the midwife`s journal < contents

6. the challenge
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The woman challenged me to enable her to plan a homebirth. She came to me knowing well what she was asking. She knew that no hospital in our area would permit her access to a birth centre or midwife care program.

I was conscious of my own doubts. I had no way of knowing if this particular woman could give birth normally - if I needed that information prior to accepting someone into my care I would be out of business. I offered what seemed to me another option - being under my care in hospital, working with an obstetrician who had experience with vaginal birth after caesarean (VBAC). But the woman was determined to avoid hospital if she possibly could. The memory of her previous experience which involved a long labour and caesar for obstruction, only two years ago, was strong in her mind.

Some of my peers, independent midwives, have had more experience with VBAC than I. Some seem to say that VBAC at home is a reasonable option. Others are adamant that the woman should be in the hospital. I went back to the Definition of the midwife and our Code of Practice. I had to work from first principles. The Definition says " [Midwife] care includes detection of abnormal conditions , the procurement of medical assistance " A previous caesarean birth is an "at risk" factor- an obstetric complication- according to the Consulative Council on Obstetric and Paediatric Mortality and Morbidity in Victoria. Was I being responsible in accepting responsibility for the care of this woman who is planning homebirth?

I know our Code of Practice well. I have participated in developing the Code, have written about it, reviewed it, and taught it to other midwives. I know that a planned VBAC at home would be a contentious question even among midwives. Homebirth is not supported at all by the obstetric profession in this country, even in the most uncomplicated cases. Midwives are supposed to work as nurses in hospitals, under the direction of a medical practitioner. Many of our medical colleagues see midwives' independence as a threat - they do not understand that midwifery is different from obstetrics. No doctor can provide midwifery care, and I certainly can't provide medical care. If a doctor is needed in any birthing situation my advice is that we go to hospital.

I agreed to provide care for the woman, to support her whether she accepted or rejected my advice. After all, if the woman and the midwife act in partnership, the woman's autonomy in decision-making, her knowing of what she needs, must be valued. I cannot say that I had a great deal of faith in the woman's ability to give birth, but I do have faith in her ability to know her own body. I know the limits of midwifery. I know that nature is not always kind, that birthing does not always follow the ideal course. I know that lives are saved by appropriate medical intervention by skilled surgeons.

As the months passed, and the woman and I met for prenatal checks we became more and more used to each other, and able to trust one another. Little facts from our pasts, irrelevant to anyone else, became significant to our partnership. The woman's little boy, a delightful and engaging child, became comfortable in my presence. This little boy, who had opened up the delights of motherhood to her, had obviously captured her total devotion. She wanted a positive experience for him.

The woman's labour began early in the morning. When she called she said "Are you well rested Joy?" She progressed well, and soon asked me to come to be with her. Her man was busily preparing the birth pool when I arrived, and the little boy was helping. Labour was strong, and I encouraged the woman to move away from the other activities in the home, and give full focus to her own work. This was not easy. She seemed to want to know what the little boy was doing, to want to make the whole process a family effort.

I drew her away. I wanted above all to keep her moving her pelvis as she approached the end of the first stage. I was particularly conscious that this was the point at which progress was halted in her previous birthing experience. I felt that I needed to initiate special action, and be very close to her the memories of this stage would inevitably return to her. We walked out of the house, down the few stairs, down the sloped drive, and into the quiet street. We did not go far. The woman did not like the feeling of exposure. We turned around and walked back, up the drive, up the stairs, and into the house. The few minutes of walking had the desired effect. There was a noticeable change in the woman's commitment to the labour.

There was an unseen guardian angel in that home that day. The woman's need for support from her man increased, but she knew that he was caring for their little boy. By about 11.30 the little one had had some lunch, and was sound asleep in his bed. The woman had asked a friend to be available to take the little boy if necessary, but she really wanted him there, so the situation was ideal.

I had earlier spoken to Annie Sprague, the second midwife, and told her that I would call her when the labour became transitional. The time for that call quickly approached. The woman did not find labour easy. I spoke to her clearly, "Do I call Annie, or do we go to hospital. You must decide." The woman replied "I don't need to go to hospital."

The birth pool was not well filled, but a little was better than nothing. The hot water supply in that house was not designed for such a large volume. As the woman began to make expulsive efforts I encouraged her to be open, to think of her body stretching and opening to allow her baby to descend the birth canal. It was not until the head could be felt distending the woman's perineum that there was any mention of bearing down.

The little boy woke up. Annie had not arrived, and there was no-one to tend to him. He came to the birthing room and his mother reassured him. Then she made a loud vocalisation and the baby's head was born. The little boy, who could not see his parents well for the blue plastic wall of the birth pool, cried. Annie arrived, and cuddled and soothed him, as the head restituted, and the baby's shoulders and body were birthed.

There was nothing serene about this birth. It was plain hard work. The woman was spent. We helped her out of the water, and she birthed the placenta without the aid of drugs. It took some time, warmly wrapped, lying in bed with the baby snuggled to her breast, before she felt any energy return. Annie had some homoeopathics which she gave, as well as a couple of energy-rich drinks.

I was also quite exhausted. I was very pleased to have the help and support of another midwife, even at a late stage in the birth. I was really thankful that this labour had taken place in the day time - when I was fully alert and fresh. So often a midwife is called upon to work through the quiet wee hours. My judgment and decisions were not influenced by physical tiredness, and I was strong.

I came away from the birth with my heart full, triumphant. I sang out loud as I drove home. I have forgotten now what I sang, but I remember that it was very beautiful.

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