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19. midwife at a distance
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The woman's phone call gave me an opportunity to be midwife, 'with woman' in a slightly different way. I did not attend her birth. I did not see her in labour. I sat with her in her home for a couple of hours, heard her story, put my hands over her baby, and counselled her the day before her baby was born. Several of her friends, lovely women in the Christian home-schooling group, whom I have come to know and love through midwifery, had encouraged her to talk to me.

The woman had planned to have her baby in the Birth Centre. A few months ago it was decided that this baby was not growing quickly enough, and she was moved from the small low-tech Birth Centre to the high-tech fetal assessment unit at a big hospital. As time passed it seemed that the baby's weight was falling below the tenth percentile line on the graph.

When the woman contacted me she was in the 39th week of her pregnancy. She has been having fetal monitoring twice weekly. The doctor who had oversight of her care seemed happy to wait as long as the baby showed no sign of distress.

Then this week another doctor walked into the room and announced to the woman that her baby had stopped growing, and that she would need to have labour induced on Friday. The woman said that she would like to talk to her husband about it, and the doctor said that the booking would be made anyway.

It was this encounter that brought the woman to telephone me. She told me that she was upset and unsure of what to do. She felt that this baby was smaller than the others, but active and strong. The woman explained to me that she and her husband are both quite small, and they did not feel especially concerned about a small baby.

In a brief telephone conversation I cannot contradict the advice of well-respected obstetricians who are experts in the medical aspects of childbirth. However I have seen enough errors in prenatal diagnosis to make me wary. The woman had been told that her baby probably weighed 4 1/2 pounds. As if to emphasise the seriousness of the situation the doctor also informed the woman that her baby would need to be given formula milk immediately after birth, or it would start fitting!

I felt angry! How dare the doctor use such tactics - power, threat, and psychological manipulation. Without seeing the baby the doctor has no way of predicting such a course of events. Had the woman been having her first baby she might have passively accepted such a package deal. But she wasn't, and she didn't.

I don't want to suggest that I was dealing with a woman who appeared confident, strong or assertive. When I visited her the next day I was greeted by a small woman with a sweet, gentle young face that gives her the appearance of someone who is quite fragile. She walks with a distinctive gait, as she herself suffers from mild cerebral palsy. Her pregnant belly was not very large.

After talking with her at her kitchen table the woman allowed me to palpate her abdomen. The baby's knee pushed back at my hand as I carefully traced the familiar shape. The head was well engaged, occiput to the left. My thumb and fingers rested either side of the baby's head.

"This baby doesn't feel like 4 1/2 pounds to me. More like six," I said.

We listened with my doppler: a strong regular beat. We listened again after bringing on a mild contraction by nipple stimulation. The heart rate sped up slightly, reactive and healthy, and very reassuring.

The woman wondered about having her baby at home. This was Thursday, and she was booked for the induction the next day.

I did not encourage homebirth. I assured her that I would support her in any decision - to accept induction, to refuse induction and continue with regular monitoring, or to turn her back on the hospital system. We talked about the various options, and some non-medical ways of encouraging the womb to release its treasure. We talked about why some babies don't grow as well as we would like then to. And we talked about small babies and effective breastfeeding.

The woman and her husband went to the hospital on Friday morning, and the doctor broke the waters. After a monitor trace showed that all was well the woman asked for it to be discontinued. It was after 10 am when they phoned me to say that labour had not yet begun. I encouraged the woman to take charge. Light touching of her nipples every five minutes until labour was underway, while remaining upright and mobile, would help. Then her man rang - their baby girl was born at about 11 am. Baby weighed 6 pounds, went straight to the breast, and remained there. Of course there was no more talk of hypoglycaemia or babies having fits.

There are several aspects of this woman's experience that are prominent in my mind as I reflect on this case.

  • There may be a genuine cause for concern. The baby was small, but not as small as was predicted. When the placenta was checked it seemed that there was a portion which was not functioning, due to a concealed clot. Had the separation been greater, or the labour more prolongued or intense or chemically stimulated, the baby may not have fared as well. This is the wisdom of hindsight. All we knew prior to the birth was that the baby was small, but OK. While acknowledging risk factors there is no indication for obstetric intervention while the woman and her baby are clinically well.
  • The doctor's decision to induce labour at 39 weeks was not in itself remarkable. The woman's body was ready, and her baby mature. However the doctor's approach, treating the 'condition' rather than the person, and her pregnancy as an illness that must be cured, a growth that must be removed, left the woman confused and threatened. I have no doubt that the doctor believed that this course of action was best for mother and baby. The doctor has probably seen cases of 'intra-uterine growth retardation' in which tragic outcomes have seemed to be linked to a failure to intervene. What this doctor overlooked is the woman's authority for her own body, her need to make decisions based on accurate information.
  • I believe that in this instance artificial rupture of the membranes was an appropriate intervention. I also know that once the waters are broken the course is set. The woman's willingness to take an active part in stimulating labour indicated her empowerment. She knew that her baby needed to come, and she engaged herself in that process by refusing to be tied to a monitor, by walking, and releasing her own powerful oxytocin through nipple stimulation. Had she been frightened or unwilling to give herself fully to the birthing her body would not have responded to the subtle hormonal influences.
  • The feeding of a small or sick baby also concerns me greatly. The woman had breastfed each of her three older children. She had an ample supply of colostrum. To doubt her ability to adequately nourish her child is another aspect of medical dominance in childbirth.

The small, frail woman is strong, and she has shown us that she is able to birth and nurture her child.

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