fear + loneliness = Brave?

I have often been told that I am 'brave' for choosing to be an Independent Midwife; I wrote about this a long time ago and can honestly say I have never felt brave, or really understood why fellow midwifery colleagues consider me such.  I am just a midwife, working to support women, some courageous and strong, some needing support to find their inner strength, but all who wish to have the bulk of their care outside of the NHS system, with a midwife they know and trust.

I attended a beautiful home birth this week; I was not anticipating to be the primary midwife, but the woman's own midwife was caught in Jury service and unable to attend. I gathered myself together and headed off to the birth - I knew the woman and her family having supported them as the second midwife with their first baby.  As always, I mentally prepared myself, and drew inner strength and calmness into my being.  I was not aware that I would be doing that many times in the course of the woman's labour..........

Birth works: if you follow my blog you will know that this belief is deep in my inner core.  BUT, and there is always a BUT in nature, sometimes birth changes and sometimes nature will challenge us, humble us and remind us that she is a force that we cannot always control, always predict, always guarantee.  After the baby made its way earth-side (a beautiful, calm, wonderful HVBAC), the woman's body was not (for whatever reason) willing to release the placenta; I was concerned.  Too much bleeding necessitated a decision to transfer; a serious maternal obstetric haemorrhage occurred,  a wonderful team of NHS staff worked very hard to save a very compromised mother.  And a very shaken midwife was left holding the baby...... until he was safely tucked back with his mother later on that day.

So, back to my 'bravery'; it was with a sudden clarity that I understood why people believe me to be brave - and it has nothing to do with me.  As I watched the team work around the woman (and I was in total awe of the NHS staff and so very, very grateful that when obstetric care was needed, we had access to it), as I supported her, reassured her, even prayed for her, I have never felt so alone in all my life; the safety net of the NHS is a strong one.    Perhaps this is the reason midwives do not challenge guidelines, or policies not based on evidence; perhaps this is why the vice on midwifery is so strong.  Not that I am brave, but because the 'safety' of working within the NHS is so strong - and watching that team, I think I understood why people would not want to 'risk' that.  Being the lone voice, choosing to leave that safety net, to be fully autonomous, to accept full accountability..... can be very lonely indeed.  The fear of loneliness is why people believe I am brave.

I am not 'brave' for choosing to be an Independent Midwife; it is a wonderful way of working.  It is 'the gold standard of care'.  It is rewarding, challenging, exciting, scary, bumpy, amazing, tiring.  It is working to keep birth normal - and safe. I am not brave...... but if more midwives were given the support to work outside of the NHS, if the government fully supported choice and continuity, if the RCM would acknowledge a group of midwives who work outside of the system, it might be a little less lonely.

angela xx

He who is brave is free. 

Lucius Annaeus Seneca 

Read more at http://www.brainyquote.com/quotes/quotes/l/luciusanna121145.html#vPE1uJcEvV29CUTm.99 

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

Feel the fear............. and do it anyway

This week has seen the launch of the Freedom For Birth DVD; over 1000 hostings of the film, across 17 countries were simultaneously held on Thursday 20th.  I was quite late to the proceedings in terms of organising, but I had a small, yet perfectly formed (!) group, attend my home on Thursday evening (including my 13 year daughter).

Within a few minutes of the start of the film, tissues had to be shared.  It was a hard and sad film to watch, to see how far some country's will go to control birth and to 'manage' birthing women; a violation of human rights.

In my small (but perfectly formed) group, we spent time after the film discussing, sharing ideas and thoughts, trying to understand where we could perhaps make a difference, what we could do on a local level, how we could encourage women to take charge of their own choices and bodies, and how we can protect midwifery in its own right.  The thread - as in the film - that kept emerging, was the FEAR that prevails in and around birth; of course, this is not a new topic in childbirth, fear, for a variety of reasons, has been part of childbirth for millennia, but we seemed to have reached an all time high - from both women and health professionals.

So what exactly is it we are frightened off?  Trying to answer this question is like trying to capture moonlight in our hands; you can see it, it's in front of us shining like a beacon, yet it moves around, changes, and although it is can be bright as day and pulls us in many ways (even if not scientifically proven), moonlight is not tangible.

Following the evening, I invited a lovely third year student to come out with me.  This student should be counting down to the end of her training, but at the moment she is so disillusioned with her journey, she is not sure how she will make it through this final year.  This intelligent, questioning, reflective woman who is following her vocation and who clearly has the potential to become a 'with woman' midwife, may become another statistic of those students who don't make it to qualify.  We shall call this student Sophie:

Sophie accompanied me to a consultation with a couple who would like to book me as their midwife.  This professional, well-informed, capable couple have already made many decisions around their pregnancy, including choosing, amongst other things, not to have routine ultrasound.  Sophie and I spent time reflecting the consultation; she wondered if I worried about attending a birth where no ultrasound could reassure me baby was 'well'; she wondered if I worried that if a women who chose not to have routine bloods might be anaemic; she wondered if I worried that a women might refuse to take clinical advice I offered.  She did a lot a worrying.  Underneath all this however, it was apparent that Sophie's trust in nature, in women, in birth is being slowly eroded; she has been 'taught' to have a deep fear of the pathological - instead of a deep respect and acknowledgement that

 "Some births in some circumstances sometimes need some help", Mary Cronk.  

As for me, being questioned and exploring these questions enabled me to reflect on my practise; and what emerged for me was that as a midwife offering continuity of care, a relationship of trust emerges with  women, we have time to explore their health, nutrition, and self-care.  Concerns around the 'motherbaby' well-being can be picked up quickly as listening to the woman, feeling her baby grow, and being involved in all aspects of her care enables you to identify changes that (as a registered health-professional) you respond to.  Supervision is also a big part of my practice, as I will talk to my SoM about putting into place plans and documentation for women who may be making choices that challenge the 'status quo'.

So how do we work in a culture of fear?  How do we empower women to trust their bodies? How do we inspire the next generation of midwives to practise autonomously - and without fear, but with respect?

In all honesty, I don't know!  But, I plan to - as long as I am capable - try my best to work towards answering those questions; to protect birth; protect women; and to protect my profession as much as I can.  Burn out is high when you are passionate, so of course this needs to be balanced with protecting me (and my family), but I find it hard to sit still for long, or to ignore what my heart and soul is shouting.  I shall, as long as I can, feel the fear...... and do it anyway!

“The best thing you can do is the right thing; the next best thing you can do is the wrong thing; the worst thing you can do is nothing.” -Theodore Roosevelt

angela x