Liberating childbirth: a lecture

This is a new posting of a lecture that I originally gave in 2005. It was published (in a slightly different form) in the AIMS Journal 2005, Vol 17, No. 3. It felt timely to repost.

 It was my first baby.  I had booked a homebirth but had been transferred in for lack of progress and possible mec after 18 hours.  In hospital I had been put on a drip and suffered agonies without any pain relief.  All of a sudden, at the darkest hour I felt it. . . was like a pop inside, my contractions felt different and I felt that maybe this baby was going to be born!  The midwife was summoned (yes it was shared care)  “I think I want to push” I told her.  I was examined>”You are 10 cms but let a doctor check you”.   I was surprised but asked “where is the doctor?, when will he be here?”  “In about 15 minutes came the reply.  I said to the midwife “I have waited 24 hours to have this baby.  I am not waiting any longer.  You are a midwife!  Do your job! “  However I did not say it quite as politely as that.

This little cameo encapsulates much of what I want to say today about what needs to change in the birthing care women receive today.

In this country we do not have woman centred care we have consultant centred care.  Woman centred care is where the care revolves around the woman, her wants needs and foibles.  Care is based on mutual respect and open access to information, the woman speaks directly to the professionals who control her care, and these professionals will refer the woman to specialists if and when this maybe needed.

With consultant centred care a doctor who you may never see or meet dictates the choices you can make for birth. The consultant is at the top the hierarchy, the centre of the wheel.  The service we receive revolves around their interests, wants, needs and foibles.  The needs and wants of the birthing woman are subjugated to him/her.   For example Bradford does not have a birthing pool, not because women don’t want it – they were never asked – but because the consultant does not want it.

Consultants are specialists in abnormal birth, skilled in dealing with the medical problems that may occur in pregnancy and birth and they save lives and we are grateful for that.  However, we do resent the way in which this has been done, taking away our autonomy as women, the professional independence of midwives, and exerting authority over normal birthing which is outside their specialism. 

For example: in Bradford, rather than the experts in normal birth, midwives deciding on the merits of birthing pools as pain relief in normal births, it is the specialist in abnormal birth, the consultants who make the decision.  And so it was that  a senior midwife had to visit me at home and we both had to sign to say that she had told me how bad it was that I should choose warm water for my pain relief.  And so it was that at my second birth 8cm dilated, in transition, one of the midwives spoke up and said:”  “At this moment, I have to ask you to leave the pool as it is not Bradford Trust’s policy to allow you to remain in the pool for the birth.”  I politely refused and proceeded to give birth in the pool unimpeded – but what a farce!  So even though my consultant was not present at my NHS births, he was present in the actions and words of the midwives who were.

So when we women are not the centre of our care, reality is defined, not by us, the birthing woman, but by the (absent) doctor.  And so in my cameo, what carried weight was not my description of what was happening to me, nor the opinion of a trained midwife’s examination, but only the hands of the doctor. Only he could inform me that I was in second stage.  And one of the most shocking things I find about the medical literature is how little medicine thinks to ask the woman! 

And so we have a culture of disbelief which does not consider or validate women’s experience of birth.  It is the doctor who really knows what is going on and so women have stopped believing in their bodies – they can no longer read its messages, and midwives are trained to defer to doctors and machines rather than their own eyes and hands and expertise of normal birth.

It is a phenomena that has its roots in women’s socio-cultural standing through history.  The feminism of the sixties did not challenge it, but we must do to retain our dignity as birthing women, mothers and midwives.

Furthermore, the Historical dominance of the male doctor and the medicalisation of birth has produced a false dichotomy between the welfare of the mother and that of the baby, pitting the welfare of the one against that of the other.  The most common example is to tell the mother that she is putting the baby AT RISK if we do not do as we are told. I have mercifully been spared this experience but so many friends and customers have been threatened with the dreadful risks to their baby of having a homebirth – sometimes after the healthy baby has been born! 

But more insidiously the medical orthodoxy tells women unhappy with their treatment at birth, that they should stop complaining and be grateful for the healthy baby received from their hands.  It took me to my fourth child to make a complaint about the care at my birth.  Their response was of this very kind – as if the birth of a healthy baby was down entirely to them and I did not play any major role. 

What I WANT TO SAY LOUD AND CLEAR is that a healthy mother and baby does not excuse substandard care, lack of respect and unnecessary intervention.  We women want it all – a healthy baby and a good birth and I believe we are entitled to expect it without apology or qualification.  It is not an either a good birth or a healthy baby, it is a both: a healthy baby and a good birth.  What makes a good birth is not an ideal birth but one where we are satisfied that what happened was as right as it could be.  This false dichotomy is a product of our social standing as women, and the centrality of the medical perspective of birth.  And we need to challenge it.

And midwifery.  The midwives who had been so central to my care at home, who had been confident and competent professionals, became invisible under the bright hospital lights.  I remember my GP God Bless her, confronting every doctor who walked into the room with the words:  “I am Dr Eisner, Mrs Weston is my patient and she will want all the interventions explained and discussed with her.”  The midwives said nothing.  Not out of a lack of compassion but because they were not independent professionals in that setting but servants doing as they were told.  And for me as the woman, user, that rendered me both vulnerable and alone because I had no advocate and no protection.

The demise of the independent professional midwife has its roots in the socio-economic, discrimination of women down the centuries and has been documented by greater souls than mine – but I can tell you the contemporary results from a users perspective:

The midwife in hospital and increasingly in the home has become silent and complicit in the mistreatment of birthing women and their partners.  They can act outside their own professional code, their motherly compassion and sometimes downright common sense and medical evidence, in order to fulfil their contract with the consultant led medical hierarchy.  Even the independant minded NHS midwives conspire with the system becoming what my mentor, radical theologian John Vincent calls “the soft underbelly of the oppressive state”, mitigating the cruelty with kind words and ameliorating the rules with subversive practices.  I don’t denounce this care but we do need to recognise its limitations.

Three examples: 

  1. one: my wonderful NHS midwives more than once responded to one of my more outlandish suggestions>”I know, I know, Ina May Gaskin might do it but it is more than my job’s worth”. 
  2. Two.  A senior midwife photocopied the manual on how to handle a natural third stage to attach to my notes because it was likely that I would have a midwife who had not practised a natural third stage.  –  Is that scary or what!  Midwives unable to oversee a normal third stage because they have only been trained in an unproven medical intervention. 
  3. Third.  I find it difficult to forgive the midwives who stood at my rear end at my first birth shouting instructions at me as if I were an animal.  I called that birth my crucifixion: I felt like I gave birth in fear and agony gazing at a white hospital wall and a drip machine.  I was not important enough to be spoken to face to face.

Please be clear.  I am not saying all this to rubbish NHS midwives as individuals, but as a user I need everyone to be clear what are the consequences of midwives complicity in and enslavement to, the current medical system.

So what are we going to do about it?  How can we change the scenario and make that young midwife of my story in to a confident professional.  How can I come to receive the care of a midwife who I can trust not to leave me in the crisis but who will advocate for me and support my birthing.

 

Part III: Tools for change.  Subversion, avoidance and confrontation

 So what are we going to do about it?  How can we change the scenario and make that young midwife of my story in to a confident professional.  How can I come to receive the care of a midwife who I can trust not to leave me in the crisis but who will advocate for me and support my birthing.

 Well first of all the change starts here with me and you.  I need to decide within myself that I do not want to play the game anymore.  I am neither going to be a victim of it or a stakeholder in it.  I am going to be the woman, mother, midwife I am, and be confident and sure of my dignity and worth.  Believe you me as a long time campaigner I have learnt that they can take your job, your financial independence, they can mock and ridicule and demean you but if you know your true worth and stand within that, they ultimately cannot touch you or win out against you.  

So cultivate your soul, your personhood your faith whatever you call it, and stand tall as the woman, mother, midwife you are.

Then we have to start asking Why.  And you will find like Ricardo Semler  – the radical and successful businessman and entrepreneur – that you need to ask the question tow or three times consecutively.  The first time you will get the pat answer, the second time you get a a more carefully constructed explanation, the third time – that is when you start getting a feel for the strength of the underlying argument.  Anyone who has a pre-school child will know what he is on about.

Ricardo says that any policy that cannot stand up to the second or third why should be ditched.  I read his book at Christmas and I am trying it out – I invite you to do the same.  As Whyse women we need to get behind, pat answers, we have always done it this way, custom and practice.  Phrases like: What evidence do you have?  What follow-up research has been done?  Has anyone researched this? Why not? Who did the research? 

We may be powerless to say it to their faces but always ask the question in your mind.  Always be asking yourself ‘why’ – it is the fundamental tool for change.

This maybe so, but  Women who stand tall alone tend to be ignored, ridiculed or shot down.  The medical system picks us off midwife and mother one at a time.  We are defeated birth by birth, woman by woman by the weight of the system.  So as my mother used to cry faced with a buffet to be eaten:  Women of the world unite!  It is time to organise, unionise, and here is how:

There are three ways to work against an oppressive system:

  • Subversion
  • Avoidance and
  • Confrontation

SUBVERSION

Subversion, I would suggest, is what many midwives and mothers practice now.  For example, after my second miscarriage, when I refused my D&C I was put under enormous pressure by the doctors.  In between one of the rounds, I sat on a stool in the laundry room and sobbed – because after all I was a grieving mother – and a nurse came in and put her arms around me and whispered in my ear “Its your body, love, you can do what you want with it.”  For example: it is the midwife who at one of my births said “I should call the ambulance and have you transferred right now but I am not going to.  You are going to have your homebirth.”

Women subvert the system often unconsciously by smiling sweetly and doing their own thing – and calling the midwife too late to do anything about it. . . At the birth of my fourth child, during my labour, we were told that there was no midwife available competent to attend my waterbirth.  When told this my husband smiled and said to the attending midwife “That’s OK I have attended two waterbirths and Jeanie here has attended one – we will tell you what to do.”  Thirty minutes later three mdwives had arrived!

Subversion is the valid defiance of the powerless and I want to encourage it.  Like rabbit burrows and wood worm it can undermine big structures and edifices.  But I doubt whether it will be enough to bring the whole system tumbling down even if it grinds it to a halt.  We need to do more.

AVOIDANCE

Avoidance is another form of opposition.  It is practice by women and midwives alike.  It is where you circumvent or bypass the system altogether.  So you become an independent midwife or you engage and independent midwife, or go to a birthing centre (Do you know a woman was accepted for a local birthing centre but then she got a letter out of the blue at 36 weeks telling her that she was no longer eligible – no reason was given)  or you plan an unassisted birth.  Some women have even left the country in search of the birth they want. 

This action is costly for the protagonists.  Midwives give up security and income and invite the hostile attentions of the medical establishment.  The families who engage independent midwives or birthing centres pay substantial sums – for us fifth time around it represented 15% of our then income.  Unassisted birth invites the hostile attentions of the medical establishment – for how is a woman to give birth without a medic to ensure she does it correctly!

Those of us who have practised avoidance one way or another and have paid handsomely for the privilege will probably say that one way or another it is worth every penny and every sacrifice.  But it can be a difficult road and so we must recognise that it is an important part of the opposition because it is providing an alternative model and practise.  It shows that the alternative is realistic, workable and effective.  Like the radicals and nonconformists of the past we must take courage and be proud.  We have done it because (to coin a phrase) we are worth it.

CONFRONTATION

Confrontation.  Ah this is the difficult one because we are so well conditioned not to make a fuss and to do as we are told.  And of course we cannot win because if we are nice nobody listens but if we get angry we are dismissed as emotional neurotic bitter women.  Sadly the feminism of the last century has not overturned these cultural norms particularly in the maternity services.  But I want to say to you now that silence is complicity and doing nothing for change is actively supporting the status quo.  Ultimately to bring about change we must confront the beast and bring it down.

My husband is an archaeologist and he says that ancient human hunters knew that they could not kill large prey like bison and mammoth with one shot of their little arrows.  So what they did was make arrows that did not kill but made very messy wounds.  They aimed arrow after arrow at the beast making such a bloody mess that the beast finally bled to death.  We may not be strong enough to bring the beast down with one shot but if we fire arrow after arrow at our prey, aiming to make as big a mess as we can with our puny arrows, it will finally fall bleeding from a thousand wounds. It is not a pleasant picture but it illustrates the tactic very well.

There is a problem in that for women like myself the moment of confrontation happens at our weakest moment on enemy ground.  And so I would say we need to organise, we women do not just need advice we need advocacy.  We need someone at the consultation acting as a witness, if necessary a spokesperson and advocate.  There is precedence for this in many areas of advice work.   We need someone strong enough to help us say no when we want to say no.

Midwives have told me about the bullying and the bullying culture, the fragmentation, the lack of cohesion.  Unfortunately this is not uncommon for an oppressed group.  It reminds me of some advice the late veteran MP Tony Banks once gave to a new MP  – your opponents sit opposite you, your enemies sit behind you”.  Oh that I had had that piece of advice when I worked for the church!  I suspect that if you work for change some of your toughest and most hurtful opposition will come from colleagues.  Be prepared for that and start thinking of ways to deal with it.  Here are a few of my ideas I am sure we can come up with more:

My experience of working with deprived groups in Britain is that what you need in a particular place is just a few people getting together and organising, for change to happen.  But we also need groups of midwives at local and district level deciding not to play the bullies game and supporting one another, and supporting one another in pressing for change and combating and withstanding the bullying.  And we need a network of women and midwives who will turn up and be there to support midwives and women being taken to the cleaners for their good practice.

And midwives need a union not a royal College.  You need a union, a NASUWT, a NUT an AMICUS, a union with a track record of sticking up for its members through thin and thinner, and who campaign vigerously for change.  You don’t have such union representation at the moment and you are suffering for the lack of it.  Some one or some persons need to put their hand up and sort out a union or two to campaign and protect midwives.  Don’t even bother to pay your subs to any association that does not have a good reputation for standing up for its members because you will be wasting your money and your good faith if you do.

And what else, well we need groups of parents to band together for letter writing sessions to challenge  current Trust policy and change legislation.  We need groups who will band together to do some high profile direct action and publicity stunts.   A vicar and a 60 year old woman hit the headlines and raised the issues of council tax for being willing to go to prison.  And I am telling you they were being backed by a strong organised union, they had their supporters in court with them.  And imagine a babysit in.  Imagine a squat in.  Imagine an impromptu NHS nativity play.  A Midwife ducking! What about a t-shirt group producing T-shirts.  Confrontation can be fun too – and needs to be to relieve the tension.

To conclude:

And so to bring about the change we want we must repeatedly ask the question ‘why’ and not accept the pat answers, and we must be subversive, and we can practice avoidance and set up independent structures . . . .but ultimately ultimately we must confront the beast.

And we need to be determined, cunning, fun.

We need to band together to organise and unionise,

 to write letters and demonstrate

And we need to educate, educate, educate.

Talk to our daughters, sisters, mothers

Talk to our sons, and husbands and brothers (after all they have 50% of the vote)

And we need to fearlessly claim our heritage to birth and bring to birth,

To be the women, the mothers, the midwives we are

We need to campaign as determinedly and creatively as we give birth

Because our daughters are worth it

                                                            – and so are we.

 

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PHE advises temporary suspension of heated home birthing pools filled in advance of labour in home settings.

Please be clear this alert is NOT for baths and birthing pools filled from domestic or hospital hot water systems then pumped out when cold/dirty or then going through normal plumbing. This IS for heater filter units which re-circulate warm water. This is not about these circulatory systems being innately dangerous either – just that the sanitzation and effectiveness of all units now have to be checked to ensure safety before being hired out or used. There is a potential for contamination if the unit is not fully disinfected, or the unit is not working properly or the users do not follow the strict instructions. Investigation is under way. So if you have one, lend one, or hire one, then contact your local Health and Safety Dept at your local authority to get advice on ensuring this awful situation does not happen to you, a loved one, or a customer.

 Every good wish

Ruth@Aquabirths

 https://www.gov.uk/government/news/alert-after-legionnaires-disease-case-in-baby

Press Release Text:

Public Health England (PHE) and NHS England have temporarily advised against the home use of birthing pools with built-in heaters and recirculation pumps, potentially filled up to 2 weeks in advance of the birth. This follows a single case of Legionnaires’ disease identified in a baby born in this specific type of birthing pool at home. The baby is currently receiving intensive care treatment in hospital.

Samples taken from the heated birthing pool used have confirmed the presence of legionella bacteria, which cause Legionnaires’ disease. Tests are ongoing to establish if it is the same strain which infected the baby. This is the first reported case of Legionnaires’ disease linked to a birthing pool in England, although there have been 2 cases reported internationally some years ago.

NHS England has today issued a Patient Safety Alert rapidly notifying the healthcare system – and specifically midwives – to the possible risks associated with the use of these heated birthing pools at home. The alert recommends that heated birthing pools, filled in advance of labour and where the temperature is maintained by use of a heater and pump, are not used for labour or birth. In the meantime, a full risk assessment into their use is being carried out.

The majority of birthing pools used at home are filled from domestic hot water systems at the time of labour – these birthing pools do not pose the same risk and are excluded from this alert. There are no concerns about these types of pools as long as pumps are used solely to empty the pool and not for recirculation of warm water.

Professor Nick Phin, PHE’s head of Legionnaires’ disease, said:

This is an extremely unusual situation, which we are taking very seriously. As a precaution, we advise that heated birthing pools, filled in advance of labour and where the temperature is then maintained by use of a heater and pump, are not used in the home setting, while we investigate further and until definitive advice on disinfection and safety is available.

We do not have concerns about purchased or hired pools that are filled from domestic hot water supplies at the onset of labour, provided that any pumps are used solely for pool emptying.

PHE and relevant local authorities are investigating the infection control measures required for this type of birthing pool and local authorities will be working with the small number of companies who supply these heated birthing pools for use at home.

Louise Silverton, director for midwifery at the Royal College of Midwives, said:

Women planning birth at home using a traditional pool that is filled when the woman is in labour or using a fixed pool in an NHS unit are not affected by this alert and should not be concerned. Birthing pools in hospitals are subject to stringent infection control procedures and monitoring. Home birthing pools filled during labour come with disposable liners and are only in place for a relatively short time period, reducing opportunity for bacterial growth.

Any women with concerns about using home birthing pools should contact their midwife or local maternity unit.

Legionnaires’ disease is extremely rare in childhood, with only 1 case in children aged 0 to 9 years reported in England between 1990 to 2011.The infection does not spread from person-to-person – people become infected with the bacteria through inhalation of contaminated water droplets.

Dreaming and Practice: Notes from Midwifery Today Conference 2014, Bury St Edmunds, UK,

midwifery today conf 2014midwfery today conference 2

Midwifery Today Conference May 2014, Bury St Edmunds

These are some notes taken at the conference but they are really only a small representative sample of the practical workshops, seminars and main sessions attended. Most of all I met strong, inspiring courageous midwives, working sometimes against the odds , for good birth.

The strongest memory: Outside in the dark watching an amazing fire eating display by a midwife.

Quote of the conference: ‘I’ll give myself a treat and go and have a pee.’ Sara Wickham: “Having a pee is not a treat!!”

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Jan Tritten and Robbie Davis-Floyd – International Activism

Jan Tritten’s Introduction:

Quote Harriet Tubman ( the anti slavery activist):

“Every great dream has a dreamer”

Barriers to YOUR dream include: Fear – the antidote to this is Faith

Answer the call – stories of women around the world who have felt a call to midwfery and have had health and other problems until they answered the call.

  • Lies and myths are rampant
  • But we have dreams and callings to follow
  • Birth is sacred ground
  • We are called to a calling to change childbirth and to the benefit of both women and communities
  • What is YOUR dream/vision?
  • Don’t share dreams with negative people
  • Take first step then next step – implement your dream one step at a time
  • Dare to dream and dare to do it.

Participants in the workshop shared their stories:

NZ Chair of Council of Midwives shared their work in Bangladesh setting up midwifery led birth practices with good effect.

Midwife in Philippines told her story of being called by the local Bishop to set up a clinic in the Church because of his concern for the health and wellbeing of local women ( the hospital care was not good enough)

She talked of the importance in her practice of trusting the Higher One she also said that ‘what you believe can be done’

Robbie Davis-Floyd talked about the IMBCI and the 10 steps for implementation of mother/baby human rights.

She talked about the 4 demonstration sites about the world. the full stories can be found on the IMBCI website

One is in Brazil, in a hospital which has now become a ‘high risk’ hospital for high risk women in the region. Even so their CS rate is 25%. Every woman there has a doula.

Then the amazing story of Mercy Mission in the Philippines with their birth centre in a poor district ( recently flooded they piled the beds up on top of each other so women could birth out of water and midwives wading in the water – coz women still coming to birth!)

They set up a maternity clinic in the disaster zone last year, in tents, with no water, no electricity and no sanitation, women traumatised and lacking food and essentials – but still implementing the IMBCI 10 steps.  they maintained their 2% CS rate even within this situation. Amazing work – worth looking up.

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Fear in Midwifery and Birth Workshop by Eneyada Spradlin-Ramos and Elena Piantino

Fear is not necessarily a bad thing – it can be a signal that a change is taking place, a call to pay attention, of the balance being changed. Fear is not necessarily a bad thing

Richard Davidson of Harvard re mindfulness – be aware of changes within yourself and room.

@ finding homeostasis for the brain
Homeostasis is the brain in equilibrium/balance. A perceived threat or stressor upset s homeostasis our balance – there is a response eg- fight or flight or fear. Then there can be a process of adaption to a new homeostasis.

In some contexts, the adaptive process makes midwives immune to situations (eg in a medical hospital context on large busy labour ward) that can upset or hurt women – midwives can act without compassion because they have adapted to their context and no longer feel the stressors and fear.

Fear alters our perception of risk and danger and it numbs empathetic responses
eg. homebirth – perceiving risk where evidence does not
decision making effected by emotional stress

Antonio Damasio, Neuroscientist found that brain damaged brains that cannot feel emotion also cannot make a decision.  He said: ‘Every decision is made with a cognitive balancing and tipped by an emotional factor.’

Fear affects labour – blood for fight or flight goes to arms and legs but not for thinking.  No blood to womb so contractions go off, fear tension pain cycle.

Coping with fear/uncomfortable emotions –

Short term coping mechanisms are:

Keeping busy, withdrawal, distraction and parties, letting off steam on other people (shouting and intolerance), expecting and working for the worst, abuse of substances etc.

Positive coping mechanisms:

Recognise triggers, know difference bet feelings and reality
Be aware re feelings/fear: is it history and memory ( what happened last time), is the fear coming from another person in the room, or what someone has brought into the room from elsewhere?
Emotions – is fear coming from in me, of from outside
Express/feel emotions, acknowledge and accept them – not block or repress them.

Other coping mechanisms: journalling, art therapy, red tent sessions ( safe spaces to share feelings without judgement or advice).

Red Tent specific experience:- talking stick. With stick – talk not interrupted. People can and do cry – but nothing said, no advice just accepted.

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Twins  – with Jane Evans

Notes pick up when Jane is talking about nutrition:

Everything is the same more but more!

Tweak the diet because pregnancy is not the time to completely change diet all at once.

Mums need plenty of protein for growth; Vit B and Vit C – via whole grains and meat.  Complex carbs via beans and pulses.

Problems in pregnancy is often to do with liver problems – 2 babies twice the stress on the liver. So beans and pulses needed. If Mum not into lentils – suggest brown rice once a week as ‘medicine’, also soya, quinoa etc. As an aside: This is why students survive for years on beans on toast – cheap and nutritious. all there to support liver.  Mums need to drink plenty of water.

Salt is important: good sea salt. Himalayan pink salt. Can test if woman low is slat ( sodium?) give her glass of water with half, the teaspoon of salt – if she not taste a glass of water with salt in it then she is low on sodium. Also if woman eating crisps and chips etc. say they are needing salt so instead of eating crisps and chips and processed food add salt to their food instead. found that having enough salt in diet/body reduces swelling odeoma and incidence of pre-eclampsia.

Make sure eating iron. if not meat eating make sure getting it anyway.

Nutritionist in group said: they have worked out woman needs 300 calories extra over normal diet when pregnant, breastfeeding need 500 calories extra. It will be more for twins – up to double? Tweak diet and change it gradually.

Keeping woman safe and healthy through the pregnancy:

Not just check haemoglobin. also look at mcb, hcb .  Reason Eg. You can have normal haemoglobin but low ferotin and have problems mcb 70-99 normal so don’t iron supplement. If symptomatic then check ferotin. to supplement, avoid pharmaceutical iron which has bad side effects and not easily absorbed – try spatone ( favoured) also floradix.   Food and nettle tea also suggested.

Tweaking diet gradually:  Eg.ple feel better after eating veg so encourage to eat more veg. This starts a good habit for feeding themselves and their children in the future.

32-34 weeks is the crunch point – at this point need to make a big issue of food. There is less room for food but need to be constantly eating – feeding the babies. If you can get through the 32-34 crunch time to get calories into woman and babies, then the pressure is off after and then they can eat back at normal pregnancy rate. If this is done then pregnancy normally goes to the natural term – whatever that might be.  Normal term is usually the length of pregnancy for her previous (singleton) baby. (One example:1st baby 40+12, twins 40+11 days)

Concern: Induction of twins at 37 weeks – why do this when infant mortality risk of twins is at 37 weeks – so why induce at this dangerous time. why not wait until babies are ready to come out?

Obstetric practice. Concern re serial scanning. Research show that the thing that scans do is restrict the growth of the baby – so routine scanning is not good for the babies’ growth rate.

Palpating is good. then scanning when it is needed – scanning: need it when need it but not for routine. Midwife should palapate regularly: you are saying hello to the babies so they know you & you know them. Ask mum what she is feeling. Check differing sizes and think if differences are normal or pathological eg could it be boy/girl differing physiology. If you have concern offer scan to check.

Position of Babies for Birth. ‘Twin babies dance all over the place’ – 2 babies move about more than 1 baby. For birth the most stable is head down head down – but they can move as birthing. Eg. first baby head down for birth, when 1st come out then other baby will change position to birth –  unless lying on back(obstetric method)then movement is restricted.

Leaving cord attached after birth of first. As contractions start for the second the cord starts closing down so cut cord and give baby to dad.

Timing between each baby – does it matter? Listen to the heartbeat if all OK – wait. For mum contractions usually restart after half and hour.so if baby ok why rush it? Heartrate (decelerations) can drop very low. if baby ok before prob ok – keep listening and if a continuing problem ( eg baby’s heart rate not pick up) then need to act. Between babies, cervix can pull in – eg to 5 cm but dilation is fast.

Placenta. Some women want to push out placentas.
Remember there is alot of placenta: ‘two handfuls of placenta’. Jane holds to cord of first baby ( which has been cut) as bearing down. Very satisfying to have one big one out. But often placentas will abut as one placenta can support the other. Placentas coming out separately not like as not know which one is which.

Remaining upright during births is what works – this point repeated several times.
About 25% of her twins babies have to have a cs despite their care.

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The following notes are from an unscheduled session so I do not have name of the speaker, however, the following was too interesting to omit!

Quote from Grandma Beatrice, South Dakota who told twins birth story. She said she washed her hands then moved baby so baby born safely. Asked how she knew what to do, she replied:
‘Mother knows how to give birth, woman knows how to help’

Working in a remote area in Afghanistan setting up maternity services
Talked about how women generally treated – photo of a man with a whip fighting women back trying to get food.
Early marriage – photo of woman who aged 15 got married to 70 year old man had 10 children, he now dead.
She went with French NGO, decided to work with traditional midwives as they are always there – ngos will leave
But then Afghan Government adopted US/CMU programme to get rid of traditional midwives and train new set of midwives. They worry: it will be white uniforms and hosp care and this not work in poor remote areas.
Talks about looking at US aid programme and traditional midwifery program and how we bring them together. Lack of life choices: Choice for these women is having access to ANY care or none

‘We want local women and mothers to be the experts not us. We are wary of coming in and telling them what to do and what is happening.

Inuit in Northern Canada. How to preserve the tradition.  Women not telling their story because they do not speak/write in English or other mainstream language.

Photo: This how women Inuit traditionally give birth, isolated in their own little hut/igloo. With fire in there. Very hot in there and steamy .
The amazing story of the Inuit people. Harrowing story of oppression and suffering. Then one community took birth back for themselves, replaced the medical man with a strong Anouk woman. Made decision not to continue the medical practice of taking the women away from their communities for 6 weeks around birth, to boarding houses by hospitals thousands of miles away. They knew that some women might die if they not travelled to city hospital for 6 weeks – but the disruption and damage to family and community life so great that the community decided to take that risk. However, outcomes vindicated their decision: although no immediate access to cs – 8 hours (until recently, now 2 hours) – their outcomes have improved anyway. The old prescriptive hospital model did not work for outcomes either!

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Sara Wickham – Homebirth Emergencies in Perspective

Sara Wickham’s session was excellent and way over my head as a lay person.  Midwives please do not use my notes as an alternative to spending time with Sara the expert!  Find her website here and book a session with her: http://www.sarawickham.com/

The more we deal in physiology the less likely we are to see an emergency. Also find that there are fewer emergencies the longer you are in practice Experience and normal physiology support safety.

Piece of recent research: proportion of cord prolapse associated with ARM
(2013) Results:  risk of cord prolapse at home is vastly reduced because the key reasons for cord prolapse above are not done in home/physiological practice. Research showed that as practitioners got better at supporting physiological 3rd stage then incidence of pph reduced. There is alos the question of measuring blood loss/defining pph.

Cases of ‘Safety Labour’ – women have a very long slow labour, eg. one case 40 hours because short cord and needed long labour to descend safely (and gave birth choosing lateral lie and leg up). Another example: slight heart defect and so need a long gentle labour – fast one would be too much.

Necessary Prep for Home emergencies:  which included making sure you had good backup, looking after yourself and making sure you had the right equipment checklist and rountines.

Other tips included, working with people you trust, dont’t fear fear doing the dummy run! Oh yes and be ready to ask for help or check stuff when you need to!

Why aren’t all emergencies equal.

Sarah’s Top ten tips for emergencies

Sarah then went through the research showing the incidence and circumstances of emergencies. Basing it on a homebirth caseload of 25 per year. Some of the emergencies on this baisis would be about once every 63 years! I was not able to get all the figures down but they were extremely interesting.

Eg. Incidence of pph in home environment based on 25 HB’s per year = 2-4 years; serious one every 5 years. This reduces with practitioner skill.

After looking at the incidence of main obstetric emergencies pertinent to the home environment, Sara said there were just three skill sets most needed regularly! So make sure you have these skills most practiced and uptodate
Other emergencies will happen between once in 20 and once in 50 years.

Sarah finally talked about her pph emergency kit which included the partner!