Shhh..... I practise physiological third stage

The third stage of labour feels like a topic that is discussed in secret amongst student midwives and midwives; whispered 'what do you do?' questions and the caginess around what one actually 'does' is tangible.

Practice around third stage came up in a recent conversation I was having, and I felt it was time this subject was explored, caginess put aside, and clarity about the NORMALness of a physiological third stage heralded high and loud.

As a student midwife, I was clear about the skills I wanted to learn; I was also very fortunate to have a mentor who was skilled in facilitating physiological birth, and another mentor whose trust in me enabled us to learn together about the third stage.  I was, however, unique in being one of only a handful of students who qualified having gained this knowledge and developed this skill: most only knew how to 'manage' the delivery of the placenta.  I know this is still happening and frankly I find it worrying.

It is normal within the hospital setting for managed third stage to occur; a reason cited to me is that it takes 'too long' to wait for the placenta.

Q1. How long does a physiological third stage take? 

20 minutes is about average, maybe 30, very rarely an hour or more.  If you assume it will take around 20 minutes, even in a busy unit, this should still be the time that the mother and baby are bonding and shouldn't be 'hassled'.  Plenty of time therefore for the midwife to be quietly and attentively watching.

 Q2.  What about the risk of haemorrhage?

Firstly, in a physiological birth, the risk of haemorrhage is relatively low  (I could reference this, but am choosing to use innate midwifery knowledge here).  The clue in this statement is physiological birth, i.e. spontaneous onset, contractions regular and rhythmic, no pharmacological pain relief (okay, a little gas and air is fine), spontaneous explusive urges, no interference with the mother-baby dyad.  In other words, with absolutely no intervention - just a mother working with her body, oxytocin flowing, adrenalin reduced, trust and patience high. 

Okay, so it doesn't take as long as you might have thought, and mum might not bleed to death, but what about the shift leader who is knocking on the door asking if the placenta is out?  What about the assumption from the woman that she will have the injection?  If the shift leader is knocking, it is our job as midwives to politely, but firmly inform them that we will let them know if we have any concerns, we will update them as and when is appropriate, but will not accept people knocking on the door (you could point out that this is like trying to have a pooh with people hanging around outside, and maybe they would not be comfortable with that?).  Midwifery is an autonomous profession, you have a duty of care to the woman, not the shift leader.

Q3. What about informed choice?

It is currently bang on trend for women to choose 'delayed cord clamping'; therefore half the work is done for you.  You know the benefits of a physiological third stage - if you have supported her in a physiological birth, surely you are just continuing with that?  I'm going to put my neck out here and say why does she need to make a choice?  That would mean you are questioning her body, and getting her thinking brain to respond.  Remember, at this point its all about the oxytocin - and quiet, watchful waiting.

 In The Midwife's Labour and Birth Handbook there is a very good chapter on third stage and a clear explanation of what a midwife 'should' and 'shouldn't' be doing; Elizabeth Davis also offers a clear summary in her beautiful Heart and Hands: A Midwife's Guide to Pregnancy and Birth book (definitely recommend that one).

Q4. What do you do?

I myself have learnt FIVE key skills to supporting a physiological third stage :

1. Keep the woman warm after birth: if she is cold, it affects the physiology of the placental separation

2. Keep the room quiet: too much excitement raises adrenaline and impacts on uterine contractions

3.  Watch carefully and listen fully: you will see the tell-tale trickle of separation and mum normally notices stomach pains

4.  Use gravity to aid delivery: the mother will normally push the placena out herself.  However, toilets are magical here; help the mother to the loo, she will pee and pass the placenta all at once.  Never fails if time is passing! 

5. Do not Fear it - IT WORKS!

“Nothing in life is to be feared. It is only to be understood. “~Marie Curie

What thoughts do you have to share around the third stage?

angela xx

but that's just silly!......

Last week, and with my home-educating mummy hat on, I ran a 'morning with a midwife' workshop.  12 bright eyed children aged between 9 and 15 arrived at my home for a two-hour interactive workshop.

We started of by covering the role of the midwife, and what kind if checks we do; they played with my sonic aid and listened to each others hear rate; they guessed if one of the mum's BP would be high or low, and they giggled as they 'explored' their own pelvis - finding their coccyx and poking around their bottoms!

Children are brilliant (well mostly brilliant, unless they are annoying or I am having a bad day), but on the whole brilliant.  They see things so clearly, and haven't been dis-illusioned by adult-hood, and are still naturally thinking out-side the box - this, I am delighted to say, made teaching them great fun.

After they had labelled up some large pregnancy charts, we looked at the physiology of how the cervix opens, how the baby descends through the vagina and how the baby rotates and fits (perfectly) through the pelvis.  Having tired of the poor messages passed to children (and adults) about birth, I used positive language: I talked about the intensity of birth, and how women cope really well with this and can rest between surges, I talked about how the baby is squeezed and 'cuddled' by the uterus with every surge, I talked about how the baby is pushed out and it feels like a huge urge to pooh!  They got it, and accepted it, and asked about it, and then there was this Eureka! moment: to help the children visualise the size and weight of a growing baby, I had created a basket with different items weighing approx weights at different gestation.  I had an orange for 20 weeks (200gms) and so forth, with the final weight of the basket about 3200g (7 1/2 pounds ish in old money).  Using the pelvis, I showed how easy it was for the orange to get through when the 'mummy' was kneeling or on all fours, then I turned the pelvis into semi-recumbent and......... the Orange just sat there.  Eureka!  

..."but that is just silly!  why would you do that?!....."

asked a 9 year old.  Why would you do that?  Why would a woman give birth in the most physiologically challenging position you could choose? Why would a woman shut her pelvis and work against gravity?  Why would we do something so silly?  Well if a 9 year old can get that, then why are the vast majority of women giving birth on their backs?  Why are student midwives qualifying having NOT supported women in 'alternative' (don't get me started on that phrase) positions? Why why why? 

One for Mr Marr!

I feel there are many reasons (sadly) why this continues; the medical mode of birth, the use of pharmacological pain relief, ease for the midwife, the images of birth that are portrayed in the media?  None of these of course make it OK, or acceptable, but I do think the latter is a huge influencing factor. It's almost as if women expect to birth in that position - the children did, as that is what they have seen - until shown otherwise.  So perhaps then, it is the Film and TV producers of the world we should be talking to?  Certainly, in the opening issue of Andrew Marrs' History of the World (a brilliant programme I might add) the ancient African homosapien is seen to birth in the 'typical' semi-recumbent position.  Historically, women birthed upright; using trees, kneeling, squatting to give birth; not sitting with their bums and vagina's in the dirt.  It would have been much cooler Mr Marrs if your production team had shown that!

Perhaps it's time to remind ourselves of the Wonderful Female Pelvis, to remind women, doctors, parents, teachers, children, and the Film Industry of how perfectly designed we are to birth and how women - when well supported - will adopt the 'alternatively brilliant' birth positions that aid birth naturally.  Perhaps it's time for a new slogan:

'don't take it lying down!'..... 'knees for ease!......'using the (all) fours of gravity!......  suggestions please!

and here is a little something to share: (catch it here too http://www.youtube.com/watch?v=MswFqXdOq2U)

Enjoy!

angela xx

It's in the words

Two weeks ago, I took my three home-educated children along to the Science Museum to enjoy The Human Body film on their IMAX screen.  The film was really interesting, with lots of amazing facts, clever imagery and clear explanation.

Then, we get to the 'birth bit'; I am an experienced 'TV birth' avoider now, having wasted too much energy shouting at rubbish programmes (OBEM is right up there in my list of hates), so I tried not to get too excited, so as not to be disappointed   That was the right decision, as four-hundred children of varying ages were presented with the typical birth scene I strongly feel should not be broadcast: the woman, on her back, full epidural, stirrups, a team of people (I think they edited out what was clearly an assisted birth), baby taken away, wrapped and returned to the proud mother.  And the icing on the cake..... the midwives phrase that makes me want to want to jump up and down like a raving bloody looney (and that is being tame on what I really want to say):

"come on, push, push, push, push, push,....

get ANGRY (with your baby?)".

Get Angry?  Angry....... so is what we're really saying, is that we want the woman to be this:

and then expect to her be this:

A diametrical concept to the extreme.

And it's not just here that the language of midwifery needs addressing;  how many times do we need to remind women and midwives that pizzas are delivered, shopping is delivered, parcels are delivered.  Babies are BORN. I do not deliver babies; I facilitate birth, I support, I catch, I guide.  I am in awe as a woman delivers her own baby.  Not me.

To empower women, we need to think carefully about the language we use: midwives are in a very powerful position.  Women listen to us, they value us, they (hopefully) respect us: what we say and how we say it sticks.  Let's look at some other examples:

"ohh.... that's a big baby your growing there."  ( Woman hears "oohh, I ain't ever gonna get this baby out of my vagina.")

"would you like some pain-relief?"   (Woman hears "midwife thinks I can't cope; better get some drugs before this gets worse")

"just pop up here on the bed, there's a good girl"   (Woman hears "I better stay here where I am told")

In a recent issue of the Midirs Essentials, there was an interactive section encouraging the reader to reflect on some of the common phrases used and often said to women;  I, even as a student, have never told a women to get angry, have never asked a women to "take a deep breath and push", and have always encouraged women to listen to their body.  I have seen students swiftly adopt these 'standard phrases', as if these mantras somehow make them a midwife, a part of the 'gang', or somehow more competent in their mentors eyes?

As a midwife, my aim and hope is to empower a woman to feel like this:

because, I believe, that only when she has released her inner-lioness, only when she has birthed her baby (in her own unique way), only when she has felt that she did it (even with an assisted birth), that she is the woman, the mother, the strong-one, can I expect her to be this:

Words are powerful.  Women should be central to that power.

The most common way people give up their power is by thinking they don’t have any. – Alice Walker.

angela x

Choice?

Following the FFB Screening, I was going to write a blog about choice and choice for women, however The Mule has written a great blog piece on this, so I am not really feeling the need to re-write that.  So I started thinking about choice for midwives, and choice in midwifery.  Or lack of it.

When I started my midwifery journey, I entered it with this fierce passion and a strong belief that I was going to 'change midwifery services'.  Three years of training knocked most of that out of me, and moving into Independent Midwifery enabled me to start practising the 'midwifery' that I had read and  dreamed about.  My choice to be an Independent Midwife is under threat; insurance issues and EU rulings have seen to that, and within 12 months if there is not a solution found, it seems, that the only choice that may be open to me is to return to the NHS.

Apparently, as a registered Midwife, I am an autonomous practitioner; I am accountable for my actions, the advice I give, the women in my care; I have to maintain my knowledge base and demonstrate that I keep up-to-date; I have to attend study days that are relevant to my sphere of practice; I have to work a certain amount of clinical hours each year; and I have to keep up my registration (and pay my fees) with the NMC.  In short, in order to say 'I am a midwife', I have to work bloody hard at it!  And yet, and yet, my right to choose how to work is not being recognised.  The only midwifery (potentially) that will be 'legitimate' will be within the system of the NHS, and whilst there are amazing and wonderful NHS midwives out there, it's 'the system' that scares me.

So, what about being an autonomous practitioner?  Well, it seems that the rules that govern me as a midwife don't quite fit into the NHS system; I would not be free to choose my working hours; I would not be free to choose who I care for; I would not be free to choose the study days I attend (unless the 'off-duty' enables that); I would not be free to choose what I wear (please - tunics?  talk about putting a barrier between woman and midwife!); policies and protocols would dictate my practice - not the evidence and to support women in choices that would challenge these would, I fear, be a daily battle.    Burn-out in the NHS is high, midwives work long hours with little or no breaks, morale is low, staffing issues create stresses on midwives trying to juggle 2 -3 women at once. Choice?  I don't think so.

If women are going to get the care they deserve (based on the evidence and one-to-one care) and have the chance to 'reclaim birth' then it is essential that midwifery remains an autonomous profession, that midwives have the right to choose how they practice (remember, we are already well-governed), and that all maternity provision is not handed over to 'the system'.

Loosing Independent Midwifery will not just affect women; it has the potential to change midwifery in a way that I can not even bare to think about, it has the potential to remove the woman from the focus of care, and to remove any form of choice - whether that choice is a home-birth, an epidural, a caesarean section..........

What can you do about it?  Tell every woman, every person, everybody that you talk to about Independent Midwives; share this page on facebook, email to it to 10 people you know, and ask them to forward it to another 10 people, and another 10 people, and another 10......  tell them about the brilliant NHS midwives who cared for you, who held your hand, and then tell them that if Independent Midwives disappear, so too might that midwife who 'was so lovely' to you.  Because, if you don't tell people, and we disappear, the real tragedy will be that one day, choice will simply not exist for women or for midwives.

A young girl was walking along a beach upon which thousands of starfish had been washed up during a terrible storm. When she came to each starfish, she would pick it up, and throw it back into the ocean. People watched her with amusement.

 

She had been doing this for some time when a man approached her and said, “Little girl, why are you doing this? Look at this beach! You can’t save all these starfish. You can’t begin to make a difference!”

 

The girl seemed crushed, suddenly deflated. But after a few moments, she bent down, picked up another starfish, and hurled it as far as she could into the ocean. Then she looked up at the man and replied,

 

“Well, I made a difference to that one!”