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To be honest I feel like I had a really clear definition at one point. It was really clear to me that normal birth was no intervention, healthy woman, healthy baby … I feel like my definitions are shifting quite significantly in terms of what is a normal length of birth, what is the normal length of pushing … why if everything is going well and baby and mum, mum and baby are doing fine, then can we stretch those meanings of normal a little bit more?
Strategies used by midwives to keep birth normal
Working with women from the early pregnancy
I have this expectation for every delivery that I go to that it will be normal in the end. There may be little challenges here and there but that’s what my experience and training is for, to overcome those challenges and still allow women to have a vaginal delivery. Of course there are some cases that are different, you know if there is major pathology then of course, I have to let go of that expectation but throughout, or let’s say from the first day that I see a woman that’s what I work towards. I have 9 months so it’s quite a bit of time to prepare her and myself getting to know her, have a good delivery with you know a vaginal birth in the end and no major complications.
We do a lot of prenatal education, we talk a lot about what labour looks like, how to prepare for it, we talk to the partners about how to support them in labour, we talk about all the different kind of management techniques and comfort measures and we talk to them about pain relief options all the way from non-pharmaceutical to pharmaceutical and epidurals and what’s available … so I really prepare them for the idea that we’re going to do a lot of this outside the hospital even if they’re planning a hospital delivery that they have the tools and the resources that they need to cope with labour, that labour’s a very normal thing and uh, we make sure that we’re available to them.
[If] she’s communicating that she’s really really tired, I have this you know gut feeling that if I rupture her membranes things are going to move really fast and there’s going to be a baby and she can just snuggle her baby and go to sleep then that may be an intervention I use in that moment, as something I might offer her and explain it that way, “it’s an intervention, it can help things move along quicker, is that something you want to try?”. These are the risks and benefits.
I’ve had people say things like when you get to 42 weeks your risk of stillbirth will double and then just leave it at that, whereas we’re very conscious to say well yes your risk of stillbirth will double but this is what it is doubling from and to and these are the actual stats, these may be some other factors to bear in mind when you’re making this decision. So I suppose it’s about using the information accurately and not using it in a frightening way or a way to be able to coerce women into what would be the community standard. So you know if I just stop at your risk of stillbirth doubles at 42 weeks, what sane woman wouldn’t choose to be induced but if we then go onto say what that actually involves then I would find, we have a very low induction rate compared to some places.
Managing early labour
… we talk a lot about what labour looks like, how to prepare for it, we talk to the partners about how to support them in labour, … especially for the primips … that prodromal labour stuff I mean that’s a mental game and that’s why a lot of women end up in the hospital too early, so we do, we do a lot of home support for that and phone calls and making sure they’re well prepared for that and coping with that … when I’m talking with them prenatally about what early labour looks like versus active labour.
… I really emphasize very strongly with my clients about how to manage their early labours and sleep in early labour and I encourage them to consider Gravol [Dimenhydrinate] … for sleep, even like I said certainly the first night if they’re starting early labour at night and even sometimes the next day like late in the day or early in the evening, if they’re taking their time. I just find that rest can have a huge effect in beneficial ways and also making sure that they eat and drink and making sure that they, hoping and helping them to ignore as much as early labour as they can.
Well I think there’s research to show that the earlier you go into hospital the more likely you’ll end up with intervention cascade so one of the things I try to do, because we’re watching more and starting to document more, if they’re in a big hospital system, then I think there’s more of a tendency and I think midwives are no different, as a practitioner you kind of think you have to be doing something whereas at home you can go listen to baby, do the blood pressure, listen you know and reassure and make sure she’s eating and drinking but it’s not so much okay now we’re going to do a check again in 2 or 3 or 4 h for a vaginal exam and see if there’s any progress when you’re starting at, you’re not really in labour. So let labour establish itself before you start thinking there should be progress …
The birth environment
I feel like whenever I can actually get people to have babies at home or if we do go to the hospital have a home birth in the hospital—meaning we don’t use a lot of the technology in the room and we push it out of the way and we kind of keep to ourselves a little bit—we can have a home birth in the hospital and some women will end up with these magical amazing births on the floor of the bathroom at the hospital which is just as normal as the magical birth in the tub in the living room and it just happened in a different environment but it’s because we didn’t engage with all of the rest of the equipment and I find what I need to do in those situations is because I’m experienced now and people know me and I have a reputation, I can close the door and the nurse can come in when I want her to and I can ask her to come in.
I feel that women and their partners do much better with privacy and intimacy during the birth process and that, my role is to sometimes protect that privacy and intimacy first of all by educating them that that might be really important and to talk about you know the effect both positive and negative about um, support during that time can be or even just letting people know hey, we’re in labour, the Facebook kind of thing but you know keep it quiet, keep it down, don’t fritter the energy away by drawing other people to it or drawing the expectation that something’s happening rather than just letting something evolve … I think guarding the space by keeping the space as calm and quiet and private as possible is key and giving people tools to do that during the prenatal time to deal with over eager family members or friends.
Try to make sure she’s well supported so for example with our teen clients that’s not always, well with any clients, but specifically with our teen clients that’s often not the case. It’s often the case that they are not well supported. So they may or may not have the partner in the picture, they may have an estranged relationship with their parents. I would say more so than on the average other clients we have so for them we make sure that we get them doulas, we make sure they have doulas and we do a lot more intentional labour work with them.
Careful watching and waiting
I think the most important thing from my perspective is that my grounding in normal helps me recognize the abnormal … it’s like a line, the straight line of normal and if there’s a wavering off to one side or the other you just try a little tiny subtle intervention to nudge it back to normal … like if the baby is malpositioned you know, ideas and ways, and position changes, manoeuvres we can do to try to get the baby into a better position, things like that … so you know if she’s dehydrated, hydrate her. If she’s tired give her some food, you know, those kind of things … if it’s getting tachycardic and you hydrate mum and you cool her off, if she’s in the tub you cool her down, get her out of the tub, those little nudges and then quite often it normalizes, stabilizes and then you’re not creating a problem.
And so part of that is I do think doing a vaginal exam in and of itself is an intervention that can slow things down for the mom … and now I really think about why am I doing this? What information am I going to get? Things like that and I do think that helps keep things normal because you’re doing less unnecessarily vaginal exams which is an intervention.
I try to keep a fairly quiet presence, try to work out what the woman and her partner, or partners, whoever’s around her, are being able to sort of do themselves … I think it’s probably better to let women go into themselves if they want to do that, so trying to support the woman in the kind of personality and needs that she has, and keeping that low-key presence with things like monitoring being a subtle as it can be, and I don’t really care for doing regular VEs so it’s more about clinical indications or their impression rather than it’s been 2 or 4 h since your last one so therefore you have another one.
You have to be present and I think that’s one of the things that keeps birth normal, we can go on and on about all the tools and I think those are valuable, I’m not saying they’re not, but I think that the message is you can’t do it from a distance so you can’t be at home while someone’s labouring, get up come in and do the birth. [If you don’t] You will have a higher section rate, so part of that is you need to be in attendance to keep the birth normal and some of it is just to have an opinion about the strip, some if it is literally where you feel like you’re standing guard, not against bad people but against keeping the space for the woman private and without a lot of stuff going on around her that’s going to distract her just being in her labour. So that’s part of our philosophy as a team that we tell our patients … You don’t leave a woman pushing ever so I think constant presence, I’ve come to believe that that’s really important.
Helping the woman to cope with labour
… you know a lot of it is attitude like I say and going through the positive part of pain in labour and, and using your rest periods really effectively, not getting ahead of yourself, trying to just stay in one contraction at a time and I teach them that prior to labour but I also reinforce that a lot in labour and then comfort measures like water, we have great showers in our hospital, we don’t have tubs which is unfortunate but it is true the hot water never stops running so lots of my clients spend long times in the shower and different position changes and heat and ice and all of those things that we can use. I definitely like to use all of them—the ball, going up and down the stairs.
I always have held this in my heart—don’t sacrifice the relationship between the mother and baby because you want the woman to have a completely unintervened birth. I’ve seen that many times where a mom is so miserable by the time she has her baby and so exhausted and so out of it that she’s not even happy to see her baby when, you know as you become more and more experienced you realize there are ways that you can help that to be avoided.
But then the other situation is really straight up for pain relief when I, most of the time, when I would recommend an epidural is when I see, and am I wondering if that woman is crossing the line between pain and suffering. And so I, when I do offer that I could offer it very judicially and very gently but I would say something like “what I’m seeing here is this, I’m wondering if you might benefit from some pain relief” and basically either they jump on it or they’re like “no, no, I can manage”.
Tools in the tool kit
It’s like tools in your toolkit and you’re filing that away and it’s like that idea of lifelong learning, you’re always going to be adding tools to your toolkit, you shouldn’t let it get full of cobwebs like you need to keep adding to it because there’s always something that’s going to work and make it a little change and for me the mechanics of it … and understanding all of those mechanics and bringing that to the mechanics of the pelvis and how babies come down and all of that and so there is a part of me that kind of, I can think it’s very cool that there are ways that this baby can come down and the more experience you get the more you realize yeah we can nudge this a little bit. Change that position, tilt, do this, do that.
… we can run into little obstacles on our way and there are tools available and mostly they are my clinical skills but occasionally I suggest an epidural or maybe the patient really demands one and I have not enough to offer that she can do without, yeah of course, interventions need to be used wisely in order to achieve that goal … So I’m open to anything … I use a lot of alternative, I pretty much use any tool that is available, hopefully in the right situation to achieve that goal.
I only have basic training in acupuncture so I sometimes do some, I sometimes send them to a practitioner … so I just do routine things like birth preparation if, induction points, turning the baby if it’s a breech baby so I just do basic things … we have some really good acupuncturist in town so I can send them out. I might use it in labour if her contractions slow down. If she’s not letting go and just I go again a little bit by my feelings and say okay this would benefit her in this situation.
And a lot of that is about cervical ripping and stuff so with people who have a history of going postdates, I really encourage them to do stretch and sweeps and acupuncture and we do like cervical ripping tea and stuff like that. So we try to help them get ready at least to help their cervix ripen before we have to do something more serious and then if they don’t have a history, like I would say we do the same, basically the same thing. We just maybe leave it up to them a little more.
… we have a high water birth rate here, mostly because we have this water birth room, which is available with tons of hot water and a big beautiful tub and so essentially if I get them in the room, I get them in the water, I’m listening to the baby, I shut the curtains around the tub, I turn the lights down and I just give them that hour, like 1 to 2 h of kind of privacy where I’m sneaking in to listen to the baby.