Articles by Month: September 2006

Wales moving ahead with midwifery

The group in Canterbury (the next day) were also very interested in the kits. They could see immediately how elements of the kit could be used in various specialised classes, such as VBAC or refresher groups. They are working to re-vamp all the programs they offer and are especially keen to attract some women who do not normally come to parentcraft sessions.

Friday, I travelled to Wales to facilitate a one-day workshop for a group of midwives who had already purchased The Essential Educator kit and others who were planning to buy soon.

I walked them through a number of activities so they would feel confident in presenting these exercises themselves and we also explored some of the practical tips and suggestions for adding zing to the classes as a whole.

In the evening I had dinner with Polly Ferguson and Sandy Kirkman (both speakers on our next Future Birth tour). Polly is the Midwifery Advisor to the Welsh Assembly and she is very excited about these kits, having already instructed all the heads of midwifery in Wales to consider using them in their hospitals. After more than a year of working to standardise the classes across Wales (and not achieving any concrete outcomes as yet), Polly has suggested that these kits will do the task for them simply and easily.

I will be back in Wales in February to facilitate another workshop for 20 midwives who will be using the kits by then. Wales has a very proactive approach to midwifery services and has some very dynamic leaders. They have tackled the problem of caesarean rates and introduced the All Wales Pathway for Normal Birth, which has helped to keep birth normal and avoid interventions.

I am glad that I spent my last day on this trip in Wales. Britain’s NHS is in such disarray at this time, with huge budget overruns and general gloom and doom that spending time with a bunch of people who are upbeat and going forward has been a welcome change.

I am hoping that my next visit will be in better circumstances and that some measures will be in place to lift the spirit of midwives across this country. Off home tonight and back in Sydney on Monday.

Posted by andrea at 03:55 AM

What images should pregnant women view?

This week has been a hectic round of presentations in the UK to showcase the Essential Educator teaching packages for childbirth and parenting educators.

On Tuesday I was in Dublin as I noted in my last Diary entry. The next day I hosted a group in London who were very enthusiastic. One interesting topic of discussion was the DVD we have included in the labour and Birth kit called “The First Breath”. This is a wonderful collection of images of dozens of women, in all stages of pregnancy, labour, birth and immediately afterwards, with their babies. The gentle music complements the pictures and as there is no spoken commentary, this offers the opportunity for personal comment or interpretation of the various images.

A couple of the midwives were concerned that these images would not be acceptable to the women who attend their programs. I found this interesting for a number of reasons: first that they would make assumptions about what the women would or would not want to see; second that they would contemplate censoring the images to fit their own personal expectations; and the idea that women would not appreciate these magnificent picture of women giving birth in powerful, masterly ways with midwifery help.

Where do women get their ideas about birth anyway? Often from TV, films and the print media. The message of many of these shows is often quite disturbing with women in agony, lots of technology to the rescue and doctors in control of the situations. Why not show women something that is gentle, normal, empowering and completely woman centred? Perhaps it would help to change perceptions of what birth is all about - at least we should give women the option. If they are then disturbed or upset by what they see, clearly some sensitive discussion will be necessary to help resolve their feelings.

I love this DVD - you can buy it separately form the kit. I can see many ways of using it in classes - short snippets to illustrate various aspects of physiology or women’s reactions; as a way of setting the scene at the start of a group; during refreshment breaks to continue the story of natural birth. Why not check it out yourself?

Posted by andrea at 03:51 AM

Are Irish women wimps?

I made a day trip to Dublin today, to showcase The Essential Educator to a group of midwives and educators from across the country. They were very keen on this teaching package and no doubt many will want to use it in their work.

After my presentation, we had a general discussion about childbirth education and some fascinating points were raised. One educator (from Holles St - the National Maternity Hospital) pointed out that at her hospital (the “home” of The Active Management of Labour) the epidural rate was now 70% and that this had not produce poor outcomes. The caesarean section rate was 15% and they also had a low rate of forceps/vacuum (not specified). She felt that if there were no poor outcomes then there was no way she could encourage women to consider alternatives to epidurals, especially if women demanded them and the hospital was to “keep up” with the services offered in other Dublin maternity hospitals.

What is going on here? It was apparent that Irish women are being denied information about the adverse effects of epidural on their babies, which is a primary motivator for women in other countries to manage their labours without drugs. When I demonstrated the role play from The Essential Educator that enables women to understand exactly what is involved in an epidural, I was told that this might “frighten” women. Eductors felt they should censor the information they gave in case women might be upset by some of the possible side effects or potential outcomes.

Irish women are, of course, used to being given information that someone else has deemed “allowable”. Feminism has not really surfaced in this country, where for generations, women’s lives have been ruled first by the Church and now by the doctors. All kinds of limitations are imposed on women in Ireland that would be completely unacceptable in other western countries: the freedom to speak out (lots of whispering behind hands goes on); the freedom to voice opposition or even question policies of all kinds (lots of undercurrents of threats to jobs and plenty of backstabbing); restrictions on who can be involved at births (no extra support people, be they friends, family or a doula); domination of midwifery by obstetricians (ridiculous policies and protocols); restricted services (closing small maternity units, denying the right of women to have home births); and various political manoeuvres that protect vested interests at the expense of women’s rights.

The one shining example of modern maternity care - the Birth Centre in Drogheda, which was established as a pilot project, is apparently under threat, from internal bullying of staff and restrictions that are so onerous that its availability is restricted to very few women. Other small maternity units are being closed and there seems little political will to fulfill the promise of rolling out maternity services modelled on this pilot projects, across the country.

Of course, none of this will be discussed in the open, although I will gets some personal emails. The maternity care system in Ireland is being used to keep women in their place - flat on their backs, unable to help themselves and under the direct control of the doctors. The epidural is a modern form of subjugation that robs women of their dignity as it ties them up with tubes, monitors and catheters. Anaesthetised, unable to even manage their own bodily functions, women have their babies pulled from their bodies or are bullied to push them out according to instructions from their “caregivers”. It is a modern, ritualised form of torture.

When looking for a counter argument to present against the epidural for labour, one has only to look at the baby, and the psychological impact this form of treatment has on the mother. One of the most insidious effects of anaesthetising women and babies during labour is the disruption that occurs to the nurturing hormones (oxytocin and endorphins) which are vital for forging a close bond between mother and baby at birth. Artificial oxytocin does not produce the caring and nurturing behaviours associated with naturally produced hormones. The baby, full of drugs, will not breastfeed well, and is at risk of being fed formula as a result - not the best nutrition for babies.

What is happening in Ireland is an example of what can occur when medical dominance of women is allowed to flourish unchecked. Women don’t find their own power and strength through giving birth unaided; babies are not bonded to their mothers at birth through the natural flow of hormones; breastfeeding rates are low, leaving babies to survive on less than ideal formula foods, and women’s voices are stifled through systematic subjugation by powerful, vested interests. Fear is rampant, women are afraid to speak out and leaders who are willing to take up the challenges are ostracised or even punished. For this to happen in poor oppressed nations struggling to provide the basics for human survival might be almost understandable, but to see it in a wealthy first world country which claims to be affluent and progressive is unacceptable.

One measure of how well a country is doing is to examine their health care system. Until options are in place that freely offer women choices for childbirth, births that don’t compromise the baby’s health through the use of obstetric medications, professional practice based on evidence, home births, water births and other non-invasive comfort measures for labour - in other words mother and baby friendly services - no country or hospital can claim to be civilised.

Posted by andrea at 06:20 PM

Cutting the umbilical cord

One lively topic we discussed at the Stoke Mandeville Active Birth workshop today was when to cut the umbilical cord.

The typical approach in hospitals is to cut the cord as soon as the baby is born, before the placenta arrives. If the mother has been given Syntometrine or Syntocinon ( oxytocic drugs) to speed separation of the placenta the midwife will probably not wait for the cord to stop pulsing first, clamping and cutting the cord as soon as possible after the birth. Left alone, nature has provided a safety mechanism for the baby immediately after birth, when it may take a few minutes for breathing to be established. The cord continues to pulse, gradually phasing out as the cold air causes the cord to constrict and reduce the blood flow. The whole process takes a few minutes, although with a birth in water, the cord may continue to pulse for longer.

Once the cord stops feeding oxygen through to the baby, it is unimportant when it is cut: many midwives will leave it alone until after the placenta arrives, then clamp and cut. Others cut the cord earlier, leaving the placental end to drain a little, which reduces the pressure in the placenta and makes it easier to separate from the uterine wall.

The benefits of leaving the cord uncut until its work is done are now clear. The baby will get extra blood which is now known to be protective and important for preventing anaemia in babies. (Delaying cord clamping reduces anemia Pediatrics 2006; 117: e779-86). If the baby doesn’t breathe immediately, it still has a lifeline supplying oxygen. Earlier fears that delayed clamping will leave the baby with extra red blood cells that may precipitate jaundice are unfounded - some jaundice in the newborn is natural and excessive levels are more likely to be the result of the baby’s kidneys struggling to metabolise drugs such as artificial oxytocin and opiate drugs that were passed on from the mother during labour.

When the cord is wrapped tightly around the baby’s neck at birth, delaying the birth of the shoulders, the cord should also be left uncut. In this situation, a sudden surge of oxytocin (perhaps triggered by the baby’s potential distress signal) causes a big contraction and the baby will tumble out all at once, enabling the cord to unwrap itself from above. It is frightening for the midwife to wait when the baby appears to need help, but once again nature will take over and provide a rescue. Once the pressure is off the cord, the blood will again flow, giving oxygen to the shocked baby (who might also need a little oxygen via bag and mask). The cord should not be cut, and help should come to the baby, rather than taking t he baby away to be assisted.

There are always important biological reasons for the mechanisms involved in natural labour and birth an we should leave well enough alone. Cutting the cord provides a means to speed up the third stage of labour and gives the attendants something to do. Why not wait - what’s the hurry?

Posted by andrea at 06:13 PM

Breech babies

I have started to include a reprint of my article on turning breech babies using Moxa sticks in my workshop participant packs. The issue of breech birth always comes up when we are exploring ways of reducing the caesarean section rate and given the current protocol in western hospitals to manage all breech births with caesarean operations, it seem sensible to look for ways of turning the baby to a head down position during the pregnancy. Once the baby is in a vertex position the problem of the baby being breech disappears, along with the need for a scheduled caesarean.

The use of heat to encourage the baby to turn is simple, costs almost nothing, can be done by the mother in her own home and is safe. Moxa sticks can be bought very cheaply at any shop selling herbal remedies, especially Chinese remedies, or if there are none of these outlets available, then on-line.

The article can be downloaded by expectant parents, who can follow the diagrams, photos and instructions for themselves.

For midwives, I always recommend the book “Breech Birth, Woman Wise” by Maggie Banks. This straightforward, “how-to” manual sets out the basic principles of managing a breech birth safely in any settling and the research, photos and case histories offer practical tips and reassuring messages. Given that breech babies are still being born vaginally, often having been mis-diagnosed during pregnancy, midwives need to be prepared to manage an unexpected breech birth. This book is therefore essential reading for anyone working with labouring women.

Posted by andrea at 11:53 PM

Visiting Scotland

I’ve spent my last few days in Inverness in the north of Scotland. I won’t be posting any blogs from here though, because the standard of internet service in British hotels has once again let me down and getting any access to email or the internet is next to impossible (and expensive). I’ll put these messages up as a block as soon as I can find a workable connection.

The group in Inverness was a mix of local midwives and a large group of students. Raigmore Hospital in Inverness has about 2800 - 3000 births each year and a caesarean section rate of around 30% - typical of many hospitals in the UK. We ranged across the usual spread of topics in this program, and I was particularly asked to address how to avoid intervention when labour was progressing slowly (midwives are often under pressure to conform to pre-determined birth plans typified by partograms), building midwives’ confidence in facilitating normal birth and the management of third stage.

The students in the group also voiced their concerns that although they are being taught from a woman-centred care perspective, they are often frustrated by the requirement to adhere to caregiver and hospital system based protocols (often not evidence based) when they undertake their practical placements.

Once again I heard of silly health and safety, and infection control measures that are stifling any kind of lateral thinking or common sense approaches to providing comfort for labouring women. The lack of floor mats (condemned as hotbeds of infection in this area!), restrictions on the use of hot packs for easing labour pain (deemed as unsafe) and the requirement to have women give birth on beds because anywhere else may place a strain n the midwives’ backs, were all examples quoted by the midwives here.

As ever, I provided examples from other units where these issues have been successfully addressed through lateral thinking and co-operative effort, for everyone’s benefit. I find it frustrating that midwives in the UK don’t bother to look beyond their own hospitals for examples of best practice and innovation that are not only more professionally appropriate, but more importantly, benefit the women they are supposed to be serving. There are many good stories to be told in the UK, but a general lack of curiosity and an almost rigid need to maintain the status quo is affecting forward thinking and innovation in many places. Midwifery is going backwards at the moment in the UK, and is at great risk of being subsumed by medicine into a maternity service staffed by obstetric nurses.

I am hoping for more positive news from my next group in Aylesbury (England). In the meantime, I am hoping that I have been able to give the midwives in this area a glimpse of other ways of doing things and perhaps a vision of how they can achieve more personal satisfaction with their work.

Posted by andrea at 11:45 PM

Training to administer Epidurals

A couple of weeks ago, on ABC television’s program “The Inventors”, a new simulator for teaching practitioners how to administer epidural anaesthetics was showcased.

The inventor of this teaching tool explained that until now, doctors learning the techniques of epidural insertion had to practice using oranges or latex rubber blocks as crude substitutes for simulating the important feedback reactions of the human body as the needle is inserted into the epidural space surrounding the spinal cord. This learning method was very unsatisfactory, and usually after just a few practice runs on an orange, the doctor would resort to using human guinea pigs (women in labour?) to hone their skills. This is clearly an unacceptable situation, as inserting an epidural successfully takes a high degree of skill and accuracy if unwanted side effects are to be avoided.

All this was explained in graphic detail by the inventor of this training model. Using a combination of real time visual feedback monitoring, an appropriately constructed humanoid dummy and even audible signals (“OUCH!” if the needle was inserted incorrectly) the learner can now master the necessary techniques without ever going near a real person.

This was a fascinating segment of very popular television show. The inventor of this device was very frank and open about the side effects and possible consequences of a poorly performed epidural (he mentioned spinal headaches, and even paraplegia) while explaining the virtues of gaining the proper skills using his clever simulator.

It also highlighted that one of the major risks with an epidural is the level of skill of the anaesthetist and that this is not a procedure to be undertaken lightly. I sincerely hope that this new invention will quickly gain universal acceptance and that women in labour will no longer be used as “real time” learning tools.

Posted by andrea at 10:39 PM

Is labour pain different to other pain?

I am back on deck this month, after a few anxious weeks caring for my elderly mother, who out of the blue, was discovered to have a major heart problem that needed surgery. She is now recovering well and I can turn my thoughts back to my work.

One thing I will say, is that having spent the best part of a month in close contact with our health care system, I have now greater insights into its strengths and weaknesses. I also know that I have seen enough of Emergency rooms to last me a life time!

I have always said that you can learn from every situation. For me, in this case, it was how I was reacting to someone else’s acute pain, especially when it concerned someone very close to me. The anxiety and helplessness I felt, and the overwhelming need to find a cure for the pain was stressful in the extreme. At one point, my daughter said to me that I should use some of the skills I have developed to deal with the pain being felt by the women whom I have been supporting during labour. At that moment, I realised that this was quite a different situation - a woman in labour is having normal, healthy pain that is productive and useful and therefore not something that is frightening or needs fixing. Watching someone experience severe heart pain is quite a different story, as it signals pathology and an urgent need for a cure. I am not stressed at all when I work with a women during labour - in fact I feel very calm and even buoyed by what I am observing. The experience I have gained from being with many women during birth was no preparation for being with someone acutely ill with a life threatening condition, who also needed my support and assistance.

Looking back, I can see how many women will approach labour pain - basing their fears on perhaps their own direct experience of pathological pain, or of witnessing and trying to alleviate the pain and suffering of some close to them. No wonder they are scared and uncertain about how they will handle the inevitable pain of labour and it is no surprise that many will resort to pain-killing drugs at the first opportunity.

It once again highlights the enormous gulf between the medical model for birth (based on an illness model) and the midwifery model of care (based on normal bodily functions). There is still an enormous amount of work to be done in educating women to the difference between these two approaches to birth......

Posted by andrea at 10:30 PM