Elly Copp is a guest blogger today.
Photo: Elly Copp
Elly is a hospital midwife working in a birth centre in the
south-west of the UK. She is also an integrative therapist in
private practice in Bristol and where she lives, in Somerset. I
first 'met' Elly on twitter over a year ago and liked her approach to
midwifery, women and birth. I was interested in Elly's many 'hats' and how
she managed to work within the system with her approach to women and their
families. I invited Elly to write a piece for this blog to share her rich
understanding and experience and here it is.
Enjoy!
Elly writes:
"I recently attended a conference on “Attachment,
Loss and Significant Change” which taught me such rich and relevant information
that I have been able to synchronise all my learning for the first time. This experience
feels like a culmination of years of process which has made a direct and
immediate improvement to my work as a midwife and mentor.
The two presenters, experts in their fields,
shared their knowledge with us:
Sir Richard Bowlby, spoke about his father,
Sir John Bowlby and his work on attachment theory. He identified the key needs
we all have in order to survive our life, which begins as early as birth. By
the third trimester, a baby is equipped with senses, feelings, reflexes and a
personality. We are born ready to make contact with our parents. Attachment is
a core need and initiates in us a sense of belonging and feeling ok in the
world.
Conversely, the effects of not having our
needs met in the early days and not being ‘seen’ just as we are, is likely to
have long lasting effects on health and relationships. Considering the impact
on a baby when she loses her mother temporarily or permanently will have us all
unsettled as we don't like the idea of it or how it felt when that was our
experience. As midwives we are in a prime position to assist at these moments
of a person’s life: mother, father and new baby, the evidence is there and now
our challenge is to bring it into our daily work. The rewards for us as
individuals will fuel more courage, compassion and love we have for ourselves
and the women we meet.
The second speaker, Dr Una Mccluskey, talked
about the roles of care seeking and care giving and the dynamic between the two.
In our world these are the roles of ‘mothers’ and ‘midwives’. Midwives with
good attunement antenna will pick up the ‘state’ a mother is in and will
consider the next appropriate step. Dr Mccluskey says it's what the care giver
does with that knowledge which is important. In order that she does that
effectively, a midwife has to be aware of her own state, her own ability to
regulate her internal system. This ability to self-regulate takes attention,
commitment and support.
When fear diminishes, the ability to explore
and be curious expands. That is true for midwives and the women they care
for. When we model our own state we see it
mirrored and replicated. In her book “Why Love Matters" Sue Gerhardt
looked at effects of being and feeling loved. When young people experienced no
or poor attachment the consequence on their internal regulatory system was an
inability to find equilibrium and resulted in negative, anti-social behaviours.
What is known is that we do not manage so well in life if we have not felt the
feeling of being loved and cared for, cherished, touched and cuddled by our mother
or a mother like figure, a person who will stay with us long enough to
understand us and regulate our internal state, and will keep coming back to us,
again and again.
Watching film clips of mothers and their
babies interacting and learning the theories behind this brings to life vividly
the need for a secure attachment from the start, as well as feeling empathy for
the newborn, the impact of a secure attachment for the baby on lifelong health
is absolutely clear.
I consider myself very lucky , because I have
been involved in some very profound births .I am often moved to tears and have
the sense that I have been appreciated at a very deep level of the mothers' being. These spiritual births where I feel a
connection with the mother often come after she has experienced a traumatic
time in a previous labour and birth .My understanding is that these women had
been holding their trauma in mind and body and are very relieved to be able to
let it go and feel pleasure, happiness and wonder in a birthing environment. It
is my quest to remain open, available, curious and exploratory and I offer
these mothers the same, and work very hard not to move myself or be manoeuvred
or coerced by others into a fear state. The ability to translate that knowledge
into practice is transformational and meaningful for the mother, the father the
baby, the midwife and the student midwife.
As a midwife of 20 years, I am familiar with
the realm of labour and birth and work in a birth centre where the environment
is spacious. I learn here, and carry that knowledge to other places I go to,
such as the delivery suite or ante /post natal ward for example. Even in a different
environment I bring with me the assumption that this doesn't have to change a woman’s
ability to birth and bond, and the baby to attach. When the environment is out
of our control, we can still make it work, as everyone needs a supportive and
companionable attachment system wherever they are.
A recent birth demonstrated to me how it is
possible for a mother to change her physiology and emotional state when the
people she has supporting her are present, being in the now, mindful and observant.
I wish to share this with the intention that midwives reading this will be
motivated to make their own deliberate but subtle and invisible switch in their
own understanding and response. All the names have been changed to maintain
confidentiality.
As a hypnotherapist, I am familiar with the
mind and how it works, the limbic system, the cognitive brain and how the two
are affected by each other and the environment. Dr Stephen Porges describes the
neurophysiological foundations of attachment, emotions, communication and self-regulation
so well in his book “The Polyvagal Theory ". It is quite manageable to
digest and process the theory, the difficulty is making theory useful
practically in such a busy environment where risk is calculated and
expectations and therefore stress is high.
"Help for the Helper" by Babette
Rothschild discusses how roles can get confused when boundaries are not
maintained, the mirror neurones in our brain mean that before we realise it,
care seekers are mirroring and mimicking the care givers own state.
It is significant that working in a fear state
a lot of the time is not helpful or healthy for us, and has a part to play in
burnout. We have a real vested interest to self-care and ensure we regulate our
systems frequently to maintain our health. This is extra difficult when we are
working a shift pattern which is pre-arranged for us. Add to that the variety
of work needing to be attended to, which can be acute and immediate for a short
or prolonged time, plus no breaks and the situation for the midwife can become
untenable.
When a midwife is in fright / flight mode
herself she needs to become aware and notice it quickly so she can shift it.
Her brain will prevent any connectivity or attunement as long as it it is
focused on anxiety. In such a situation the midwife cannot create a safe
birthing environment; instead she becomes distracted and loses focus. No one is
grounded, no one is self-regulating.
Dr Mccluskey stated that in supportive
relationships, a genuine response must match the depth of the other person’s situation;
Women will know it if we show mixed messages. The words need to match our
actions for us to be seen and trusted by the women in our care to have faith in
us She states: " we are all hard wired to care for other people, to seek
care for ourselves and to pursue interests " As midwives in a work
environment where the care we give is increasingly scrutinised and critiqued
retrospectively, seeking care for ourselves and pursuing interests can be the
aspects where we are not so successful, and therefore less able to self-care.
In addition our workload becomes greater and visibility around each other is
reduced.
For a mother, when the fright /flight brain
is in ascendance, dissociation from the self, the body and the baby will result
(as a survival technique), it will not be easy for her to experience an
empowered birth. I believe that when doctors, midwives, anaesthetists and
health care assistants operate collectively from this place of flight/fright,
disconnect is a constant presence.
When women can be in a calm and regulated state
there is sufficient capacity for them to utilise internal resources, to stay
exploratory and look for ways to cope. Ultimately they give birth in an engaged
and connected way.
When a midwife successfully regulates her own
internal state, the woman she is with can be in touch with her own skills
necessary to deal with any upset. We are facilitating an environment within
which a woman can build her own competence in the world, which is what she will
simultaneously be passing on to her baby. Having worked in a birth centre since
2008, I have found my own ability to problem solve and find solutions has
expanded and that is apparent in the confidence I have and pass to the parents
I meet.
I am also a Bowen technique practitioner
(Bowen is a way of working with the fascia and muscle spindles which rebalances
the body via the vestibular system). During a Bowen session, a body can restore
health and vitality to the best of its ability. There are clear parallels
between Bowen and birth, because the same environmental conditions are required
for best outcome. Michel Odent commented " an ideal situation for a mother
to birth in is where there is as little interference to the mother’s natural
process as possible: speaking, feeling cold, feeling unsafe and bright lights
are stimulation which is not conducive to giving birth."
What seems to be happening during a Bowen
session is that the body is allowed to re-orient to a memory of a previously
healthy state or an original blue print of health. Many of the moves are made
on areas significant during embryological development (John Wilks, The Bowen
Technique). Like the mind and its ability to move from a fear state into a calm
state, the body can do too, physiological changes occur when liquid crystals in
the cells which hold memory and have the capacity to register a new experience
which are highly receptive to change are touched.
Sheila Kitzinger writes about birth crises
and the effects on bonding with the baby as well as any future births. Where a
woman has experienced a shocking birth experience and felt helpless and out of control,
that memory of helplessness stays with her. If she does some work to recover
from her trauma, restore her self-esteem and confidence, she can experience
healing in advance of her next birth. If she's doesn't, her bonding and
attachment with her next baby will be negatively affected
Sir Richard says:
“If she doesn't recognise that state and therefore remains static
she cannot release the dynamic energy needed to give birth to her next baby.
She becomes stuck in her thoughts and in her muscles. This is visible in the
way a mother uses her body in labour, during and in-between contractions, her posture,
her eye contact and how she expresses herself and receives support”.
Putting all this into practice is sometimes
straight forward and sometimes very complex. The woman I met called Suzy* and
her husband John* seemed initially to be quite a simple care in labour, part of
my daily work, but moved into a more complicated area as she moved through her
labour and some details emerged.
Two years ago. Suzy had been in labour with
her first baby in the pool, and out of the blue, the midwife became worried
about the baby's heart rate. Suzy was rushed and hurried along a long corridor
to the obstetric theatre where her daughter Imogen was born by forceps. It
happened fast. Suzy and John were handed Imogen after a while when she was
dressed. There were no other concerns about her health; the perceived concerns
about her wellbeing during labour had not affected her wellbeing at birth. This
aspect was never discussed though, and the couple were not given any more
information about what had happened.
Suzy and John decided to have another baby a
year later, but Suzy was very worried about how the birth would go during the
second pregnancy. She only told John about this, he was as supportive and kind
as he could be. He couldn't see they had any choices. Suzy started her labour in the early hours
and they drove to the birth centre, she wanted to use the pool again but was
plagued by lack of confidence, worry and fear about it. She questioned herself
so much that she couldn't actually think any more. It was a busy night and the
couple met 4 different midwives over 4 hours. Suzy began to panic that her
contraction pattern was spacing out. She started to think that this was an
impossible situation for her. She was kneeling and closing her eyes a lot of
the time.
I entered the room and saw a lovely and
supportive man talking gently to his wife and introduced myself and my student
who is gentle and kind and softly spoken.
My colleague who was leaving thought that the
birth was imminent so we waited for some signs; it was 07:30 am.
We watched and attuned to Suzy and through
John we learned about their experience with Imogen. Suzy said it was awful, she
had been worrying about it, she didn't want that to happen again but she was
frightened it was heading the same way.
I am very careful about discussing previous
births with couples because my experience is that it can detract from this
baby, but on this occasion, the nature of Imogen's birth needed to be spoken
about out loud because the residual fear seemed to be stopping Suzy from giving
birth. It felt like an elephant in the room.
My thinking is always how do I give the woman
my full and complete attention, my whole person support without judgement or a
set of conditions - as well as give her free reign to find her own path to
birth her baby. I wonder and worry that I may be perceived as unsupportive,
disinterested or lazy. In "Birthing Normally” Gayle Petersen details birth
stories where she has attuned herself to women’s fears and needs and in doing
this, has enabled the mother to birth her baby herself without any
interventions. Whilst Gayle knows the women she describes, I am unfamiliar with
the women I meet and not knowing them I cannot know their preoccupations and
concerns.
Nine o'clock now and I observe Suzy in a
pickle, she is wanting it to be over, saying she can't do it and becoming
increasingly negative, defeatist and a little self-centred; rejecting Johns
loving support. In my calm state I am wondering how to move Suzy out of her
fear state and back into exploratory without being dictatorial or overbearing.
Where is that internal space for her to
connect with herself, find her resilience and prepare to meet her baby? Dr
Mcclusky says we are moving inside ourselves with other people all the time,
and that self-regulation goes on as background music. "We are born with
the expectation of being met as a person” resonates within me, and I want that
for Suzy so that her baby receives that meeting.
Meanwhile Suzy is becoming more despondent
and closer to giving birth (9cm dilated). Is analgesia the right thing to
offer? Is that kind and appropriate I ask myself? Maybe, but I think not is my
internal answer.
After another of Suzy's desperate outbursts
that "she cannot do it", I realise she is overwhelmed and I ask her 3
questions very carefully.
What does she need right now - she answers “not
to feel any of this”
What does her baby need right now - “to be
born quickly”
How can the two align? A pause and then - “I had better get a
grip", said with a sense of authority and humour.
John smiles at me, as if we have made a
breakthrough, it feels like she has moved from her fear state to her maternal
and problem solving state.
That is the moment the labour changes,
because 30 minutes later and without any pushing at all her baby's head is born
in the pool, the membranes are intact and still over his face when Suzy brings
Harry to the surface.
We were all in tears, moved by her capacity
to change and in how by releasing something negative from her past she became
free to move energetically and give birth so smoothly.
A few hours later, we chatted it over and she
said last time her birth had been taken away from her, she felt she had lost a
part of herself which she hadn't realised until this birth. I told her what had
been going through my mind about analgesia, and she agreed she had been thinking
that too - I reflected how we had synchronised. She loved having so much skin
to skin with her baby because that had not been included last time, and she
valued us as helpers and enablers whilst we saluted her for her courage and
commitment to her baby.
To conclude, I do not say that having this
understanding will mean all births are going to be smooth or straightforward, but
I do believe that seeing a woman for who she is gives her choices and with
those choices she can make the best decisions for herself and her baby.
The approaches I use incorporate my knowledge
of hypnosis and Bowen technique, directly and indirectly. Sometimes I use touch,
and sometimes calm and reassuring suggestions. The midwifery training itself
did not give me a good enough education to understand the minutiae and nuance
of what birth entails. I was shocked when I was in labour with my first baby
that my training had not prepared me for the realities of birth and what
resources I needed. It has taken years of work and application, critique and
evaluation to reflect on what holistic means and how to see women holistically.
It is a journey not encouraged within the hospital system and finding my own
identity has been a hard slog but one I could not avoid. My passion has stemmed
from a mixture of sources and is maintained by the appreciation I receive from
women and their families as well as colleagues and students. When a mentee says
"all we are told about is litigation and self-protection" I worry a
little bit more about the lack of self-awareness and acknowledgement these
fledging midwives are being trained in.
The other motivation is personal: as a
daughter, wife and mother of four, I have to keep working at all my relationships
- and in trying, my efforts will be seen, and I will be met as a person.
REFERENCES
Bowlby,EJM.
(1997) Attachment: Volume 1 of the
attachment and loss trilogy. (1st ed) UK:Vintage publishing.
Gerhardt,S.(2004).
Why love matters: how affection shapes a
baby's brain.(1st ed.)UK:Brunner-Routledge.
Kitzinger,S.(2006).
Birth Crises. (1st ed.).UK:
Routledge.
McCluskey,U.(2005).To be met as a person: The dynamics of
attachment in professional encounters.(1st ed) UK:Karnac.
Peterson, G. (1984). Birthing Normally: a personal growth
approach to childbirth (2nd ed.). USA: Shadow and Light.
Porges, S (2011) The Polyvagal Theory: Neurophysical
foundations of emotions attachment communication self-regulation. (1st ed)
USA: W.W.Norton and company.
Rothschild,B.(2006)
Help for the Helper: self care strategies
for managing burnout and stress.(1st ed ) USA:W.W Norton and company.
Wilks,J (2007)The Bowen Technique: The inside story
(1st ed) UK:CYMA LTD.
in the 1974. Researchers at Wellcome Trust Centre for Neuroimaging at UCL (University College London) in collaboration with Aarhus University in Denmark have found activity in the reward centre in the brain shows that the