Articles by Month: June 2003

Maternity Care in Spain - 2

This was written at the end of the workshop in Spain, the day after my previous entry.

As I mentioned before in a Diary entry, Spain has a very medicalised approach to birth. In many ways this is not so different from other countries, but they have developed some unique routines that are amazing.

I was staggered by some of the things I have been told about by the midwives here. For example, every woman in Spain goes for a CTG each week, starting from 38 weeks (or even earlier if a problem is suspected). until the baby is born! They seem to have the idea that this is done in other countries, and the reason they offer for this service is that women want to know that the baby is OK and also in case the baby dies later - they can say that it was doing well before the birth. Since the rate of litigation is very low in Spain and women are not inclined to sue, even if there is a clear problem with her management, it is hard to justify this routine on legal grounds.

I think this practice is a prime example of setting women up for intervention. How easy to would be to say that there is a problem with the baby and that an induction is indicated! A caesarean could also be offered with ease, should the caregiver wish, and as most women are seeing an obstetrician, this seems a likely possibility. Given the varied interpretations of these traces, almost anything could be read into them. Women, of course, will take up the offer to the CTG because they see this as “care” and every woman craves attention for her pregnancy and baby, especially at the end of her pregnancy.

Imagine what this must be costing the Spanish health system! If every pregnant woman in England lined up for weekly routine CTG s from 38 weeks on , the whole health system would grind to a halt, as it would in other countries. They were surprised when I said that this doesn’t happen elsewhere.

We had a long discussion about unnecessary pregnancy testing and what is means in relation to creating the feeling that pregnancy and birth are normal physical events for a woman. Frequent ultrasound scans are another popular pastime, especially in the private sector, and lots of other tests abound. It is hard to change a culture a fear about birth when there is so much emphasis on testing and technology and it is no wonder that women want it all to carry over into the labour. The midwives in this group had very limited knowledge of many of the issues we explored, probably because they see themselves as servants of the doctors and they assumed that the doctors would know best. Some of the older, more experienced midwives however, who knew what birth was like before all this palaver became entrenched, were able to share some very valuable insights drawn from their own practice and this was enormously helpful for the group. We need ways to celebrate this expertise and to capture the skills for others to draw from, before they retire and it is too late. Spain certainly needs to learn from these wise women.

Posted by andrea at 05:22 PM | Comments (2)

Maternity care in Spain - 1

I have been havng trouble accessing the Internet in Spain, so will include two Diary entries today to catch up...

Working in Spain is proving a fascinating experience. It’s been a steep learning curve - discovering the workings of the Spanish health care system, hearing about the way birth is conducted here and thinking, on the spot, of ways I could adapt the normal Active Birth workshop content to better fit local conditions.

Spain has a three tiered health system. The national health service is similar to those elsewhere - everyone pays through their taxes - and it is apparently fraught with the usual problems: lack of money, long waiting lists, under staffing. Many people take out health insurance as it is cheap and offers the alternative of faster care and a private room in the hospital. The third layer is for the rich - they by-pass the rest and just pay outright for the care they want.

Until around 30 years ago, all births were in the home. The Government then decided to move birth into the hospital (this will be familiar to my British readers as the same thing happened there) and homebirths became an things of the past. The hospitals were staffed with many doctors who then got involved in the births and because there were plenty to go around, more than were really needed, it was decided to cut back on the training of midwives. All of the schools of midwifery were closed and the nurses were given extra training when needed. The doctors took firm charge of the whole birth process.

However, as the midwives aged, and then retired it became apparent there was an acute shortage and there were none being trained. The few midwives left were allocated to the labour wards and nurses were left to undertake the prenatal and postnatal care. After eight years, the midwifery schools were opened again and now there si some new blood entering the scene.

Meanwhile, women, although they may have seen a nurse during their pregnancy for the routine tests etc, started seeing a doctor as well, as he could provide continuity of care. The first and only time a woman would see a midwife was during the labour and even then the doctor would arrive for the birth itself.

The initial breastfeeding rate is very high as Spanish women want to breastfeed their children. While it may be 95% plus after the birth, there is no support in the hospital and by two weeks the breastfeeding rate has dropped dramatically, and by 6 weeks is almost non-existent. Formula feeds are freely available in the hospital and samples are given are given out post partum.

There is no midwifery organisation in Spain and few nurses would consider themselves as “midwives”. Of course there are exceptions, and these will likely be women who have trained elsewhere, probably in Britain. There is an informal network of these people and I am fortunate that this workshop is being organised by one of them, Rachel MacLeod who works at the Acuario birth centre south of Valencia (more about Acuario later).

In the light of all this, birth in Spain is very medicalised. Midwives are firmly under the control of the doctors who dictate all the protocols and demand strict adherence to rigid routines. All women give birth on a narrow table with their legs in stirrups - they will have had a perineal shave and an enema and can expect an episiotomy. There is routine starvation of women during labour and most births as augmented. Needless to say the epidural rate is very high and so are the caesarean, forceps and vacuum rates.

It is all so antiquated, and a real reality check. Two days ago I was debating the finer points of physiological third stage with British midwives, and here I am being told that the doctors insist that if the cord is not cut immediately the baby’s blood will drain back to the mother! As a consequence, I have left out whole sections of my normal workshop program because they are not even at first base with physiological birth.

Tomorrow I have been asked to give them some practical pointers about how they improve birth for women who are on the beds as there is no way they can enable women to give birth on a floor mat. Although it goes against all my basic teachings (as many of you will know) I will be as creative as I can and give them some suggestions so that they can try putting some of the basics (such as upright birth) to the test with the women on the beds. It will be a challenge!

More on how this turns out tomorrow.

Posted by andrea at 05:19 PM | Comments (9)

Off to Spain

Today I am off to Spain for a few days. I don’t know much about the birth scene there, except that it is very medicalised and doctor centred. There is a Birth Centre, in Acuario, between Alicante and Valencia and it is there that I will be presenting an Active Birth workshop.

I will be working with a translator and that always presents some challenges. It will be fun to meet some Spanish midwives and I am sure I will learn much, perhaps more, than they will learn from me!

More in the next few days.....

Posted by andrea at 07:56 PM | Comments (1)

Midwives and litigation

Today is the second day of an Active Birth workshop in Bristol, England. Many of the participants in this group have a lot of experience with home birth, which is not surprising, given that we are not far from Bath, an area well known for its midwifery led units and home birth.

We canvassed quite a few issues related to home birth during the day. We also talked about the problem of litigation, which has midwives running scared in this country. Midwives are adamant that they must “document, document, document” to avoid litigation and this is regularly drummed in by management and the obstetricians.

I would have thought that poor practice and lack of communication with women were the underlying factors that trigger litigation and that no amount of documentation will cover this up. As someone pointed out yesterday, there is nothing to stop midwives from “filling in the gaps” after a birth, especially when the labouring woman requires actual hands-on midwifery care rather than a pen-weilding baby sitter.

I threw in the comment that the NICE (National Institute for Clinical Excellence) guidelines that the baby be monitored using pinards or sonicaid every 15 minutes during first stage and after every contraction in second stage, is an intervention in a normal birth. These guidelines were put in place as an alternative to routine CTGs, which NICE have now said need not be used as a routine, especially on admission. The underlying reasoning for this recommendation seems to be that if there is litigation, extensive documentation of the baby’s heartbeat will somehow make a difference to the outcome. The issue of the effect of disturbing the woman labouring normally every 15 minutes was dismissed by my group yesterday as unimportant - they claimed that women “like to know how the baby is doing”. I wonder how they divine women’s feelings on this? Perhaps they have asked her in this way “you want to know how your baby is doing, don’t you?” when in fact the real reason for meddling with her concentration is that the midwife is terrified that she will be carpeted for a gap in the records for the fetal heart rate.

The state of midwifery in this country is dire. Fear of litigation is shaping midwifery practice, the obstetricians (who know virtually nothing about normal birth) are dictating midwifery practice and trust in birth as normal process is slipping away. If women in Britain were more forthright and less pathetic, if midwifery leaders appeared from somewhere to offer solutions and take strong public positions in support of normal birth and everyone learned how to celebrate those successful midwifery practices that do exist, perhaps something could be done. I will not be holding my breath!

This is my last workshop in the UK for this trip. Tomorrow I go to Spain for a program there and then I will be off home, where I hear that the NSW Government is finally rolling out the first programs under the NMAP. Great to hear of progress being made somewhere!

Posted by andrea at 05:23 PM | Comments (1)

Coaching skills for midwives

I really enjoy working with Welsh midwives, although there are a fair few from Britain in this group as well. Many of the Welsh midwives work in a variation of caseload practice (which they call “integrated midwifery”) which gives them a lot of flexibility. They carry a birth kit in the car and go to the woman in labour. The decision about birth place is made during labour, and of course, this means that the home birth rate is climbing steadily in many parts of southern Wales.

We explored the impact that “coaching” could have on morale in the workforce, given that moaning and complaining are fairly common amongst midwives when they feel undervalued and stressed. This is a topic that I am very interested in and one that I am exploring in more depth myself at the present time. I feel it has great potential for improving morale and supporting innovation in midwifery and it will form a significant part of the new workshops we are planning for Australia on “Team Building” and “Managing Change”. How to develop coaching skills will be part of these programs. We may consider offering them in the UK later as well - they could use them too!

Posted by andrea at 06:07 PM | Comments (1)

Midwifery moves ahead in Wales

I was a speaker at the All Wales Midwifery Conference near Cardiff yesterday - the theme was “In it Together” and it celebrated the new initiatives being taken in Wales to strengthen midwifery and improve maternity services for mothers and midwives. A series of new strategic frameworks have been released that set out the basic principles that will underpin midwifery services into the future. They set targets for the implementation of various reforms that will ensure choice and improved care for women. One key strategy is to raise home birth rates to 10% by 2007, and they are well on their way up, with some areas well over this target already. The reforms being planned will put Wales well ahead of other areas in the UK and the energy and enthusiasm amongst the Conference participants was palpable and exciting.

Today I am in the Brecon Beacons (fabulous mountainous area of Wales) and will be presenting an Active Birth workshop over the next two days. I hope to have a day off on Sunday to do a bit of walking in the area, before travelling to Bristol for my next event.

Posted by andrea at 05:43 PM | Comments (2)

Meddling in the affairs of midwives?

Yesterday I had a classic case of “shoot the messenger” syndrome. We were discussing the ways that the topic of pain is covered in classes and exploring how we could be sure that women are given all the information about the various effects and consequences of taking drugs during labour. It was clear that there were a couple of midwives who felt very uncomfortable about this session, and afterwards on the feedback one of them wrote that she was “sick and tired of non-midwives telling midwives what to do” when women clearly wanted to take drugs for easing the pain.

It has been a long time since anyone levelled the charge that I was a “non-midwife” meddling in the affairs of midwives. The fact that I am not a midwife has always been a great advantage to my work and I have never found it to be a problem. In fact, I know a lot about midwifery and have learn much from the many women whose births I have shared. No-one can claim to be an “expert” anyway, given that there are so many possibilities when it comes to the way women manage their labours.

Perhaps this midwife was feeling embarrassed by her lack of knowledge on the topics we were exploring ( I am often surprised that midwives are not aware of the effects of these drugs on the baby and also the research that has been done on the long term effects of pethidine and nitrous oxide) and I realise that these can be uncomfortable subjects for a midwife who has been happy to provide women with any drug that either she or mother thinks fit.

Being confronted with a gap in one’s knowledge and the unpalatable fact that some of the information being given to parents may be lacking, or even inaccurate, is difficult for an educator. We all must try to keep up with the research and be ready to change our story as new evidence comes to light. It is clear that many practitioners are unaware of the research, and it is part of our role to keep everyone informed. I certainly see my job in this light.

Posted by andrea at 05:50 PM | Comments (2)

Useful ideas

I had some lovely feedback today - last year I presented a workshop in Dumfries (Scotland) where they have a small midwifery unit. They have now appointed a midwife to co-ordinate a number of educational programs across the area, including a revamp of the prenatal programs, and she has come down to London to attend the Teaching Skills workshop I am currently presenting at Kings College Hospital.

She reported that after the workshop, the midwives got really busy with the ideas we explored and have been happily incorporating many of them into their practice. They have even been out and bought a number of plastic buckets, so they could easily provide hot wet towels to women for easing labour pain! The new ideas have proven highly successful and the midwives have enjoyed using them.

It was great to hear of their success - it is important for me to know that the ideas I am suggesting in workshops are of practical benefit and that midwives are trying them out. So often I wonder if I am making any progress at all because it is not always possible tp get direct feedback from workshop participants some time later. I was therefore very heartened to know that things are actually happening as a result of all the tripping about I am doing in the name of encouraging natural birth!

Posted by andrea at 06:16 AM | Comments (1)

Whiteboards in maternity units

We’ve been discussing issues surrounding privacy at the last few workshops. It is obviously an important ingredient for the labouring woman, but some associated concerns have been raised as well.

One that was mentioned is the fact that some maternity units still have those big whiteboards in their central area used to display the name and labouring status of the women currently in the unit. If this is on view to everyone who passes, it means that other women (or more importantly, their support people) can see the details of other women in labour and this amounts to an invasion of their privacy. It could be a particular concern in, for example, a small town, where everyone knows everyone else.

These boards are used to keep everyone informed of what is happening to the women in the unit and are often a focus for the ward rounds and handovers. They can also be used to encourage “throughput” by managers, for example “why haven’t you ruptured Mrs X’s membranes yet?”. If the unit also uses centralised CTG monitoring, a bizarre scene could unfold, where no-one needs to spend time with the woman, as her progress is being plotted by the monitor and the midwife just checks regularly so the board can be updated. It may sound unlikely, but I have heard of some units that are fast developing such a “production line”, similar to those used in industry to achieve targets and maximise productivity.

The whiteboard have got to go. There must be a more humane way of passing on vital details from one shift of midwives to another without relying on this blatant display of personal details. Privacy and confidentiality are issues that are central to a feeling of safety in a unit, and that goes not only for the women giving birth but also for the staff.

Posted by andrea at 11:28 PM | Comments (1)

Appropriate support for birth

The important role of fathers during pregnancy, labour and birth was a topic we discussed yesterday. Twenty years ago, when we first started promoting the “active birth” concept, we realised that fathers needed support during labour, almost as much at the mothers at times.

As Michel Odent has pointed out, if anyone is anxious during the birth process, this contagious emotion will be picked up by the labouring woman and this can have an adverse effect on her ability to labour well. Fathers could easily be frightened by the events of labour and their needs must be recognised and appropriately supported.

In Australia, hospitals responded to these needs by opening their labour wards to all comers (sometimes they regretted this, as large families and multiple friends arrived!) and the prenatal classes were rescheduled to nights so that fathers could attend and learn practical measures so they could be useful birth partners. On the whole, it has worked well, and it is clear that the men have appreciated being involved. Being present at the birth not only enhances the bond between the father and his baby, but also better supports ongoing breastfeeding.

Some of comments following our video yesterday (Giving Birth: Challenges and Choices) highlighted the active involvement of the father. I will be showing a video clip from The Art of Birth today, where the father enthusiastically praises the concept of home birth, as another reminder of the importance of fathers at birth.

The Southern General Hospital in Glasgow, where this workshop is taking place, still has a policy of only one support person at the birth. It is hard to imagine how such an antiquated policy could still be in place and I will be challenging the midwives in this group to press for changes to bring this hospital into line with others elsewhere. It is a discriminatory policy and also a social intervention in birth and it needs to be changed without delay.

Posted by andrea at 05:47 PM | Comments (2)

Tradition

It’s Scotland again this weekend - this time in Glasgow. It is a country of contrasts - we have midwives in this group who work in very rural areas around Aberdeen where epidurals are unknown and we have midwives from as far away as Liverpool as well as local units. There is also one man - a “childbirth therapist” from Israel who is currently living in Denmark. It is the usual diverse group !

Scotland is the home of diamorphine - almost every woman is given this opiate during labour which means that almost every baby gets a dose of heroin before they are born! At the same time, there is a huge amount of money being spent to increase the rate if breastfeeding in Scotland, but until they come to grips with the opiates being given to babies in utero, I can’t help thinking that this is going to be an uphill battle.

As I write this in my hotel, I am watching on TV out of the corner of my eye - the Trooping of the Colour for the Queens Birthday. It is a magnificent display that underlines the enormous longevity of tradition in the UK - they have been doing things in the same way for hundreds of years. As I watch the soldiers on parade, about the only thing that has moved on are their weapons - they are carrying semi-automatic weapons these days instead of swords. Seems like an analogy for the state of maternity care where the foot soldiers (midwives) have moved on to working with epidurals! Of course the choice of weapons is always dictated from above.....

Posted by andrea at 06:09 AM | Comments (1)

Attaining reaccreditation

Today’s task is to complete the last remaining requirements for the re-accreditation of our Graduate Diploma in Childbirth Education. Every five years we must submit the Course to the Vocational Education Training Accreditation Board (VETAB) who accredit Courses on behalf of the Federals Governments’s Australian National Training Authority. It is always a bureaucratic process and one that takes considerable time to prepare. One problem we face each time (this is our second five-year review) is that VETAB changes the way it wants the process to proceed, and they don’t always explain this until the application is submitted, at which point they tell us they want it in a different format or have added new requirements from those listed on their web site.

It is all rather frustrating. However, those enrolling in this unique program can be assured that we definitely have Government approval and that the Course is of the highest quality!

Thank heavens we have a very efficient and thorough Course Coordinator in Cassandra McBurnie, who manages to take all this in her stride and produce the necessary paperwork. These tasks always seem to crop up when I am out of the country and I am eternally grateful that I have a wonderful staff who manage magnificently to keep Birth International running smoothly. I “dips my lid” to them (as we say in Aussie vernacular!).

Posted by andrea at 11:04 PM | Comments (1)

Spreading the natural birth message in South East Asia

I am staying with my friends Melanie and Tanit Habanananda in Bournemouth for a few days. They spend half of their year in the UK and the other half in Thailand, where they work with the Childbirth and Breastfeeding Foundation of Thailand.

Getting together with them, as I try to do as often as I can, gives us a chance to compare the birth practices in Thailand, the UK and Australia, and we often spend hours tossing ideas back and forth about how to promote natural birth across these vastly differing cultures. The Foundation has been invited to present programs in Vietnam and Laos, which is very exciting, and it seems there are some real chances of improving birth in those countries as well, given time.

One project we will start working on soon is the development of a training package that can be used to “train the trainers” in ways of introducing natural birth practices into these developing countries. It is not that women don’t have the chance to give birth without drugs in upright positions - the problem often revolves around the dehumanisation of birth and the lack of sensitivity and basic human rights that occurs when women are forced to go to clinics or hospitals to have their babies.

These are exciting projects and I am looking forward to assisting with the development of the training materials the Foundation will need. Writing a training manual for a country and culture I know little about will certainly be a challenge!

Posted by andrea at 08:54 PM | Comments (1)

Midwifery up close

The “Essential Midwifery” tour has now ended, and what a great time we have had. The last event was in Portsmouth, and again we had an enthusiastic group, who joined in with the role plays, explored barriers to normal births and absorbed the practical tips on dealing with “complex” labours and births.

Lynne Staff’s slides and videos, which beautifully illustrate the women’s stories of a variety of births, have been very well received, even though I am sure that the midwives often felt very uncomfortable with the degree of intimacy and connectedness between the woman and her midwife that the pictures demonstrated. There is a strong reticence to get “up close and personal” amongst midwives in Britain, and I must admit that I often have some difficulty in imagining some of them being “with woman” as labour progresses. There have been occasions during my Active Birth workshops, for example. when midwives in the group have declined to participate in basic back massages with others (even thought we were all fully dressed) because they felt it was too intimate!

This tour has brought a number of issues into sharp focus for me, particularly those surrounding the culture of birth in this country. I am preparing some notes for an article I will write for “The Practising Midwife” (if they will publish it!) that will explore some of my observations and propose some solutions for lifting midwifery out of the trough it has slid into here. I sense a level of despair and defeatism that is dangerous and may jeopardise the professional as a whole, unless some positive, practical measures are taken. I don’t claim to have the answers, but I am willing to offer some suggestions to get the ball rolling. More in future Diary entries too.

Posted by andrea at 09:05 PM | Comments (1)

Darley Birth Centre

Yesterday, we took a day off and visited Darley Birth Centre at the Whitworth Hospital. This small unit, located in the Dales between Sheffield and Chesterfield, has been operating as a midwife led unit since 2001, offering 100 women each year the chance to birth in a very progressive, peaceful environment.

There are 11 GP practices across this very rural area that feed into the unit, and the midwives offer clinics at either these surgeries or in the Centre itself. The Centre is staffed 24 hours a day by a single midwife, who works a 12 hour shift, and many women will choose to have their prenatal check-ups in the evening or at night, so they can see the same midwife each time, if that where they are working.

Birth outcomes, as you would imagine, are good. They have a very dedicated group of midwives who form a very stable team, with many working part time to fit in with families and other commitments.

Mavis Kirkham drove Lynne and I to visit this unit, across the most lovely countryside that was all green trees, lush pastures and neat stone villages. The contrasts between city and country in this small island are remarkable and everything is just so close together. The British have developed the art of compacting a lot into a tiny space and it makes getting into the country very easy from any of the regional cities. It was a lovely day and a very welcome respite from the hectic round of workshops over this last few days.

Posted by andrea at 05:40 PM | Comments (1)

A new idea for midwives notes

One of the aspects of the midwife/mother relationship we are emphasising on the Essential Midwifery tour is the way that midwives are being required to keep copious records and how this is severely restricting the amount of time a midwife spends actually “with woman”.

Mo Harris, working at Derriford Hospital has videotaped many births and has revealed that midwives regularly spend only around 10% of their time actually interacting with women, even when they are assigned solely to her care for the duration of the labour. 43% of the time, the midwife is writing up the notes!

There must be a better way of doing this. In other situations where careful note taking is required solutions have been found. Think of the forensic pathologist who must describe, in detail, the findings as an autopsy is carried out, or the Scene of Crime Officer, who must make accurate notes about the intricate details of a crime site for Police records. They need their hands free as they carry out their tasks and they use tape recorders to note their impressions and record their findings as they go. Both will have their taped findings rigorously examined in courts of law.

Midwives could do the same. Modern mini dictaphones are tiny and are easy to fit in pockets . A microphone can be placed on strap around her neck so she can talk freely while using her hands. Times can be spoken and the feedback to the woman about what is happening will form the basis of the record that can be transcribed later onto the computer. Most of the actual paper notes could be abandoned - the tape recording and the computer would form the basis of the medical record. Midwives will need to learn to speak their findings for the benefit of the tape and to remember to turn it on when observations are being carried out.

There would be several peripheral advantages for this system, apart from the obvious one of freeing the midwife from onerous writing. The tape would also record the mother’s reactions and comments by other caregivers, thus ensuring that all people involved in the care had their input noted. This could be very useful when there was a problem, or later when specific detail regarding what was actually said to the woman or the details of the treatment carried out needed to be established.

Another advantage would be that a secretary could transcribe the notes, a move that would save money ( clerical staff are cheaper to employ) and they could do the task quickly (think of the speed of the typists who handle Hansard). Clerical staff are more plentiful than midwives, so this may also ease the chronic shortage of midwives, who could once again concentrate on using their professional skills.

There would need to be some paper notes - perhaps a quick summary of specific times and events that could be matched up with the taped transcript. The current partogram could fulfil this function.

There have already been some moves in Australia to try hand held computers (Palm Pilots, for example) for community nurses to record their treatments and notes as they move from client to client. These gadgets can be programmed to display a series of screens that require quick taps to record drugs given, dosages, observations etc. which are then uploaded at the end of the shift onto the patient record in the main hospital based computer. While this works well in that context, I think recording births would need a different approach, and tape recorders might do the trick. Midwives might also find this easier technology to master than a Palm Pilot.

I will be interested to hear what others think of this proposal. Given the current high levels of dissatisfaction with the onerous record keeping amongst midwives, the shortages of staff and the need to better deploy the skills available, it is time to “think outside the square” and look beyond traditional approaches to solving this pressing problem.

Feedback please!

Posted by andrea at 04:12 AM | Comments (2)

"Sweeping" the cervix

During the Birmingham workshop yesterday, we discussed the many blocks that stand in the way of normal births occurring. Unit policies always features high on this list, and many maternity units are still using outdated guidelines that are not evidence based. One of the policies that always rankles midwives is the unit’s approach to post-date pregnancies and the resultant guidelines for induction of labour. Everyone knows that an induction is the start of the cascade of intervention for many woman. Reducing the rate of induction would be a quick way to reduce the numbers of caesareans, since an increasing reason for a surgical birth is “failure to progress”.

I was therefore very shocked to hear of midwives being encouraged to “sweep” the cervix either at the end of pregnancy or in early labour in order to “bring induction rates down”. Apparently the National Institute for Clinical Excellence (NICE) recommends this procedure! This is perhaps not surprising, as the NICE body is controlled by obstetricians. Other NICE recommendations have already been challenged as non-evidence based and one would have to wonder where this hair-brained idea sprang from.

What on earth are midwives doing, “sweeping the cervix”? Have they seriously thought about the implications of this procedure? This is a very invasive, painful and potentially risky procedure, and one that could be interpreted by many women as a physical assault. I appreciate that midwives may think that sweeping the cervix may avoid an induction, but why are so many women being induced in the first place? Surely logic suggests that the way to reduce induction rates is to reserve this procedure for only those cases where clear medical indications (not a date on a calendar) indicates the baby would be healthier if born. A careful selection process would return the induction rate to a more justifiable rate if under 10%. Midwives must learn to say “no” to unnecessary inductions and to use their professional judgement to argue against this procedure.

Subjecting women to physical abuse, especially at the hands midwives, is shameful and must be discouraged. This is an issue I will be exploring further as we travel around - another challenge for midwives!

Posted by andrea at 05:33 PM | Comments (1)

Placenta possibilities

The Exeter workshop today was a hoot. We spent quite a bit of time exploring various aspects of placental birth - the way that third stage is managed. Lynne Staff, my co-presenter, kicked of the revelations with her description of her very first home birth as a solo midwife, when the placenta took 7½ hours to be born. There were many shocked expressions, mainly because the midwives in the group found this very hard to imagine, let alone deal with.

This is what happens when birth is centred in hospitals - the impatience of caregivers and the lack of insight into the broad realms of normality mean that third stage is usually managed “efficiently” and any delay beyond an hour will be dealt with aggressively.

As Lynne pointed out, if the woman is OK and the there is no bleeding, it is safe to wait. At her home birth, the woman has a snack, had a shower and then a sleep (with the cord tucked up into her panties). The oxytocic had been given but had not worked (t wears off after 30 minutes) so there was nothing to do but wait. Eventually, the time was right and out it came.

After this introduction to the management of the placenta, the conversation shifted to the concept of “lotus birth” where the cord is not cut and the placenta is left attached to the baby until it is ready to drop off of its own accord. Most of the group had not heard of lotus birth at all and there was a mixture of incredulity, shock and amusement at the thought of how the mother would manage a baby with the placenta still in place. Most thought that it would be smelly (it isn’t) and very inconvenient (it does require some juggling). I explained how to care for a baby with an in situ placenta and my description certainly raised some curiosity, mostly about why any woman would want to bother. I will have to make editing the video footage I have of a lotus birth as top priority when I get back to Australia.

Posted by andrea at 05:39 PM | Comments (1)

Bolshie women are a gift...

The role play during yesterday’s London Essential Midwifery workshop provoked some very interesting discussion. The scenario involves a midwife admitting a woman into the Labour Ward and in this case, the woman (played by Lynne Staff) asks the midwife (my role) ever so gently if she has to get on the bed for basic observations to be carried out. A challenge such as this to the midwife’s authority and skills may be a rare occurrence because women are generally so compliant and “will do as they are told”, especially in labour. However, every now and then, women do manage to speak up and ask for something “different”, especially if they have are well informed or, in the UK, have been to the NCT classes.

When this kind of request is made by a woman, often she is labelled as “one of those women” and the midwives may respond with defensive statements, such as “I’m not getting down on the floor - I have a bad back” or “I need to be able to check you properly, so you’ll have to get on the bed” or with a minifism, such as “just a few moments and you can get up again”.

We talked about some of these reactions in the workshop group, and one lovely midwife (Elke, from Germany) made the comment “bolshie women are so liberating for midwives”. This stopped everyone in their tracks because it was such a perceptive, yet different, view from the more usual reactions of midwives. She is right, of course. A woman who has given some thought to how she would like to give birth, who can be spontaneous and uninhibited in her responses to the power of the contractions and who is open to trying anything, is a gift for a midwife. This woman will enable a midwife to explore the wonderful possibilities of normal birth. Forming a close partnership will enable both to fly together, to take off on an adventure that is uplifting, rewarding and immensely satisfying for them both. This is the joy of midwifery, that inexpressible pleasure that comes from enabling a woman to discover her own power through the very personal journey that is birth. Elke knows this, and that is why she is an independently practising midwife, a role she has chosen so that she can really facilitate births in the best way possible for women.

Long live bolshie women! Where would we be without them? And long live midwives like Elke, who know the value of flying and appreciate the multiple possibilities of women’s bodies.

Posted by andrea at 05:21 PM | Comments (1)