Birthing business

There were many different descriptions of what occurred during birth, there were differences both between and within the different language groups and also differences depending on the place of birth. These differences are best described in the women's own words in the section titled 'Stories'. For that reason we have not included lengthy descriptions in this section.

Traditional midwives - Jin-guwelamagepa

In this region there were women who were known to be experienced in childbirth. In the Burarra language the name for these women was Jin-guwelamagepa. There did not seem to be any special name for them in the other languages though most women knew who they were. These women would pass information about childbirth on from one generation to the next. They seemed to be matriarchs of a clan and would often have been present at the births of many of the babies born to women in their extended family. Usually these women would not be present at the births of women outside their own family group. For ease of identification throughout this guide we have called these women traditional midwives.

Aboriginal health workers (AHW)

Some of the health workers were very experienced in birthing business. Most had received training in a variety of ways. Mostly they had trained in an apprenticeship model, learning from the midwives who had worked in the community. Five of the health workers in Maningrida had spent 12 weeks in Darwin doing midwifery training; this had included both theory and practical experience. Most of the health workers had also learnt from older women (the traditional midwives) who assisted with births in the community and from experiences that they had with their own births.

Molly described how she would work differently depending on where she was. When in the community she would advise women the way the older women had taught her, always birthing in an upright position. The women would often have an older woman sitting behind them and they would rub their tummy or their back for them.

When the pain was really bad the woman would be told to break the bag of waters, to pinch them with their finger, like a balloon. You shouldn't push till they are broken, it can make the baby die. Then, they would be told to put their feet together and to hold their bum together when the baby was coming out, this would stop them from tearing.

When Molly was in the health centre she would advise women the way the Balanda midwives had taught her, making sure they showered and mostly birthing lying semi-recumbent on the bed. She would check their progress by vaginal examination and used savlon to clean the perineum. It has been well documented that the 'power of place' strongly influences how midwives work and how women birth.[47] This was evident with Molly's stories and is probably one of the reasons women want to be able to birth in their own communities, so they can birth 'their way'.

During birth

If a woman is birthing in the community encourage at least one support person of her choice to stay with her throughout labour and birth. It is important that she is able to move about freely and choose a position of comfort for birth. Often placing a mattress on the floor can assist in more upright positions such as the one shown in the photo below. These positions, now being promoted in many hospitals, have been used in the bush for hundreds of years. Talk to the woman and ask her what she wants. At birth do not place the baby up on the mothers tummy without asking first.

Every mother needs a support person with them when they go to a strange place to give birth. If a mother is less than fifteen then she will automatically have an official escort. Older than this, then we have to advocate strongly for an official escort. We argue for one if the mother is travelling for her first labour regardless of her age. Otherwise we advise mothers to ask family to save money for someone to accompany them and also for shopping for baby clothes. If the mother is well supported then the risks for complications are decreased! (Hellen Matthews RAN/RM)

I had my fourth baby in Darwin hospital and I went to the toilet and I had strong pain, I got scared. Then that lady came and said 'now be a good girl and jump on the bed'. I said 'I want to sit on the ground I don’t want to sit on no bed'. But she wouldn’t let me, she gave me a pan to sit on but no wee came out, it was just the baby pushing down. So I had to jump on the bed and they gave me a needle. That needle made me sleep. I didn’t know that my baby was born, I was sleeping all day. She said 'push, push,' well I couldn’t push you know I wasn’t ready. I said 'I can’t do it'. 'Don’t be naughty like that, be a good girl' she said. 'No I don’t like no baby'. 'No well you’re going to have your baby'. I couldn’t stop what was happening after that. (Phyllis)

We know as midwives that it is important that women are active and more upright during labour as it helps to progress the labour and to make it less painful. Traditionally women had physical support to hold them upright during the labour and to squat for the birth. We might think that it is a good idea but the mother might not! Many times I have tried to help the mother be active and move about during labour or to keep pushing at an appropriate time only to be told “wait, I’m tired, I want to sleep”! (Hellen Matthews RAN/RM)

Young girls were allowed to watch, I was about seven or eight when I saw my first baby being born. (Molly)

Her mother told her to hold on to a branch of a tree and swing to help stop the pains. She was standing up and suddenly that baby girl was born straight onto the soft sand while she was standing up. She had her mother and grandmother with her when it happened. The baby bag came out not long after the baby was born, just by itself. (Mabel)

I was the only female apart from the patient there that night. She followed her partner in there and he was in there and he was in the shower with her, admittedly he didn’t take his clothes off, but that was really unusual. She was a young girl, he was a young man. He was only about sixteen or seventeen that bloke. There have been a few that have had their partners in. (Remote Area Nurse Midwife)

My husband was with me for all of my babies. Some husbands will stay together with their wife and some will want to sit by themselves or go hunting. Some will see the birth with their own eyes. (Barbara)

When life was more traditional women had very few difficulties with birthing. ‘Survival of the fittest’ would have ensured that a small pelvis was rare and because of smaller babies CPD was also rare. Women were lean and strong and birthing was relatively easy with postnatal bleeding lasting only a few days. Involution of the fundus occurred very quickly, gone in a matter of days! The Grandmothers of today had few difficulties when they gave birth many years ago, but it is a different story for the young mothers nowadays with the increase in lifestyle diseases. (Hellen Matthews RAN/RM)

Babies coming early (preterm birth)

Sometimes the babies would come early, mainly if it was twins or something. I said to one lady - you've got two babies in there but she didn't believe me. But that second one was sick, you could tell - the cord was white and skinny and we had to call the seaplane to take that baby to Darwin. (Molly)

Preterm labour is a major cause of perinatal mortality in Australia. It is defined as labour commencing before 37 weeks of pregnancy and in 2000 it occurred in 7% of all births with a higher incidence occurring in the NT (10%).[43] It is diagnosed when there are at least three regular contractions in 30 minutes, with accompanying cervical changes, prior to 37 weeks. The goals of management are:

It is ideal to transfer to a tertiary setting while the baby is still in utero as before 32-34 weeks it reduces the incidence of neonatal mortality by 60% when compared to transferring after birth.[44]

Preterm premature rupture of membranes (PPROM) is defined when the membranes rupture at least 1 hour before the commencement of labour prior to 37 weeks pregnancy. If this occurs in the remote setting the goals and management are similar to preterm labour.[44]

Case study

Mandy presented to the health centre stating she felt generally unwell, with abdominal cramping, lower back pain, and stinging when passing urine. You have been seeing Mandy antenatally and have estimated she is about 31 weeks pregnant with her third pregnancy.

Q. Which ones of the following are not associated with preterm labour?

A history of previous preterm labour
Asymptomatic Bacterial Vaginosis
Twin pregnancy
Asymptomatic urinary tract infection
Diabetes in pregnancy
Pylonephritis
Cervical polyps
Lower socioeconomic status

ANSWER: 5 & 7 - diabetes in pregnancy and cervical polyps are not known to be associated with preterm labour.

Preterm labour is more common in women who have had previous preterm births:

1 previous preterm birth = 15% will have another preterm birth

2 previous consecutive preterm births = 30% will have another preterm birth

>2 previous preterm births = > 50% will have another preterm birth

Maternal infections that may trigger preterm labour include: urinary tract infections (UTI’s), which may be asymptomatic; sexually transmitted infections (STI’s), which can also be asymptomatic and include Gonorrhoea, Chlamydia, Syphilis, Trichomonas and Bacterial Vaginosis; or febrile conditions including chest infections, pyelonephritis or a viral illness. Treating UTI’s with antibiotics, even when asymptomatic, reduces the incidence of premature birth and low birth weight (LBW). Dipstick testing of urine is not enough to detect UTI’s, cultures need to be performed. It is recommended that clean catch MSU be performed at first visit or between 12 -16 weeks for this reason. This requires the woman to wash her hands first. Then she needs to part her labia to clean the area with either a towelette (sometimes supplied by the pathology departments), or gauze / cotton wool and water or saline, wiping from front to back. Then she needs to start to pass urine into the toilet catching the middle part of the urine stream into a sterile container. The container only needs to be 1/3 - 1/2 full and then needs to be stored in the fridge till it is transported to the pathology department.

Other risk factors for preterm labour include a history of ruptured membranes, increased uterine size (twins, polyhydramnios etc), maternal trauma, and pregnancy complications such as antepartum haemorrhage (APH), abruption, uterine anomalies or cervical incompetence.[44]

Management of preterm labour

Is Mandy in labour, have her waters broken and does she have any other risk factors present that need to be managed (eg. maternal infection or fever, history of trauma)?

Mandy is contracting every 8 minutes and does not think her waters have broken. The stinging that is present when she passes urine suggests Mandy could have some form of infection, either urinary or genital.

The main thing to do is to transfer Mandy to a facility that has an appropriate level neonatal nursery for the gestation (Level 3) as then Mandy's baby will have a much greater chance of surviving.[44] If possible it would be best to arrange for someone to go with Mandy as outcomes are know to be better if women have support in labour. As the baby is preterm this is a very frightening time for Mandy and having company can be very important, particularly if the outcome is not optimal.

Things to do include a general physical examination including fetal heart rate and assessment of contractions. You should perform a clean catch MSU and a Low Vaginal Swab for MC & S. You need to follow your local protocols and test for STI's (PCR testing on either a tampon test or urine test if available). DO NOT PERFORM A VAGINAL EXAMINATION. If digital vaginal examinations are performed when the membranes have ruptured then you are increasing the risk of infection and can reduce the latency period before labour begins. It is preferable to do a speculum examination which will also allow you to look for pooling fluid (to help diagnose ruptured membranes), dilatation of the cervix and any signs of infection (though these will not always be evident and trials have shown that even experienced practitioners can not accurately identify infection without laboratory confirmation).

Additionally Mandy will need a cannula inserted and prophylactic IV antibiotics to prevent Group B strep infection of the newborn. Traditionally bed rest and IV fluids have been recommended. Although there is no solid evidence to suggest these make a difference they may be appropriate depending on individual circumstances but fluids should not be given unless clinically indicated as pulmonary oedema is a potential side effect if too much fluid is given particularly if there is an underlying cardiac condition. Avoiding narcotics and sedation is advisable, particularly if the birth is imminent as narcotics can have profound effects on preterm infants.[44]

One thing that is really important is the administration of IM Betamethasone (corticosteroids).[44] This will help to mature the lungs of the fetus and prevent respiratory distress syndrome, and it is highly effective in lowering intraventricular haemorrhage and infant mortality. It is recommended during 24-34 weeks of pregnancy. Check that there are no contraindications to steroids (eg. active TB).

Use of Salbutamol in Preterm Labour

Salbutamol (Ventolin) is a smooth muscle relaxant and must be given intravenously via some form of pump, (refer to local protocol for dose). Contraindications include cardiac disease, hyperthyroid, uncontrolled diabetes, APH, uterine infection. Be aware of side effects, they can include tachycardia (fetal and maternal), palpitations, anxiety and restlessness. Ventolin should not be used for more than 48 hours. Using Ventolin can put women at risk of pulmonary oedema from fluid overload. Fluid balance must be monitored carefully, particularly if other infusions are running. Despite the widespread use of tocolysis, from drugs such as Ventolin, there has been no change in the rate of preterm birth. However they often provide enough of a delay to transfer the woman to a high risk centre and administer steroids, both of which effect the outcomes for the baby.[45]

Other drugs used in preterm labour

Nifedipine is a calcium channel blocker shown to be equally effective to Ventolin but classified as a Class C drug (not recommended in pregnancy- can cause fetal hypoxia from hypotension). In fact several small trials have shown fewer side effects, admissions to neonatal nurseries and a longer time till birth when calcium channel blockers have been used.[32] More trials have been recommended. However some areas are using Nifedipine which could be given orally as per local protocol. Contraindications include hypotension, cardiac disease, pre eclampsia and uterine infection. It has less side effects than Ventolin but they include hypotension, dizziness, headache and vomiting.

Other drugs that are being used include: Indomethacin (Indocid suppositories) is believed to be effective but there are concerns over effects on fetal circulation including constriction of the ductus arteriosis therefore it should not be used; Glycerin Trinitrate (GTN patches), for which there is insufficient evidence for use in practice; and, Magnesium Sulphate which has not been shown to be effective if given in safe doses.[44,32]

A new drug being trialed overseas is an oxytocin antagonist (Atosiban) and although it has not been shown to be more effective it has less side effects than Salbutamol. It is not yet available in Australia.[45]

Possible problems[45,32]

You may not be able to stop Mandy from having her baby in the community before the transfer team arrive. Do make sure you have family members to support Mandy in labour.

As the baby is preterm it may not be in the head down position and could be in the breech or transverse position. Cord prolapse is also a potential complication in this situation.

Other conditions that are associated with preterm birth include pre eclampsia, abruption, placenta previa, multiple pregnancy and intrauterine growth restriction.

The cervix does not always have to get to 10cm dilatation for a preterm baby to birth.

The routine use of forceps and episiotomy for preterm birth should be abandoned.

What if Mandy has her baby before she is transferred?

Summary

5. Treat with compassion and communicate everything you are doing with her and her family

Breech babies

Breech births occur in about 3-4% of births but are more common with increasing prematurity.[44] Just as we do today, Maningrida women and traditional healers used to turn the breech babies to make the head come first. External cephalic version is now being recommended for anyone with a breech presentation. External cephalic version is usually recommended at around 37 weeks of pregnancy, if done any earlier there is a higher chance of spontaneous reversion and after this time, as the baby gets bigger, the success rate decreases.[44]

You know when that baby’s up the wrong way they try and twist them. The old people and the bush doctor even if he is a man he can still do that, twist it, twist it, little by little until it is straight, till the head is down and the legs are up. Push it, push it and they can make it straight. (Charlie, traditional healers)

Nobody helps the baby come away, they don’t touch it, just leave it. The mother has to push to do it, the mother has to do everything for the baby to get it out by itself. (Elizabeth)

The baby gets born onto paperbark and no-one needs to touch the babies till they are out. When they come feet first the birth is the same way, just nice and slowly that baby has to come out. Not like in hospital where it has to come out quick, here it has to be slow. (Lena)

The cord

After the baby was born they would use breast milk to put on the cord to heal it up. (Marie and Nancy)

Many years ago many of the outstation ladies would birth their babies out bush. Generally the mothers were lean and healthy. I would provide antenatal care and when the baby was born, I would receive a radio message telling me of the event. I would then either drive, fly or go by boat to the outstation and check the mother and baby to ensure all was well. There was very few problems apart from small babies but they usually thrived after the birth. The umbilical cord stump usually separated in 2-3 days and there was very little infection. (Hellen Matthews RAN/RM)

The afterbirth

Make sure you talk about the placenta with the woman and her family. Many areas have special ways they like to dispose of the placenta. It can be particularly important to the older women. It is important to listen to the older women as they know what should be done to keep the culture strong.

If a baby is born here at Maningrida it is important to old people what happens to the placenta.

After the baby is born, while the mother is still sleepy, she has to lie down. Another lady is standing up and she uses her foot to push down on the stomach to bring the baby bag out. They always did that to get the baby bag out, pushing with the foot. They never had any problems with it, they never tried to put their hand up inside and pull that baby bag out, they didn't need to. They usually bleed a lot for one day but then the bleeding stops. The bleeding always stops they never had problems with women bleeding too much, always they could stop the bleeding. (Mara Mira)

Managing the third stage

A Cochrane Review showed active management of the third stage, when compared to physiological management, decreases the risk of PPH and blood transfusion.[46] The recommendation was that active management be routine when birthing in a maternity hospital but the results were not as clear when birthing in other settings including the home or developing countries.[46] Active management includes the administration of prophylactic oxytocics, early cord clamping and cutting, and controlled cord traction.

Controlled Cord Traction: Watch for signs of separation of the placenta, a lengthening of the cord, a show of blood and the uterus rising in the abdomen. Place a metal clamp on the cord near the vulva. Hold the clamp in one hand. Place the other hand above the pelvic bone and gently push in and up to prevent the uterus being pulled out. Use gentle traction to pull down on the cord. Never pull on the cord without applying counter-traction as in the diagram below. Stop if there is resistance, if it feels like tearing or if the placenta does not descend after 30-40 seconds. Once the placenta comes through the vulva, turn the placenta around twisting on the membranes and VERY GENTLY deliver them to prevent leaving some behind. Keep the placenta for inspection; to ensure the placenta and membranes are complete. Discuss with the family to see how they want to dispose of the placenta (particularly the older women as they may feel very strongly about it).

Alternatively physiological third stage can be practiced whereby the placenta is born by maternal effort (this is often easier in the squatting position or sitting on a pan) and the cord is cut and clamped when it stops pulsating. Nipple stimulation can be used to assist this process. It is important to discuss the management of the third stage antenatally so that the woman and her family can make informed decisions about whether they want to use active or physiological management.

The grandmother used to take that baby bag and put it in pandanus and then put it in a tree where the green ants would eat it. This would help to stop them having further babies. If they go to Darwin from Maningrida when they are in labour that girl should tell one of the sisters to give her the baby bag. After birth they can have a rest for a little while. When they get a little bit stronger, they can wrap up that baby bag in the plastic bag, and she can take a girlfriend with her and they can fix it. They have a lot of like, jungle places there near that hospital, and they can go and hang it up quick and the black ants can eat them up. If they put that baby bag in the fridge it is no good it can make the baby sick. (Esther, Ruby and Molly)

The baby bag should be given to the family and they will take it to the ant pit. (Wendy)

After the baby was born her husband used the sweat from under his arm and he put the sweat on the babies’ body. This makes sure the baby grows up strong and will do the right thing culturally. (Mabel)

Still birth

If a baby dies it is important to talk to the family about it. The baby may need to go to the referral centre to try and find out the cause of death but many families will want the baby to come back home for a proper ceremony and burial.

A young teenager with RHD and blood clotting abnormalities, despite denying sexual activity was found to be six months pregnant. Never assume that even though you might have a good rapport with a client and that she denies having a boyfriend, that a client does not need contraception! Soon after the first antenatal visit she had a premature labour and delivered a stillborn female baby at the health centre. The young mother wanted to see the baby even though the grandmother did not. She was still angry and disappointed with her daughter because of the pregnancy. The young mother was evacuated to the regional hospital, but I wrapped up the little baby and gave it to the Grandmother to be buried somewhere nice. The reasons for the labour were obvious at the birth. A week later the Grandmother told me that her sister had dreamt of their own mother holding onto the hand of a little girl. They had buried the baby next to the grave of their own mother and were happy with the knowledge that they were together. (Hellen Matthews RAN/RM)

If that baby is born and it isn’t alive then they take the baby to the bush and they have a funeral for that baby. But if it is a small one like premature, then they might just leave it. (Lena and Nancy)

She’s talking about the dead one what happened to it in the olden days. The dead baby when it’s outside, when that baby has past out, they just cut the cord and the baby just lies there. Sometimes when the baby dies they just go and bury it straight away. They just wrap it up in the paper bark but mostly they used to put the baby in the sun high up on a shelter, to stop the smell. The mother just keeps an eye on them so they keep the birds away and the baby, dead body baby, stays up there in the sun by itself. Then they would make a dilly bag (string bag). After two days they would bring the baby down and wrap it up, and put it in the dilly bag (string bag). The bag would be carried around with them sometimes for many years, not in town but out bush. These days the babies are buried and the placenta gets thrown into the bush for the ants to eat. (Marie, Mary and Nancy)

Sometimes, a long time ago, they would eat those babies, or even the older people, cut them up like a piece of beef. (Barbara)

This made all the women laugh and an older lady laughed and said to me 'be careful or we will eat you', and then we all laughed.