That Cut

It does not surprise me how often the conversation turns to "the stitches" when women get together to chat about their births. It is not just the shocking assault on a very intimate part of our bodies but it just plain hurts!!

So the big question I am so frequently asked is " Was it necessary?" The simple answer is, possibly. As I covered previously, routine episiotomies were introduced without any research on the heresay of mainly one individual who thought they were a good idea.

An episiotomy creates an injury that is equivalent to an extensive tear that is called "second degree" as it involves not just skin ( first degree ) but muscle as well.  A second degree tear may be small or large.  So what could be the advantage of creating a fairly serious " artificial tear "?

The debate continues to rage over what are the proper indications to perform one. The main reason sited, that a cut "protects the perineum from third degree tears ( real nasty tears that run into your anus )and prevents incontinence", has been disproven by research.  Another is that a cut is easier to sew up than a tear.  Can I say I have not found any experienced attendant who finds this an issue.  Having selected perineal integrity as my main area of interest during my time as a midwife I found my observations did not support many popular theories.  The cutting of an episiotomy during birth often lead to worse tearing as the baby would generally emerge in an uncontrolled rush.  The best outcome was always a slow, slow delivery of the head with the woman upright and bottom in the air.  However, there are still occasions when I still perform an episiotomy during a birth.

The most important reason is that the baby is seriously distressed and needs to get out and fast.  If the baby is being held up by the perineal floor there is no alternative.  Another is that the perineum begins to swell and begins a tear in the middle ( button hole tear ) before the baby is low enough to put it under much pressure.  By cutting a fairly modest episiotomy and carefully and slowly delivering the babies head I could actually reduce the amount of damage that took place.  An unusual one is that the woman is circumcised and cutting the scar tissue is the only way to allow the baby out. Except for this unusual situation, it is rare for a perineum to be so resistant as to prevent a birth but occasionally it is seen. The old idea that most episiotomies are performed to save time, prevent the attendant from having to explain why they couldn't prevent a tear and that it makes the obstetrician appear as if they have done something useful as they often appear only for the birth does, in my opinion, hold some water.  

The good news is that the current trend is to reduce the routine episiotomy rate.  Research has been called for to determine if it really is helpful when using forceps or if cutting an episiotomy does protect the premature babies head during birth. So lets hope this trend continues as looking after a new baby is hard enough without being unable to sit down or walk in comfort.

A Promise is a Promise

Mrs A was 42 years old and in labour with her first child.  She and her husband had tried every fertility treatment available to fall pregnant and all had failed.  To their disbelief, they had found themselves pregnant nearly a full year after finishing their last unsuccessful attempt at IVF.  Mrs A realized this was likely to be her only birthing experience and before I was even able to introduce myself, she began begging me to " Please please, please, help me have a beautiful birth!!" I noticed she had carefully arranged her birthing room with pictures, gentle music, soft cushions from home and curious oddments such as a colourful collection of polished stones.

Between contractions she outlined her desires for this birth.  It was a curious mix of all the birthing stories she had read over the many years of trying to fall pregnant. As she was a private patient I assured her I could help her with most things on her list but when the actual delivery was imminent her private obstetrician would be called.  I was relieved to note her doctor was a favorite of the staff with his combination of excellent obstetric ability and a warm and gentle nature.

It wasn't long before Mrs A's gushing enthusiasm was muted by the hard work of labour.  She stopped talking and began humming.  She paced slowly between contractions only stopping when I checked her or the baby. We dimmed the lights and threw mats and beanbags on the floor which she would periodically rearrange. Once she realized she was not going to have to fight to get what she so badly desired, she relaxed, turning herself inward and slipping into her own world. This is, of course, the perfect lubricant and labour progressed very rapidly. Leaning forward onto her husband as he massaged her back during a particularly long pause between contractions, she suddenly sat up and announced she had to push.

Like magic, her obstetrician arrived, knocking quietly on the door.  I surprised him with the good news and asked if he would like me to turn up the lights and ask Mrs A to get on the bed so he could examine her.  He smiled and declined saying " Let's just wait and see what happens".  He sat himself unobtrusively in a corner of the room and smiled encouragement.

Mrs A stopped her pacing and began to sway, arms around her husband's neck.  With each contraction she would bend her knees, look into her husbands eyes and push.  The scene was curiously intimate.  Mrs A had long since forgotten her long list and was responding innately to her own personal needs.

It soon became apparent that the birth was very close and although loathe to break this magical moment, I was aware that Mrs A would need to move to the bed to deliver.  Dr M was no longer young and asking him to get down onto the floor to deliver the baby was not feasible. I began to set up the delivery trolley and was surprised when Dr M shook his head.  Seeing my confusion he came over.  "Set everything we need on the mat over there".  I couldn't help but blurt out " But you can't "  He smiled again and said " A promise, is a promise. " 

It took a great deal of care to get Dr M down to floor level and comfortable.  He suffered with arthritis in his knees and sitting with them bent was painful. He grabbed one of the beanbags, plumped it up and leaned back.  Mrs A was now on her knees, arms still around her husbands neck while he sat on a birthing ball. Dr M waited patiently, rocking forward with each contraction as Mrs A pushed. The baby arrived calmly,without a sound.  I asked Mrs A to reach down as Dr M was unable to pass him forward.  There was then that familiar moment of suspended time, when the baby opened his eyes, parents and baby made eye contact for the first time. He breathed quietly, curling his fingers around his father's finger. I placed a soft blanket over mother and baby. 

And there we sat, obstetrician, midwife and new family in the semi darkness for a full thirty minutes waiting until Mrs A delivered her placenta. Mrs A suddenly seemed to become aware of her surroundings. She handed her baby to her husband and turned.  " My dream baby, my dream birth, I can't tell you, I know how difficult that was for you doctor, there are no words ..........." and with that, she leaned forward and put her arms around us both. I heard Dr M, clearly moved, mutter, " A promise..... is a promise".

 

The Unkindest Cut

Episiotomy is a surgical incision made at the time of birth to enlarge the vaginal opening.  It was a rarely used procedure restricted mainly to complicated deliveries until 1915 when it was made popular by two prominent obstetricians, Pomeroy and DeLee. De Lee had developed a delivery technique which involved cutting a large episiotomy and delivering the baby with forceps as soon as a woman was found to be fully dilated.  He theorised that his technique prevented tears that could lead to incontinence or a sagging pelvic floor( those muscles which criss-cross between the vagina and anus and keep everything in place).  Without evidence or research the theory was taken as fact and soon became standard practice in many hospitals with most obstetricians incorporating episiotomy into their normal delivery routine. It wasn't until 1983 that the first major study of episiotomy was undertaken. Its conclusion?  Episiotomy disastrously weakens the perineum making it far more likely for a woman to sustain a serious perineal tear ( known as a third degree tear ).

The Devil You Know

One of the disadvantages of being a midwife in a busy delivery suite in Australia is that you seldom meet women before they are in labour. As shifts change we often take on women who are heavily into labour and must take on the difficult task of determining a woman's desires and needs while she is in no mood for idle chit chat.

Mrs K was just such a woman.  She was heavily into labour with her fourth child when I arrived taking over from the previous midwife.  With three previous births under her belt I was sure Mrs K would have a clear idea of what she wanted from this birth and indeed she did.  With each contraction she would stop walking, grab her husband's shoulders and rock from side to side. Startled to find she would periodically burst into fits of giggling she explained she was just happy as she was finally getting that "natural birth" she had always wanted. Progressing rapidly, she was soon showing  signs that her private obstetrician would have to be called. I had to be careful as her doctor was known for his somewhat aggressive use of intervention and I didn't want to worry that I had called him too early.

At that moment, to my alarm the doctor himself arrived with an anesthetist in toe.  He demanded Mrs K get into bed and upon examining her declared she was 9cm.  He told the anesthetist to insert an epidural.  I protested that Mrs K had not requested one and desired to have a natural birth and perhaps we should ask her first.  Dr T responded by telling the anesthetist to go ahead and quietened Mrs K's protests telling her she would "put her baby in danger" if she refused. Within a few minutes, as the anesthetist inserted the epidural catheter, Mrs K screamed she wanted to push. 

Dr T began shouting at Mrs K that she did not want to push. Mrs K shouted back she couldn't stop herself.  The anesthetist, trying to withdraw from the situation was told by Dr T to put in the drug into the epidural catheter NOW!!.  In the middle of this madness was the midwife, trying to get someone to realize that  the baby was arriving with or without the epidural! Within minutes, after a large episiotomy, Mrs K was delivered of her baby, stitched up and her obstetrician gone. 

I found it hard to know how to comfort Mrs K as she held her baby and sobbed.  She was unable to move as by now her epidural was fully in effect and feeding her new baby seemed an impossible task.  I handed her new daughter to her husband, made her a cup of tea and ignoring all my usual tasks sat and talked her through what had just happened.  Mrs K tearfully described how it felt to have "my beautiful birth torn from me". 

" This is my last birth." she explained.  "I so needed it to be happy, to be the birth that I could remember as wonderful.   My previous births were all horrible like this.   Each time I thought I wanted to be the one to make the decisions and each time Dr T would arrive and make his decisions ignoring my requests.  From the first one I decided that was it!  Next time I will go to another doctor and each time I decided  IT WAS BETTER TO STAY WITH THE DEVIL YOU KNOW!!!.............."

"You're a What??!"

Having a chat with a new neighbour while waiting for the school bus I was rather startled to hear she was unaware that midwives existed in this "modern age . Her understanding was that midwives currently exist only in small villages or remote places in the third world "where proper medical care is not possible"!! 

Ahhhh...... so perhaps for all those out there similarly "surprised" let me enlighten you. Most babies in the world are delivered by midwives not doctors!  This includes many developed nations such as Australia, England, Germany and in fact through most of Europe.  The system in the USA where pregnancy and birth take place strictly under medical supervision and profit is the main motivator, is not the norm for maternity systems around the world.  It has been shown by many independent surveys that it does not lead to better outcomes for mother or baby!  Countries in Europe such as Holland where midwife lead care is the primary focus and home births are commonplace, have much, much better outcomes with phenomenally lower rates of death and injury to mother and baby than the USA. This may surprise you. If you are not convinced, the World Health Organisation has a lot to say about maternity services around the world and is worth a look.

A Timeless Birth

Mrs M was one of my few clients while working as a doula in an Asian country who was not an expatriate. Her first birthing experience had been most distressing. She had been happily labouring at home when she was forced to transfer to hospital for reasons that were never make clear. She was strapped to a monitor, had intravenous fluids hung, was forced to stay in bed for her labour and birth, subject to an episiotomy which she had made clear she didn't want, and her baby was removed at birth for 3 hours for "routine cleaning and assessment". She was vastly relieved that for her second birth, against the odds, she had found an obstetrician who would "allow" her to birth at home with a doula, but her fear of transferring to hospital remained great.

Mrs M rang early one morning to say she was having contractions. She claimed they were coming every 5 minutes, were short and not very painful. When asked she said she did feel some pressure feeling with some contractions.

It took just nine minutes to get to Mrs M's house. As the taxi pulled up outside I got a phone call. I didn't bother answering as I could hear she was pushing from outside the house. I flew through the front door and up the stairs to find Mrs M standing in the shower happily pushing away by herself!! Immediately it was clear the baby was just a push away from birth but that a thick lip of cervix was all that was holding up proceedings. I shuddered to think what would have happened had the cervix not held the baby back while Mrs M was standing unattended.

I phoned the obstetrician and said "Mrs M's. Come NOW!” I encouraged Mrs M to come out of the shower and to move to a more comfortable location. We got as far as the sink where she stopped. I asked her if this was where she wanted to give birth and upon confirmation I managed only to throw down some towels and put on some gloves before the next contraction

At this point Mrs M's husband arrived and almost clapped his hands with excitement. He exclaimed "So she is finally in labour! " He then tried to to go and change out of his gym gear. Mrs M was obviously not oblivious as to how progressed she was as she said calmly, " I am about to give birth at any moment, I suggest you stay here". With the next push the cervix disappeared and the baby's head descended to where you could see lots of black hair and more importantly for the midwife, the lovely pink scalp that shows a happy baby. I showed Mr M who was stunned. "But she was hardly doing anything when I left less than an hour ago"!

I was somewhat desperate for the obstetrician to make this delivery as the home birth system we had set up together was new. I wished to work together as a team and see how this obstetrician operated in the home environment. Trying to slow this birth was difficult because although Mrs M was calm she was not comfortable to move from her standing position into one which reduced the effect of gravity nor could she control her urge to push.

Slowing the delivery of the baby's head as much as possible, I encouraged Mr M to move in closely while Mrs M calmly stroked her baby's head. I checked for cord and in the pause between contractions was amused to see the baby pull a variety of faces. With the arrival of the next contraction she was born into my hands. I told Mrs M to reach down and take her baby. She held her closely gently rocking as I dried her gently with a towel. Mr M kept repeating " But that was so easy, so easy".

At this point Dr T arrived and remained pleasingly unobtrusive as we waited for the placenta to separate. When it had stopped pulsating Dr T clamped and cut the cord. I took the baby and gave her to Mr M. With the next contraction the placenta delivered and after ensuring her blood loss was minimal Mrs M decided to hop back in the shower to clean up. It took just minutes for me to throw the towels in the washing machine and clean up the considerable mess in the bathroom. By the time Mrs M was tucked up in her bed you would have been unaware that a birth had just taken place.

After the baby had finished her breast feed a few stitches were inserted for a small tear. Dr T departed to another birth while we all enjoyed a cup of tea sitting on the rather large bed. Mrs M's two year old son bounced into the room having slept through the entire drama in the room next door. He was fascinated with his new baby sister and helped dress her in her first clothes.

I sat back to write and noted it was a mere hour and fifteen minutes since I had arrived. I watched the timeless scene as the family examined its newest member. I wished that many more women and families could experience birth like this, as a part of family life, without the drama and fear that so often surrounds birth in our modern world.

Just for the Birth

One of my most enjoyable periods working as a midwife occurred in an Asian country where birth is highly interventionalist and natural birth and midwives are seen as an "evil foreign influence". Working with a handful of adventurous obstetricians I would meet women at home, assess the health of mother and baby and transfer with them to hospital for the birth. I would stay as a support person or doula during the labour and provide postnatal support in the weeks following. Most of my clients were expatriates, terrified of delivering in a system where women have few rights to reject treatment deemed appropriate by their obstetrician.

Mrs B was an Australian woman who was determined to have a low intervention birth with her second baby. When she rang one morning with what she described as 'mild contractions', I suggested a visit.

It was a short taxi ride to Mrs B's apartment where I found her relaxing in the bath with only her son's rubber duck for company. She was vocalising in such a way that it was clear to me her birthing was going to be rapid. Suggesting it was time to leave for the hospital I was startled to find she didn't agree. "Not till I'm in proper labour" she said and headed back to the bath. And then came her next contraction!

It was a proper full on transitional contraction that went on and on and Mrs B let the world know it! Needing no more convincing, we headed towards the front door passing Mr B who had his head in the fridge. "Let's go now" I urged. Mr B took his head out to say "I can't find the beer. We can't go without the beer". What Mrs B had to say about beer is, well, shall we say, not repeatable but it did get the desired response. Mr B sadly picked up the "beerless" esky full of snacks and headed for the door. Mrs B took two steps out and let out a bellow that shook the walls and had a dozen curious heads peering around corners and over balconies. Reaching the car, I was stunned to find the back seat full of boxes and when these were removed, a child's car seat, which refused to come loose. A baby should either be born at home or at hospital. A car park is not a desirable option. About to suggest we return to the apartment, the seat snapped loose allowing Mrs B and I to jump into the back seat.

By now Mrs B was in full transition and although the hospital was only 10 minutes away I wasn't sure we were going to make it. I phoned the obstetrician to suggested he meet us there. Dr C casually asked "Oh, do you think she is in labour?" Mrs B let out another blood curdling yell. "I see" he said "On my way." Looking up, I was perplexed to see how slowly the world was passing by and realized the car was barely moving.

It was at this point that I heard "The Sound". It is a certain catch in the throat that indicates a woman is, or soon will be ready to push. That is when things really began to get interesting. As calmly as possible I said to Mr B to "Go Fast!! " and to Mrs B " Try not to push!!"

With the next contraction many things happened simultaneously. Firstly, Mrs B bellowed at the top of her lungs and pushed like crazy, secondly, Mr B finally hit the accelerator in an attempt to overtake the slow moving bus and thirdly, everyone in the bus looked down to see what the noise was all about. At this point there was nothing for me to do but get Mrs B into the head down, bum up position and try to persuade the baby to stay put. Keeping Mrs B fully clothed and working entirely by feel was the only option as by now a whole busload of mesmerized onlookers were looking down with their mouths gaping.

The hospital entrance only a few feet away we stopped. Furious "beeping" by Mr B failed to dislodge the driver blocking the entrance. Arriving at last I threw open the car door and was surprised to be greeted by two men pushing a wheelchair. "How did you know?" I asked. "Are you kidding? We heard you coming a block away." Mrs B refused to sit as by now she had a bulge to contend with and desperately hoping for a break in the contractions, which was granted, we set off on foot.

We only just made it. Mrs B jumped on the bed on all fours to the astonished disbelief of the local delivery nurses. Attaching the fetal monitor or doing an internal examination was impossible in this position and they had no idea how to proceed with the required protocol. Not a second too soon Dr C appeared. Giving him just enough time to put on his gloves, Mrs B rolled onto her side and delivered her beautiful little girl.

These first moments are very special and I retreated to the corner to allow the couple privacy to explore their newborn. I reflected on what I saw as an unfortunate, frantic rush which didn't allow the couple to relax and settle in before the birth. But, as I should have known by now, never assume anything about what a birthing couple want.

Mrs B looked up over her breastfeeding baby and spotting me said "That was absolutely, absolutely amazing! I could not have hoped for a better birth. We had spent so much time worrying in pregnancy that I would arrive too early and have to submit to the required monitoring. We hoped and dreamed we would arrive just like this, just for the birth!!"