The Role of the Midwife in the Normal Process - Research Paper Example

The Midwife as Expert of the Normal: Although women were giving birth with the help of midwives—or not, as the case may have been—for thousands of years, in the last few centuries medical doctors have taken over pregnancy and childbirth and transformed them from a natural, normal process into a medical process. Medical advances, especially in sanitation and in extreme interventions, have been absolutely necessary to raising survival rates for women and their babies. These advances, however, have had the effect of cutting midwives and normality out of the loop. It is time for doctors and midwives to co-exist and for childbirth to return to being a “normal” process—with the support of medicine on an as needed basis. This statement does not seem radical to midwives. We have always been in the business of leveraging knowledge and experience to help women through pregnancy and childbirth as a smooth phase of their lives. While this may seem obvious to midwives, the idea of normal birth has been upended in the last few centuries, such that what is called a “traditional” birth involves lying down with monitors and IV tubes strung from various parts of the birthing mother’s body and a skilled surgeon waiting just outside the door with a sterile scalpel to intervene “if necessary.” Those women who choose a hospital birth find themselves treated as subjects for every tool available to modern medicine—whether they need it or not. Lavender and Kingdon (2005, p. 302) sum up the prevailing attitude by saying, ‘It is easy to surmise that in British society today, little value is placed on women’s unique capacity to give birth; technology is seen as progressive and birth without intervention ‘old-fashioned’ and high risk’. As a result of technology, the physiology and emotional states of women and their new babies is altered. We do not currently understand the effects of these alterations; they have been discounted as either minor or completely unimportant by the medical community. But, simply ask a woman who has experienced natural childbirth how the process went, and she will inevitably say it was quite wonderful. It feels good—or so her brain tells her later on, if the birth proceeded normally without major intervention. The Role of the Midwife in the Normal Process It is generally understood that the presence of a midwife or even a doula or other birthing attendant leads to less complicated births and the need for fewer interventions (Righard, 2001; Romano & Lothian, 2008; Stephens, 2006). (See Hays (2008) for a good definition of the word doula.) Throughout the process, the midwife must follow the woman’s needs—even if the mother does not know or cannot articulate what she needs. By experiencing a number of uncomplicated, normal births, the midwife can predict what the woman will need at each step. So, what does the birthing team (including the mother and her partner) do to avoid extreme medical interventions in otherwise normal births? First of all, they must psychologically view pregnancy and labour as a natural process that empowers a woman through a life-enhancing experience. A peaceful atmosphere focused on her needs, sans unnecessary conversation and bustle, helps the mother relax and experience the flow of the process as it comes along (Righard, 2001; Downe, 2007). A normal birth is centered upon the woman and her moment-to-moment needs, so everything from furniture placement to using medical interventions in supporting roles must center on that one object (Richardson, 2005; Albers, 2005). And, very importantly, when a woman feels “in control” of her birth experience, she has more positive outcomes (Jomeen & Martin, 2008; Day-Stirk, 2005). Basically, ‘a woman’s relationship with her caregiver and her involvement in decision-making are more important than pain in determining how she views her birth experience in retrospect’ (Hays, 2008, p. 20). The specific memories of pain fade away; the memories of the entire experience remain. Labour wards are not factories, no matter how many women are in the process of giving birth at one time. Ideally, midwives attend one mother at a time and encourage the women to listen to their bodies as well as calling upon their skills and training to guide the process (Sinclair, Boreland, & McCabe, 2007). Time constraints could make for hurried consultations or introducing psychological pressure on a woman to complete the process (Stephens, 2006). This pressure may be entirely unintentional, but if a midwife does not step back and take a deep breath, she may transfer the pressure she feels back to the birthing woman. Romano and Lothian (2008, p. 95) point out five ‘Ps’ that mark the progress of a normal birth: the power of the contractions, the passenger (the size and position of the baby), the pelvis of the woman, the pain and the woman’s ability to cope with it, and the psyche or emotional state of the woman and her attendants. These factors work together and are excellent indicators of how smoothly the labour will progress and the amount of pain a woman will experience. Midwives can observe these factors and decide which actions will be helpful for the woman’s comfort and timely progression. The midwife must attempt to not control the situation, however, simply because of experience. Although generalizations can be made, each woman and each situation is different in some ways. The point is to empower a woman and allow her to feel in control, while at the same time supporting and guiding her progress (Jomeen & Martin, 2008). Realistic Risk: Balancing Safety with Quality of Life The primary concern for all medical doctors and midwives is the safety of the mother and child. Yet, as Albers (2005, p. 68) surmises, ‘Ideally, a safe birth and optimal health of the new mother are both necessary goals, for which spontaneous vaginal birth and intact genital tract are key elements’. In other words, once the concerns of safety are met, the midwife must turn to quality of life issues, meaning the experiences of pregnancy and birth—certainly including comfort, and even enjoyment of the process. Rather than treating pregnancy and childbirth as a medical condition, midwives can make strides toward returning the process to a natural, normal part of life, even if the patient experiences some level of complications (Albers, Sedler & Greulich, 1999; Murray Davis, 2009). Medicine is a confusing and complicated field, and often the first time a woman has extended contact with doctors is during her pregnancy—or perhaps not until the birth. The authoritative position taken by even the most well-meaning doctors can cause a woman serious anxiety and make her susceptible to suggestions of medical interventions (Murray Davis, 2008; Downe, 2007; Downe, 2006; Jomeen & Martin, 2008; Albers, 2005). Using all the tools at her disposal, a midwife can make the judgment whether medical intervention is necessary or if a “wait and see” attitude is the best course of action (Stephens, 2006, p. 475; Sinclair, Boreland & McCabe, 2007). Each pregnancy progresses and each birth happens in its own good time, if allowed to do so without extreme intervention. Proper training and proper use of tools equips the midwife to observe and measure and decide if further intervention is necessary, taking the mother’s wishes into account. While the physiology of the process seems complicated when broken down into its component parts, birthing is actually straightforward in most cases—if it is not complicated by medical interventions which disturb the flow. What Constitutes a Normal Birth? Basically, a normal birth happens with as little medical intervention as possible. Labour induction, episiotomies and epidurals are all interventions; certainly a Caesarean section (CS) is a major intervention. It is helpful to this discussion to examine several medical interventions in a little more depth. According to Albers (2005, p. 67), United States estimates show that 70-80 percent of women are normal and healthy at the start of labour. In a major cohort study, it was found that women who delivered in a hospital “traditional” setting experienced double the number of medical interventions versus those who delivered in a collaborative setting (with a midwife’s help). These statistics are also borne out by Sinclair, Boreland and McCabe (2007). The most common medical interventions are CS, induced labour, restricted movement of the labouring woman, and interventions immediately following birth. Vaginal versus CS delivery. Vaginal birth rates can never be 100 percent of all births—but the CS must be viewed as a tool in the obstetrician’s skill set, not as a quick end to the birth. Each part of the process connects with all other parts: if a labour is induced, it is more likely to end in CS than in vaginal birth, and women who have experienced one CS are far more likely to have subsequent cesarean sections. In their response to a pro-CS article published in the Observer, Lavender and Kingdon (2005, p. 302) recount anecdotal blog entries from women who experienced normal births and CS births. Opinions range all over the map, but one insightful commentator states, ‘Where we get it wrong is perpetuating and encouraging the notion that natural birth has to be an incredibly painful and traumatic experience’. Pain can be managed using the right tools and knowledge; if a woman experiences extreme pain, it is not normal. To opt for a CS when it is not strictly necessary, just to avoid normal pain, is also not normal. CS birthrates hover at about 30 percent of all births in the United States, where almost all births happen in hospitals (Hays, 2008); in nations where midwives are a respected and preferred part of the birthing team, CS births are about half that rate or lower (Dunkley-Bent, 2005; Jomeen & Martin, 2008). Natural term versus induced labour. Sinclair, Boreland and McCabe (2007) report that by reducing the number of inductions at the Lagan Valley Maternity Unit in Northern Ireland, the number of CS births was halved. Of course there are situations where an induced labour is indicated for the health and safety of mother and child. The effects of induction for convenience have been researched, and a host of problems is statistically more likely with an induced labour (Romano & Lothian, 2008; Sinclair, Boreland & McCabe, 2007). Even inductions for certain medical reasons are not always strictly necessary, and often lead to a CS outcome because the labour does not progress naturally. The strong and frequent contractions of an induced labour do not give the baby time to recover and make it more difficult for the mother to handle the pain (Righard, 2001). There is a complex of factors that leads up to a woman going into labour, primarily initiated by the foetus (Romano & Lothian, 2008, p. 94). Basically, ‘spontaneous onset of term labor signifies the fetus’ readiness to be born as well as the mother’s physiological receptiveness to the process’. When labour is allowed to progress according to the natural unfolding of the complex process, both mother and baby fare better during the delivery. Inducing labour changes both their bodies in response to an unnatural rush of hormones. The progression of labour and freedom of movement for the labouring woman. An amniotomy, which is supposed to hurry the labour along, is not indicated as frequently as it is performed, and if done early in labour can increase the chance of infection. In addition, the cushion of the waters reduces the pressure on the baby’s head (Righard, 2001; Hays, 2008). Coupled with allowing the labour to begin in its own time is the idea that freedom of movement during labour is important to reduce pain and anxiety. Constant foetal monitoring, which severely limits a woman’s physical movements during labour, hovers at 94-95 percent for hospital births (Sinclair, Boreland & McCabe, 2007; Albers, 2005; Romano & Lothian, 2008), a truly astounding figure. If a woman cannot move freely during labour, she cannot contribute to her own pain reduction; thus hospital births which employ constant foetal monitoring automatically discount a normal labour progression right from the outset. Various birthing techniques such as walking, using a birthing ball, bathing (or actually birthing in water), and employing positions which are not flat on the back help the labour progress naturally and ease the physical pain of the process (Sinclair, Boreland & McCabe, 2007; Righard, 2001). Research shows over and over that labour time is shortened and more comfortable if the woman is allowed freedom of movement. Transition immediately following birth. One key element to a normal birth is holding the baby immediately after delivery, a simple action that can make a significant difference in how a woman experiences the process (Sinclair, Boreland & McCabe, 2007; Righard, 2001; Hays, 2008). Beyond the actual birth experience, interventions with the mother and child reduce breastfeeding rates upon discharge (Sinclair, Boreland, & McCabe, 2007). The mother’s body is not finished working once the baby is delivered. The continued rush of hormones readies the woman for the next step: immediate breastfeeding. If this is interrupted because the baby is not placed skin-to-skin with its mother as soon as possible, the hormonal triggers are delayed in both the mother and the child (Romano & Lothian, 2008; Hays, 2008). Bonding begins in those first moments and gets off to a good start (physically and psychologically) if the mother and child have that opportunity. The Midwife as Expert of the Normal The technological advancements of modern medicine are vitally important to ensuring the health and safety of a mother and her new child, and should not be ignored or discounted by midwives simply because it is better to give birth without those interventions. At the same time, the medical community should not ignore the contributions of midwives, nor should an uncomplicated birth be viewed as something outside “traditional” medicine. Normal births should be the norm, and doctors and midwives should use each others’ expertise to help women experience pregnancy and birth as a normal part of life. Righard (2001, p. 3) reports that in Lund, Sweden, where she practices, there were about 3,500 births per year with only two obstetricians to attend the most complicated cases. She states, Midwives are in charge of all normal births in Sweden, and the country has one of the world’s lowest neonatal mortality rates. If every practitioner that a woman meets during pregnancy and in the birthing room looked on birth as a normal physiological process, as part of life, natural birth would be the norm and a birth with medical intervention the exception. Viewing pregnancy and childbirth as normal reduces a woman’s anxiety levels and influences the fear or depression she may feel as well (Jomeen & Martin, 2008). If a woman is certain that medical intervention will be necessary because something is very likely to go wrong, she will either ask for or accept those interventions more readily just to reduce her anxiety (Dunkley-Bent, 2005; Murray Davis, 2008; Downe, 2007; Downe, 2006; Jomeen & Martin, 2008; Albers, 2005). Throughout the articles researched for this essay, one point was repeatedly mentioned: those who participate in natural, normal childbirth should tell their stories to anyone who will listen, but especially to those who believe that pregnancy and childbirth are medical conditions which should be treated by every advanced technology available. A midwife’s role is not finished at the end of a successful, normal delivery. We must also encourage doctors, nurses, and pregnant women to view childbirth as normal. Thus, the midwife becomes the expert of the normal, and she promotes normalcy in childbirth as a matter of everyday living. References Albers, L.L., Sedler, K.D., Greulich, B., 1999. Midwifery care: the “gold standard” for normal childbirth? Birth, 26(1), pp. 53-54. Albers, L.L., 2005. Overtreatment of normal childbirth in U.S. hospitals. Birth, 32(1), pp. 67-68. Murray Davis, B., 2008. How authoritative texts reinforce the medical model of birth. British Journal of Midwifery, 16(4), pp. 212-217. Day-Stirk, F., 2005. Campaign for normal birth: The big push for normal birth. Midwives, 8(1), pp. 18-20. Downe, S, 2006. Engaging with the concept of unique normality in childbirth. British Journal of Midwifery, 1(6), p. 352-356. Downe, S., 2007. Campaign for normal birth: Confidence through support. Midwives, 10(8), p. 391. Dunkley-Bent, J., 2005. Consultant midwives. Maternal request for caesarean section. Midwives, 8(6): 274-275. Hays, B., 2008. Is there still a place for normal birth? Integrative Medicine: A Clinician’s Journal, 7(4), pp.18-22. Jomeen, J., and Martin, C., 2008. The impact of choice of maternity care on psychological health outcomes for women during pregnancy and the postnatal period. Journal of Evaluation in Clinical Practice, 14(3), pp. 391-398. Lavender, T. and Kingdon, C., 2005. Caesarean delivery at maternal request: Why we should promote normal birth. British Journal of Midwifery, 14(5), pp. 302-303. Richardson, J., 2005. Are you normal? Midwives, 8(11), pp. 462-463. Righard, L., 2001. Making childbirth a normal process. Birth, 28(1), pp. 1-4. Romano, A.M. and Lothian, J.A., 2008. Promoting, protecting, and supporting normal birth: a look at the evidence. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 37(1), pp. 94-105. Sinclair, M., Boreland, Z., and McCabe, N., 2007. Campaign for normal birth: Less intervention. Midwives, 10(5), p. 210. Stephens, L., 2006. Campaign for normal birth: Jane’s story. Midwives, 9(12), p. 475. Read More