Midwives magazine: December 2005
The midwife’s story
Emma was about 16 weeks pregnant with her second child when, as friends, we discussed place of birth. Knowing that she had birthed Grace in water at a birth centre, I wondered if she had considered a home birth.
Although keen, she recognised that space and privacy could be compromised at home and was planning a hospital waterbirth in her locality (as the birth centre was deemed too far to travel for a second birth).
It was at this point that I offered to be her midwife. I encouraged her to discuss it with her husband Paul and let me know – to my immense delight they were happy to accept my offer. For the remainder of her pregnancy, care was shared between the hospital (where I was attached as a community midwife) and antenatal visits at either my home or Emma’s.
While Emma wrote to the head of midwifery stating her intention to birth with me as her midwife, I arranged two weeks annual leave 39- to 41-weeks’ gestation and kept my fingers crossed that she would labour during that time! The telephone call came at 5.30 in the morning at 40+1 weeks exactly and I arranged to meet Emma and Paul at the hospital. My supportive colleagues had prepared the room for us and the pool was filling as we arrived. Emma’s plan for birth was minimal intervention, specifically stating a preference for no vaginal examinations (VEs) unless indicated. She planned to birth in water with her own and Paul’s hands guiding their baby to the surface, as well as preferring a physiological third stage.
As we had had the pregnancy to discuss and prepare for the labour and birth, Emma was very well-informed as to the likely scenarios necessitating intervention. It was clear at the point of admission that Emma’s contractions were not suggestive of active labour (at which point I stopped filling the pool).We felt that perhaps she needed to acclimatise herself to the hospital environment and so we had a cup of tea and played music of her choice. However, for the next few hours her contractions remained the same with some stronger than others, but not regular, and we discussed the likelihood of a latent phase.
Emma felt that the contractions ‘weren’t doing anything’ and so she and Paul set off on a walk around the hospital. On her return an hour later, the contractions had reduced to very mild and even more irregular, so they opted to go home for a rest at midday. The next phonecall was at 2.30pm. On returning home Emma’s contractions had started again and she felt they were indicative of ‘real’ labour – certainly on meeting her back at the hospital half an hour later there was a very different ‘feel’ to them.
Emma at this point was no longer able to chat, she had become far more withdrawn into her body and was needing support from Paul. It really did look as if labour had finally begun. By 5pm Emma was contracting regularly with her own pattern of three contractions in ten minutes and a break of five to ten minutes in between. During each contraction Emma had begun to move onto her toes and found it increasingly difficult to stay still. We discussed her wishes and she stated that she and Paul would like to be left together in the darkened room to labour together. I said that I would pop in at 20 minute intervals to monitor the fetal heart (which had been fine throughout).
At about 6pm Emma felt ready to go into the pool and we discussed a VE to assess progress, but she declined. I was happy to support her in this decision as she was very obviously in established labour – her face was flushed and she was unable to enter into conversation, and, as mentioned previously she moved onto tiptoe during each contraction.
Once in the pool, after a 20 minute lull, her contractions continued, although still in the three in ten minute pattern with five to ten minute rests (at this point I was wondering if the baby was not in an optimum position for birth, despite being occipitoanterior on abdominal palpation). Emma coped beautifully with her contractions and during her frequent ‘breaks’ continued to eat and drink. At about 9pm I was beginning to expect some transition signs, and I could visualise the Rhombus of Michaelis opening up, but not the familiar bump that indicates the head is moving down. The fetal heart continued to be auscultated at least every 15 minutes and was within normal range the entire time so I was not unduly concerned. However, I could see that Emma was tiring, particularly as she continued her own labour pattern – that provided a break where she had micro-sleeps with her head against the side of the pool.
We discussed the option of a VE to determine the station and position of the baby’s head but Emma declined. I felt at this point I needed to intervene slightly in order to encourage descent. I asked Emma to stand with one foot raised on the step of the pool. She did this and during contractions leant forward onto Paul, holding his neck – it was a very beautiful sight seeing a couple working so harmoniously. The room was lit only by the light in the pool and with a Sarah Vaughan CD playing in the background, it had a very tranquil atmosphere.
After a few contractions in this position it was clear from external signs that descent was occurring and I encouraged Emma to maintain this pose. Half an hourlater her membranes ruptured with clear liquor draining – this was a welcome relief for Emma and a sign to her midwife that things were happening! A few contractions later, the first signs of crowning were obvious and so Emma dropped gently back into the water into an all-fours position. She had sustained a second degree tear with her first baby and was hoping to avoid the same thing happening this time. I encouraged her to breathe or blow through the pushing sensation and to let her body do the work on its own. This she did with amazing control and before long the head was born. There followed a break of approximately two minutes, during which time the baby did some incredible head movements and I could see the cord around its neck that it was obviously trying to free itself of. When the next contraction came, the baby’s body just slid free and I guided it through Emma’s legs where I told her to reach down. Baby Nell was born at 10.55pm and was brought to the surface of the water by her mother where I unravelled her from the cord that was wrapped once around her neck and body, and she lay in her mother’s arms, pink and breathing, but not a sound. Paul meanwhile announced to the room that she was a girl.
Emma was then helped out of the pool and onto the waiting birth stool to await the placenta. While the cord was still pulsating the placenta plopped out with minimal effort from Emma, the cord was then clamped and cut and Emma was helped onto a bed. On inspection it was clear that she had sustained a tear that would require suturing, but as it was not bleeding I left the new family alone for some special time.
Nell lay on her mother’s tummy and 20 minutes following the birth she fed for over an hour. As it was late and I was very tired by this point, my colleague sutured Emma and I said my goodbyes for the night. This was not an easy multipara birth – 12 hours of latent phase followed by nine hours of active labour is pretty arduous in anyone’s eyes. Emma’s strength and commitment to normal birth was awe-inspiring – she never wavered and showed great fortitude when faced with what I am sure was a malposition of the fetal head. She knew she could do it and did so beautifully. Sharing that experience with Emma and Paul once again proved to me how much I love my job, but it also makes me sad that not every woman will have the opportunity to experience such an empowering event in such a special way. The effect of a positive birth experience stays with women forever, the baby has a gentle, natural start to life and recovery is easier.
Emma’s belief and trust in her body and the process of labour meant that she never faltered on her journey through labour. I hope the day never comes when birth in such a way is a rarity and only confined to the pages of journals.
The mother’s story
In the summer of 2004 I discovered I was expecting my second baby. Once over the initial excitement (and shock!) of my new pregnancy, I began considering place of birth. My first daughter had been born at a local birth centre, but this had been decided at the last minute, owing to a house move.
This time I wanted my plans in place sooner so that I could benefit from feeling more settled. Having given birth in water the first time around, I knew I wanted to use the pool again. I decided against a home birth, because of lack of space, and because I did not want my toddler present at the birth. Fewer than half of the midwives at my local hospital were trained to ‘do’ water births, and my nearest birth centre seemed too far away now that we had moved. A
t a party that October, Jane Dutton, my friend of 18 months offered to be my midwife, and attend the birth at a hospital nearby. Her offer was so touching, and I felt fortunate and very relieved. Having Jane as my midwife meant having someone I was comfortable with, who had confidence in me, and whom I trusted completely. Antenatal appointments were relaxed and informal, and often accompanied by lunch. Jane was nonetheless thorough, taking nothing for granted despite our often-shared opinions about birth. My first birth had been amazing and empowering. Everything had gone well, but a shift change during established labour meant there had been no rapport with the midwife who attended me. I had been encouraged to use Entonox long before I needed it, and in the absence of the support I needed, I relied on it, feeling ‘out of it’ by the time I gave birth.
This time I really wanted to keep a clear head, and Jane and I had the opportunity to discuss this antenatally.We agreed that this time Entonox would not be offered, instead I would need to request it at least three times. We also discussed other aspects of my previous labour, such as the second stage during which I experienced a latent phase and no urge to push.We also discussed my desire to avoid VEs, unless labour did not appear to be progressing.
After a straightforward pregnancy, the Braxton Hicks contractions that had been constant for two days were strong enough to wake me at 2am. Unable to get back to sleep, I decided to get up (as did my husband Paul) and go downstairs. The contractions were neither very strong nor very regular, but I knew things were beginning. My main concern was to arrange care for my daughter Grace, so at 4am my father was summoned to our house as planned.
Unfortunately, Dad declined my offer to return to bed and instead he sat with us, doing the crossword. This lack of privacy impelled me to telephone Jane and say I wanted to go to the hospital. During a chat and a cup of tea there, the contractions petered out and a few hours later Jane popped home for breakfast while Paul and I rested. Around lunch-time, things were still quiet so we returned home. My dad had taken Grace out for the day, so, far from feeling disappointed, I relished the chance to sit at home with Paul and enjoy an empty house. However, it was like flicking a switch – very soon my contractions took on a new dimension and I decided to return to hospital.
At the hospital, I found I could cope well with the contractions by keeping mobile, and Jane left Paul and I to it for a while. Some time later I got into the pool – even though I was still coping just fine, part of me just could not wait to get in! I expected my contractions to become gradually more intense and more frequent, but instead they stayed in their pattern – one big one, two small, then a lull, but I felt safe and secure, and just let my body do its thing. I was relaxed, and rested quietly in between contractions while the music gently filled the room. Paul supported me brilliantly by offering water, the odd bit of food and the occasional shoulder massage.
Over time, I sensed that things had reached a plateau, but did not think much about it. Jane and I discussed the possibility of a VE and although Jane felt this unnecessary, she did suggest getting out of the pool for a couple of contractions. This I did, and the difference was quite amazing. Paul will bear witness to this as I nearly pulled his head off during these contractions. They were more intense, but much more satisfying, as they felt so productive. Jane stepped out of the room for a moment, and on her return, my waters broke. I was so relieved that I could barely express it – I just enjoyed the moment and watched the liquor fall into the pool, which was lit from below.
Very soon after I felt my baby’s head coming down. I could not believe how quickly it was coming. It felt amazing, as, with a few words of encouragement from Jane, everything just opened up. My baby would soon be here, so Jane prompted me to get back into the pool on all-fours. The overwhelming sensation of the head emerging brought back feelings of my first birth. In an instant, Jane sensed my slight panic and said ‘don’t be frightened’ – these words were just what I needed, and I relaxed and allowed my baby to come. Amazingly, the contractions seemed to do most of the work, with just a small urge to push rising as each contraction tailed off, but the urge to push felt fantastic, almost euphoric. Once Nelly’s head was born, she wriggled in an attempt to free herself from the cord. This extra movement was the hardest part to cope with, but I remained focused, my eyes fixed on the step of the pool. Shortly after, my beautiful baby girl emerged beneath me, quiet and peaceful, but lovely and pink. My first thought was how tiny she was, how on earth she came to have her grandfather’s nose, and I will never forget the first time I touched her.
I had barely sat down on the birthing stool when the placenta emerged of its own accord, by which time Nelly was at the breast. She remained happily at the breast as Paul and I gazed at our new little girl in wonder and admiration, just the three of us. The hours of calm remained unbroken. Despite people saying how brave I was to give birth with no pain relief, my lasting impression of Nelly’s birth is that nothing about it was dramatic. From the atmosphere in the room to the contractions to Nelly’s demeanour, all were quiet, unhurried and unfussy. I felt calm and slightly detached, yet in control throughout. A key factor in this calm and control was the relationship between Jane and I in the run-up to the birth.
Having continuity of carer meant I went into labour knowing that my midwife and I were in tune from the outset. My hopes were to birth physiologically, experience everything with clarity and remain in control. These aims were achieved simply by feeling secure, believed in and supported. Though it is often heard, for me, Nelly’s birth really does sum up the phrase an ‘everyday miracle’. Our joint accounts of Nell’s birth show just how important the relationship is between woman and midwife.
Pregnancy provides time to discuss and reflect on what a woman wishes for her birth, whether it be at home or in hospital, and also to form a new partnership. This partnership should be available for all, not just for the privileged few who can afford an independent midwife.We are certain that if they are guaranteed a model of midwifery that can fully encompass all aspects of a woman’s pregnancy and birth, then those midwives who are not practising at the moment will return. This model will also reduce rates of intervention in a society that has a rising level of caesarean section, as well as giving back to women the belief that they can birth their babies normally.
For those women whose pregnancies require obstetric input, then a midwife and obstetrician can work closely together with the woman remaining the focus of attention. The ‘One mother one midwife’ campaign, one aim of which is to see the government implement the NHS community midwifery model proposed by the Independent Midwives Association, is not an unrealistic dream, but a workable alternative in a climate of growing dissatisfaction with the existing system.
Further information
To find out more about the ‘One mother one midwife’ campaign, please visit: www.onemotheronemidwife.org.uk or contact them via email: campaign@onemotheronemidwife.org.uk There is also a campaign group that is always looking for new members. To join, please visit: http://groups.yahoo.com/group/ midwifecampaign
