Responsibilities in the mother-midwife relationship

When I facilitate workshops with midwives and students, there is always a lot of discussion and debate about professional responsibilities in the mother-midwife relationship. These debates often get heated, and the complexities of legal, professional, and ethical issues can become confusing. This post is an attempt to ‘un-confuse’ and simplify these matters a little. Please note that this post is aimed at registered midwives ie. midwives who register each year, thereby agreeing to meet professional standards. It is also about Australian midwifery and may or may not be applicable to other countries.

Midwives can get caught up in meeting the needs of the institutions they work in, and/or feeling responsible for the decisions that women make (eg. to follow or not to follow institutional recommendations). So, it can be helpful to reflect on what our core responsibilities are in the mother-midwife relationship, and how we can meet them. These core responsibilities remain regardless of the care model and/or setting.

As midwives we have guidance about our responsibilities via our professional bodies. The International Confederation of Midwives (ICM) provide a number of core documents that are reflected in national codes and standards e.g. the Nursing and Midwifery Board of Australia (NMBA). These documents are referenced when determining whether a midwife met their professional responsibilities. In this post I discuss my interpretation of these documents and the law in relation to responsibilities. I would be interested in your interpretations too so please comment.




“Midwifery care takes place in partnership with women and is personalised, continuous and non-authoritarian… Midwifery care empowers women to assume responsibility for their health and for the health of their families.” (ICM 2010)

In essence midwifery care is ‘woman-centred’. This means that the midwife must primarily meet the needs of the woman – not the institution, or cultural norms, or colleagues, or a personal agenda.

In order to meet their core responsibilities, midwives need to be research literate. By that, I don’t mean they need to be able to conduct research or understand complex statistics. However, they do need to be able to find evidence, evaluate it, and apply it to practice. This is why university midwifery programs include research in the curriculum (and yes, students generally hate it!). The NMBA Competency Standards for Midwives state that:

[The graduate midwife] “understands and values the imperative to base practice on evidence, is able to access relevant and appropriate evidence, recognise when evidence is less than adequate to fully inform care and identify areas of practice that require further evidence.” (NMBA 2006)

[The graduate midwife] “Values and acknowledges the importance of research and evidence; Maintains current knowledge about relevant research; Demonstrates skills in retrieving and understanding research evidence including levels of enquiry and forms of evidence… Interprets evidence as a basis to inform practice and decision making.” (NMBA 2006)

The ICM go a step further placing the responsibility of advancing midwifery knowledge on ‘all midwives’ stating that:

“The ICM further believes that all midwives have a role and a responsibility in advancing knowledge within the midwifery profession and the effectiveness of midwifery practice, essential for improvement in the health of all women and childbearing families.” (ICM 2008b)

So, like it or not – midwives need to be research literate.


Adequate Information

“Midwives develop a partnership with individual women in which they share relevant information that leads to informed decision-making, consent to an evolving plan of care, and acceptance of responsibility for the outcomes of their choices.” (ICM 2008a). “The woman is the primary decision-maker in her care and she has the right to information that enhances her decision-making abilities.” (ICM 2010).

It is essential that midwives provide women with adequate information. A failure to do so not only breaches professional standards, but can also result in legal action for assault and battery (due to invalid consent) or negligence (of information giving). The legal standards for ‘reasonable information’ are listed in a previous post; and there are also professional standards about information giving.

Firstly midwives need to be clear about how they practise, their responsibilities, and their boundaries (NMBA 2008a). For example, a woman needs to know that a private practice midwife is… “guided by the profession’s guidelines for consultation, referral and transfer – the National Midwifery Guidelines for Consultation and Referral (NMBA 2008a); and what this means if her situation is categorised as a ‘consult’ or ‘refer’. In Australia, private practise midwives can withdraw care if a woman declines consultation or referral. A woman needs to know her midwife’s threshold for withdrawing care before engaging her/his services.

When a decision is required about any aspect of care – from place of birth, to vitamin K for the newborn – adequate information must be provided about the option/procedure/intervention. In the case of a procedure – the person performing the procedure needs to gain consent ie. ensure adequate information is given. For example, if a midwife is about to start an induction process for a woman – that midwife is responsible for ensuring the woman is adequately informed. It would be nice if the person arranging the induction, or the person prescribing the medication provides adequate information… but the midwife cannot rely on this. It is her/his responsibility.

If the midwife is employed by an institution she may be obliged to offer particular options eg. a 4 hourly vaginal examination during labour. However the key word is ‘offer’. In addition to this offer, the woman needs adequate information to consent or decline the offer. If the midwife is in private practice she/he needs to inform the woman of the ‘standard’ or mainstream practise, particularly if there are state, national or international guidelines/recommendations.

For an option or intervention adequate information includes:

  • The rationale for the recommendation: why guidelines suggest the option or procedure.
  • A description of the option or procedure: what it is, how it is carried out, what it involves, etc.
  • General benefits and risks of all options: including current research, and whether guidelines are support by research.
  • Individualised benefits and risks of all options: are there different stats/research that the woman needs to consider in regard to her individual circumstances?

This information sharing must include the woman “…having the opportunity to verify the meaning and implication of information being given to her when making decisions…” (NMBA 2008b). NMBA offer further guidance stating that:

“When midwives provide advice about any care or product, they fully explain the advantages and disadvantages of alternative products or care so individuals can make informed choices. Midwives refrain from engaging in exploitation, misinformation or misrepresentation with regard to health care products and midwifery care.” (NMBA 2008b)

Lets take a look at some examples…

Eg. What a woman needs to know about induction of labour for post-dates pregnancy:

  • That most clinical guidelines recommend induction of labour at 41 weeks + because there is an increase in perinatal mortality (baby death) for pregnancies that continue beyond 41 weeks. I can see that some of you are already cringing, but this is the truth. You also need to quantify that risk for the woman in a meaningful way eg. 30:10,000 for waiting vs 3:10,000 if labour is induced (see this post). It is not adequate to just state ‘there is increased risk’ or to say that ‘the risk is small’.
  • What induction of labour involves and how it is different to physiological labour; and what would happen if she chose to wait eg. options re. monitoring.
  • The general risks and benefits of induction, and of waiting (see this post).
  • The individual risks for the woman i.e. factors that change her risks eg. is this her first baby? Are there other health concerns or issues (eg. VBAC)?

Eg. What a woman needs to know to consent to a routine vaginal examination during labour (as per a hospital guideline rather than in response to a situation):

  • That the hospital guidelines requires the midwife to offer a vaginal examination, for example, the midwife might say “The guideline in this hospital recommends that I offer a vaginal examination to you because you have been in birth suite for 4 hours. The reason for this is to attempt to estimate the progress of your labour.” (you must do this to meet your employee requirements if there is a hospital guideline or policy)
  • The evidence supporting (or not) the recommendation, and the risks and benefits of the intervention: “There is no evidence to support that a vaginal examination is an effective method of assessing labour progress because it can’t predict the future…” insert explanation about how all women have a different labour pattern… and the risks and benefits of the a VE (see this post).
  • Any individual factors that alter risks or benefits eg. if her membranes are not intact there is an additional risk of infection. In some cases a VE may be helpful to support decision making with regard to necessary intervention eg. if labour seems abnormal or the baby’s heart rate is concerning.

It can also be helpful to assert that it is the woman’s decision and that you will support her in whatever she thinks is best for her (many women think they have to follow recommendations).

It is particularly important to provide clear information when a woman is making decisions outside of recommendations or the norm. There is no risk free choice – the woman must decide which risk is most significant for her. In order to do this she needs to have adequate information. For example, if a woman is choosing to birth at home she needs information about the benefits, risks and other options. She needs know the difference between home and hospital, including how the setting might alter the management of any complications.

Information sharing needs to be documented. Like any aspect of care there needs to be evidence that it happened. For example, when gaining consent for a vaginal examination – rather than writing ‘VE with consent’, list the risks discussed (bullet points will do). Some hospitals are using consent forms for common interventions eg. VE and ARM with a list of risks for the midwife to read out and get the woman to sign. If you give the woman any information resources – write down what you gave her.

It is also important to be clear about your scope and abilities by “acknowledging one’s own strengths and limitations” (NMBA 2008b). This involves being honest with women about your experience and ability to meet her needs. For example, if you have limited experience in attending breech births, and her baby is breech – she needs to know. If she is wanting a physiological placental birth and you (the midwife) have limited experience in supporting this – she needs to know.

A word about words… I realise the word ‘risk’ is used a lot in this post. However, the reality is that as midwives we are expected to talk about ‘risk’. We can change the word for ‘chance’ in many cases – but not all. Like it or not, we operate in a ‘risk’ discourse and for legal purposes need to disclose ‘risk’ information with women. However, I avoid the word ‘safe’ when talking to women about their options. Safety is in the eye of the beholder – it is up to the woman whether she thinks a 1:1000 chance of something happening is ‘safe’ or ‘unsafe’. Saying something is ‘safe’ is a judgement and can be seen as an endorsement of a particular option.

Which brings us to the issue of bias. Information sharing needs to be unbiased, and this is extremely difficult because we are all biased and have our own beliefs and opinions. However, there are some strategies to avoid transmitting your bias whilst giving information:

  • Present both sides of the coin (see above) ie. risks and benefits of all options in a matter of fact manner ie. don’t share your personal opinions or experiences (with other women) about an option.
  • Avoid advising or recommending particular options unless a complication or pathology is actually occurring. For example, you wouldn’t recommend induction, or waiting for an uncomplicated post-dates pregnancy; but you would recommend a medical review if a woman’s blood pressure was abnormally high.
  • Ensure that the woman knows you are not invested in her decision, and that you do not want to influence her either way – say this to her.
  • When asked “what would you do?” – point out that you are not her , and not in her situation, and what you would do is irrelevant to what is best for her.
  • Avoid telling her what you did with your own pregnancy, birth, baby – again, this is not relevant to her.
  • Don’t create unnecessary fear about other options, for example if she is choosing to homebirth, it is unprofessional to tell her how awful the local hospital is. Not only can this influence her decision, but it can also make things problematic if a transfer to that hospital is needed.

A good way to assess whether you are providing un-biased information is to look at what women in your care choose to do. If all of the women you care for choose the same option – you need to consider if you are influencing them. Women are individuals and there should be a range of decisions being made.


“Midwives advocate for the protection of the rights of each woman, her infant(s), partner, family and community in relation to midwifery care.” (NMBA 2006)

Once the woman has made her decision the midwife supports and advocates for her. For example, if a woman declines the offer of a vaginal examination – you simply document her decision and carry on. You may need to let colleagues know what her decision is and ensure that they respect it. In some settings you may be question or pressured about her decision – but ultimately you are fulfilling your legal responsibilities regarding consent. This trumps any institutional cultural norms or expectations.

However, for a midwife in private practise responsibilities regarding support are not so clear. If a woman chooses care outside of recommendations the midwife has the choice to carry on providing support – or ‘withdraw’ care (ACM 2013). Unfortunately this has resulted in midwives being held responsible for women’s decisions, simply by agreeing to carry on providing care.

Competent Practice

“Midwifery care combines art and science. Midwifery care is holistic in nature, grounded in an understanding of the social, emotional, cultural, spiritual, psychological and physical experiences of women and based upon the best available evidence.” (ICM 2010)

The scope of the midwife “…includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures” (ICM 2011)

The midwife needs to provide competent care within the constraints of the woman’s decisions. For example, competent management of an emergency situation will be different in a home setting compared to a hospital setting.



Unlike midwives, women are not registered and regulated. Therefore, there are no guidance documents regarding women’s responsibilities in the mother-midwife relationship (and this section is a lot smaller!). However, if midwives meet their responsibilities (above), then women become accountable for their decisions and the outcome of their decisions.


By law, women have the right to make decisions regarding what is done or not done to them. Midwifery should support women to take responsibility for their decisions (ICM 2010).

Many factors influence decision making, and the information a midwife provides is only one piece of the puzzle. Humans are active seekers and interpreters of information. We pick and choose, using and discarding information according to internal and external constraints and considerations. Embodied knowledge, personal experiences and other people’s experiences influence the selective designation of knowledge as authoritative or not. We often start with a conclusion, then rationalise it with evidence. We surround ourselves  with people who have beliefs and opinions aligned with our own. The internet has increased our access to information and people who will reinforce our beliefs and choices. Midwives cannot, and should not take responsibility for the sources information a woman chooses to engage with.

Most women will be influenced by the mainstream risk discourse and cultural norms. Women who make decisions against this discourse must seek information and people who will support their decisions. Some do this in response to previous experiences with the medical paradigm. Some choose the support of an unregistered care provider (or no care provider) to birth away from the medical paradigm and its intervention focus and inherent discourse about risk.

Outcome of Decisions

ICM (2008a) state that women should accept responsibility for the outcomes of their choices (if the midwife met her responsibilities). This is not about blame. It is about accepting that an outcome (good or bad) directly associated with a decision is the responsibility of the decision-maker.

Whilst midwives can be affected by outcomes – they cannot take responsibility for the outcome of a woman’s informed decision. For example, if a woman chooses an induction and the outcome is fetal distress and a c-section – this outcome is not the midwife’s responsibility. The midwife’s responsibility is providing adequate information about induction, supporting the woman’s decision to induce, and competent practice (management of the induction process, identification of the fetal distress, and alerting the medical team).


Registered midwives have a responsibility to provide information, support and competent care to women. In return, women take responsibility for making decision and for the outcome of their decisions. Whilst this appears simple, it is an incredibly complex relationship and I would be interested to read your comments about these issues.


ICM (2008a) international code of ethics for midwives

ICM (2008b) role of the midwife in research

ICM (2010) philosophy and model of midwifery care

ICM (2011) international definition of the midwife

NMBA (2006) national competency standards for the midwife

NMBA (2008a) code of professional conduct for midwives in Australia

NMBA (2008b) code of ethics for midwives in Australia


Posted in law, midwifery practice, opinion and thoughts, uncategorized | Tagged , , | 29 Comments

Supporting women’s instinctive pushing behaviour during birth

Artwork by Amanda Greavette

This article was published in The Practising Midwife journal in June 2015 along with ‘practice challenge’ questions for midwives (not included here).


Clinical guidelines recommend that women should be guided by their own pushing urges during birth (National Institute for Health and Care Excellence (NICE) 2014). However, directing women’s pushing behaviour has become a cultural norm within maternity care. Women are still told when to push, when not to push and how to push. In order to promote and support physiological birth we need to reconsider the assumptions underpinning this practice. In addition, we need to reflect on how this practice influences women’s experience of birth. This article discusses supporting instinctive pushing behaviour during uncomplicated, physiological birth.

The current discourse around pushing and cervical dilatation is underpinned by a mechanistic understanding of the birth process: that the cervix opens first, then the baby is pushed through the vagina. However, this does not reflect the multidimensional and individual nature of birth physiology. Descent, rotation and cervical dilatation happen at varying rates, and are not necessarily related.

The urge to push is initiated by the position of the baby’s head within the pelvis (Roberts et al 1987). Therefore, the cervix can be fully dilated without the baby descending deep enough to initiate an urge to push. Alternatively, spontaneous pushing can begin before the cervix is fully dilated. Directing a woman to push or not to push fails to support the individual physiology of her body and birth process. In addition, it contradicts the notion that women are the experts in their own births.

Directing women to push

Once full dilatation of the cervix is identified or suspected, it is common practice to direct women’s pushing behaviour in an attempt to aid descent of the baby. Pushing directions usually involve instructions to use Valsalva pushing, or a variation of this method which includes: taking a deep breath as a contraction begins; holding the breath by closing the glottis; bearing down forcefully for eight to ten seconds (into the bottom); quickly releasing the breath; taking another deep breath and repeating this sequence until the contraction has ended (Yildirim and Beji 2008). Directed pushing was introduced in an attempt to shorten the duration of the ‘second stage of labour’ in the belief that this would improve outcomes for women and babies (Bosomworth and Bettany-Saltikov 2006). This type of pushing has been found to have a number of detrimental consequences for women including alterations to circulation (Tieks et al 1995), and increased perineal trauma and long-term effects on bladder function and pelvic floor health (Bosomworth and Bettany- Saltikov 2006; Kopas 2014).

Valsalva pushing may also reduce oxygen circulating via the placenta to the baby (Aldrich et al 1995). Current research reviews do not identify a significant impact of directed pushing on fetal wellbeing, but further research is needed (Kopas 2014; Prins et al 2011).

In addition, Valsalva pushing does not reflect how women push instinctively (Kopas 2014). Instinctive pushing does not commence at the start of contractions, and women do not take a deep breath before pushing: women alter their pushing behaviours, and use a mixture of closed glottis and open glottis pushing. The number of pushes per contraction also varies, with women not pushing at all during some contractions. Women also instinctively alter pushes according to their contraction pattern. For example, if contractions are infrequent women tend to use more pushes per contraction, and if contractions are frequent they push less often. This individual and instinctive pattern of pushing helps to oxygenate the baby more effectively than Valsalva pushing.

Directing women not to push

Some women will instinctively push before their cervix is fully dilated. This is often treated as a complication, and a common approach is to encourage the woman to stop pushing due to fear that cervical damage will occur. However, there is no evidence to support this concern. Two studies examined pushing before full dilatation and found that between 20-40 per cent of women experienced an ‘early urge to push’ (Borrelli et al 2013; Downe et al 2008). Borrelli et al (2013) found that the sooner the midwife performed a vaginal examination in response to a woman’s urge to push, the more likely they were to find an undilated cervix. They also found that ‘early pushing’ was much more common for primiparous women, and occurred in 41 per cent of women with babies in an occipito posterior position. Both studies conclude that an ‘early urge to push’ is a normal variation and is not associated with complications. Perhaps there is a physiological advantage for ‘early’ pushing in some circumstances? For example, additional downward pressure may assist the baby to rotate into an anterior position, or assist with cervical dilatation.

The impact of telling a woman not to push when her body is pushing also needs to be considered. Once the baby is applying pressure to the nerves in the pelvis that initiate pushing, the woman is unable to control the urge. Attempting not to push at this point is like trying not to blink or breathe. In addition, telling a woman not to push when her body is instinctively pushing suggests that her body is wrong, and that she needs to resist her urges. After resisting her body’s urges, she may find it difficult to switch into trusting and following her body once given the ‘go ahead’ (Bergstrom et al 1997). Encouraging a woman not to push when she is instinctively pushing can be distressing and disempowering for her.

Another situation in which women are encouraged not to push is during crowning. The rationale is to minimise the chance of perineal trauma by slowing down the birth of the baby’s head. A slow birth of the head reduces the chance of tearing as it allows the perineal tissues to gently stretch over time (Aasheim et al 2012). A number of techniques have emerged aimed at slowing down the birth of the baby’s head, including instructions and hands-on approaches. However, these approaches fail to acknowledge instinctive birthing behaviour. There is one study examining what women do during birth when following their instincts (Aderhold and Roberts 1991). This very small study of four women birthing without instructions found that they altered their own breathing and stopped pushing as the baby’s head crowned. This is consistent with my own observations of undisturbed birth. The intense sensations experienced during crowning usually result in the woman ‘holding back’ while the uterus continues to push the baby out slowly and gently. In addition, women will often hold their baby’s head and/or their vulva during crowning. Some women will bring their legs closer together, not only slowing the birth but also providing more ‘give’ in the perineal tissues. Telling a woman to ‘stop pushing’, to ‘pant’ or to ‘give little pushes’ distracts her at a crucial moment and suggests that you are the expert in her birth. Instructing her to open her legs to ‘give the baby room’ contradicts her instinct to protect her own perineum by closing them.

Conclusion and suggestions for practice

Evidence supports the notion that women instinctively push in the most effective and safe way for themselves and their babies during birth. A birthing woman is the expert regarding when and how she pushes. Providing directions implies she needs our guidance and that we are the experts. Facilitating women’s instinctive birthing behaviours rather than directing them is evidence based and reinforces women’s innate ability to birth.

Suggestions for practice:

  • Include information about the physiology of birth in antenatal education/preparation. Reinforce the message that women have an innate ability to birth without direction.
  • Provide an environment that facilitates physiological birth and instinctive behaviour – low lighting, minimal disturbance, comfortable furniture that supports mobility and movement (floor mats, beanbags, birth pool, shower).
  • Avoid asking the woman if she needs to push, or feels ‘pushy’ as this may suggest that she should and could interfere with her inward focus and instinctive behaviour.
  • If the woman tells you she feels the urge to push, reassure her that this is good, but don’t encourage her to push. There will come a point when she is spontaneously pushing rather than feeling an urge to.
  • Avoid vaginal examinations to ‘diagnose’ full dilatation. If you are not going to provide instructions about pushing based on cervical dilatation, there is no benefit in knowing this information.
  • Do not disturb the woman’s instinctive pattern of pushing and breathing. Avoid directions and, if you must speak, gently reinforce her ability to birth.
  • Avoid directions or distractions as the baby’s head is emerging to facilitate the woman’s instinctive perineal protecting behaviours (such as gasping, screaming, closing her legs, holding her baby and perineum).

Related posts: perineal protectors; pushing: leave it to the experts; the anterior cervical lip: how to ruin a perfectly good birth.


Aasheim V, Nilsen ABV, Lukasse M et al (2011). ‘Perineal techniques during the second stage of labour for reducing perineal trauma’. Coch Data Sys Rev, 12: CD006672. DOI: 10.1002/14651858.CD006672.pub2.

Aderhold K and Roberts JE (1991). ‘Phases of second stage labor: four descriptive case studies’. Jour Nurse- Midwif, 36(5): 267-275.

Aldrich C, D’Antona D, Spencer JAD et al (1995). ‘The effect of maternal pushing on fetal cerebral oxygenation and blood volume during the second stage of labour’. Brit Jour Obs Gyn, 102(6): 448-458.

Bergström L (1997). ‘”I gotta push. Please let me push”: social interactions during the change from the first to second stage of labour’. Birth, 24(3): 173-180.

Borrelli SE, Locatelli A and Nespoli A (2013). ‘Early pushing urge in labour and midwifery practice: a prospective observational study at an Italian maternity hospital’. Midwif, 29(8): 871-875.

Bosomworth A and Bettany-Saltikov J (2006). ‘Just take a deep breath: a review to compare the effects of spontaneous versus directed Valsalva pushing in the second stage of labour on maternal and fetal well- being’. MIDIRS Midwif Dig, 16(2): 157-165.

Downe S, Trent Midwives Research Group, Young C et al (2008). ‘The early pushing urge: practice and discourse’. In: Downe S (ed.). Normal childbirth: evidence and debate, 2nd edition. London: Churchill Livingstone: Elsevier.

Kopas LM (2014). ‘A review of evidence-based practices for management of the second stage of labour’. Jour Midwif Wom Health, 59(3): 264-276.

NICE (2014). Intrapartum care: care of healthy women and their babies during childbirth. NICE clinical guideline 190, London: NICE.

Prins M, Boxem J, Lucas C et al (2011). ‘Effect of spontaneous pushing versus Valsalva pushing in the second stage of labour on mother and fetus: a systematic review of randomised trails’. BJOG, 118(6): 662-670.

Roberts J, Goldstein S, Gruener JS et al (1987). ‘A descriptive analysis of involuntary bearing-down efforts during the expulsive phase of labor’. Jour Obs, Gyn Neon Nursing, 16(1): 48-55.

Tieks FP, Lam AM, Matta BF et al (1995). ‘Effects of valsalva maneuver on cerebral circultation in healthy adults: a transcranial doppler study’. Stroke, 26(8): 1386-1392.

Yildirim G and Beji NK (2008). ‘Effects of pushing techniques in birth on mother and fetus: a randomized study’. Birth, 35(1): 25-30.

Posted in birth, midwifery practice | Tagged , | 50 Comments

Vaginal examinations: a symptom of a cervical-centric birth culture

This post is about routine vaginal examinations (VE) during physiological birth ie. an uncomplicated birth without any medical intervention. The VE is a useful assessment in some circumstances, but it’s routine use in an attempt to determine labour progress is questionable. As birth knowledge evolves, and research challenges the current cervical-centric approach to labour progress, there is an opportunity to shift practice. I’m hoping this post will inspire readers to reconsider their beliefs and practices regarding cervixes and VEs.

History: the rise of the cervix

How did we get fixated on what one small area of the body is doing during the complex and multidimensional birth process? An article by Dahlen et al. (2013) discusses the history of VEs. It seems that midwives (and others) have been performing this intervention throughout recorded history. However, for most of this time VEs were carried out in response to suspected pathology eg. an obstructed labour or an unusual presentation. The VE provided an assessment of a complication and informed the response. Midwifery text books warned against unnecessary VEs: “Too much vaginal meddling is bad too: the best thing is to wait patiently, alert to all cues” – French midwife Madame du Coudray [1563-1636] (cited in Dahlen et al. 2013).

The development of medicine was influenced by the notion that the body could be understood like a machine, with distinct parts that could be studied and understood separately. The birthing woman was ‘broken’ into physical parts – uterus, cervix, baby – and a systematic, linear understanding of progress created (McCourt 2010). This is still evident in modern textbooks. The woman has disappeared in favour of diagrams depicting her ‘parts’ (and the fetal skull) alongside precise measurements. This simplified and incorrect understanding has underpinned education about birth, and practice during birth. In the 1970s, based on this reductionist and linear approach, the partogram became established within medicalised maternity systems. The aim of the partogram was/is to measure and control labour progress by plotting cervical dilatation onto a graph, along with descent of the baby’s head. If the cervix does not open along the prescribed timeframe (1cm per hour or 0.5cm per hour depending on the hospital), labour will be augmented ie. speeded up with an ARM or synthetic oxytocin.

Now: new understandings and contradictions

In recent years, new knowledge about birth physiology and research has challenged the cervical-centric approach to labour progress assessment. A previous article/post discusses the research regarding labour patterns and partograms. In summary, the research shows that women’s labour patterns do not fit the timeframes prescribed by partograms. A Cochrane Review (2013) on the use of partograms in normal labour concluded that: “On the basis of the findings of this review, we cannot recommend routine use of the partogram as part of standard labour management and care.” Partograms and VEs go hand in hand – filling out a partogram requires regular vaginal examinations to ‘plot’ along the graph. However, there is no evidence that routine VEs in labour improve outcomes for mothers or babies. A Cochrane Review (2013) concluded that: “We identified no convincing evidence to support, or reject, the use of routine vaginal examinations in labour…” (Downe et al. 2013). Another recent study (Ferrazzi et al. 2015) found that cervical dilatation during spontaneous natural labour is non-linear and unpredictable.

Without adequate evidence for the use of the partogram, or routine VEs there is increasing debate in academic circles about the way forward. Unfortunately we are so cervical-centric that the proposed solutions still involve cervical measurements, and therefore VEs. For example, Zhang et al. (2015) in their article ‘statistical aspects of modeling the labor curve’ state: “…any labor curve is illustrative and may not be instructive in managing labor because of variations in individual labor pattern and large errors in measuring cervical dilation. With the tools commonly available, it may be more productive to establish a new partogram that takes the physiology of labor and contemporary obstetric population into account.” At the ICM Conference in Prague (2014) and at the University of California (article/interview available) it was proposed that the partogram (ie. the clock) should be started at ‘6cm dilated’ rather than the current ‘3-4cm’ to avoid unnecessary intervention.

There is also reluctance to change hospital policies, underpinned by a need to maintain cultural norms. The Cochrane review on the use of partograms on the one hand states that they cannot be recommended for use during ‘standard labour care’, and on the other hand states: “Given the fact that the partogram is currently in widespread use and generally accepted, it appears reasonable, until stronger evidence is available, that partogram use should be locally determined.” Once again, an intervention implemented without evidence requires ‘strong’ evidence before it is removed. The reality is that we are unlikely to get what is considered ‘strong evidence’ (ie. randomised controlled trials) due to research ethics and the culture of maternity systems. Guidelines for care in labour continue to advocate ‘4 hourly VEs’ and reference each other rather than any actual research to support this (NICE, Queensland Health). Interesting whilst Queensland Health guidelines recommend 4 hourly VEs, their parent information leaflet states: “While a VE can provide information about how a woman has progressed so far in labour, it cannot predict how much longer you will be in labour…”  and that there are “…other factors such as the strength, duration and length of contractions as well as a woman’s behaviour and wellbeing that can indicate progress in labour”. Which begs the question ‘why bother doing a VE’?

The cervical-centric discourse is so embedded that it is evident everywhere. Despite telling women to ‘trust themselves’ and ‘listen to their body’, midwives define women’s labours in centimetres “She’s not in labour, she’s only 2cm dilated”. We do this despite having many experiences of cervixes misleading us ie. being only 2cm and suddenly a baby appears, or being 9cm and no baby for hours. Women’s birth stories are often peppered with cervical measurements “I was 8cm by the time I got to the hospital”. Even women choosing birth outside of the mainstream maternity system are not immune to the cervical-centric discourse. Regardless of previous knowledge and beliefs, once in labour women often revert to cultural norms (Machin & Scamell 1997). Women want to know their labour is progressing and there is a deep subconscious belief that the cervix can provide the answer. Most of the VEs I have carried out in recent years have been at the insistence of labouring women – women who know that their cervix is not a good indicator of ‘where they are at’ but still need that number. One woman even said “I know it doesn’t mean anything but I want you to do it”. Of course, her cervix was still fat and obvious (I didn’t estimate dilatation)… her baby was born within an hour.

Vaginal examinations: not just a benign procedure

In order to gain consent for a VE, women need information about the lack of evidence supporting VEs, and about the potential consequences of VEs. I’ve started a list below and welcome any additions you can think of:

  • VEs are invasive and often painful: There is limited research into women’s experiences of VEs (surprise, surprise). Most women report being ‘satisfied’ with their VE experience, some find it painful, for a few VE is associated with PTSD (Dahlen et al. 2013). I’d be interested in your comments about experiences of VEs.
  • The findings can be misleading: What the cervix is doing at the moment of a VE does not indicate what the cervix is going to do in the future. Therefore, the findings cannot effectively inform decisions about pain medication or other interventions (although this is often the rationale given for performing them).
  • The measurements are subjective and inconsistent between practitioners: The accuracy between practitioners is less than 50% (Buchmann & Libhaber 2007).
  • A VE disregards the woman’s knowledge and reinforces the ‘external expert’: Often the findings do not match the woman’s experience and the result can be disempowering, for example in  early labour.
  • A VE can result in accident rupturing of the membranes: It is not uncommon to accidentally break the amniotic sac whilst carrying out a VE – this alters the birth process and increases risk for the baby.
  • VEs can increase the chance of developing an infection (Dahlen et al. 2013).

Other ways of knowing


Amanda Greavette:

The truth is that women’s bodies are complex, unique and immeasurable. Birth is a multidimensional experience that cannot be accurately defined by anyone outside of the experience. We – those of us who give birth and/or attend birth – know this. Midwives already assess labour based on other (less invasive) ways of knowing. In my PhD findings midwives’ birth stories were filled with descriptions of mothers’ behaviour. One participant said: “It’s like a performance… at this stage of this performance what is it saying? And… it’s not what she’s saying, it’s what she’s not saying. And it’s what she’s displaying, the way she’s moving, what her body is doing in a physiological sense.” Other studies have also described this approach to labour assessment. Dixon et al. (2014) mapped their research about the emotional journey of labour with findings from previous studies, and integrated this with physiology. Duff (2005) studied women’s behaviour during labour and created an alternative ‘partogram’ based on her findings. There are also physical changes that occur to women’s bodies during labour that can be seen and indicate labour progress (eg. the shift of the Rhombus of Michaelis and the purple line). It is not within the scope of this post to discuss these behaviours in depth (perhaps a separate post?). I am just trying to point out that the cervix is not the only indicator of labour progress. Yes, women’s behaviours are individual and may not fit any expected patterns, therefore relying on these methods may be misleading in some cases. But VE’s are also inaccurate and misleading (see above)!

Suggestions for midwives

  • Be mindful of language and how we communicate about labour to each other and women. Stop talking about centimetres and start talking about behaviours and other signs of progress.
  • During pregnancy: provide women with honest information about VE’s, their limitations and the potential consequences; and the alternatives. This should also include information about policies in their chosen birth setting, and their right to decline policy recommendations.
  • Care in labour is influenced by the setting. For example, a hospital may have a policy of ‘4 hourly VE’s’ – and as an employee you are obliged to follow policy. However, your obligation is to offer a VE, not to carry it out. To do a VE without consent is assault and battery and a breach of professional standards. If you provide the woman with adequate information (see above), and make it clear that this is an ‘offer’ based on policy (not your own needs), and that from all external signs she is progressing well… some women will decline your offer. You can document her decision and carry on having fulfilled your duty to the woman, and to the hospital.
  • If you are in a setting where VEs are not routine (eg. homebirth) and the woman asks for a VE (which they do)… try and work out what she really wants. Does she want reassurance that all is well and she is progressing, or does she really want to know what her cervix is doing. If it is the latter, encourage her to feel her own cervix. If she insists -do a VE with consent.
  • When communicating the findings of a VE include other changes – “the baby has descended, rotated, flexed” – and positives about the cervix – “it is stretchy, soft, opening up nicely”. If she needs a number, give her one, but demonstrate that this is not important to you. Do not use the findings to dictate her behaviour eg. pushing or not pushing.


Routine vaginal examinations during physiological birth are a symptom of a cervical-centric birth culture. There is enough evidence to support a shift away from this common intervention towards a more woman-centred approach to labour progress assessment. We need to value the ‘other ways of knowing’ that are already established, and reinforce the woman as the expert in her own birth experience.

Posted in birth, midwifery practice | Tagged , , | 87 Comments

The Human Microbiome: considerations for pregnancy, birth and early mothering


Updated and edited: April 2016

This post was co-authored by Jessie Johnson-Cash and based on her presentation at the USC Midwifery Education Day.

The human microbiome is rather fashionable in the world of science at the moment. The NIH Human Microbiome Project has been set up to explore correlations between the microbiome and human health and disease. To date the human microbiome as been associated with, amongst other things obesity, cancer, mental health disorders, asthma, and autism. In this post I am not going to provide a comprehensive literature review – this has already been done, and the key reviews underpinning this discussion are: Matamoros et al. (2012) ‘development of intestinal microbiota in infants and its impact on health’ and Collado et al. (2012) ‘microbial ecology and host-microbiota interactions during early life stages’. Instead I am going to focus on what this means for pregnancy, birth, mothering and midwifery.

What is the human microbiome?

Based on a chart by Matamoro et al. 2013. Adapted and extended by Jessie Johnson-Cash.

Based on a chart by Matamoro et al. 2013. Adapted and extended by Jessie Johnson-Cash.

Considerations for mothers and midwives

The following are not research based recommendations – the research is yet to be done. They are more considerations/questions arising from the developing knowledge around the human microbiome.

Pre-conception and Pregnancy

The commonly accepted belief that the the baby inside the uterus is sterile (whilst membranes are intact) is being challenged. It seems that maternal gut microbiota may be able to translocate to the baby/placenta via the blood stream (Jiménez et al. 2008; Metamoros et al. 2013; Prince et al. 2014; Rautava et al. 2013Zimmer 2013). And the unique ecosystem of bacteria in the placenta may originate from bacteria in the mother’s mouth. Women’s gut microbiota change during pregnancy and this impacts on metabolism (Koren et al. 2012Prince et al. 2014). So ideally, women need to head into pregnancy with a healthy microbiome and then maintain it. Unfortunately our modern lifestyle is not very microbiome friendly, and many of us have dysbiosis (an imbalance in gut bacteria). Dysbiosis and too much of the ‘wrong’ bacteria has been linked to premature rupture of membranes and premature birth (Fortner et al. 2014; Mysorekar & Cao 2014; Prince et al. 2014). Gum disease (bacteria) has also been linked to pre-term birth. Suggestions:


There is a difference between the microbiome of a baby born vaginally compared to a baby born by c-section (Azad, et al. 2013; Penders et al. 2006Prince et al. 2014). During a vaginal birth the baby is colonised by maternal vaginal and faecal bacteria. Initial human bacterial colonies resemble the maternal vaginal microbiota – predominately Lactobacillus, Prevotella and Sneathia. A baby born by c-section is colonised by the bacteria in the hospital environment and maternal skin – predominately Staphylocci and C difficile. They also have significantly lower levels of Bifidobacterium and lower bacterial diversity than vaginally born babies. These differences in the microbiome ‘seeding’ may be the reason for the long-term increased risk of particular diseases for babies born by c-section.

The environment in which the baby is born also influences their initial colonisation. A study by Penders et al. (2006) found that term infants born vaginally at home and then breastfed exclusively had the most ‘beneficial’ gut microbiota. It is likely that these babies only came into contact with the microbiota of their family during the key period for ‘seeding’ the microbiome. No one has researched waterbirth and the microbiome yet. Might it dilute the bacteria? The chance of colonisation and infection with group B streptococcus (GBS) is reduced with waterbirth (Cohain 2010Neugeborene et al. 2007). This may be due to dilution of the GBS or additional colonisation of the baby with beneficial bacteria. Another future research topic is caul birth and the microbiome. Does a baby born in the caul miss out on colonisation via the vagina?

What we do know is that antibiotic exposure alters the microbiome in adults (see above). When a woman is given antibiotics in labour her baby also gets a dose. In 2006 a medical expert review (Ledger 2006) raised concerns about prophylactic antibiotics in labour. A study in 2011 found that antibiotics given in labour increased the incidence of antibiotic resistance when treating late-onset serious bacterial infections in infants (Ashkenazi-Hoffnung et al. 2011). A more recent study found that antibiotics given during labour or a c-section are associated with infant gut microbiota dysbiosis (Azad et al. 2016). This is concerning considering the number of women/babies given antibiotics in labour (eg. for ‘prolonged’ rupture of membranes or for ‘epidural fever’). Add to that the use of prophylactic antibiotics for c-sections = a significant proportion of women and babies being exposed to antibiotics around the time of birth. Suggestions:

  • A vaginal birth in the mother’s own environment is optimal for ‘seeding’ a healthy microbiome for the baby (Penders et al. 2006).
  • Minimise physical contact by care providers on the mother’s vagina, perineum and the baby during birth.
  • Avoid unnecessary antibiotics during labour. If antibiotics are required consider probiotics for mother and baby following birth.
  • If the baby is born by c-section… Research is currently being undertaken into the use of vaginal swabs* to ‘seed’ c-section babies. The preliminary results are that the microbiome of swabbed babies are more similar to vaginally born babies. The protocol the researchers are using is:
    1. take a piece of gauze soaked in sterile normal saline
    2. fold it up like a tampon with lots of surface area and insert into the mother’s vagina
    3. leave for 1 hour, remove just prior to surgery and keep in a sterile container
    4. immediately after birth apply the swab to the baby’s mouth, face, then the rest of the body (you can see photos of this process here)
  • If a baby is born by c-section it is even more important to encourage and support their mother to breastfeed. It may also be worth considering additional probiotic intake.

*There has been a bit of hysteria about the safety of vaginal swab seeding in the media. I will leave it to Sara Wickham to address (rant about) this one.


After birth, colonisation of the baby by microbiota continues through contact with the environment and breastfeeding. There are significant differences in the microbiota of breastfed babies compared to formula fed babies (Azad, et al. 2013; Guaraldi & Salvatori 2012). Beneficial bacteria are directly transported to the baby’s gut by breastmilk and the oligosaccarides in breastmilk support the growth of these bacteria. The difference in the gut microbiome of a formula fed baby may underpin the health risks associated with formula feeding. In the short term, infant colic may be associated with high levels of proteobacteria in the baby’s gut (wish I’d know this 20 years ago!). Suggestions:

  • Immediately following birth, and in the first days, baby should spend a lot of time naked on his/her mother’s chest.
  • Avoid bathing baby for at least 24 hours after birth, and then only use plain water for at least 4 weeks (Tollin et al. 2005).
  • If in hospital, use your own linen from home for baby.
  • Minimise the handling of baby by non-family members during the first weeks – particularly skin to skin contact.
  • Exclusively breastfeed. If this is not possible consider probiotic support.
  • Avoid giving baby unnecessary antibiotics (Ajslev et al. 2011; Penders et al. 2006). Again, if antibiotics are required probiotics need to be considered.
  • Probiotics may also be beneficial for babies suffering from colic.


The more we understand about the human microbiome the more it seems fundamental to our health. Pregnancy, birth and breastfeeding seed our microbiome and therefore have a long-term effect on health. More research is needed to explore how best to support healthy seeding and maintenance of the microbiome during this key period. I have discussed a number of considerations and suggestions arising from what we already know. I welcome any comments, discussion and further suggestions from readers.

Further reading and resources

Posted in baby, birth, midwifery practice, pregnancy | Tagged , , , , , , , , , , | 112 Comments

The Future of Midwifery and Homebirth in Australia? June 2016

A lot of changes have occurred in Australian midwifery over the last few years, and I think many midwives and women are unsure or confused by them. I am going to attempt to make a clear and coherent summary of the changes, and discuss the impact of them now, and in the future for midwifery and homebirth. There are going to be a lot of acronyms in this post which may be new to some and familiar to others. So here is a glossary before I begin:

  • ACM – Australian College of Midwives
  • AHPRA – Australian Health Practitioner Regulation Authority
  • AMA – Australian Medical Association
  • ANMC – Australian Nursing and Midwifery Council
  • ICM – International Confederation of Midwives
  • NMBA – Nursing and Midwifery Board of Australia
  • PII – Professional Indemnity Insurance
  • PPM – Privately Practising Midwife
  • RANZCOG – Royal Australian and New Zealand College of Obstetricians and Gynaecologists

Before AHPRA and PII (pre 2010)

The following is an overview of how PPMs worked based on myself and other midwives I know. I realise there will be some variation across individual midwives…

Before AHPRA PPMs were regulated in the same way as any other midwife – at the time this was by ANMC. They collaborated with GPs, hospitals and other health care practitioners, referring and transferring care when needed. The ACM’s ‘consultation and referral guidelines’ were freely available online which meant women could access them, and they formed the basis of discussions around scope of practice and consultation/referral. If a woman transferred to hospital during labour the PPM could no longer act as a ‘midwife’ – instead handing over the professional role and responsibility to the hospital midwife. This allowed the PPM to focus on the woman’s emotional, physical and advocacy needs rather than on the needs of the institution. Hospital midwives are well placed to work within their environment – they know how to deal with the obstetricians, equipment, medications, policies and paperwork. There was no indemnity insurance available for PPMs (since 2001) – so they worked without it. PPMs were employed directly by women and worked directly for women. The above factors were discussed and stated in a signed mother-midwife contract

Meanwhile consumer groups such as Maternity Coalition and the ACM were pushing for medicare funding for PPMs. I supported this, and still believe that the health care system should fund homebirth, and that all women should have access to PPMs regardless of their financial situation. There was/is also a government commitment to increasing access to continuity of care for all Australian women.

In 2009 AHPRA was formed in order to have one National registration body rather than individual State registration boards. This was to prevent dangerous healthcare practitioners switching states to continue practising. The ANMC was absorbed into this new registration body. The role of AHPRA is to register and regulate all health care professions including midwifery. Each profession has their own Board within AHPRA – and the Nursing and Midwifery Board of Australia (NMBA) is responsible for midwives and nurses. To understand why midwifery is so entangled with nursing in Australia see Fahy’s (2007) article ‘an Australian history of the subordination of midwifery’ . The perception of midwifery as a branch of nursing underpins the ongoing medical control of the profession described below. Anyway – back to the NMBA. The primary role of the Board is to ‘protect the public’ ie. these are the people who deal with misconduct hearings and ensure midwives are undertaking continued professional development. The formation of AHPRA brought with it two key changes to PPM practice – eligibility and indemnity insurance.

Eligible midwives

In 2010 the ‘eligible midwife registration standard’ came into effect. The aim of this was to enable women to access medicare rebates for PPM care. In order to get rebates women need to engage the services of an ‘eligible midwife’. Note that rebates are not available for homebirth – only antenatal care, birth in a hospital/birth centre (where the PPM has visiting rights) and postnatal care. To become eligible, the midwife must apply to AHPRA for notification and demonstrate that she mets the requirements which are:

  • current general registration as a midwife in Australia with no restrictions on practice
  • midwifery experience that constitutes the equivalent of three years’ full-time post initial registration as a midwife
  • current competence to provide pregnancy, labour, birth and postnatal care to women and their infants
  • successful completion of an approved professional practice review program for midwives working across the continuum of midwifery care
  • 20 additional hours per year of continuing professional development relating to the continuum of midwifery care
  • formal undertaking to complete within 18 months of recognition as an eligible midwife, or the successful completion of a course to acquire the skills required to order diagnostic tests and prescribe scheduled medicines

You can download the ‘guidelines and assessment framework for the registration standard for eligible midwives‘ for further details about the requirements. It could be argued that these requirement (excluding prescribing – which is whole other rant/issue) merely reflect the normal scope of midwifery according to the ICM. However, in Australia most midwives are unable to practise to their full scope due to constraints imposed by the structure of the medicalised maternity system.

The ‘eligible’ classification is often misunderstood, with many believing that you must be eligible to be a PPM or attend homebirths. This is untrue, and many of us continue to work as described above, choosing not to be ‘eligible’ for a number of reasons. There is also an assumption that an eligible midwife is ‘better’ and ‘more experienced’, and again this is not necessarily true. For example, a midwife can gain eligibility without any experience in attending homebirths. The point of eligibility was/is for women to access medicare rebates – not to create a separate and higher class of midwife.

Medicare eligibility has resulted in a number of changes. Firstly, it has increased women’s access to continuity of care and given them access to rebates for maternity care via a PPM. Many midwives have set up as PPMs and midwifery group practices are popping up everywhere – again this increases women’s choices. Some midwives are continuing their homebirth practice with the additional benefit of women being able to claim rebates if they wish. Other midwives are setting up new practices. There are so many different ways in which eligible midwives are working… I am not going to attempt to list them all. In my local area maternity service options for women have increased from hospital (public or private) or PPM in 2009; to hospital, midwifery led birth centre (medicare rebates), midwifery group practice (medicare rebates), non eligible PPMs and eligible PPMs. And for those who do not want to engage with standard maternity services there are birth workers, doulas and the option of freebirth.

However, medicare rebates come at a price…

Collaborative arrangements

In order for a woman to claim medicare rebates for care by a PPM, the PPM must have a collaborative arrangement. The nature of this arrangement has evolved since 2010…

Initially, during negotiations with AHPRA about eligibility, the requirement was going to be that the midwife must ‘demonstrate’ collaboration with medical practitioners and health services. This would have been easy – PPMs were doing this anyway (see above), and documentation would have provided evidence. However, the AMA and Rural Doctors Group ensured that the requirement became a signed collaborative arrangement with a medical practitioner. Interesting that doctors got the final say in midwifery practice. I doubt there are any midwives involved in negotiations with AHPRA about how obstetricians practice. That this signed collaborative agreement made it through despite opposition from all midwives and consumers ‘at the table’ is a testimony to the power of medicine in these ‘negotiations’. Some midwives thought that if they secured eligibility they could change this requirement in the future. Personally, I think they should have refused to allow medicine to control midwifery practice in this way, even if it meant walking away and losing eligibility. Instead, the types of collaborative arrangements midwives were required to have were determined as (Dept of Health):

  1. being employed or engaged by a medical practitioner or an entity that provides medical services; OR
  2. receiving patients on written referral from a medical practitioner; OR
  3. a signed written agreement with a specified medical practitioner/s; OR
  4. an arrangement in the midwife’s or nurse practitioner’s written records

There was/is no obligation for doctors to collaborate. And in case there is any confusion about this, the AMA published a handy  guide for doctors ‘collaborative arrangements – what you need to know’ stating clearly that: “If you do not want to be part of a collaborative arrangement, or you are unable to reach agreement on the appropriate terms of a collaborative arrangement, then there is no obligation to be part of one. You do not have to commit to being part of a collaborative arrangement for any particular period.”

The collaborative arrangement was the equivalent of requiring the manager of Woolworths to agree in writing to allow customers to buy vegetables directly from a local farmer.  Not surprisingly, getting a collaborative arrangement, and therefore claiming medicare rebates was fairly impossible. In 2013 in response to the predictable ‘difficulties with establishing collaborative arrangements’ an amendment was made to the requirement expanding the types of collaborative arrangements. Now, in addition to a collaborative arrangement with a doctor who provides obstetric services (as above), a PPM has two further options for collaboration:

  1. That she is credentialed for a hospital, having successfully undergone a formal assessment of his or her qualifications, skills, experience and professional standing. It is expected that appropriately qualified medical practitioner/s would be involved in the assessment; OR
  2. That she has a written agreement with an entity other than a hospital that employs or engages at least one obstetric specified medical practitioner.

Effectively medical practitioners, individually or via the institutions they work in still control access to medicare for PPMs.

Midwives are pretty resourceful, and many have found ways to make this work for them and the women they care for. However, it is very dependent upon the people and organisations providing collaborative arrangements. Because it is so complex, there is a lot of confusion and misunderstanding. For example, some believe that a medicare eligible midwife cannot care for a woman having a VBAC. This is not true. She can – just as any PPM can. She may not be able to secure a collaborative arrangement to do so ie. there will be no medicare rebate for that care. However, in some cases medical practitioners or hospitals will agree to antenatal and postnatal care by a PPM for VBAC women. Women need to discuss options and boundaries with their individual PPMs… regardless of eligibility. This is part of negotiating the mother-midwife relationship.

Currently eligibility and collaboration remain an ‘opt in’ choice for both midwives and women. Personally I have chosen not to ‘opt in’ because I feel that the current collaborative arrangement requirements are not aligned with my philosophy of midwifery and ‘with-woman’ care… and I won’t compromise. There are women who also feel this way, and specifically want a non-eligible midwife. Or, who do not want to jump through the hoops required to access a medicare rebate (eg. booking into hospital). While both options are available – eligible and non-eligible PPMs – women can choose the option that works best for them.

However, this choice may disappear in 2015…

Professional Insurance Insurance – the wolf at the door

AHPRA registration standards require that all health care professionals have ‘professional indemnity insurance’ (PII) for all aspects of their practice. No big deal for midwives working within the system because they are covered vicariously by the organisations they work for. But this left PPMs with a problem. There was no insurance product available for them, and to practice without insurance breached their registration standards. Long story short, following a lot of protests and negotiations a compromise was found. Two insurance companies stepped in with PII and we now have two products, both excluding homebirth. MIGA only provides insurance to eligible midwives and covers antenatal care, labour in hospital/birth centre and postnatal care. Medisure will insure any PPM for antenatal and postnatal care only. 

Because there is no cover available for homebirth an exemption for PII during a homebirth is in place until June 2015. Not surprisingly, neither insurance company is jumping at the chance to offer PII for homebirth. The NMBA recently published a report on PII for midwives which analyses the issues involved with offering an insurance product that covers homebirth with a PPM. The difficulties centre on the size of the market (ie. number of homebirths/PPMs buying the product); working out the probability of a claim; and working out the size and type of a potential claim. The report includes a lot of discussion about ‘risk’ and ‘risk assessment’. It also suggests that an option could be to make any PII product only available for medicare eligible midwives to ensure ‘confidence and certainty’ within the insurance market about PPM practice. It is likely they will also dictate further requirements for cover such as women must undergo particular screening tests (bloods, u/s, etc.) and be classified as ‘low risk’. These issues are already being faced in the United Kingdom by women and PPMs.

So far there has been no official response to the insurance report from the ACM. The recent Maternity Coalition magazine included this divisive statement in relation to protecting midwives and women’s choices:

“Many midwives feel that they are in a vulnerable legal position. This is often because they are not doing these things [following professional standards re. scope, information giving and documentation]. If we could confidently demonstrate that homebirth midwives as a group were practising in this manner then it would be easier to secure insurance for intrapartum homebirth care and resist the push to regulate homebirth more strictly.” (Ann Catchlove)

It is the NMBA’s role is to regulate midwives… all midwives, including homebirth midwives. All midwives must follow professional standards, provide adequate information, and keep adequate documentation. Yes, individual homebirth midwives may fail to do this… and so might individual hospital midwives. Some would argue that information giving by hospital staff is often below the legal standard for consent (e.g. ARM, induction). Either way, there are already mechanisms in place to hold midwives accountable for their practice via NMBA and civil law. Indeed, considering the number of vexatious reports submitted to the NMBA against PPMs, it could be argued that the mechanisms are working too well (Jo Hunter is presenting about this issue at the Homebirth Conference in March). Unfortunately, we are never going to ‘confidently demonstrate’ that all midwives within any model of care or birth setting are practising in a particular way. Aligning midwifery with medicine and allowing medicine to regulate midwifery practice will not reduce risk. Evidence-based, woman-centred care will reduce risk. How about requiring all midwives to undergo a regular consumer-led ‘midwifery practice review’ assessing their practise against evidence and midwifery philosophy?

The future of midwifery and homebirth?

The following predictions are from my own crystal ball, and some optimists may consider them pessimistic. I think that in 2015 a PII insurance product will be made available that will cover homebirth, but only for eligible midwives accredited by hospitals, and for women booked into the hospital system for shared care and who meet particular ‘low risk’ criteria. PPMs without eligibility will no longer be able attend homebirths – to do so would mean practising without insurance ie. breaching their registration. Women who are not classified as ‘low risk’ will be unable to have a registered midwife at their homebirth (eg. previous c-sectiongestating beyond 41 weeks). I think that the professional midwifery organisations will go along with this in order to gain the mandatory insurance and protect private midwifery practice (limited) at homebirth. These changes will have a significant impact on a minority of midwives and women:

Midwives: Non eligible midwives will either become eligible; or stop providing PPM services; or hand in their registrations and become unregulated ‘birth workers’ (however, in South Australian this could lead to criminal charges). Newly qualified midwives will struggle to gain the experience required to become eligible due to limited continuity of care within the maternity system. PPM practice will be dictated by the constraints of an insurance product who’s focus will be on eliminating risk based on medicalised notions of ‘risk’.

Women: Access to midwives and options for care will be limited. Women who do not meet the requirements for insurance cover will be unable to have a registered midwife at their birth. Many women will go along with the requirements (including to switch to hospital birth) but others will not, and their only option will be to freebirth (this is already happening in Ireland). There is a big difference between choosing to freebirth and feeling there is no other choice.

I think we have lost sight of what is important – the essence of midwifery, being ‘with woman’ regardless of where or how the woman chooses to birth, or with whom she chooses to birth. Unfortunately, I think we have come too far down the track and midwifery has become entangled with medicine and the needs of insurance companies. I can’t see a way out of this mess can you? What I find most frustrating is the lack of discussion about these issues within the Australian midwifery profession. In contrast, in the UK where PPMs face the same insurance issues there are protests, marches and campaigns – even support from a Professor of Obstetrics and Gynaecology. Either, Australian midwives don’t know what is going on, or they agree with the changes, or they don’t care – I’m not sure which. I’d love to know your thoughts.

Update: March 2015

There are rumours that the PII exemption has been extended to December 2015. I am unable to find any evidence of this online on either the AHPRA/NMBA website or on the Australian College of Midwives website.

Bruce Teakle (Maternity Choices Australia) as written an essay on ‘what next’ for exemption outlining possibilities.

Anecdotally, from my own experience / contacts – private practice midwifery is shifting. There are increasing numbers of medicare eligible midwives/midwifery groups, and some are gaining visiting rights in hospitals. This is great for women who want continuity of care and a hospital birth. As these midwives are increasingly ‘networked’ into the mainstream maternity services they are less and less ‘risk adverse’, particularly in relation to homebirth. Due to vexatious reporting and the involvement of hospital staff in the care of their clients, PPMs are being very careful about what they are seen to take on. In addition, PPMs without medicare eligibility are in decline – either becoming eligible or stepping out of the market. The result is that many woman are left without the option of midwifery care for a homebirth e.g. women seeking support for VBAC.

Update: April 2015

AHPRA have extended the PII exemption for homebirth until December 2016. Meanwhile Medisure (Vero) announced that they are withdrawing their insurance product for PPMs (antenatal and postnatal) from April 2015. PPMs who already have insurance with them can renew up until June 2015 ie. ending in June 2016 at the latest. This is the only product available for non-eligible PPMs. MIGA will only insure medicare eligible midwives. All midwives must have insurance for antenatal and postnatal care to fulfil registration requirements. Without it they cannot practice. This move will effectively prevent PPMs from practising without medicare eligibility and reduce women’s options.

Maternity Choices Australia have produced an information document about what the withdrawal of Medisure (Vero) means for consumers (women).

Update: June 2016

It looks like the PII for homebirth will be extended for another year (again). Meanwhile, non- eligible midwives have ceased practising because the only PII product available for antenatal and postnatal care is for eligible midwives only. The ACM are attempting to get a Midwifery Practice Scheme approved through Queensland Health which potentially could provide all PPMs with insurance cover – in Queensland at least.

Posted in midwifery practice, opinion and thoughts | Tagged , , , , | 98 Comments

Midwifery Practice During Birth: rites of passage and rites of protection

Finally I have completed my Phd! It took me six years – the last two mostly writing… and writing… and rewriting. Entire chapters did not make the final ‘cut’. There is so much more I wanted to say (and did) about authoritative knowledge and the ritual nature of midwifery practice. Hopefully I will share this work another way in the future.

My aim was to contribute to an understanding of birth, and midwifery practice, grounded in women’s experience. I believe we need to develop (reclaim?) our own birth knowledge in order to shift the current medical paradigm that is failing women.

The Phd journey has been a rite of passage itself, and I pushed myself to my edge and beyond. I thought about giving up at times, and felt self-doubt about my ability (I left high school with no qualifications and a baby in my belly). I accepted my fears and kept going one step at a time. In the process, I learned not only about my topic, research, and writing; but also about myself.

The abstract is posted below, and you can download the full thesis here. I’d welcome comments, questions and discussion about the research.

There are two published journal articles available from this study (apologies they are not open access):

Big THANKS to the participants – mothers and midwives – who generously shared their birth stories.


This study explored midwifery practice during birth. In particular, the experiences, actions and interactions between midwives and women during uncomplicated, normal births.

Most of the existing literature focuses on outcomes associated with individual practices; and there is a lack of research evidence supporting many of the common midwifery practices carried out during birth. There is also limited research exploring midwives’ experiences and perceptions of their practice during birth; although it seems that the context of midwifery practice, and cultural norms influence practice. Studies exploring women’s experience of birth have identified an altered state of consciousness, and issues of control as key factors. However, there has been very little research specifically examining women’s experience of midwifery practice during birth. This study sought to explore the experience of midwifery practice from both the perspective of the midwife and the woman.

The study is a narrative inquiry, and a feminist approach was taken throughout the research process. Birth stories were gathered from mothers and midwives during in-depth interviews. The participants had either experienced or attended an uncomplicated vaginal birth, and were encouraged to share their story of this experience. Narratives were created from the interview transcripts and analysed to identify common themes. An explanatory framework ‘rites of passage’ was then applied to further illuminate the narrative of midwifery practice during birth.

The findings are presented in three chapters. The first focuses on the mothers’ experiences of birth as a rite of passage. This chapter provides the foundation for the following chapters that present midwifery practice during birth. Midwives enacted ‘rites of passage’ during birth that tended the boundaries of aloneness, and nurtured self-trust and inner wisdom. Midwives also enacted ‘rites of protection’ which contradicted rites of passage, but tended the needs of the institution. Tensions arose between these two types of rites, and conflicting cultural values were transmitted and reflected through their performance.

Findings are discussed in relation to the literature, and the thesis concludes with recommendations for midwifery practice, midwifery education, and further research. Recommendations centre on a model of midwifery practice as ‘ritual companionship’ as the basis for developing midwifery practices that are aligned with women’s experience of birth.

Conceptual map of findings

Posted in birth, midwifery practice | Tagged , , , , , , | 63 Comments

Amniotic Fluid Volume: too much, too little, or who knows?

This post is in response to readers asking me to cover the topic of induction for low amniotic fluid volume (AFV). Most of the content is available in textbooks, in particular Coad and Dunstall 2011 and Beall and Ross (2011), and I have provided references/links for research where I have stepped outside the textbook sources. I use the word ‘may’ quite a bit in this post because little is known about AFV, therefore a lot of the available information is theoretical. In fact, this post probably raises more questions than answers! Also note that I am focussing on AFV at term.

Amniotic fluid volume regulation

Amniotic fluid is in a constant state of circulation. In the second half of pregnancy the main sources of fluid production are from the baby:

  • urine (700mls per day)
  • lung secretions (350ml/day)

And the main sources of fluid clearance are:

  • the baby swallowing fluid and passing it back into mother’s blood stream
  • direct flow across the amnion (placental membrane) into placental blood vessels

The balancing act required to maintain a healthy AFV may be influenced by hormones (prolactin and prostaglandins), osmotic and hydrostatic forces, and the baby. Maternal hydration is also associated with AFV (Patrielli et al. 2012). From day to day there is little change in AFV, however volume decreases towards term. This is normal. Perhaps this reduction reflects reduced lung secretions as the baby nears term?

The amniotic sac and fluid play an important role during pregnancy and birth – you can read more about that in an earlier post.

Abnormalities in AFV occur when there is an imbalance between fluid production and clearance. Too much fluid is called ‘polyhydramnios’ and too little fluid is called ‘oligohydramnios’. However, measurement and thresholds of normal/abnormal are not clear.

Accurate Measurement?

Here is the first problem… there is no accurate method for measuring AFV. The two ultrasound tests aimed at assessing AFV are:

  • Amniotic Fluid Index: four ‘pockets’ of fluid are measured by ultrasound and added up resulting in an Amniotic Fluid Index (AFI) eg. AFI = 10cm.
  • Maximum Pool: The ‘single deepest vertical pocket’ of fluid is identified by ultrasound and measured in centimetres.

Neither of these methods are supported by research (that I can find). However, studies comparing the two conclude that the ‘maximum pool’ measurement is the ‘better choice’ (Nebhan & Abdelmoula 2008Magann et al. 2011). The reasoning for this is interesting… AFI increases the detection of oligohydramnios resulting in increased rates of induction without improving outcomes for babies. So the best method is the one that does not detect the ‘problem’ you are looking for?

Measurement of AFV by AFI or ‘maximum pool’ is part of the Biophysical Profile assessment which aims to identifying babies with inadequate oxygenation via the placenta. However, it is unclear whether there is any benefit to this test. Indeed, an umbilical artery doppler test may provide a better assessment of placental function, and therefore how well oxygenated the baby is (Alfirevic, Stampalija & Gyte 2010) – which is what everyone is worried about.

There is of course the old fashioned method of assessment, also not well researched. Abdominal palpation is usually carried out during antenatal visits. In addition to working out what position the baby is in, a midwife assesses the amniotic fluid volume. When you have palpated lots of pregnant bellies, ‘real’ polyhydramnios and oligohydramnios are usually pretty obvious. Mothers are also experts regarding their own body/baby and notice differences themselves – particularly if they have been pregnant before and can compare pregnancies. What you may find:

  • Oligohydramnios: baby is very easy to feel – in some cases you can see limbs; the uterus is smaller than expected; the mother may notice reduced movements.
  • Polyhydramnios: baby is difficult to palpate and floats away as you apply pressure; the uterus is bigger than expected; the baby’s heart rate may sound muffled; the mother may notice breathlessness, vulval varicosities, oedema and gastric problems.

When you are working as a midwife in a continuity of care situation you get familiar with the individual woman’s bump over time, and it is easier to notice changes. Measuring (with a tape measure) is often used to assess uterine growth – particularly when care is spread between a number of practitioners. Whilst measuring can assist with identifying polyhydramnios, it is unreliable in identifying oligohydramnios (Freire et al. 2013).

Here is the second problem… there is currently no agreement about what constitutes ‘high’ or ‘low’ levels of AFV. Megann et al. (2011) conclude that: ‘high and low levels [of amniotic fluid] have yet to be established in the literature and are difficult to directly link to adverse pregnancy outcomes.’ So we are busy finding measurements that we don’t really understand the implications of?

Most of the time there is no known cause for the ‘high’ or ‘low’ volume of fluid, and there is are complications caused by it. However, there are some factors worth considering if you are labelled with oligohydramnios or polyhydramnios.

Oligoydramnios – too little

The definition of oligohydramnios is usually less than 500mls of fluid; <2cm maximum pool; or AFI <5. Around 3-5% of pregnant women are diagnosed as having too little fluid. Because of the complexities of measurement and the diagnosis of oligohydramnios, I have differentiated between what I believe are two types:

Physiological oligohydramnios

Most cases of ‘oligohydramnios’ are an outcome of 2 factors:

  1. The normal physiological changes that occur to AFV as term approaches (see chart above) and/or the ‘normal’ level for the individual mother/baby is comparatively low to the general ‘norm’.
  2. Women having routine scans for ‘post-dates’ which then identifies this normal ‘low’ AFV.

There is a lack of evidence supporting induction for oligohydramnios in ‘low risk’ pregnancies ie. when there is nothing else ‘abnormal’ going on with mother or baby (Quiñones et al 2012). Driggers et al. (2004) concluded that: “evidence is accumulating that in the presence of an appropriate-for-gestational age fetus, with reassuring fetal well-being and the absence of maternal disease, oligohydramnios is not associated with an increased incidence of adverse perinatal outcome.’’

A recent review of the literature (Rossi & Prefumo 2013) found that in term or post-term pregnancies oligohydramnios (with an otherwise healthy pregnancy/baby) was not associated with poor outcomes. However, it was associated with increased risk of obstetric interventions… probably because the diagnosis leads to intervention.

Pathological oligohydramnios

Pathological oligohydramnios is generally a consequence of reduced urine output (baby) which can indicate a redirection of blood flow away from the kidneys to the vital organs in response to reduced oxygenation. This usually occurs alongside pregnancy complications such as pre-eclampsia. In this case the low fluid volume indicates inadequate placental circulation to the baby. These babies often have significantly low AFV (easily identified by palpation), and are often growth restricted i.e. small and with limited glycogen supplies. These babies are at significant risk and further assessment and intervention should be offered. As a midwife there are few things more concerning than being able to see baby’s form though their mother’s abdomen.


Induction of labour is the usual management for oligohydramnios (regardless of type) because there is concern that the baby has inadequate placental circulation (which is correct in relation to pathological oligohydramnios). However, women need to consider that the induction procedure is associated with reducing placental circulation and causing hypoxia and fetal distress. In addition, if the baby is post-dates he may have already passed meconium, and/or will if he becomes hypoxic due to the induction process. Oligohydramnios = less fluid to dilute the meconium = increased risk of meconium aspiration. Therefore, it is very likely that the baby will become distressed during labour before birth occurs. This is why electronic fetal monitoring is important – in clinical practice I saw the inevitable fetal distress and rush to theatre resulting from induction for oligohydramnios over and over again. So, the mother must be prepared for, and informed of the likelihood of c-section. The other alternatives are planned c-section or awaiting spontaneous labour. Whilst spontaneous labour is more gentle on the baby than an induction, waiting for labour with a baby who is not being well supported by their placenta requires serious very consideration (and nerve) – time will not improve the situation, only worsen it. Even spontaneous labour is likely to result in fetal distress once contractions start – these babies are already struggling. Pathological oligohydraminios is a serious complication.

Polyhydramnios – too much

The definition of polyhydramnios is usually around 2000mls of fluid; >8cm maximum pool; or AFI >25cm. Around 1-3% of pregnant women are diagnosed with having too much amniotic fluid. In 60% of cases there is no known cause, but factors that increase fluid volume include:

  • The baby producing too much urine
  • Decreased fetal swallowing (baby)
  • Increased water transfer across the placenta by the mother

These factors may be influenced by the general well being of mother and baby ie. may occur if there are complications present such as diabetes, rhesus isoimmunisation, congential abnormalities, etc. But, usually no complication is present.

Complications associated with polyhydramnios

  • Preterm birth – as the uterus become over stretched with fluid.
  • ‘Unstable’ position of the baby – the baby can float about into helpful and not so helpful positions.
  • Cord presentation or prolapse – because the baby is floating about the cord can get between his head and the cervix.
  • Placental abruption – may occur with a sudden change in fluid volume and therefore size of uterus/placental site.


Tests may be suggested to see if a cause can be identified (although nothing can be done at this point). Induction of labour with a ‘controlled’ artificial rupture of membranes may be suggested to manage the risk of an unstable lie and/or cord prolapse. This involves breaking the waters whilst holding the baby in place… and with quick access to theatre as the procedure can result in a cord prolapse. Alternatively, the woman may choose to wait until labour begins, and assess her baby’s position once contractions have started. Either way – the risk is the woman’s therefore she must be the person to decide which risks are best for her – induction or waiting.

In Summary

  • The exact mechanisms involved in regulating AFV are still unknown.
  • AFV reduces significantly after 37 weeks – this is normal.
  • There are no accurate methods of measuring amniotic fluid.
  • There is no agreement about what measurements indicate ‘high’ or ‘low’ AFV.
  • The intervention used to manage polyhydramnios or oligohydramnios ie. induction also carries risks which need to be taken into consideration.

So, as you can see this topic creates more questions than answers which is why I previously avoided it!

Further Resources

Science & Sensibility – What is the evidence for induction for low amniotic fluid in a healthy pregnancy?

Posted in birth, intervention, pregnancy | Tagged , , , , , , , | 149 Comments