Births, being an LMC and American doctors.

So far this week, I have attended two births, one a VBAC with slow progress but a good outcome in the end, and the other a lovely physiological birth with a primip who was perhaps the most relaxed woman I have ever come across in labour. She laboured while sitting with legs crossed gently on a chair, eventually getting on to her side when she wanted to push. She did the whole thing in just over four hours, with only 20 minutes of pushing. Truly a lovely birth. the VBAC delivery was a bit more difficult. A long latent phase, followed by very slow progress, eventual syntocinon augmentation, and then a long second stage. I had to hand over care to the hospital eventually, due to sheer exhaustion and was appropriately villivfied as being a lazy uncommitted independent midwife. They argued that the woman was needing "primary midwifery care" I argued that syntocinon augmentation with a VBAC is very much secondary care!

But, what am I talking about, ask my non kiwi readers. Well, here is a quick run down of how being an LMC midwife works in kiwi land.

Section 88 is the legislation that governs maternity care in NZ. Under this legislation, Midwives gain the ability to practice at home or in hospitals, by gaining "access agreements" which allow them to use a facility, and receive support from that facility. We provide antenatal care under our own supervision throughout the pregnancy. when labour begins we must attend a woman within twenty minutes of her arrival in a hospital/ birth unit, or by negotiation with the woman in a home birth. We are not bound to follow the protocols or policies of a particular hospital, although there is an expectation that you will be able to well defend any variation. We are able to prescribe medications applicable to common pregnancy problems, and IV fluids, etc. We are responsible to provide all primary midwifery care, either by ourselves or by arranging another midwife to cover from the arrival of the woman at the hospital, until at least two hours post partum.

The referral guidelines list the criteria for consulting/referring or handing over to obstetric care. therefore, if something is a "level two referral" such as syntocinon augmentation, then we are required to inform the woman that we recommend that she allow doctors to coordinate her care. We can stay and provide the midwifery care for these women, or we can "hand over" to secondary care. In most instances, we stay with our women, for as long as we can. But when you have been awake for 27 hours, you are perhaps not the safest practitioner, especially in a complicated labour.

We are then required to provide at least five to seven home visits during the four to six weeks following birth. Most of us do more than this. for this, the government pays us as per the schedule in the above link. As you can see, it is not a huge reward for 24/7 on call! However, I don't think anyone becomes a midwife for the money. That is a really basic rundown!

So, having explained that... my issue the other day was that i had been caring for a woman who was secondary care from the outset by dint of being a VBAC attempt, who then had slow progress, ARM, Meconium, syntocinon, etc etc. At the 27 hour point, i knew I could not safely continue. And I was basically attacked, for being lazy and uncommitted. What do you want? Blood? Right, that is that rant over. Onto the next....


My dearest friend in the world, who I will call Blond Ambition, is a beautiful and vivacious 22 year old midwife, working for a different busy hospital. Once a week we move heaven and earth (and shift rotations and labouring women) to get together and spend time catching up on our lives. This week, we went for a lovely walk on the beach, where there was sunshine, small children, and lots of dogs. There was also ice cream (goody gum drops and marshmallow coconut ice for BA, and rum raisin, cappuccino and butternut pecan for me!) and lots of chatting.

During the chat, BA told me about an American doctor, doing an obstetric rotation at her unit. She had a conversation with him, where they discussed the difference between NZ and American obstetric care. She asked him what was the most different, and he replied "you". It really was a challenge to him to work in an environment where most of the labour care happens independently of the doctors, with midwives doing the ordering, and doctors doing the "fixing". It highlighted for me just how different our systems are. Here, a midwife is the primary carer for the vast majority of women. Therefore, obstetricians really do provide "secondary care", just as they should. But maybe, that is why they are so anti midwives... because would you want to give up all your normal births, and only have the complicated and problematic cases?

BA asked the doctor what he thought of homebirth and he responded "I wouldn't touch it with a bargepole". when asked why, he said "well, for a start I would lose my licence to practice". Surely that is not true? If a doctor backs a home birth, he is delicenced? Or is he just concerned that if something went wrong he could lose it? Or so convinced that homebirth is inherently unsafe that he KNOWs he would have something bad happen, leading to the loss of his licence?

Blonde Ambition ended their chat their on the grounds that he was not open to the chat, and she had way more important things to do... but it saddens me that doctors can't see the difference between a normal woman birthing at home, and say a really dangerous situation like a placenta praevia delivering at home. Hmmmm.

Maybe, this then draws back to our language difference. Maybe this basic difference between doctors and midwives is more than a misunderstanding... As pointed out by both Peggy Vincent and Penny Armstrong in their memoirs, doctors view birth as normal only in retrospect, and midwives see it as normal unless it deviates away. If you do not believe that birth is inherently natural and safe, then how could you, ethically, deny women the right to avail themselves of medical care. Think about how you would feel if a woman with twins, placenta praevia and preterm labour with both twins breech requested you to attend her at a home birth... Now what if doctors feel that ALL deliveries are that dangerous?

I don't know how we save the women from this attitude, but I begin to understand why none of our evidence is enough to change the minds of doctors so heavily indoctrinated into a model of birth as pathology.

Wow. BA will read that and laugh her head off, cause it is not where I planned to go AT ALL.

Never mind.