Waiting for Agnes

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More sense November 26, 2010

From the excellent Ina May Gaskin…

 

 

 

 

It’s not only obstetricians who think I’m batshit crazy – I tried explaining this concept to a student midwife the other day. If only I had had this video to hand, she might have been a whole lot less ‘back away from the hippy midwife before she tries to hold my hand and sing’ and a whole lot more ‘why yes, wise and passionate teacher, I totally get you’.

 

Sense

Filed under: Midwifery — titchandboofer @ 12:33 am
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If you have worked with birthing women, the following conversation will be familiar. If you have had a baby – or been with someone having a baby – in a hospital, this is the conversation that the midwife and the obstetrician were having outside the room sometime after you arrived:

Obstetrician – Has Trixie Whosibob arrived?

Midwife – Yep, she’s in room 23.

Is she in good labour?

Yes. She’s an uncomplicated primip (first time mother), well in pregnancy, no risk factors.

How many centimetres is she? (meaning: how open is her cervix? not how tall is she)

I haven’t done a VE (vaginal examination) as Trixie doesn’t want one.

When are you going to do one?

Not as long as the woman doesn’t want one. (grinding teeth just a little)

So, we don’t know if she’s in labour. (huffiness is kicking in about now)

She is in labour. (oh dear, I see where this conversation is going)

So you have done a VE? (elevator music?)

No. My clinical judgement (as a goddamn health professional, with eyes) is that she is in labour. She’s contracting 3/60, the head is…….(trailing off as am talking to a fast retreating back)

Just page me when you’ve done a VE. (as her baby will be unable to come out unless someone touches her cervix, you mad hippy midwife, don’t you know this is a hospital?)

(kill me now)

*     *     *

 

I used to wonder how an eight hour shift with a labouring woman could be so draining. I’d leave the hospital absolutely washed out, just capable of steering the car home, not interested in any post-work action more taxing than lolling on the couch and mainlining tea. How could it be so very tiring, when much of my time was spent sitting quietly in the semi-dark and writing stuff down? For a while I thought it was the pressure of responsibility – eight hours of a voice in my head chanting ‘two lives in your hands, two lives in your hands, two lives in your hands’. And that is kind of tiring, but the acuteness of it fades after the first few months in. Then I thought it could be the politics, the non-stop jostling for recognition, understanding, autonomy, respect. And that too can be tiring, but it’s also oddly invigorating, the constant justification of my professional judgement. Hard to get in a rut if you have to talk about it all the time. It could be the hospital itself, the hideous fluorescent lighting, the constant hum of air-conditioning, the alarms, the phones, the visitors, the doing everything in triplicate, the glacial pace of change. But even all of these things slide into the background over time.

Now I think I’ve got it figured out. It’s one of the best parts of midwifery, but also one of the least understood and respected by our medical colleagues (and, disappointingly, by some midwives). It’s this… if you’re open to it, midwifery is a job that engages every one of your senses and something more, something utterly intangible.

Yes, if a woman lets you, you can stick your fingers in her vagina and feel how open her cervix is. But that is just one piece of information and it’s not as illuminating as so many people believe. You can put your hand on her belly and feel how often her contractions are coming and how long they are. And you can feel her belly all over, feel what position her baby is in and how far down the baby’s head is. You can do all of this and still not know very much. Where it gets interesting is beyond touch, beyond the measurable.

Sit in the room with this woman. Not up in her face, but off in the corner. Be quiet. Pretend to occupy yourself with notes though, so you’re not just sitting staring at her like a zoo exhibit. Now watch. Listen. Smell. What is the look in her eye? What does she sound like when she’s getting through a contraction? What is the smell on her breath? How chatty is she? How restless? How out of it?

Beyond this again, what do you feel? Can you sense momentum? Do you just know that this labour is steaming ahead, relentless. Are you with a woman who is so quiet, so still, but somehow you know you cannot leave this room, that her baby will be here in minutes? Or is it an absence of momentum? Are you watching a woman who is making a good show of being in labour, because that’s how she thinks she should act? Or is she stuck in a labour that is going nowhere, that is every bit as intense, but is somehow stalled? Is this feeling of absent momentum her? Or is it you? Are you impatient, wanting her to birth on your shift, at your pace? Are you hesitant, willing her to hold back, fearful that her reportedly ‘big baby’ will get stuck in your hands. How are you, even subconsciously, pushing your needs into this space?

Now get out of the room and summarise this for the obstetrician on shift.

Is Trixie in labour?

Yes. I can feel it in my body.

No obstetrician is going to give two hoots for what I can feel. They want a quantifiable measurement. They want a number they can pass onto their colleagues without fear of ridicule or criticism. They want a timeline, a schedule, a plan. This isn’t really their fault. We work in a big system that thrives on order and predictability – not feelings.

This is why my job is draining. I’m sitting quietly in the semi-dark, writing stuff down, with every nerve-ending on high alert. I’m as open as I can be to absorbing this woman’s labour, to sensing it, integrating it into my body. It might sound mad, but it is based in something real: hormones are catching. I’m sure every one of you has experienced sensing someone else’s mood. Have you walked into a room and been stopped short by tension or anger? Have you ‘caught’ someone’s ‘infectious’, buzzing happiness? Wisdom has it that what we say accounts for far less of how we are perceived than how we say it (ie body language matters more than words), but even that isn’t the whole story. So, I’m feeling all of this, absorbing all of this. Then I walk out of the room, push it all down, look the obstetrician square in the eye, put on my best serious health professional voice, summon the magical phrase ‘My clinical judgement is…..’ and hope like hell that it’s enough.

 

Step Back in Time August 5, 2010

Filed under: Midwifery,No baking today — titchandboofer @ 9:44 am
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I am a midwife. It is 2010. I work for a large public hospital. To be specific, I am employed by the hospital. Like most of my midwifery colleagues in the hospital system, I work with many different medical professionals, obstetricians, GP-Obstetricians, paediatricians, anaesthetists, endocrinologists and so on. Some I like, some I don’t, some I have great respect for, professionally, and some I emphatically do not. I do not work for any of them. To reiterate, I am not employed by an obstetrician. Midwives, by and large, do not work for obstetricians. I know I’m being heavy-handed here, but we are employed by hospital management. We go to work for professional fulfillment, to earn a living, to care for the women and their families, and to care for their babies. It has been several decades now since we have gone to work to be subservient handmaidens to the obstetric staff.

Oh I could go on and on in this vein…we are health professionals in our own right, we can be autonomous practitioners, we have professional codes of practice and ethics, we undergo years of study and supervised practice, we are held to a high standard and undergo professional appraisal every year. We don’t just get to show up, hold a woman’s hand, wrap the baby in a clean blanket, make her a nice cup of tea and empty the bins afterwards. We don’t get to do this job because we’re all so bloody nice. Culturally, socially, there is a commonly heard suggestion: ‘oh, she’s such a nice girl and she really loves babies, she’d be an excellent midwife’. Well that’s crap. Some of us are nice and some of us aren’t very nice at all, but most of us are damn good at the job. Obstetricians, well do I even need to say it? No one cares if they’re men or women (but mention a male midwife and you might as well have three heads), or if they’re ‘nice’, or even if they’re particularly experienced (yet I cannot count how many times I’ve been asked how many babies I’ve delivered – one, my own, the others I’ve caught as their mothers have brought them into the world). And somehow everyone assumes that they’re our employers.

Well they might not have to strain themselves to think differently for much longer. Despite the Government stating, in March, “there is no intention to provide a right of veto over another health professional’s practice” that is exactly what they have done. While they’re proudly advertising their great health reforms of increasing options for women by allowing midwives access to pharmaceutical prescribing rights and Medicare rebates, they’ve carefully put a considerable hurdle in front of any privately practicing midwife who tries to make this happen. Any midwife who wants these rights must not just show that they are collaborating with an obstetrician, but have their practice endorsed by said obstetrician. The first analogy that springs to mind is that of dentists and orthodontists. You go to a dentist for normal tooth care and then get sent off to the orthodontist when things are a little more complicated. No-one is suggesting that orthodontists get a say over whether or not dentists can set up shop.

I’m all for collaboration, for standards, for guidelines, for safeguards, for accountability. I’m not for my colleagues from another profession having a say over how I get to practice. We have a regulating body for that already. And I doubt that they’d appreciate the reverse, if each private obstetrician had to get a midwife’s endorsement (oh, the hilarity – ‘Dr X? He’s lovely but he does routinely cut episiotomies on every first time mother’. ‘Dr Y? Not a great bedside manner and tends to suggest formula feeding in case the baby sucks to hard on the mother’s nipples’). Fortunately we all get a say over whether politicians get to keep their jobs.