Sterile Water Injections for Managing Back Pain in Labour

I was having a conversation with a woman via twitter about back pain in labour. The woman said the birth was 'excruciating' because of back pain. I mentioned the use of intradermal sterile water injections (ISWI) to alleviate back pain in labour. 

The woman said she had been offered them but decided against it because she was told that they "really hurt going in" and she was scared to have them.  

Another woman tweeted that she'd 

"never heard of those! I had two posteriors and the back pain was intense …"

It seemed a blog post on intradermal sterile water injections could be useful. 

Giving birth is an experience rich with emotional, physical and psychological sensations. How we cope with those sensations (or not) has many facets. 

Most women feel a strong pressure in their lower back as their baby’s head rotates and pushes the sacrum out on the way down the birth canal in second stage. I've been told that in Thailand, those sensations are known as 'the opening of the gate' – which is a wonderful description of the sacrum swinging back to allow the baby’s head to descend and turn as it meets the pelvic floor. 

Women who expect that sensation recognise that their baby is close to being born when they feel that pressure.  

That sensation is followed by a feeling that their hips are being pushed apart as the baby descends further down the woman’s pelvis and comes around the 's' bend. 

For some women, back pain, especially if it occurs in the first stage of labour, is 'intense' and can be unbearable. Some women can find it difficult to relax, ‘let go’ and welcome the sensations and impending birth of their baby with the pain they feel in their lower back in second stage. 

Movement, heat, water and counter pressure are some of the ways that women find useful to help them alleviate and/or manage the pain. Other techniques include positioning and/or lifting parts of the woman's pelvis to change the shape of the woman’s pelvis and to help shift the baby’s head’s position in the pelvis.   

Some women seek refuge in an epidural anaesthetic block.  

I first heard about the use of intradermal sterile water injections (ISWI) for back pain in labour when I was manager of a stand-alone birthing service.  I read an article by Peart, James and Deocampo (2006) in the journal Birth Issues and was fascinated. 

The main reason for women transferring in labour from our birthing service was to have an epidural to relieve intractable back pain when none of the usual strategies worked. Although the numbers of women transferring to the tertiary referral hospital were small, women would have preferred to stay at the birthing centre, so any ideas that could help them manage the sensations of labour were welcome. 

I invited Janice DeoCampo, one of the authors of the paper, to the birth centre and teach us what to do. We were delighted when she agreed to come. We invited midwives from the surrounding hospitals to be part of the workshop. About forty midwives enjoyed the day learning about this remarkable and non-narcotic pain-relieving technique. Janice told us she saw the technique used very effectively in Sweden and that was what fuelled her passion to bring the procedure back to Australia.  

We had a wonderful service manager, Dr Anne Saxton, who was very supportive and after much proposal writing and refining, we finally gained ethical clearance and permission from the health service for the new procedure to be midwife-initiated in all the hospitals in the region. A study by Lee (2012) found that despite a desire by midwives to use ISWI to help women in labour, few were actually doing so. In my experience there needs to be good support from maternity service management when negotiating the legal and bureaucratic requirements to get acceptance of this still relatively new, midwife-initiated procedure.    

So what is it? 

Intradermal sterile water injections (ISWI) are given under the skin, into the layer known as the dermis, as close to the surface (epidermis) as possible.  You can see those layers in the diagram below.  

Skin (source Wikipedia)

 
Sterile water (0.5ccs) is drawn up into 2 tuberculin syringes. The recommendations are that sterile water is injected via 25g needles, bevel up, in four sites; approximately 0.1- 0.2cc administered at each site (see diagram below from Peart, James & Deocampo, 2006). Two midwives are needed for the administration of the sterile water, both injecting the water at the same time.  When the water is injected in the optimal way, a small 'bleb' is raised in the skin which sends the signal to the spinal cord to switch on the 'gate' that controls deeper pain messages up the spine to the brain.

  

 

The history of the use of gate control methods of pain relieve is very interesting.

Counter irritation or ‘gate’ control methods of pain management

The earliest use of “counter irritation” was in 1945 (Gammon and Starr; Parsons and Goetzl) with the use of mustard plasters to reduce pain by inducing an analgesic effect. According to these authors, the best result occured when the counter irritant is administered directly over or near the vicinity of the pain site (Gammon and Star 1941).  In 1965 Malzack and Wall (1965) hypothesized that nerve impulses, evoked by injury, are influenced in the spinal cord by other nerve cells that act like gates, either preventing impulses getting through, or facilitating their passage. Intradermal sterile water injection (ISWI) is thought to trigger the gate control mechanism. 

As the skin is the outer barrier for the body, anything that threatens the skin gets transmitted to the brain quickly, shutting off the slower pain messages from inside the body, so the individual can take evasive action and escape the 'threat'. In 1975, Dr Michael Odent acknowledged the use of sterile water injections for sacral pain in labour having observed that pain itself is actually an obstacle to dilation. The best thing is that ISWI provides a form of non-pharmacological pain relief that has no harmful effects and they don't stop movement. The woman who uses ISWI for back pain can still move freely and is not hooked up to either intravenous fluids or continuous monitoring systems.

Controlled studies using sterile water injections has been conducted for their use in relieving pain from renal colic, phantom limb pain, chronic neck and shoulder pain from whiplash and chronic lower back pain. Well-designed RCT’s have consistently demonstrated a dramatic analgesic effect on lower back pain in labour from ISWI at 4 points in the lower back area, approximately corresponding to the borders of the sacrum. 

Women's satisfaction with this method does vary, but it is a simple and inexpensive way of providing a medication-free option to women who prefer to avoid or delay the use of epidural block (EDB) or for those women for whom the option of EDB is not available or not wanted. As ISWI doesn’t fit into classic understanding of pain relief, clinicians are sceptical until the obvious and dramatic relief has been witnessed. This simple measure deserves further evaluation but on the present available data would seem a worthwhile option for use as a non-pharmacological method to reduce lower back pain in labour. 

A systematic literature review (Fogarty 2008) found the following benefits of sterile water injections:

• rapid and effective low back pain relief during labour
• no apparent side effects
• simple to use and a high level of success
• non-pharmacological
• decrease the use of epidural anaesthesia
• delay the use of epidural anaesthesia
• may be used while waiting for an anaesthetist
• may decrease the caesarean section birth rate
• may be used in first and second stage of labour
• have applications for use in rural/remote areas and developing countries where alternative treatments are not available
• have a role to play with their analgesic effect on pelvic floor one, cervical tension and fetal rotation 

·         While evidence suggests that ISWI are more helpful in the early stages of labour rather than later, anecdotally and experientially, they have been found to be just as effective in late first stage or second stage for women whose back pain interferes with pushing.  In fact, the woman's pelvis can relax so completely when the back pain is gone, the baby can rotate and emerge quite quickly after the injections are given!

Touching, massage or rubbing the area of injection is to be avoided as it defeats the purpose of using sterile water to get the ‘sting’, as the ‘sting is the thing’ that interrupts the deeper pain signals. Research by Lee et al, 2011) on the number of sites injected found that using the four sites as indicated in the illustration above is more effective, but also found to be more painful for women. In practice, we found two sites above and distal to the site of pain to be effective. We also found these injections could be used for intractable suprapubic pain in labour. 

When women indicate they want something for the back pain labour, they are asked to point to the site of their pain and rate their back pain before and after the water injections on the Visual Analogue Scale (VAS) below. 

We’ve found that the score has to be above 6 for the ‘sting’ of the actual injection to be considered ‘worth it’ by the woman.  In practice, it is rare for the intradermal sterile water injections to not have a positive effect on the reduction of pain for the woman, especially if her pain score was high.  Women are provided with an information sheet and a consent form for Intradermal sterile water injections in labour when they book into the service. Some people wonder why sterile normal saline isn’t used instead of sterile water, as the pain of injection would be less. The sting of the sterile water seems to be key to the ‘gate control’ mechanism of pain pathways and the normal saline would not therefore be as effective, if it was effective at all. 

Here's an interview about the technique on Belly Belly 

Despite our practical experiences with this procedure and the volumes of research so far, more information is needed on the effects of intradermal sterile water blocks on obstetric outcomes, women’s experiences, the effect of repeated injections, its mode of action and the effects of varying dosages, locations as well as the number of sites injected.

Have you had experiences with sterile water injections either as a midwife or a birthing woman? What were your experiences like? Do you recommend them? 

References

Fogarty, V. (2008) Intradermal sterile water injections for the relief of low back pain in labour – A systematic review of the literature, Women and Birth, 21 pp. 157-163.

Lee, N., Webster, J., Beckmann, M., & Gibbons, K. (2013). Comparison of a single vs. a four intradermal sterile water injection for relief of lower back pain for women in labour: A randomised controlled trial. Midwifery, 29 (6), 585-591.

Melzack, R., & Wall, P. (1965). Pain Mechanisms: A New Theory. Science, 150 (3699), 971-979. Retrieved from http://www.jstor.org.ezproxy1.library.usyd.edu.au/stable/1717891

Peart K, James W, Deocampo J: "Use of sterile water injections to relieve back pain in labour." Birth Issues 2006, 15 (1):18-22.

Midwives, exhaustion and safety

A recent survey of midwives and maternity support workers in the UK, found that the majority were stressed because of their workload and fearful of making mistakes because of exhaustion. Over half of those surveyed had observed errors and incidents which could have caused harm to women and their infants. These stressors are not restricted to the UK. I hear similar concerns from Australian midwives.

This situation is untenable for the midwives and the women and families in their care. 

 

It's about time governments and funding decisions reflect and respect the vital importance of childbearing to the fabric of society and fund maternity care appropriately. 

Better staffing levels are required. 

Staffing of maternity services decisions need to be made in acknowledgement of: 

• The increasing complexity of maternity care
• The fundamental requirement for adequate time for antenatal visits
• One-to-one care from a known midwife in labour 
• The need for adequate postnatal care

Only when these aspects are factored into the staffing model can we ensure that women of all risk and their infants get the care they deserve and the care which keeps them safe. 

Midwifery Continuity models for women of all 'risk' are what's required. 

Whatever model of maternity care is provided however, there must enough staff to provide the service safely - safely for women, their infants and safely for the midwives.

Midwives are dedicated professionals and consistently go above and beyond to care for women and their infants. That dedication should not be exploited. The current practice of staffing to the bare minimum, putting midwives on call after they've already had a full day at work in case there's an increase in activity, coupled with the ever-expanding list of mandatory education and competency requirements means the demands on midwives are creating a pressure cooker environment.  

Running midwives 'ragged' is not good government or health service policy. 

Appropriate and adequate funding of maternity care is essential.

We have a duty of care as a society to care for midwives and other maternity health care providers so they can care for the women and families they work with in the best possible way. 

The future depends upon it. 

Midwives warn of making mistakes due to burnout

The secret life of a midwife: I feel I work in a factory

Staff levels the risk: midwives

Fads, birth and safety

A 'prominent' Perth obstetrician and president of the Australian Medical Association (WA) Dr Michael Gannon, was reported as saying that "an “obsession” with skin-to-skin contact between mothers and babies after birth is a fad that is putting newborns at risk of death and serious injury".  His comment appeared in the article 'Skin-to-skin' fad blamed for deaths of babies published in The West Australian online newspaper 5 March 2016.

The coroner is investigating the death of a newborn at the Fiona Stanley Hospital. The article suggested that the baby is thought to have died 'after the mother fell asleep while holding or breastfeeding the baby'.

The AMA president rightly raised concerns about drug affected, exhausted women:

"New mothers are often exhausted by a long day in labour and there are the side effects of opioid drugs, epidurals or c-section"

 Photo from Midwifery Today site

However, he also criticises what he calls a

" new obsession amongst mothers and midwives with immediate skin-to-skin contact after birth ... which "stemmed from taking whatever possible measures that might lead to small increases in the number of women who breastfeed"

Far from a fad, skin-to-skin contact for women and their newborns at birth and beyond is a well-researched instinctive behaviour. This instinctive behaviour has been shown to not only improve breastfeeding success, but also, combined with breastfeeding attempts, reduce the rate of primary PPH, along with enhancing the sense of safety and attachment for the newborn and her mother. There are implications for the newborn's microbiome and there is some evidence that skin-to-skin experience reduces mothers' stress levels.

The doctor is reported to have said, in response to the claims for skin-to-skin, that:

 “I think that gets over-interpreted. Babies, instead of being in a safe environment like a warming crib, are being left on their mother’s chest”

Now the attitude that a newborn is better off in a warming crib than with its mother is the nub of medicalisation of the childbearing process and the disconnect between the use of technology and our humanity.

The medicalisation of childbirth is a done deal. Whilst physiological birth is appealing from both an evolutionary and capacity building perspective, the reality is the majority of women in the western world, are already heavily socialised into accepting and wanting medicalisation. Whilst choosing and embracing medicalisation and interventions, women are drawn to the idea of having their newborns with them skin-to-skin from birth and in the main, to breastfeed them. There is even a push (excuse the pun) for 'natural' and 'self-assisted' surgical births. Midwives are drawn to 'keeping things normal' and whilst supporting women in their choices; they are also drawn to facilitating skin-to-skin for the woman and her newborn at birth.

There is no doubt that 'drug affected, exhausted women' are vulnerable, as are their newborns, to the creation of potentially asphyxiating situations. A review of Apparent Life-Threatening Events in Presumably Healthy Newborns During Early Skin-to-Skin Contact  highlighted the issues for six babies left prone, unsupervised by a midwife or other health professional, on their mothers' abdomens. 

The reality is that midwives are increasingly having to care for postnatal women who are 'drug affected and exhausted'. The current staffing levels are woefully inadequate to care properly for these 'drug affected and exhausted women' together with their newborns.  Some people suggest recruiting partners or other family members to observe the newborn who is skin-to-skin with its mother, but that's a cop-out. 

Daily Mail

Often partners and others don't know what to look for and the bottom line is, the woman and infant's well-being is the responsibility of the institution that provides the 'care'. 

Whilst a decrease in medicalisation of birth would be ideal, that ideal will need a revolution in society's attitudes. In the meantime, what the good doctor and the AMA should be arguing and agitating for is not a separation of a mother and her infant, but for women and their infants to be treated with the profound respect they deserve and adequate midwifery staffing levels so that women and their infants can benefit from best practice and have the support and expertise of the midwife's presence to ensure that experience is a safe one.

Dr Gannon and the AMA need to understand that it is not skin-to-skin experience at birth that is putting newborn babies at risk.

What's putting newborns and childbearing women at risk is the rampant, unfettered medicalisation of childbearing that pervades modern maternity services coupled with ridiculously inadequate staffing levels - that situation is lethal.

The mother whose baby died at the Fiona Stanley hospital deserves our heartfelt love and support, kindness and respect - not blame for her baby having skin-to-skin and breastfeeding at birth - she was doing the very best she could for her baby.

If the little one is found to have succumbed because of airway obstruction, then our society has failed her and her family.  Our society does not value childbearing women enough to provide adequate staffing levels and midwifery expertise to be their guardians through their most vulnerable time. 

Educational Videos about childbearing & newborn care

Global Health Media has a rich, diverse repository of educational videos about childbirth & newborn care. 

 Photo from Newborn Care series

Videos are a powerful way to teach and these videos provide accessible and accurate life saving education about the provision of basic health care for childbearing women and their infants.
Their site states: Our mission is to improve health care and health outcomes in resource-poor areas by developing videos that “bring to life” basic health care information known to save lives.

Their videos can be downloaded in a variety of languages which makes them accessible to health workers and families in diverse areas. They are looking for people who can translate the videos into other languages.

I’ve spent time exploring their site, finding out about the people involved and how they work. Their passion, dedication and desire for safe motherhood and newborn health is exemplary. Please explore their site, share their videos and support them in whatever way you can.

Should Midwifery have its own National Board?

A massive change in the way health professions, including midwifery, are regulated

Four years ago Australia underwent a huge change in the regulatory system that oversees health professions. A National Registration and Accreditation Scheme (NRAS) was created.  This change saw the consolidation of 75 Acts of Parliament and 97 separate health profession boards across eight States and Territories into a single National Scheme. The National Scheme sets a minimum standard for safe practice by health professionals. This minimum standard can be and is, augmented by states, professions and institutions. 

The National Scheme is overseen by the Australian Health Practitioner Regulation Agency (AHPRA); each profession regulated by the National Scheme has its own board apart from nursing and midwifery who have the one board. The Nursing and Midwifery Board is responsible for the regulation of midwives which involves setting midwifery policy, standards and guidelines; managing midwifery registration; dealing with complaints against midwives; and assessing overseas midwives.

Midwifery coming of age as a profession

Whilst for many decades midwifery was seen as a nursing speciality, there has been an increasing recognition of the differences between nursing and midwifery. Australian maternity services and the way midwives are being educated have been changing dramatically in the past two decades in response to consumer demand and an increasing body of national and international evidence on the importance of midwifery models of care in meeting women's needs and resulting in cost effective, best outcomes for childbearing women and their infants (Barclay et al. 2003; McLachlan et al. 2012; Renfrew et al. 2014; Sandall et al. 2013; Tracy et al. 2013). There has also been increasing recognition of the necessity for midwifery to be developed as a separate profession. 

The National Registration and Accreditation Scheme (NRAS) is under review

The review is being led by Mr Kim Snowball, and the public consultation closes today, on the 10th October 2014.  Our Australian College of Midwives has submitted a proposal for a separate Midwives Board to the review: 

http://www.ahmac.gov.au/cms_documents/Consultation%20Paper%20-%20Review%20of%20the%20National%20Registration%20and%20Accreditation%20Scheme%20for%20health%20professions.pdf

Why we need a Midwifery Board!

The ACM has provided a list of concerns about the current combination of both nursing and midwifery professions under the current board in their document above.  They also identify that midwifery must be regulated by midwives in the form of a Midwifery Board, in order to ensure that:

• Midwifery practice issues are assessed and regulated by a full Board who are both credible and cognisant of the issues in the provision of contemporary, safe maternity care

• Issues associated with privately practising midwives and eligible midwives would receive attention from individuals who are appropriately qualified and experienced

• Complaints are managed in an appropriate and timely manner which includes the application of the principle of natural justice i.e. to be judged by peers who are competent to make a judgement

• Protection of the public is increased through the nimbleness of a midwifery focussed Board thus improving responsiveness to emerging issues associated with rapid escalation

• There is an increased understanding of the regulatory context for midwives in private practice providing a fee-for-service model

• Community representatives who are aware of the relevant issues for childbearing women and families are recruited to the Board thereby ensuring accurate assessment of practice-related issues for midwives

• Cost effectiveness is achieved by appropriate regulation and protection of the public

• Data collection about practising midwives is improved, which will improve workforce planning

• The issue of midwifery invisibility in the legislation, and its consequences, would cease 

• The Nursing Board would be free of the time consuming complexities of midwifery issues and able to concentrate fully on the important issues for nursing.

Do you support an Australian Midwifery Board? 

If you do agree that midwives should be regulated by midwives, please make your voice  heard by writing to Mr Snowball by close of business today, the 10th October and attach the ACM submission:

(http://www.midwives.org.au/scripts/cgiip.exe/WService=MIDW/ccms.r?PageId=10162)

or write a letter outlining why you think midwives should have our own Board and email to: nras.review@health.vic.gov.au

Share the ACM submission with colleagues, even if they are not ACM members, and encourage them to make their own submission.

Any questions about the NRAS Review or the ACM submission, please contact Sarah Stewart, ACM Professional Officer: sarah.stewart@midwives.org.au or phone (02) 6230 7333.  

A midwife's personal journey into supporting birth honestly

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. 

You can contact Elly via her email eleanorcopp@me.com and she tweets as @EleanorCopp

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.

Midwifery voices needed on WHO draft of Every Newborn Action Plan

Calling all midwives: Please read this request from the International Confederation of Midwives and ensure the midwifery perspective is included in this important plan to save newborn lives.

Your voice is urgently needed: The WHO together with partners have drafted an action plan to end preventable newborn deaths (Every Newborn Action Plan). The draft is now online for a public consultation process with the deadline on the 28th of February. It is crucial that midwives have an input as the plan will affect midwives in their work and midwifery on a global level. Strong indications from midwives are needed that this Action Plan is about high quality midwifery, normal birth and normal care of healthy babies (as well as the complications and treatments highlighted in the document).

Feedback is coming in to WHO, but sadly not (yet!) from midwives. The voices of midwives are urgently needed!

Thank you to those who have responded. For those who have not yet, kindly take some time from your busy schedule and provide feedback to this important document. 

Don’t miss this opportunity to make your voice heard and make sure the midwife perspective is included in the plan! Click on the link to comment: http://www.who.int/maternal_child_adolescent/topics/newborn/enap_consultation/en/ 

The deadline is FEBRUARY 28th and unfortunately cannot be extended.

Thank you for the time and effort.

Kind regards

Charlotte Renard
International Confederation of Midwives

Calling for Abstracts for the 6th Virtual International Day of the Midwife Conference

The organising committee for the 6th Virtual International Day of the Midwife Conference (#VIDM2014) are calling for the submission of abstracts for the 2014 conference.

Please see http://vidm.wikispaces.com/ for information.

The conference is a free, 24 hour online spectacular.

Midwives, obstetricians and consumers from all over the world present their point of view/research/experience from their own homes or offices to others, all around the world in their homes or offices.

Each session lasts about 50 minutes. Each presenter has a facilitator, so that anyone can do it.

The webpage provides the following information for those of you who are considering sharing your world with the rest of us:

"While the EOI must be in English, we welcome presentations on the day in other languages. We also welcome EOI from non-midwives and midwifery students. Presenters need not be experienced in using electronic media - each presenter will be allocated a facilitator who will be able to give support at every stage. However, presenters do need to have access to a computer with reliable Internet access, a headset and preferably a webcam. Presenters will also need to commit to attending a practice session so that we are all as assured as we can be, that the technology will work well for you on the day".

This beautiful statue was commissioned for a conference in Europe and photographed by one of the conference participants.  He put the photo on Facebook and gave permission to share it.  I can't find the details, but as soon as I do, I'll put them on here.  In the meantime, enjoy the beauty and the art.