Hello everyone, have just come back onto the list after some time away. I
have missed the rich discussion that is generated in this forum, and of
course was captured by the discussion about twins. Rhonda's poetic and
poignant words have distilled the essence of what follows from me. Thanks
Rhonda, can I give your words to the mother and father I talk about here
please?
The discussion about twins is a potent example of the core issue - the world
view which is at the heart of maternity care provision. Nowhere is the
discrepancy between what constitutes health and human functioning in the
social model of health and the medical model so sharply delineated than in
the constructions around the birth of a second twin. I want to focus on the
medical model and its perspective and then relate a modern day (last week)
example of the application of the medical model on a woman's functioning
during the birth of her twins (from my and the parent's point of view)
There are two fables/stories which can be used as metaphors to illustrate
the medical model as it is currently being expressed in maternity care. One
is the real story - "The Emperor has no clothes" instead of the promoted
version "hospital and medical care and issues of safety when birthing" the
second is "the sky is falling in - Chicken Little who runs around predicting
doom and gloom" with no evidence, aka "your body is defective and we have to
fix it for you - disaster is inevitable if you don't do what we want".
(Conversely, the social model story lines are "if it ain't broke, don't fix
it" and "there's more to this than meets the eye")
It is essential that we humans take a helicopter view of events so that we
can understand them. This enables the threads that weave the tapestry to be
seen - it enables us to join the 'dots' and see the emerging picture. For
example, if we only take the evidence of our senses as the 'truth', we would
still believe the sun rose in the east, the earth was flat and the sun moved
whilst we stood still. A view of the earth from outer space, shows us that
the world is, in fact, a ball and it moves around the sun.
So let's take a helicopter perspective look at a particular woman's
experience of medical care during her recent twin pregnancy and birth.
Jenny and Trevor (not their real names) are soft, gentle people, with a deep
appreciation of life and each other. They are loving, kind parents of an
intelligent, active, happy (now 20 months old) daughter. They discovered
they were having twins at the 18 week scan of their second pregnancy. They
were delighted and excited. From the time of the 'diagnosis' of twins, the
medical people talked to Jenny about the dangers associated with the birth
of the second twin. Jenny and Trevor are 'natural' health people. They eat
well and choose natural methods of dealing with life's challenges. Jenny
and Trevor are meticulous with their research, discuss possibilities and
choose courses of action that match their particular understandings and
values. For her first baby, Jenny had had a long drawn out labour and
following a normal birth, a PPH. She realised how she had felt during the
last labour and how she could make it different the next time.
They were delighted with their care for the first pregnancy (a hospital
based midwife team) and full of gratitude for the midwife who had helped
them obtain the normal birth they wanted. They sought the same care for the
second, but, because of hospital protocols and now as Jenny put it, labelled
as 'a red dot' - meaning 'high risk' this option was denied them. They
were disappointed but reassured that the hospital cared about them, their
birth and care and that the hospital staff would help them with the birth.
Jenny and Trevor had a perspective which was based on the belief that birth
is normal and Jenny trusted her body to do what needed to be done. They
were keen to avoid exposing their babies to unnecessary ultrasound and so
managed to negotiate to have 'only' three during the pregnancy. Jenny was
healthy, active and generally happy during the pregnancy. During the course
of the pregnancy however, Jenny would ring Trevor, crying after each doctor
visit. She was upset that she was seen as a problem waiting to happen.
>From her perspective, she was being pressured to have an epidural,
intravenous therapy, induction at 38 weeks, continuous monitoring etc,
because ''the second twin was at risk". She said there was lots of talk
about breech and caesars and in her view, the doctors went to great lengths
to reiterate the problems with the birth of second twins. Jenny felt like
the medical staff thought they cared more about the second twin than she
did. Jenny and Trevor realised they needed to develop a birth plan and to
present it to the medical staff, which they did at 36 weeks. In this plan,
Jenny and Trevor outlined their desires to have a normal, active birth for
both babies and intervention only to be used if necessary. Jenny was
deeply distressed by the attitude of the obstetrician called in to
'counsel' her about the problems associated with twins (and yet again the
full litany of horrors associated with the birth of the second twin).
Trevor was becoming increasingly alarmed by the way Jenny was continuously
dis-stressed by her antenatal visits with the doctors.
Her visit at 38 weeks was with a young female registrar (Sally - not her
real name), who, once again, went through the list of horrors, in even more
graphic detail. Jenny was really worried and with Trevor, anxious about how
the staff would treat them and how were they going to be able to cope in
labour with the constant barrage of doom and gloom about the birth of their
babies (especially the second twin). After the 39 week visit, Jenny
decided she wasn't going to go for any more antenatal visits, she was fed up
with having to defend her position of wanting to birth her babies naturally
and in a calm, loving environment. Jenny and Trevor had two support people
who they wanted to be with them to help them stay focused on their plan and
desires.
At thirty nine weeks, Jenny went into labour. She wanted the birthing room
(one with a bath). She was aware that the staff didn't like women with
twins using that room (or having baths in labour) - having been told that by
the doctors during her antenatal care. She rang before she went to the
hospital at about six am. The night staff allowed Jenny and Terry to have
that room and she was allocated a young, pregnant, normal birth - friendly
midwife by the morning staff. Things were looking good and Jenny and Terry
allowed themselves to relax. Labour was progressing nicely. Jenny walked
and moved, feeling free to do what she wanted. Eight am, the day registrar
came on and it was Sally. Sally was overheard to say in an angry voice, as
she was told that Jenny was in labour and about her birth plan "Well, THAT
has made my Sunday!" She came into the birthing room and once again went
through the litany of horrors, emphasising the problems with the second
twin, placenta coming off the uterine wall when the first baby was born,
bleeding etc.
Sally came in a couple more times, talking about problems and second twins,
bleeding and cannulas, caesareans and the position of the second twin and
the need to have the medical intervention. Sally was asked at one stage, was
she enjoying obstetrics, to which she replied "not really! I've been doing
it five years and there too many weekends and 24 hour on call shifts". The
senior midwife also came in and said to Jenny 'you look tired - poor thing'
and bustled around, noisily moving resuscitation trolleys in and around the
edges of the birth room. The registrar rang the obstetrician on call and
told him of Jenny's birth plan and progress. Following that phone call,
Sally came back and told Jenny and Trevor that 'Dr zzz is not happy" and
explained why, saying he has told Sally that she has to write a letter
outlining how they are refusing medical advice and they have to sign it.
She went through the list of things again and went out of the room to write
the letter. Half an hour later, she was back with the letter and the notes
and went through the information again. She was called away to see someone
who had blood pressure problems and left the notes with Jenny and Terry to
read and sign. Jenny said, "let's sign it quickly and get her out of
here". Her labour slowed down whenever Sally came into the room and took a
little while to get going again when she left. Jenny and Trevor added a
statement to the effect that they were happy for help if it was indicated
and signed the note.
Jenny was feeling distressed by all the interruptions and decided to get
into the bath to refocus and relax. It had the desired effect. Jenny
progressed quickly and when she felt pushing sensations, got out of the bath
onto the birth stool. There was a mat on the floor in front of the birth
stool. The young midwife was wondering out loud how it could be moved to
give the doctor access for her ultrasound of the second twin. The doctors
and senior midwife were waiting, with the ultrasound, behind the curtain.
Jenny asked her to stop bothering about that now. She quickly gave birth to
her first twin. The baby was immediately lifted up by Jenny onto her skin
and welcomed into the family. The second twin was continuously monitored
with a hand held monitor and the fetal heart was 126 - 132 and on
palpation, the baby was moving head down towards the pelvis. Within minutes,
the first baby's cord was cut and Jenny was being asked to get on the bed so
that the doctor could scan the second twin to make sure it was head down and
to have a vaginal examination to break the waters. Jenny was reluctant to
move and asked couldn't the scan be done on the stool. She was told no,
that it was easier on the bed and the pressure was on to hand over the first
twin to her husband and get up on the bed. She finally said, in
resignation, "lets get it over and done with then" and got up on the bed and
laid flat on her back. Sally brought the scan over and identified that the
baby was head down.
The fetal heart was listened to and was found to be between 75 - 80 bpm.
Sally rescanned to check it was fetal heart and it was. She then vaginally
examined Jenny, said the baby was too high to rupture membranes and that
there was blood in the vagina (Jenny had a first degree tear from the first
twin's birth) and so needed an urgent (code one) caesar.
Suddenly, people were attempting to put cannulas in, there was flurry
everywhere. Jenny was white, her eyes were rolling back in fear and she was
being pushed, in her bed, out of the room to theatre. Trevor was dazed,
unable to keep up with the events. Apparently in theatre, it took some time
to catheterise Jenny (the head was well down when the caesar was done - the
liquor was clear - no blood or meconium and the placenta were still adherent
to the wall of the uterus). Jenny had a general anaesthetic and was
delivered of another girl with apgars of 7 and 9. The baby passed meconium
at birth and had a ph of 6.8. She needed some oxygen for respiratory
distress for four hours following her birth and was out of the crib and
breastfeeding beautifully, with her sister that evening. The senior midwife
on duty was saying "what a pity, I just KNEW this would happen!"
So what do we make of all this? We know that fear releases
corticosteroids, that corticosteroids suppress oxytocin and causes vasospasm
and reduced oxygen flow to various organs and parts of the body. We know
that women need safe and calm, private surroundings to birth their babies.
We know that pregnant women laid on their backs get supine hypotension
syndrome - which can result in abnormal heart rate patterns and bradycardia.
We know from psychological studies all about self fulfilling prophecies and
"group think" and we know that world views dictate behaviour and actions.
We know that when people feel unsupported and threatened, their physical
body undergoes stress cycle changes which changes their physiology, decision
making ability and coping skills.
The constant bombardment of negative messages about one's self interferes
with performance. What happened to Jenny can be likened to a sports athlete
being taunted before and during a race or event by powerful people who are
supposed to be ardent supporters. Jenny and Trevor are left feeling bullied
and dismayed. They feel the natural course of events ( which were going
well) were unnecessarily interfered with and their baby was put at risk by
unnecessary interventions (lying on the bed and the scan and the subsequent
emergency situation). Jenny feels distressed at her lack of strength at not
resisting the negativity and staying on the birth stool when that's where
she wanted to be. Trevor upset and shocked by his inability to protect
Jenny and help her achieve their ideals. They felt worn down by the constant
bombardment of negative messages and lack of respect for what they were
wanting to do. Now this woman has a 20month old and twins and a painful
scar. The couple have feelings of anger and distress around the issues
associated with choice and control. They also have regrets about
separation of themselves and the babies and the amount of distress the
second twin endured. They are anxious about the long term effect of the low
ph the second twin had at birth. The staff obstetrician went to see her the
next day and without any other staff present and with her husband absent,
told Jenny off (in her view) for being naughty and stupid and for putting
his staff under stress. Jenny wants to know what's wrong with believing in
her body and wanting a normal birth?
What we have here is differing world views. There is no doubt that each
group and each mindset has the same outcome in mind - that of safe birth for
mothers and babies. What is clear when one takes a helicopter viewpoint is
that the pathways for obtaining the desired result are very different and
how one measures outcomes have commonalities but also very different
markers.
The medical model view of birth is out of control. Motivated by fear and
threats of litigation, underpinned by distrust of women and their bodies,
medicine seeks to control the wild, sexual and primal. It's cries of
"unsafe, unclean, dangerous" creates fear and dysfunction and then it sits
around saying "I told you so". One has only got to look at the rising rates
of operative delivery, post natal depression and youth suicide and drug use
(perinatal psychology shows the link with pregnancy/birth experiences) and
family problems to realise that what we have been doing isn't working. The
Emperor has no clothes. One definition of madness is to keep doing what one
is doing and expecting a different result.
It's time to wake up. We (society) need true consultative partnership with
women, midwives and medicine. Those who want to see a movement towards
respect and support of the innate intelligence of birth and women's
processes need to join together to ensure a vibrant, healthy, powerful force
and safe, sane birth practices. We need to speak up, to end the silence
around the iatrogenic morbidity issues in birthing. Women must claim their
right to be unmolested, both emotionally and physically in birthing.
Midwives must claim their role as guardians of the normal and protectors of
the birthing space. Medicine must realise the inappropriateness of a blanket
approach to birthing women. They snuff out the fire of spirited birth. If
medicine can recreate themselves as a safety net, that is much more helpful
and supportive for birthing women.
Joining and becoming active in Maternity Coalition is one such creative
pathway for safe change. It is only when enough women (and their families),
midwives and medical men (and women) come together in true, consultative
partnership will we see the build up of enough momentum to change the focus
and direction of the current reality.
promoting and celebrating women's innate birthing intelligence,
Carolyn Hastie
"No pessimist ever discovered the secrets of the stars, or sailed to an
uncharted land, or opened a new heaven to the human spirit"
Helen Keller (one of my
many heroes)
Heartlogic Consultancy
Life Architects and interior designers
"Our mission is to help people discover how to be really excited about their
lives"
Phone 1800 505 337
Fax +61 43 886 819
Mobile 0418 428 430
Your future awaits you. Which one will you choose?
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