Andrea’s Diary

I have arrived into Italy - Venice to be specific. After a couple of days of rest I am due in Padova on the weekend for the workshop.

The Italians are very interested in water birth, and also in prenatal aquanatal programs. My guess is that getting used to water, floating, swimming, immersion etc is something that is not commonplace for Italians (and perhaps other Europeans as well) and so that is why some planned experiences in the pregnancy are useful to encourage them to use water during labour and birth.

In Australia, we all swim from an early age and being in the water is a natural thing. Almost all of the population of our vast country lives within 100 kilometres of the ocean and beach holidays are the norm, especially for children. A recent visitor that stayed with me couldn’t believe that there were so many beaches in the city of Sydney!

There is no doubt that being in water when you are pregnant is a great way to relax. The floatation and buoyancy provided by the water is wonderful for relieving aches and pains and also for enabling freedom of movement. I must say that I am not keen on chlorine, and most swimming pools, especially those that are heated, have high levels of chlorine that make me feel a bit sick, and I can’t stand the smell of chlorine on my skin and hair even after showering. Salt water pools are a big advantage in this respect, or ones that are cleansed using ozone, but I think they are probably rare in a public context.

No doubt we will talk about water immersion during labour this weekend, and probably some of the participants will avail themselves of the spa waters at the hotel we are using. Not me!

Tomorrow I am leaving for Italy and a workshop in Padova (not far from Venice). This will be the first time I have worked with Italian midwives and I am looking forward to the challenge. Piera Maghella will translate for me and it will be fun tot work with her in this way. She was the organiser of the very successful Conference last year on the theme of waterbirth and she is a well known author of books for expectant parents in Italy.

There are always loose ends to tie up before I travel for an extended period. A request has come from Armenia asking us to tender for a US Aid funded project to train childbirth educators for a pregnancy education program that is to be rolled out across the country. The scope of work I was emailed is very detailed - they are hoping to achieve a frankly impossible amount in the space of a three day in-service, and after that the people in this initial group are supposed to then go out and train everyone else. When I think of the time and effort that goes into making a basic educator in this country, and what it takes for us to “train the trainers” I doubt that this program will achieve its stated goals. However, good luck to them - I won’t be submitting a tender, but I will give them some feedback on their proposal. I wonder what Armenia is like….. I guess I will never know!

I have also been approached by a midwife from my recent Israeli workshop group who is keen to translate my book “The Midwife Companion” into Hebrew. That would be exciting ! I suggested she explore publishing possibilities before we get too far into this project, but it would be great to have it available in yet another language. Let’s hope this propject can go ahead.

My neighbour seems to be in early labour today, so I may be at a birth tonight… that would be a lovely way to get “in the mood” for my next round of travels.

Friday provided me with an opportunity to spend some time exploring a whole new aspect of midwifery (for me, in a workshop format) with a group of midwives from the Sunshine Coast area in Queensland.

I was asked to facilitate a program on “Perceptive Midwifery”, focusing on the emotional, physical and psychological histories that women bring with them to a birth and how midwives can assist. We were also looking at the midwives themselves and their perceptions of their role, and how they impacted on the women. It is a huge topic and one I feel very strongly about, so I had set about planning a really involving program that would give everyone a chance to explore the issues thoroughly. When I worked out the timing I realised that this would take two days, much more than the allotted four hours!

Having done some heavy editing, I decided to focus on the kinds of histories that women might bring with them, the areas were midwives could have influence, how to communicate effectively to discover women’s stories and looking at our own choices and wishes regarding our practice. We had a busy time with a number of interactive activities and everyone participated very willingly and productively. I will await the feedback with interest - this is an area that might be useful to expand further if this “trial run” proves to have been useful for the group members.

I will be spending the weekend relaxing with my wonderful midwife colleague Lynne Staff. She and I will be presenting our Essential Midwifery program again in the UK next April, following our successful tour last year. This time we will be visiting Scotland, Ireland and Wales and more details will follow in later Diary entries.

I spoke to my former neighbour today. She is four days overdue with her second baby and as I was present for the birth of her first baby, we have kept in touch throughout this pregnancy. She has been having building work done at her house, and this has been stressful and worrying and this could be the reason why she is holding onto her child - she is still not feeling really settled after all t he upheaval she’s had in the last couple of weeks.

She is booked into the local birth centre this time, which she has so far found to be a very satisfying experience. At her check-up yesterday, the midwife, noting that she was now overdue, suggested that she come in for a cervical sweep in 3 days time, to attempt to get labour started on its own. My neighbour has always avoided medical interventions of all kinds and so asked the midwife for details about this procedure, which she had never heard of.

She was told that is was a “completely natural” was of promoting labour and in response to a direct question, stated that there was no risk to her or her baby. I was speechless when I heard this, and angry as well. I explained exactly what this cervical sweep entailed - inserting a finger inside the cervix and circling it around between the amniotic membranes and the wall of the uterus to lift the membranes away from the uterus and cervix. My neighbour said that she had not understood exactly what would be done and was surprised to hear what it involved.

The midwife had said that the procedure was “uncomfortable” but many women have reported it as quite painful. The insertion of finger (or an instrument) into the cervix requires some dilation to be undertaken and depending on the way this is done, it can cause pain. I also explained that she would probably bleed a bit afterwards (something else she wasn’t told). There is also the risk of introducing infection into the uterus and of causing the membranes to rupture prematurely.

There is some evidence that this procedure (also called a “stip and stretch”) may shorten pregnancy and encourage labour to start. However, to describe it as “completely natural” is unworthy of midwives and dangerous misinformation. Putting anything into the cervix in this way is far from natural, and will inevitably carry risks.

I have noticed that midwives are now promoting this procedure because they see it as less risky than an induction, which is a well known starting point for the cascade of intervention. Some women may experience a procedure like this as a form of rape, and it may evoke considerable anxiety, especially is a woman goes home in pain and bleeding.

I explained the risks to my neighbour. She knows her baby is well and she herself is in good health. She also knows she could be out in her dates. I have suggested that instead of submitting to this interventionist technique, she find ways to calm herself and get over the trauma of the home repairs - a massage, quiet dinner with her husband, picnic in the park, or whatever else takes her fancy. The baby will come when it is ready and her body is ripe for action. Why do some midwives suddenly start acting like “pregnancy police” and reading the riot act when quite the opposite would be a far more woman friendly way of achieving the desired labour? A cervical sweep is a medical technique, dreamed up by obstetricians and should not become the province of midwives.

The program for the “Preparing for Birth” Conference in the UK next April is now finalised. I have spent the day sending the details to our list of invited speakers:

and of course - Andrea Robertson (Australia).

It will be an exciting program. All have been asked to prepare interactive sessions that will enable participants to practise teaching strategies and explore practical skills. Each workshop session will last and hour and a half, to enable some real work to be done and the keynote sessions at the beginning and end of each day will help focus and guide the overall program.

People on our catalogue mailing list have been given a chance to register their interest already and they will receive advance copies of the full program. A general mailing will be done at the end of the year. There are student prices and group discounts, plus the early birds will make savings off both individual and group booking prices.

The full program will be posted on our web site very soon, together with registration details. Put these dates in your diary now: Friday April 8 and Saturday April 9. Where? Reading University, about 25 minutes to the west of London - right in the middle of England!

With the Federal election campaign underway in Australia, it seemed a good time to get some bumper stickers prepared, to help sell midwifery and get it into the consciousness of our aspiring politicians. Everyone has an election in their area at some time, so get yourself prepared with some useful ammunition!

We’ve got two stickers available, which can be ordered through our website.

Midwives - The Safe Birth People

for normal birth, vote 1 midwifery

Check them out!

p>With the Federal election campaign underway in Australia, it seemed a good time to get some bumper stickers prepared, to help sell midwifery and get it into the consciousness of our aspiring politicians. Everyone has an election in their area at some time, so get yourself prepared with some useful ammunition!

We’ve got two stickers available, which can be ordered through our website.

“Midwives - the safe birth people”

“ for normal birth, vote 1 midwifery”

Check them out!

One issue that arose in the Israeli workshops was the management of third stage, especially the timing of the oxytocic injection. Group members reported two different hospital regimes - the injection was either given with the birth of the baby’s shoulders (or very soon after) or else after the placenta had been born.

This variation is a good example of the “habits” that can develop in maternity care. In the US, the oxytocic drug is always administered after the placenta has arrived. In the UK (and Europe, as far as I know) the oxytocic is given as the baby is being born and very definitely before the placenta arrives. Each camp are surprised at the routines of the other, and are doubtful of the wisdom of that approach. The research in the Cochrane Library, for example, appears to assume that the oxytocic will be given before the placenta is born and the reported studies centre mainly around the advisability of then applying controlled cord traction and the other elements of a “managed third stage” versus a more relaxed approach. Retained placenta is a possible outcome of early oxytocic administration, as is the entrapment of an undiagnosed twin (a very unlikely event these days due to the ubiquitous ultrasound) .

The active management of third stage is an example of the “through- put approach” to obstetrics. Left alone, and when the mother can cuddle and perhaps suckle her baby, the placenta usually arrives about 20 minutes after the baby. For some, this is too long, and no doubt that is why the practise of giving oxytocic drugs to speed up uterine contractions, coupled with cord traction, was developed, to enable the women to be tidied up and moved out of the labour room in a timely fashion.

I find it fascinating that some elements of the American way of birth have been adopted in other western countries, but not all. It seems that any practises that will speed up birth have gained favour (drips, drugs, rupturing membranes etc), while their habit of leaving the third stage to proceed at a more leisurely pace have been overlooked. It seems that research will also be based on local routines to some extent, with perhaps the basic premise of some studies being acceptance of a local habit and then investigating from there. This raises the question of the assumptions underpinning some research studies and the applicability and validity of their findings.

Meanwhile, do we wait for the placenta to arrive in its own good time and give the oxytocic drug after it comes, or do we administer it as soon as the baby puts in an appearance? Alternatively, do we not give the drug routinely at all and wait for the evidence that it is needed to stop heavy bleeding or a haemorrhage, before injecting? I favour the latter approach, to ensure that the woman receives appropriate care, rather than blind adherence to a routine or protocol that may have no relevance to her specific birth circumstances. It is an issue that always encourages heated discussion.

Last week I was in Israel which was fascinating. I am sure that I have learned as much from the midwives, doctors, childbirth educators and doulas in the two groups I facilitated as they have from me and each other. Both groups were lively, interested and willing to take on new ideas. There was lots of discussion and many questions, as it became apparent that birth and midwifery care in Israel have both their own style and substance.

There were many interesting issues that arose. Everyone in Israel has private insurance to cover their needs within the health care system. Maternity care is provided by both doctors and midwives and is based in hospitals. All pregnant women receive their pregnancy care from doctors and there is a heavy emphasis on tests and technology. Pregnancy is confirmed by ultrasound around 6 weeks (and the last menstrual period may even be adjusted at that point), followed by regular ultrasounds to assess fetal development over the following months.

Women meet a midwife for the first time in labour. Perhaps that is one reason why parents don’t phone the hospital when labour has started - they just arrive at the labour ward and expect to have a baby soon after. They will phone their mothers, however, and it is common for a whole family to arrive, laden with food and ready to witness the labour and eventual birth. I gathered that crowd control was one skill that midwives needed to develop!

Labour is usually managed using “Active Management of Labour” principles. Vaginal examinations (VEs ) are undertaken regularly and steady progress is expected. I was told of women having a VE from several different midwives over the course of the labour and rupturing membranes and oxytocic drips appear to be standard procedure for almost every woman. I mentioned the issue of the potential for vaginal examinations to raise anxieties in women, especially those who have had some form of sexual abuse, and this appeared to be a completely new thought. It seems that discussion about sexual matters is not generally on the agenda, perhaps another result of doctors managing pregnancy care rather than midwives.

There were many stories of intransigent doctors who were rigid in their management of labour and very unwilling to listen to midwives. There are always some, though, who are more open and more prepared to use evidence based principles to guide their care. Some midwives also shared stories of collaborative care successfully negotiated with their medical colleagues, and it seemed that watching “alternative” approaches, such as an all-fours birth position, was the best way to get the message across.

The workshops were held in the Tel Hashomer Hospital - a vast campus in Tel Aviv that is the major centre in Israel for medical care and also education. Their maternity unit has on average 900 births per month - that is around 30 babies born every day! Epidural use is high (not surprising in this kind of “factory” setting) and the midwives are normally looking after 3 or 4 women at a time. They are keen to help women achieve natural births whenever they can and their labour rooms are well equipped to do this. I’ll do another Diary entry about their new Birth Centre and the political scene for midwives in Israel at a later date.

Overall, birth is very medicalised, an interesting mix of American and British ideas. This probably reflects the educational background of the obstetricians to some extent, as they have a very firm grip on the way that services are provided and maternity care is carried out. Home birth is a possibility in some areas and I’ll look at specific birth practices and midwifery options in my next entry.

In Australia there are no recognised competency standards for childbirth or parent education at the present time. This means that there are no nationally agreed standards that can be used to ensure that facilitators and leaders of prenatal programs have the necessary skills to do their jobs or that the programs themselves meet minimum requirements.

When we first had our Graduate Diploma in Childbirth Education accredited through the Federal Government’s Australian National Training Authority (1992), we were obliged to establish our own set of competency standards that could be used to measure the outcomes of our training. We drew on the work that had been done in a NSW State Government Review of Obstetric Service in 1987, when basic qualifications for educators and minimum requirements for prenatal classes were defined and agreed, through a wide consultation process, prior to their acceptance by the Review Panel (and the then Department of Health in NSW).

This year, when VETAB ( the accrediting Board for all Courses in Australia) re-accredited our Grad Dip for a further five years, we were informed that next time we applied for re-accreditation (2008) the course would have to be measured against nationally agreed competency standards for educators and parenting education programs.

This has left us with a dilemma: who is going to undertake this work, and how will the competencies be agreed before they are submitted to VETAB for endorsement? Given that this is going to be a time consuming and expensive process, involving wide consultation and considerable administrative support, I can’t see that there is anyone or any group, other than ourselves, who are in a position to take this on.

It might be said that we have a vested interest in doing this work, because it will directly impact on whether we can get our Graduate Diploma re-accredited. However, in reality, there is no professional group with the resources to undertake this task, and no-one else has the means to complete the process in a timely and efficient way. Over the coming weeks, we will be working out a basic strategy for developing these competencies, including the consultation processes that will be needed and investigating the administrative and support work that will be required. There will also be consideration of the budget and how we might cover these expenses.

If any of you would like to have some input into this task, or have suggestions regarding the competencies themselves, please email them to: graddip@birthinternational.com. If you want to check the competencies that we are currently using, as a basis for your contribution, you will find them listed in the Course information on our website, described as the “Learner Outcomes”.