It has been a great week... starting with a baby last Sunday and leisurely postnatal care since. Breastfeeding is going well, the baby is gaining weight and I've had the privilege to witness at close hand a family integrate and welcome a new family member.
Last Sunday morning the call came in… not that I was aware of it as the night before I had gone to the movies with the expectant couple and had turned my phone volume down to avoid interruptions, and completely forgotten to turn the volume back up. On-call midwife no-no of the biggest order… thankfully with no serious consequences, but I have learned my lesson, and it won’t be happening again.
Neither the text saying things had started, but nobody was needed yet, nor the four phone calls that followed over the next couple of hours woke me on that glorious Sunday morning: one call from the doula; two from the dad; and one from the mother… Instead it was the knock on my front door from Kabir (the dad) that woke me up. I answered the door, half asleep, and he told me that things had started but they weren’t in a hurry… come over but take my time. I was in the midst of my morning routine, wondering why Kabir had come over and not simply called, and somewhere between making coffee and getting in the shower I checked my phone to discover the text and four missed calls… and only then did I realise that my volume was off, and had been since the night before… Wow!... I felt terrible. Really bad that they had been calling me and must have been worried as to why I hadn’t picked up. Really bad that Kabir had, had to come to me and knock on my door. Really bad that I hadn’t realised when he had come over, and hadn’t apologized immediately.
I was just out of the shower and about to drink my coffee when the doula called and said the waters had just released… no time for coffee… I jumped on my scooter and was at their house in a few minutes… luckily I’m living just down the road. I parked my bike still feeling bad… took a few deeps breaths and let it all go… no need to take that stress and feeling bad into the birth room… I could apologise later… I walked up the stairs breathing in calm and allowing myself to come fully into the present moment and quietly entered the birth room.
Layla and Kabir had planned for two close friends to be there to film the birth – Guy acting as cameraman, his partner Lotta as doula. I had been a bit nervous about how this camera presence might effect Layla and her labour, and how two people, never present at a birth before would add to the energy in the room… but when I arrived I could see that it was all fine… more than fine… Layla was deep into her flow in the pool. Guy was moving around with his camera – getting different angles, but she was hardly aware of him… she was already deep in the zone, and Lotta was perfectly tuned in. I organized my things, and felt into the calm, quiet, space - slowly and consciously adding my energy and my presence.
After the next contraction I listened in to the baby with the Sonicaid (Doppler) . All sounded well. I was grateful this baby had chosen a day time birth-day, as I had been worried about the lights that Guy had said he needed for filming, and how that might intrude on the much-needed cosy, dark space… but with daylight streaming through the windows the additional light they had made little difference. Their Indian landlady who lived downstairs was helping out, and she put a pot of water onto the boil so I could sterilize my instruments. They had organized a cloth to hang from the ceiling and Layla would move to her knees and hang on it during a contraction… moving back into a seated position leaning against the edge of the pool when the contraction faded. Lotta was feeding her morsels of fresh watermelon, Kabir was whispering words of support and encouragement into her ears and I was listening in to the baby and checking the water temperature.
Soon after arriving, Layla was pushing at the height of contractions, and when she knelt and hung from the hanging cloth, I could see a purple line extending from her anus and extending up between her buttocks… the infamous purple line, not visible when a woman is on her back, in a semi-recumbent position, but with Layla so mobile and getting on her knees to push I could see it very clearly. The rhombus of Michaelis, (written about by midwife Jean Sutton in an article in the The Practicing Midwife in 2000, which I don't have access to, so can't share with you, but is called: Birth without active pushing and a physiological second stage of labour), was also visible and I pointed it out to Lotta quietly so she could also observe the marvel of a woman’s body in action… those little telltale signs that labour is progressing and the baby is descending. No need for an internal examination when the body is communicating so clearly. To read more about this, Sara Wickham wrote a great piece for the Practicing Midwife, based on an interview with Jean Sutton, that you can read here (http://sarawickham.com/…/…/tpm8-the-rhombus-of-michaelis.pdf)
A little while later, Layla whispered to me that she was pushing, and did I think that was ok. I had a choice here… in antenatal visits she had said that she might want a VE to see how she was doing for reassurance that her cervix was opening. She had explained that since her last baby she had done a doula training and learned that sometimes women can have contractions that are not actually opening their cervix. I had explained how I generally prefer to stay away from VEs unless clinically indicated: like an obvious delay or lack of progression - a labour pattern that doesn’t seem to be changing, contractions not increasing in frequency, strength or duration, a woman who stays very chatty and does not seem to be going into the zone; or a query about baby’s position; or needing a fuller clinical picture for whatever reason; or early labour at a woman’s request. But that if all was well I preferred not to do an examination that usually resulted in an interruption of labour flow.
Choice time… Should I offer a VE even though I did not see any reason to do one?... Labour was clearly progressing... Or should I do what I thought was best? Since she hadn’t actually asked for a VE, I decided to wait and see… if she asked for one directly, I would oblige, so instead I encouraged her to listen to her body and trust what it was telling her:
“See how you feel not pushing. Try it, but if your body takes over and is pushing anyway, then trust that.”
Layla fell back into her labour trance, and with the next contraction was on her knees hanging on the cloth and pushing again. She never asked for a VE or any further reassurance… she was well in the zone. As we had discussed antenatally she kept a hand between her legs as the baby was descending and starting to crown, applying counter pressure as she needed… so I couldn’t see anything for a bit, till the crown of the baby’s head was getting bigger. She was very vocal and making incredible noises – instinctual, primal and loud. She looked at me suddenly, eyes wide open, almost afraid:
“Everything is burning.”
“I know - it’s intense. That’s your baby coming. Behind that burning is your baby in your arms. Do this bit nice and slow. Use your hands to control the head so it comes out nice and slowly.”
Crowning happened slowly and gently, and Layla controlled the delivery of the head beautifully. And then, just like that, the head was out. Layla looked beautiful – flushed, radiant and with that special look of wonderment that women have as they realize that there baby has just been or is about to be born. Time stood still. I checked my watch - a minute had passed… I breathed deeply and looked around at the expectant faces: total quiet and focus in the room… another minute passed…
“Layla. With the next contraction I want you to give a really big push. Ok?”
It was my gentle but firm midwife voice. I checked my watch again – three minutes had passed and not a contraction in sight. I asked her permission to feel if there was a cord around the neck – she nodded, and I checked – nothing. Another minute passed, the baby’s head had been out for four minutes now, and I was starting to get nervous, if the baby was stuck and we had to start doing manoeuvres we had already wasted four minutes waiting for the next contraction. I couldn’t see the baby’s face as it was facing towards the bottom of the pool, but the head looked a good colour. I asked her if I could check for shoulders – she agreed, and I popped my fingers down past the baby’s head, and swept them in all directions, but couldn’t feel anything holding this baby up. I breathed again and reminded myself to stay calm, and then at four and half minutes, the next contraction finally came,
“Nice big push now,” I said as I reached down and helped guide the baby out of the birth canal as she pushed. I was quick to remove my hands so Layla could lift her baby out of the water as she had wanted.
Four and a half whole minutes at the perineum… five minutes from the birth of head till the full emergence of the baby… what was that baby thinking? Relief flooded my body and I could feel the tension that had accrued in the five minutes of watching and waiting leave my body. A gorgeous baby girl – incredibly alert, and great tone, but had not yet had a breath – I asked Layla to turn her around so she was facing outwards and her body could open fully and lungs expand. That did the trick and she gave a small cry and gained an extra point for her 1 minute APGAR. Over the next few minutes her tone remained good and the cord was still pulsing but she was still blue-ish and had not yet another cry. It was as if all her attention was on life on the outside and she had forgotten that she also needed to breathe. I gently asked Layla to give her a couple of breaths – we had already discussed that sometimes babies need a little extra help breathing, and that this can be normal, so she was not concerned. That did the trick - the air from Layla’s mouth went straight into the baby’s small lungs, she started to cry and was nice and pink in no time. After that she was breathing just fine, but still not crying much – a gentle arrival and now in the arms of her mother, both of them still in the warmth of the pool, there was nothing to cry about really.
After some time of bobbing her head and thrusting it against Layla’s arm and breast, she found the nipple she was programmed to look for and self-attached. It is such a wonderful thing to witness, but not something most midwives see very often.
Us midwives can be impatient creatures of habit, and unfortunately working in certain environments can add to this. Working in hospitals and birth centres where the focus is on efficiency, cleaning the room and departing from it to the postnatal ward as quickly as possible; getting the baby latched is just another task to tick off on the long list of postnatal jobs. Newborns are operating on a totally different time frame to us… man, they’re slow… and watching a baby try to self attach can be almost painful to watch…. so slow, so inefficient… almost there… but not quite… no that’s not the nipple… that’s not even the breast… most midwives just want to help… and they do… positioning the baby, holding the breast, tickling baby’s nose with the nipple, so they open their mouths wide and then with a deft and experienced movement getting the baby on. We just want to help. But if you can sit on your hands, and bear to watch the slow and almost agonizing unfolding of a baby nuzzling, bobbing, grasping, missing, trying again, and then again and then finally at some point getting it, it’s a beautiful thing to witness. Working as I do, there is no rush… not before the baby is born and certainly not after. I have come to love watching the oh-so awkward dance a baby does trying to find the nipple.
Since the blood loss had been minimal, I was happy for Layla to stay in the pool for the birth of her placenta. I sat quietly by the edge of the pool… watching her and the baby. Baby was well, parents were ecstatic, Layla was radiant, and the water of the pool was still the same colour since the baby had been born, which meant she was not bleeding into the pool. About forty minutes later, Layla started to move her bottom around a bit looking slightly uncomfortable, and I knew it was probably her placenta. When the next contraction came I suggested she push and at the same time pull on the cord gently. She did this a little but said she felt some resistance, so I followed the cord up with my fingers and could feel that the placenta was just sitting there at the top of the vagina. I reassured her that the placenta had detached and she could pull gently, and would be so much more comfortable once the placenta was out. She had not enjoyed her actively managed third stage last time, and remembered it being uncomfortable and therefore seemed a little resistant to proceed. She tried pushing and pulling with the next contraction, and I offered to help. With the next contraction, while she pushed I gently pulled and a couple of minutes later we had a lovely placenta birthed and I plopped it into a bowl so it could float in the pool.
Yup… you read that correctly: I gently pulled on the cord during a physiological third stage. And yes I usually do. And yes, I know that we’re taught not to.
It’s funny this business around physiological third stages… what I was taught as a student both in theory and by most midwives in practice is that when you do a physiological third stage you are COMPLETELY HANDS OFF. Bear in mind that most of these midwives were not used to doing physiological third stages… hardly ever… even in low risk women… and I know this for a fact, because one night at the stand alone birth centre when we had no laboring women, I read through the entire birth records book where all the details of labour are recorded and there were VERY FEW/HARDLY ANY physiological third stages recorded… most women, despite being low risk enough to birth at the centre had their shot of syntocinon for an actively managed third stage.
However, what I have learned since through seeing and doing is that a little bit of help can speed the process up and reduce the work for the mum. I only did seven physiological third stages during my three-year training, and as I said, most of these were with midwives who were not very experienced, and therefore not very comfortable with them. One shift I was working with a midwife who did lots of physiological third stages, and once she was sure the placenta had detached, she started pulling gently on the cord as the woman pushed. Afterwards she guiltily told me not to tell anyone what I had seen, as we are supposed to be hands off, but in her experience a little pull helped. I had recently seen Cecily Begley present the 2012 MEET study (Midwives’ expertise in expectant management of the third stage of labour) at The Royal Society of Medicine, and had already heard about the gentle pulling on the cord to help the placenta out, and reassured my mentor. In the study (that I suggest you read), they interviewed 27 midwives experienced in facilitating physiological third stages (what they called expectant management) and 26 out of 27 of these midwives talked about giving a little pull to help the placenta out once it had fully detached. What I then saw with other midwives, who were completely hands off, was a whole lot of waiting and often interruption… remaining hands off meant getting the mum into different positions to help with gravity, getting her to blow into a closed fist and generally disturbing the bonding with her babe. What I had seen with the midwife who had guiltily told me her little secret, was that we disturbed the mum a lot less, and we had a placenta much sooner. In the physiological third stages that followed I wondered about the full hour it usually took to get the placenta out with other midwives, I wondered how long it had actually been sitting there detached, and how much sooner we could have had it out, with less disturbance if we had given a gentle pull. In cases where the mother wanted to change position, or move, or go to the toilet the placenta did come of its own accord much sooner… but in the instances where the mum was happily bonding with her baby where she was, it seemed a pity to get her to move.
Just before I qualified I went to the annual Birth Gathering and the lovely Becky Reed (of the Albany Practice), gave a brilliant presentation about how they managed physiological third stages of labour with the women in their practice… basically, once they’d seen the signs of detachment, they suggested that the woman guide her own placenta out, by gently pulling on the cord. here it was again: gentle pulling during a physiological third stage! The thinking being, that no woman is going to invert her own uterus, which of course makes sense - she is not going to pull too hard since she can feel what is going on inside her as the placenta comes down. But actually, nobody is going to invert a uterus if the placenta has completely detached and is sitting by the cervix or in the vagina. The art is in knowing that it has fully detached. So Layla’s birth was the first one where I got to try putting Becky’s experience into practice.
But let’s be clear: I’m not suggesting that mixed management of the third stage is a good idea… we have studies to tell us that this is not a good idea at all and can have disastrous results. I’m not fiddling with the fundus or doing controlled cord traction or pulling hard on a placenta when oxytocics have not been administered… But what I am suggesting is that we as midwives continue this conversation, so we can better serve women. It seems silly that so many midwives experienced with physiological third stages are secretly and guiltily helping the placenta out… doing ‘good by stealth’, but not adding this knowledge and experience to our shared wisdom and body of knowledge. I’m not sure that maintaining that a physiological third stage must be completely hands off is helpful, when a little bit of help at the right time, can so often clearly helpful.
If you are a midwife or a student midwife, please read Begley et al’s 2012 MEET Study, and let’s get talking, and thinking and learning. Certainly what I’ve learned by seeing and doing is to carefully help once I know the placenta is detached. Why wait for a placenta that is detached and sitting in the vagina? Why disturb a woman who is happily bonding with her baby and get her to move about in various positions so gravity can assist? ... So, if mum and baby are fine, I’m sitting close by and watchfully waiting… I’m not cleaning up or doing other tasks... I’m monitoring blood loss and carefully watching to see how the mum is feeling and behaving... a) so I know that there isn’t concealed blood loss behind the placenta that I can’t see, and b) so I catch the signs of detachment – maybe a gush of blood, but maybe not; maybe the cord lengthening, but again, maybe not - this can sometimes be hard to see when the baby is still attached to the cord; often however, the woman starts to look a teeny-weeny bit uncomfortable and if I’m watchfully waiting, I catch these signs, as as cramping starts up again or she shifts her bottom about, and I can reassure her that it’s now time for the placenta… Why?... Because this discomfort and heavy feeling usually indicates that the placenta has detached and is sitting at the cervix or come down into the vagina. And in terms of watchfully waiting, it gives me the opportunity to sit comfortably after being in all sorts of contorted and uncomfortable positions throughout labour and catch a breath and witness the utterly delicious time of meeting and bonding - a real perk of the job smile emoticon
As we know, midwifery is both an art and a science. But it seems that these days in the medical model, midwifery and birth have been boiled down to science only. We’ve lost and are losing so much of the art – vaginal breech; labour care and assessing progress (without routine VEs); working with the fetal ejection reflex (instead of directed pushing at full dilation of the cervix); physiological third stage of labour, and sadly the list goes on. What I’m suggesting around our third stage practice is indeed about art rather than science. I suggest it's time we got creative.