From MIDWIFERY MATTERS, Issue No. 90, Autumn 2001
Chris Warren
"Syntometrine 1 ml, expiry 08/02, OK?"
"Yes, Fine".
IT IS USUAL HOSPITAL PRACTICE for two midwives to be present at a birth: the first catches the baby and the second, called in once the vertex is advancing well, gives the oxytocic drug of choice. This is the rational for two midwives but is it necessary or even a good idea? Does it matter if the attending midwife waits for the woman to give birth and then, if active management is wanted, gives the Syntometrine? Where is the evidence that giving the oxytocic with the crowning of the head or with the anterior shoulder is better than waiting until after the baby is born?
Should there be more than one midwife at a birth? Is it safer, for mother, baby or midwife? Could it even be a harmful practice?
My usual practice does not involve routine drugs for the third stage, as women booked with me usually deliver their placenta physiologically and I am usually on my own. I have found no evidence to support the need for two midwives and believe it to be opinion based on the premise that there should always be paediatrician (or at least a midwife) waiting at every birth to resuscitate the baby. This may be reasonable and understandable but is neither evidence nor fact. One could take this 'what if' view further and have an obstetrician and anaesthetist also waiting, or a spare midwife to take over if the first one drops down dead.
Regardless of the rational or the rightness, the policy is untenable as no midwife has right of entry and just as a woman can opt to have no midwives at all she can say no to a second midwife. Why should it be thought good practice?
The reasons midwives usually give for having two midwives present are:
There are occasions when I think it is better to have two midwives but my reasons are different.
If having two midwives present is sometimes a good idea, why not plan always to have two? Could having two do more harm than good? I believe midwifery care has enormous potential to benefit women and their families, but that doubling up on a good thing is similar to adding an extra scoop to the baby's bottle – potentially disastrous. Marjorie Tew has argued convincingly that increasing a woman's contact with health care professionals does not necessarily bring any health gains. It is time to question the supposed benefit of having two midwives present at every birth.
I knew they were talking about me, knew things were going wrong. They did not think I could do it. I could not understand the jargon – what were they hiding from me? - Holly
Holly's distress first alerted me to the possible negative effects of having two midwives present at a birth. I have been guilty, talking to colleagues in the labouring woman's presence, explaining my way of doing something, or chatted about mutual friends, or discussed changes in policy. I don't now. If necessary, I explain things to the woman or her partner and include the other midwife/student in the conversation. Every woman is different, a few want conversations in the background, but most do not. Respecting the woman in her labour usually results in very little chat.
Samantha was very angry at the way the midwife had argued with the GP and disrupted the flow of her labour. The antipathy between the professionals adversely affected the way she felt about her care. Five years later, when I met her she was still very bitter, she had also felt bullied by her midwife.
Disagreements between carers can affect the woman even if the protagonists leave the room to argue. Women in labour, particularly when undrugged, have a heightened awareness of what and how things were said. I was not there for Holly or Samantha's first births so I don't know exactly was said or how but such events still occur. Some midwives may not realise how just talking can disrupt a woman's concentration, slow her labour or cause her such anxiety.
Other potential harmful situation may occur when midwives don't know each other well, or are not used to working together. Care may not be smoothly given, the fetal heart might be listened to twice in ten minutes, greatly disrupting the labour process - or missed for an hour when both midwives assumed the other had listened in. Conflicting information might be sought or offered, all with the best of intentions and within the bounds of safe practice but this undermines the woman's confidence.
Even when the two midwives get on well, the one-to-one, woman-to-midwife bond can be broken by the presence of another midwife. I believe the experience is different when two midwives are sharing in the woman's unique journey of birth. The sharing dilutes the intensity of the relationship somehow. The presence of a doctor, the woman's partner or other support person doesn't usually have the same effect because there is an expectation of a different role.
I think it unlikely that the presence of two midwives results in birth that is less physically safe but the equality between the labouring woman and her midwife is jeopardised. With two midwives, a 'them and us' feeling can develop, reducing the woman's confidence in her own abilities. Maybe one midwife indicates that all is well and two anticipates problems ahead. The quality and the uniqueness of the bond that develops between the woman in labour and her midwife, is difficult to define, but it is essential for a good birthing experience. Three-way relationships are not as easy as partnerships or one-to-one interactions.
In my practice the following strategies have evolved to minimise possible harmful effects of having two midwives:
The last two are contradictory. It is important to be flexible when applying any strategy; each woman, her circumstances and her labour and birth are different. If we need to discuss something out of earshot, we might find an excuse or we might say outright, "We are going to have a cup of tea in the kitchen and chat about anything else we can do to help your labour speed up."
The second midwife's 'doula' activities are wide-ranging: making tea, running the bath, making a birth cake with the four children, setting up the Lion King video again, fetching more Entonox, back rubbing or face mopping, dealing with the pool.
It is useful to respect each other's strengths; sometimes I have called on a colleague because my energy levels were getting low and I wanted inspiration. There is nothing wrong with asking for help, by phone or in person. Often this can be done openly, but if any conversation seems to disrupt the woman, is best done elsewhere. I have done this with prolonged rupture of membranes pre-labour, long third stage, stop/start labours and when with emotionally draining women or their families.
Apart from the practicalities of current active management of the third stage, and my reasons stated earlier, I think it is best to have one midwife only at a birth and another on call. We need to dispel - or at least to question - current opinion on the requirement for two midwives to be present at a birth.
It is extremely rare for both mother and baby to need emergency care simultaneously and therefore providing two midwives at all births is uneconomic and is not an efficient use of scarce resources.
Any another competent person in the house can call for medical aid in an emergency while the midwife deals with the clinical situation. You don't need to be a midwife to dial 999!
It would be poor practice to rush away immediately and it is not necessary to do all the tidying. I find it usually takes one and a half hours to sort and clear away my equipment, settle the mother and baby, and complete my documentation. This is a good time to leave the new family to themselves.
Midwives who feel that they need another midwife present for back up for fear of litigation perhaps lack confidence in their professional skills and their ability to practise autonomously. They might benefit from a period of re-education to increase their confidence to the level where they can practise without fear; a midwife practising in fear may pass on that fear to the women she supports.
The Cochrane team should look into the practice; they may well find that the 'two midwives' rule will fall into the category of treatment that does more harm than good.
Maybe the real question we should ask ourselves is, "for whom is two midwives beneficial? For the mother, for her baby, or for the midwife?"
This article was originally published in Midwifery Matters ISSUE 90 Autumn 2001, p17-18
See our archive page - Two midwives at a home birth?
LW updated February 4, 2005