Davies, SE

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AIMS JOURNAL VOL:20 NO:3 2008 9Articlehave two children, now in their teens, both born athome. My first labour went on for a long time.Labour stalled at 6cm dilatation for 12 hours, but Iwas healthy, had a supportive midwife and my family andfriends around, and knew that both I and the baby wereOK, so it was just a question of gritting my teeth andkeeping going (as well as cuddling in bed with mypartner for a while).I was a midwifer y teacher at my local hospital, knownfor my enthusiasm for home bir th, so when thoughts ofescape (i.e. hospital admission and an immediatecaesarean section) crossed my mind, I thought about howsome of my colleagues would be saying ‘told you so’, alsorealising that in fact there was no rescue from thisphenomenal process. I then somehow accessed newenergy and determination: eventually and triumphantly, Igave bir th to my daughter, and was on cloud nine forweeks. We never worked out why my labour had goneon for so long (52 hours in all) - was it the shor t cord,was it something psychological, or was this simply normalfor me?For the bir th of my son three years later, I opted to usea bir thing pool. Labour progressed quickly. The midwife,an experienced and wise colleague, listened in and weboth heard a fetal hear t of about 60 (half the rate ofnormal). She looked me in the eye and said ‘you knowwhy that is, and I know why that is.’ Indeed, we bothknew that the slow rate was my baby’s response to thecompression of his head as he came quickly through mypelvis, and that it was nothing to worr y about. No panic.I got out of the pool, because it felt cold. My son wasborn on dr y land, a little blue and floppy, with the cordaround his neck, but we left the cord to pulsate so thathe received his full complement of blood from theplacenta. Gradually he began to respond and we allgreeted him; another wonderful bir th.However, depending on the experience and viewpointof the clinician, these physiologically normal bir ths couldboth be seen as having elements of abnormality,(prolonged labour, abnormal fetal hear t rate). Indeed inany obstetric unit in the UK, my first labour would haveundoubtedly ended in a caesarean section for ‘failure toprogress’. I am inclined to wonder how many women’spregnancies and bir ths in the current climate are deemed‘normal’, and to consider how problematic the concept ofnormality can be. After all, the role of the midwife innormal bir th was set down by doctors in the ear ly par tof the 20th centur y as they decided to leave to midwivesthe ‘tiresome and unremunerative work’1 of attendingnormal bir th! In those days, twin and breech bir ths wereseen as normal events, and took place at home. Sonormality is a changing and changeable concept, one thathas been captured by an often ner vous and unreflectiveobstetric establishment, and one that many women andmidwives are now tr ying to redefine. As a midwife whoattends home bir ths, I see how amazingly adaptivewomen’s bodies are; how so often women knowintuitively what to do when events are not quitestraightforward.Billie Hunter’s evaluation of the All Wales ClinicalPathway for Normal Bir th (NLP) gives insight into thecomplexity of the notion of ‘normality’2. The NLP is athree-par t document which acts as a protocol formidwifer y practice, with the aim of suppor ting normalityin labour and reducing unnecessar y inter ventions.Implemented throughout Wales in 2002-2004, it is abrave and impor tant initiative which has brought normalbir th centre stage; but so far, surprisingly, there has beenno increase in the rates of normal bir th. The problemwith defining normality may be that such a definition canbecome restrictive - women are either ‘on’ or ‘off ’ thepathway and the ‘grey’ areas are no longer included in therealm of ‘normality’. Some of the midwives Hunterinter viewed said that the pathway resulted in a rigidnesswhich undermined their clinical judgement. Womenthemselves described varied understandings of themeaning of the phrase ‘normal bir th’, seeing it as anindividualised concept and emphasising the differences.2Pregnancy, labour and bir th are an individual journey foreach woman, often characterized by uncer tainty andcomplexity; therefore teamwork and consultationbetween clinicians are necessar y to achieve bestoutcomes.To give an example of the impor tance of teamwork inachieving positive bir th outcomes, I would like tell a stor yof genuine collaboration. I suppor ted one of ourmidwifer y students, Eva, for the planned home waterbir thof her four th baby. She chose to give bir th accompaniedby her husband, her best friend Sharon (another studentmidwife) and myself, her midwifer y tutor. Eva’s third babyhad been delivered by caesarean section for an unstablelie. Ear ly on in Eva’s pregnancy I wrote to the consultantobstetrician asking for his suppor t should we needmedical referral, and received a positive response. Italked with my super visor of midwives, who introducedme to the super visors who might be involved should werequest suppor t or if Eva transfered into hospital. We allknew who was who, and we all had the same aim - thatEva should have the bir th experience she wanted.Home Birth and NormalityMidwife and mother of two Sarah Davies reflectsImmmm10 AIMS JOURNAL VOL:20 NO:3 2008Ar ticleWhen Eva went into labour, there was old meconium inthe amniotic fluid, so we noted it as a sign of a maturefetus, and made sure we listened to the fetal hear tbeatregular ly. The presence of old meconium only indicatesgreater risk where there is also an abnormal fetal hear trate. Eva had a long first stage, and at one point I wasconcerned about progress as the baby’s head was stillhigh despite good contractions; Eva and I were bothwondering about transfer to hospital, so I rang thesuper visor of midwives on duty and we discussed thewhole labour in detail, deciding that it would be a goodidea to allow more time and then review the situationafter an hour or so. What really struck me about thisconversation was the super visor’s complete suppor t forEva’s choices and the way this guided her response. Thissuper visor had never met Eva or me, but her primar yconcern was for this woman’s experience. This telephonediscussion ensured that Eva had the bir th she wanted: athome with her family around her, Eva gave bir th to abeautiful baby boy. She had had a previous 3rd degreetear and again her perineum needed exper t repair, so shewent into hospital where the registrar repaired herperineum with skill and kindness, suppor ted by themidwifer y team, and soon she was back home.When I discussed the bir th with the super visors ofmidwives afterwards, they were truly delighted for Eva.Throughout the pregnancy and bir th, there had been nonegative mutterings about risk, or attempts to ‘encourage’Eva to give bir th in hospital. From my perspective, thiswas super vision and teamwork at its best. If I had beenundermined and unsuppor ted I would have felt anxiety;this would have been sensed by Eva (labouring womenare exquisitely sensitive to the emotions of theirattendants) and this awareness would have caused herown adrenaline levels to rise, hindering the smoothprogress of her labour.Eva and her baby were best cared for through having aslittle disturbance to the labour process as possible,through unobtrusive obser vations, and by havingsuppor tive companions - not just in the bir th room itselfbut within a wider network of suppor tive relationships.When Eva needed medical assistance, this was providedseamlessly and with the same respect for her autonomy.This kind of care should be provided wherever womenfind themselves, and whether they choose to give bir th athome or in hospital.As Downe3 suggests, perhaps now is the time to moveaway from the ‘ster ile debate of tr ying to define and reify“normality” which attempts to classify an “ideal” type ofbirth and what “is done to” women (…) towards seeingwomen as individuals with agency, and with a subjectivesense of choice, power and control regarding childbirth.’ Sowhere does this leave the clinicians who care for womenin the climate of an increasingly risk-averse society? Theonly possible solution, it seems to me, is teamwork: wherewomen’s agency is central, but where clinicians also havemutual respect for each other’s exper tise. The need formutual respect has been emphasised by recent HealthCare Commission Repor ts, which identified ‘tribalism’between doctors and midwives as a reason for poor care,finding that they did not see themselves as sharing thesame goals.4It is time, perhaps, to reiterate that all of us, cliniciansand parents, have the safety of mother and baby as ourcentral aim. Safety must be understood in a holistic sensethat encompasses physical, psychological and spiritualsafety. Perhaps we need now to include in ourunderstanding of safety the ‘existential’ safety each of usfeels when we trust, and are trusted; this is what helpsbir th progress smoothly. Where I teach midwifer y(Salford) we are now focussing upon ‘multiprofessionalteamworking’ as a way of improving maternity care.Basing our approach on that pioneered by Sally Pairmanin New Zealand, we are beginning to explore ways ofensuring that women, their par tners, and childbir thactivist groups are central to our curriculum.Student midwives carr y a caseload (their care in futureto be evaluated by the women themselves); AIMS, ARM,NCT and home bir th groups collaborate, whileenthusiastic midwives and super visors work to promotewomen’s freedom in bir th. Mutual respect betweenmidwives and doctors is of crucial impor tance. Forexample, working alongside the midwives and physician,one of our local obstetricians recently actively suppor teda woman with insulin dependent diabetes to achieve thehome bir th she wanted. This woman is now chair of theMSLC and regular ly lectures to students, midwives andobstetricians.Hierarchical relationships do not encourage safe care;the key change needed is to foster asser tivecommunication between all involved in order to createmutually respectful relationships. Clinicians need tounderstand that risk and safety are in the eye of thebeholder5 and will be viewed differently by differentindividuals depending on their life experiences. Ratherthan being feared, these differences in perspective shouldbe respected and valued.Sarah DaviesSpecial thanks to Eva and her family; to Sharon (thenstudent midwife), to super visors of midwives Carol Ellisonand Nora McLaughlin, and to the team of midwives anddoctors at Trafford Maternity Unit. Thanks to Dr JoMurphy-Lawless for commenting on a draft of this ar ticle.References1. Witz, A. (1992) Professions and Patriarchy Routledge.2. Hunter B (2007) The All Wales Clinical Pathway forNormal labour ; what are the experiences of Midwives,Doctors, Managers and Mothers? Final Project Repor t,Institute of Health Research, Swansea University.3. Downe S (Ed) (2008) Normal childbir th – evidenceand debate. 2nd edition. Churchill Livingstone.4. Health Care Commission (2008) Towards better bir ths:a review of maternity ser vices in England. Commission forHealthcare Audit and Inspection. Accessed online atwww.healthcarecommission.org.uk/_db/_documents/Towards_better_bir ths.pdf5. Fox N (1999) Beyond health; postmodernism andembodiment. Free Association Books

Home birth and normality

Beyond health; postmodernism and embodiment.

Normal childbir th – evidence and debate. 2nd edition. Churchill Livingstone.

Normal childbirth – evidence and debate. 2nd edition. Churchill Livingstone.

Professions and Patriarchy Routledge.

The All Wales Clinical Pathway for Normal labour ; what are the experiences of Midwives, Doctors, Managers and Mothers? Final Project Repor t,

The All Wales Clinical Pathway for Normal labour; what are the experiences of Midwives, Doctors, Managers and Mothers? Final Project Report,

Towards better bir ths: a review of maternity ser vices in England. Commission for Healthcare Audit and Inspection. Accessed online at www.healthcarecommission.org.uk/_db/_documents/ Towards_better_bir ths.pdf

Towards better births: a review of maternity services in England. Commission for Healthcare Audit and Inspection. Accessed online at www.healthcarecommission.org.uk/_db/_documents/ Towards_better_births.pdf

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Home birth and normality

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