Island Nurses

by Howie, Leonie; Robertson, Adele;

  At first, the locals were appalled at the idea that we—the midwives, Ivan as the doctor, the mothers themselves and their support people—would be so reckless as to risk the lives of women and babies by allowing women to birth at home. But, with each successful, uneventful and joyous delivery, opinion has come full circle. The fact that up to half of the eight to ten women on Aotea whom we care for each year will give birth in their own island homes is now a source of considerable pride to the community. In fact, it is even beginning to flow on to the next generation of childbearing women, who are choosing to birth at home even if home is no longer on the island.

  This is not to say that women feel under pressure to give birth at home. It is more a case that the community expresses itself willing to support a woman if she chooses to do so. And once the baby is born, it is enfolded by the community and owned, in a special sense, as ‘our’ baby.

  Each labour is unique, and it is always extraordinary to watch as a new baby emerges into the world. No matter the struggles during the antenatal period or the birthing, we are left pondering, How will this life unfold? What special things will this baby achieve as he or she grows to adulthood? We have both been fortunate—Adele especially—to have watched over many island babies as midwives. These babies progress to become toddlers and preschoolers and, as rural nurses, we remain involved with their care. The watching and nursing continues through their childhood illnesses and their teenage crises to adulthood. Some, of course, are 30-year-olds now, with their own burgeoning families—so the cycle starts again.

  The central person in a birth is the mother herself. This may seem so obvious as to be a truism, but sometimes it needs reiterating. The birth of a baby—in most cases, a natural event that a woman’s body is capable of performing with minimal assistance—has sometimes become over-medicalised in modern society. This is not to deny that Western medicine has vastly reduced the dangers inherent in difficult births, but the fact that medical intervention can save lives has also given rise to the assumption that it can improve upon the natural process in every case. Over time, this assumption has been increasingly challenged.

  Research has shown that a series of chemical events and processes occur in a woman’s body when she gives birth. It is described as a hormonal cascade, and each step needs to happen at the right time and in the right way for an easy, natural birth to occur. It seems that one of the keys to triggering and maintaining this process is that a woman is in a familiar place and feels safe enough to birth her baby. The place that most women feel private and safe in is their own home, surrounded by people known to them.

  Sometimes professionals are the only people present at the birth, assisting the woman and her partner. But most of the time numerous people come and go—mothers, sisters, close friends, children, aunts, grandparents. This could be overwhelming in a hospital birthing room, whereas in the home environment it is less so, as the woman can move to a private space in the house away from everyone. Close support people are vital, as they contribute to this sense of safety, and of course tend to continue their support postnatally with cooking, babysitting and housework. Usually by the time we leave the house, the whole community knows a baby has been born; often there is a sign put on the gate or at the general store. When British natural childbirth advocate Sheila Kitzinger describes the importance of ‘god-sips’—support people who assembled to assist at childbirth in medieval times and who turned birth into an important social occasion (there are echoes in our sense of the word ‘gossip’)—she could have been describing the way it is done on Great Barrier Island.

  The word ‘midwife’ comes from an old English term ‘mid wyf’, which merely meant ‘with the woman’. Even as professional midwives, our job is to support the woman, who is the leader. After that first home delivery, Adele has assisted at many, many more. Each event has been individual, and she came away each time richer in knowledge and experience. She quickly learned that the best approach was to be open and flexible and to look at each woman and birth individually. She even learned to relax about the lists of risk factors that she drew up for each. Quite often, the women themselves have known instinctively what is right and safe for themselves. And they have invariably been willing to change their minds if Adele has shown herself prepared to compromise. Over time, her thinking has fallen into line with her convictions—that women have the right to choose, even where their choices could, from the outside, appear slightly risky.

  As the lead provider of maternity services on the island, she has always had a team around her. In the old days, the team was Ivan. One day, he was sitting quietly in the kitchen while Adele attended the woman, and one of the children asked him why he was there.

  ‘Well, Adele is here to help your mum if she needs it, and I am here to help Adele if she needs it.’

  Quite unlike many doctors—especially in the 1980s—Ivan was happy merely to hold a torch to give Adele light. Once, the sister-in-law of the birthing woman asked Ivan to move out of the way so she could take pictures. Adele nearly laughed out loud, imagining how a hospital obstetrician would react to being pushed out of the way for photos!

  While Ivan was more than qualified by postgraduate training and by temperament to perform the role of assistant, Adele was conscious that calling the sole general practitioner on the island away to a birth was often disruptive to the running of the medical clinic. She was grateful when Leonie stepped in to the role. Even so, in the early days, Adele often ended up attending on her own. Later, when best practice dictated that there should be two midwives for each birth, we began to work more closely together. Midwives have also come to the island to relieve when unforeseen circumstances have arisen, or specifically to be with women whom they have assisted at births elsewhere in New Zealand. From time to time, midwives have lived for short periods on the island and, where possible (if the women agreed), Adele has involved them in any births occurring while they were here. These days, Adele also has a rural nurse who supports her in her nursing practice in the north and is sometimes able to assist her with maternity care.

  The island women and their families have allowed us to share an intimate part of their lives and this has strengthened us. We have met wonderful men and women present as support people who have radiated caring and love. We have learned new skills—massage, for example, from other women present at the births—and in turn have passed this knowledge on. We have witnessed the natural acceptance and excitement of children present at the arrival of a new sibling. We have been exposed to different music, languages, religious beliefs and philosophies of life, and we are the richer for it. We have shared food and cried and laughed with people we did not previously know well, and have built lasting friendships. We have learned that birth can occur in all sorts of places and positions, in differing amounts of light, with varying numbers of people present. We have witnessed how a community can rally around and give support to families, and how birth viewed as a positive and happy event can contribute to community well-being.

  Community midwifery can be terrifying, exhausting, challenging and immensely satisfying. Mostly, when Adele asks women if they have any plans for the birth, they reply, ‘No, I trust you.’ In the old days, this made her anxious, because she did not feel experienced enough or worthy of this trust. Gradually, though, she came to understand that women being able to trust her (and leave her to feel the anxiety) freed them to give birth without fear, and that it was all part of a process that ended in a natural birth. No fear equalled no tension equalled a steady progression of labour, which equalled a woman easily able to cope with contractions and led ultimately to the birth of a healthy baby. Even so, after 31 years of community midwifery practice, Adele is still learning not to lie awake at night and worry—about decisions that have been made and about things that might happen—and simply trust the women themselves. All this time, and she is still learning.

  Two births are imminent and Adele is experiencing her usual doubts, only at greater than usual intensity
. One of them is a birth she has agreed to attend on an island off the coast of Great Barrier Island. Amber’s* whānau is tangata whenua, and this will be her fourth baby. Her first birth, in hospital, was a set of premature twins who had a twin-to-twin transfusion—a condition where two foetuses share a single placenta and the blood flow is generally shared disproportionately. It usually has profound implications for the babies, and in Amber’s case one baby died, and the survivor was left with cerebral palsy. Her second birth, that of her son, was on the mainland, and all went very well. This, her third pregnancy, has progressed smoothly, but Adele is thinking about the 30-minute boat trip to the island, and the weather, and about what happens if anything goes wrong. And what if the birth is at night, and she loses sleep? How will that affect her performance and judgement, if she is called upon to attend the other birth soon afterward? And of course, what happens if both go into labour at the same time?

  The call, when it comes, is at six on a beautiful summer’s morning. Amber has been contracting since 4 am and is sending her brother-in-law to collect Adele.

  At 7 am, she loads her emergency gear and extra pads, towels and linen into the brother-in-law’s fishing boat. He throws the engine into gear and gives it a bit of throttle, and just as they are leaving the wharf, the glassy waters of the bay are disturbed by a pod of dolphins seeking out the pressure wave from the bow. No time to play, they roar out towards Man of War passage, between Kaikōura Island and the southern headland of Port FitzRoy. Twenty minutes after setting off, they hit the open sea. It is not calm (it rarely is) but the boat and skipper are well accustomed to these conditions and handle them effortlessly. As they reach the lee of the destination island, Adele sees two orca hunting the shallows for stingray, their distinctive, tall fins weaving above the shadows of their large bodies beneath the water. The skipper drops the engine to an idle and shifts out of gear and the boat glides into the wharf. The engine bellows as he gives it a quick squirt in reverse and brings them expertly alongside the wharf. He leaps off nimbly and drops a bight of rope around a bollard as Adele waits with her bag. She scrambles stiffly up on to the wharf. Twenty years ago, when she first visited Amber’s grandfather on this very island, she jumped off just as easily as the skipper did. Now she can only envy him his agility.

  Beyond the wharf, they pass through a barricade designed to stop wandering small children, and then walk up a steep path to the house. Adele was last here in her capacity as rural nurse just prior to the tangi for the family’s grandad, and as she steps into the cool of the house she is surrounded by photographs. His photograph is there, with others who have gone before alongside the new generation coming forward. The morning is full of significance: life is ratcheting in its circle, and it is joining Amber to the spiral of the generations that have preceded her on this land.

  It is twenty minutes to eight. Adele finds Amber coping with very long and strong contractions. Her waters are still intact. Her husband and mother-in-law are in attendance. As Adele is talking to Amber, another powerful contraction begins. She rolls on to her hands and knees, and her husband moves in and places a heat pack on the small of her back and lovingly rubs her back and shoulders. After a couple of minutes, it passes.

  The interval between the contractions shortens, and fifteen minutes after Adele’s arrival Amber moves from hands and knees to sitting. Adele is able to quickly take the opportunity to listen to the foetal heart through the smooth bulge of Amber’s belly. There is no time to count, but the beat is reassuringly strong and steady. Twenty more minutes later, when she gets another chance to check immediately after a contraction—the time at which the foetus is under the most stress—she finds that all remains well with the baby.

  Another contraction sets in. Adele sees that Amber is pushing this time, and she unhurriedly starts to pull on her gloves. She has only got as far as putting the left glove on when the head comes.

  ‘Well, you told me your babies come at first push!’ she says to Amber, and Amber nearly smiles.

  Adele gets her other glove on and performs a quick examination. The umbilical cord seems to be around the neck, but loosely so. Adele leaves it alone, and with the very next contraction a well-toned baby boy emerges, who cries and coughs immediately. Adele unravels the cord, and passes the baby through Amber’s legs and up to her. After a few minutes of skin-to-skin contact, Adele takes the baby boy and gives him a quick dry while Amber shuffles over to sit on the couch, whereupon Adele hands the baby back to his mother. Ten minutes later, Amber experiences another contraction. The cord has stopped pulsing. It is now safe for Dad to cut the cord, which he does, and then gathers the baby to him and takes his turn holding his son, skin-to-skin. Amber squats and pushes, and the whenua (the placenta) is eased out into a bowl. Adele examines it carefully for any evidence that it is only partial, or that there was a secondary attachment to the uterine wall. All seems in order.

  She switches her attention to Amber, who has come through it well, too. Her perineum is intact with no need for suturing. It has been an unbelievably smooth birth.

  ‘I’m so glad we didn’t have to pack up the kids and get the boat and the car to get to Mum’s place,’ Amber says, as she sips a cup of Milo. Her mother lives on the mainland.

  ‘True that,’ her husband agrees. ‘Ten hours, a real mission, and look at how easy it all was, right here.’

  They look around appreciatively at their home, at the new layer of significance it has gained for their whānau.

  Two hours later, all is normal with mother and baby—if the afterglow of a birth can ever be considered exactly normal—and Adele is back aboard the fishing boat. The reverse journey to Port FitzRoy is more sedate. The headlands with the swell crumbling at their feet and, beyond them, a few shreds of cloud around the summit of Hirakimata—it is a beautiful prospect. Adele thinks back to the beginning of this journey, blessed with dolphins and orca. It was such a perfect start to the day, a day on which a baby boy has started his own journey in the best possible way—an easy birth into a loving family at their home, with the photos of their ancestors looking on.

  It is four years since Adele visited Jill’s father in his isolated bay. Jill is now living in his bach—he has grown too unwell to live in such remote conditions and has shifted to the mainland—and she is in a relationship with the man who was clearing land for a house in nearby Allom Bay. The building of the house is underway, and they are expecting their first child (Jill’s third). They contacted Adele because they are planning a home birth, possibly a water birth.

  Now, late one autumn afternoon, Jill has rung to say the labour has started. Adele has had an early meal so that she can get to the house before dark. Shortly after she gets there, finding Jill glowing with excitement, Jill’s partner also arrives home, just on dark. As soon as he has had his dinner, he and Adele begin the laborious process of heating water for the birth pool.

  The birth pool has been hired from Auckland and shipped over on the cargo boat. Jill’s partner has set it up in the kitchen of one of their two small baches and has the wood ranges in both baches going strong. Each range heats a small hot-water cylinder from a wetback, and to move things along he also has an open fire blazing between the baches with two big cauldrons of water heating there as well.

  Just at the right time, the pool is full of lovely warm water. Jill lowers herself into it with a grateful sigh.

  Ivan arrives. Adele called him as her backup, and the two of them retreat to another room where Adele tries to get some sleep and Ivan sits reading. Jill enjoys the bath until the later stages of her labour, when the sensation of water on her skin becomes uncomfortable. She climbs out, and it’s soon clear the baby is on its way. The delivery is quite straightforward: a few pushes and a lovely, 7.5-pound baby is born at sunrise—a magical time of day, especially in such a magical place.

  A phone call comes to say that Jill’s father passed away that same morning: one soul passes out of their lives as another passes in.

 
It is two years on and Jill and her partner are expecting their second child. Leonie and Ivan arrive ahead of Adele; she asked them to attend when she learned Jill’s waters had broken and labour had begun. They live closer to Okupu than Adele does.

  This time, the trip to reach Jill involves a small boat across to Allom Bay. It is late afternoon but, unusually for the day of a birth, the weather is benign. Adele arrives to find the house finished. Jill’s stonemason partner has crafted it with love and skill and it is truly a work of art.

  We catch up quickly, and Adele learns that when the waters broke there was thick meconium in the liquor, likely indicating the baby has been or is stressed. Night is falling fast. We know that calling the helicopter to land in the dark would be challenging and Jill, her partner and Ivan are in full agreement not to take any risks. We call the helicopter, and farewell Jill and her partner.

  They are back the very next day, with a healthy baby boy who was born within an hour of their arrival at the hospital, and Jill introduces this latest addition to her daughter and elder son.

  We find that there is a slightly manic period between receiving the call from expectant parents and arrival at the house. This seems to produce a heightened awareness when we walk into the birthing room. You find yourself noticing things that you might not otherwise have noticed—the photos on the walls, the time of day or night, the other people present, the view outside, the lighting or, quite commonly, the music.