Monday, February 28, 2011

History of Midwifery - Why women died in childbirth

The history of midwifery has always fascinated me and especially those heroes and heroines who have tried to advance the profession of obstetrics and midwifery.

I am going to start with one hero in particular, Ignaz Semmelweis, a Hungarian physician working in Vienna.  It was Semmelweis, who in 1847 investigated the cause of puerperal sepsis or childbed fever among women attending the lying-in hospital.  He found that there was an increased death rate amongst women during childbirth who were attended by Doctors rather than midwives, who worked in another ward.  After conducting his own research, Semmelweis found that the cause of the sepsis was because physicians were not washing their hands between carrying out post-mortems and then attending women in childbirth.  Midwives did not attend postmortems so they were not to blame.  Semmelweis insisted that physicians attending his ward washed their hands with a chlorinated lime solution and, with this procedure enforced, he found that the death rate dropped considerably.

However, the medical fraternity dismissed Semmelweis' theory and refused to accept the blame for causing so much death.  As the germ theory had not yet been developed unfortunately the deaths continued, although Semmelweis continued to persue his theory, he was vilified from every corner of the medical profession and eventually suffered a nervous breakdown.  One comment made by an outraged physician to Semmelweis' theory was "A Doctor is a gentleman and a gentleman's hands are clean."  That would be funny if it were not so tragic, Semmelweis was committed to an insane asylum where he died in 1865.

By the end of the 19th century, the need for obstetric and midwifery hygiene and cleanliness was accepted by the medical profession.  The developement of antiseptic and discovery of antibiotics have greatly reduced the maternal mortality rate.

Further reading:
Pairman, S., Pincombe, J., Thorogood, C., Tracy, S.  (2006).  Midwifery preparation for  
     practice. Elsevier:Australia. 

Thursday, February 24, 2011

Monday, February 21, 2011

My first waterbirth

In 1992 when I was a newly qualified midwife and just got my wings and gleaming new gold and blue Queen Charlotte’s medal to prove that I was now well and truly a midwife.  Waterbirths had begun to get notice in the press, not yet at the height of popularity but certainly being brought to the attention of women as an alternative option to birthing rather than the hospital delivery bed.  A woman and her partner had come to delivery suite with their birth plan and asked for a waterbirth.  The ‘old hand’ midwives on delivery suite who’s wisdom in years between them was phenomenal, however viewed waterbirths with somewhat suspicion, thinking it a ‘new age’ idea that would wear off.  

This labouring woman wanted her waterbith and was shown to the pool room.  However the midwives who were on duty had never dealt with them and were somewhat reluctant to participate or even understand why any woman could possibly want to birth in water.  Dolphins, fish and octopus are some of the words that spring to mind when I recall sitting amongst their discussion as to why women should birth on land and not in the water.  The midwives suddenly turned and looked at me and said “Marie, you're newly qualified, you know all this stuff, you can birth her.”   I smiled sweetly at them and said "of course" through my tightly gritted teeth.  As much as I read a lot of information on waterbirths and understood the theory behind it, I had never actually birthed a baby in water.  I left the pool filling while the excited but nervous parents waited patiently as I ran to where the text books were kept and pulled out the booklet on waterbirths.  I can tell you that I absorbed as much information as I could in the 20 minutes it took for the pool to fill and returned to the smiling parents with, as much of an air of serenity and calmness as I could muster.  Inside, my heart was beating like a drum, "you can do this Marie."

Full of confidence and hope and with my head full of wondrous knowledge, I returned to the lady who by now had got into the pool.  The list I had memorised from the book, continually churned in my mind :

  • ·         Temperature must be checked every half an hour
  • ·         Check temperature of the woman at the same time
  • ·         Make sure the woman drinks lots of water due to the sauna effect
  •          Hands off and let the baby come out into the water, Hands off, Hands off, Hands off AND REMEMBER hands off.
With those points in mind and butterflies in my tummy, I made sure that I followed the rules.  Every time I thought I should be doing something to the woman (as surely as any good midwife should), I left the room for a few moments to make the partner a drink or pretend to go to the loo, or if I ran out of excuses to leave the room, I sat on my hands, reciting the mantra I had learned, "hands off, hands off."  Just a little about task orientation, as nurses we tend to be task orientated to a certain extent, well we were back then where I trained in England and felt that if we are not doing anything to the client we are neglecting in our duties.  

Several hours later a little baby girl was born in the water, much to the joy of two very ecstatic parents and I have to say an overjoyed but relieved midwife who, I hasten to add, has never looked back since. I learned so much from that particular couple (thank you guys) who didn’t even realise it was my first (of many) waterbirths.  I also learned that midwifery is not theory alone and using four of our five senses, but our wonderful intuition and having faith in a woman and her ability to birth her baby.

Thursday, February 17, 2011

Pain Relief in labour

Clients are often scared when it comes to pain in labour, and it is fear of the unknown for those of you expecting your first baby or, even a subsequent baby if the first time around was not a good experience for you.

I am not not going to lie to you, labour is painful but it is not pain that harms you in any way, in fact, it actually tells us your body and you are going through a completely normal physiological process.  

In early labour there are things you can do for yourself to help with the pain.  Rest and sleep in the early stages is important, to save your energy for later when the hard work begins.  You can also soak in the bath or sit on a plastic chair in the shower and let the warm water flow on your back (especially good for backache).  

In established labour
Walking around (being upright) helps gravity bring your baby's head down on your cervix (neck of the womb) to assist in dilatation. 
  • You can get into the warm bath water (see my blog on Waterbirths to see how this helps with pain relief).  
  • Having your support person massage your back can help to take that pressure off your back and help with pain.  
  • Warm packs applied to your abdomen or back can help with the pain, a lot of women find a warm pack very helpful for backache in labour.
When you are in pain and provided you have had no pharmaceutical analgesia, your body will produce its own 'opiates' which are very similar to morphine but not as strong and act as a natural analgesia or pain killer.  The endorphins act on the sensory nerves that carries pain messages to the brain and prevents some of those messages being sent.  For those who have been privileged enough to be with a labouring woman, you will notice a change in her as she goes into her 'own space' as she goes between being awake and asleep.  Michel Odent, a French obstetrician suggests that these endorphins pass from mother to baby, providing 'pain relief' for the baby.

Gas and air or entonox
A combination of nitrous oxide and oxygen.  The labouring woman inhales the gas through a mouth piece at the start of a contraction alll the way through until the contraction finishes.  If the apparatus is used correctly it can provide good pain relief although, the effects of gas and air are short lasting as the woman exhales the gas from her lungs when the contraction has finished.   Side effects are that, for some women it can make them feel nauseous.  

Is a synthetic narcotic drug similar to morphine that is injected in to a vein or buttock during the first stage of labour. It can take 15-20 minutes to take effect and because it can make the woman feel sleepy and crosses the placental barriet, it can make baby sleepy too, so for this reason it is not given within 2-4 hours of birth.  Pethidine does not take the pain away, it sedates the woman to enable her sleep between contractions.
Side effects that it can make women feel sleepy, 'out of it' or 'high.' which some woman like and some do not, although until you actually have the drug, it is difficult to say how it will affect you.  It can make the woman feel nauseous or even vomit, in which case your midwife can give you something to reduce or stop this.  If the pethidine is given near the time your baby is born it can make your baby is sleepy and slow to breathe at birth, the midwife may have to give an antidote called narcan to your baby to reverse the effects of pethidine.  
It can take a few days before the pethidine is eliminated from your baby's body so your baby's may be quite sleepy and slow to suck at the breast.

The anaesthetist sites the epidural which is an injection of local anaesthetic into the epidural space around the spinal cord.  Because there is a complete loss of sensation from the waist down, means that you will be confined to the bed.  Advantages are that it is a good form of pain relief although there are rare instances where the epidural block may not work or may partially work, in which case your midwife will contact the anaesthetist to come and check the epidural.

An intravenous drip with be sited in your hand or arm so fluids can be given to you through a vein - this is done as a precaution in case your blood pressure drops following the epidural.  You will be continuously monitored on a cardiotocograph, a machine that monitors your contractions and your baby's heart rate.  With your consent, a urinary catheter (tube into your bladder) will be inserted because you will not be able to feel the sensation of wanting to pass urine.
The disadvantages with epidurals are that, they can slow down your contractions so a hormone (oxytocin) drip may be needed to speed up your contractions again.  On rare occasions the dura or cover of the spinal cord may be punctured and cause leaking of spinal fluid and you develop headaches.  If this happens, there is a remedy and the midwife will ask the anaesthetist to see you.  An epidural relaxes the muscles of your pelvic floor and may lead to an instrumental (forceps or ventouse) delivery or even a caesarean section.  There can be some tenderness over the epidural site for some days following the birth of your baby.

Please chat with your midwife about the benefits and disadvantages of the types of pain relief and options available to you.

Here are some links :
Pain relief in labour

Tuesday, February 15, 2011

Vitamin K - What does it do and does my baby need it?

Parents often ask what Vitamin K does and does their baby need it? 

What does Vitamin K do?
Vitamin K plays a role in blood clotting and occurs naturally in the intestine where it is produced by bacteria.  We also get if from the food we eat, leafy green vegetables, alfalfa, whole grain cereals, cheese and milk.

 Why is it given to babies?
Newborn babies have less Vitamin K than adults although these levels increase during the first weeks of birth.  Why babies should have less Vitamin K is not known, there is speculation that the reason for the low level is to prevent clotting problems during birth (Wickham, 2001).  A newborn baby’s gut will not have the bacteria present to start Vitamin K production until they start to feed.

What is Vitamin K deficiency bleeding?
A small percentage of babies can have low level of Vitamin K in the blood which can lead to a bleeding disorder called Haemorrhagic Disease in the newborn.  Early Vitamin K deficiency bleeding occurs within 48 hours of birth and is rare.  It can be caused by certain medications taken by the mother during pregnancy which interfere with Vitamin K metabolism.   The most common form of Vitamin K deficiency bleeding occurs in the first week of life in healthy infants and caused by insufficient amount of Vitamin K in breast milk or a delay with breast feeding.  Vitamin K deficiency bleeding in the newborn is serious and can cause brain damage due to bleeding into the brain or even death.

What babies are more at risk?
It is not certain what baby will develop vitamin K deficiency bleeding but there are factors where the risk increases, eg., if the mother has had certain types of medication, babies who have problems absorbing food, birth injuries that have caused bruising and babies who are not breastfed from birth or not having sufficient quantities of colostrum.  The evidence suggests that colostrums and hind milk produce the richest source of vitamin. Giving your baby Vitamin K can prevent most cases of Vitamin K deficiency bleeding 

Vitamin K in breastmilk
Ensure that your baby is breastfed soon after birth and let your baby feed when he/she wants for as long as they want. This will ensure that they receive the vitamin K present in the colostrum and in the hind milk.  

How is it given to your baby?
Either by
·         By injection into baby’s thigh of a single dose of Vitamin K.
·         By oral administration of three doses.  1st dose given after birth of your baby.  The 2nd dose is given at approximately one week of age and the 3rd dose is given between 4-6 weeks of age.

Is vitamin K safe?

In the early 1990’s researchers suggested that there was in increased incidence of childhood leukaemia in infants who had received the injection of vitamin K and not from those who had received the oral vitamin K.  However, further studies in Europe found no increase of leukaemia or cancer in infants who received the injection of vitamin K, the UK department of health also found no association between childhood leukaemia or cancer with infants given the Vitamin K injection.  As with any injection there are risks associated.

It is your choice whether to give your baby Vitamin K, if you do decide your baby will be given Vitamin K, you have a choice of either the injection or drops.  Read about the benefits and the risks of Vitamin K with your midwife to help you make an informed decision.

Wickham, S., (2001).  "Vitamin K - an alternative perspective." Aims Journal. 2001.13 (2)

Saturday, February 12, 2011

When should you call your midwife?

Pregnant or new mums are often unsure when to call their midwife, here is a guideline but should you have any concerns about you, your pregnancy or your baby, the midwife will want to hear from you.  Your health and your baby's health is very important to us, so please call us.

In pregnancy
  • If you have any vaginal bleeding.
  • If you think your waters have broken.
  • If you are worried about your baby's movements (eg., less than 10 movements in 12 hrs).
  • If you have regular painful tightenings/contractions before your due date.
  • If you have headaches, see 'flashing lights' in front of your eyes, or indigestion type pains that wont go away.
  • If you have any pains in your back or abdomen.
  • If you think you have a bladder or kidney infection.
  • If you have been in contact with an infectious disease like chicken pox, slap cheek or TB.
  • If you have any worries about your pregnancy.
 In labour

  • If you have regular contractions.
  • If you think your waters have broken, even if you have no contractions.
  • If you have any bleeding.

After you have your baby

  • If your bleeding suddenly becomes heavy again.
  • If your discharge becomes offensive smelling.
  • If you think you have a temperature or feel unwell.
  • If you think your baby is unwell.
  • If your baby is not feeding.

The link below is a link that will take you to a pregnancy website

Wednesday, February 9, 2011

Breast feeding

Breast is best!  You will hear us and other health professionals continually reinforce that breast is best.  

Can anyone breast feed?  The answer is yes.  
Does everyone have the same shaped breasts and nipples?  No, having different size breasts and nippes does not mean you cannot breastfeed your baby.
My nipples are flat!  The baby actually suckles on your breast and not the nipple.

There are awesome benefits for both you and your baby if you breast feed (Riordan & Wambach, 2009), here are some listed:

  • Promotes bonding between you and your baby.
  • Helps your uterus return to its pre-pregnant state quicker by releasing oxytocin also called the love hormone. (Michel Odent, Sarah Buckley) when your baby suckles.
  • Builds up bone density to reduce the risk of osteoporosis in later life.
  • Reduces the risk of ovarian and breast cancer.
  • Possible quicker return to pre-pregnancy weight.
  • Reduces the risk of asthma and respiratory infections.
  • Reduces gastrointestinal infections.
  • Protects against SUD's (Sudden Unexpected Death Syndrome).
  • Helps protect against allergies.
  • Possible higher IQ scores
  • Less ear infections.
When your baby is born he/she will be birthed onto your abdomen for skin to skin contact.  This wonderful contact assists with temperature control (you and baby), helps with bonding, helps your baby to adapt to his/her new world and promote breastfeeding.

For the first three days following the birth of your baby, you will produced colostrum (in fact you may leak some colostrum in the last trimester of pregnancy, this is normal but do not try to express any from your breasts, it may lead to  premature labour).  Colostrum is rich in protein and helps coat the lining of your baby's gut to protect against bacteria, illnesses and viruses.  

The mature milk usually comes in on day three following birth, although sometimes it can be delayed if you have had a caesarean section.  Because of the composition of breastmilk, your baby does not need any extra water, fluids or solids for 6 months, that is because your milk is uniquely produced for your baby and in the exact proportions your baby needs.

Know that you will produce enough breast milk if, you allow your baby 'free access' to the breast.  In other words, let him feed when he wants for as long as he wants.  The suckling on your breast stimulates the release of hormones to build up your milk supply.  You have no rules and regulations about when you eat, so dont expect baby to follow any.  Enjoy your baby and breastfeeding - it really is a wonderful time for both you and baby.

Speak to your midwife about benefits of breastfeeding, it really is best for you and baby.  I have put some weblinks to breast feeding organisations.

Riordan, J., & Wambach, K.  (2009).  Breastfeeding and human lactation (4th Ed).  Jones and Bartlett:Boston

'The Love hormone'

Breastfeeding and where to get help,78,0,0,html/For-Women

Sunday, February 6, 2011

Home Birth or Hospital Birth?

Are you going to have your baby at home or hospital?  How many times have you heard that hospital births are safer than home births?  I have heard this said many times during my midwifery journey when discussing birth place choices with women.

Would it surprise you to learn that, for low risk women (eg., women who have no medical concerns regarding themselves or their unborn babe)  home births are as safe if not safer than hospital births (Johnson & Daviss, 2005).  It is safer because at home there is less medical intervention, less pain relief and less instrumental births).  The woman at home is more relaxed and in more control to make decisions (Kontoyannis & Katsetos, 2008), she also feels safer in her own surroundings.  It is known that if animals in the wild are disturbed or feel unsafe or stressed, they will stop their labours until they have found somewhere quiet and dark.  The hospital environment is a strange and unfamiliar one and it can a scary place if you have never been in hospital before, and  If women are very anxious and stressed their labour can slow down, possibly leading to a cascade of interventions.  I am not saying that all women who have their baby in hospital are going to have medical intervention because not all will, however, the risks are greater.

We could debate the patriarchal intervention that came about when data from a British study had been misinterpreted and, the study claimed that home is a dangerous place to birth (Tew, 1995), but we will save that story for another time. Midwives in New Zealand and worldwide are trained to detect any deviations from the normal, that means, if she feels that a problem is arising during your pregnancy/labour or birth, she will, with your consent, discuss the concern with the obstetrician or paediatrician.  This may mean transferring you to hospital but it should be a three way discussion between you, your midwife and the obstetrician. 

The main point is that you have a choice to birth at home or hospital so please discuss your options with your midwife. For women and midwives who would like further reading, I have put the references in full below, also, for those interested in having a home birth a link to the home birth association and the New Zealand College of Midwives are included.

Johnson K.C., & Daviss, A. (2005) Outcomes of planned home births with certified professional midwives:large prospective study in North America.  British Medical Journal, 330, 1416.
Kontoyannis, M., & Katsetos, C. (2008).  What influences women in Athens to chose home births?  British Journal of Midwifery,16(1),44-49.
Tew., M. (1995). Safer childbirth?  A critical history of maternity care (2nd ed).  London:Chapman and Hall.

Thursday, February 3, 2011

Antenatal blood tests

When you see your midwife for the first time she will take a detailed history of your health, your previous pregnancies and your present pregnancy.

This is a very brief introduction to the blood tests so please talk with your midwife, she can offer a more detailed explanation.

A full blood count will be done to check your haemoglobin (iron) levels to make sure that you are not anaemic.  If you iron levels are low, your midwife will discuss your dietary intake of iron and you may need to take iron tablets. 

Your blood group (O, A, B AB) and rhesus factor (negative or positive) will be tested.  If you are rhesus negative you will have further blood tested at 28 weeks and again at 36 weeks to ensure that you are not developing antibodies that affect your baby (usually in second and subsequent pregnancies) by seeing it as a 'foreign body.'  You may require an injection of Anti D immunoglobulin during the pregnancy and/or after the birth of your baby.  At birth blood will be taken from the umbilical cord and then your baby's blood group will be tested.  If your baby is rhesus negative, you will not require Anti D, if your baby's rhesus factor is positive, you will require Anti D.  Simply put, the way Anti D works is by coating any fetal  blood cells that have escaped into your blood circulation following the birth to prevent any antibodies forming that will affect a subsequent pregnancy.

Rubella or Germany measles is checked to see if you immune.  If you are not immune, you cannot be vaccinated during pregnancy, your GP can vaccinate you after you have delivered your baby.  

Your blood is also tested for syphilis and Hepatitis B. If you are a carrier of Hepatitis B, your baby will be vaccinated at birth.  You will also be offered an HIV test, this is because early detection can reduce the risk of mother to child transmission.

You will also be offered maternal serum screening.  We will not discuss that test here, please talk to your midwife.

All women have their blood rechecked at 28-32 weeks of pregnancy for Iron levels, antibodies and a polycose will be done.  A polycose is to check that you are not developing gestational diabetes (diabetes in pregnancy).

Tuesday, February 1, 2011

Birthing in New Zealand

How I love the philosophy of partnership and birthing here in New Zealand.  I came to this beautiful country about nine years ago and fell in love with its peoples and the country.  Here, was the midwifery I have always wanted to practice.

I trained in England and the word 'autonomous midwifery' was banded around but I am not certain that anyone knew what the true meaning of the word meant.  It was not until I came to New Zealand and it left me hungering to know more of the partnership in care model.  For the first time I knew what 'autonomy' was and it was like one of those 'eureka' moments - YES, this is autonomy.

The pregnant woman and her family are equals in the partnership of care with her midwife, giving them a voice here where they are often not heard in other places.  Unfortunately in most countries the system is male dominated and this, effectively wipes away centuries of human history where Midwifery was the domain of the woman.  These women were the 'wise woman' in their villages and used the knowledge of herbs and the natural world to help and heal their fellow humans.  

Here is a link to the New Zealand College of Midwives for both midwives and women,78,0,0,html/For-Women

And for parents