In this chapter, I will present two themes: ‘This is what we do’: Transforming risk scenarios into safety procedures; and Developing a Personal Sense of Safety: The Tailored Risk Appointment. Understanding the ‘risk discussion’ appointment and how it was implemented aids in understanding how risk was transformed into a dialogue of safety about birthing at the birth centre. This was especially in regard to the significance of one-to-one care and the respect for the needs of the women and their partner. In addition, for women who had experienced a previous traumatic birth, the second appointment was an opportunity to discover if the birth centre could really offer these women a place to give birth that they considered safe.
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11.1.1 ‘This Is What We Do’: Transforming Risk Scenarios into Safety Procedures
On my first day of observations at the birth centre, Karla, one of the midwives, recommended that I go with the midwife Rebecca to her appointment with Iris, pregnant with her second child in week 35. This was Iris’s ‘risk appointment’, also referred to as the ‘second appointment’ by the midwives. At this appointment, the midwives informed the pregnant woman and her birth companion about the risks associated with labour and the postpartum period. This was Rebecca’s description of the appointment from her interview:
It is actually just a description of our work, what we can do, what our limitations are and when we might have to transfer. It’s about how far our scope of practice reaches. I don’t even call it a risk discussion—I just call it the second appointment. I tell them: ‘We have a so-called second appointment, and it is about transfer situations’. This is what it’s about—in order to prepare the parents well. (Midwife interview, Rebecca)
The depiction of this appointment as the risk appointment seemed ironic to all of the midwives, since the ‘what-ifs’ at birth can happen anywhere, even in a hospital—or especially in a hospital, as many of the midwives believed. The ‘what-if’ scenarios discussed at the risk appointment ranged from non-emergency circumstances, such as contractions stopping at some point during labour, to emergency circumstances, such as postpartum heavy bleeding. I have conducted this appointment countless times at the birth centre where I work, so I was curious to hear how Rebecca would conduct this appointment.
Rebecca, Iris, her husband, and I went into one of the appointment rooms together. I still wasn’t familiar with the rooms at the birth centre, so Rebecca went into another room and grabbed a chair for me. She put the chair at one end of the table, which let me easily observe both the pair and Rebecca. After the four of us got seated at the table, Iris handed Rebecca several pages of what looked like a questionnaire. Each page had a birth centre logo at the top with questions that Iris had answered by hand. I hadn’t yet had the opportunity to look at the internal documents at the birth centre, so I wasn’t sure what these were. Rebecca skimmed over the answers that Iris had written down and mumbled to herself, “ah, okay, atony, meconium stained amniotic fluid” (FN 1). She then laid out two documents in front of her. One of these was the official informed consent form from the German Midwifery Association and the midwives’ liability insurance carrier,
148 the other was a checklist. I had brought a notebook in with me to take notes, something that I would refrain from at later observational sessions.
Rebecca looked at both Iris and her husband as she told them that the ‘risk talk’ was less about risk, and more about defining the scope of practice of the midwives at the birth centre. Specifically, it was about the possible situations that could arise during labour that the midwives would not be able to treat. These situations, should they arise, would require transfer. I found this explanation not only clear and coherent, but also novel. From my field notes:
Rebecca: Here is the form from our liability insurer. I will use our form for our talk, since it is in logical order and uses the proper names and conditions for the reasons for transfer, without the overly emotional language of the form written by our liability insurance carrier. I’ll give you this form when we’re finished. You are required to read it and sign it as a condition for giving birth at the birth centre, but you must wait 24 hours after this risk discussion (Risikobesprechung) before you make your decision. Only then, should you sign the form. (Field notes, record 1)
Rebecca explained the operational structure of the birth centre to Iris and her husband, focusing on the advantages of one-to-one care during labour and two-to-one care (two midwives for each woman) at birth (the emergence of the baby). One of the main advantages, according to Rebecca, was that the close, intimate care created a deeper exchange between the midwives and women than was possible when a midwife was caring for more than one woman at a time or having to go in and out of the room to accomplish other tasks. She explained, for example, that the midwives were able to expeditiously detect situations that would either necessitate an intervention at the birth centre or require transfer to a hospital during labour, before they became emergencies. Transfer would be necessary only if the treatment needed by the woman or baby went beyond the scope of practice of the midwives. While listening to this and taking copious notes, I realized that, although this was a ‘risk’ appointment, Rebecca, while focusing on specific unplanned events that could occur during labour, did not use the word ‘risk.’ Again, from my field notes:
She goes through the list and doesn’t mention the word RISK even once! How has she managed this? I am waiting for it, waiting to hear the word, but it never comes. She uses phrases like: This is something that happens very rarely. This is something that I have never experienced at the birth centre, but it is known to happen on very rare occasions. Rebecca allows time for questions. Iris and her husband have very few. Iris describes the situation at her first birth, which was in a hospital delivery room. She says: “Four people threw themselves on my belly and pushed down very hard (Kristeller manouvre); then they took my baby away.”
149 She wants to know what happens at the birth centre after the birth if the baby has a problem.
Rebecca: If the baby is having problems adapting, then the baby stays with you, still attached to the placenta if the cord is still pulsating. We can bring all of our resuscitation gear over to where you have given birth. You can hold your baby in your arms or between your legs and talk to him. He should hear your voices. This is very important. We call a neonatologist. An ambulance is here within 10 minutes. In the meantime, we are all trained to perform newborn resuscitation. We also have to call a second team of emergency medical technicians. The room fills up quickly with strangers (Fremde) who have come to help. If we call a neonatologist, then they will almost always take the baby with, even if he is okay when they arrive. If they take the baby, then there is no space in the vehicle for you or for your husband. Your husband can either stay here with you, or go in a car to the hospital where the baby will be. Sometimes, you cannot be admitted to the same hospital where your baby is. It is an unhappy situation, but this is sometimes what happens. We often try to find a solution, even invent a medical indication, so that the mother can be admitted to the maternity ward in the same hospital where the baby is. (Field notes, record 1)
I discovered after the appointment that Rebecca knew all the details of Iris’s first birth. At that birth, which was in a hospital, Iris’s cervix dilated quickly to 10 cm. Iris felt overwhelmed and asked for an epidural. The epidural slowed down the progress of the birth so much so, that she needed to have an oxytocin drip to augment her contractions. During the expulsion phase of labour, the heartbeats of her baby were pathological, and she couldn’t push because of the epidural, so the doctor pulled out the baby using vacuum extraction. Her baby needed to be resuscitated after birth, was taken to a different room for this, and transferred after that to a neonatal clinic. She didn’t see him until 90 minutes after the birth and wasn’t allowed to hold him the first day. Her baby remained in the hospital for a week. Iris suffered from postpartum depression after this birth. She had reflected on her birth from her perspective as a medical professional, and had come to the conclusion that the epidural was perhaps unnecessary and had probably led to the need for the oxytocin drip, which then affected the heart rate of the baby. The epidural left her unable to push, which led to the need to use physical force on her abdomen (Kristeller manouvre) and the vacuum to expedite the birth of her baby.
Throughout the discussion, Rebecca kept the focus on the scope of practice of the midwives within the framework of the birth centre. She made it clear that there were possibilities for interventions at the hospital that midwives were allowed to carry out under the supervision of an obstetrician that were not permitted at the birth centre. A few of these that were mentioned were administering an oxytocin drip during labour to augment contractions, caring for women with elevated blood pressure, and caring for women who needed intravenous antibiotics.
150 Iris believed that the circumstances at her first birth, as well as the dramatic, poor outcome and transfer of her baby to a neonatal ward, was caused by a combination of fragmented care at birth and the utilization of interventions that she didn’t actually need. She didn’t feel safe going back to the hospital for the upcoming birth. She had chosen the birth centre this time because the interventions that she felt had led to a poor outcome were not available there. For her, as a physician, she understood that one-to-one care meant having someone watching her and keeping track of all of the changes and developments during her labour. The most important piece of information for Iris was that the midwives would do everything possible to keep her together with her baby, even if problems would arise.
Iris was separated from her first baby after his birth and felt reassured after hearing Rebecca explain the measures that would be taken if her baby would need physician care after her upcoming birth. For Natalie, however, pregnant with her first child, hearing about the ‘what-ifs’ at the second appointment frightened her, especially hearing that she and her baby would be separated if the baby had to be transferred after birth. Natalie said:
I went to the second appointment with my husband and found it really unpleasant. It lasted two hours. We talked about everything that could go wrong. For me, the biggest risk is that maybe the baby won’t be okay, and that it would have to get transferred to a hospital, and I wouldn’t be there. That is a terrifying thought. But, with me, if there would be anything with me, that’s an unpleasant notion for my husband, but it’s not so dramatic. But the idea that I would come here with a full belly and leave without my baby—that is awful. (Antenatal interview, Natalie)
Natalie was the only woman I interviewed who wasn’t reassured at the second appointment. Like Natalie, Magda was also worried about what would happen if her baby had problems adapting after birth and had to be transferred. She explained:
The second appointment really helped both of us. We had to come to terms with all of the risks. We heard about a lot of things that I didn’t know anything about before. And I got to confront the fears I had had about what would happen if there would be anything wrong with the baby. … And then we were told in detail what happens if there is an emergency with the baby. … I felt that my baby was safe after that. (Antenatal interview, Magda)
Magda felt that the information that she heard at her second appointment had given her the opportunity to air her fears and talk openly about them. Hearing exactly what the procedures would be should problems arise took the abstractness out of the notion of
151 ‘what if’, giving her concrete answers concerning her fears. The rest of the interviews with the women echoed what Magda had said to me. Tamara told me at her interview:
I guess you can always have concerns about almost everything you do, you know, like that something could happen. We had the second appointment, the risk appointment. We got a really good explanation about what the midwives do in particular circumstances. Most of the transfers are non-emergency transfers— only rarely is there an emergency. The distance to the hospital isn’t long. … They don’t take any risks here. The continuous support from the midwives means that they have a better and more complete picture of what’s going on with the woman than in the hospital. Because of this, we both feel that we’re in good hands here at the birth centre. (Antenatal interview, Tamara)
For Nadia, pregnant with her first child, hearing exactly how problems are managed made all the difference for her. She made sure that all of her questions were answered at her second appointment. She told me:
I didn’t make my decision about giving birth here (at the birth centre), didn’t know if I had enough trust, until after the second appointment. I had left it open. … I needed to hear the drill here. I asked at the second appointment: What do you do if a woman has excessive uterine bleeding postpartum? What exactly do you do? And then what happens?
I wanted to have the answers. I also had to hear from them: “We have partussisten (a medication used during labour to supress uterine contractions); we can insert a venous catheter; we can give you an oxytocin injection postpartum (to stop heavy bleeding)”. I had to hear about those kinds of things. It’s not like they can’t do anything here. That had been my fear. (Antenatal interview, Nadia)
One of the midwives, Beatrice, thought that it would be beneficial for women and their partner to have time to ask questions of the birth attendants in whatever setting they’re planning to give birth. Her explanation shows that the parents-to-be have a chance to have agency if they have heard in advance what the specific procedures at their chosen birth site are. She said this to me:
The topics at the risk appointment are always so intense, like placental abruption (when the placenta detaches from the uterus before the baby is born) and the death of the baby and, in spite of this, it’s possible to inform parents without making a horror story out of it. You know, so that the parents don’t end up feeling like—Oh God, it would be best not to have a baby at all, but rather this: an informed decision for or against something so that you feel safe about whatever decision you make. …
152 This isn’t about us avoiding getting sued. It’s about being in the know—knowing what the risks are so that the parents can decide for or against something. And to be able to talk about what happens if the birth doesn’t happen according to the plans they’ve made. We tell them—this is what we do in this or that situation. We tell them about the various medications we have and about our emergency equipment. (Midwife interview, Beatrice)
Beatrice also spoke about the legal protection that midwives at the birth centre have through getting informed consent from the women registered to give birth at the birth centre. The woman’s partner/husband or birth companion is also required to sign the form, a feature of the contract that the midwives found beneficial.
11.1.2 Summary of Section 11.1
The midwives believed that the risk discussion was primarily for the women, since a well- informed woman could better take part in decision-making should a situation arise that might warrant transfer. In addition, the midwives built trust through transforming the risk discourse about birth at the birth centre into a discourse of action and safety based on the scope of practice of the midwives. The reassurance that the women and their partners experienced after this appointment helped to solidify their confidence in their decision to birth at the birth centre.