Episode 54 - What midwives do at a homebirth
Mel:
[0:00] Welcome to the Great Birth Rebellion podcast. I'm your host Dr Melanie Jackson. I'm a clinical and research midwife with my PhD and each episode I cast a critical eye over current maternity care practice by grappling with research and historical knowledge to help you get the best out of your pregnancy, birth and postpartum journey. Welcome everybody to this week's episode of the Great Birth Rebellion. We've got a little bit, something a little bit exciting for you today. I've invited my work wife. That's what I call her, my work wife. Got a few work wives, but Ashlee's my main work wife. So we've got Ashlee Anslow here from the Birthing Tree Midwifery, and we work together doing home birthy things as home birth midwives. So welcome, Ashlee.
Ashlee:
[0:51] Thanks for having me.
Mel:
[0:52] Yeah, Ashlee gives me feedback every week on every single episode because she's a very good work wife and listens to all the podcast episodes and offers feedback. So today she's on it herself. And the reason why I've got Ashlee here today is that carrying on from our episode last week where we were talking all about private practice midwifery in Australia,
Mel:
[1:15] we're going to go deeper on that today because Ashlee and I are home birth midwives. And so we would love to answer people's questions about what privately practicing midwives do at a home birth. And while we're doing that, we'll chat through what equipment we bring and some of the questions that have come through and just talk to you about how we operate as health professionals in a home birth setting. Yeah. People don't really know what happens at a home birth because not very many people get to go. So we hope that today we give you some insight into what we do as private midwives, what we're capable of, and also the type of equipment that we bring. And we've got, we had about, I only really just called out for questions a few hours ago, actually. And we caught about 20 or so. I'm not going to be able to answer them all, but we've plucked out 12. I think that's ambitious, Ash.
Ashlee:
[2:11] We'll see how we go. So, yeah, some of them are deep.
Mel:
[2:15] Yeah, we've left the deep ones for the end and we've left, like we've got the easier ones at the beginning.
Ashlee:
[2:22] Yeah, we'll start with easy.
Mel:
[2:23] Okay, great. All right. And, you know, also if this is an area of interest for you, if you're really super interested in becoming a privately practicing midwife or just want to know what all the bits and pieces are that have to be put together in order for you to start a private practice, i am running a one week free immersive education experience for anyone to join it will be concentrated um on the australian setting so you know this would be most valuable to australian midwives but if you go in the show notes down below click the button to go to my website melaniethemidwife.com and you can register for that free one week information week whatever we're calling it on how to become a privately practicing midwife all the content gets sent to your email account so you can watch the pre-recorded videos and ask your questions and it's just a full week of getting to understand what private practice midwifery could be and if it could work for you so feel free to join that but today we're going to give you a whole other episode on private practice midwifery
Mel:
[3:29] and what we do all right should we get started let's do this let's do this All right. The first question is about what emergency tools we have. So we might just do a really kind of broad suite over what kind of equipment we have. And that would obviously cover some of the emergency stuff.
Ashlee:
[3:49] I'm mentally unpacking my bag.
Mel:
[3:50] Yes. So we run into the... No, we don't run. We calmly enter the birth space.
Ashlee:
[3:56] I have wheelie bags.
Mel:
[3:58] You have wheelie bags. I have wheelie bags. I have three... Sewing machine bags which I love because they've got all these little pockets that are designed for little gadgets and bits of equipment which is great and they're all clear so I can see them so I've got three wheelie bags you've got are yours two big wheelie bags I've.
Ashlee:
[4:19] Got two big wheelie bags that look like ambulance bags they're like you know very medical looking but one holds so first piece of equipment my oxygen cylinder
Mel:
[4:28] Right so we bring an oxygen cylinder which answers that question. Oxygen cylinder, suction, and all the resus equipment that we might need for a baby or a mama that I've ever had. Gosh, I've never had to resuscitate a mama, but we've got the equipment. And I even very rarely need to do any major resuscitation on a baby. You know, that oxygen tank maybe at the most gets turned on once every one to two years.
Ashlee:
[4:58] Oh, yeah. Mine's like at 90% and I've had it since I started in private practice.
Mel:
[5:02] I haven't had 90% full, not 90%.
Ashlee:
[5:06] 90% full and yeah, I've had it since I started in private practice. So it has not ever gone back to get refilled or anything. I actually have two.
Mel:
[5:13] So that's the first bit of equipment. We've got oxygen and anything we need to do, resuscitation or suction on a baby. Again, super unlikely, but we do have that. So that's the first thing. That's what's in my birth box. There's one box there. Then I have a box that's full of blueys. So if you're a midwife, you know what that is. It's kind of like basically to catch any goop that comes out with the baby or any blood or amniotic fluids. So not really medical equipment, just kind of hygiene stuff, some gloves. We have all the basic equipment that we need to listen to a baby's heart rate. So we have Dopplers and blood pressure cuff. And everything that we need to do, blood pressures and basic OBS, like check pulse, temperature. What else? I've got a measuring tape, baby scales.
Ashlee:
[5:58] I've got like individual compartments. So I've got like one compartment that's like my, you know, vitamin K stuff for the baby. I've got one compartment that's like my suturing material.
Mel:
[6:11] So we can suture at home. So we can do stitches if you need it. So, yes, we carry all the lignocaine, suturing material, all the tools that we need to do for that needles syringes all that kind of thing my.
Ashlee:
[6:23] Next compartment would be like my cord clamps and my sterile scissors and then I've got a pair of sound bad faucet you know what I mean when I'm talking they're like just in case you know kind of need a little bit help getting membranes out but they stay in the bottom
Mel:
[6:37] There yeah so it's not like forceps like four clips for the baby it's like a little clampy thing that if we need to help a placenta out you can use the forceps to clamp onto the placenta or the cord to help but again a lot of this stuff a lot of the equipment stays we never use it and it's all just there just in case the main things that we use would be the torch my.
Ashlee:
[7:01] Torch and my
Mel:
[7:02] Mirror torch in the mirror that's right and then my.
Ashlee:
[7:05] Sterile scissors for cutting the cord because not everyone's doing a lotus birth
Mel:
[7:09] Yeah um uh peri you know when we check your perineum after you give birth we've got little gloves.
Ashlee:
[7:16] Your sterile gloves and your gauze
Mel:
[7:18] Yeah gauze and lube uh what else i've got a tens machine in there i've got clary sage so all the little handy little medicines that we can use obviously yeah all variety of needles and syringes for various things but very rarely do we need it and.
Ashlee:
[7:34] Then the rest of my stuff is basically postpartum hemorrhage sort of stuff
Mel:
[7:37] Yes and We'll talk about how we manage postpartum hemorrhage. The other thing we can do is if you need a catheter for any reason, I've got a catheterization kit, urinary catheterization kit. Again, that goes in bag number three. Bag number one is birth. Then there's an antenatal, postnatal bag. And then there's bag number three, which is called the sometimes bag. And in the sometimes bag, I've got my perineal suturing kit, my IV fluids kit in case we need to give IV fluids, and catheterization,
Mel:
[8:09] maternal recess is in there as well and just some spare bits and pieces. So that very rarely actually gets opened. What else have we got?
Ashlee:
[8:19] Yeah. Yeah, I've got catheterization fluids. I actually have a spare catheter and a bag of fluid with a tibutylene ampoule that's my like cord prolapse at home kit, which touch wood I'm never, ever going to use. I've already changed over because it expired twice.
Mel:
[8:39] Yes.
Ashlee:
[8:40] And not needed it.
Mel:
[8:41] No. And if we go through the medications that we carry, because that's one of the questions, this first question is about emergency tools. So the resus stuff would be emergency tools. The forceps that we use for placental birth, that would be counted as an emergency tool, our suction.
Ashlee:
[8:59] For the resus stuff, it's like bag and mask, mostly oxygen such monitor for both a mother and a baby. I also, I have an emergency background, so I can be a little bit OCD with my birth care. So I actually have an LMA, which is basically just a way of putting an airway down into a baby without having to use some of the more invasive tools sort of thing, which Touchwood I have not also had to use.
Mel:
[9:31] And a lot of the stuff, we have it there as a just-in-case so that we're prepared for everything. We very rarely need to use it but if we ever need to use it we know that our kits are up to date and after every single birth we go through our kit make sure it's fully stocked make sure it's clean everything's in date all that kind of stuff so the equipment is there in the background obviously and so yeah all of this resus equipment yeah.
Ashlee:
[10:00] Like like that's the resus side of things and then there's probably more like yeah the medication side of
Mel:
[10:04] Things medications so emergency medications let's do a hypothetical for pph so postpartum hemorrhage, So if you are losing too much blood and the woman is becoming symptomatic, then we've got medication. The first line medication that we carry is syntocinon, which is an artificial oxytocin. This is the same thing as you would be offered in a hospital. Then you can move on to syntometrin. You could move on to tranexamic acid, which we also have. We've got IV fluids if you need 40 units of syntocinon. So there's, what else do we have?
Ashlee:
[10:44] So we've got Cinto, Ergot, trans-examic acid, mysoprostol, IV fluids, catheter in the bladder, and suture and etare sort of thing. So basically we have everything except blood products and a theatre.
Mel:
[11:01] Correct. And the number of times I've had to move to second-line treatment, so Cintosinon is very, very, very effective. So the first line medication that we would give is super effective at a home birth and probably more effective than at a hospital birth because we're never, ever giving it as a preventative treatment. So in hospital, if you've had your baby, they'll often give you an injection in your thigh of syntosin on and then bring out your placenta. If you bleed after that, They need to move to the next stage of medication and keep sort of escalating up the line.
Ashlee:
[11:42] So they're actually now doing a second 10-unit injection, which is amazing because it's like, oh, you're doing what we do.
Mel:
[11:50] They already gave her first.
Ashlee:
[11:53] Yeah, so that's kind of cool.
Mel:
[11:56] Yeah, that's cool. But basically, I guess what we're trying to say is we've got everything that would be offered at hospital is offered at home and midwives do have the capacity to do an IV cannula for a woman. So if the woman hasn't responded to the medications that we've given for postpartum hemorrhage and we're intending obviously to transfer for that if she hasn't responded, we can give the next line treatments while we wait for the ambulance.
Ashlee:
[12:26] And trans-examic acid is extremely effective at controlling bleeding while you're needing to do a transfer correct but they've recognized um i was having a discussion with one of the hospital managers because they've been they're always changing the postpartum hemorrhage um policy around how they're going to do it and they're moving more towards trans-examic acid as a first-line treatment because oxytocin isn't as effective in treating postpartum hemorrhage but That's because so many of the women have been flooded with oxytocin in their labour, whereas my experience in the home birth world is, yeah, you don't really have to go past that.
Mel:
[13:03] Yeah. Well, I guess if you've had an induction, which is about 40% of women have had some kind of artificial oxytocin during their labour, then the effectiveness of another dose of artificial oxytocin is going to be diminished. So they would have to move and change their policies, whereas we're dealing with normal physiological birth that is usually the woman's body's very very responsive to a single dose of syntosin or artificial oxytocin if you're in america it would be called pitocin then so yes we have all those kind of emergency tools and emergency skills the idea though is we're not there to provide ongoing emergency care so if we're experiencing an emergency we have everything we need for first-line treatment and sort of to sustain everybody until the ambulance arrives. And that's the idea behind our emergency preparation. It's not to be looking after an emergency for hours and hours and hours and hours. It's to be able to intervene early to keep everybody healthy until a point as to which we can safely transfer. And so that's what we are prepared for.
Mel:
[14:15] And then the woman is booked in to the local hospital just in case of transfer. So we have this safety and safety transfer sheet in our note set that we basically fill in when women are pregnant during our time. We make sure we've got their address correct. We know the nearest cross street. We know which hospital she's booked into.
Ashlee:
[14:42] All the questions that you get asked on a triple O call.
Mel:
[14:45] Exactly. So if we ever need to bring an ambulance, we flick to that sheet. Every single question that that ambulance officer is going to ask, the answer is on the sheet. We don't have to go and find that in our brain or in our phone or somewhere else on the notes. We are 100% always prepared for the possibility of transfer. And so...
Ashlee:
[15:03] Down to the number of kilometres, to the nearest hospital, number of kilometres, to the booking hospital.
Mel:
[15:08] Exactly. We've already told the women to install a car seat in their car in case we need to transfer the baby to hospital or back, not in an ambulance, depending on the circumstance. All of these little tiny details are organised before anybody goes into labour. We've talked to them about arranging childcare if we transfer for the other children, all these things.
Ashlee:
[15:32] But we don't transfer for postpartum hemorrhage.
Mel:
[15:36] Oh, so rarely. Very rarely. So rarely. And the only time I've administered IV fluids this might be one of the questions that's on the list, Do you ever do cannulas and run IV fluids? We've done it one time, haven't we?
Ashlee:
[15:54] Yes. Yeah. I mean, I've made, like if someone had a specific history of like nausea and vomiting or something like that in labour, yeah, I'd be more than happy to give people that kind of supportive therapy. Or if you had someone that maybe had a particular risk factor, potentially you'd talk to them about having a cannula in labour. It's a little bit of a hard one because there's nothing like having a cannula in your arm and reminding you that someone believes that you're going to bleed.
Mel:
[16:19] Yeah, and it's so unloving.
Ashlee:
[16:21] The psychology behind it is not insignificant.
Mel:
[16:25] Yeah. Yes, I agree. There's only been that one time that I can remember that we specifically planned to have IV fluids and cannula actually out and ready in case for this particular woman, and she was on board with that, and we did use it, but I don't think we've ever used it again.
Ashlee:
[16:43] There's been a few times that we've been like, we'll get, you know, ready maybe in case someone might bleed and we've gotten out. But, you know.
Mel:
[16:51] Yeah.
Ashlee:
[16:52] Yeah.
Mel:
[16:52] Yes. So we can, but we don't often need to because we've got to remember we're dealing with normal physiological birth here. We're not dealing with unwell people or people who've had already had the cascade of intervention where we can rely on physiology to work. And so we're only intervening if there's an issue or a particular risk factor.
Ashlee:
[17:13] And if it was, like, yeah, if someone was, like, dehydrated because they were vomiting heaps and it was, like, something that was just going to be supportive therapy to prevent, like, transferring into hospital for something that, you know, the labour is otherwise normal.
Mel:
[17:28] Yeah, 100%.
Ashlee:
[17:28] Absolutely, I'll do that, yeah.
Mel:
[17:30] Yeah, yes, we can and we have, but very infrequently with that. Yeah. All right, this is a fun one. I like this question.
Ashlee:
[17:38] I'm already laughing.
Mel:
[17:41] I reckon this question came from either a midwife who attends home births or a birth worker or like someone who's been at a birth. All right, here we go. If the woman is in the bathroom labouring, how do you use the toilet as private midwives? So, I mean, this relies on women only having one single toilet in their house. It doesn't happen too often.
Ashlee:
[18:07] Although I... We're adept at camping between us, so we're not...
Mel:
[18:11] Yeah, bushwees.
Ashlee:
[18:13] Bushwees are good.
Mel:
[18:14] Well, okay, so most people, the vast majority of people have two toilets in their house, thankfully. But there is a collection of women who don't, me included. I mean, I built a new house and chose to only have one toilet. I've got a whole philosophy behind it. I'm not going to talk about it now. So, yes, okay, often women will labour on the toilet or if they go to the toilet, they spend some time there because it's really hard to get back off again. But basically, if you need to do a wee, you've got to basically wait for the woman to have exited the bathroom and then the minute they've gone, everyone just takes turns at doing a wee. So you're trying to like doing a preemptive wee.
Ashlee:
[18:59] Is it ethical to be like suggesting to a woman like, let's try some mobilization?
Mel:
[19:04] No. No.
Ashlee:
[19:08] Like secretly use your toilet.
Mel:
[19:10] Do you know what the hard thing is? Like my bowel movement is regular. It's like a morning, you know, in the morning on the dot, you know, and so many babies are born at poof time. So anyway.
Ashlee:
[19:27] I don't think I can go very often at birth.
Mel:
[19:30] Yeah.
Ashlee:
[19:31] I'm very much a Holden.
Mel:
[19:35] Although we did have a funny story though, didn't we? Oh, yeah. I'll tell a story. I'm not going to identify any people. If the person's listening, they will be the only one who knows. But we were at a birth and obviously in the house only had one toilet and the woman had a birth support person there. Um i have a feeling actually i did go to a birth once and the the house this is the second complete other story i didn't realize this was so in depth that i'd have to think about it so much but of, We do. I went to a house once that was off grid and the toilet was way away from the house and it was freezing. Like there was ice on the ground. Oh, yeah. Ice on the ground. It was dark. And then I inquired about, I hadn't seen the woman's house before because I was coming as the second midwife. And I inquired to the partner about like, where's the toilet? Anyway, he handed me a torch and said, follow the path. And I looked at Ashlee and I was like she's like it's a pit toilet and I thought you know what it was the middle of the night it was freezing anyway I thought I might just use the toilet I don't know that I was busting but it was just I thought I'll take this opportune moment to do that um I decided to hold my wee because I did not want to make the journey to the very dark toilet out in the cold and put my bum on a pit toilet that I'd never met before but that's a different story but this other one the other one was uh yeah so the woman ever.
Ashlee:
[21:04] On the toilet like that was her dilation station it was just working
Mel:
[21:08] For her when i think it was a while like it was a long kind of a long laborable trying a few things and a friend, needed to use the toilet and so decided to just take a baggie outside into the garden and pop a squat into the bag and was courteous enough to take the bag with her into her car to just not leave home.
Ashlee:
[21:31] Yeah like she didn't leave it behind or anything
Mel:
[21:34] Yeah so you know but.
Ashlee:
[21:36] Then remember what happened after that
Mel:
[21:38] Did she find it later she.
Ashlee:
[21:40] Forgot to take it out when she got home because she was traveling
Mel:
[21:43] With her own co and.
Ashlee:
[21:46] It was like what
Mel:
[21:47] Is that so that's my ute so I mean I've never gotten to that desperate point where I've needed to go out and do a wee in the bush but you know yeah we do think about it the other thing sometimes I will decide not to have a cup of tea at those houses like if I know there's only one toilet and the woman's using it a lot I often have cups of tea to birth and I'll just decide not to or.
Ashlee:
[22:12] If you hear that change in that noise where they're going from like just you know nice vocalization to the sounds you're like and i'm gonna go to the toilet now if it's available before
Mel:
[22:23] Before we start whatever happens after this you're right exactly so we do strategic wheeze so that's how we manage our own wheeze and poos at a birth that only definitely.
Ashlee:
[22:35] A birth worker
Mel:
[22:36] Question that 100% yep all right next question is how do you guys document your work okay good question me and actually do it differently, which is great.
Ashlee:
[22:49] Yeah, we started off the same and then I I got modern.
Mel:
[22:53] I actually got modern. So, okay, we are health professionals. We're registered. We're insured. And so it's an absolute, like, basic requirement that we take thorough, regular notes on absolutely everything that we're doing clinically so that we can legally, you know, this is a legal requirement of any registered healthcare provider. You have to keep records of the care that you're providing. So, yes, I personally have a full, beautiful set of clinical notes. I had a graphic designer make it all pretty for me. It's got absolutely everything, right from the beginning, care for the booking in history, all the woman's clinical notes, blood test results, ultrasound results, all of the antenatal care that we've done, all of the birth care that we've done. There's templates to record if there's been any perineal trauma, if there's been any bleeding. We record the timings. Every time we check blood pressure or the baby's heart rate or anything like that, that's all recorded. So we heavily document almost, I'd say, more than a hospital.
Ashlee:
[24:10] Oh, yeah, I think,
Mel:
[24:12] Yeah. Yeah. because we're used to having to defend our practice, I guess we'll call it. And if anybody ever brings our clinical care into disrepute and starts to claim things that might or might not be true, we are expected to have full evidence of everything that we've done for our clients. And so we absolutely go over the top with documentation education. And Ashlee uses a – there's a lot of digital platforms now that are offering clinical note sets on a digital platform that you can fill in electronically. There's lots of different suppliers of those. I still really, really like the paper notes, but either way is completely fine, but 100% we document.
Ashlee:
[25:02] Yeah, so I use the digital platform for basically the booking, all of the antenatal care and all of the postnatal care I can do it for the like the contract the care plan um the pathology all of that sort of stuff my ultrasound referrals I don't use it for birth and this is where I struggle most with things in the hospital system I left the hospital system before it fully changed over to digital stuff and I just can't bring myself to type on a computer while someone's in labor yeah Yeah, I kind of have my way of being set up for birth and I'm going to get stubborn about changing from that one.
Mel:
[25:47] Well, and it's not nice to have the glow of a computer in the birth space or hear this tapping away when someone's in labour. We keep the birth space so quiet and usually very dark. Like it would be, I think, offensive to have something glowing in the distance.
Ashlee:
[26:05] Oh, it would just not feel right.
Mel:
[26:06] No.
Ashlee:
[26:07] And it almost says something about your birth environment If you can kind of have a computer sitting there with a bright screen, maybe your birth environment needs to change a little bit.
Mel:
[26:16] Yeah, yeah. We don't have, what do they call them in hospital, the cows, the computer algorithms. We don't have cows at home births. The next question is, do you listen to fetal heart rates at a home birth and how frequently? All right, so for people who have no idea what this question is, So in labor, there's a few options for listening to the baby's heart rate. And you can either use a Doppler, which we call intermittent auscultation. And the Doppler, you hold it onto the woman's tummy. You can hear the baby's heart rate, but it doesn't give you a printout or anything. Some of them have a little screen. You can count it manually, whatever you want to do. So every midwife who goes out to home births, 100%, every single one of them has a Doppler. And a pinnards, which is a way, way more low-tech version of intermittent auscultation.
Ashlee:
[27:15] But also will always be available to you. Yes. You're not going to run out of battery.
Mel:
[27:21] You're not going to, even if you drop that guy in the pool, it's going to keep working, right? So we've got those two options. In hospital, the next option that they have is CTG monitoring, so continuous monitoring that they'll actually strap to your belly that you get a printout of that just goes for the entire labour. So we do not do CTG monitoring at home, partly because there's a lot of issues with it. It's not evidence-based. It restricts women's access to their own.
Ashlee:
[27:51] Go to Kirsten Small's education stuff if you want to get your head around all of that stuff.
Mel:
[27:58] Kirsten Small from Birth Small Talk does courses all about fetal monitoring. So I can highly recommend, Ashlee's done it, can highly recommend it, but we, so to enter this, we don't have CTGs at home because they're not evidence-based. And also if you're starting to consider that your client maybe does need a CTG, then you need to be in hospital because that is no longer a straightforward, normal birth. We're now monitoring what we would believe to be a complex birth circumstance. So if you're ever considering at a home birth that you might need a CTG, that is your queue to transfer into hospital. But we don't.
Ashlee:
[28:36] Get abnormal fetal heart rate patterns very often without something else being like a different part of the picture.
Mel:
[28:44] Yeah. And so, yes, we do listen to fetal heart rate in labor. Now, there's actually very little research. And again, please refer to Kirsten Small's information on this, on her blog, Birth Small Talk, mention it again. There's very little research about the yeah the best frequency to be monitoring a fetal heart rate and so because we're usually dealing with women who are very low risk who are not anticipating any issues with my typical strategy is every half hour to listen to the fetal heart rate if the woman's having a v-back so vaginal birth after cesarean at home we'll listen a little bit more frequently because changes in fetal heart rate are the first indicator of an issue in those types of births. Having said that, we're always just catering to the woman's needs.
Ashlee:
[29:38] So in the expulsion stage, we also listen far more frequently.
Mel:
[29:43] Correct. So if the woman's actually bearing down and it's obvious that she's working at bringing the baby out, then it's typically considered good clinical care to listen more frequently, which we will do. Every.
Ashlee:
[29:55] Five or 10 minutes yeah yeah depending on how frequent the contraptions are
Mel:
[29:59] And depending how close you're watching like if there's a time where you know we're really concerned for the baby we might not even we might hold it on there the whole time yeah.
Ashlee:
[30:08] So you're continuously listening you're listening for all of those signs of something being abnormal yeah but plenty of other times we're like oh look there's a head
Mel:
[30:16] There's the head yeah and.
Ashlee:
[30:17] Second stage notes commence
Mel:
[30:21] And sometimes the woman declines having such frequent fetal heart rates during her pushing phase. And so, you know, we'll offer the opportunity to listen and they'll say no.
Ashlee:
[30:32] That's where we just document. Correct. Doesn't want it.
Mel:
[30:35] Yeah. And sometimes you just absolutely can't get the Doppler ring to whatever position they're in. And I would be, it'd be very far from me to actually request that a woman change position just so that I can listen to the fetal heart rate.
Ashlee:
[30:49] But we've also got a relationship with the women. So a lot of this stuff has been discussed antenatally. So if a woman says no and you document declined fetal heart rate, you've actually got that relationship with someone where you're like, I know that they know. What this sort of means i've actually got a picture of mel doing a pinard yes fetal heart rate over a birth pool in labor so yeah pinards are great but they're not so great in labor purely from the point of like you actually need to basically lie down and stay still for a second for it was that the
Mel:
[31:25] One so the woman had declined fetal heart rates and she declined it during pregnancy which totally fine and then also didn't want them in her labor and so she was prop she was popping her belly.
Ashlee:
[31:38] Up out of the water and
Mel:
[31:40] Then I was leaning over into the birth pool with my head on the pinard.
Ashlee:
[31:44] And I nearly had to like hold on to the back of your t-shirt
Mel:
[31:46] So I wouldn't fall in.
Ashlee:
[31:49] And I have heard from other midwives that I mean yeah there is a growing trend of people declining fetal heart rate monitoring, but that's in pregnancy. And that's a conversation that definitely needs to be had well before the birth.
Mel:
[32:03] Oh yeah. There's, we will always talk to women about what our habits are for fetal heart rate monitoring. And so they know what to expect from us before they even go into labor. And we know already what they will agree or are not going to agree to. So yeah, that woman, I already knew well ahead of time. And then we'd spoken about, you know if something is unusual is it okay then if I start using the Doppler and she was like yeah totally 100 so we need yeah.
Ashlee:
[32:30] And she did and she was happy and did end up
Mel:
[32:32] We did use the Doppler yeah for that birth didn't we yeah yeah so yes we do listen uh but there's actually not a lot of research as to how often we should be listening and our we don't operate according to hospital policies or anything so we can go completely off this the clinical picture and the preference of the woman and kind of our comfort levels as well. Yeah. All right, next question. We are powering through these. I did not think we would get this done, but I think we will.
Mel:
[33:05] What's the difference between the first midwife and the second midwife? So, again, back story for this one is that when you hire a home birth midwife, there's always a second midwife who shows up to your birth. It's the requirement that we have two midwives at a home birth. For Ashlee and I, it's the woman knows, like it's kind of a named second midwife for every single client. So the minute they're booked in, they say, right, I booked Ashlee as my midwife. And Ashlee says, well, you know, your second midwife is Mel. Is that okay? And then if they say, yep, cool, that's a decision made. The woman knows from the beginning who her second midwife is. So the difference between the first and second midwife. So usually the first midwife is the midwife that the woman has chosen to hire and who's sort of she's paying her money to and who's giving the majority of the antenatal birth and postnatal care. The first midwife is the woman's point of contact. That's her midwife. The second midwife is like the backup midwife, what we call the backup or the second. And the second midwife is in a way there to serve the first midwife's needs or serve the woman's needs in the absence of the first midwife so the way that we work with each other is that uh so the first midwife goes off to the birth that's the midwife that the woman's hired that's the one she chose that's the one she wants.
Mel:
[34:32] She goes off as it seems as though the woman's going to enter into the pushing phase of her birth. Then the second midwife gets called and is ideally there for the birth of the baby. And is mostly there to assist the first midwife. So the first midwife is still there providing the care to the woman. The second midwife is in the background only stepping in if needed, doing the little things like taking down notes and recording times and doing paperwork and passing things to the first midwife, tidying up the space, filling or emptying the pool. It's very much a supportive role, not necessarily clinical.
Mel:
[35:15] So then the woman may or may not have met that second midwife. Ashlee and I work in a way we always offer our clients an opportunity to meet their second midwife. If they want it, then the second midwife will go and meet the woman before the birth.
Mel:
[35:29] But if if not then we just come in for that purpose the other thing that the second midwife is for is if for any reason the first midwife is unavailable the woman knows she's always got another midwife who can come to her and step into the role as the first midwife and that first midwife is often the one who's organizing all the paperwork the payments you know referrals all that kind of stuff the second is 100 support and a lot of midwives have second midwives who aren't actually home birth midwives like they don't take on their own clients they solely work as a second midwife Ashlee and i have always worked with each other and i've always only had second midwives who are actually for themselves as first midwife because and this answers one of the other questions about long labors if for any reason the first midwife isn't available and the second has to stand in I personally really like the idea of a midwife who's got a full kit who's fully aware of everything and can absolutely 100% step in in a long labor or if I can't make it for any reason doesn't happen very often, Uh, you know, if you've got a birth class, you know, that you can send.
Ashlee:
[36:53] Yep. Which they very, very occasionally do happen.
Mel:
[36:57] Well, and you do, you have to have a full birth kit and be fully prepared to maybe be the only one who's going to get there in time if there's lots happening or if the labor's really fast. Uh, yeah. So that's the difference between the first and second midwife.
Ashlee:
[37:12] I do occasionally. so most of my caseload I share with Mel but I do occasionally have some clients in the opposite direction to where I live that's sort of between me and Mel and the difference there is yeah my second midwives there really do feel just the function of being the second pair of pants for emergency stuff because they don't operate as private midwives they don't operate as home birth midwives I don't have as much of a guarantee because they all work um in like a local hospital also Mel and I are working together you know one of us will walk in and like we'll just hand the folder straight over to the other person and it's
Mel:
[37:51] A very fine-tuned.
Ashlee:
[37:52] Yeah I think we've got it yeah I think and we almost have it down to like non-verbal communication yeah like
Mel:
[37:59] Complete telepathy like you know.
Ashlee:
[38:02] You hear something and you just look at each other and it's like
Mel:
[38:06] We know what we need to do in this situation yes and yeah in those long labors you know there was a question about do you clock off after 12 hours no we don't we don't have a policy where we have to leave our shift after 12 hours or anything like that but we do so we're basically responsible for gauging our own level of alertness I suppose and if we're feeling like we are not completely alert and ready to deal with anything that will arise we'll tap out and call the second midwife and the first midwife will often just go to sleep in the woman's home like we don't sort of go home it's just like, can you come? I need a sleep. Then the second midwife moves into the first midwife role while the first midwife has a lengthy nap to be there for when the woman's having her baby.
Ashlee:
[38:53] It's not like at the hospital where it's like you start at this time and you finish at this time. It's a little bit more fluid.
Mel:
[38:59] Yeah, shift doesn't really get over, is it?
Ashlee:
[39:01] It's kind of a never-ending shift in some ways.
Mel:
[39:05] Until the baby's born and everybody's well. But that's where we tap in and out with our first and second midwives and this is why I really like having midwives who have a full kit and who are, you know, able to completely take over if they need to because it's not uncommon that we have done that for each other. Yeah. Yeah, 100%. And the other thing that we can help each other with, if I know you're at a birth but one of your clients also needs to be seeing antenatal or postnatally, I can step in and do your antenatal or postnatal visits while you're actually at birth with somebody. Yes. You know, so we've done that before as well. All right. Well, let's keep going with the birth questions and then we'll move
Mel:
[39:44] on. There's a placenta question here and transfer questions and stuff. So what happens if the midwife doesn't make it to the birth? What happens? The baby comes out without the midwife. That's what happens because really I'm just trying to think of how often I actually have to do anything actual clinical that kind of really impacts on the well-being of anybody. A lot of our job is to just keep reassuring women that everything is normal and that they are well and that they're doing an amazing job.
Ashlee:
[40:18] It definitely happens.
Mel:
[40:20] Yes, it happens.
Ashlee:
[40:21] Ideally, it doesn't happen on a public holiday.
Mel:
[40:24] When you're stuck in traffic. And, you know, so often, so this is what happens. Women who often plan home births manage their labours very, very well. There's a low level of fear around the birth process. And they don't necessarily always call you as early as we would hope.
Ashlee:
[40:46] Or sometimes it just doesn't follow what you expect and sometimes people's births are just way like but even like you know in a textbook you have to have contractions this many frequency in this long and you know someone might have a baby of 15 or 20 million contractions and you kind of go oh I didn't think that that was physiologically possible and for 99% of people out there no that is not going to happen for you but it can well
Mel:
[41:16] We are we're dealing with physiological labor which doesn't subscribe to a textbook we don't subscribe to a textbook we don't prescribe how long we will allow i'm doing inverted commas allow your labor to go for or what's normal i'm doing inverted commas again and so yes uh they're so the babies can be born before the midwife comes but that is not an emergency situation.
Ashlee:
[41:41] Although I do have a conversation with all of my clients, like, you know, you talk about your fast birth pathways and your long birth pathways, like what are your resources, what are in your toolkit for all of those things. I do talk to people what happens if the baby comes beforehand, before I get here, and we talk through that and, you know, what it looks like, you know, bring your baby up to your chest, have you got your towels, keep the baby warm, turn your fans off in your house. I do tell women that if they want I would call an ambulance if it was going to become very apparent that I wasn't going to make it on time for the birth I haven't actually had anyone take me up on that though no I because I think by the time you finished with you know roughly six months of decent amount of birth education they're like well it's like your problems in birth are when your babies don't come out not when they
Mel:
[42:30] Do come out yeah that's right if the baby comes before the midwife probably everything's progressed really really beautifully and normally and what we do is uh we are on the phone as we're driving so usually there's already we're kind of already probably on the way yeah we just verbally guide people you know the the partner or whoever's there will relay what they can see or put you on facetime so that you can see and then we just basically give some really basic instructions so you know same thing just breathe the baby out once the baby comes out, it should it will most likely cry if it does that's excellent check the cord hasn't snarked, I invite them to keep the baby skin to skin and to wrap both mum and bub up nice and warm to sit back and rest back and monitor the amount of blood loss. We talk to them about how much to visually expect there to be because it.
Ashlee:
[43:29] Can- And there's also those emergency drugs are in their fridge.
Mel:
[43:31] Correct. So we do have the medications that we have.
Ashlee:
[43:34] We carry it in person, but we also leave it all in a set of everything.
Mel:
[43:39] In their fridge.
Ashlee:
[43:39] Which means that we have a lot that expires and get chucked out.
Mel:
[43:42] Yeah. That's okay. And I take clients who are relatively close to my home. So I don't usually travel further than 40 minutes. So Ashlee travels a lot further. That's why she's giggling. And I have to talk to you about our client list because I had a look at it the other day. You are like, there's an, anyway, you're going to.
Ashlee:
[44:00] You're not, you don't have to go to the further ones.
Mel:
[44:02] Just saying. Anyway, I, for this reason, I really like close to home, but that's, it's a lot of midwives travel. I'm not, I'm not, I shouldn't have poked fun just now. Um then yes so then we just I mean it unfolds and honestly at births we don't really do a whole lot except maybe stop the baby from landing on the floor or or push the baby towards the mom in the birth pool so she can pick it up so you know I think I feel like this question could have come from like whoa what happens if the baby comes out and there's no midwife there usually what happens is the baby just comes out as if the midwife was there because they usually always do come out the The same way, whether we're...
Ashlee:
[44:42] Especially if it's happening. Like, generally for us to not be present, it's happening very fast.
Mel:
[44:46] It's happening quickly. Correct. It's not like there's been a big delay. So, yeah, I feel like that answers that question. All right.
Mel:
[44:55] What? Oh, okay. What is your emergency plan? All right. Which emergency? Well, all emergencies. I mean, we start emergency planning from the minute we book women in, don't we? We've got an emergency planning sheet and we're encouraging them to book into the hospital, their local hospital in case of transfer, to install car seats. Do they have ambulance cover? We asked them if they would accept blood products. We talked to them about how we manage lots of different emergencies like shoulder dystocias and postpartum hemorrhages and all this kind of stuff. We talked about all the reasons we might transfer. We talk about whether or not there are some things we would go by ambulance some things by a car we always make a plan of like how do you think you would go in if you if you transferred by car we've had clients where the woman was the driving partner and the partner couldn't drive uh so we, There's an emergency, there's a plan for everything in our minds and we also encourage women to have planned and prepared for everything in their minds. And it's always just you prepare for everything and then usually it doesn't happen.
Ashlee:
[46:14] Yeah, plan for the best and hope. What is it?
Mel:
[46:16] Hope for the best and plan for the worst. Yeah, and it usually always goes just fine. And if we do need to transfer, you're absolutely prepared for it. So there's no stress, there's no uncertainty, tea there's no wondering oh no but.
Ashlee:
[46:29] Even when emergencies happen like that's actually what we're there for
Mel:
[46:33] 100 i mean.
Ashlee:
[46:34] If emergencies didn't happen everyone should just go free birth like what are we there for
Mel:
[46:38] And this is it when people say what do you do at a home birth i'm like usually very little there's a lot of tea drinking some crocheting i am patience patience a lot of patience sensible cups of tea we tidy up the birth space we make sure that the woman's needs are met that if she has any questions, we're there, that we're monitoring the well-being of the woman and the baby, that we're out of the way when we need to be out of the way and then we're in the way when we need to be in the way. And it's a lot of sitting and observing and internal dialogue that goes on in your own midwife mind.
Ashlee:
[47:17] If you must sit on your hands.
Mel:
[47:19] Yeah, you just, a lot of hands sitting. Yeah. And then, you're right. if everything's going beautifully well you probably don't need a midwife the only time we we are there to monitor that things are still going normally and reassure the woman that that's happening or to step in when things are becoming abnormal or to predict possible you know poor outcomes so we can anticipate a lot of emergencies and transfer ahead of time before an emergency actually eventuates and that's part of our skill.
Ashlee:
[47:56] And in the other ones where we were good at.
Mel:
[47:58] And then obviously, yes, being prepared at engaging in an emergency if it should occur. So heaps of emergency planning, not in a scary way, just in a like let's be prepared. Let's all agree that in any birth an emergency is possible and it's our job to be prepared and manage it. Yeah. Okay. Oh, Ashlee, how do we support placental births? I've just seen so much learning happening in this space.
Mel:
[48:29] All right. How do we support placental birth? I'm going to encourage you, whoever asked this question, to go back. We have a whole Great Birth Rebellion episode on placental birth. But essentially, and I want you to go back and listen to that because I'm not going to talk about everything. But essentially, managing placental birth is exactly the same as working with the birth of a baby itself. All the basic ingredients that are required for a normal, safe, physiological birth of the baby are the same ingredients that are required for placental birth, physiological placental birth. The mum still or the woman still has to put in some effort and attention. We still need to keep the environment safe. We're still monitoring for signs of things being normal or abnormal. We're basically just supporting the physiology that's required for a placental birth. And that means keeping the space quiet, keeping the woman warm, not interrupting the bonding and oxytocin process that happens once the baby's born. We're looking for signs of separation in the placenta. giving the woman any kind of guidance or support that she needs to get into a comfortable position to actually have her placenta.
Ashlee:
[49:46] You know. And not making phone calls. No, yeah. Not ringing everyone to announce the birth yet.
Mel:
[49:53] Yeah. Keeping your base, it's not finished yet. We're basically acknowledging that you still need to nurture that woman and baby and birth space as if we're still waiting for a baby to be born.
Ashlee:
[50:04] This is probably the area that took the most amount of unlearning for me And I think that's just because, and I'm sure anyone that is a midwife who has spent any indecent amount of time or even not decent amount of time in the hospital knows, like you are under pressure. And you kind of have to ask yourself why because really it comes back to getting people with a postnatal, like getting them. It's like you're operating constantly on to-do lists, like tick this, tick that, tick that. Like you can't just wait around.
Mel:
[50:36] When hospitals, they often, like there's this half an hour to hour window where they start to get nervous in if the placenta's not out yet, whereas for me I feel like that's just like the winding up. Like I guess we are not.
Ashlee:
[50:48] It might come now.
Mel:
[50:49] Yeah, not like it should be out now. It's just like, oh, okay, we're coming up to the time where it's probably going to come out. But there's not a lot of nervousness around the second stage in the same way that there is at a hospital because, though, we've got to remember that we are dealing with normal physiological birth. So we have an expectation that if the birth has proceeded physiologically that so too will the placenta. And if it doesn't, we've got all those medications and strategies that we talked about so we really can have faith that the physiological process will work because we haven't already interrupted it yeah and.
Ashlee:
[51:25] Generally speaking the baby comes out and if they're not bleeding
Mel:
[51:27] You've got time you've got so much time yeah what.
Ashlee:
[51:32] Happens after a baby's born in the hospital everyone's sort of been like okay like you know let's check for a tear like let's get the placenta out let's do this and the first thing i noticed in the home birth world is it's like cup of tea
Mel:
[51:44] So yeah I think I think you're right well so when the baby comes out in hospital it's almost like activities ramp up whereas when the baby's born things we slow it down even more like we allow we offer more space and more quiet and more support in a way because we're like right this is really important to get this last bit right because this is going to, potentially be the difference between a post-final hemorrhage or not, Right, this is going to be our last question that we're going to answer.
Mel:
[52:17] What do you do if a woman declines transfer to hospital? Oh, Ashlee's face just scrunched up. So I don't think it's actually happened where we were having an actual emergency and the woman said she's not going in. I have had a woman who was bleeding.
Mel:
[52:41] She declined I said to her I'd like to give you this medication to stop you bleeding it was a syntocin on she said no, I was like okay well I'm not going to give it to you if you decline I'm going to let you know that I think you need it I think you've lost a lot of blood I can see that your body is compromised, and I would like to give it to you she said no, and And but the following days did express regret at not having taken that medication because she felt rubbish. And I said to her, I said, if you pass out, I will be giving you treatment for postpartum hemorrhage if you're unconscious. And she said, that's fine. But she declined it. So, I mean, but if somebody declined, if we thought, yes, you absolutely need transfer, and they declined. We are obliged. We can call an ambulance.
Ashlee:
[53:42] I would call an ambulance and have an ambulance wait and the woman can tell the ambulance to go.
Mel:
[53:46] Correct. So she can decline to get into the ambulance, but we would be required to have it there.
Ashlee:
[53:53] Well, have initiated that we recognize. So, yeah. I mean, but this also comes back to, like, I've had... People request a home birth quite a lot where they go, you don't have to do any antenatal appointments. You don't have to do any postnatal appointments. I just want you to facilitate the birth.
Mel:
[54:13] We don't do that.
Ashlee:
[54:14] And obviously, you know, I get that it's expensive and all of those sorts of things, but it's actually, I want people to trust me. And if they don't trust me, I'm not the right midwife for them. And I don't feel like I'm going to, you know, unnecessarily transfer people. I don't kind of, you know, flinch at like every little thing that sort of happens. But that's where that relationship, like, yeah, I actually haven't had that tested to date.
Mel:
[54:43] Yes.
Ashlee:
[54:44] And I feel like, you know, I could go, maybe now's a good time to transfer and someone might say no. And I'd probably just document that.
Mel:
[54:53] Yeah.
Ashlee:
[54:54] But like, I guess if you get into like the really punchy end of things, like, you know, I mean, if someone was like. Bleeding out or like, you know, pre-eclampsic version on a kinetic.
Mel:
[55:07] I have had a client who was profoundly pre-eclampsic.
Ashlee:
[55:11] You see, that's probably the most, you know, inadvertent quite scary sort of thing to have happen outside.
Mel:
[55:18] Well, and I guess if we're talking about what we would do if they declined, we can't force a woman to go to hospital.
Ashlee:
[55:25] Absolutely not.
Mel:
[55:26] We wouldn't, you can't force them into an ambulance. The other thing we wouldn't do is leave a woman who declined what we recommended. We would stay there. We'd heavily document all the advice that we'd given. Depending on the circumstance, we would have called an ambulance in case the woman did agree to transfer it.
Ashlee:
[55:48] I'd also probably ring the hospital.
Mel:
[55:50] Yes. So I'd ring the.
Ashlee:
[55:52] Actually, I know, well, I have had someone decline transfer it. In something that made me feel really uncomfortable. I was actually like dry reaching when I got home and with a press response from it. I don't think women, like, you know, I had a very calm and collected face there and then went home and like that was my, like, this is making me feel dreadfully uncomfortable. I rang the local hospital and was like, this is the situation. She's declining transfer. And that was actually a really good way of me communicating with them that like, you know, I'm awful. We're making all the choices that they need to make but that was me keeping myself safe so that they knew that I wasn't recommending that
Mel:
[56:31] Yes so we do there's an element where obviously we would never give a woman medical care against her consent so we can't ever and would not ever impose a transfer on a woman that she doesn't want because she is allowed to make all of her choices even if that results in a really bad outcome so we acknowledge that our job is to give all the education and supportive care we possibly can document everything we've done and recommended and keep her as safe as possible within that circumstance without compromising her autonomy so what would you do you would stay and provide care you could call an ambulance she's not obliged to enter the ambulance she can turn that away we provide all the care we possibly can all the education we possibly can and we'd also really communicate the urgency of things like I do think that you could, bleed so much that you would become unconscious and if that happens this is what I'm gonna do so you know these are the things that we navigate as private midwives because we very much focus on the woman's autonomy and right to choose and we seek consent for absolutely everything including transfer including emergency medication so if I need to give a woman medication I don't just give it we always say I would like to give you this medication is that okay and as.
Ashlee:
[58:00] I normally they're like looking at the like you know if they're bleeding and they're looking at their bleeding and they're like
Mel:
[58:05] Please yeah yeah and um you know in you wait for the nod or you know and then it doesn't.
Ashlee:
[58:14] Take long to get that level like to get that no
Mel:
[58:17] And as Ashlee said because we do continuity of care the woman is aware that we're not acting out of our own selfish intention we we want them to have home births as well we're on the same philosophical page they trust that we are on the same page as them they know that if we've said hey we think you need to transfer that that's probably because there's a clinical reason for transfer and not just because we're scared or we're tired or whatever else is happening so I think it's very rare for a woman to client transfer, and all unexpectedly declining transfer. Like there are some clients that will say, I really don't want to go to hospital. I will only go in the most dire of situations.
Ashlee:
[59:02] Like I have to be dying.
Mel:
[59:04] Right. But we know that ahead of time because we've had all these conversations and we did have a client who had a history of bleeding and who did say, I have no plans to go to hospital this time if I bleed. So we over the top prepared for that.
Mel:
[59:20] Yeah yeah which and it was fine yeah you know and it was a little it was yeah we did a little bit of stuff but not yeah so I think that's my answer to that question I'm not going to dig any more holes about private practice midwifery but that's what we've got for you this week we've covered well I hope we've covered what do private midwives do at a home birth the type of equipment that we had and we answered some of your questions now if you really really want to go deeper into this still have way more questions and are way more curious than you thought you were before this episode please go ahead melaniethemidwife.com you can register for a full free week of information about how to become a privately practicing midwife it starts on october 16 2023 if you're listening to this episode later down the track I do it every year in mid-October so you can still register to be on that list to get all the information that'll be mailed to you it'll just be next year so please get on that list it'll cost you nothing you'll just get to find out way more about private practicing midwives and midwifery here in Australia I'll.
Mel:
[1:00:32] That's our episode for now. Thanks for being here, Ash. Thanks for having me. Yeah, you're welcome. I mean, I needed to have a private midwife here with me for this episode because, you know, and Ash.
Ashlee:
[1:00:45] I'm proud of my work wife.
Mel:
[1:00:47] Yeah. Ashlee is always proud of myself. She's like, oh, gosh, you did such a good job. You know, it's so nice to have people in your corner and that's what you need in private practice is to have someone, a sister who's always got your back and then, you know, this becomes a lot more of a safer supported working opportunity so thanks thank you thank you all right see you guys it's been this week's episode of the great birth rebellion to get access to the resources for each podcast episode join the mailing list at melaniethemidwife.com and to support the work of this podcast wear the rebellion in the form of clothing and other merch at thegreatbirthrebellion.com. Follow me, Mel, @MelanietheMidwife on socials and the show @TheGreatBirthRebellion. All the details are in the show notes.
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