I have had the honor and privilege to care for quite a few midwives lately, having their babies either at home or in hospital. I’ve just come home from a postnatal appointment for a midwife, now Mother who had the most straight forward, physiological and stunning water birth of her first baby. She said she has rarely seen first time Mothers be able to push their babies out without masses of coaching “Hold your breath and push” type coaching.
How sad is that!
On reflection, I remember early in my career working in Birth suites at one of the biggest Level 3 (has neonatal intensive care) hospitals in Melbourne for 18 months and on leaving the hospital I could count on one hand (5 or less) how many births I had had that were truly physiological over that time. I worked full time, yes 5 days a week for 18 Months and would have cared for less than 5 women having what I would call a truly physiological birth (Mumma and baby just do their thing, cervix opens at its own pace, baby comes down and Mumma pushes when she feels like it).
How sad…actually tragic is that! And sadly I think the situation is getting worse from when I first graduated as a Midwife.
So why? Why so much intervention when our standards of health are so high? Why do women need so much help? Is all the interference and rigid ‘black and white’ hospital policy causing the issue? Is it that the women are different in some way now from what they were 24 years ago (when I graduated as a Midwife)?
Although I think the issue is a complex one, a number of factors are a cause. Firstly, I think many women fear the process of labour and birth. Why wouldn’t they? After all they hear their friends horror stories of birth, being cut with scissors, screaming in agony, their body couldn’t labour naturally so they had to be induced…oh boy and that was torture! And I also believe our hospitals have become so medicalised, rigid, and put all women into one basket…the one size fits all approach.
I’m not going to discuss fear in this blog as I think I need to write a blog on fear later. What I’d like to discuss is intervention in labour, and the problems I think this causes.
Many of my clients planning a hospital birth like the idea of me caring for them at home until labor is very well established (head well down and cervix almost all taken up-dilated). So we go into hospital and sometimes what has been truly physiological and straight forward has within 2 hrs become pathological…all because of intervention and the hospital’s staff suggestions on ‘what needs to be done’. Let me share a story with you…
A straight forward uncomplicated first time mother in labour at home, planning a hospital birth, rests in her own bed, walks around her own house, eats her own food, wees on her own toilet…labour usually progresses very well…we go into hospital in what appears to be advanced labour, in 2.5 hours this is what happened;
We need to do a Vaginal examination, no I don’t want one…we need to examine you within the hour…it’s hospital policy. Woman says OK, she is 7cm dilated. Very happy. We would normally break your waters this far along…no thank you…it will help labour to go faster…no thank you.
Platelets have been on the lower side in pregnancy, lets do an FBE to check their level…fair enough, but while we are taking the blood, we would like to leave a cannula in your arm ‘just in case’. Just in case what? Just in case you hemorrhoage? Really, I say, can we consult with an Anaesthetist… consulted…long discussion…he has no issue.
When did you last empty your bladder…it was about 3 hrs ago at home…how much did you wee…adequate amounts. Lets get you up to the toilet to wee…doesn’t feel like weeing… Can I get you back on the bed so I can feel your tummy and see if I can feel a bladder. No bladder palpable, but lets put an in-out catheter in your bladder and drain it ‘just in case’. Client agrees…small amount of urine drained (50 mls) and increased chance of bladder infection gained. Your urine has ketones in it so we would like to put a cannula in now and give you IV fluids…no need for IV fluids…she isn’t vomiting and can drink large amounts of fluids…lets get some apple juice and hydralite. No, we want to put a cannula in and if you don’t agree I’ll get the senior Dr. Get the senior Dr then…comes in, full on discussion about IV fluids. Client declines.
It’s been 2 hrs since your last examination, we want to re examine you, client says not right now…no we need to do the examination at …o clock, it’s essential to see how far you have progressed…about an hour later re examined…7cm!
Are you surprised?…I’m not…not at all. This woman’s labour was so disturbed, so interrupted, so much cognitive thought processes required. Her ability to birth so undermined when all she needed to do was ‘switch off’ and be ‘allowed’ to do her thing.
Another woman, first time Mother, same scenario, planning a hospital birth, arrives in well advanced labour…midwife greets us with a smile and warm touch…I’ve tried to prepare the room so it is warm, dark and relaxed…it is beautiful. How clever are you, the Midwife whispers to the woman, let’s run the bath, let’s get you in as I know this is what you would like…warm water running on her belly, sips of water and crunching hydralite icypoles…cold flannels to face as she is so hot…working so hard…baby’s heart beat great, so is the woman…sounds a bit grunty…some gentle efforts to bring the baby’s head down…after some time, quite some time that urge to push gets stronger…soon we see the baby’s head slowly advancing…crowning, born…into the bath, Mothers and Fathers hands gently guiding the baby out.
Both these women presented to hospital in similar circumstances, but both had such different outcomes, I believe all to do with being disturbed or undisturbed, having labour intervened with or ‘allowed’ to take it’s course…
So who writes these hospital policies…especially around ‘active management of labour’ and what level of evidence is used to formulate them? What evidence is there to support that disturbing a women in perfectly physiological labour with suggestions and in fact demands for vaginal examinations, blood tests, catheters, cannulas etc etc helps facilitate good outcomes?
I will access some of these ‘Active labour’ policies and examine the ‘evidence’ and write another blog!