Birthspirit - Page 4 of 6 -

Insights through the murk of meconium-stained liquor

Posted on February 12, 2014 by birthspirit

Originally published in Essentially MIDIRS 2011; 2(9): 47-49. Revised

As I compiled the statistics of my home birth practice covering a 22 year period many of the individual instances of how my knowing developed became definable – the watershed moments which influenced my ongoing practice. This post elaborates two such moments during the care of one woman, relating to both meconium-stained liquor (MSL) and as to how I position myself with women.

gardenofholiness.blogspot.co.nz/2012_06_01_archive.html

This began with a phone call from the husband of a woman I will call Arlene informing me, “the waters have broken and they’re slightly cloudy.”

Exploring ‘slightly cloudy’ revealed a picture of meconium-stained liquor in early labour which warranted an immediate visit to Arlene, now at term with her first baby. I contemplated the unknowable as I drove to her home nearly 25 years ago – was this baby just one of the nearly 9-12 percent of babies who pass meconium in labour Katz & Bowes (1992); Paul et al (1989)? Would he ‘escape’ meconium aspiration syndrome (MAS)? Meconium-stained liquor had always been written in red on the ubiquitous Delivery Suite board as a flag reminding all that this baby ‘needed’ a paediatrician at birth in what had beome a ‘high risk’ labour. It was this culture that I had initially brought with me when I commenced home birth practice in 1989. As I drove to her home, I was comforted by the knowledge that Arlene was well and her baby was moving but I felt disappointed at the thought that I would be recommending transfer to hospital from her planned home birth.

The towel which Arlene had used to mop up the liquor showed heavy, fresh meconium-staining; her pad exhibited fresh smudges. Palpating her abdomen, her baby, who had been in an LOP position at our last visit 5 days earlier, was now ROL with his head not yet fixed in the pelvis. Listening to the heart beat indicated a baby who was coping well with labour, which was now well established. As part of the routine assessment I had used when attending women in hospital, and which I used early in my home birth practice (though soon abandoned), I performed the ritual vaginal examination. This revealed a very posterior, closed and thick cervix; I could only just tip the baby’s head with my finger. This information did not tally with the strength and frequency of Arlene’s contractions; her cervix had not ‘caught up’ with the labouring she was doing.

Following this assessment and some discussion, I recommended that we transfer to the obstetric hospital so I could “monitor the baby closely and suction him at birth”.

“Can’t you do that here?” she enquired.

“Well – yes – I can,” I responded. I was skilled in intermittent auscultation, and over 2 years working in a neonatal intensive care unit prior to midwifery registration had honed my suctioning skills.

“Then, I don’t want to go to the hospital!”

Arlene would birth at home nearly 9 hours later, her baby having rotated progressively into an LOA position prior to birth. Throughout labour, the baby had continued to move and his heart tones, the rate of which never missed a beat, were punctuated with early accelerations as the contractions started, with a return to his normal baseline heart rate following contractions. The release of the meconium had been an early labour incident only, perhaps as a stress response to his head being firmly pressed while pivoting on an initially ‘unyielding’ cervix; by the time of birth there was only faintly stained, old meconium present. I had suctioned him once his head was born over the perineum, again simply following the ritual used in the obstetric hospital from which I had recently departed. Baby had excellent Apgars and required no further ‘treatment’. Arlene was aware of what his normal breathing pattern should be and would contact me if she had any concerns about his breathing, which did not occur.

Getting to grips with meconium-stained liquor

As has repeatedly happened over the decades following an ‘out of the ordinary’ practice experience, I began a ‘watching brief’ of the literature, this time on meconium-stained liquor. By 2009, midwifery colleagues around New Zealand reported that the practice of oro- or naso-pharngeal suctioning of newborns was no longer a routine treatment for MSL, but this was 5 years after publication of the Vain and colleagues’ Vain et al (2004) large randomised controlled trial (n=2514) concluding that suctioning does not prevent MAS; the change had coincided with the 2009 instructional message Vain et al (2009) to desist from the practice. This was nearly two decades after the Linder et al (1988) prospective study of 572 vigorous newborns with MSL determined no benefit and, indeed, harm to newborns in suctioning under view, a finding supported by Paul et al (1989), and a decade after meta-analysis confirmed the lack of evidence in suctioning vigorous newborns to prevent MAS Halliday & Sweet (1999). I had also found a lack of evidence to support which equipment to use – bulb syringe or DeLee suction Locus et al (1990), yet penetrating suction catheters which damaged delicate mucous membranes and initiated bradycardias following stimulation of the vagal nerve continued to be used in my region, and babies continued to be suctioned on the perineum despite a lack of difference to the incidence of MAS shown between late or early suctioning Falciglia et al (1992). No correlation was found between consistency of meconium and MAS Trimmer & Gilstrap (1991) in the early 1990s, yet, as mentioned previously, routine suctioning to prevent MAS did not appear to change in New Zealand hospitals till 2009. It was as if a routine intervention could effectively be introduced immediately with no or minimal evidence to support it but an intervention could only be withdrawn after decades of papers being published indicating a lack of benefit or actual harm relating to the intervention.

A year of tracking this early literature after Arlene’s labour and seeing how little of the evidence was incorporated into the ‘routine’ care of meconium exposed infants was the initiator for me to no longer rely on protocols or guidelines but to instead search out the evidence myself. As a result, my own practice changed. That year coincided with me starting to value my own midwifery experiences as another valid form of evidence. I witnessed babies coughing on the perineum and meconium-stained liquor draining freely from babies’ mouths and noses prior to birth and it made me further question the value of suctioning in the presence of meconium in an otherwise normal labour.

I also stopped recommending transfer to hospital with MSL in the absence of abnormal heart tones, though, for the majority of the time, there was no real option of transfer as the membranes tended to rupture with the onset of spontaneous pushing or following birth of the baby’s head. I came to believe that this timing was probably the result of avoiding unnecessary vaginal examinations in labour and, therefore, avoiding exposure of the amniotic membranes to synthetic substances, such as latex or vinyl, which may weaken them.

A practice that also changed was the other thread to Arlene’s story.

Securing my withWoman position

During Arlene’s labour her decision to remain at home sat well with me but this incident happened prior to the return of midwifery autonomy in New Zealand in September 1990. It was a time when midwives were required to have a medical practitioner over-see their practice, including domiciliary midwives, as homebirth midwives were then known. This was an in limbo time when midwives did not have access agreements to provide services in hospital and the very few of us who practised in homebirth did so with varying degrees of support or obstruction from hospital staff Banks (2007).

clipart-finder.com/clipart/scalesofjustice646.html

With Arlene’s declining hospital transfer, I had felt in a tricky position. While the general practitioner was comfortable with the refusal to transfer, he did not practise obstetrics in the local hospital and I knew he would not experience the fallout if transfer was needed later in labour. Rather than seeking instruction on what to do, I wanted to try to temper the criticism of my practice that would eventuate from the staff at the obstetric hospital. I wanted to engender support for myself from an obstetrician. The fallout from transfer was costly for both midwives and the women they cared for with horizontal violence being a common occurrence in transfer situations Banks (2007). I discussed my plan with Arlene, and she supported my proposed action.

Explaining the situation to the midwife in charge of the Delivery Suite and the on-call consultant obstetrician, I was instructed to continue recommending transfer to hospital throughout the labour. If Arlene continued to decline transfer I should, the obstetrician advised, get the general practitioner to accept responsibility if the advice was not accepted.

This ‘advice’ was unacceptable on three levels. Firstly, to repeatedly recommend transfer to hospital throughout the labour when Arlene had made her decision was – in real terms – a bullying tactic to ensure she acquiesced and made the ‘right’ decision – “informed compliance” Stapleton et al (2002) in action. Avoiding that process was one of the major reasons why many of the women I cared for chose to birth at home. As I felt it was unethical to revisit that decision unless some new factor arose which required reconsideration of her decision, I could not, and did not, comply. Secondly, I knew Arlene did not make this decision lightly; she embraced the responsibility for that decision in the same way as she made every other decision on nourishing and caring for herself (and, therefore, her baby) in pregnancy. It was made with her baby’s welfare uppermost in her mind. And finally, I had left behind the deference to medical practitioners on non-medical matters when I left hospital employment. I could not defer responsibility for my midwifery practice to a medical practitioner even if I wanted to, which I did not.

So, Arlene’s labour was the catalyst for significant changes in my practice. I became a continuous student of wide-ranging literature, contemplating content and context and incorporating it into my practice when it was appropriate and robustly conducted. This would, at times, give rise to midwifery care that was counter to the care recommended in the local hospital protocols. As a result of this positioning, Arlene’s labour proved to be my first and my last attempt to seek support for myself in orthodox obstetric fora.

The obstetric bed: resistance in action

Posted on February 12, 2014 by birthspirit

Originally published in Birthspirit Midwifery Journal 2009; 4: 43-46. Revised

adion.ro/mobilier-medical-paturi-en.php

Bedbirthing has predominated in Western countries reputedly since it gained acceptance after Louis XIV’s mistresses birthed in bed; the king covertly watched from behind a curtain Glasscheib (1963, p. 91). American anthropologist, Wenda Trevathan, reports that a minority of cultures prefer to lie during birth; of 159 cultures, 47 prefer sitting, 44 kneeling, 26 squatting, 17 semi-reclining or in a hammock, 16 lying down and 9 standing Rosenberg & Trevathan (2002). This low preference for lying down or semi-reclining during birth, except when in a birth pool, has also been my own and other home birth midwives’ experiences. Yet, the obstetric bed remains commonplace in maternity facilities in New Zealand despite evidence that walking and upright positioning in labour shortens labour and women are less likely to use epidural anaesthesia Lawrence et al (2009).

I have constantly observed the intuitive movements women in labour make to exaggerate their spinal curvature which, as we know, is already increased in late pregnancy from the non-pregnant state. This observation, amongst other things, has led me to believe that obstetric beds should be viewed as hazardous furniture that hinder women’s intuitive movements during labour and birth, and that we need to recognise the role obstetric beds play in bed dystocia.

What Is bed dystocia?

Bed dystocia is the entrapment of the woman’s pelvis against the unyielding metal base of the obstetric bed and its thick PVC covered mattress, which combines to prevent progressive descent of the baby. This may occur for two reasons. Firstly, weight bearing applies direct pressure on either the ischial tuberosities (sit bones) and/or the sacrum when sitting or lying down. Secondly, semi-reclining and supine positioning tilts the pelvis backwards to reduce the accessibility of the pelvic brim to the baby’s shoulders, in particular.

Distinguishing bed dystocia from shoulder dystocia

Bed dystocia is distinguishable from shoulder dystocia in both how the baby is freed from a ‘stuck’ position and the responses of the woman when she is not receiving epidural anaesthesia.

Shoulder dystocia will require vigorous rocking by the birth attendant of the baby’s shoulder up, over and off the pubic bone if stuck at the brim, and/or facilitated birth of the posterior arm and/or turning of the baby’s shoulder through internal rotation – the latter two actions applying also if the baby is stuck in the mid pelvis. During shoulder dystocia the non-medicated and (normally) uninstructed woman will be agitated. If off the bed and on her hands and knees, she is likely to shift her weight from one knee to another, arch her back and/or swing her hips in exaggerated rocking movements from side to side. She may also lift one knee up and out to the side as a forerunner to her attendant’s instructions and actions, or push over her pubic bone in an attempt to dislodge the baby’s shoulder herself.

In the case of bed dystocia, once the cause of the problem (the backward tilt or neutral position of the pelvic brim and sacral weight bearing on the hard bed surface) is removed, the problem will resolve. This is achieved by turning the woman onto her hands and knees or by using the exaggerated stranded beetle position (hyperflexion of the woman’s legs onto her chest in a back-lying position). As Gherman and others have clearly demonstrated through x-ray pelvimetry of women who were at least 37 weeks pregnant, this McRoberts’ manoeuvre, which employs hyperflexion of the legs, does not change the actual dimensions of the woman’s pelvis; the position straightens the sacrum relative to the lumbar spine, and the symphysis pubis slides over the unborn baby’s shoulder Gherman et al (2000). It is a correctional technique used to release the entrapped sacrum held by the woman’s weight on the bed against a firm mattress and bed base.

It is the widely variable reported incidence of ‘shoulder’ dystocia (0.2 – 3.0 percent of all vaginal births Gherman et al (2006), along with the effectiveness of the McRoberts manoeuvre alone as a correctional technique in 42 percent of ‘shoulder’ dystocia cases Gherman et al (1997), which may give the best clue as to the real cause of the ‘stuck’ baby.

Intuitive positioning

The woman in a forward leaning position, whether that be on all fours or leaning, for example, on the edge of the birth pool or over the kitchen table almost universally uses the floor as her ‘anchoring’ surface (Figures 1-3), including when she is in the birth pool.

ObstetricBedResistanceInAction1-3H This forward leaning accentuates the spinal curvature and opens the angle of the pelvic brim as the pelvis is tipped forward to enable the baby’s head to enter the pelvis if it has not already done so prior to labour, and enables his shoulders to pass through the pelvic brim.

Women are intuitively drawn to exaggerate this spinal curvature as labour progresses. While this can be achieved by a hanging squat with her partner’s support, as in Figure 4, I have seldom observed women intuitively use this position. Perhaps they feel freer to ‘hang’ when they are not worried about others bearing their weight, or perhaps getting into a partner-supported hanging squat requires conversation at a time in labour when many women do not use language to communicate.

Once she deepens her squatting action (Figures 5 and 6) she begins to deploy the leverage that her upper legs (femurs) exert on the hips to widen the mid pelvis and flatten the pubic arch. In each of these positions the brim of the woman’s pelvis remains tilted forward and all diameters of the mid pelvis and pelvic outlet are increased Russell (1969), (1982); Michel et al (2002).

ObstetricBedResistanceInAction4-6H Women who are working hard to deal with ‘bony’ pain in labour as baby moves through the pelvis, intuitively adopt positions such as the ‘exaggerated runner’s start’ (Figures 7 and 8), leaning one way or the other to increase leverage on the hips (Figure 9) and widen both the mid pelvis and the pubic arch.

ObstetricBedResistanceInAction7-9H Women on the floor do these intuitive movements without consideration of either falling off a bed with their (sometimes) sudden movements, or that they will run out of surface area to place their knees and feet wide apart. The midwife, having witnessed this primal drive to move in labour that non medicated women exhibit, will have no doubt about the inherent dangers of the obstetric bed.

Rhetoric and resistance

During my time as a student midwife in the late 1980s it was common to hear the expression “You can swing from the chandeliers if you want!” during the ‘booking in’ visit at the obstetric hospital. This comment was intended to imply support for woman-led positioning in labour and birth. The hospital lacked chandeliers, and it also lacked any furnishings to support active labour and birth. Rather than birth pools and balls, hanging ropes, floor mattresses and comfortable couches, the layout of the room had an obstetric bed centrally placed, a nightingale table on roller wheels straddling the bed, a standard issue hospital locker beside the bed and a vinyl armchair in one corner. In short, a hospital room by any description, designed for the sickness model of care with an incapacitated ‘patient’ lying in bed.

The obstetric bed remains entrenched in maternity facilities, whether that is an obstetric hospital, a midwife run or midwife owned and operated facility. As long as obstetric beds remain in the birth space, women will continue to be given a very strong, unspoken message that beds should be used for labour and birth.

Resistance to ‘normalising’ the birth space is as prevalent in midwives as it is in nursing and obstetric staff, even when managers of primary care facilities try to create more appropriate spaces for labouring women. In Elaine Hodnett and colleagues’ Hodnett et al (2009) Canadian study of ‘ambient clinical environments’, the first three hospitals the researchers approached to be in the study refused to participate because the usual obstetric bed would be replaced with a double floor mattress, large pillows and a birth ball. In one of the two teaching hospitals which did participate, “considerable resistance” was encountered from senior nursing staff who “strongly objected” to the trial. The authors surmised: “Although lip service is paid to the benefits of upright positions, freedom of movement, and ambulation in labour, many staff members seemed certain that the bed was the safest place to be…” Hodnett et al (2009, p.166).

Midwifery rhetoric frequently supports women’s choice of birth position but the reality can be very different. Regina Coppen (2005) surveyed 66 UK midwives on their views on birthing positions; these midwives worked in a facility with 2000 births per annum (p. 80). The midwives identified the most frequent position for birth as recumbent or semi-recumbent on the bed and, most frequently, cited woman’s preference as the reason for this (p. 102). However, in her discussion on the findings, Regina notes:

“… the evidence suggests that midwives were more likely to deliver in a position that reflected their own preference than one that reflected the woman’s preference … and that, irrespective of how much collaboration, cooperation or discussion took place, midwives’ preference for birthing positions appeared to supersede women’s own preferences during the second stage of labour” (p. 169).

Continuity of carer does not necessarily ensure that women’s choice of birth positions will be influential. de Jonge et al (2008) used six focus groups in the Netherlands to study the views of 31 independent midwives on position during birth. These midwives practised in different parts of the country in rural, semi-urban and urban areas, providing primary care at home or in hospital. These researchers found women often gave birth in the midwife’s preferred position, which was dependant on the midwife’s exposure to different positions in her training and practice, the midwife’s knowledge and skill, her routine practice and the amount of her experience.

Creating a safe birthing space in maternity facilities

Being active, rather than reclining on an obstetric bed during labour and birth, is a central concept of the natural childbirth movement. One could well have expected that for all but the very small minority of women whose poor health precludes them from being active in labour, the obstetric bed would certainly have disappeared from hospitals and that it would be absent in primary maternity facilities. Instead obstetric beds remain standard issue in these environments for women who are well and who have the potential to experience labour and birth as a healthy life phase.

Maternity facilities are the ‘homes’ of the midwives, doctors and nurses who work in them, despite the fact that there may be considerable instruction to the woman to ‘make yourself at home’. Locked cupboards and secret coding systems on doors do not give free access to food and equipment as a woman would have in her own home. Social conditioning prevents overt ownership of the environment, and instructional messages about keeping doors closed, the cleaning and replacing of equipment, fire drills (and so on) clearly signify this is a public space controlled by an authority other than the woman. Any attempt to remove the obstetric bed can be treated as a major transgression, as my own recent experience showed.

In our role as facilitators of the physiological birth process, midwives need to examine the environment that they provide for women during birth. Intuitive positioning is not supported in the hospital or birthing unit environment where, rather than reflecting home furnishings, an environment of sickness and incapacity is replicated. Midwives need to take a proactive stance and ensure that at least 85 percent of any facilities’ rooms reflect home furnishings. Until midwives permanently relegate the obstetric bed to the hazardous goods lock up and replace it with home-like furnishings – sofas, divans and floor mattresses – the obstetric bed will continue to be seen as appropriate birth furniture.

Special thanks to Niki Carroll and the late Bruce Cleland for the generous gift of photographs taken the week prior to the waterbirth of their daughter Amber Lily at home, as planned.

Series photographer: Tony Banks

The FTPs of caesarean section

Posted on February 11, 2014 by birthspirit

Originally published in Birthspirit Midwifery Journal 2009; 4: 25-30. Revised.

The artwork in this post was historically available at http://cesarean-art.com. As the artist did not engage in dialogue, permission was unable to be sought to reproduce this previously freely available work. It is intended that the context in which the illustrations have been reproduced will be seen as honouring the artist’s journey which spoke to my thinking about Nadine (as I call the woman of this post).

WomenAreNotResealableBabyContainers

When Nadine gave birth at home to her second baby, a daughter, she fulfilled a dream of natural childbirth and immediate, uninterrupted in-arms mothering. Her first labour had ended with her son born by caesarean section after she was transferred to hospital from a planned home birth. Nadine’s notes recorded the diagnosis of “dysfunctional uterine activity resulting in failure to progress” as the rationale for caesarean section.

FTP1-3 Having worked with numerous women who have been given this Failure To Progress (FTP) label in their previous birthing, my experience has shown that this abbreviation more often than not actually reflects a caregiver’s Failure To be Patient when the notes are perused. While the permanently scarred uterus that results with caesarean section is lifelong, the emotional scarring of the ‘failure to progress’ label is frequently one that never lets go of the woman until she has experienced birth on her own terms. Nadine’s second birth, a waterbirth at home, was accompanied by a noticeable restoration of her faith in her ability to give birth – faith that had been ruptured by her previous experience. Both these births and the issues that impacted on Nadine’s first labour and birth are addressed in this story.

I first met Nadine after a public meeting to celebrate Home Birth Awareness week in New Zealand at which I had spoken on Giving Birth in a Caesarean Culture. Nadine had approached me afterwards asking if I thought she could give birth at home, despite having had a caesarean. So began the unravelling process of her previous birthing. I explained that it was important to spend time exploring her childbirth history and the physical healing process, going over her notes and weighing up the advantages and disadvantages of both the hospital and home environments for birthing. The latter would help in her decision-making and hearing her story and reading the hospital notes would enable me to answer her question. We arranged to meet in a fortnight and when we did so, she was six weeks pregnant.

Within a very short period of time Nadine determined she would birth at home. She had devoured Artemis Speaks Koehler (1984) and Silent Knife Wainer Cohen & Estner (1983), two valuable classics for women as they come to terms with having had a previous caesarean section. While I fulfilled my obligation in my funding contract and discussed obstetric consultation with Nadine, she did not agree to visit an obstetrician. Her exploration and our discussions meant she understood the nature of the different birth environments and what that meant for her labouring and birthing.

Nadine started labour spontaneously at 40 weeks and five days from a sure last menstrual period date – the same gestation as with her first baby. She gave birth at home just over 48 hours after labour started, after 14 hours of established labour. Her contractions came every 3-6 minutes once it was established and she lost all cervical pain 4 ½ hours before she birthed. Nadine used the shower in labour and then the birth pool for the last 4 ½ hours.

The baby’s head was no longer palpable above the brim 2 ½ hours prior to birth, which is when she started spontaneously pushing with most contractions. Her baby continued to move regularly throughout labour and, when I listened with a Pinard’s stethoscope, the heart beat was always fine. As Nadine started to push, the heart beat was heard centrally, just above her pubic bone. As her labour was progressive throughout there was never a need to examine her vaginally in the 10 hours I attended her – so I didn’t.

Nadine gently birthed her baby with uninstructed pushing after about 2 ½ hours of pushing. She was a woman who smiled and quietly talked to her baby as she birthed and gave me unprompted progress reports about how far down her baby was, when she slid back, when she stopped sliding back and when the full stretch came on her perineum.

She delighted in touching her baby’s head frequently as she was being born.

FTP4-6 She gave birth in the pool and lifted her baby up immediately into her arms with that smile for her baby that only a mother can give – and the little ‘hello’.

The placenta came 10 minutes later when Nadine stood up to get out of the pool.

Her baby started breastfeeding within ¼ hour after birth and bed shared with her (and her husband and first child).

Nadine had many quiet smiles in the weeks that followed. This baby weighed 7lb 4oz (3290gm) at birth which was 4.5oz (130gms) heavier than her first. (Both these babies were appropriate for Nadine’s size – she is a tiny woman.) The baby piled on weight and at six weeks weighed 10lb 6oz (4710gms), which amounted to a 47 percent increase on her birth weight.

Nadine’s birth by caesarean section with her first child had transformed her. She told me she had an unremarkable school career and had left school with the feeling that she was “dumb”, and she felt unsupported as she grew up in her family, which extended into her birth choices. Even though her father had been born at home her family did not support home birth. She had, however, gained a real sense of valuing herself through completing an arts course at the Polytechnic and her jewellery making was something at which she excelled. The other thing that she believed she could succeed in doing in her life was giving birth, and she had cared for herself wonderfully in her first pregnancy in preparation for that. Her Caesarean section took that belief away.

So what happened with her first birth?

Nadine had been well throughout her pregnancy. That labour started with spontaneous rupture of membranes (SRM) in the late afternoon and, when she called her midwife to attend the next morning, Nadine was contracting every four minutes.

Sandra, as I call the midwife, could not palpate the baby’s head at all so she examined her vaginally; Nadine was 8cm dilated with a fully effaced cervix; her baby was cephalic-presenting and had descended to Station 0 at 6.45am. With the arrival of the midwife, Nadine’s labour spaced out and she was given four doses of Caulophyllum in the next half hour.

Three and a half hours later (10.20am), Nadine was encouraged to stimulate labour through movement even though she was shaky and sleepy. At lunchtime (12.20pm) Nadine had an anterior lip of cervix on vaginal examination, which was pushed back over three contractions; it slipped back again. The baby’s head was determined to be at Station 0 to -1. Though the baby was LOA, Nadine was encouraged into a left lateral position and she was given four doses of Gelsemium, (possibly to encourage the remainder of the cervix to retract). One and a half hours later (14.05pm) another vaginal examination showed no change and Nadine was transferred to hospital.

Nadine did not want pain relief – she knew about the effects of drugs on her baby – but she was given an epidural following an ‘informed compliance’ Kirkham (2004); Pilley Edwards (2005) process – and her labour was augmented with an intravenous infusion of Syntocinon. The epidural anaesthetic effect was patchy, but the drug was effective enough to give her a pyrexia of ‘unknown’ origin (37.8°C) within 2 ¼ hours and she was started on intravenous antibiotics.

Nadine had another three vaginal examinations over the next 4 ½ hours by which stage her cervix had closed down to be 7cms dilated as it was oedematous, and a caesarean section was performed. Her baby had a gastric aspirate, blood tests and an arterial gas and cord pH done. That baby weighed 6lbs 15 ½oz (3160gm) at birth.

This all too familiar story of Failure To Progress also had parallel FTPs for the midwife.

Sandra was a new midwife and Feeling Tender in Practice. She had gone immediately into self employed case-loading practice in the community following graduation, which bears testament to the strength of her educational programme.

However, Sandra was not well supported by the profession. She was mentored by a midwife carrying a high caseload; Sandra paid for this mentorship – and excessively. Half of her income went to the midwife which meant Sandra was experiencing Financially Tough Pressure in her ability to maintain an income to support her family while also paying off her considerable student loan. To meet her financial obligations Sandra cared for six women a month.

Sandra was exhausted, not only during this birth but also in her practice. The mentoring midwife was also Sandra’s practice partner and, as her mentor had gone on holiday, Sandra was caring for her mentor’s caseload as well as her own. She had been in self-employed practice for less than a year but she was Far Too Pooped to continue. Sandra had made a decision to stop her caseload and work in the hospital on rostered shifts.

This exhaustion of months was compounded by attending Nadine from early morning until after midnight when the baby was born. Such was the lack of collegial support in the hospital that Sandra received no relief from the hospital staff. It is unknown if she asked for assistance but, in the first decade of direct entry midwifery in New Zealand, midwives who were educated through that means Felt Totally Persecuted when frequently told of the benefits (sic) of the nurse-midwife route to midwifery. Such attitudes may well have placed an additional burden of forced independence onto Sandra’s shoulders, though this lack of collegial support in hospital was also felt by many other self-employed midwives who came to midwifery through the nursing route.

By the time Nadine was transferred to hospital her membranes had been ruptured for 14 hours. At the time of this labour the hospital had an expectation that women would have intravenous antibiotics and an augmentation of labour after 12 hours of SRM. While such guidelines are seldom evidence-informed, midwives can feel unable to avoid this instruction From The Pulpit in obstetric facilities. A motivating force ensuring compliance in these environments frequently comes from the midwife’s heightened Fear of Traumatic Prosecution, which, most commonly, is initiated by hospital authorities. Those midwives that do challenge evidence-lacking guidelines frequently experience Fingers That Point if there is an untoward outcome, despite a lack of causal link. The gossip, rumour, derogatory or denigrating remarks and sarcasm that can result leaves the midwife feeling alone and isolated.

Caesarean recipe

The story of Nadine’s first birth was all too familiar – a whole series of events combined into the ‘perfect storm’ of caesarean section. There were many points within the midwifery care during that birth that would almost certainly have been influential in the end result but perhaps none is likely to have been as potent as the lack of support that this new midwife experienced.

Many midwives readily recognise the circle of support needed for women in labour. But how conscious are we of the importance and influence of the many concentric circles of support needed around the midwife (and woman) that enable healthy childbirth to unfold – the circle of mentoring, the circle of practice partners, the circle of hospital midwifery and, when necessary, the circle of obstetrics?

Perhaps the last of the FTPs of (at least) Nadine’s caesarean section rests with the wider midwifery (and obstetric) community through the Failure To Participate in supporting Sandra, which existed. The lack of engagement in this space had a consequence for Sandra, who actually left the profession within 10 years, when, potentially, because of her age, she could have had many decades of midwifery practice before her.