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A home birth, with a midwife
A home birth, with a midwife

ParentsFebruary 16, 2017

We ask a midwife every embarrassing question you’ve ever wanted answered

A home birth, with a midwife
A home birth, with a midwife

Spinoff Parents editor Emily Writes interviews a midwife and unwittingly reveals plenty of baggage from her own labour – mainly focused on how much she pooped.

This is the fourth in a series of posts in which I ask health professionals questions about child health, crowd-sourced from you. Today’s interviewee is a lovely midwife who is remaining anonymous so she can be as honest as possible with us. Read the first interview with dentist and comedy writer Sam Smith here, the second with a GP, and the third with a paediatrician. – Emily Writes

Content warning: This post includes a question about stillbirth and references to Sudden Infant Death.

Emily: Everybody poos during labour right? What is the percentage? Is it like 90% of women?

Lovely Midwife: Probably more like 50%. It generally only happens late in labour and it is common enough that you really, truly, absolutely 100% completely do not need to worry about it. And if it happens, your midwife is probably cheering because you’re going to push out a baby soon.

During my first labour I was really chill but in my second I screamed at my midwife and my husband and anyone near by – why are labours all so different?

There are countless variables to labour: the baby’s size and position, your positions in labour, your general health and fitness and nutritional status, who is there with you and whether you feel safe and supported with them, the time of day, the location… and loads of others besides. Any one of those can change a labour, so altogether it’s no wonder they’re different.

What do you wish women knew when they go into labour?

I wish more women had been to other births before birthing themselves. Women really benefit from having seen others birth, from seeing the ebb and flow of the process and understanding how it builds, because it’s really different from the edited process we see in the media. It would also mean there was more of a pattern of women supporting other women in labour. It’s a big process to go through with only one support person.

How should mums pick a midwife? What questions should they ask?

Get recommendations from people who know you – it’s too personal a relationship to assume that a stranger on the internet can recommend the right midwife for you. Once you have recommendations, read the midwife’s profile on a site like Find Your Midwife or her own website. Ask her about her midwifery philosophy if you can’t find information about it in her profile. I don’t think it matters what questions you ask her, as long as she is open to answering them and has answers you’re comfortable with. You don’t always know what you don’t know, so ideally find a midwife who spontaneously shares information, rather than waiting for you to ask.

What advice do you have for women to better advocate for themselves during labour?

Find a midwife who you truly trust to begin with, because a lot of self-advocacy starts before labour. If you have that trusting relationship, she’ll do some of the advocating, knowing your preferences from your birth plan. Inform yourself ahead of time, and make sure your support people are truly on board with your plan and will also advocate for you; it is hard to advocate for yourself when your support team have different priorities to you.

If you don’t connect with your midwife what should you do?

If you really just don’t get on with her or like her philosophy, look for another midwife as soon as possible. If you have specific problems relating to availability, practice arrangements and so on, talk to her about it, because it’s often easily fixed. Do ask around to make sure your expectations are reasonable though; it’s normal for a midwife to have 30 or 40 clients on the go, and she’ll need to prioritise some over others because of the stage they’re at or situation they’re in. Sometimes you may, by necessity, be a lower priority, but it doesn’t follow that she won’t be available to you down the track. You’ll be the high priority at some point.

How hard is it for a midwife to pick up PND? Or antenatal depression? And what approach would a midwife take if they saw depression or anxiety in their patients?

I generally think that antenatal depression is harder in the sense that women often won’t talk about depressive feelings antenatally; they’re still developing a relationship with their midwife, and it can be hard to say you’re depressed when everyone expects you to be excited – we rely on risk factors such as a personal or family history of depression, and what women tell us.

PND can often take time to identify if it’s not an acute episode, and most diagnoses take place after the six week postnatal period. Emotional lows aren’t uncommon in the early weeks; what we’re screening for is lows that are dominating a woman’s early experience of parenthood, or women being overwhelmed by other negative emotions such as anxiety, anger, or fear. A lot of talking and gentle questioning is the first step to identifying these conditions, but the Edinburgh Postnatal Depression Survey is a helpful tool, and I often suggest women use it as a self-test, because it can be a useful periodic check-in.

Usually our first step on recognising mild to moderate depression or other postnatal mental illness is to send a woman to her GP, or to local PND support groups who provide low cost counselling and peer support. The pathways depend on what resources are available locally. Acute episodes require immediate assessment, often from the local DHB mental health team.

How realistic should mums be about their birth plans?

You can’t be realistic when you don’t know what your reality is going to be, and you can’t possibly plan for every eventuality, so I think some idealism is just fine. Birth plans often work best when they encompass two aspects; the first is your ideal if everything is straightforward. The second is your preferences or priorities if things deviate from a physiological process. Again, you can’t plan for every eventuality, but you can consider who you want to discuss proposed interventions with, who will stay with you and baby if you need to be separated, your priorities in terms of feeding and immediate postnatal care of baby and whether you are outright opposed to particular treatments.

Can you tell if a mum is going to be a screamer?

I really don’t think women are definitively “screamers” or “non screamers”. For most women it all goes back to those variables in labour – every labour is different, and women can be in such different emotional states from one labour to another, or during the course of one labour.

Does screaming in labour stress you out?

Women making a lot of noise in labour doesn’t stress me out at all, but screaming can be stressful when women feel they need a whole lot of things right this minute. You necessarily have to prioritise tasks in labour, there are a lot of requests that can’t be satisfied instantly, and you can end up feeling torn in umpteen directions and unable to do what is really urgently needed, which is help her feel less fearful.

Do you hate cleaning up poo or are you used to it?

We’re used to it. We’re not going to say it’s pleasant, but we really don’t dwell on it, because once there’s poo, we’re getting ready to catch a baby.

Does seeing vaginas being ripped apart all day make you feel differently toward your own vagina?

My work life isn’t nearly so dramatic as that – mostly I’m taking blood pressures, weighing babies, palpating bellies, talking a lot and writing copious documentation! And I often see women not tearing at all. As for my own feeling about it – seeing women tear, and seeing them heal up quickly again, made me pretty relaxed about the possibility of needing stitches when I gave birth myself. It’s a sensitive area, but it’s rich in blood vessels that allow it to heal quickly in healthy well-nourished women. In the meantime, take the pain relief, and make icy pads your friend for a few days.

Do midwives hate drugs? How do you feel about interventions? Lots of mums feel like midwives are anti-epidural. What are your thoughts about epidurals?

I think these are really variations on a theme so let me tackle them together, although it’s way too complex to do justice to in a paragraph or two.

A midwife’s role is essentially to support women to have a safe, healthy, positive birth. There is plenty of evidence to suggest that many interventions, including pain relief drugs, can reduce the chances of a woman having a straightforward birth if they’re used indiscriminately. So most midwives will try to use interventions when we believe the benefits outweigh the risks; that’s what is expected of any health professional. Every midwife can have slightly different ideas about when medical interventions might be needed, but we all know that interventions, including pain relief, can help keep women and babies safe when used judiciously.

Epidurals are an intervention in labour, even though our society often treats them as a simple yes/no preference. It’s OK if women decide an epidural is what they need to have a positive birth experience, but it’s not risk free, and so I feel like I have a responsibility to try and help women find other tools so they don’t feel it’s their only option for coping. As midwives we do see that there are important differences between labour and birth with drugs and without. Evidence and experience tell us that taking away labour pain often doesn’t mean women end up feeling better about their birth experience, so we know that just getting an epidural won’t necessarily help make her feel better about her birth just because it reduces pain.

Do you find the criticism of midwives hard to deal with? It seems they get treated so horribly in the media and people always paint all midwives as horrible just because they struggled with their midwife.

Yes. Every midwife is different, but I’m pretty switched into current affairs and politics, and I feel more battle-weary with every bout of midwife-bashing in the media. As a profession midwives want women and babies and families to thrive; that’s why we do the work we do, and make the massive sacrifices we have to make to provide 24/7 one-to-one care. It’s awful when the media hold individual midwives, or midwives collectively, responsible for outcomes that are the result of systemic failures or plain awful luck. Every midwife I know struggles with the demands of the job sometimes, and if the frequent criticism makes us practice more defensively that’s not a good outcome for women and families.

What can birth partners do to support mums in labour?

Remember it’s not about you. Whatever experience of labour you have, whatever baggage you carry, has to be left at the door. Let her know that you trust her body to do this, even if she’s struggling to trust herself. If you can’t find it in yourself to do that, then stay quiet and limit yourself to physical support.

My husband said during labour that he was hurting as much as I was because I bit him on his shoulder. It has been almost two years do you think I should forgive him for saying that?

My general approach to grudge-holding is that I’m too lazy to bother, so I’d forgive him, but I wouldn’t stop teasing him about it. Mercilessly.

Why do you do it? It seems like the worst job – women scream at you and poo on you and call you names and you don’t get paid enough and the hours are awful and people are jerks in the media. What makes you keep doing it?

I seriously never knew I’d spend so much time talking about poo! Antenatally we’re trying to stop you freaking out about pooing yourself, and then it’s all about nappies, and how often the kid is filling them, and whether you’ve starting pooing again yet.

Seriously though, this is the ultimate generalist’s job; the draw for me is the variety. I love the mix of task-based and big-picture work, I both love and loathe the politics. I get to be both “holistic” and “medical”, professional and completely casual. I get to be around all sorts of people, and I get to BE all sorts of people for them. I will never, ever get bored, unless the administrative work buries me.

There’s also this moment when you see everything click for people, when they realise they are actually being parents, and I will never get sick of seeing that moment happen.

A stillborn baby or a baby dying during childbirth is a mother’s worst fear – have you ever been at a birth when that has happened? How did you cope?

I’ve experienced stillbirth, but not during labour. A baby that dies unexpectedly in pregnancy is heartbreaking, but our grief can be wholly for the woman and her family. It’s sort of a pure grief, and you can just support the family in that. When a baby dies in labour or as a result of labour, there is very different stress for the health professionals involved; good practice support, counselling, supportive debriefs are so important, but it affects practice for a long, long time, especially if there are ongoing investigations. Media can break the professionals involved as well; there’s often an apportioning of blame which relies on oversimplification of the situation, and that can be very cruel. I know too many amazing midwives and obstetricians who’ve been irrevocably changed by a death, and some of them never recover from it.

Many women go into labour terrified – what would you say to mums to be to calm their fears? How dangerous is labour?

When you dig down, you find that women have quite different fears about labour, and you can address the specifics more easily than the general. It’s never a single conversation though; you combat fear through the cumulative effect of all the conversations you have during a woman’s pregnancy. Our culture loves drama, and I encourage women not just to listen to the competitive story-telling that favours that drama. Stop watching “One Born Every Minute” and start seeking out positive stories – not just straightforward stories, but also those where everything diverged from the plan, and women still come out of it feeling like they were treated respectfully and are positive about the experience.

It’s hard to answer how dangerous labour is, because different risks hold greater or lesser weight for different people. Antibiotics for postpartum infections and anti-haemorrhage drugs transformed labour and birth, but we simply cannot guarantee safe outcomes for everyone with our current medical and midwifery knowledge.

Some women feel the risks of labour – particularly vaginal labour – aren’t discussed enough. Do you think we need to talk more about prolapses and birth injuries?

I think it’s just not possible. Events like cord prolapse or amniotic fluid embolism can be catastrophic, but are also incredibly rare, and practically speaking there is no way to cover every eventuality. If we did, it would prevent us from informing women about far more important and likely possibilities and the choices available to them. At some point, I think we just have to recognise that childbearing is not, and can never be, a risk-free process, and trust that women are being cared for by professionals who have knowledge and skills to deal with MOST of the situations that can arise. I think it’s also important to understand that fear can be very detrimental to the labour process, so when we focus on risk to a great extent, we actually risk scaring women into having less straightforward births.

What do you think of the “birth wars” the idea that “natural” is best and mums should give birth in a forest field and that mums who have C-Sections are “too posh to push”?

Mostly, it’s media bullshit.

There’s ample evidence that the increase in c-sections is about the recommendations of health professionals, not primarily maternal preference. “Too posh to push” accounts for a minute percentage, as does the giving birth in a forest field crowd. I work across the scope of midwifery, from home-births to women with high-risk pregnancies and planned caesarians, and I have never met a woman who didn’t want to hold a healthy baby in her arms at the end of the process; women are making the choices that they believe will keep them and their babies healthy, based on their experiences and the information they’re given.

After a baby is born, do you notice how messy someone’s house is?

Yes, but not in a judgmental way (I come from mess myself!). I’m often relieved to see a bit of mess in that it suggests the family are focused on their baby and getting sleep when they can!

Do you ever want to be friends with the mums you’ve gotten to know?

Yes, there are women who come through who I want to be friends with, and sometimes it happens. There’s a bit of negotiation involved though to make the shift from midwife/client to a genuine two-sided friendship, and it doesn’t always work.

Do you ever miss mums and babies?

Not miss them exactly; my work is too full for that, and you can’t carry everyone with you all the time, it’d be too overwhelming. But I do think about past clients and wonder how they’re doing, and I’m always happy to run into them around the place.

An amazing midwifery lecturer said in my very first week of training that being a midwife is about preparing women to say good-bye to their midwife. In other words, you work to get women to the point where you can walk out knowing they’re thriving as parents, and don’t need you anymore. In a way, I feel like the end of that midwifery relationship is the test of whether I’m doing a good job along the way.

What do you really think about co-sleeping?

The demonisation of co-sleeping makes me very uncomfortable because SO many cultures and families rely on it. I think we need to find ways to talk about reducing any risks (and the risks are very much dependent on the family) because people are going to do it, like it or not. I think the often-quoted research into its safety does not sufficiently differentiate between suffocation and SUDI, and largely ignores the benefits, such as increased breastfeeding. And I co-slept with my baby myself, when it suited us.

Do you think most babies have colic or reflux? Is it over diagnosed?

I prefer to talk about PURPLE crying than colic. A lot of babies are being treated for what is essentially developmentally normal behaviour. True reflux exists, but it’s not as common as people think, and especially not in the early weeks when midwives are working with babies. Tangentially, I’m really against the idea that all breastfeeding women should avoid certain foods for fear of causing colic or reflux. There is no food that causes problems for all breastfed babies (the advice women get about foods is very culture-specific), and routinely telling women to cut out certain foods as a matter of course just makes breastfeeding harder.

Are tongue and lip ties over diagnosed?

Yes and no. Anterior tongue ties are easier to spot, but not overly common, the treatment is fairly straightforward, and it can prevent problems beyond breastfeeding. Posterior tongue ties and lip ties are a bit more controversial, because the diagnosis is less anatomical, more functional. There are breastfeeding relationships that are substantially affected by them, but I have seen many babies who showed some of the signs of a posterior tongue tie or lip tie, but ultimately had no trouble breastfeeding. So I try to be conservative about it; if I see signs I’ll be vigilant, but I tend to take an “if it’s not broke, don’t fix it” approach to breastfeeding.

Do you ever see a mum and think there’s no way she will be able to breastfeed, and would you tell her that? Are you allowed to talk about formula? What’s your take on the breast is best war?

Lots of questions in there! There are very few women who have anatomical abnormalities that prevent breastfeeding, so I’d never tell a woman she couldn’t breastfeed on appearance alone. There are conditions and situations like PCOS and diabetes, or previous breast reduction, where I’ll talk about the potential for difficulties, and find out what a woman’s priorities are if problems eventuate.

We’re allowed to talk about formula but the balance can be tricky. I discourage women from buying it “just in case”, because they’re more likely to call their midwife and discuss their problems if they don’t have it on hand; often a conversation is all that’s needed to put a family’s concerns to rest so breastfeeding can continue. We can’t recommend brands of formula, but if families wish to formula feed, I think we can, and should, discuss general types of formula and safe formula use.

If I’m perfectly honest, I think the breastfeeding/formula wars have been largely stoked, very cleverly, by formula companies.

If you look at the evidence, then it’s pretty clear that there are some massive benefits to breastfeeding that formula just can’t match.

BUT!! That is not relevant for everyone. Some just don’t want to breastfeed, and that is their right. Some want to, and it doesn’t work. The worst thing about breastfeeding/formula wars is that they make women feel it’s all or nothing, and that’s a shame. There are many babies that would still be getting some breastmilk, and enjoying the benefits of that, if their parents got the message that it’s not all or nothing.

There are a lot of misapprehensions about breastfeeding that lead to women switching to formula though, and information-sharing ahead of time (not just antenatally but as the breastfeeding relationship progresses) goes a long way to combatting that I think.

Did you become a midwife so you can smell babies because sometimes I wish I could be a midwife just so I can smell babies but also labour terrifies me and the poop is an issue.

I love babies, but I’m more into talking to them than smelling them. Really, babies only come in towards the end of the process – two thirds of the work happens before the baby even arrives. I went into it because I wanted to work with women during that entire intense process. The wonderful thing about midwifery is that you do develop such a complex and intense relationship that goes beyond just labour. With that complexity and intensity in mind, repeat after me: The Poop Is Not An Issue.

Emily Writes’ book Rants in the Dark is out now in all good bookstores (and some bad ones). Buy it here. Follow her on Facebook here.

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