From MIDWIFERY MATTERS, Issue No.109, Summer 2006
For the purposes of confidentiality, names have been changed and no identifiable
information has been given.
During early shift on the birth centre, I welcomed a woman and her partner
into our unit and introduced myself and my midwife mentor, Jenny. Lucy was expecting
her second baby and had been experiencing regular uterine contractions for two
hours with intact membranes. Lucy's contractions were regular, every five minutes
lasting for approximately forty seconds. On palpation the contractions felt
moderate to strong. Lucy's fundus was term, and the fetus was presenting in
the left occipito anterior position with a cephalic, longitudinal lie. Lucy
was a strong woman who was breathing through her contractions and mobilising.
I asked Lucy and her partner Paul if they had a birth plan. Paul handed me
a comprehensive plan which stated that Lucy wished to have an active birth with
minimal intervention; they wanted to have intermittent fetal heart monitoring
and no vaginal examinations. Lucy also stated very strongly that she wanted
to birth her baby in the pool. I started to fill the birth pool as it can take
fifty minutes for the pool to fill. I was excited by their birth plan and relished
the opportunity to 'sit on my hands' and just be with them and support them
through their birth experience.
After an hour of mobilising and squatting on a birth ball, supported by Paul,
Lucy wished to use the pool as her contractions became more intense. As the
pool was ready she got in straight away and relaxed as she immersed herself
in the warm water.
The pool room was dark and quiet and Lucy commented on how relaxed she felt.
During this time I realised that my shift was coming to an end and decided
that I would stay until Lucy and Paul had their baby. The midwife taking over
introduced herself as Catherine, and Jenny said goodbye. I had not worked with
Catherine before but was optimistic that she would be as excited about Lucy
and Paul's birth plan as I was.
After Jenny had left Lucy began to experience expulsive contractions and external
signs of fetal decent became apparent. To my surprise Catherine informed Lucy
and Paul that she could not 'allow' them to birth in the pool as she had not
been trained in water births. Catherine said that Lucy must get out of the pool
to birth her baby and that she should do so straightaway. Catherine then stated
in a paternalistic manner that she thought water births were dangerous and that
she wanted Lucy out of the pool. Lucy complied with Catherine's request as she
was frightened at not having a midwife who was confident with birth in water;
it was at this point that Lucy's contractions stopped.
Once dry, Lucy adopted a standing position and thankfully her contractions
returned, I remained calm and guided Lucy to listen to her body and do what
it was telling her. After two contractions the membranes ruptured spontaneously.
Lucy then gave two huge roars. Daniel was born into his parents' hands.
Physiological third stage was completed in ten minutes. Lucy's perineum was
intact. Both Lucy and Paul had skin to skin contact with Daniel while both Catherine
and I left the new family to bond.
Lucy's labour and birth was wonderful and I feel very privileged to have witnessed
it. I felt I had a bond with Lucy and Paul and went back to see them the next
day and thanked them for allowing me to attend. Together we reflected on the
birth and both Lucy and Paul were disappointed that they had not birthed Daniel
in water. However, they both stated that they would want a midwife who was confident
with water birth.
Nevertheless, I remain angry with Catherine; I believe it was bad midwifery
practice to order Lucy out of the birth pool at such an important phase in labour.
I felt that Catherine should have enquired whether any other midwife was available
to support Lucy during a water birth so she did not have to leave the pool.
I feel disappointed in myself that I was not an advocate for Lucy and Paul,
I feel that I should have stood up for them more, but thought it might aggravate
the already tense atmosphere. I feel that as midwives we have to have up-to-date
knowledge and skills so that we can offer holistic care to women.
However, the aspect that concerned me most was the manner in which Catherine
had spoken to Lucy and Paul, when she had stated that she thought water births
were dangerous. This was said at a crucial time when Lucy needed encouragement
and belief in her body's ability.
It is also of concern that in a birth centre facilities are offered but can
be withheld from women during labour owing to lack of knowledge or experience
on the midwife's part.
On the other hand, I also want to acknowledge the positive way in which Lucy
and Paul prepared for their birth. Their birth plan was comprehensive and addressed
all their needs. Lucy remained calm and adopted various positions while labouring
and birthing. Paul was supportive and calm.
To summarise this evaluation, I think this labour and birth experience was marred
by lack of experience, knowledge and a belief in water birth on the part of
the midwife.
Water Birth
According to Richmond (2003) during a water birth the newborn emerges into warm
water, an environment that many feel is much closer to conditions in the womb
than emerging into the air. Furthermore, water birth also has a positive influence
on women during labour, an observation made by Burns (2004) in her systematic
review of the effects of labour and birth in water. Burns concluded that there
was a significant reduction in pharmacological pain relief when women laboured
and birthed in water. A randomised controlled trial by Cammu et al (1994) had
found that women were more relaxed while labouring in water.
As the evidence suggests, labour and birth in water for some women can have
a positive impact on their birth experience, it is disappointing when midwives
are not 'trained' to 'do' waterbirths and the service cannot be offered to women
(Burns 2002).
According to Baston (2004) although the usual observations are made and recorded,
managing the second stage in water is purely 'hands off'. These observations
should be fetal heart auscultation, maternal pulse, maternal temperature and
water temperature. Baston (2004) also states that water birth should only be
conducted by experienced midwives.
Nevertheless, as midwives we are expected to undertake evidence-based practice
and the lack of knowledge or training in water birth restricts women's choices.
Women are told they have choice, but in reality they are often denied some options.
Furthermore, denying women the option of birthing in water is a waste of resources.
Burns (2002) is concerned that NHS finances are wasted when pool rooms are established
but used infrequently.
According to Wickham (2003) water birth should be a compulsory component of the education of midwives and student midwives.
Communication skills
Women take their cue from midwives while in labour and so midwives should empower
them; midwives need to feel empowered by their training and development.
Communication skills are very important. According to Baston (2002) effective
communication is fundamental to all aspects of midwifery care. Positive communication
can empower and enhance a woman's experience of pregnancy, birth and life with
a child (Baston 2002).
In this case the communication skills demonstrated by Catherine were inexcusable,
at no point was Lucy asked to vacate the pool, only ordered. Catherine's negative
attitude towards Lucy's birth choice was an example of the culture of 'bullying'
which exists in midwifery. Kirkham (2004) writes that bullying in midwifery
stems from the culture of blame known to be widespread in the NHS. The culture
of blame and bullying intimidates midwives; they start to doubt their skills
(Robertson 2004). A paternalistic attitude develops towards women and care can
then become institution centred and not woman centred. Catherine expressed her
own fear and inexperience at a time when Lucy required empowerment and faith
in her birth choices.
Moreover, Robertson (2004) states that as birth is a social process, midwives need the opportunity to support women and each other, through mutual sharing and caring, recounting birth stories and talking through concerns and safe practice issues. Childbearing is a highly emotional time for most women and this can be reflected by how they interpret their birth experience and retell their birth stories (Stephens 2003).
To conclude, to be a midwife is to be 'with woman'. In this scenario, although Lucy received care from a midwife, the midwife in question could not provide care for all of Lucy's requirements as she did not have the skills to support her. If we are to support women effectively as midwives we must recognise that lifelong learning will give us influence and strength. This strength can have a positive impact on the empowerment of women, midwives and the midwifery profession.
REFERENCES
Baston H (2002). 'Midwifery basics - communication', The Practising Midwife,
5, 10, 26-30.
Burns E. (2004). 'Water: what are we afraid of?' The Practising Midwife, 7,10.
Cammu H et al (1994). 'To bathe or not to bathe during the first stage of labour',
Acta Obstetrica Gynecologia Scandinavia, 73, 468-70.
Flint C (1986). Sensitive Midwifery, Chapter 11. 156-166, Heinemann Medical
books, London.
Gibbs G (1988.) Learning by Doing: A guide to teaching and learning methods,
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Kirkham M (2004). 'Midwives: Praise and beyond', The Practising Midwife, 7,
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Richmond H (2003). 'Theories surrounding waterbirth', The Practising Midwife,
6, 2.
Robertson A. (2004). 'Changing Britain's birth culture', The Practising Midwife,
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Stephens A (2005). Leap of faith - From Direct Entry midwifery student to independent
midwife. Midwifery Matters, 104, Spring 2005.
Wickham S (2003). Waterdurals - Thinking outside the Box', The Practising Midwife,
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Updated LW October 3, 2006