the midwife`s journal <
34. a plain midwife
I have had the opportunity in the past month or so to attend several births which have had a common element. In each one there has been a set of beliefs or so called 'alternative' therapy that has had an impact on the woman giving birth.
For some time now I have described myself as a 'plain' midwife. Plain in my direct and logical approach to understanding the complexities of life and particularly birth. Plain by way of my basic understanding that birth is not an illness. Unless illness imposes itself on the birth process I must trust the woman and her wellness to birth her baby.
A couple of thousand years ago the Greek physician Soranus wrote:
"What persons are fit to become midwives? A suitable person will be literate, with her wits about her, possessed of a good memory, loving work, respectable and not unduly handicapped as regards her senses, sound of limb, robust, and, according to some people endowed with long slim fingers and short nails at her fingertips."
I find much to agree with in this statement, and I think that the hands of a midwife are particularly significant. However I prefer the comment that
"A good midwife has a good pair of hands and she knows how to sit on them".
The history of early settlement in colonial Melbourne, in the middle of the nineteenth century, includes concerns expressed about the activities of "ignorant and meddlesome midwives." As the medical profession of the day began to develop a new understanding of disease, infection, and early principles of aseptic technique, there was a rapid movement towards the medicalisation of childbirth. Midwifery also became medicalised, with respectable women being trained by doctors in hospitals, and calling themselves midwives. With increased control of registration and education there was a loss of women's knowledge which had previously been passed from midwife to midwife, woman to woman.
By the early- to mid-twentieth century most Australian babies were being 'delivered' in hospital; women were being 'confined' to their beds for a couple of weeks, and the authority figure was 'Sister' or 'Matron' who answered directly to the doctor. Women were frequently managed in the left lateral position for birth, so that the 'accoucheur' could 'control' the flexion of the baby's head, and 'protect' the perineum. It was also noted that the left lateral position was good for teaching, as a number of students could gather round and watch the process in the hands of a skilled operator. The woman herself had little involvement, other than to do as she was told.
At a time when medicalisation of childbirth is becoming ever more pervasive, I am constantly challenging what we, the midwives and the others, do to women. I have had to un-learn a great deal of the nursing techniques that were carefully instilled into my mind years ago. A labouring woman does not usually need me to tell her when she should eat or drink, or where she should go. She is active, and in control of her own actions.
Part 1. Appropriate intervention
Last week a woman called me to attend her for the birth of her third child. Her husband and friend were already with her when I arrived. The friend had lived in a small rural community in the USA where she had apprenticed herself to a lay midwife, and then attended births on her own responsibility. Having left that community several years ago, this woman was obviously eager to use her skills once more.
It soon became apparent to me that the woman in labour was looking to her friend for more than support. Labour was slow. The lay midwife administered a mixture made from herbs, which she said would tone the womb and help the labour. The two women breathed deeply together through each contraction, the friend assuming the role of coach.
I began to realise how easy it would be for this birthing woman to be caught between different models of care. Here was a lay midwife, who probably considered herself to be totally 'un-medical', yet she was ready to intervene when I wanted to stand back. I saw no problem with slow labour. Both mother and baby were well, so even if I had had something that would stimulate labour I would not have thought it necessary at that time. And as far as coached breathing is concerned, I stopped doing that years ago, even before I left the hospital. The woman needs to trust herself enough to take the lead. I have seen too many women disappointed and disempowered when they think that they can't breathe properly.
At one stage I heard the labouring woman say to her friend "Do you think we should get Joy to check how I'm doing?" I did not wait to be asked. I explained that I had no reason to examine her. The plain midwife does not do internal checks out of mere curiosity. "It doesn't matter if you are 4 cm or 8 cm" I said. "You and your baby are well, and your labour is progressing. That's all I need to know."
The friend and I withdrew, and the labouring woman and her husband had some time alone. I explained to the friend a little of my 'hands off' approach. The woman must take the lead, in response to the power of her body doing its work. I encouraged the friend to see slow progress as good. The woman's body and her baby need to take their time, not to be stimulated and pushed along from outside.
This woman had told me of some doubts and fears that she had to overcome. An early ultrasound scan had revealed a 'low lying' placenta. During the following months of pregnancy the woman talked a lot about placenta praevia and caesarean birth. Subsequent scans eventually showed that the placenta had migrated away from the cervix, and the experts considered vaginal birth a possibility. But in the process of this 'high tech' eye on the womb, the woman had been informed that her baby was very large. "They don't get any bigger" she was told, along with mentions of obstructed labour, shoulder dystocia and haemorrhage from an atonic uterus. The medicalisation of childbirth had played a significant role in this woman's pregnancy, and it did not surprise me that she needed time to make progress in labour.
As the evening shadows became softer, and we were all beginning to feel weary and a little hungry, the woman asked me if I would check her progress. This time I agreed, confident now that the woman was making her own decisions. As I expected the baby's head was high, and the cervix almost fully dilated.
The high head concerned me. I explained that the baby needed to come down deep into the birth canal in order to be born. I offered an intervention which I know as the 'pelvic press'. The woman was in the spa tub, and she knelt, leaning forward away from me, and I worked from behind. As a contraction became strong I placed my hands on her hips and sustained steady, strong pressure towards her spine. As the contraction eased off the woman said "that's enough".
It was enough, because soon after that the signs and sounds of expulsion were present, and a lovely healthy boy was born through the water. His parents, his two brothers, and we midwives greeted him joyfully. His head showed no molding, and when we weighed him the next day he was a healthy 4.4 kilograms - not too big and not too small. Just right.
Part 2. "I want to do it myself"
The woman was planning to give birth at a hospital where I have visiting access, and we went there together in the wee hours of a Monday morning. I had been with her at home, and despite her stated plan to give birth naturally, this woman was very distressed by her labour. Water, the wonderful analgesic used constantly by homebirth midwives, did not seem to relieve her pain.
The situation did not improve at hospital. At about 3.30 am I felt that on abdominal palpation the baby's head was well into the pelvis, and suggested that I examine the woman internally. Her cervix was about half open, the head well applied, and deep in the birth canal. I explained that there could be several more hours of strong labour. Did she want me to call the doctor and organise an epidural anaesthetic?
It is very uncommon in my practice for me to feel as powerless to help as I did that night. This woman is herself a practitioner of various New Age alternative therapies. Her partner is strongly involved too. I had asked if she wanted some lavender oil in the burner, but no, there was nothing that seemed to give her any relief. Medical pain control seemed the only other option.
The woman took a few minutes before responding, then she said "No. I want to do it myself"
That seemed to be the turning point. The woman seemed to realise that no one else could do it for her. No therapy could open up a short-cut. No skilled midwife could take over. She was giving birth.
Progress from that point onwards was quite rapid. She stood, supported by her partner, and brought her baby out. It was as though all she needed to do was to let go, and her wonderful body did the rest.
I had not called a doctor for the birth. The doctor who the woman had booked with was away for the weekend, and would be back on duty at 7am. This doctor had not been very supportive of the woman's plans for natural birth - he heard that sort of thing every day, and most young women having their first baby ended up with a cocktail of obstetric treatments and medications. When the woman said she wanted to be able to choose her own position to birth, and have soft lighting, the doctor said she could have that if she understood that she would thereby have a bigger perineal tear. He said that if he could not control the baby's head she would be sure to tear, but he did not mind stitching her up.
Well, my hands were poised nearby, but no-one controlled the baby's head. And the woman did not require any stitching.
As the birth became imminent I asked the woman if she wanted me to call the doctor. This is the usual practice. No. She and her partner were adamant. They had not met this covering doctor, and they did not want a stranger called unnecessarily. As long as I was confident that there were no complications they did not want a doctor. I asked another midwife from the maternity unit to assist me, and all proceeded normally. Physiological management of third stage, with delayed clamping and cutting of the cord are my usual practice, quite different from the active management practised by most doctors. The placenta was born within the hour, and the little one had uninterrupted skin contact with his mother while we waited.
By the time I left the room I was able to telephone the woman's doctor and report on the events of the night.
The medical monopoly of childbirth is very strong here. The doctor has complained about me to the management, because his substitute was not called to the birth. I am now being asked to give reason for my actions.
The answer is that I am a midwife. A plain midwife. I will not play the game by rules that disadvantage the woman.