Articles by Month: August 2005

Men at birth

There is an article about the impact on fathers of being at the birth in the main Sydney newspaper today. Written by a psychologist who sees men in therapy sessions, he describes how some are traumatised by seeing their partner give birth, especially when episiotomies are cut, or forceps are used.

For some men, seeing their partner giving birth deeply affects their view of her as a sexual being, especially if they had a full view of the baby emerging, perhaps through a vagina that had been cut open. The scarring that is left after an episiotomy may be a turn off too - a reminder of the genital mutilation (my words) that has been witnessed. Such intimate views can expose the mystery of a woman’s body goes, and perhaps remove the sexual allure that had attracted her partner.

I can vividly remember a birth in a hospital, now some years ago, where the father witnessed the obstetrician cutting a large episiotomy as the baby was born. His wife’s legs were then put into stirrups and the whole area, normally tucked away in a very private place, was laid bare, with a gaping wound seeping blood. His face showed his shock, and I remember wondering how he would later view his wife after seeing her in this undignified and very unromantic position.

I posted this link onto the ozmid list this morning to see what others thought of this issue. Several replies stated they thought that the basic problem was that the births being described took place in hospitals, a place where intimacy, romance and privacy are impossible to obtain. Men often feel uncomfortable in hospital settings at any time, and may feel much worse when placed in a position of impotence and then confronted by these kinds of brutal images. When birth takes place at home or other place where couples can work together to bring forth the baby, the lasting impression for the man might be more positive. In these situations it is unlikely that he will be a bystander and observer and much more likely that he will be closely involved in the birth, providing physical support and comfort. In a situation like this, it is also unlikely that the man will be left on his own, staring at his partner’s body being manhandled.

Michel Odent has suggested that women might want to maintain their sexual allure by keeping their men at a respectful distance during birth. This was always the case in the past, when birth was very much “women’s work”. I don’t think we should make any kind of blanket rule about men at birth because every couple and birth will be different. However, I do think we need to recognise that men can be severely traumatised by some aspects of birth management and they may need help in dealing with this. Left unrecognised and unacknowledged, his fears and concerns may hold sway over the choices his partner makes regarding her next birth. Many men have encouraged elective caesareans so they can avoid traumatic emotional and psychological reactions. This need may be unconscious or even openly expressed - either way it must be recognised and understood.

Posted by andrea at 05:26 PM

Giving birth in South Australia

The report from South Australia on Pregnancy Outcomes for the year 2003arrived on my desk today.

The statistics reveal that for the third year in a row there was a fall in women having normal spontaneous births, and this rate now sits at 58%. The Caesarean rate has climbed to 30% (13.3% of these were elective procedures) and the VBAC rate was a paltry 20%. Almost all pregnant women (96%) had at least one ultrasound in pregnancy, and 50% had their labours either induced or augmented. The percentage of induction done for other than medical reasons has rapidly increased from 35% in 1998 to 44% in 2003. The episiotomy rate was 13.3%.

The table showing rates for analgesia was interesting. A third of women received no analgesia at all during labour, which is a remarkable figure. Narcotics were used by 26% and epidurals for labour pain by 31.9%. Nitrous oxide was used by 35.8% (some women will have used more than one type of analgesia).

Fetal monitoring also showed some interesting results. External fetal monitoring was used by 52.2% of women, but 40% had no electronic monitoring at all during labour (presumably they would have been monitored by Doppler or Pinards instead).

Several birthing units (often called midwifery led units in the UK) have been established in SA. For the women who planned to give birth in these units, only 51.1% achieved this goal, with 48.9% being transferred to the labour wards before the birth. This would include women who developed problems in the pregnancy, and would not be the numbers transferred during labour, however this still remains unacceptably high. Of those who were transferred, 26.9% eventually had a caesarean birth and 15.9% had instrumentals deliveries.

The number of homebirths has risen in the past two years, having dipped since 1981 and there were 60 planned homebirths (0.3% of all births) during 2003.

This report doesn’t give the detail that is available in the similar NSW report and it is difficult to get the figures for individual hospitals, except for the five metropolitan maternity units in Adelaide. Of these, it is clear that The Women’s and Children’s Hospital, which now uses a team midwifery model for all its clients, has generally better outcomes than the other hospitals. Since this report was prepared more women will have had the opportunity to experience midwifery care, and the figures for the coming years will reveal any improvements that theoretically should flow from this development.

Posted by andrea at 04:10 PM

Could hypnotherapy work for labour?

There was a very interesting segment last week on Catalyst, the weekly science program on the Australian Broadcasting Corporation (ABC). It concerned hypnosis, and the way it can be used to cure phobias, change personal behaviours and reduce the experience of pain. At one point, they showed a woman who had an acute allergy to anaesthetics, undergoing abdominal surgery with just hypnosis to block the pain.

There was a very brief suggestion that it could be used for labour and birth (really nothing more than an image of woman in labour) but it got me thinking. For years I have been very sceptical of hypnobirthing, given that there is no hard evidence that it works, and that it has the potential to create false expectations that may not be fulfilled.

The TV program made it clear that there are discernable differences in brain function when a person is hypnotised. Using brain scanning techniques, researchers showed that the bran received and registered sensations in a different way when the subject was under hypnosis, and that in some people this could be enough to block acute sensations such as pain.

It was also explained that hypnosis does not work for everyone. Ten percent of people are highly susceptible to hypnosis, an other ten percent will find they cannot be hypnotised at all and the rest will be somewhere in between. If hypnosis is to be used for any treatment, it is important to identify in advance those for whom the technique won’t work, before the treatment is begun. There will also be a number of people who may find it is not as effective as hoped.

The other important point that I noted was that the subjects had been fully hypnotised before the post-hypnotic suggestions were made. The hypnosis was administered by fully qualified medical or forensic hypnotists, who were trained professionals and very experienced.

The reason I am still sceptical about hypnobirthing is that as I understand it, the subjects (pregnant women) are not put under full hypnosis but undergo training where suggestions are made and affirmations are learned and absorbed. This may be enough for the very suggestible (the ten percent who are very easily hypnotised) but may work less well for the majority. I also question the qualifications of the “therapist” in these sessions - I am not aware of any locally who are medically qualified or professionally trained (in the sense of having an accredited, professional qualification).

Perhaps hypnobirthing will work for enough people to justify its hype and promotion - there seem to be enough “testimonials” to keep business turning over. If it works, then some women will find labour is manageable without medications. If it doesn’t then there is the risk that women will blame themselves (“ I didn’t believe in it enough”, or “I didn’t practice enough”) rather than the technique or its avid promoters. A result like this could very easily undermine a woman’s self confidence, right when she needs it most.

Posted by andrea at 03:05 PM

Feedback from Salford

I received this feedback regarding my Diary entry of June 30, and as I am unable to offer the comments facility for my Diary at present, I am reprinting it here.

In June through the value of partnership working a number of Midwives from Salford along with a larger number of midwives from Greater Manchester conurbation we fortunate to be able to be funded to experience Andreas two day workshop on active birth - This partnership developed via the local university ensured a mixed group of practitioners both rom Hospital , Community and Birth centre settings.

On the 30.6.05 Andrea posted her feedback on the two days in her diary section of the website - and as she suggested it has certainly generated some food for thought.

The article which is written in a very negative tone is not helpful, at a time when midwives across the city are trying to embrace the philosophies of normal birth . Suggesting that the group were challenged and made excuses serves little purpose other than the alienation of midwives striving to enhance their practice .

Although some of the group - less than half do practice in Salford the larger part of the group were based in other parts of the GM conurbation and therefore to title of the piece 'Midwifery in Salford' is not truly representatative [sic] of the group in attendance

The team participated well through out the two days and certainly don't apologise for the seeking questions they posed to the facilitator. They were quietly reassured that on the whole they learnt nothing new from the two day session but were pleased that much of Andrea's teaching reflected their own current practices. They have left the forum with a couple of redesign ideas [sic] for the birth environment which came from within the group discussion and confirmed their underlying knowledge that they see the future of their birth centre as strong and supportive to our local client group

The midwives from Salford over recent years have worked hard and been committed to developing a birth centre out of the old GP practice which had been custom in Salford for a number of years . They are motivated to provide the model of service most acceptable to their user group and have spent the last 12 months in heavy consultation with their users to ensure the service model was designed to for the user and not the midwife.

It is distressing to read such negative expressions from Andrea who is unaware of the numerous positive and supportive evaluations the Salford Midwives receive from their users who will also be devastated to see a service they value undermined by such unjust comments regarding insensitive midwives who undetermined and patronise their client group.

K Murphy, Consultant Midwife, The Birth Centre, Hope Hospital, Salford Royal Hospitals NHS Trust.

It is good to have feedback. As K Murphy points out, this group was from a number of different hospitals in the wider area, and my title for the Diary entry “Midwifery in Salford” was intended to convey the place where I was facilitating the program, rather than the midwifery in the Salford maternity unit itself. It is heartening that many of the midwives from her own unit felt the workshop validated their own practice and I am glad they were able to take away some more good ideas. This was a very full (over subscribed) workshop, and many who came were from other units, and some of them were very definitely challenged......

Posted by andrea at 10:45 AM

A workhop in Tehran?

Last week I received an invitation to visit Iran, to present a workshop on childbirth education for the Ministry of Health. This came about through email conversations I have been engaged in with a midwife/educator who is researching parent education for a PhD. Her specific interest is on “training women in ways of managing labour pain” and we have had a lively discussion about the issue of “training” women for anything to do with managing labour. I have also flagged the broader issue of the influence that the care giver exercises over birth outcome and pointed out that there is no evidence that any “training method”, no matter how well rehearsed by women prenatally, will be used in labour unless there is good support from the midwives and doctors involved in the birth itself. Several studies have shown that women usually abandon their chosen method of managing labour as soon as they reach the hospital - it is the attitude of the first midwife they meet in the hospital that makes the difference.

I have tried to explain this to my Iranian friend, to alert her to other approaches rather than the breathing techniques she has been pursuing. “The breathing” is still encouraged by many despite any evidence of its effectiveness and its potential to cause chemical imbalances in the woman’s blood stream that may be detrimental to her and her baby’s health.

Funding is being made available for a training workshop for parent educators in Iran, hence the invitation to me to speak, but I have suggested that they wait until they see what I have written in my books (I have sent them a set of my publications) before they decide if this is what they want. I have explained that I know nothing about the Lamaze or Bradley methods, that these are American ideas rarely used outside the US and that women in the rest of the worked have developed other ways of handling pain, based on their own physiological needs rather than a learned response.

It will be interesting to see whether they come back to me to discuss a workshop further. I will quite understand if they decide to invite someone else. Whether I decide to travel to Tehran is also something that I will have to consider.....

Posted by andrea at 05:53 PM

The hottest titles at the ICM

The most popular items at the ICM were charts, videos and some of the new book titles.

There is no doubt that our series of “Giving Birth Charts” are unique - there are no other charts showing women upright birthing their babies, anywhere in the world. We had lots of interest in these beautiful charts.

The ACE Graphics Technical Series also proved very popular, especially the “Cascade of Intervention” char and many were bought with the express purpose of displaying them in labour wards, in front of doctor’s noses. This chart is also reproduced in “Preparing for Birth: Mothers” and the second edition of “The Midwife Companion - the art of support during birth”. It is important to have a consistent message across all the material that is used by midwives, and women.

In the Technical Series, we also take care to depict women in upright positions (see the Pelvic Floor Chart as an example). Almost all the other charts available from other suppliers around the world have women in recumbent, un-physiologic positions, signalling that women should be passive and compliant during birth, for the benefit of the caregivers. The “Progress in Labour” chart does not have any time indications for labour, also an important consideration.

We are working to produce these useful charts in a desk size format so use with individuals, rather than groups. We will let you know when they are available.

Amongst the videos, there was a lot of interest in Psalm and Zoya (available only on DVD) and also "Working under restraint: Monologues from the Delivery Room "(DVD only). The birth videos “Giving Birth, Being Born”, >“Inner Strength”, “Mila’s Journey” and “Birth Day” attracted a lot of interest. The first two have no spoken words in English, which is useful for those who just want images. “The Art of Birth” was also popular, especially for educators looking for lovely waterbirths on film. The inspirational short film “In a simple way a child is born” is now out of DVD, and the few copies that arrived in time for the Congress were snapped up instantly.

Amongst the books, some of the new titles sold like the proverbial hot cakes. The most popular were:

25 Ways to Awaken your Birth Power

Breech Birth - what are my options

Gentle Birth Method

To Mother with Love

Labour of Love

Ina May’s Guide to Childbirth

Normal Childbirth Evidence and Debate

Water Labour Water Birth

The Water Birth Book

There was considerable interest in the launch of a new title at the ICM - “Midwives’ Tales”, but I will write more about this in a later entry.

Posted by andrea at 11:24 AM

I thought you might like to see some photos taken at the International Confederation of Midwives Congress in Brisbane last week.

Here is the stand - it was one of the busiest and we always seemed to have people four or five deep waiting to have a look at or products. THis was a rare quiet moment!

This is our trade stand, with myself and Katheryn Jettar (my very able assistant) still upright after a very hectic time with customers.

The stilt walker was a great hit - he was giving away chocolates and having a ball!

Posted by andrea at 10:45 AM