Articles by Month: March 2004

Unexpected outcomes

It is time to pack up and get ready to return home to Sydney. This trip has offered the usual diverse experiences, including travelling to Scotland and Ireland and meeting midwives from a large variety of maternity units.

My final program was a Teaching Skills workshop in Bristol. Many of the group had been to an Active Birth workshop in the past and it was good to see them again. We had a lot of fun exploring all kinds of interesting and involving ways to get information across to parents and many new ideas were explored and discussed over the two days.

The topic of stillbirth and handicap came up too. This is a topic that many educators avoid, because it is always an emotional issue, tapping into fears for the unborn baby that many/most women harbour during their pregnancies. We looked at ways of bringing the topic up, such as bolting it onto other issues, such as pregnancy tests, signs of premature labour, fetal developments, nutrition, and newborn care. Almost any topic in a prenatal program could provide an opportunity for raising this area of concern, and although it can be hard to facilitate, a discussion around the basic needs of parents when one of these tragic events occurs is vital - it must be acknowledged as a genuine and common fear or concern.

I have written up some ideas for presenting this topic in prenatal programs. The paper is called “Unexpected outcomes - mention the unmentionable” and it offers some suggestions for those responsible for facilitating parent education. It might be worth a look, if this is your field......

I won’t be back tomy Diary for a few days. There are a number of issues that have popped up in the last 24 hours and I will be exploring these in entries early next week. See you then!

Posted by andrea at 11:14 PM | Comments (0)

Saving small maternity units

Tonight’s news on the BBC had a great story about women and midwives marching on Westminster to demand that the proposed closure of two small maternity units in the west of the country be cancelled. The units, at Malmsbury and Devizes are typical of those lovely smaller units that provide care close to home for many families. The local Area Health Service is claiming that they are “too costly” but after today’s publicity, they have said they will consider the community’s concern (and the 8,000 petition signatures) in May when they make their final decision.

Many smaller units have faced these kinds of cuts and a number have been “re-invented” as midwifery units. There are some great examples in the UK, where not only are women and midwives experiencing normal births, but where the local health authorities are actually saving money.

It will be the economic argument that finally saves midwifery, I am convinced. Community action is also an important ingredient in forcing home this argument and the news item on the news tonight was a beauty. Women, babies, prams, balloons, banners and voices all combined to create a colourful and powerful message.

Midwives and women, working together, can achieve amazing results, and it is to be hoped that those politicians in Westminster were taking note of the strength of feeling on this particular issue.

Posted by andrea at 05:13 AM | Comments (0)

The effect of labour drugs on newborn babies

More meetings with midwives this weekend, this time a group that has representatives of 6 hospitals around Birmingham. The contrast in maternity services (that exists in every country) was very apparent, with some midwives telling excited stories of their new midwifery unit opened six weeks ago and others bemoaning the rigid obstetric policies being applied in another unit.

We talked about the usual topics including the effects of drugs given for pain on both mothers and babies. I am always surprised that many midwives have not considered the consequences of giving these drugs on the babies. Many consider that Entonox is “harmless” when it clearly has an anaesthetic effect on women and will therefore be having some impact on the unborn baby. Opiate drugs are still widely used even though they are not pain killers but sedatives and the depression on the baby’s respiratory system and sucking reflex should be well known.

We talked yesterday about the continuum between pregnancy, labour, birth and the immediate post natal period, which includes breastfeeding. Putting the baby to the breast is part of the birth process, triggering the flow of oxytocin that causes placental separation and birth. When babies are drugged and drowsy, or irritable and unsettled, these precious moments are likely to be disturbed and this first breastfeed unsuccessful. Fortunately, any stimulation of the nipple, such as licking, nuzzling or even touching, will initiate the release of oxytocin, an important safety mechanism provided by nature in case the baby is unable to nurse normally.

The effects of drugs on newborns is well set out in an important new book “Impact of Birthing Practices on Breastfeeding” which is the first to collect the evidence into one convenient reference. All of the obstetric practices and drugs offered to labouring women are included. This books should be required reading for midwives and doctors, so that they are clear about the implications and consequences of the treatments they offer women during labour and birth. In the UK, where much effort and money is being expended on attempts to boost breastfeeding rates, the link between labour ward practises and post natal problems is one area that needs close attention. Reviewing the evidence included in this book would be a good place to start.

Posted by andrea at 04:39 PM | Comments (0)

Educating abour labour pain and epidurals

I finished the week with an interesting group of childbirth educators in Manchester. We had fun exploring a number of different ways of presenting information about some of the more difficult topics that are included in prenatal programs, including labour pain and epidurals.

Enabling expectant parents to explore basic concepts around labour pain is a tricky exercise. I took the group through a practical exercise that enables parents to experience some of the basics: dealing with stretching muscle; the benefits of yielding, not fighting it; the impact that experience has on confidence; the uncontrollable nature of contractions and the role of supporters during labour. It is a very effective exercise that enables a number of aspects to be explored and assimilated and I have had a lot of success with it in parents groups.

One of the most effective ways of informing parents about epidurals is to use a simple role play that shows them what will be involved when an epidural has been chosen in labour. Most parents have no idea that siting an epidural will also mean intravenous drips, continuous electronic fetal monitoring (probably with an internal fetal scalp clip), intermittent blood pressure readings and probably a catheter.

For women to have a straightforward, efficient and relatively comfortable labour they need to have 100% mobility at all times. The loss of mobility that results from the epidural itself and these trappings is the most negative aspect of an epidural. Instead of liberating women from the pain of labour, an epidural enslaves them to the medical system, quite literally tying them down and making them entirely dependent on others. The risk of requiring forceps or vacuum to extract the baby rises dramatically (to around 50%, according to the research) placing the baby at increased of complications as well.

The activity I demonstrated to these educators highlights these effects and is a powerful way of getting the message across to parents. This role play can be presented simply and factually - there is no need for comment or personal views. The picture it creates is better than a thousand words.

These workshops are fun and informative. I have another one early next week with a group in Bristol. But first, another Active Birth program in Birmingham.

Posted by andrea at 06:34 PM | Comments (0)

Learned helplessness

At one point today, during the Teaching Skills workshop I am currently presenting in Manchester, the comment was made that many people find some activities and topics a “bit embarrassing” and are reluctant to participate. Later, an educator said that she sometimes gives the group permission to feel embarrassed, suggesting that “if they are unhappy practising these positions in front of the group, then they can practice at outside the room”. This was in the context of preparing them for having to make themselves comfortable in labour, perhaps under the watchful eyes of a midwife.

It seems to me that this is a good example of the “learned helplessness” that afflicts many English women. If someone suggests that “they might feel embarrassed” doing something it encourages women to feel this way. No wonder that people don’t participate easily in group work, or feel comfortable exploring some issues - if the facilitator gives out these kinds of messages it is hardly likely to help people see themselves differently.

It is the same in the labour wards. When midwives say to women “you’re doing well now, but don’t forget that of you need something for the pain later, just let me know” it sends a message that women are poor creatures that will need help, that this is not a matter of “if” but “when”.

This is one aspect of the birth culture that needs changing. Instead of telling women that they are strong and resilient and capable of looking after themselves, they receive various messages that they are weak, need looking after, rescuing from uncomfortable situations and shielding from difficult issues in life. Imagine the difference if they were told they were strong, had ideas that were worthwhile, could develop any skills they needed to further their own personal goals and had the internal fortitude (guts!) to make tackling any task possible!

Pregnancy and birth offer unique opportunities for self discovery and we must find ways of enabling it to happen. The way we communicate with women throughout this life experience will shape their views and colour their interpretations of not only of this momentous event but of themselves.

As educators we must carefully weigh the words we use in our classes. Honesty is an important ingredient and confidence building activities and exercises that promote self discovery are important elements in our programs. I don’t see any place for giving women permission to feel “embarrassed” or for “sitting out if you are not happy to participate”, except in exceptional circumstances, which would be best dealt with individually.

Learned helplessness is an issue that I will be raising in the group tomorrow. It will be interesting to get their views!

Posted by andrea at 06:00 AM | Comments (0)

Office work

Another catch-up day in the UK office today. Next week we are having a trade display at a big breastfeeding conference in London, so I have been packing up stocks of books, videos and models for sale and display at that event.

I am also monitoring the situation in Israel, as I am due to travel there in a few weeks to present two Active Birth workshops. My main concern is being stranded if the airport is closed - I have a number of workshop commitments in Australia both before and after this trip, so cannot afford to experience travel delays.

Tonight I am off to Manchester, for the first of three workshops that will conclude my trip to the UK. Two of these programs are on Teaching Skills for childbirth educators and the other is an Active Birth program. It will be good to be covering some different topics with these groups, although each workshop is always unique because the groups, their needs and personalities are so different every time.

I will report from Manchester in the next day or two.

Posted by andrea at 01:46 AM | Comments (0)

Birth information in Spanish

The three Spanish midwives I had in my workshop last weekend were discussing the need for more information on natural birth to be available in Spanish. It is hard for both midwives and women to consider alternatives to the highly medicalised birth in Spain if they are not aware of other possibilities.

One web site that might be a useful starting point is www.obstare.com - Ob Stare is a professional journal for midwives, produced in Spain by a team dedicated to promoting natural birth. I have just given permission for one of my articles to be translated for inclusion on this site and I know there are many others there that will be prove helpful to women.

I am hopeful that a translation of my book “The Midwife Companion” into Spanish will be completed soon and that a publisher will undertake to have it printed and distributed in all Spanish speaking countries. Midwives will need textbooks to help them learn the necessary skills for supporting natural births and this text is used widely in English speaking countries for this purpose. It is a best seller in the Italian version, and their struggle to normalise birth is well underway. It would be wonderful is Spanish women could have a humanised birth - they are certainly suffering at the present time under a very obstetric model that would be completely unacceptable elsewhere.

Posted by andrea at 01:26 AM | Comments (1)

Using an Epi-No to avoid episiotomy

There was an interesting discussion on the ozmidwifery list a few months ago regarding the use of the Epi-No vaginal dilator as a preparation for birth. Several contributors thought that it was a useful tool and quoted anecdotal evidence of good outcomes. Others thought it was a bit strange, and using a gadget to stretch perineal tissues was seen as mildly distasteful.

A study undertaken in Israel has now been published that compared perineal outcomes for women who used the Epi-No and women who did not, in a culture where episiotomy a is routine part of birth management. In this climate, many women have tried the Epi-No as a means of avoiding this routine procedure and many hundreds have used it over the past 4 years.

Using a descriptive, retrospective approach, all women who had bought the device before April 2002 were contacted and surveyed. The results were compared with published episiotomy rates for the same period. When analysed, the results showed that users of the vaginal dilator had lower episiotomy rates than women generally, and there was an increased confidence in giving birth amongst users, who felt better prepared for pushing and the sensations of birth. There was also a reduced need for episiotomies when vacuum was being used.

It seems that this device may have its uses, particularly for women who fear second stage and face birth in a climate of routine episiotomy. It is expensive and takes time and commitment to use. It may not be attractive to all women but for some, it seems to provide a useful alternative to routine perineal surgery.

Reference: Siome Cohain J. MIDIRS Midwifery Digest. vol 14, no 1, March 2004, pp 37-41.

Posted by andrea at 05:29 PM | Comments (2)

The need for midwifery guidelines

It is encouraging that midwives in Britain are starting to write their own midwifery guidelines for the provision of maternity care. What usually happens in a hospital is that a Committee is formed, mainly composed of obstetricians, with perhaps a few token midwives, to draw policies up for the management of labour and birth in the unit. In the past, these were often a formal documentation of the doctor’s personal practise habits and preferences rather than evidence based guidelines. The midwives were told they had to follow them religiously, often with the threat of being censured if they deviated from them in any way.

Hospital administrations also felt they were covering themselves legally if the unit had documented procedures for the management of labour and stated that if everyone “followed the rules” then the risk of legal action was reduced (perhaps even eliminated). Senior midwifery managers backed up t he doctors and kept their staff in line. Midwives joining the staff were quickly inculcated into the policies of the unit, which were very likely different to those encountered elsewhere.

The availability of the Cochrane Library, the explosion in obstetric and midwifery research, the rapid increase in litigation, and the legal ramifications of “informed consent” have all had a huge impact, and “policies” are now becoming “guidelines” rather than rigid rules for practice. The importance of basing guidelines on clear evidence has been recognised, even though there are huge areas yet to be formally investigated and truly informed consent is rarely obtained from women undergoing any aspect maternity care.

Many of the policies are still being drawn up by the doctors in the expectation that midwives will follow them closely. Apart from being completely inappropriate for one professional group to be dictating the practises of another, few doctors will ever follow the hospital’s policies, even if they have been instrumental in drawing them up. Obstetricians have traditionally “done their own thing” and many birth suites maintain a book where specific practise habits of the various consultants are recorded, to avoid having to disturb them frequently about care plans. Thus one doctor may leave blanket instructions that “all of his women” are to have their membranes ruptured routinely at a certain point, or that they can be given a specified dose of pethidine if required without further consultation. It is a handy system, especially in the private hospitals (where doctors must be consulted about every aspect of the woman’s labour management), and it saves disturbing the doctor at inconvenient times.

It is high time that midwives stopped colluding with this charade of “informed choice” and took steps to individualise care to specific women’s needs. Midwives work differently from doctors, and this must be reflected in the guidelines that they follow. Where clear evidence exists is can be used to under pin these guidelines, where it does not a degree of flexibility should be acknowledged in their wording.

When I was in Norwich I was told about the new midwifery guidelines that the midwives were developing. It was exciting to hear of this development and to see midwives taking positive action to clarify their professional status and skills. It is time that all midwives began this process of exploring and writing up appropriate guidelines for their units - there is a lot of evidence available and the exercise of working on this important issue as a collective would be a useful step in encouraging co-operative teamwork within the unit.

Posted by andrea at 12:53 AM | Comments (1)

Entonox (nitrous oxide) use in labour

I have just obtained the information on Entonox supplied by its manufacturer (BOC Medical). It makes very interesting reading. Following details about its product name, dosage and method of administration, contraindications, interaction with other medications and its effects on the ability to drive or operate machinery, it lists the following:

Undesirable effects

The nitrous oxide constituent of Entonox causes inactivation of vitamin B12, which is a co-factor of methionine synthase. Folate metabolism is consequently interfered with and DNA synthesis is impaired following prolonged nitrous oxide administration. These disturbances result in megablastic bone marrow changes. Exceptionally heavy occupational exposure and addiction have resulted in myeloneuropathy and subacute combined degeneration. Theoretically similar adverse results could occur from heavy and prolonged Entonox exposure. All these effects are well documented, are extremely rare and may follow prolonged exposure to levels of nitrous oxide over 5000ppm or to frequent (more than once every 2 days) exposure to analgesic concentrations. It has been suggested that prolonged occupational exposure to high levels of nitrous oxide may affects a woman’s ability to become pregnant.

Use in pregnancy and lactation

Mild skeletal teratogenic changes have been observed in pregnant rat embryos when the dam has been exposed to high concentrations of nitrous oxide during the period of organogenesis. However no increased incidence of fetal malformation has been discovered in 8 epidemiological studies and case reports in human beings. There is no published material which shows that nitrous oxide is toxic to the human fetus. Therefore there is no absolute contra-indication to its use in the first 16 weeks of pregnancy.

Special warnings and precautions for use:

Administration of Entonox more frequently that every 4 days should be accompanied by routine blood cell counts for evidence of megoblastic change in red cells and hypersegmentation of neutrophils. Thorough ventilation or scavenging of waste gases should reduce operating theatre and equivalent treatment room levels of ambient nitrous oxide to a level below 200ppm. Entonox is non flammable but strongly supports combustion. It is highly dangerous when in contact with oils, greases, tarry substances and many plastics.

These comments have many implications for midwives, who regularly, even routinely, offer women Entonox during labour and birth. Apart from the potential impact on the labouring woman and her baby, for midwives there are risks as well, and it is clear that pregnant midwives should be considering their exposure to Entonox carefully. Scavenger units are being installed in some maternity wards, but most have no such protection for their staff. The recommendation for regular blood testing is also noteworthy.

The final comment about the danger of contact with oils, greases and plastics is also of concern. These dangers are not spelled out in these notes. Many women use massage oils during labour and plastics of various kinds can be found in labour rooms. I will try and discover the nature of these “dangers” and report further if I can.

The statement that there is no published material regarding the risks to the unborn baby and the conclusion that therefore there is no absolute contraindication to its use during labour, once again demonstrates the assumption that no evidence means no problems. Until research is undertaken to test this hypothesis, it may be wise to err on the side of caution.

Entonox is being sold rather heavily at the moment, it would seem, from the advertising being undertaken. It is very freely used in UK hospitals and elsewhere, including Australia. Perhaps it is time to reconsider its use in maternity care, where frequent and prolonged exposure of the mother, midwife and the un born baby is a common occurrence.

Posted by andrea at 10:39 PM | Comments (0)

Finding out what is happening in midwifery

The program today (and Active Birth workshop in Norwich, East Anglia) raised many familiar issues. Several times comments were made by group members that they felt “these things ( several practises were mentioned) only happen in Norwich!” I was able to point out that this was far from the case, that many others across the country have similar experiences. Of course, I feel privileged to be able to travel to widely and hear from midwives in so many cities and towns, and it makes it easy for me to spread the word about what is happening across the country.

England is a small country with a vast network of roads and excellent public transport links. Towns are only a few miles apart, and travel is easy. Modern communication, however, makes all this irrelevant, given that the internet and email can link everyone across the world with ease. Given all this, I find it very surprising that midwives often don’t know what is happening in the town down the road, let alone the major centres a few miles further away. They are surprised to hear about practises, research and programs that have been successful elsewhere, perhaps for many years.

Many of these successes are written up in the various midwifery Journals, of which the UK has a good number. Conferences and study days abound and are well publicised in professional journals and various on-line sites. Yet midwives on the whole don’t investigate what is going on, they have little curiosity and there seems to be a level of suspicion as well.

I can’t help feeling frustrated that more is not achieved in British midwifery. There are so many supports for midwifery - at a Government level, through legislation, within the Health Department, and at all levels of the hospital system. Perhaps if midwives “got out more” they would learn of their successes as a professional group and also discover other ways of doing things. The information is there, and to not take advantage of it seems such a waste of opportunity.

Posted by andrea at 06:13 AM | Comments (0)

Catching up in the UK office

I’ve spent today in the Birth International office in the UK. Things are busy - the latest catalogue is generating many sales that need processing as well as registrations to process for the remaining workshops in my current tour of the UK and the coming series in June.

I had a message waiting for me - would write a few words for the re-printed 3rd edition of Grantly Dick-read’s classic “Childbirth Without Fear” which is being reprinted in Britain. My copy of this classic has long gone missing (the original appeared in the 1940s), and as it has been a while since I read this book I have asked for a copy of the text so I can make an appropriate comment. There have been several editions of this work, including some that were heavily edited and revised. I will be keen to re-read his original ideas.

I have also come across advertising for Entonox - the brand name for the nitrous oxide/oxygen mix that is commonly used in Britain for easing pain during labour and birth. The manufacturers are offering information CDs and leaflets to childbirth educators, presumably as a means of promoting the use of this ubiquitous gas mixture. I will be sending off for my copy of this material and will be very interested to see what it contains. More about this issue when I get the package and have had a chance to peruse it.

The proofs for the article I have written for The Practising Midwife on ideas for changing the birth culture in Britain were also waiting for me. It is a provocative piece, designed to make people think and I am very pleased that they have given it prominence in the April issue. It will be interesting to see if there is any feedback - the 11th idea (the article gives 10 ideas) is to write to the Practising Midwife with another strategy. I wonder if there will be any suggestions?

Posted by andrea at 05:31 AM | Comments (0)

Scandals in Ireland

This weekend I am facilitating an active Birth Workshop in Dublin for the Irish Childbirth Trust. I have altered the emphasis of this program slightly, at their request, to spend more time on activities and presentations for prenatal programs and have omitted some of the more midwifery orientated materials.

There are midwives in this group, and their concerns very much echo those I heard in Drogheda over the last two days. The power of the obstetricians is still affecting women and midwives in a major way, although things are changing very slowly. I’ve heard many stories during these past few days of midwives being censured for speaking out, being subjected to unreasonable protocols that are clearly not evidence based, being forced to subject women to procedures they feel are unjustified and at times even dangerous, all because a doctor demands they be done. In many ways this is not unusual - it is the same story in many countries. However, in a developed, first world country, which has a thriving economy and a prosperous lifestyle, it is strange that women are still haven’t found an equal place in this society.

The High Court last year ruled that women were not entitled to a home birth in Ireland, supporting the medical case that said it was dangerous. Home births are available, but are hard to arrange due to very few midwives being willing to offer this service in the face of stiff opposition. Holles Street (as the National Maternity Hospital is known) has been offering a domiciliary service for the past 5 years (the only service of its kind in the country), and women using it can opt for a home birth, should they want this and meet the stringent criteria. About 10% of the women in the program are now having home births - a major development, if somewhat limited.

Recently, an obstetrician working in Drogheda was struck off the Medical Register for misconduct. He had removed the uterus from over a hundred women, during caesarean births, when there was no medical indication and no consent from the women concerned. It appeared that he was exercising an extreme form of contraception on unwilling women, and it took years for this to be exposed, Many of his colleagues knew what he was doing but colluded and failed to act. Just before the announcement of his “retirement”, and the inevitable publicity as his terrible practises became public, obstetricians mounted a very active campaign against home birth, trumpeting that midwives were killing babies by carrying out births at home. It was seen as a cynical attempt to force the spotlight onto midwives so that one of their colleagues, who was deliberately butchering women’s bodies would receive lesser publicity. It appears to have been a fairly successful ploy, because there has been no general community outrage over this doctor’s shocking mutilations, and homebirths (and midwives) are still fair game and receive little support.

It was a scandal of similar proportions involving an obstetrician’s lack of treatment for women who had cervical cancer that tipped the scales in New Zealand in the late 1980s and enabled midwifery to achieve its deserved recognition. This was achieved because the community were outraged and demanded that the health system be changed - women lost confidence in obstetricians and the Ministry of Health were forced to act. They agreed to support the midwives, changing laws to make sure that they had the opportunity to work alongside their medical colleagues, with equal rights, pay and conditions. The changes to the laws that resulted, have transformed childbirth in new Zealand and created the best midwifery service in the world, with outstanding results and true chocie and freedom for women. It would be wonderful if the women in Ireland could achieve similar results. Right now, the culture surrounding women’s place in the community and general attitudes don’t seem yet ripe for such a change to occur. Perhaps in time.....

Posted by andrea at 07:00 AM | Comments (1)

Optimal Foetal Positioning?

The Midwifery Unit has not yet opened in Drogheda. When I last wrote about their plans it was hoped that it would have been operational around the middle of last year, but the time taken for decisions at the highest political levels have delayed its opening. The proposal has now made it to the top of the “urgent health initiatives” list and so its implementation is expected in the coming months. The midwives are still hanging in there, clearly impatient for its to be started, but happy about the prospect of finally having more say in the overall provision of maternity services in this area.

During the workshop today, the topic of OP labour, i.e. where the baby is positioned in a posterior position, came up. One the group members, midwife who has travelled all the way from Saudi Arabia, mentioned that in Saudi, the rate of OP labours is very low, in the region of 5 - 10% overall. Midwives in western countries have noted a huge increase in OP labours over recent years and anecdotally note that around half of all labours seem to begin with the baby in this less favourable position. It is thought to be due to the changed lifestyles of many western women: sedentary lives, little exercise and sitting in reclining positions, often with feet up, especially during the last weeks of the pregnancy. Many theories around “optimal foetal positioning: have been offered, together with strategies for preventing or even curing the problem.

When asked about these low rates in Saudi, this midwife said that she thought it was because of the way that women sit during their pregnancies - on floor cushions and frequently squatting. Saudi women are very sedentary, she reported, and tend to view pregnancy as an illness that requires rest. They exercise very little and even though they are not allowed to drive, they try not to walk anywhere either. However, when they get together, especially with other women, they often squat, perhaps sharing “tea and dates” as a social pastime.

This is interesting, because to is the direct opposite of many of the theorists who suggest that squatting during pregnancy is a cause of poor foetal positioning and resultant OP labours. They recommend that women avoid ever having their knees above their hips when sitting, and recommend either using birth balls or ergonomic chairs that position the knees below the pelvis. Squatting during labour and birth are also not recommended.

Women in many parts of the word squat to rest and to use the toilet. They give birth like this as well. We know from work done on the pelvic floor muscles, that squatting enables the pelvic floor muscles to relax completely (which is why squatting for defecation is so effective, particularly for constipation) so it makes sense that it would also work well for birth.

Once again, we need to be wary of dogmas and dictums when it comes to advising pregnant women. It makes sense to encourage pregnant women to take some exercise such as walking or swimming because of its general health benefits. Spending a lot of time sitting on chairs will often cause pubic symphysis pain which is a clear message to get up and move. Yes, we are more sedentary these days and we know this has health implications. No-one would suggest that Saudi women should avoid squatting in case it made their baby turn into a posterior position, so perhaps we can learn something from this as well. I will be talking about all this some more with this midwife - it is so interesting to have the opportunity to learn from other cultures.....

Posted by andrea at 03:53 AM | Comments (0)

Another visit to the Irish Republic

Today I have travelled from snow and freezing winds in London to the slightly warmer Republic of Ireland. This will be my fourth visit to Drogheda and I will again be presenting an Active Birth program for the midwives in the surrounding areas.

I am keen to hear of their progress with implementing the ideas we discussed last time. I remember that in the last group we hade some midwives from Northern Ireland who worked in a wonderful midwifery led unit in Craigarvon and that their approach had been quite a revelation to many in the group. Many of the group were keen to develop their midwifery practises, especially as a real alternative to the “active management of labour” protocol that is so prevalent in Ireland and I hope to hear that they have been making good progress.

We shall see....

Posted by andrea at 03:43 AM | Comments (0)

Childbirth videos for workshops

Each time I present an Active Birth workshop, I like to show a number of videos, to illustrate the points I am making and to push the boundaries of the participants’s experience. I always show “Giving Birth - Challenges and Choices” because it such a powerful film that would be very suitable for early pregnancy programs, when parents are beginning to consider their options and choices regarding birthplace and caregivers. It is very thought provoking, challenging ideas of safety of epidurals, hospitals and medications whilst showing what is possible with normal birth.

I always show the Brazilian “Birth in the Squatting Position” as it is the best film for demonstrating the mechanics of upright birth. It is a classic, made 25 years ago, and sadly no longer available to buy. I treasure my copy, which I must have seen 600 - 700 times by now!

For variety, I add videos on water births, home births and midwife led births, and these I vary according to the interests and needs of the specific group that I am working with. During this trip I have been using the Russian water birth video “Birth Into Being” to demonstrate how easy and uncomplicated water birth can be. So many rules and regulations are developing around water birth that we are losing sight of how simple underwater birth is for the mother, baby and the midwife. When you see these babies swimming out into the warm salt water of the Black Sea, you have to question the rigidity of some hospital protocols! I often show the “Water Babies” video from Belgium as an alternative because it shows breech babies and twins arriving under water. Shivers of alarm usually spread around the group when they see the breech coming through, but then it is clearly not a problem for these parents or their caregivers(in this case, an obstetrician).

I will be adding the new video “Inner Strength” to my workshop collection next time I am in the UK. This new film is wonderful, showing us how strong women can be when labouring naturally, in the peace and quiet of a birth centre, with caring support from a midwife and partner. I think it is the best new video in a long time.

Posted by andrea at 12:26 AM | Comments (0)

Toxoplasmosis

You know you are in the country when you come across leaflets in the Maternity Unit on “Toxoplasmosis and Lambing”. This weekend I am in Dumfries, south of Glasgow and not far from Penrith and Carlisle. This is a rural area that was badly affected by the outbreak of foot and mouth disease that devastated British agriculture two years ago. Hexham, the town I have just left, was the place where it all started, and the Conference Centre that we used for the workshop was adjacent to the cattle sale yards when the outbreak first occurred.

I knew about the risk to the baby of acquiring Toxoplasmosis from exposure to cat’s faeces during pregnancy, but I hadn’t realised that lambing ewes and newborn lambs also prosed risks for pregnant women. This leaflet explains how pregnant farmers can avoid infection, including scrupulous showering and washing of clothes after handling newborn lambs or a lambing ewes. It advises that handling clothing worn by others should also not be handled and if a proper clean up is not possible at night, then separate bedrooms should be used (!).

It is good to be back in Dumfries again. Their new unit has now opened and they are striving to make it completely midwifery orientated. There is no anaesthetic service, so that is a good start. Many of the midwives work out in the community as part of midwifery teams, but most women give birth in the hospital rather than at home. The midwives are also keen to encourage more home births so this is a topic we will explore further tomorrow.

Posted by andrea at 03:27 AM | Comments (1)

Petty rules thwart practical midwifery

It is amazing how bureaucracy and petty mindedness can get in the way of common sense and block practical midwifery skills. Yesterday I heard a number of stories from midwives of how their efforts to be “with women” were being thwarted by silly rules.

One midwife told the story of being a second midwife at a home birth, and her job was to lug jugs of water upstairs for hours in an effort maintain the water pool temperature at exactly 37.4 Degrees C! Another said that at her hospital it is forbidden to carry hot water anywhere, and providing a bucket of hot water to heat up wet towels, would certainly not be allowed. Many said that at their hospital it was absolutely forbidden for anyone to heat up a gel pack for a woman in the microwave in the kitchen (which is strictly off limits to patients and support people anyway) because the microwave might be used by staff to heat up their lunch!

Women are routinely restricted to only two support people in labour, and they must not leave the labour room once arrived. If one needs to go home, they are not allowed to be replaced by a substitute! It appears that the main bother is the need to buzz them into the unit - security is like Fort Knox in British labour wards - you practically need a password to gain admittance. All of this because every few years someone snatches a baby from a post natal ward somewhere in Britain and “precautions must be taken”. I pointed out that baby snatching was most unlikely to happen in the labour ward because the baby was still safely inside the woman, but “just in case” these places are run like prisons. The outdated term “confinement” is actually more current now that it ever was in the past, it seems! Anyway, as soon as the baby is born it will be fitted out with a leg band that will set off an alarm if the baby is moved away from the unit (the same system they use for preventing shop stealing!).

It is interesting that when these practices are questioned, it is usually stated that “this is policy”. Midwives can be so easily cowed by this bold statement. I would suggest they ask to see the written policy - if none is forthcoming, then there is no policy, and these directives can be safely ignored. Who do midwives let themselves be bossed and bullied by these ill thought out petty rules and regulations? No wonder labouring women feel intimidated when they come into hospital to give birth - often the midwives are already cowering and simpering to avoid being caught up in political power plays within the unit.

The only real solution is to remove birth from hospitals altogether. No-one is going to challenge the right of a woman to use water and heat for easing pain when she is in her own home. Her partner’s ability to manage a jug of boiling water without burning himself will never be questioned. Midwives will not have to worry about some senior staff member waiting to pounce if some puerile rule is infringed. Home birth is the only sensible alternative to hospital madness.....

Posted by andrea at 04:21 PM | Comments (0)

Educators and midwives in collaboration

The group here in Leeds has a high proportion of midwives who are involved in the parentcraft education programs in the area. There are several National Childbirth Trust teachers as well, so I have slanted the workshop program to focus a little more on ideas for parent education courses than I would normally.

It makes a huge difference to midwives in labour wards when women arrive in labour with a few ideas about alternatives to drugs for easing pain. It is also very heartening for childbirth educators when the receive feedback from the parents that their ideas were supported and encouraged in the labour ward. Good communication and co-operation between the parent education leaders and the labour staff is vital if we are to provide better, more woman centred maternity care.

It is also important for educators who work in the community to be aware of the pressures and working conditions being experienced by midwives in the hospitals. The NCT educators in this group have been working with some of the midwives to offer “Active Birth” classes for parents, and it is clear that they have enjoyed this collaboration. I wish more educators could have this kind of contact with midwives as I think it would be of great benefit to both groups. We will explore these issues further tomorrow.

Posted by andrea at 04:43 AM | Comments (0)

A warm welcome in snowy England

I have arrived in England to find it is very cold and snowy - a major contrast to the last few days in Bangkok.

I had a lovely day catching up with Caroline Flint yesterday and hearing about her midwifery practice - it is probably the only place where midwives can work with complete autonomy. There are nine midwives in the group, but the demand for their services is so high that they are looking for more - if any midwife wants the chance to really practice her craft, through facilitating births at home, in the Birth Centre or in hospitals, they can contact her through her web site: www.birthcentre.com . They offer an incomparable service for women in the greater London area and valuable experience for midwives.

This afternoon I begin the first of my journeys around the UK. I will be off to Leeds for the first Active Birth workshop of this tour. I am looking forward to meeting the midwives at St James Hospital as this is the major teaching hospital in this region. I have had some midwives from this unit in programs over the years, but this is the first time I have presented a workshop exclusively for their staff.

I am wondering how deep the snow will be in the north - should be a pretty sight from the train!

Posted by andrea at 10:01 PM | Comments (1)