Waiting for Agnes

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Not in the zone October 5, 2010

I’m feeling very gloomy this evening. A bit short and snappish, preoccupied with the unfolding of events at work over the past two days. Usually it’s other people’s inadequacies and crappy decision making which send me home fuming, but tonight I’m just gloomy about my own.

I cannot count the number of times I have heard other maternity care professionals justify their decisions/refusals/interventions with the phrase “I’m just not comfortable with ______________” (insert any of the following: waiting for you to go in to labour on your own/allowing you to birth on the floor/you using the bath during labour/not giving you antibiotics/not doing this test/not giving this drug/letting you go home yet…). The list is endless and the language is always saturated with notions of permission-giving and implications of women being naughty, rule-breaking girls who don’t give a fig for their babies’ welfare. This notion of practitioner comfort as a guide for practice irks me as much as the statement “If it was my wife ____________ (having a breech baby/questioning the necessity of a test/being female and pregnant and conveniently oppressed by archaic obstetric care) I would advise her to _____________ (just do what I say even if it’s based on nothing but fear or financial incentive/not question me/just shut up already). Midwifery and obstetrics and having babies are not meant to be about being comfortable, not for anyone. As an aside, there is never a dumber question asked of a labouring woman than “Are you comfortable?”. This job of caring for women as they step into motherhood should be about understanding the normal and knowing the evidence for intervening in the abnormal. It should be about providing the information and honouring the woman’s ability to make decisions for herself and her baby. Should should shmould.

So, what have I done? I have run smack bang into the invisible wall of my very own comfort zone. Let me set the scene:

On Sunday evening, around seven o’clock, a woman gave birth to her first baby. I was not there, but I know she had a spontaneous, vaginal birth, using only nitrous oxide (the gas) for pain relief. She did not bleed excessively and is otherwise well. At birth, her baby was handed straight into her arms and lay, skin to skin, on her chest. She wants to breastfeed but her baby is not interested. Sensibly, she keeps her baby skin to skin with her, allowing him plenty of opportunity to breastfeed. Over night, the midwives help her to try and express some colostrum, but report that they are unable to express even a drop. By eleven o’clock the next morning her baby still has not been able to breastfeed. He has attached on and off a few times but hasn’t attempted to suck. He is settled and remains skin to skin on her chest. He has had a poo, but no-one is sure if he has had a wee (disposable nappies can be tricksy for detecting the teensy wee of a newborn). The woman’s husband is with her, anxiously attentive, lovingly stroking her and the baby. Her mother in law is sitting by the bedside, tutting and tsking as hard as she can, muttering about starvation and formula and glaring hard at everyone. The unit lactation consultant is off for a training day. All very helpful. The midwife looking after her asks me for help. I whip out my breastfeeding cure-all and show the woman how to position herself and her baby to feed lying down (really, it is a very useful skill). Baby has a go at attaching but still isn’t swallowing. He is starting to cry and is no longer easy to console. Together, we have another go at expressing some colostrum. Three glistening drops appear. I suck them up painstakingly with a 1ml syringe. It is twelve o’clock and has now been seventeen hours since birth. Conferring with my fellow midwife, we decide to finger feed the baby these three precious drops of colostrum mixed with 1/2 a ml of sterile water. Gently sliding a finger into his mouth and dripping the liquid in slowly, I hope fervently that this will trigger the switch in his brain – that he will start to connect sucking with swallowing with feeling something in his belly. As he starts to suck my heart sinks a little. His mouth is dry and he is so very uncoordinated, not sealing his mouth around my finger, not bringing his tongue forward but instead using it to push against my finger. But afterwards he turns back towards his mother’s chest and settles again, so we don’t give up hope. I step out of the room and back to into the relentless pace of another October day.

A few hours later, just before we morning midwives finish our shift, I check back with this woman and her baby. No change. It is now twenty hours since birth and he is starting to look truly hungry, crying and crossly pushing at her breasts. She is tearful, her husband more anxious. On the upside, her mother in law has tutted herself to sleep in the bedside chair. I step out again, seeking out the midwife who will care for her next. Hating the words coming out of my mouth, I suggest that while the woman should continue to keep her baby skin to skin and keep expressing, the baby may need a supplementary feed of formula. Then I go home.

Today, I’m back on the ward, every room full. Our lactation consultant is back on deck. She is frantically busy and she is furious – furious that this woman’s baby has been given formula with no medical indication. On paper this is true. The baby is not lethargic, jittery, under 1.5kg, admitted to the nursery, septic, hypothermic or hypoglycaemic (that we know of – no blood sugar measurement was done). His mother is not sick or absent. I feel horrible. I have great respect for our LC and we usually work well together. Usually she respects my professional judgement. Now, buffeted by the wave of her anger, I suddenly find myself questioning my decision. Should I have been more trusting? Should I have waited longer? How long? I ask this and the answer is firm – no medical indication, no formula. But really, how long? Until a medical indication arises. How do I feel? Uncomfortable.

And there it is. Discomfort. Have I really interfered unnecessarily because I wasn’t comfortable? I come home and haul all my breastfeeding textbooks off the shelf. Am I trying to justify my decision? Or can I find something to stretch the boundaries of my comfort zone a little? There are answers, sort of. Although the authors vary in how many feeds they feel should occur in the first 24 hours post-birth, they concur on one point: if a baby has not latched on and fed by 18-24 hours of age, the mother should be assisted to express colostrum and feed it to the baby by finger, cup or spoon. But none of these texts suggest what to do if there is no colostrum. In a perfect world, this woman would have a sister/cousin/friend who was breastfeeding, someone who could donate some breastmilk to tide her baby over until her own milk comes in. Or we could access donor milk from a breastmilk bank. But this world is far from perfect. This woman’s only family in Australia are her husband and tutting mother in law. And if they were here, the idea of sharing breastmilk amongst family and friends is disappointingly taboo. We will have a breastmilk bank up and running in Victoria soon, but even then it may not have enough to provide milk for babies not under nursery care. So what is the answer? How long can a baby wait?


2 Responses to “Not in the zone”

  1. BLF Says:

    Your dedication to your job and the welfare of the women and children you care for is so impressive. It is equally impressive how well you analyse your actions/advice to confirm that you are being as objective as possible and not pushing your personal preferences upon others. However – there is a point in every job (and I think perhaps more so when the welfare of other people is involved) where it is important that you are “comfortable” with what is occurring around you. As much as we can seek advice and follow rules of thumb and best practice, at the end of the day you need to leave a shift and be able to sleep relatively soundly with the decisions you have made.

    Surely it’s all a balance? The mother was distressed. The father was distressed. The baby was distressed. You know I concur re the problems with formula – but there are a range of other factors to consider. How does waiting for the baby to become in need of medical intervention help this new family start their lives together – especially the poor mother, who is probably beating herself up at her “inability” to breastfeed her dehydrated, cross baby.

    Shake it off and tell the LC to get off her high horse. Bah!

  2. LMF Says:

    ditto, tell the LC to sit with the distressed mother, father and baby for 8hrs…….you’re an awsome midwife and i love you dearly if you said you thought my baby needed the dreaded formula even I’d give it after all my 6yrs of breastfeeding!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

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