Betsy_water Birth 2010

8/17/2019 Betsy_water Birth 2010

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Sydney Edinburgh London New York Philadelphia St Louis Toronto

midwifery preparation for practice

SAMPLE CHAPTERS

Sally Pairman

Jan Pincombe

Carol Thorogood

Sally Tracy


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Table of contents

Contributor list

Foreword

Preface

Acknowledgements Introduction

Part A Partners

Section 1 Context Chapter 1 Understanding world views for midwifery

Carol Thorogood and Karen Lane Chapter 2 Australian and New Zealand context

Jill White Chapter 3 Australian and New Zealand health and maternity services

Karen Guilliland and Sally Tracy

Chapter 4 Risk and Safety Joan Skinner

Chapter 5 Ways of looking at evidence and measurementSally Tracy

Chapter 6 The Place of Birth Maralyn Foureur and Marion Hunter

Section 2 The woman Chapter 7 Challenges to women’s health

Caroline Homer Chapter 8 Making decisions about fertility

Liz Sullivan and Sally Tracy Chapter 9 Transitions

Jan Pincombe

Section 3 The midwife Chapter 10 Professional frameworks for midwifery practice in Australia and New Zealand

Sally Pairman and Roz Donnellan Fernandez Chapter 11 Legal frameworks for midwifery practice in Australia and New Zealand

Jackie Pearse and Helen Newnham Chapter 12 Ethical frameworks for midwifery practice

Lynley Anderson and Bronwen Pelvin Chapter 13 Life skills for midwifery practice

Bronwen Pelvin

Part B Practice

Section 1 Partnership Chapter 14 Theoretical frameworks for midwifery practice

Sally Pairman and Judith McAra Couper Chapter 15 Working in partnership

Sally Pairman and Nicky Leap Chapter 16 Working in collaboration

Suzanne Miller and Sally Tracy Chapter 17 Promoting physiological birth

Nicky Leap


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Section 2 Autonomous practice Chapter 18 Physiology of conception and pregnancy

Sally Baddock Chapter 19 Nutrition for childbearing

Sandra Elias Chapter 20 Working with women in pregnancy

Celia Grigg

Chapter 21 Physiology of labour and the postnatal periodSally Baddock and Lesley Dixon Chapter 22 Supporting women in labour and birth

Juliet Thorpe and Jackie Anderson Chapter 23 Working with pain in labour

Stephanie Vague and Nicky leap Chapter 24 Water for labour and birth

Shea Caplice and Robyn Maude Chapter 25 Maintaining the integrity of the pelvic floor

Sue Hendy Chapter 26 Supporting women becoming mothers

Lesley Dixon

Chapter 27 Supporting the newborn infant Jackie Gunn Chapter 28 Supporting the breastfeeding mother

Ann Henderson and Marlene Scobie Chapter 29 Pharmacology and prescribing

Marion Hunter and Jackie Gunn Chapter 30 Completing the midwife/woman partnership

Rhondda Davies Chapter 31 Contraception

Helen Calabretto

Section 3 Collaborative practice Chapter 32 Screening and assessment

Sally Tracy Chapter 33 Challenges in pregnancy

Christine Griffiths and Carol Thorogood Chapter 34 Disturbances to the rhythm of labour

Catherine Mostyn Williams and Carol Thorogood Chapter 35 Interventions in labour: the evidence

Sally Tracy Chapter 36 Life threatening emergencies

Carol Thorogood and Sue Hendy Chapter 37 Complications of the postnatal period

Jenny Gamble and Debra Creedy Chapter 38 Complications of the newborn

Linda Jones and Annette Wright Chapter 39 Grief and bereavement

Chris Stanbridge

NOTE

Please note that these sample chapters

are part of a work still in progress, and

that some changes to text and images

may yet be made.


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C H A P T E R 6

The place of birth

Maralyn Foureur and Marion Hunter

KEY TERMS

Birth centre, small maternity unit, primary birth unit (used

interchangeably): a low-technology maternity facility that

does not have available epidural analgesia, operating

theatres for Caesarean section or on-site obstetricians,

anaesthetists or paediatricians

Chapter overview

This chapter focuses on the power of the place of birth

to influence the behaviour of women and their midwives

during childbirth. We propose that neither the type of careprovider nor the model of care delivery alone is able to

affect outcomes without sufficient attention paid to the

physical and psychological environment for birth. Through

exploring the complex nature of modern maternity care,

with its focus on hospital birth and the use of technology

to guarantee ‘safety’, we discover that the influence of

‘environment’ may be so pervasive that the full, potential

benefits of ‘new’ systems or models, such as continuity of

midwifery care, fail to be easily realised in hospital settings.

Important insights into why this might occur are provided

through the lens of one New Zealand study comparing

the practices of midwives who move between small and

large birthing units. The midwives’ own words will be

used to clearly illustrate what they have come to know as

‘real midwifery’. The chapter begins with a brief historical

account of childbirth history in Australia and New Zealand,

to explore the reasons why women moved from their

homes to hospitals for birth at the turn of the twentieth

century and why they continue to go to hospital to give

birth over a hundred years later. This will provide a contextfor considering what has been lost in the process and how

the modern birth environment affects outcomes for wome

and babies, as well as midwives. This chapter aims to

reveal what midwives can do to ensure that the potential

benefits of midwifery-led care are optimised, no matter

where the place of birth.

Learning outcomes

Learning outcomes for this chapter are:

1 To explore the impact of the place of birth on women

and midwives

2 To explore different perspectives on why women

moved from home to hospital for birth at the turn of

the twentieth century, and to discuss what was lost in

the process

3 To explore the risks and benefits of the three location

for place of birth: home, birth centre or hospital

4 To discuss the ‘fear cascade’, a plausible theoretical

model that explains why the birth environment may

affect birth outcomes

5 To describe some of the physiological consequences

of birth in an unfamiliar or fearful environment

6 To describe the key competencies required for

practising ‘real midwifery’ no matter where the place

of birth.


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6 SECTION 1 • CONTEXT

Introduction

In the twenty-first century, birth takes place in the intimatespaces provided in women’s homes, in small birth centresor primary birth units which aim to provide a home-likeatmosphere, and in large hospitals surrounded by an arrayof technology and personnel. This chapter argues that each

location exerts a powerful influence on how the woman’slabour unfolds and how she will give birth and greet herbaby. Importantly, each location also exerts a powerfulinfluence on, and is influenced by, the midwife whoaccompanies the woman. Therefore, a comprehensiveunderstanding of the influence of ‘environment’ on thephysiological processes controlling labour and birth is

essential for all midwives. We will endeavour to provide apoint of entry into that knowledge by exploring the answersto two important questions: why did women move fromhome to hospital for birth, and what was lost in the process?In addition, some of the many studies that have explored

the complex relationships between environment andphysiology of birth will be examined in order to offersupport for the proposal that this is essential knowledge formidwives. Finally, the chapter provides an in-depth discus-sion of the way in which one group of midwives discoveredthis knowledge in what they described as doing ‘realmidwifery’.

Birth moves from home to hospital

The turn of the nineteenth century marked the beginning

of the move of childbirth into institutions throughoutBritain, Europe, North America, and Australia and NewZealand. Therefore an examination of the past two hundred years of the history of childbirth in any of those countrieswill reveal the complex interplay of human and social forceswhich ultimately dislocated childbearing women fromtheir homes and families, and moved apparent responsibilityfor childbirth to the medical profession based in hospitals(Graham 1997). Far from being the rational sequentialscientific development that one might expect, such anexamination reveals that the systems have been shaped andmoulded by class and gender, fashion and fallacy, andprofessional and economic competition (Rowley 1998).

This chapter begins with a very brief glimpse into thathistory in Australia and New Zealand. While there are parallelsbetween the development of maternity care and midwiferyin Britain and Europe and among the non-indigenous populations of Australia and New Zealand, there are alsoimportant differences emerging from Australia’s initial roleas a penal colony and the later development of both Australiaand New Zealand as nations with booming economies wherea vigorous medical profession was seeking to establish itself(Tew 1995). Mein Smith claims that in these two colonies,the revolution in the organisation of childbirth began earlierand progressed faster than in either Britain or Europe (MeinSmith 1986). However, it should first be acknowledged thatmost historical accounts in both Australia and New Zealandhave largely ignored the childbirth experiences and expertiseof the original occupants of the land. Since we must rely onsecondary sources of information, this account will do thesame, in order not to misrepresent the birth traditions ofeither the Maori of New Zealand or the Aboriginal peoplesof Australia.

The origins of midwifery in Australia

The ships of the First Fleet, which landed in Sydney in1788, carried several women who were free settlers as wellas numbers of convict women. The ships’ logs record thatduring the long voyage to Australia, several women gavebirth, allowing others to gain midwifery experience (Adcocket al. 1984). The military and ship’s surgeons accompanyingthe colonising forces probably had little or no midwiferyexpertise, and there were no midwives listed among eitherthe free settlers or the convict women. Therefore it appearsthat midwifery in Australia began with women helping eachother as best they could, accessing medical help where it wasavailable and when it was required. Some of the women whofound themselves in the role of midwife continued to assist

women in childbirth and became well known, loved andrespected for their abilities.

Female convicts were transported to Australia for thenext fifty years in an attempt to empty English prisons of‘hardened cases’ but covertly to provide sexual servicesfor men (who outnumbered the women six to one) andultimately to stabilise the economy of the new colony(Rowley 1998). Early census records reveal that by 1806, twoper cent of women were in skilled trades, which includedtwo women who listed their occupation as midwife, althoughwith every woman under the age of forty-two producing ababy each year, there were clearly more than two ‘midwives’in the colony (Adcock et al. 1984). No ‘learned’ midwiveswere recorded among those early settlers until forty yearslater, when Mrs McTavish, identified as the first ‘trained’midwife to settle in Australia, advertised her services in aHobart newspaper (Barclay 1993, cited in Rowley 1998).Therefore it is reasonable to propose that the midwiferytraditions of Australia were established by community-based, ‘lay’ midwives, without access to any theoreticalknowledge or teaching other than what they had gleanedfrom observation and experience. These were the ‘accidental’


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CHAPTER 6 • THE PLACE OF BIRTH

or empirical midwives of the convict era assisting women togive birth in whatever place constituted ‘home’.

The first maternity hospitals in Australia

In 1820, a midwife or ‘fingersmith’ was appointed to theFemale Factory at Parramatta, which was built to housefemale convicts. Some midwives chose to work in the

Female Factory for short periods to gain experience beforemoving out into the community and private practice.Convicts in domestic service who became pregnant weresent to Parramatta for punishment and confinement.Once delivered, the women returned to their employer,often leaving the baby behind, where their infants werewet-nursed by thirty convict ‘nurses’ who resided there. TheFemale Factory became the first maternity hospital, as thepregnancy rate among convicts was high. Soon, poor anddestitute women also sought to be confined there, since theauthorities were reluctant to build hospitals for the generalpopulace. The Female Factory was eventually closed dueto an epidemic of puerperal sepsis. Following the closure,

convict women continued to give birth at home, as did thefree settlers, attended by relatives, neighbours, or a midwifeif they could afford one or find one, but rarely by a doctor.

The transportation of convicts ended in 1848 just beforethe discovery of gold near Bathurst in 1851. The newcolony prospered. The government of the day encouragedthe immigration of young single women to redress theimbalance in the sexes and to populate the country. Assettlers moved out into rural areas, even neighbours weresparse, and there are numerous accounts of women beingattended by Aboriginal women during childbirth (Willis1989). Learned midwives who had received midwifery

training in England and Scotland were also among thenew immigrants. As the settlements grew into towns, somemidwives began taking women into their own homes for‘confinement’, and thus began the first private maternityhomes, which were eventually to become community orprimary hospitals (Shephard 1989, 1991). Later, concernover the deplorable conditions under which poor anddestitute women were ‘confined’ in their homes led to theestablishment of (initially) charitable and (ultimately) State-funded women’s hospitals in the cities of Melbourne (1888)and Sydney (1893) just prior to the turn of the twentiethcentury (Forster 1965).

The origins of midwifery in New ZealandChildbirth for Pakeha¹ women in New Zealand prior tothe 1904 Midwives Act was described by Donley (1986)as a neighbourhood affair conducted in homes. Womenwere attended by either (English or Scottish) trained orlay midwives, who took charge of domestic responsibilitiesas well as supporting the woman in labour, delivering thebaby and getting breastfeeding established. As in Australia,these early midwives were loved and respected for their

competence and care, and there are several accounts othe good records of the pioneering midwives in terms omaternal and perinatal mortality (Donley 1986). As thtowns grew and cities evolved, many midwives set up theown small, private maternity homes. It is estimated thaby the turn of the twentieth century, there were over twhundred one- or two-bed maternity homes run by midwiveor by doctors, located throughout the towns and cities o

New Zealand (Mein Smith 1986).

The first maternity hospitals in New Zealand

Several events coalesced just after the turn of the century thainitiated major changes in the way childbirth was managedand changed it forever from a relatively private family affainto a concern of the State. Reports to Parliament had fosome time recorded the fluctuating maternal and infanmortality rates in the new colony and, in particular, the ratof maternal deaths from puerperal sepsis. In 1903, a peain the maternal mortality rate caused alarm in governmencircles. At the same time a Royal Commission set up i

New South Wales in 1904 to investigate falling birth ratein both Australia and New Zealand found that the declinwas highest among the ‘better classes’ and that ‘while th“unfit” were having many children . . . [they] had a higherate of infant mortality’ (Donley 1986, p. 32). The PremieRichard Seddon, demanded action and a champion emergein the person of Grace Neill,² who was easily able to persuadhim that the way to increase the birth rate and improvthe appalling rates of maternal and infant mortality was tregister all midwives and establish State-subsidised hospitalwhere the wives of working-class men (the deserving poorcould give birth in comfort and safety. This saw the setting u

of St Helens Hospitals in the major centres of New Zealandwith the first established in a rented cottage in Rintou

St Helen’s Hospital, Dunedin, New Zealand c. 1923.

Reproduced with the permission of Alexander Turnbull

Library, Wellington, New Zealand. Photo from the S C

Smith Collection


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Street, Wellington, in 1905 (Donley 1986). The hospitalsprovided midwifery training for both nurses and womenwithout a nursing qualification, and offered either hospitalor domiciliary care (without prejudice).

Why did women move from home tohospital?

Over the next twenty years, simultaneously in both countries,women started to move from home to hospital in increasingnumbers. Why this happened is an intriguing question. Asimple answer would be to find that mothers and babiesdied in large numbers at home in the care of midwives, andthat women chose to move into hospital, where medicallymanaged birth was safe. This is not the case, however.Different authors quote a variety of maternal and infantmortality rates, all purporting to provide evidence of eithera dramatic improvement in, or worsening of, mortalityas a consequence of the move (Ehrenreich & English1973; Shorter 1983). Gaining a clear picture of what was

happening at the time is difficult, and this allows differentinterpretations of the significant events to emerge. Whatmotivated women to move from birth at home to hospitalcan never be known for certain, but the parallel movementin Australia and New Zealand suggests that the motivatorsfor the change may have been similar, and several issues canbe identified which may have played a part.

The first is the issue of falling birth rates at the turn ofthe twentieth century and the intervention of both colonialgovernments in childbirth, with the aim of increasing thesize of their respective populations and ensuring their healthand vigour (Donley 1986). The Health Departments in bothcountries promoted the hospitalisation of birth in order

to decrease the rate of maternal deaths particularly frompuerperal sepsis, and to ensure women accessed antenatalcare that would lead to the birth of a healthy baby. Bothgovernments were disturbed by the parlous physical stateof many of the men recruited into the armed forces duringWorld War I, and saw the birth of a healthy baby as essentialto the health of the nation in the event of another war (MeinSmith 1986).

Other themes relate to the views of women themselvesand what they may have been seeking. Some may havesought increased material comfort around the time ofthe birth, because many homes in both New Zealand andAustralia were described as lacking in all but the barest ofnecessities (Mein Smith 1986; Rowley 1998; Tew 1995).Other women may have found the promise of a temporaryrelease from domestic burdens attractive (Tew 1995). Stillothers may have been seeking the support and company ofother women, which had been dislocated by the IndustrialRevolution (Wilson 1995), or greater access to doctors andtheir forceps (Loudon 1992; Rowley 1998; Tew 1995), orgreater access to midwives since the lay midwife had largelydisappeared from the community following the setting up

of registration and hospital-based training. Added to theseissues were the promises of a pain-free labour (Loudon1992) and increased safety for themselves and their infants,largely and falsely promoted by the medical profession (Tew1995). In New Zealand, the medical profession activelyencouraged women’s groups in political activity to persuadethe government to build more maternity hospitals, whichthen became a focus for the growing power of the emerging

medical specialty of obstetrics (Mein Smith 1986). All theseissues have been debated in the literature cited, and thestudent of history is encouraged to pursue particular linesof inquiry using the references and further reading lists atthe end of this chapter as a guide. It is interesting to note,for instance, that both forceps and the pain relief offeredby twilight sleep were liberally administered by doctorsattending women in childbirth at home, so these two reasonsalone do not seem to be convincing arguments for the moveto hospital (Forster 1965; Mein Smith 1986).

Far from increasing safety as promised, deaths frompuerperal sepsis increased with hospital birth, in all but

the St Helens Hospitals (Wood & Foureur 2005), but thisappeared to go unnoticed by women as they started to moveinto hospitals in increasing numbers. Mein Smith (1986)

Trainee midwivees, St Helen’s Wellington 1927.

Reproduced with the permission of Archives New Zealand


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CHAPTER 6 • THE PLACE OF BIRTH

asserts that by 1920, most New Zealand women continuedto give birth at home, while approximately 35 per centof deliveries occurred in hospitals. In Australia, ‘births inpublic institutions . . . increased from 3% in 1907 to 7%in 1920 but then leapt ahead to 55% in 1929’ (Tew 1995,p. 65), with one account quoting a rate as high as 67 percent for hospital deliveries in 1925 in the State of Victoria(Loudon 1992).

By 1935, deaths from puerperal sepsis were rarely seen, dueto the advent of the drugs Prontosil and, later, sulphanilamide(Tew 1990). Perinatal mortality also began to declinebetween the world wars, due to dramatic improvementsin the general health of women and raised living standards

most studies are limited in what they can contribute to ouunderstanding of this complex event. Hodnett realised thsynergistic nature of caregiver and location for birth whe

she wrote that the environment may favourably influenccaregivers’ attitudes towards the care of labouring womenand that therefore it may be the influence of the caregivemore than just the location for birth that leads to gooobstetric outcomes (Hodnett 2004). We will return to thidea later in the chapter.

Birth at home or in hospital: which is safer?

The debate concerning the safety of the home as the place obirth has been in progress for over one hundred years anno doubt will continue into the future, unless it becomepossible to conduct an extremely large trial where wome

are randomly allocated to either a home or a hospital birthOne such study involving only eleven women was identifieduring the process of systematic review published by thCochrane Collaboration (Olsen & Jewell 1998). Becausof the small size of the study, the reviewers were forced tconclude that there is no strong evidence to favour eitheplanned hospital birth or planned home birth for low-riswomen. Many other studies using less robust designs (sucas observational, case control or cohort studies and audof maternity services) have been conducted internationallbut few of these have been within Australia or New Zealan(for example, Chamberlain et al. 1997; Rooks et al. 1989Young & Hey 2000). Most studies of this nature suffer from

a lack of ‘denominator data’, meaning that the researchecannot be certain that all women giving birth at home itheir particular data set have been accounted for. Thereforstudies may under- or over-estimate the risks. Howevethe large volume of international evidence, even fromstudy designs which have limitations, must be considereas strongly supporting the case for home birth as a safchoice for ‘women who [have] been screened properly ithe antenatal period and planned a booked delivery fo

(Johanson et al. 2002). However, in the minds of manymoving to hospital for birth had improved safety for womeand babies, and it was not until 1990 that a critical historof maternity care undertaken by Marjorie Tew (1990) waable to convincingly demonstrate the fallacy of this belieToday the vast majority of women in either country will givbirth in hospital, be it a birth centre, primary birth unit osecondary/tertiary hospital. Home birth occurs in less tha

one per cent of the population of childbearing women iAustralia, and although the estimated rate may be highein New Zealand, at approximately six per cent (Pairman &Guilliland 2003), birth at home is the choice of few womenOr, paradoxically, is it that there is no choice?

What was lost in the move?

Several important things were lost in the move from hometo hospital. The first was the opportunity to labour in afamiliar environment. The second was the close personal and

trusting relationship between the woman and her midwifeand the continuous support in labour that the midwifeprovided. The third was the belief in the concept of birthas a normal physiological event. These were and are stilluniversal aspects of home birth provision, and the wholepackage of care provides clear benefits for women (Walsh2004). Let us explore these ideas a little more.

The concept of ‘environment’ is multifaceted andencompasses much more than the geographical or physicalbricks and mortar of the location for birth. It is importantto consider that ‘environment’ also includes the spiritualand emotional space and place in the mind and heartof the woman (Simkin & Ancheta 2001). We must also

acknowledge that the environment too exerts a powerfulinfluence on the midwife and that, in the future, new areasof research in what some have termed ‘neuroarchitecture’ (or‘psycho-geography’) will improve our understanding of thisconcept (Foureur 2002; Lepori 1994; Newburn 2003; Page2002; Walsh et al. 2004).

In their calls for more home-like environments for birth,more continuity and more choice and involvement indecision-making, women may have unknowingly articulatedtheir longing to replicate the idealised birth environment ofhome. Policy makers have attempted to put back componentsof the package, and researchers have undertaken numerousstudies to explore the safety and impact of differences

in location for birth (home, birth centre, primary unit,hospital), type of care provider (medical, midwife, doula),models of care (fragmented versus continuity of care andcarer) and philosophies of care (belief in birth as a normalphysiological event or only normal in retrospect; risk-embracing or risk-averse). However, if the three componentsof birth at home are an integrated and inseparable package, itbecomes apparent that most studies to date have focused oneither one or another part of the package. As a consequence,


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home’ (Chamberlain 2000; Macfarlane et al. 2000). But formothers with a twin, breech or post-term pregnancy, thecurrent state of evidence asserts that there is an increasedrisk of perinatal death at home (Bastian & Keirse 1998;Young & Hey 2000). The comprehensive UK study ‘Whereto be born?’ concluded that, given the current state ofknowledge, ‘there is no evidence to support the claim thatthe safest policy is for all women to give birth in hospital’(Macfarlane et al. 2000).

However, the rhetoric that began over one hundred yearsago persists, and society still views birth at home as a poorchoice. Indeed, Tew (1995) identified that data had beendeliberately misinterpreted in UK studies between 1958 and1970 to support the claim that ‘the family home is the mostdangerous place for birth’ (p. 29). Tew stated that an impartialobserver could clearly see that the perinatal mortality ratewas higher in hospitals, yet this fact was distorted in reports

of the time. Obstetricians throughout the world used thefalse interpretation of these statistics to influence the futuredevelopment of maternity services. Midwives may also beinfluenced by the rhetoric and either refuse to provide ahome birth option for women or unconsciously bias theway it is discussed, leading women to ‘choose’ a hospitalbirth (Walsh 2004).

The birth centre: a halfway house?

Moves to address the loss of the familiar home environmentfor birth appeared in the late 1970s with the call for morehumanised or home-like birth spaces, culminating inthe development of the birth centre in many locationsthroughout Australia and New Zealand (as elsewhere). Birthcentres may be free-standing or located within hospitals,either adjacent to or within hi-technology and medicallystaffed labour wards, thus enabling immediate consultationor rapid transfer if the need arises. Primary birth units maybe located in urban or rural settings and share many of

the attributes of birth centres. Although birth centres maydiffer in their structure, location, furnishings and staffing,all share a strong philosophical orientation towards assistingwomen to achieve normal physiological birth (Coyle et al.2001; Kirkham 2003). They are intended only for womenclassified as ‘low risk’, the very women who would fulfilcriteria for birth at home. However, even in this low-riskpopulation, numbers of women are transferred out formedical assistance or pain-relieving drugs before, duringor after labour. Transfer rates vary from as low as 12 percent (Rooks et al. 1989) to more commonly around 20 percent but even up to 63 per cent in some settings (Hodnett2004). In Australia, around 5 per cent of women give birth

in primary birth units (Griew 2003)—this includes 5379births in birth centres in 2002, ‘representing 2.1% of allconfinements’ (Laws & Sullivan 2004). In New Zealand thecombined birth centre/primary birth unit rate is 10 per cent(Pairman & Guilliland 2003).

Numerous randomised controlled trials and observationalstudies examining the effectiveness and safety of birthcentres/primary birth units have been conducted worldwide,and have demonstrated that birth for low-risk womenis at least as safe in small low-risk maternity units as it isin hospitals (Kirkham 2003; Walsh & Downe 2004). Inaddition, a recent consumer satisfaction survey conductedin New Zealand has revealed that women ‘are more likelyto be satisfied with maternity services if they birth at aprimary maternity facility’(Ministry of Health 2002, p. 4).In a Cochrane Systematic Review, Hodnett (2004) includedevidence from six trials involving almost 9000 women, andconcluded that there appear to be some benefits from home-like settings for birth. However, one recent study has raisedconcerns about the safety of out-of-hospital births, and itneeds to be considered here (Gottvall et al. 2004).

A ten-year retrospective review of the Stockholm Birth

Reflective exercise

Imagine that you are a midwife who cares for

women wherever they want to give birth (indeed,

this might be a reality for many midwives). Some

women want to be at home, others want to be

at the small, local birth unit, and still others want

to be in the hospital. Ask yourself the followingquestions.

1 How do I feel about supporting women in

each of these locations?

2 Are the feelings different depending on the

location?

3 Where do these feelings come from?

4 How do I react when a woman asks me to

support her in planning a home birth?

5 How do others react to her decision for a

home birth?6 Why is this so?

7 How inconvenient/uncomfortable/scary is

it for me to have to travel to the woman’s

home? Do I have to support her choice?

8 How inconvenient is it for me to have to

travel to the birth centre rather than the

hospital?

9 Do we (women and midwives) have any real

choices of where to birth in our region?

• Is there a need to change anything?

• How can I do that?

• Who will help me?


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CHAPTER 6 • THE PLACE OF BIRTH 1

Centre undertaken by Gottvall et al. (2004) revealed atrend to higher perinatal mortality in primigravid women.Following scrutiny of each perinatal death by an obstetrician,Gottvall and colleagues (2004) claimed that a potential riskof birth centre care is the ‘philosophy that emphasises astrong belief in the natural process’ (p. 77). Hodnett (2004)echoed concerns regarding the emphasis on normal birth andstated that this belief might delay recognition of imminent

complications or the ability of the midwife to take avertingaction. However, concluding comments from Gottvallet al. (2004) indicate a potential bias in the study introducedthrough an underlying concern with intrapartum care thatdoes not include technology and medical assistance. Manyof the perinatal deaths in the original Stockholm trial(Waldenstrom et al. 1997) occurred after transfer and wereassociated with clearly documented suboptimal care in thereceiving hospital. Gottvall and colleagues did not commenton this. On the other hand, Walsh (2004) refuted anysuggestion that birth centre midwives are over-orientatedto normal birth and therefore may delay recognition of

complications. Walsh asserts that birth centre midwivesare highly skilled practitioners with an astute awarenessof normal labour and that these midwives are particularlydiligent in updating their skills in emergency care. Walshacknowledged that it might very well be the midwife’s beliefin physiological labour, especially for primigravid women,that enables such women to achieve normal birth in birthcentres.

Sociologists who have paid particular attention tochildbirth also show concern regarding interpretationsof safety. Annandale (1988) used both quantitative andqualitative methods to study the structure of birth ina North American birthing centre. Her study included

eighteen months of observation, repeated focus group

interviews and content analysis of 900 women’s recordover a five-year period. Obstetricians did not see womeunless a risk factor arose; however, Annandale commentethat midwives and obstetricians disagreed about whaconstituted a risk factor. Midwives tended to disagree witthe assertion that a post-term induction was high riskand that intervention was required after twelve hours orupture of membranes. Annandale found that birth centr

midwives adopted strategies to maintain the ‘normal’, sucas encouraging women to stay at home until active labouwas well established. This strategy reduced the likelihood otransfer to a large hospital for perceived prolonged labouHowever, Hodnett (2004) cautioned that ‘just as an oveemphasis on risk and intervention can lead to unnecessarinterventions and avoidable complications for healthchildbearing women and their families, an over-emphason normality may lead to delayed recognition of or actioregarding complications’ (p. 5). Eternal vigilance is requiredMidwives need to be alert to the need for detection anprompt action in the case of abnormality. To be vigilan

without being fearful is one of the hallmarks of an expermidwife.No doubt, more research will be undertaken in the comin

years to examine the safety of out-of-hospital birth, and thdebate will continue. Perhaps if greater emphasis is giveto the whole package of what constitutes home birth rathethan fragments of the package, our understanding will benhanced enormously.

The return of a familiar caregiver

The second component of the care package to be lost ithe move was the familiar caregiver and the continuou

support she provided. This has been addressed througcalls for increased continuity of care, which midwives hav

Reflective exercise

Think about the place of birth in which you work

and ask yourself the following questions. (It may

be helpful to write down your responses.)

1 What do I honestly think about safety and

place of birth?

2 What is the underlying belief system that I

take with me to a birth?

3 What does the physical environment say

about birth in this place and our beliefs

about birth?




Auscultation of baby’s heart with Pinard stethoscope.

Reproduced with the permission of the New Zealand

college of Midwives


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provided, first in experimental models tested in numerousrandomised controlled trials, and more latterly in NewZealand following the changes to the Nurses Act in 1990leading to midwifery autonomy.

There now exists overwhelming evidence, from nearlytwenty randomised controlled trials conducted in Australia,Canada, Sweden, Hong Kong, the United Kingdom, Scotlandand the United States of America, that continuous labour

support for women during childbirth should be the norm,rather than the exception (Biro et al. 2003; National Institutefor Clinical Excellence 2004; Rowley 1998; Rowley et al. 1995;Waldenstrom & Turnbull 1998). It is clear that any maternitycare system that is not founded on this model of care placeswomen at increased risk of interventions such as epiduralanalgesia and operative birth by forceps, vacuum extractionor Caesarean section. Although the short-term effectsof such procedures are well documented, it is becomingincreasingly apparent that these are all major interventionswith potential for unanticipated, adverse, long-term physicaland behavioural effects on both mothers and babies (Bahl

et al. 2004; Beech 1998; Carter et al. 2001; DiMatteo et al.1996; Gottvall & Waldenstrom 2002; Jacobsen & Bygdeman1998; Jacobsen et al. 1990; Mayberry et al. 2002). Some effectsmay be permanent.

The financial costs of the long-term consequences ofintervention in childbirth have received less scrutiny, buteven the increased costs of the procedures themselves mustlead health care planners to consider more carefully themodels of care to which women are subjected (Roberts etal. 2000; Tracy & Tracy 2003). These findings cannot beignored, and many maternity care systems have focusedattention on ways and means of increasing opportunities

for women to experience continuous labour support, withvarying degrees of success.

However, while continuous labour support is a form ofmaternity care that should be available for all women, it isclearly not sufficient, in and of itself, to enable normal birth.Three issues will be explored here. First we will examine theNew Zealand maternity care system, which has successfullyembraced a model of care that provides continuous laboursupport for all women, but still sees women experience highand rising rates of intervention (NZHIS 2004). Second,we will consider what it is about continuity of care andcontinuous labour support that influences outcomes, by

exploring the concept of the fear cascade (Rowley 1998).Finally, we will consider whether a better understandingof the physiology of birth contributes to keeping birthnormal.

What is a ‘normal birth’?

Continuous labour support aims to decrease interventionin childbirth and thereby increase the numbers of womenwho experience ‘normal’ birth. Much debate has arisenaround the concept of ‘normal’ birth, and for the purposesof this chapter it is defined as follows: labour occurs at term,

is spontaneous in onset, and there is no requirement foraugmentation or analgesia; the birth occurs spontaneously,vaginally, and the mother and baby are healthy. Someauthors have estimated that in the twenty-first century,fewer than one-third of women in ‘developed’ countrieswill be enabled to give birth as nature intended (ConferenceReports 2001; Sandall 2004). Many women are fearful ofthe process and shocked by their experiences. Rates ofintervention vary between and within countries, betweendifferent locations for birth (hospital, birth centre and homebirth), and between different models of maternity care inthe same settings (public and private, fragmented care andcontinuity of care). Even the rates of intervention found inrandomised controlled trials of continuous labour supportand continuity of care reveal differences depending on thelocation of the trial—whether in a labour ward or a birthcentre. However, very few trials and even fewer nationaldata collection systems report birth outcomes in terms ofthe numbers of women who experience normal birth.Therefore the extent (or disappearance) of normal birthhas been unintentionally hidden from our gaze until veryrecently.

‘Continuity of care’ versus ‘continuouslabour support’

Continuity of care describes the actual provision of care bythe same caregiver or small group of caregivers throughoutpregnancy, during labour and birth, and in the postnatal

period. This model usually implies, but may not alwaysinclude, continuous one-to-one support throughout labour.Continuous labour support describes the process of one-to-one supportive care from a companion throughoutlabour. It is apparent from at least one systematic reviewthat continuous labour support provided by a non-hospitalcaregiver is more effective at reducing interventions thansupport provided by members of the hospital staff (Hodnett2004). This raises interesting questions as to why the impact ofcontinuous labour support differs depending on the type ofcaregiver. Hodnett (2004) proposes that the difference resultsfrom the ability of non-hospital caregivers to give greaterattention to the mother’s needs, since such companionsare not distracted by the diverse responsibilities of hospitalemployees and organisational issues such as shift changesand staff shortages. We propose that this explanation is toosimplistic. If Hodnett’s proposal was valid, we could expectto find low rates of intervention in maternity care systemswhere both continuity of care and continuous one-to-onesupport throughout labour from non-hospital caregiverswas the norm. Arguably this is the situation that has emergedin New Zealand over the past ten years. However, while it


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is apparent that New Zealand women are overwhelminglysatisfied with their experiences of midwifery-led continuityof care since their emotional/social needs are well met

(Ministry of Health 2002), there exists some disquiet aboudecreasing rates of birth without intervention (Strid 2000Let us examine this more closely.

The New Zealand experience

Around 54,000 women give birth annually in New Zealand

at tertiary and primary care hospitals, in birth centres and athome. There are just over 2000 qualified midwives currentlypractising in New Zealand and they are almost evenly dividedbetween those who work as hospital (or core) midwivesand those who work as independent (or caseloading)midwives. While core midwives are employed and generallywork on shifts in maternity facilities, independent midwivesmay be employed or self-employed and provide continuityof care to an identified caseload of women. All womenare required to have a known caregiver or ‘lead maternitycarer’ (LMC) throughout their childbirth experience.Although a general practitioner or specialist obstetrician

can be chosen by the woman as her LMC, over 75 per centof women choose a midwife. If the LMC is a midwife, sheor he will usually provide continuity of care throughoutpregnancy, one-to-one continuous labour and birth support,and postnatal care. The research evidence suggests thatthis model of care will result in low rates of intervention.However, it is apparent from emerging (and as yet incomplete)data collections published by the Ministry of Health ofNew Zealand that this is not the case (NZHIS 2004). Therate of intervention in childbirth is apparently high andcontinuing to climb, with the national rate of Caesareansection in 2000 and 2001 (the most recent data available)at 20.8 and 22.1 per cent respectively. The rate of normal

birth in those years is described as 68.4 and 67.6 per centbut the definition of ‘normal’ in this instance simplymeans ‘spontaneous vaginal birth’. What this descriptionof ‘normal’ birth does not reveal are the numbers ofwomen who also experience induced and augmented labour(around 30 per cent), the rates for epidural, which areas high as 60 per cent in some centres, and the wide variationbetween rates of intervention in small and larger maternityunits.

Another recent publication has examined the outcomesfor women giving birth in one New Zealand health servicethat has a tertiary-level hospital and two smaller primary carebirth units (Fisher et al. 2004). In this setting, continuousone-to-one labour support for around 3000 of 3500 womenis provided by non-hospital midwives. Here the rate of‘normal’ birth in 2002 for all women was 42.3 per centand for primiparous women a low 32.2 per cent. Thedefinition of ‘normal’ birth for this study was ‘spontaneousonset of labour at term, no augmentation or analgesia andspontaneous birth’, which possibly hides the numbers of

women in the ‘normal’ birth category who also receive

opiates during labour or an episiotomy at the time of birthIt is apparent that in both the national study and this studneither the benefits of continuity of care nor continuounon-hospital, one-to-one labour support appear to bpresent. How can this be possible?

Further analysis of the national and local data setis required, to explore the possible causal relationshipcontributing to the low rate of normal birth (such athe increasing age of first-time mothers). Until then it useful to consider a plausible explanation provided bKitson et al. (1998). In exploring the problems encounterein implementing research evidence in practice, Kitso

and colleagues developed a useful model described aSI = f(E,C,F). In essence this means that the successfuimplementation of research (SI ) is a function ( f ) of the typof evidence (E ), the context (C ) in which the research waproduced and to which it will be applied, and the facilitatio(F ) that occurs to enable research implementation. is important to consider the contexts within which thevidence of effectiveness for both continuity of care ancontinuous labour support was produced. The evidence iboth cases is a product of numerous randomised controlletrials. Such trials usually occur in settings which are openlsupportive of innovation and exploration, since they arrequired to invest resources to carry out such studies. The

are potentially more likely to have a high awareness of thevidence of effectiveness for many aspects of maternity carwhich may influence processes and outcomes not measurein trials. They are special places and attract staff interested iexploring the evidence base for practice. Arguably this is nothe situation found in the messy everyday world of real-lifmaternity care. In reality, midwives in New Zealand worin highly medicalised environments which clearly overridthe potential benefits of continuity of care and continuoulabour support. They also provide care to women with a furange of risk factors, not only those considered to be ‘low riskThe model itself is not powerful enough to provide benefino matter what the setting, since the setting is imbued witthe power of a risk-averse belief system. We propose thaincreasing our understanding of how the ‘package of careactually influences the physiology of birth will provida means of addressing the environmental constraints. midwives (and others) had a greater understanding othe physiology of birth, fearful belief systems would bovercome.


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What do we know about birth physiology?

in uterine contractions (as well as many others). Disruptingthe rhythmical release of oxytocin can result in incoordinateor absent contractions. This can both slow the progress oflabour and increase the amount of pain experienced by thewoman. The result is uterine inertia or failure to progress.On the other side of the fear cascade, the effect of adrenalineon uterine blood flow and placental perfusion can be seen.During the ‘fight or flight’ response, blood is diverted awayfrom non-essential organs to the brain and limbs, and in thiscase the uterus is considered a non-essential organ. This mayresult in shifts in the amount of blood to the uterus. Even asmall decrease in the volume of blood passing through theplacenta can have an impact on fetal wellbeing and, thus,fetal distress may become apparent.

Finding supporting evidence for the fear cascade requiresan eclectic approach to searching the literature, becausethe research has largely been conducted in animals and has

occurred across a thirty-year span. Although results fromanimal research are not directly transferable to women, theydo need to be given due attention. As Naaktgeboren says:

Extrapolation from studies of parturient animals to humanreproduction is inherently unwise since we assume humanbehaviour is much more complex than that of animals . . . butcomparative obstetrics has demonstrated that . . . differentspecies have made specific adaptations to the ecology ofwhich they form a part; however common mechanisms whichhave a fundamental value, are observed in all mammals. Thisis just as true for the behavioural as for the physiological,endocrinological, anatomical (and many other aspects) ofparturition (Naaktgeboren 1989).

Labouring undisturbed

In a classic work in 1978, perinatal psychologist NilesNewton noted the neuro-hormonal similarities betweenhuman sexual response, un-drugged birth and the let-downreflex in breastfeeding (Newton 1978). Newton suggestedthat all three processes were mediated by oxytocin, and thatthe pleasurable feelings they promoted had evolved to ensurethe continuation of the species. Newton also observed thateach could be inhibited by environmental disturbances,which she explored in a series of elegant experiments onmice (Newton et al. 1966).

Newton randomly selected labouring mice from alaboratory mouse population and moved them from theirsecure nest into the hostile environment of a nest containingbedding contaminated with cat urine. She then comparedthe length of labour for each group of mice and foundthat the disturbed mice had longer labours, to the pointwhere many did not give birth until moved back into theirsafe nest. Significantly fewer mice gave birth in the hostileenvironment. What was even more disturbing was that the

During birth, ‘a range of physiological adaptations’ (Ginesi& Niescierowicz 1998a) are coordinated by a delicatelybalanced cascade of interrelated hormones such as oxytocin,endorphins, prolactin, ACTH and more, which flood thebody and brain (Ginesi & Niescierowicz 1998b; Vose 2003).

This is a largely unconscious process controlled by the partof our brain that initiates and responds to emotions—thehypothalamus or primal brain. Although the process hasevolved over millennia to ensure the survival of the humanspecies and is therefore relatively robust and successful, itis clearly possible to disrupt it by stimulating the neocortexof our brain into counter-active mode. Bright lights, harshnoises, foreign smells, strange and unfamiliar surroundings,loneliness, lack of trust in companions, loss of control,invasive procedures, pain and fear are just some of thephenomena that will stimulate the neocortex. This can bemore fully appreciated by examining a process named the

‘fear cascade’ (Figure 6.1) explored by one of the authors (MF,nee Rowley) as part of a randomised controlled trial of teammidwifery in Australia (Naaktgeboren 1989; Rowley 1998;Rowley et al. 1995). The fear cascade provides one plausibletheoretical explanation of why the two main reasons forall interventions in childbirth—uterine inertia (failure toprogress) and fetal distress—occur. This is what it suggests:A healthy increase in maternal anxiety (eustress) can beexpected as labour commences and the birth approaches.Nature has intended this as a signal to find a safe place togive birth so that a helpless newborn infant can be hiddenfrom dangerous predators. However, the fear cascade maybe initiated if the level of maternal anxiety increases to the

extent that high levels of the catecholamine, adrenaline,are produced. This is a component of the well-described‘fight or flight’ response. Adrenaline has an impact on thecontinued release of oxytocin, which has a major role to play

Fear cascade: fight or flight

Catecholamines ↑

• Oxycytoxin ↓

• Uterine contractility ↓

• Uterine blood flow ↓

• Placental perfusion ↓

• Fetal oxygenation ↓

Uterine inertia Fetal distress

Figure 6.1 The fear cascade (Rowley 1998)


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newborn pups of the disturbed mice were more likely to befound dead soon after birth, suggesting that fetal damage hadoccurred in utero. Newton hypothesised that fear generatedby the hostile environment had disturbed the productionof oxytocin, slowed labour and interfered with the supplyof blood to the uterus. She questioned whether the samemechanism might operate in labouring women subjected tothe variations between home and hospital environments.

Newton’s work offers much support for the fear cascade,at least in mice. Other research conducted with rhesusmonkeys also adds some weight to the case for a fear cascade(Adamsons et al., cited in Rowley 1998). Adamsons andcolleagues were also interested in the role of catecholaminesand uterine blood flow. They discovered that catecholaminessuch as adrenaline injected directly into the fetus of apregnant rhesus monkey had no effect on the fetus otherthan raising its heart rate. However, when catecholamineswere injected into the mother, fetal asphyxia and acidosiscould be induced, and it was postulated that this was dueto the vasoconstrictor effect of catecholamines leading to

impaired uterine blood flow.There is now much more evidence concerning the impactof fear on the physiology of pregnancy in human studies,including those using ultrasound to examine uterine arteryresistance in response to maternal anxiety (Teixeira et al.1999). It is now possible to demonstrate that maternalanxiety increases the uterine artery resistance index, andreduces blood flow to the baby, affecting fetal developmentand leading to small-for-gestational-age infants and thepossibility of premature birth. All of these studies offersupport for the fear cascade and suggest a role for reducingmaternal anxiety through ensuring undisturbed labour as anessential aspect of keeping birth normal. Continuity of care

that also includes one-to-one support throughout labourprovides one way of achieving this. What ‘support’ shouldentail is well described in The Labor Progress Handbook bySimkin and Ancheta (2001), which provides midwives witha myriad of practical and seemingly simple ways to applythis theoretical understanding to clinical practice. The readeris urged to find a copy of this valuable publication and toshare it with women and colleagues alike.

Continuity of care provides opportunities for a close andtrusting relationship to develop between the woman and hermidwife. Continuous one-to-one support in labour providesan opportunity to ensure that labour is undisturbed andthe fear cascade is not initiated (Buckley 2003). Adding thiscomponent to the package that already includes a familiar orhome-like place for birth increases the likelihood that birth

will be normal. However, there is one other component othe package that appears to be essential—the belief in birtas a normal physiological process.

Reflective exercise

Take a careful look at the birth spaces in

your local unit and ask yourself the following

questions.

1 Can women labour undisturbed in this

environment? 2 How can I ensure that no one disturbs the

woman unnecessarily?

3 Am I disturbing her by talking too much?

4 Is there a sign on the door asking people

to knock and wait for a reply if they want to

come in?

5 Do unknown staff walk in unannounced?

6 Are there locks on the door?

7 Can we hear the woman next door giving

birth?

8 How private is the space?

9 Who ‘owns’ the space when a woman is in

labour and giving birth here?

10 Is the woman free to move around—to sit,

stand, walk, squat, lean, lie down?

11 Are there en suite facilities for her to shower

or use a bath during labour or birth?

12 Where is the bed located and what kind of

bed is it?

13 Is there a space for her family/supportpeople?

14 How welcoming is it for them?

15 Are food and drink available?




Belief in birth as a normalphysiological process

A recent study conducted by one of the authors (MH) inNew Zealand provides important insights into the power of

the place of birth to influence the midwife’s belief in birtas a normal physiological process (Hunter 2000, 2003). In


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series of in-depth interviews conducted with independentmidwives who cared for women in both large (secondary/tertiary) and small (primary) maternity facilities, Hunterdiscovered that the midwives overwhelmingly preferred toprovide labour care in small maternity units, where theyfelt they were more able to attend to women, as opposedto attending to machines, and where they had developedadditional midwifery skills. This they named as practising

‘real midwifery’. In the small unit, the midwives felt trulyautonomous, able to take time to let labour unfold ratherthan rush women along as if on a conveyor belt, able to givethe woman time to settle into her labour before intrudingwith a vaginal examination to assess progress, and moreable to tolerate the woman making noise without fear thatthey would be regarded as a less than competent midwife.Importantly, the midwives revealed how the additionalresponsibility of being alone in the small unit caused themto reflect carefully on their skills and ability to manageany challenge, keeping them alert and watchful. Despitethe additional responsibility and feeling that they would

‘carry the can’ if anything went wrong, they were unshakenin their belief in the normal process of birth and had theconfidence to enable the process to occur with minimalintervention. Hunter (2003) proposed that the followingskills are necessary for midwives who practise in primarymaternity units:

the confidence to provide intrapartum care in alow-technology setting

being comfortable with using embodied knowledgeand skills to assess a woman and her baby, asopposed to using technology

being able to let labour ‘be’ and not interfere

unnecessarilythe confidence to avert or manage problems thatmight arise

the confidence to trust the process of labour and beflexible with respect to time

being willing to employ other options to managepain, without access to epidurals

being solely responsible for outcomes withoutaccess to on-site specialist assistance

being a midwife who enjoys practising ‘realmidwifery’.

‘Real midwifery’ was articulated by one of the participants,

named Elizabeth, as follows:

At [the small maternity unit] it’s like real midwifery in away, because you’re not interfering . . . When you are using thesynto and the epidural, a lot of it’s taken away from the womanand, in a lot of respects, probably taken away from you a littlebit as well.

. . . I think with real midwifery, a lot of it is not doing, in a wayletting it happen, being there, but you’re still there and you stillwant to make sure that things are happening as they should . . .

●

●

●

●

●

●

●

●

And I think real midwifery can be not being that overpoweringperson there.

Midwives in primary maternity units need to have a beliefin normal birth and the skills to be unobtrusive while stillensuring that labour is progressing normally. Women alsoneed to believe that they are able to labour and give birthin a primary facility (Coyle et al. 2001). Antenatal visits and

childbirth education classes held at primary units generallyfoster women’s confidence and enhance their commitmentto labouring in a primary facility. In this study the midwivesendeavoured to influence women with regard to place ofbirth, as evidenced by the following words from one of theparticipants:

With first-time mums when they come to me, we talk about whohas actually influenced them into thinking they need to be at alarge hospital. We talk about the statistics that show women areactually safer in a smaller hospital, and a good percentage of themwill end up coming to the smaller hospital (Rosemary).

Rosemary could be referring to a number of studies,

including a landmark study undertaken by Rosenblatt andcolleagues (1985), which showed that New Zealand womenhad good outcomes in primary facilities and that suchfacilities had an important place within a population that isdispersed throughout urban and remote rural areas.

Being confident to provide intrapartum care in a low-

technology setting

Most of the participants interviewed stated that they wereproficient with the technology in the large hospital. Yet theypreferred practising in primary units, where there is low useof technology. Participant Elizabeth emphasises this point:

The technology has got its place. I can go from having a womanon a syntocinon infusion and an epidural pump, to the next day,at the small unit, and the woman is squatting in the corner, orwhatever, and it is totally different.

For the midwife, being hands-off and just being there forthe woman is often more challenging than being constantlybusy attending to equipment and machines.

Being comfortable to use embodied knowledge and

skills to assess a woman and her baby, as opposed to

using technology

The ability to be attuned to embodied knowledge growswith midwifery experience, and includes the ability to listento one’s gut feelings. Using embodied knowledge does notpreclude the use of technology. For example, the womanmight elect to have the fetal heart monitored by Doppler toenable flexibility with positions during labour. The use ofthe Pinard stethoscope might require her to change positionto enable the baby’s heart sounds to be heard. A waterproofDoppler is a useful tool when the woman elects to have awater birth, as this enables her to remain in the water aslong as she chooses.


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There are times during a woman’s labour when themidwife needs to step back and acknowledge the feelings andsignals that arise from her own body. Embodied knowledgerecognises that the mind and body are inextricably linked. Anexperienced midwife spoke to us about her mild tachycardia,which indicated to her that something might be astray. Guiver(2004) undertook a grounded theory study about midwiferyknowledge in relation to normal birth. Participants talked

about their gut instinct, which assisted them as midwivesto know whether the labour was normal. Participants inHunter’s (2000) study stated that over-use of equipment andmachines meant less use of the midwife’s internal senses.One participant said that switching on the cardiotocographmachine was almost simultaneous with switching off herown assessment skills related to fetal wellbeing.

The following examples show midwives using their ownassessment skills and knowledge:

You need your eyes and your hands more than any equipment.That will tell you more than any monitors. In the large hospital you’re actually thinking more in the high risk, using all the

instrumentation you have, or all the technology, rather than using your own ideas or what you are seeing yourself (Cluain Meala).

When the woman’s lying there with her epidural, you’re watchingmachines. Whereas, at the small unit, it’s sort of like watching andwaiting . . . and you have to have confidence in women’s bodies just to let it flow (Bronnie).

The midwives talk of using their hands, eyes and ownideas through observation with the woman, as opposed toa total reliance upon equipment. Observations might entailwatching and waiting. The midwife needs to have confidencethat the labour will flow and progress normally. Experiencedmidwives know that the art of palpating contractions

provides a vast amount of information, including thestrength and characteristics of contractions. This is incontrast with the limited diagrammatic representation ofcontractions on cardiotocograph machines, which reallyonly show the frequency of contractions.

Being able to let labour ‘be’ and not interfere

unnecessarily

Midwives described ‘real midwifery’ as ‘being there andletting it happen’. Sometimes it consists of ‘not doing’ and just letting the labour unfold. But the midwife is alwayswatching to make sure things are progressing, without beingobtrusive. Working in primary units and attending home

births fosters learning about real midwifery and fostersconfidence in one’s own practice. High-technology settingsmight hinder the development of low-technology midwiferyskills. Other participants echo Bronnie’s words of being ableto ‘go with the flow’ of labour in small units:

Looking after women in the small units, there is this expectationof going with the flow. I think you have to believe that birth isnormal and that women’s bodies are built for the job and themajority of births are normal (Kirsty).

You need confidence in birth as being normal and I think itsomething that grows. When you leave someone alone and doninterfere, then the risk of a problem is even less ( Joyce).

Being able to let labour ‘be’ requires a belief in normbirth and the ability to care for women without interveninunnecessarily. Guiver (2004) criticised the rhetoric that birtis only normal in hindsight and stated that birth withou

interventions is eminently possible with midwife-led carand a faith in normal birth.

Being confident to trust the process of labour and be

flexible with respect to time

Midwives opposed the discourse of a fixed time frame fowomen in labour. One way in which midwives showeflexibility regarding time was through limited use of vaginaassessments. Midwives commented that an immediatvaginal assessment might not be necessary (at a primarunit) if you were very sure of presentation and engagemenif the woman was obviously contracting well and had nobeen in labour for too long, and if the fetal heart was norma

and the woman did not want to know her dilatation:Sometimes women will request to have a VE just to reassure themthat they are actually in established labour. I’ll probably do a Vthen, but if they don’t request one, I’ll just sit and watch forcouple of hours (Rosemary).

Coyle et al. (2001) showed that women appreciated a noninterventionist approach, such as midwives keeping vaginexaminations to a minimum. In order to do this, midwiveneed to be adept at palpation of the presenting part, andescent and flexion of the head (Sookho & Biott 2002)Midwives also need to be willing to silently pose the questionIs it a head or could it be a breech? The presentation of th

baby assumes more importance in free-standing primarunits, where it might take several hours to transfer a womawith a breech presentation diagnosed in labour.

Midwives also stressed the importance of continuity ocare and mutual trust where women stayed at home untlabour was well established. When a woman telephoned thmidwife in early labour, the midwife might offer to attenthe woman at home and undertake an initial assessmenthat might or might not include a vaginal examination. Thprocess reassured the woman and the midwife that labour hastarted, and progress was likely as the hours unfolded. Thmidwives placed great importance on education antenatallabout the latent stage of labour and the time needed for th

cervix to efface:

This first-time mum that I am thinking of, she did have a lonlabour in the small unit—20 hours. It’s a balance betweethe woman feeling relaxed in the small unit and maybe usinthe bath and knowing that she is coping, to going to the larghospital where we have got to use active management of labou(Kirsty).

Kirsty shows the art of midwifery in allowing the womatime, and the sense of not rushing or interfering. She als


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gave the woman the choice of remaining in the primary unit,as the woman and the baby were coping with the processof labour.

Most of the midwives who offered intrapartum carein small maternity units also offered women the optionof having a home birth. There seemed to be similaritieswhen the midwives described practising in small units andattending women for home birth:

I just feel a little bit freer at the small maternity unit. It’s likebeing at a home birth in a way really—not quite, but in a way itcan be (Elizabeth).

Although all the midwives were autonomous leadmaternity carers, they still felt compelled to ‘do’ when in alarge obstetric hospital:

The difference between a small and large hospital is that once youget into the large obstetric hospital, you feel like you’ve got a timeframe to get out of there. Whereas, at the small unit, you don’twant to interfere, you don’t want to rush things (Bronnie).

The sense of a time frame appears to pervade the ambienceof large obstetric hospitals and, in turn, even autonomousmidwives are affected by the busyness of large hospitals andbecome acutely aware of time.

Being willing to employ other options to manage pain

without access to epidurals

Managing pain during labour is a major challenge to womenand midwives, and Leap (2000) has contributed her expertiseto assist midwives. In primary maternity units, midwiveshave no access to epidural analgesia, and the midwives inthe study preferred not to use pethidine analgesia. The keyto managing pain was multifaceted, but one aspect was that

the midwives tolerated noise from women during labour, asopposed to silencing them with analgesia. It is importantthat women are allowed to make noise during labour andto express their pain if this assists them to cope througheach contraction.

Not having access to epidural analgesia taught participantElizabeth how to work with women in labour. If epiduralanalgesia is on site, it is too easy to resort to this to relieve pain.Midwives in primary facilities employed all the usual thingslike mobilisation, a hot pack on the woman’s back, massage,homeopathy, shower, bath, pool, different positions, sittingon the toilet, rocking, squeezing the top of the hipbones andother manoeuvres. Being with the woman, going throughevery contraction with her, talking her through, were allviewed as methods of pain relief.

Practising as an independent midwife also changed howsome of the midwives worked with women and their pain.A big difference in continuity of care is that the woman andthe midwife know each other and therefore there is a sense oftrust. The midwife is generally working on a one-to-one basiswith that particular woman and is totally focused on her, ascompared with being focused on the needs of a busy delivery

unit. The ‘education factor’ that occurs antenatally enables aplatform for working with women and their pain:

I think that the support that you give women at one of thesesmaller units is more intensive. You know that if the woman hasthat support all the way through her labour, she is going to copea little bit better (Rosemary).

As discussed earlier in this chapter, intensive supportseems to be critical in assisting women to cope with theirpain, along with trying a variety of strategies to meet thewoman’s needs. A calm environment creates the ambiencefor birth to proceed. Appropriate background musicand the woman’s family or supporters help to (re)createan atmosphere of normality and enable the woman toproceed with the birth process. Understanding thephysiological impact of an epidural on the physiology oflabour, and the potential long-term consequences of in uteroexposure to narcotics for the baby may inspire both thewoman and her midwife to work with the pain productively(Robinson 2001).

Being confident to avert or manage problems

that might arise, and being solely responsible for

outcomes without access to on-site specialist

assistance

Situations arise in the course of midwifery practice wherethe midwife must promptly avert or manage problems. Aspractising midwives, we all carry memories of emergencyoccasions that we have been involved in and those that wehave managed. It is important that practice is not colouredby a problem focus. However, our memory tends to occludethe numerous occasions when we have driven our carwithout incident, yet we vividly recall the one time that we

had an accident. Midwives admitted that the responsibilityfor outcomes was greater when they practised intrapartumcare in free-standing primary maternity units. Sometimesit would take hours before the woman was transferred viaambulance to the large hospital and assessed by a specialistobstetrician. In the interlude, it is the midwife who assessesthe emergency situation, provides interim care and organisesthe urgent transfer to the large hospital.

In order to provide intrapartum care in primary units,midwives stressed the need for acute senses, awareness,alertness and the skills to react in a timely manner. A midwifein a primary unit has to know what to do immediately—thereare no doctors to respond to an emergency bell.

The following participant gives an example of respondingto an emergency situation:

I had a postpartum haemorrhage the other night of 1000 ml inthe small unit. I gave intramuscular syntometrine and intravenoussyntocinon and I ended up putting up a drip. I knew the placentawas complete and knew the uterus wasn’t contracting well. Herpulse didn’t accelerate, her blood pressure never wavered, theblood had clotted; so she was able to stay there. So you just dowhat you would do. You don’t wait and see (Mary).


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Mary’s assessment skills are evident in vocalising heractions. She had checked the placenta thoroughly andthus ruled out retained products. The woman had beenadministered two oxytocic drugs—intravenous syntocinonensures rapid uterine contractility and intramuscularsyntometrine is used to obtain a longer-acting contractionof the uterus. Mary then inserted an intravenous line toadminister fluids and to provide access for an ongoing

syntocinon infusion. She did not waste precious minutestrying to insert the intravenous line initially. A tourniquetcan be applied to give rapid intravenous access for syntocinonadministration. The woman’s pulse did not accelerateand, hence, Mary was reassured that the woman was notbecoming hypovolaemic and potentially shocked.

Are all midwives practising real midwifery?

In a survey administered to midwives who were not alreadworking in a midwifery-run unit, Symon (1998) askemidwives if they would be happy to do so, taking furesponsibility for a woman’s care. Replies were received from1522 midwives. The majority of midwives (76 per centstated that they would happily do so, and 24 per cent sai

they would not. Midwives with more than twenty years oexperience, and those working in units with 2000 to 299deliveries per year were least likely to say ‘yes’. Reasons fonot wanting to work in a midwifery-run unit includedpreference for consultant cover and full facilities; not havinenough experience (although most of these midwives hatwenty or more years’ experience!); not having enougconfidence; fear of complications; and fear of litigationSymon (1998) reported the following comments from midwife participant:

I strongly believe that these units are an excellent means bwhich midwives (particularly junior ones) can develop thetrue midwifery skills and practice—working in an obstetric o

consultant unit should be seen as a different type of practicaltogether. Many of today’s midwives do not seem to know thdifference or care for that matter (p. 45).

Graham (1997) indicated that it might be a certain typof midwife who prefers to work in settings away from thdominance of obstetricians:

It is intuitively obvious that systems of care which give thpractitioner more independence in decision making, a homeenvironment in which to work, continuity of involvement witwomen, and a focus on normality and natural childbirth wiattract particular individuals (p. 396).

These statements suggest that ‘true’ midwifery skildevelop best when a midwife practises in small maternitunits, whereas a different type of practice is apparenin a consultant obstetric unit. Graham concluded thamore independence and a focus on normality might bmore enjoyable for some midwives. It seems likely that thmidwives’ personal beliefs and length of time practising ia large hospital influence their choice of venue for provisioof intrapartum care. There was an inverse relationshibetween the desire to practise in a small maternity unand the number of years of experience the midwife had ipractising in a large hospital.

Is it possible to practise real midwifery in alarge hospital?

Kirkham (2003) argues that the birth centre is the placwhere ‘the complex skills underpinning normal birth cabe developed, nurtured and learned’ (p. 12). Whether thbirth centre needs to be free-standing or whether thessame skills can be nurtured in a birth centre that is part oa hospital remains to be seen (Johanson & Newburn 2001As a space between home and hospital, birth centres ma

Reflective exercise

Think about the hospital labour ward with which

you are most familiar and imagine that you are

greeting a woman in early labour who has neverbeen here before. Ask yourself the following

questions.

1 What makes this place familiar to me—is it

the smell when I walk in the door? Do I even

notice it any more? I wonder what it smells

like to this woman—safe and comforting, or

antiseptic and scary?

2 I wonder what it sounds like to her. Is it noisy

right now? What kinds of noises are there—

clanking sounds of metal on metal and harsh

surfaces, lots of voices, telephones and

beeping machinery?3 What does it look like—bright lights,

bright, busy people, paperwork on the

desk, equipment lining the corridor, signs

on the wall, businesslike, efficient? Is this

comforting to her? I wonder how her family

(who are with her) feel right now.

4 What do I see when we walk into her room

together? I wonder what she sees first and

what impression it has on her and how she

feels.

Remember, ‘environment’ encompasses all five

senses—sight, hearing, touch, taste and smell—

and each of these senses has an impact on the

mind and heart, and therefore the physiology of

childbirth.





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Online resources

Website addresses are subject to change. We recommend that you

try the following addresses, which were current at the time ofwriting. Use a search engine for locating additional sites. Search

with terms including ‘normal birth’, ‘physiological birth’ and ‘home

birth’ to gain further reading.

Active Birth Centre, www.activebirthcentre.com

Australian College of Midwives, www.acmi.org.au

Birth Works/Primal Health Research, www.birthworks.org/

primalhealth

Friends of the Birth Centre, www.fbc.org.au

Home Birth Reference Site, www.homebirth.org.uk

Lactation Education Resources (LER), www.leron-line.com

LER article on pacifiers, www.leron-line.com/updates/Pacifiers.htm

List of references on the safety of home birth, www.changesurfer.

com/Hlth/homebirth.html

New Zealand College of Midwives, www.midwife.org.nz

Penny Simkin website, www.pennysimkin.com

Royal College of Midwives, www.rcm.org.uk

Waterford Birth Centre, www.riverridge.co.nz

Notes

1 Pakeha refers to the non-Maori population of New Zealand.

2 Grace Neill was a Scottish trained nurse and midwife who was the

Chief Inspector of Hospitals in New Zealand at the turn of the

twentieth century.

References

Adcock W, Bayliss U, Butler M et al. 1984 With courage and devotion.A history of midwifery in New South Wales. Sydney: New South

Wales Midwives Association

Annandale E 1988 How midwives accomplish natural birth:managing risk and balancing expectations. Social Problems

32(2): 95–110Bahl R, Strachan B, Murphy D 2004 Outcome of subsequent

pregnancy three years after previous operative delivery in the

second stage of labour: Cohort study. British Medical Journal

328(311): doi:10.1136/bmj.37942.546076.546044Bastian H, Keirse MJ 1998 Perinatal death associated with planned

home birth in Australia: population based study. British

Medical Journal 317(7155): 384–388

offer the greatest opportunity for both women and midwivesto rediscover a profound belief in the inherently normalphysiological process of birth. As with birth at home, birth

centres are founded on a belief in the normality of birth,which appears to be the most influential aspect of the birthenvironment to consider.

Conclusion

The three components of women’s care that were lost when

the place of birth changed from home to hospital werethe familiar environment, the close personal and trustingrelationship with a midwife who provided continuouscare throughout labour, and a strong belief in the normalphysiology of birth. All three components of the care‘package’ function together, to keep birth normal. The

environment for birth not only includes the geographical

space where the event will unfold, but is influenced by lessvisible but no less powerful forces that include relationshipswith midwives and the beliefs, knowledge and skills theybring to practising real midwifery. The challenge for allmidwives is to consider these three elements in their ownpractice location.

Review questions

1 What does the theoretical model known as the fear cascade contribute to our understanding of how the place of

birth affects birth outcomes?

2 What role(s) does oxytocin play in birth outcomes?

3 What were the reasons for women moving from home to hospital at the turn of the twentieth century?

4 Why do different accounts of childbirth explain these events differently?

5 How similar are the childbirth histories of women and midwives in New Zealand and Australia?

6 What three things were lost when women moved from home to hospital for birth?

7 What are the potential consequences of intervention in childbirth?

8 How many women choose home birth in Australia or New Zealand?

9 Do midwives and other providers enable ‘choice’ for women regarding place of birth?

10 What midwifery skills are needed in order to provide care to women either at home or in primary maternity

settings?


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