Articles by Month: October 2003

Italian water birth Conference Part 2

The second day at the Water Birth Conference provided a contrast with the first day’s program. The morning session included presentations by Susanna Houd and Marsden Wagner, also Piera Maghella ( who described the aquanatal program that forms part of her work) and Sylvia Franzetti, a paediatrician from Argentina who gave an excellent summary of the myths and realities of epidurals.

Susanna Houd is someone I have been wanting to meet for many years. She is a Danish midwife, who has acted as a consultant for the WHO on a number of midwifery projects, including the three Consensus Conferences that underpin the WHO Recommendations on appropriate care in pregnancy, birth and the post partum period. She was also involved in setting up the new Canadian midwifery education program and for the past four years she has completely overhauled the Danish midwifery education system. At the end of the year she is leaving her post as Head of the Danish midwifery school to take up a job as a midwife in Greenland, working with the Inuit midwives. She is a real midwife - warm, caring, experienced and very open to women and their needs. She has never visited Australia, so I have rectified this with an invitation to join the next Future Birth tour in March 2005. I know everyone will enjoy her practical approach and fascinating insights into birth. Something to look forward to!

Marsden Wagner gave one of his rousing speeches, highlighting the escalating caesarean section rate in Italy ( around 37%) and the preponderance of episiotomy. Not many western countries have a rate of episiotomy of 70%, with the exception of Spain (which is higher) so this was an important talking point. I always enjoy Marsden’s fiery presentations and appreciate his unwillingness to side with the doctors on any issue whatsoever. This is a rare stance in a doctor - every other doctor I have very met will support their colleagues if really pushed, but not Marsden!

One advantage of speaking internationally is the opportunity to catch up with new videos, meet new people and make lots of contacts. I have discovered a fabulous new video that will be appearing on our list as soon as we can get it organised (watch this space!!). I also found that the Italian edition of my book “The Midwife Companion” is a best seller and I had nice feedback from midwives about its usefulness, just as I have had in Britain and Australia.

Piera Maghella is an amazing childbirth educator who, over the past 25 years, has made an enormous contribution to Italian midwifery and the efforts to humanise birth in Italy. My presentation at the Conference was titled “Empowering Women” and I gave Piera as an example of an empowered woman of whom they could be very proud. I am looking forward to working with her again next year as we present some workshops. Again, watch this space, for details as they are finalised in November.

Now that the Conference is over, I am taking three days off in Florence, to re-charge my batteries before heading home to Sydney at the end of the month.

Posted by andrea at 09:43 PM | Comments (1)

In Aqua - Italian Conference on water birth

Today I gave the opening presentation at the “In Water”Conference being held in Massa, Italy. The audience is a mixture of midwives, obstetricians, birth educators, aquarobics instructors amongst others and it has been an amazingly varied day. My paper was on “Empowering Women” and I offered an overview of the birth scene on a global as well as local level, including the relationship between women and midwives, the battle between obstetrics and midwifery, the need for better parent education together with some suggestions for forging a way forward.

Next came a lovely visual presentation of water in all its manifestations - lakes, rivers, ocean waves, ponds, droplets, streams etc with a minimalist voice over of appropriate “water” words.

A presentation about the nature of water, water crystals and memories imparted and reproducible through water followed. I had trouble grasping the point of this paper, an even though it was accompanied by music, an array of clever graphics and the sounding of tuning forks, it failed to convince me that water crystals would shape themselves to represent a sound, word or picture that had been shown to it.

The last presentation before the end of a very long morning was a dissertation, accompanied by lovely paintings and photographs of the essence of birth. This speaker was passionate about her topic but spoke so fast (in the inimitable Italian style) that the translation failed to keep up very well.

After lunch, the first speaker was a Russian who had worked with Igor Charkovsky, the man who has promoted birth in water followed by immediate baby swimming. I find this work very hard to tolerate and I was disturbed by the videos showing the presenter pushing floating pregnant women around a swimming pool. The aim was to acclimatise them for birth in water, but it seemed to me to be another manifestation of the man dominating the woman, and she was certainly completely submissive in a way I found quite dangerous. He also showed scenes of his swimming classes where very young babies are pushed underwater, encouraged to swim (for their lives?) and tossed into the air to be held by their feet. I am not sure what the purpose of this is, but I found it disturbing.

The last speaker was my old friend Michel Odent, talking about birth physiology and the use of water in labour. He has come up with a new idea (as you would expect of Michel!) and is now promoting their idea of the “birth pool test”. Whenever a labour is stalled, or the woman is having difficulties, he suggest that shw be given up tp two hours in a water birth pool. If there is not further progress then a caesarean is the next step. His rationale is that the calming effect of the water should lower the adrenaline and enable the birth hormones, and in particular oxytocin, to reestablish themselves. If the labour doesn’t then proceed, there is probably a mechanical difficulty and a caesarean will be the only option. He illustrated this proposition with several interesting anecdotes. It is a theory that seems worth pursuing, because it will be less invasive than other ways of accelerating a stalled labour and may be a simple strategy that works. It is certainly worth a try.

he day concluded with a wonderful new video for Austria that I will certainly be tracking down for sale through our catalogue. It was marvellous, showing women labouring using their own hormones and giving birth magnificently. I wish I has this video to show the Spanish midwives I worked with recently - they would have been blown away, as I think most midwives will be =when I have a copy to use. Watch this space for more details later.

Posted by andrea at 09:39 PM | Comments (1)

Guernsey, part two

This posting about Guernsey is rather late - I had prepared it at the end of the workshop with the intention of putting it on the site as soon as I arrived in Italy the next morning. However, I didn’t count on the telephone system in Italy. I have been unable to get access to the Internet for the past week!

Therefore, here is my final reflections on Guernsey and tomorrow I will post my observations on the Conference that I was attending in Italy.

I decided to alter my approach with the second group of midwives in Guernsey. I began by asking those who had seen a natural birth (not a normal birth, as definitions of this vary widely) to raise their hands. I then asked them to lower their hand if the birth had included: artificial rupture of the membranes; any kind of medication for pain; oxytocics for any part of labour; episiotomy; TENS, or horizontal or recumbent position for the birth. Gradually the hands fell, but still some remained in place. It transpired that these midwives had witnessed or assisted at these births elsewhere, not in Guernsey.

This was a revealing exercise, because ostensibly, the midwives on this island are trying to offer an alternative to the doctor dominated service that now exists. They have established a midwives clinic and are working towards offering home births as part of an integrated approach to care. The reality, however, is that there are 600 births per year on the island and four obstetricians, and the caesarean section rate is unacceptably high. Due dates are based solely on the scan date and births are rigidly induced at term plus 10 days, leading to “failed inductions” and caesarean births. Epidural use is high and midwives see no problems in using diamorphine (heroin) liberally in labour, especially if the woman requests it (even in transition). One midwife stated that she considered a birth to be quite normal if it included diamorphine (but then she had earlier said she used it herself, and claimed it was excellent for her).

There are 5 midwives employed by the hospital who were born in Guernsey - the other 30 or so midwives have come from elsewhere. Although I was told that this could be a strength if people contributed ideas found useful and effective in other places, it was made very clear to me that midwives were expected to conform to the rigid protocols and policies that operated on the island, and without delay. I was given the distinct impression that any “outsider” who rocked the boat would be made to feel as uncomfortable as possible in the hope that they would either buckle under or would leave.

I heard lots of “blame the woman” statements as well - excuses for the labour management style and questionable outcomes being sheeted home to the woman. “If a woman requests drugs she should not be denied them in case she complains later” was a tired old excuse that I heard once again. I was told that the Island Health Board had enough money and could support requests for completely unnecessary elective caesareans, if that was a woman’s choice.

Whenever I hear these claims being made and the women being blamed for the high rates of interventions, I know that midwives are covering up poor practice, limited skills and a lack of experience of natural birth. In some ways they can’t be blamed for their predicament - if they have never seen a woman give birth completely under her own steam then it must be hard to accept that it is possible. To not even want to find out how it could be done and to be wary of anyone who can verify that this is indeed possible (to the point of trying to discredit them) is however, unprofessional.

Yet this is what is happening on Guernsey. A midwife, with many years of successful home birth and water birth experience in Britain, was employed to institute change and move midwifery services forward on the island. Her approach was discovered to be “radical” in the eyes of the other midwives and her practice style has challenged many of the traditional views of her colleagues. Rather than learning from her experience they have set about crucifying her, with the apparent aim of getting her off the island as fast as possible. They have become so unsupportive of her that it has made it difficult for her to practice safely, an outcome that has, in turn, been held against her.

It is the old story - change is uncomfortable, and people like working within narrowly defined rules that ensure everyone toes the lines and no questions are asked. Never mind that labouring women are individuals and deserve appropriate care, or that this system makes it easy to hide mistakes (or even perinatal deaths), from scrutiny. The doctors set the pace and dictate how the midwives will work, and the hospital threatens that anyone stepping outside the guidelines, or practising in a different way, will be viewed as a dangerous radical to the status quo.

I don’t think I will be asked back to Guernsey - I think the midwifery managers found my presentation very uncomfortable and challenging. Some in the group did welcome the timely reminder of what midwifery was all about, as they indicated on their evaluations, but I suspect that anyone who really wants to practice midwifery should not consider Guernsey as a potential workplace. The “small island mentality” that is so common in these kinds of geographic locations is well illustrated by their maternity services!

Posted by andrea at 07:42 AM | Comments (1)

Maternity care in Guernsey

Guernsey is proving interesting, especially the health services, which are run by the local Health Board. People pay to visit the GP (£25.00 per visit) and a flat rate of £2.50 per prescription. Services provided at the hospital are free and the Health Board contracts the doctors to provide the in-patient care. Maternity services are in the hands of the four obstetricians on the Island, although there is a midwives clinic and midwives do catch some of the babies.

The group members today claimed that they had high rates of normals births, but I understand that the caesarean rate is 27% and epidural use is also high. Many women have OP positioned babies, probably a result of the affluent (and sedentary) lifestyle that is associated with the main industries here - banking and tourism. Diamorphine (heroin) is the drug of choice and lots of women receive it, along with Entonox. One midwife claimed that it was quite possible to have a normal birth using diamorphine!

Today’s program was a special one-day event, that I will never offer again, after this experience in Guernsey. There were so many issues that we had to leave out and time for practising skills was very limited. Tomorrow’s group will be different and I will try and include some of the topics we omitted today, as they too will only get one day. It feels very unsatisfactory to have only given them half of the program in effect and I feel very unhappy with the result. Of course, the group didn’t know what they missed out on, but I do and it feels very incomplete. The valuations that I received were fine, although I am sure some decided not to offer feedback as they were feeling very defensive and negative after my presentation.

Tomorrow will be interesting and will be yet another challenge.....

Posted by andrea at 04:20 AM | Comments (4)

Midwifery in isolation

I have finished the UK part of my October workshop program with a lovely intimate workshop in Doncaster. The group was small, which enabled lots of discussion around individual needs and issues. There was a strong feeling that independent practice was the only way some of this group could function as midwives and several expressed the view that if they had to stay working in the NHS, they would prefer to leave the profession altogether, rather than endure the limitations within which they would be required to work.

One experienced midwife had moved from a busy unit in the south of Britain to a very isolated midwifery unit in the wilds of Scotland. She was finding this a wonderful challenge, and was enjoying working with women who had a more pragmatic and practical approach to birth. There was no epidural service and very limited back up for emergencies. At times in the winter it would be quite likely that the hospital and its staff would be cut off from the outside world for days if snow was heavy. In these circumstances, all that can be done is to “get on with it” as best as can be done. This is real back to basics care and proves that midwives are capable of seeing birth through safely, often in difficult and far from ideal circumstances.

This afternoon I am travelling to Guernsey, a Channel Island that is nearer to France than England. There is only one hospital and all the staff wanted to attend the workshop, so we have devised a special program that will allow half to attend one day and the rest to attend the next, so that hospital staffing can be maintained. I will be interested to learn more about birth on this island, which is very affluent and, I understand, rather medicalised (probably as a result!).

Posted by andrea at 10:30 PM | Comments (1)

Unethical Caesarean research

Checking the news at home (I read the Sydney Morning Herald on-line when I am overseas), I discovered a report that in the US, a team of doctors are planning to mount a randomised controlled trial of caesarean versus vaginal birth for normal healthy women expecting their first baby. They apparently feel that this is a viable question to explore, on the basis that women are asking for a caesarean and they can’t “advise” them appropriately and that caesareans don’t cost much more than vaginal births anyway.

This is an outrageous proposal. To randomly require a number of perfectly well women to undergo major abdominal surgery is completely unethical, given the considerable body of evidence of unwelcome side effects and sequellae of this procedure. These may be acceptable when the alternative is a dead mother or baby, but not when no threat is present.

There has been some debate in the press in Australia and it is to be hoped that obstetricians recognise the huge outcry that would result if they were to accept this study as ethical and of value on its completion. We are attempting to lower our alarmingly high caesarean rates, not increase them.

At the same time, Caroline Crowther (obstetrician) and her team in Adelaide have already signalled their intention to mount a RCT on repeat caesarean versus vaginal birth for women who have already had one caesarean. This study has also been questioned as ethically unsound, given the evidence already accumulated that VBAC is the preferred option and that women have up to an 80% chance of success with vaginal birth.

These studies smack of a profession under duress from mounting costs, unhappy women, and pressure from insurance companies and Governments to lower their costs to the community and the health care system. They also suggest doctors are unwilling to put in the sometimes unsocial hours to support women having normal births, have greedy attitudes towards maintaining their substantial incomes and basic misogynistic attitudes towards women. How else could they be even thinking along these lines?

If the obstetricians are unhappy working to back up normal birth, then they should leave the field to others (midwives) who would welcome this opportunity. There are some obstetricians, usually salaried and working in the public system, who do care about the work they do and are providing excellent care. It seems that the allure of money in the private system has corrupted many others into thinking that women are there to serve their needs, rather than the other way around. The Americans have shown what happens when the dollar rules - their health care system is a shambles and a disgrace. Let’s hope that they keep their obstetric nonsense to themselves - the rest of the world can do without it.

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

How often should midwives listen to the fetal heart?

Birthing women are losing out all around the western world. Amongst the group of midwives on the workshop I have just completed in Burton on Trent (UK) were a number from the large Queens Medical Centre.

This unit, which is due to be redeveloped at some time in the future, has a few regular bathtubs in the labour area. Women sometimes use them for easing labour pain but the staff are under strict instructions that under no circumstances are women to be allowed to give birth in the bath. It seems that few of the staff have the necessary “training” and that without policies for staff safety, cleaning etc etc women just have to forgo this useful pain management strategy. Epidurals, pethidine and Entonox are freely available (and used) as alternatives. Never mind that some staff already know how easy it is to facilitate a water birth or that there are other maternity units nearby where the training could be obtained.Itis crazy - midwifery managers are losing the plot.

We also heard from members of the group who work in a Birth Centre nearby, that they are being forced to follow the National Institute of Clinical Excellence (NICE) guidelines that state fetal heart rates must be recorded every 15 minutes. They have been told that if they don’t follow this policy then they will be forced to close the unit down.

This is a clear case of bullying. These midwives, all experienced in normal birth and working with healthy, low risk women, are being told how to conduct their practice by people (doctors) who have no concept of natural labour the way constant disturbance can effect normal hormonal flows. The NICE guidelines are not based on any scientific evidence at all - there are no studies that state that listening every 15 minutes will given better outcomes than listening every 30 minutes, or any other time frame. They have been arrived at in an arbitrary manner by a group of obstetricians who are just plain scared of being sued if they don’t have a continuous reading of the fetal heart, The evidence against continuous electronic monitoring for low risk women is now so strong they have had to accept that it cannot be justified and so they have tried to establish frequent auscultation with a sonicaid or Pinard as an alternative. It is nonsense for well women, and midwives know it.

I am afraid that the midwives in Burton have been brainwashed into accepting these dictates and are anxious as a result. I suggested that they contact the other birth centres around the country and find out how they are coping with these inappropriate guidelines. I just hope they don’t find all the others have buckled under as well!

Posted by andrea at 02:31 AM | Comments (2)

Entonox link to pernicious anaemia

Another Active Birth workshop started today - this time in Burton on Trent. The local hospital is Queens Medical Centre where they have around 4,000 births per year and there is also a small midwifery unit, The Victoria, in Litchfield, which is near by. We have midwives from both of these units int the group, plus community based midwives and midwifery assistants. It is a lively group, with much camaraderie that stems from knowing each other very well and all being of a similar age.

There was a very lively debate about the use of TENS and Entonox - and of course I stated my view that neither of these props are necessary or desirable during labour. This was a bit of a shock for this group, who had been promoting TENS and using Entonox liberally as an alternative to pethidine and epidurals, especially in the midwifery unit.

One midwife told me that she had been diagnosed with pernicious anaemia which she had investigated and found was linked to exposure to nitrous oxide. The research she discovered was from the US, and was done in relation to its use in dentistry. She showed this evidence to her Occupational Heath and Safety Unit, but it was dismissed as “not relevant” because it was done in the US and did not involve exposure during labour and birth. This midwife had asked for a scavenger unit to be installed in the labour ward but this was not forthcoming.

I was disturbed by this disclosure. Many hospitals have now installed scavenger units because of the known effects on staff of nitrous oxide in the air they breath, often for many hours during a labour. In addition, most OH & S units are very diligent (sometimes to the point of losing all common sense) in protecting the health and well being of staff, yet in this case they have shied away from dealing with a staff safety issue. I will be suggesting to this midwife tomorrow that she investigate what other units have done about this problem of staff exposure to gases and also to check out the research on this problem I know has been published in the UK.

Meanwhile, the obvious answer is to reduce the reliance of British midwives on Entonox. If it is having this effect on staff, what can it be doing to women and their babies?

Posted by andrea at 04:19 AM | Comments (2)

The epidemic of pelvic pain

Leicester workshop today. This group includes a physiotherapist, who is involved in prenatal education at the hospital. She also sees women who have problems specific to pregnancy. Her presence enabled some important issues to be raised.

She appealed to the midwives in the group to stop referring women to her for pubic syphasis pain (diastasis) - she was being inundated with women complaining of painful pelvic instability and wanting treatment. I suggested that this is a very “modern” phenomenon that may be linked to the sedentary lifestyles many women now lead. This physio agreed and said she regularly suggests exercise, better posture and other appropriate bodywork to enable women to get into better shape, in order to strengthen and tone flabby muscles.

Perhaps something else is behind the increase in reports of this problem. Many women just want someone to listen to them and take and interest in their well being, and to have an excuse to do a little less in their busy lives. Developing a problem with pelvic pain might provide an opportunity to get attention and some time off. I have noticed that this condition is receiving quite a lot of press and there have been discussions in the midwifery journals about the prevalence of the condition.

The phsyio in our group felt that women just didn’t realise that aches and pains were a normal part of pregnancy as a woman’s body adjusts to the changes in posture and increasing looseness of the joints. Their attitude (perhaps supported by the comments from caregivers) is adding to the perception that pregnancy is an illness that should receive treatment.

Let’s not get the adaptations of a woman’s pregnant body out of perspective. Some women (and I mean a few) will have genuine problems with their pelvic joints that will require specialised care. The flexibility and instability is, however, the result of normal hormonal changes designed to make birth easier for mother and baby. Some inconvenience in pregnancy may well mean a faster, simpler birth. Perhaps this is the approach we should emphasise when we are talking to women about their concerns?

Posted by andrea at 04:56 AM | Comments (4)

Midwifery assistants, not doulas

This weekend I am working with a group in London. As often happens at workshops here, there are people from all over the country and it is an interesting mix of NCT teachers, students, yoga teachers, Midwifery Managers and staff from several London hospitals.

There are four “midwifery assistants” in this group, all from Southend Hospital. This unit, which has a very strong commitment to woman centred care and active birth, were having problems finding midwives (as are many other hospitals) so they have employed these assistants so do some of the labour support work, post-natal care and administrative tasks for the midwives. They are not calling themselves “doulas” because their role is more extensive than just labour support and they are clear that their role is provide back up so that the midwives can be “with woman” as much as possible. One task they are doing is entering the notes onto the computer after each birth and I imagine that the midwives are very relieved to be able to hand over this chore!

One subject we will tackle today the issue of drugs for labour pain - the view was expressed again yesterday by several group members that Entonox is not really a drug. This attitude makes me really mad - apart from the professional myopia and presumptive attitudes it exhibits, it is a worry that midwives are so uninformed. I have signalled that I will make sure they are aware of the effects that drugs have on newborns and I will be preparing a few hand grenades to lob about to make them stop and think!

Tonight I travel to Leicester......

Posted by andrea at 05:42 PM | Comments (1)

Not just surprises, but shocks in Spain!

The final day of the workshop in Acuario certainly provided me with some shocks.

We were discussing ways of keeping women off the beds and the impact that the initial admission procedures have in setting the tone and laying down the “ground rules” about how the woman’s labour will be managed. It transpired that in many public hospitals, standard labour management starts with the woman being taken into a room where she is put up into stirrups so a doctor can do a vaginal examination to determine if she is in labour. She is then taken to a first stage labour room where she will be examined as often as every hour to record her progress. At the end of first stage she will be wheeled into a delivery room where she will be again find herself in stirrups, being given an episiotomy and being told to “push, push, push” in the traditional obstetric manner. After the baby is born she is taken to a recovery room and then finally to her post natal bed.

Many women have no assigned midwife: any passing midwife will check the notes on the end of her bed and if deemed necessary (for example, an hour has passed since the last VE) she will perform another examination and record the results in her chart. A woman may have 10 or more VE’s in the course of her labour, perhaps by as many as 10 different people.

No wonder that the epidural rate is around 75%! I cannot imagine how a woman could endure such atrocities without complete anaesthesia!

I asked the group how the women felt about all this and the reply came back from one senior midwife that “women don’t mind it - it is what they expect”. The look on my face must have made her stop and think and she then realised what she had said. Of course women have not been asked and these midwives had no mechanism for evaluating the results of this kind of “care”.

I raised the issue of sexual abuse victims and bluntly told the group that what they were describing sound to me like a form of ritualised rape. They were pretty shocked by this accusation, but I couldn’t see any other way to sensitise them to the plight of these labouring victims. How can midwives become so institutionalised that they can’t see the effect their care is having on the women in their community? It is lucky that Spanish women seem to be unwilling to take these issues further and I warned these midwives that this kind of physical abuse might easily lead to a court case in other western countries.

This group found the workshop very challenging. They had no idea of normal labour behaviours (they mainly see women with epidurals) and therefore relied totally on vaginal examinations to determine progress. They couldn’t tell me what endorphin driven behaviour was like and only a few knew about common reactions in transition. The “rest and be thankful” stage that sometimes follows transition was a complete mystery to many and the only way they knew to manage the birth was with a lot of shouted instructions, fundal pressure and large episiotmies so the babies could be pulled out with forceps or vacuum.

Sad times indeed for many Spanish women. Perhaps these kinds of humiliating experiences contribute to the low birthrate. Until midwives witness normal births they will not be able to offer any alternatives and it will be impossible for them to gain that experience in the state run hospitals where most work. Videos may have to provide the basis of an education in normality and workshops like this one will also have a role to play in encouraging midwives to think about their actions and challenge the system.

I will be making some enquiries about having my book “The Midwife Companion” translated into Spanish so that there is at least one practical manual they can use to develop better practice habits. We are already scheduling more workshops in Spain for next year - I can see a great need to expose midwives to other ways of working.

How could they have cut themselves off so completely from developments in maternity care in other parts of Europe? That is a question I find fascinating. Even from so far away as Australia, we know what is going on in other parts of the world, yet from a distance of only a few hundred kilometres there is complete ignorance of neighbouring countries policies and approaches to care. There is much work that needs doing in Europe, I fear, and we are only scratching the surface in Spain!

Posted by andrea at 07:48 PM | Comments (4)

Surprises in Spain

It is lovely to be back in the Acuario Birth Centre. This small private clinic has a lovely peaceful atmosphere and is a centre for village life in this small town. We (Rachel McLeod, the workshop convenor and I) arrived here late at night, having altered the plan to stay in Valencia, because there was a woman in labour in the clinic who needed Rachel’s attendance. While Rachel watched over the birth, I slept in a spare hospital bed - the first time I have been “in hospital” for almost 30 years!

The group who assembled next morning for the workshop had come from all over Spain and included an obstetrician, several physiotherapists, two male midwives and some midwifery students. I decided to alter the format of the program this time and begin with a video of a normal, natural birth. I chose The Birth of Neko Pilara, a lovely video from New Zealand, which shows labour at home in the first stage and a planned transfer to hospital for the birth of a large baby, who is caught by her father, supervised by two midwives.

I asked the workshop group to watch carefully and to note anything that they saw happening that was different to the way they usually manage birth. They were quite amazed, and afterwards the comment came that it would have been easier to look for any similarities rather than differences! They had never seen a birth like it.

One lively discussion that developed was around the need for episiotomy, which is a standard procedure for all women in Spain. In the video, Neko Pilara’s mother has thick perineum, which stretches well as the baby emerges, although she does have a small tear. I found it very unusual to be discussing the merits of tearing over episiotomy with a group of western midwives (I would expect this discussion in South Ease Asia, for example) and they were hard to convince. I will try again, using the wonderful squatting video from Brazil to demonstrate how it can be done.

All of the group expressed the view that they were looking for a way of offering women something different during labour and birth, and there was an interesting debate about the power of the doctors and their rigid control of the birth protocols. Today we will explore some practical measures they can try and I will offer them some of my standard ploys to enable them to get around these protocols. We have already talked about using the women’s expressed wishes, recorded in the notes, to enable them to avoid unnecessary protocols and this was a novel idea - the doctors here don’t ever expect to be sued by unhappy women, it seems!

I am looking forward to another fascinating day with these midwives.

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

Back to the Acuario Birth Centre in Spain

Today I am travelling to the Acuario Birth Centre, near Valencia in Spain. This is a follow up workshop for the one I presented there in June, which was very over-subscribed.

It will be interesting to get some feedback from the last program. Much of what I presented was news to the Spanish midwives, who work primarily as obstetric nurses (although many are keen to de-medicalise birth) and I am hoping that some of the ideas we explored have been tried over the past few months.

It will not be possible for me to email for the next few days, so my next Diary entry will come after the workshop has finished. I will let you know how it goes.....

Posted by andrea at 06:49 PM | Comments (3)

Direct Entry Midwifery at UTS

I am receiving a steady stream of enquiries regarding the Direct Entry Midwifery Course to be offered by the University of Technology, Sydney. The University have just announced that the planned launch in 2004 has been delayed until 2005. Now that the Nurses and Midwives Act has been passed in NSW and there is a mechanism for the registration of direct entry students at the end of their education, the University has cleared the way for the development of the program, but this will take some time.

They are disappointed at this further delay, but I know the course, when it is finalised, will be the best in Australia. Those who wish to be considered for enrollment should put their names on the list of prospective students at the University - they will then be contacted when applications are being taken.

For further information, please contact:

Centre for Family Health and Midwifery
University of Technology, Sydney
9, The Terraces
(PO Box 123)
Broadway NSW 2007
Australia
Tel61 (02) 9514 2977
Fax61 (02) 9514 1678
Email priya.nair@uts.edu.au
www.familyhealth.uts.edu.au

Posted by andrea at 06:43 PM | Comments (1)

Scans instead of hands

Another issue that came up in discussions with this group is the increasing tendency of midwives to rely on ultrasound scans instead of palpations to determine the size of the baby and its position. This is a worrying trend, for two reasons.

First, the fact that midwives are embracing technology so enthusiastically is of concern. This can also be seen in the increasing use of sonicaids instead of pinard stethoscopes to listen to the baby’s heartbeat and the reliance on CTG traces to determine the strength and length and contractions. Medical technology is the province of obstetric care and has a place when complications demand specific and detailed information. An extension of this trend is the suggestion that midwives might also learn how to perform ventous extractions. Midwifery risks being suborned by medicine completely if these practices are adopted.

Secondly, by relying on technology, midwives will lose, or perhaps not even learn, basic skills they need to work effectively. Midwives have traditionally used their hands, and the laying of those hands on a woman’s body in labour is one of the best comfort aids that a midwife can offer a woman. If midwives cannot work without the backup and availability of machinery, how will they ever feel competent and confident when this gadgetry is not on hand, perhaps in a birth centre or in a home setting? Many hospitals don’t have this equipment either, so midwives may find their employment opportunities are limited.

At a time when midwives are fighting for their professional lives in the face of increasing medicalisation, one very compelling argument in favour of midwifery care over standard medical care is that midwifery is cheaper. This is only true, of course, if midwives remember to use their eyes and hands instead of machinery

I know if I was in labour, I would much rather have a warm hand on my tummy feeling how my baby was doing than a belt strapped tight!

Posted by andrea at 06:40 PM | Comments (1)

Placenta now seen as 'hazardous waste'

This weekend I am in Northern Ireland, presenting a workshop for midwives from the Belfast area. We also have two students from the first direct entry midwifery course participating, which is very encouraging.

At one stage, the conversation turned to the placenta and how it is dealt with after the birth. Most had never heard of lotus birth so I duly described the basics of placental care when the placenta is left attached to the baby until it separates of its own accord. This raised an interesting discussion, because apparently the “rules” in Northern Ireland (and perhaps the UK at large) state that the placenta must be disposed of soon after birth and that the midwife is accountable for its safe dispatch. The regulations that were quoted are European directives and are basically to do with the safe disposal of animal and human body parts. No doubt the recent outbreak of foot and mouth disease and other noxious diseases have played a part in the development of these guidelines, and for very good reasons. Body parts (left from surgery, for example) may also be diseased and may present a health hazard if they were not incinerated.

What concerned me was the statement from one midwife that when she attended a home birth she was legally obliged to take the placenta away in a hazard bag and to have it incinerated at the hospital. She had to sign a form to indicate she had supervised its disposal.

I find it impossible to believe that the authorities would consider the placenta in the same way as a dead sheep or an gangrenous limb that had been amputated (but then again, I could believe anything of authorities, who frequently operate within very narrow boundaries designed to stifle independent thought). Never mind the parent’s wishes, the healthy state of the placenta and the complete lack of evidence that a placenta poses any health risk at all if appropriately handled.

Another wonderful example of bureaucracy gone mad. The European Union may be a good idea in many ways but it is increasingly dictating how people will lead their lives, often in the most surprising ways. Watch out for placentas - the EU considers them a biological hazard!

Posted by andrea at 04:07 AM | Comments (3)

Water birth Conference in Italy

The Waterbirth Conference that I was to attend in Massa, Italy, at the end of October has had to be cancelled, due to a disastrous flood that has affected the town where it was to be held. Quite ironic that a conference about water has been water-affected to the point where it cannot proceed!

The organisers are hoping that it can be re-scheduled for either December or perhaps a date next year when things have settled down in the region, which has been hard hit by these natural disasters. I hope that it can go ahead later - the birth intervention rates in Italy are very high, with the caesarean rate standing at a national average of 37%. Any strategy that might offer an alternative is to be encouraged and using water is a proven way of keeping birth normal.

It remains to be seen whether I can participate in the re-scheduled event. I was to open the proceedings with an address on “Empowering Women” and I had looked forward to presenting ideas on how better education (of women and health professionals) could be used to open up new avenues in maternity care. Perhaps another time.....

Posted by andrea at 11:12 PM | Comments (1)

Childbirth education - my passport to Britain....

I’ve arrived into our UK office today and am catching up on the news here.

As I came through Immigration this morning at Heathrow airport, the woman checking my passport noticed that I had stated I was a childbirth educator on my Immigration Declaration. “Oh”, she said, “you should be talking to my colleague at the next desk - she is pregnant”. The woman heard this comment and said “Yes, I expect to be stamping passports right up until I go into labour!”. We had a quick smile and chat and I wished her well for the very imminent birth.

At least I sailed on through after this little exchange, and received a warm welcome to Britain, which was better than the usual surly scowls from the officers facing thousands of tired and testy travellers.

Tomorrow night I travel to Belfast, again from Heathrow. There are going to be a lot of airports on this tour.....

Posted by andrea at 12:50 AM | Comments (1)

Addiction links to obstetric medications

I receive a steady stream of emails from readers of my book Preparing for Birth: Mothers asking about the statements it contains regarding the link between exposure of the baby during labour to nitrous oxide and the increased risk it may become addicted to amphetamines in later life. The book also includes the comment that there is a similar link between in utero exposure to opiate drugs (e.g. pethidine/Demerol,) and later addiction to opiate drugs. This information worries caregivers who are usually ignorant of this research (the first papers on this subject began appearing almost 15 years ago) and who are concerned about the impact of their practice habits, especially if they have been encouraging the use of nitrous oxide (e.g. Entonox) as a “safer” alternative to pethidine and epidurals.

The references used as a basis for these comments are on the web site, and if you click here, you will get the full list.

Parents sometimes worry too, because they believe that some drugs will be necessary and they are keen to avoid any that might have an adverse impact on their baby. My answer to their concerns is to remind them that there are many ways of easing pain in labour without using drugs as our grandmothers and great grandmothers well knew. These days it is even easier, given the availability of hot water in various forms (baths, showers, hot wet towels), the encouragement of upright postures and freedom of movement and equipment such as birth balls, birth stools, floor mats and bean bags. If a woman tries all of these during her labour who will find she can manage nicely, at least until the transition phase when nothing (including drugs) will do much to help her through the turbulence of this short period. Once this phase passes, the medication free woman will be fully conscious and able to actively participate in giving birth to her baby, which brings its own huge rewards.

Drugs are not the answer for relieving labour pain. They are risky, unpredictable and carry consequences that can have huger implications for the health of the baby and mother. For the doubting caregivers who use drugs as a substitute for care during labour, the evidence is clear that dosing women and unborn babies with anaesthetics and other medication is not only exposing the baby to potential hard, but themselves to a charge of inappropriate professional behaviour. I would think that this alone would be sufficient incentive for midwives and doctors to learn more about non-pharmacological forms of easing pain in labour. The references I have cited on the web site certainly make salutary reading.....

Posted by andrea at 08:48 PM | Comments (1)