pelvis more effectively. Pelvic rocking is a well known strategy for jiggling the baby into better alignment, but sometimes women can’t quite get the hang of how to do it, and sway on their legs to circle their pelvis around, rather than moving just the pelvis while keeping their legs relatively still. Imagining that you are holding a pencil in the vagina and drawing small circles on the floor makes it easier to visualise what is needed.

At one point on the tour, amid much laughter as everyone practised this manoeuvre, Vicki announced that I would give anyone who could complete their evaluation with the “pencil in their vagina” a discount on the next workshop! Although some of the writing on the evaluations was hard to read, I decided that all had been completed by hand, and no discounts were necessary.

Sharing ideas like these in workshops is always useful. If anyone has any similar tips and tricks, please share them with us via a comment on this Diary entry.

Back in Melbourne again this week, this time for an Active Birth workshop. This group is full of bright young things - all these midwives are well under the average age for midwives in this country (47 years) and there are several students here as well.

We were talking about complications that can occur during birth and how these could be handled. Although very rare, the problem of a very tight cord around the baby’s neck that impedes further progress was one such issue. I asked the group what they would do if faced with this situation. Most said “clamp and cut the cord”. So I followed with the question “what are the risks of taking this action?” and they replied “danger for the baby is there is further delay, for example from a shoulder dystocia”.

I commented that midwifery students these days are being taught not to ever cut and clamp the cord and showed them how the baby will tumble out itself, often very quickly, if necessary, as though nature detects the baby’s distress and lends a helping hand. One of the more experienced midwives in the group told us that she had witnessed this herself and now was not at all concerned about leaving the cord intact, even when it was very tight.

One of the students said that they had raised this issue with one of their tutors. They asked what they should do when the cord was tight and the baby appeared compromised. The tutor replied that it should always be clamped and cut. When the students questioned this practice, and mentioned the possibility of shoulder dystocia creating further problems, the tutor had replied that “if shoulder dystocia occurs then the baby is gone anyway”! Needless to day, the students were a bit stunned at this reply. I do hope that they have misinterpreted this comment. Cutting the baby’s oxygen supply prematurely can never be a good idea, surely?

The Midwifery Intensive workshops are over. We had a great time and it is clear from the evaluations that we really achieved an enormous with the program.

I learned a lot as well. Let me share some of the insights I gained from our wonderful presenters.

From Vicki Chan:

Her vision of a future where

“Midwives have been reinstated as the custodians of normal birth and most obstetricians have found themselves honest employment”.

The towel trick for facilitating pushing and the “pencil drawing” for encouraging pelvic wiggling were unforgettable.

She reminded us of the protective nature of the long labour where a baby who was malpositioned, or whose cord was short or tight, would have time to adjust to the labour without undue stress.

From Maggie Banks:

The Muriwai-Beetham manoeuvre for facilitating breech births. {I will write this up further in a later posting, as it really needs a picture to explain it clearly).

“See one, do one, teach one” as a basis for gaining experience in unfamiliar techniques.

Her reminder that many of the problems that babies encounter during their births are due to them being frightened “out of their tree” as the labour progresses. For example, fiddling with the breech baby (bringing down the legs and arms etc) can startle the baby, who flings its head back, increasing the risk of entrapment of the head.

Her suggestion that we re-name the “failure progress” syndrome as the “failure to be patient” syndrome. She explained that midwives in New Zealand are working to re-name many obstetric procedures and techniques in more midwifery oriented and woman friendly terms.

“Rumping” of the breech baby - the equivalent of “crowning” in the vertex baby.

From Lynne Staff

“Enforced home births” that some women undertake because they cannot get what they want in hospital.

“Enforced elective caesareans” when women can’t find support for a VBAC.

These are just a few of the gems we all gained from these outstanding midwives. Here’s a picture of the four crones on the tour (note the initials on the hats). The caption reads:

“They tell me that you’ll lose your mind when you grow older. What they don’t tell you is that you won’t miss it very much.”

Brisbane was the venue for yesterday’s Midwifery Intensive event. It was a very rainy day, which was a treat, coming from Sydney where the drought is tightening its grip, but it didn’t dampen the enthusiasm of the large group of midwives who gathered to explore the issues around “keeping birth normal.”

The topic of breech babies seemed to especially catch their attention. Some hospitals in Brisbane have caesarean rates of over 60% and there are obstetricians in this city who will only do caesarean births (labour is “so unnecessary”!), so there is a desperate need for some midwives to reclaim their skills and find their own strengths in this face of this kind of opposition.

Because of the size of the groups who are attending, this program is not able to offer midwives practice sessions with dolls and models. However, as Maggie Banks, the wonderful midwife from New Zealand points out, a baby coming by the breech is not all that different from a baby who is head down: what is needed is time, no handling and freedom for the woman to move and the baby to wriggle out. One of the most interesting aspects of her presentation are her summaries of the risks of bed-birth, particularly as it restricts the pelvic capacity and the woman’s ability to move as needed. All our speakers have emphasised the dangers of labouring on the bed and the ease with which complications and interventions can be avoided when women have space and freedom to move during labour.

Maggie showed, using a series of lovely slides, the role that the breech baby plays in getting itself born. The baby needs space to wriggle and cycle its legs, to release it own arms and align its body within the pelvis for the birth of its head. Touching the baby can disrupt these actions. Having the arms brought down by the midwife or doctor can present special problems - the positions of the baby’s arms and hands up beside its head and face, provide a splinting action, helping to keep the head well flexed. If a baby is startled by someone handling its body or pulling on its arms, there is a great risk that the baby will thrown its head backwards (seen in the “startle reflex”) as a natural reaction, and perhaps find its head trapped within the cervix. Maggie has great respect for women and babies and complete trust that given the right conditions, a calm midwife and trust in the natural process, breech birth need be no more hazardous than vertex birth.

I wish that obstetricians would take heed of these wise words and stop being frightened of breech birth. Women can manage this kind of birth as well as any other.