To cut or not to cut... that is the question!

Further to my recent post titled 'Time stood still...' I have been thinking about the lifeline they call the umbilical cord. Initiated by the fact that the shoulder dystocia that I experienced was combined with a nuchal cord and the recent 60 minutes documentary on birth choices that had women making reference to cord around the neck as a significant complication, I am prompted to discuss my thoughts and my recent research into what should be done, if anything.

For 259-294 days (more or less!) two arteries and one vein encased in whartons jelly transport everything that a fetus needs (and doesn't need) to ensure its survival. This supply line is the umbilical cord and it is what literally bonds mother and fetus. Damage, compression or compromise of the cord is associated with fetal compromise.

So what do we do when it comes to actually severing it? Controversial issue for many but for me it seems pretty simple. LEAVE IT!!

Unfortunately in practice this very rarely happens. It is not provided as an option similarly to physiological third stage. It is just done. Research that I have undertaken is not convincing as to reasons for active third stage and the use of syntocinon or syntometrine yet its the most common birth drug used and amazingly, never formally consented to by majority.

So what is the deal with cutting the cord or even checking for cord? Seems odd to me that it would be a problem because logic would have it that if the baby is born with nuchal cord than for a reality decent amount of time previous to labour and birth, the cord was around the neck. Even more logical is the possibility of it is happening. A baby freely moving within the amniotic fluid with something resembling a jump rope, seems highly likely that it is bound to wrap around something. So as normal as it is, what is the panic?

Common responses to this have been - short cord, very very tight around the neck, impeding on the ability of the baby to be born, etc... Hmmm...

So the head has been birthed and we have nuchal cord... at which point, the only oxygen supply is still the umbilical cord as baby still has not taken its first breath. So in making the decision to cut the cord at this point for whatever reason is dicey. Not only are we cutting the lifeline and oxygen supply, in doing so there is there is poor placental transfusion of blood that is vital to facilitating the blood flow through the lungs to initiate fetal ventilation. Further to this, there is the risk of hypovolaemia, pallor, anaemia, hypotension, hypothermia, hypoxia and respiratory distress etc... in comparison to possible bruising due to a tight cord.

Any baby that has a nuchal cord is in greater need of oxygen and yet it seems that the first thing that most do is deprive them of the most effective and efficient source. I have witnessed this decision being made and in almost every case it was a decision based on panic and uncertainty and more so the preempting of resuscitation being required.

Even more frustrating for me is the realisation that the process of resuscitation that seems to be in place completely contradicts the normal and physiological resuscitation that occurs. Not only is the cord cut, the cold-crying and cold-pressor reflexes are interrupted by the warmth from the resus trolley - the process that normally constrict the blood vessels of the cord and result in the placental transfusion that initiate ventilation and assist in closing of the foramen ovale and the beginning of fetal circulation. To add to the this, the entire process is done AWAY from the mother.

Something that I also read explained a lot about the normal and natural process of birth being interrupted rudely. Why is it that women refuse to cut the cord? Morley (2002) simply states that it has everything to do with with the mothers strong inhibition to 'damaging the cord'.

Like much of what I observe, its practice based on fear rather than fact. I found this quote - More proof that science, intervention and understanding have actually caused more harm than good. In 1842 it seemed so simple and yet somehow we have made it so difficult and contoversial.

“Let the loop be loosened to enable it to be cast off over the head. … [or] by slipping it down over the shoulders. … If this seems impossible, it should be left alone; and in the great majority of cases, it will not prevent the birth from taking place, after which the cord may be cast off. … Should the child be detained by the tightness of the cord, as does rarely happen, … the funis may be cut … Under such a necessity as this, a due respect for one’s own reputation should induce him to explain, to the bystanders, the reasons which rendered so considerable a departure from the ordinary practice so indispensable. I have known an accoucheur’s capability called harshly into question upon this very point of practice. I have never felt it necessary to do it but once. … The cord should not be cut until the pulsations have ceased.”
Charles D Meigs, M.D. Professor of Midwifery Philadelphia, 1842

More equations that don't add up

Having a day off, I took myself out with the kids to do some shopping and have my coffee fix and found myself thinking about what I wrote earlier. Talk about living and breathing birth! Following on from my last post...

I made the statement that most primips, if left to gestate, will go beyond their due date. I am not yet entirely sure of all the reasons as to why this happens but I have read in places that it may have something to do with their body not ever having done it before. Obviously there is controversy as to whether or not this is true as there are many multips that go above and beyond their due date too, me being one of them. But it got me thinking anyways...

If the current trend continues, primips who reach their due date will be offered induction of labour. With or without an ideal bishop score, ripe cervix, a baby ready, the cascade will be begin. Time constraints will then impose, that is 'by this time, this will happen and if that doesn't happen then we will do this and if that fails, then we will attempt this for x amount of hours'... in the meantime, baby gets upset, distressed or completely pissed off - answer is caesarean section. If baby is happy, we continue until such time as there is some issue such as 'obstructed labour' , 'cephalopelvic disproportion' or 'failure to progress' and find our way to theatre anyways.

Or maybe its a high head, OP position or deflexed vertex, and maybe the use of forceps or a ventouse will result most likely with an episiotomy. The incline of induction rates means a greater likelihood of deviations from the norm which is inevitably going to lead to either assisted births or sections, increasing the section rate even further.

So then these primips end up with a section and when their next pregnancy comes about, they have minimal options, elective section or (cough, cough) VBAC. VBAC is certainly an option but in a system that has 'ifs' and 'buts' attached to everything, whether it remains an option will be down to whoever the woman sees on the day.

Unfortunately this is becoming the reality and women, although having an option as to what they want to do, by majority, do not realise it or believe it. And more, most place their decisions in the hands of those that do not really care about the well being or future of the particular individual but rather the convenience of booking an induction or section. It has become too difficult to give the power back to the woman and if the woman does have the power, somehow the are tainted and labelled uncooperative or radical.

Looking at it from this angle it makes sense that things are heading the way they are. What I do not understand is why women are giving into it. I know that every individual is different and varies in ideals and preferences but why is it that so few really question or seek clarification and understanding?

So here I am wanting to give the power back to women. I am confronted with a woman who by her dates is only just 40 weeks, a scan at 20 weeks suggests her dates are wrong despite her certainty. Her EDD is adjusted to suit the scan because baby is 'BIG'. On assessment, she has a bishop score of 3, head still high but nevertheless, head down, but induction is commenced regardless. What do you know, nothing happens! Discussion is had, a decision is made - C-section. Reasoning - unfavourable cervix, failed IOL, high-head, post dates (despite her only being due today based on her dates) oh and dont forget the massive baby onboard (even though she is over 6 foot and appears to have decent pelvic space). She agrees without a second thought.

Given my situation and my current role, I debate as to whether I should speak up. I realise that if there was ever time to step in and advocate for a woman it is now and I go in with the attitude that I am informing her of all her options, not just the escape route. Despite what I know, I put myself in her position and know that if someone was hanging outside of my door with choice and options, Id want them to make it known.

And so I go to her and I open her up to the options and I feel like I have fulfilled my purpose as a midwife and everything that a midwife entails...

I get shot down and feel like I am an imposition, stepping on toes and completely out of place. I walk out feeling uncomfortable not because I feel like I have said the wrong thing but because I am lost as to the reasons why anyone would not want options and choice and rather leave it in the hands of those that ''know whats best!"

I did what I felt was right and despite it not having an impact at the time, I can only hope that one day she looks back and remembers that someone was willing to stand strong and uphold her rights and autonomy. I once thought that given the opportunity to do what I did and receive the response I got, Id feel lousy, yet I feel good knowing that at least she was aware that there was a choice regardless of whether she grabbed ahold of it or not.

And so I ponder the reasons why we have become mute as humans and lack the authority and the power to make decisions based on our own choices and beliefs allowing others to abuse us and decide what is ultimately our decision.

Any comments you have in response would be thankfully accepted.

Questioning the obvious and proposing the unlikely...

Despite getting used to the occurrence of getting to work and being made aware of the amount of inductions and caesarean sections, it still gets to me. I do understand that there is a time and place in which they are needed but shockingly, the facts that Michel Odent spoke of are becoming more real and evident. I have been reflecting and addressing my frustration over this and trying to formulate some plan to change this trend particularly as I am due to take the leap next year and finally drop that infamous word 'student' from my title.

I am aware of the mass opinion that I will be up against when I finally do become registered but I am hoping that I continue on the path I have laid and stand strong and make a difference. Obviously it will be a challenge given the politics and legalities of the system but given my incessant need and want to bring birth back to what it is or in todays culture, what it should be, I will fight until the bitter end.

I have grown complete and utter despise for induction and looking back on my own experience, think myself lucky that it went reasonably smoothly. Almost every induction that I seem to witness fails or causes complications that inevitably result in a section. I am close to summing it up in my head - induction = delayed c-section. I choose my words carefully because in the delay between induction and section comes intervention. I am trying to find the words to express what I am feeling in relation to the future of this rather bold and forthright equation because I am sure that amongst the mist and the clouds, there are many that are pushing for something along the lines of - induction = c-section or worse birth = c-section.

The worrying thing for me has been the encroaching nature of the beast on length of gestation. Once upon a time it seemed safe to leave a woman to bloom until 42 weeks. Four years ago, knowing very little and being as naive as I was, I had to beg the doctors to induce me at term + 12 days. They wrote on my notes - IOL for social reasons. Now compare this to what I am seeing today

• IOL from the EXPECTED due date
• Social induction from around 38 weeks
• Failed induction due to unripe cervix (GO FIGURE!!)
• Vernix covered babies at T+ gestation (hmmm)

And thats only the start of it. Although I do not like to generalise, it seems that by majority we have lost touch with our bodies and hence when pregnancy miraculously occurs, we have no idea when we conceived, when our last menstrual period was or even care. I can understand this because sometimes the last thing I want to think about is my period and how annoying it is but what I am trying to highlight is the fact that, our bodies, our cycles, our ability to produce life, sustain it and give birth to it have become second, third, fouth, etc, to higher priorities.

I am deliberately making this point to try and justify in my minds how there always appear to question marks near or around the estimated due date. Deliberately because I want to make the point that its only an ESTIMATE!!!! Normal pregnancy gestation is 37-42 weeks, look in any text or reference and this will be clearly written, yet somewhere and somehow someone decided that that wasn't good enough. We need routine, structure, a timetable!

As far as I can gather the EDC or EDD was only created to give them woman some insight as to when labour may start. I dont think it was ever meant to be THE be all and end all OR the determinant of what will or wont happen. So unfortunately this date has been manipulated in such a way that it warrants the rights of OTHERS to make a decision as to when a baby is born.

I sat up thinking about this last night with the knowledge that primips or first time mums in general will go into labour post their due date and wondered with the understanding that we have, that being that between 41-42 weeks gestation is still safe, what would happen if we shifted the EDD to equal a gestation of 41 weeks rather than 40? Come into play politics and legalities but all that aside, what would be the outcome particularly as I am aware that 40 weeks gestation is an average gestation.

Nothing much changes. There is still an EDD, there is still that date to linger on, there is still room for manipulation. The truth of the matter is, nothing in this world is set in stone, nothing is stagnant, things change. Given that as humans we manipulate and influence so much, how can we be sure that we haven't done the same on the normal gestation of pregnancy? Its obvious we have had an enormous influence on it in a surgical, medical way but I am talking more of the physiological, psychological and environmental way. If the human race has the ability to F*#$ the planet as it has and influence global warming, seasonal shift, pump hormones into the food we consume, control life as far as messing with genes and cellular bits and pieces and possibly initiate many of the natural disasters that have occured in recent years (or months!), whats to say that we haven't done the same to pregnancy, the initiation of labour, a babies' birth??

Food for thought and my need to question...

Thought provoking reading...

I ventured onto a few other midwifery related blogs tonight, one Lisa's - definitely 'the' words that highlight, empower, rejoice and celebrate the power of a woman and her ability to birth. There is not one word, phase or story that could come from Lisa's heart that could demoralise or steal from what is a woman's right. Something that inspires me to be that midwife... the one who is in every sense, 'with women'. I can say this with confidence having not only been lucky enough to have her as my midwife, but also work alongside of her and witness and be influenced by her completeness and commitment to 'true midwifery'.

After a long week of pouring my best efforts into an assignment addressing the care of women with postpartum depression and other mental health illnesses and reading tiring journal articles and reviews that seem to overlook and totally dismiss midwives and midwifery, I needed to indulge in something midwifery.

In doing so, I came across some varied opinions of what midwifery is. Despite these coming from midwives, I was quite shocked to be confronted with almost opposing opinions... that word again... After nearly 2 and a half years you would think that I would be used to the fact that some midwives have this rather strange and deranged idea of what midwifery is (my opinion... for good measure) and yet somehow it still depresses and distresses to say it nicely.

I am lost as to how you could unjustifiably denigrate midwifery to just 'a job' or a means to an end, so to speak. Anyone who has had to opportunity to witness birth, regardless of gender, role, personality or input, would be lying if they said it wasn't one of the most emotional, amazing and fulfilling experiences they have ever been a part of. Admittedly, not all can openly confess to it whilst clouded by memories of pain, choice words, vagina and blood... take these clouds away and the beauty of the birth of a child is something that can only ever be justified by witnessing it.

Maybe its a case of 'seen one, seen them all'... however birth isn't just birth in the literal sense. Birth is what makes birth. It is not just a fragment of time, there is history and future in the making, not just for one but for many. Birth is unique; not one is the same.

And whilst I am laying out my two cents for all to see, why is it that a word such as midwifery- a neutral, empowering holistic one has managed to take on such power, indifference and control, in many instances? Maybe 'with woman' would be better changed to 'with midwife' for the majority because the most of what I have experienced has not been entirely about what the woman wants. Despite the obvious time constraints, protocols and policies in the system, there is not even enough emphasis about informing and empowering women to question and discuss their options.

Two words that kept reiterating themselves during my thought process... reciprocity and autonomy. I have experienced too much 'take' and not enough 'give'. Even the most normal and simple choices such as what a woman wears and what and when they are able to eat and drink are stripped from them. And that is not to mention the lack of consideration for privacy, dignity and respect... you would think that closing a door, pulling a curtain, covering a woman, knocking before entering and ensuring the bitching done behind the nurses station doesn't echo through the corridor to be heard by all, would be common sense. If only...

Childish behaviour has some how has grown legs and left the school yard. Time and energy that could be better spent fighting for birth, for women and for their rights.

As a student, I walk on a fine line. In many situations I have found myself pressured to do exactly the opposite of what the woman wants by midwives, registrars and consultants; to me pressure that was based on little or no indication. One such instance, the words 'infiltrate' and 'episiotomy' seem to ring in the background whilst my conscience beat them down with 'consent' and 'crowning' and 'contraction'... I stood my ground until literally removed to make way for intervention. I was fortunate enough to have a supportive midwife who up until that point placed confidence and trust in me to listen to the woman.

So I end with this, a thought provoking and real statement about who or what a midwife should be... I couldn't put it better myself so will use Lisa's words

Compromising your clients wish for a great birth isn't
our role. Keeping the space is.

A want to practice what they teach...

Despite being of the understanding and opinion that birth is normal and natural and that a woman's physiology was intended for the purpose of supporting and bearing life and being taught this, I am frustrated by the lack of normality that I have witnessed as a student. Our requirements to register include being primary carer of 40 women having a normal vaginal birth... that means no forceps, no ventouse and definitely no caesareans... Here fellow students and myself face a dilemma. Current figures suggest that the caesarean rate is encroaching on 30% or more of births and even higher rates in the private sector, and thats independent of assisted births. Lets for arguments sake say that 50% of all births are either by caesarean or assistance (the current trend suggests this) and that of the 'normal' births include those with intervention such as induction, augmentation, epidural, active third stage ( acascade that increases the risk of caesarean or assistance), what hope is there for us to firstly meet these requirements and secondly, witness anything close to the normality of birth?

The year I began this course, there was not yet any restrictions on us attending homebirths, well not for the university that I am studying at anyways and hence the reason why I was lucky enough to witness and be with a woman who birthed her bubs at home. It was the most amazing experience and having been a part of it, I couldn't think of any other way to have my next baby when the time came. Shortly after I attended this homebirth, we received an email from the university saying that we were no longer allowed to be present at them for insurance reasons... and there went out opportunity to experience a truly physiological birth. Having now had a homebirth and comparing that with the hospital experience I had with my first and that which I have witnessed on the other side of things, I know that I will only ever see a 'normal physiological birth' with a woman birthing at home.

Myself and others have attempted to try and change this but it seems that everyone we approached passed the buck on to someone who would also pass it and so we went round in circles, without getting any answers.

Another reason why I want to bring birth back to what it is in its rawest form and practice what we are taught... and I guess, naming this blog what I have.

"We don't do breech!"

Following on from my last post about breech presentation...

One of the last appointments that I attended with one of my lovely follow throughs had me reeling again. The day before she had gone in for a scan to assess the position of the placenta which was found to be low lying at her morphology scan. They found the placenta had moved clear of the internal os which was great but also found the baby to be transverse... she was at that stage approaching 35 weeks.

Her last bub has only just turned one and was a big boy so my initial thought was that there was still plenty of room about for this one try different strokes and on palpation previous to this, it was definitely cephalic. She was pretty sure that bubs had turned the night before the scan, so I was of the mind 'plenty of time for change!' and gave her some ideas for getting bubs to at least take on a longitudinal lie thinking that I would get in first before the midwife returned to do the same (haha...)

Midwife comes in and continues to palpate and discovers that yes, the baby is transverse as I had found and obviously the scan had too. She turns to the desk and starts fussing... At that stage we weren't too sure what she was doing so we both break the silence in conversation about the ideas I had given at which point the midwife interrupts and suggests that the only option for her is to get that baby 'head down' or face a c-section.

Me being me now, pipes up and asks the question 'If the baby was to turn breech, will A be able to attempt a vaginal breech birth?' (I knew it was a long shot but took the chance!) Well!!! Lets just say I was shot down in flames - 'No, the hospital does not support vaginal breech'... full stop (all with her back to me, I must add!).

Although expecting this answer, I wasn't quite prepared for how abrupt her answer and for her lack of acknowledgement of the woman sitting before her. I was further aggravated by the fact that there seemed to be no discussion of what A could do to help her baby turn or what her options were other than to say that if the baby was still transverse or breech at the next appointment, A would be visiting the doctor to organise a section.

Sometime around that time she left the room and A turned to me and said, 'I don't want a section, is there anyone that will attempt a vaginal breech?' I took this as my cue to let her know that homebirth was definitely an option which she took on with seriousness.

I have spoken to her in recent days and she seems to think that bubs may have moved, which way she is not entirely sure but time will tell I guess.

Another example of midwives claiming to be woman-centred and being blantantly the opposite. It infuriates me that convenience has become so much easier. But as much as it makes me angry, it also drives me to always, ALWAYS put the woman first, empowering her and informing her with choice and option.