Australian Midwives

by Paula Heelan

  Moving to Cairns to work was a whole new state of play for Mark. ‘Cairns is a tropical gem fringed with palm trees in the midst of the luscious green wet tropics,’ Mark says. ‘White deserted beaches, aquamarine water and of course, right beside the Great Barrier Reef. The city is a melting pot of humanity – all cultures, young sea-changers like me and a large population of Indigenous people. It is a tourist mecca – a little bit like South East Asia but with the beautiful Aboriginal Torres Strait Islander culture.’

  Growing up in Clermont Mark was used to living in dry, black soil plains. He was also used to a searing dry heat where long spells of over 40 degrees was commonplace. He wasn’t prepared for Cairns’ high humidity and incredible rainfall. ‘Arriving in January it was muggy and sweltering hot. I remember the monsoonal rain on the first day I was at the hospital and wishing some of the downpour could go further west to break the drought.’

  In Cairns after graduation, Mark took part in Team Midwifery. When a woman goes into labour a midwife she has met during previous months assists her. ‘It begins at antenatal classes when the pregnant woman is not in a vulnerable state. At that stage she could just get to know me as Mark rather than as the male midwife. It was a great idea.’

  One of the most influential midwives Mark has worked with is Kelly Kearns. ‘She was my supervisor and nominated herself to supervise a male as she thought it would be a challenge,’ he says. ‘I did a lot of supervised prac with Kelly and she taught me how to practise in different environments, particularly midwifery care in high-risk and obstetric situations.’

  Kelly remembers the day she was asked to supervise Mark. ‘I’m very traditional and dead against men in the birth suite,’ she says. ‘I think the birthing place is for women only and for the woman giving birth to have four or five women around her for that long labour, to rub her back and to offer that support.’

  When Kelly received an email from a midwifery educator asking her to mentor a new midwife in training she was more than happy to do so. ‘I love mentoring students and getting them before they touch the ground,’ she says. ‘I’m a good teacher on the floor. Yes please, I said, send me the student’s details. But when the email came back and read, The student I’m giving you is named Mark Holmes, I thought, Oh my God, she’s given me a man. She knows how I feel about men in the birthing suite. I was gutted. I’ve got to train up a bloody man. But I couldn’t get out of it. I took Mark on and yes, we made him a midwife. He actually had a fantastic rapport with the women. With the first birth we did I noticed how well he got on with the woman. We did a year together and he’s gone on to do remarkable things in midwifery. He has a natural empathy and connection with women – the essential criteria for a midwife.’

  One day in Cairns a young girl had developed pre-eclampsia. ‘When you have high blood pressure and a number of other complications, the biggest fear is the woman will have a seizure. This girl was so young and past her due date. She was induced and with excessively high blood pressure, she needed immediate medication management. Then she had to go onto an infusion to maintain the blood pressure and then an oxytocin drip to progress her labour. She ended up having an epidural – so there was a lot going on for her.’

  In the context of midwifery practice, this was very abnormal. But it was a good case of an excellent team of obstetricians and others working together to help her. ‘She was very unwell and had to have a lot of medication,’ Mark explains. As he watched her sitting there with several infusion devices and lit up like a Christmas tree, he realised this kind of situation took a huge amount of care. ‘It’s easy to just look after the machines and focus on baby vitals and numbers, but what Kelly showed me this day was to bring in the midwifery side of things. Which meant not “nursing” the machines, being task oriented and ticking things off, but instead putting the woman at the centre of the care, speaking with her, making her an active participant and applying midwifery knowledge to a high-risk obstetric situation. It means using our knowledge of how best to get the most out of the woman during birth – for example we know the best position to facilitate the descent of a baby is upright. We try to normalise and minimise the obstetric intervention along with supporting and educating the woman to empower her to tap into her intuitive knowledge.’

  The girl was extremely scared and relatively health illiterate. With Kelly’s guidance, Mark explained to her what was happening. Because she was high risk, there was a big medical team hovering around and most were keen to perform a caesarian. Mark could see the girl was terrified at the thought of having an operation. ‘So we worked hard, call it midwifery guardianship if you like, to fend people off and maintain safety and progression. Kelly changed the girl’s position with an epidural in. It was the first time I’d seen a woman with an epidural moved to another position other than being recumbent with monitors on. Kelly got her onto her feet, propped her up so her uterus didn’t have to work as hard when it contracted and rose up. An upright position taps into the power of gravity and this helps to use the woman’s innate ability to birth despite her being unwell and at the end of a lot of medical intervention. It moved the woman back into a role of power and allowed her to re-own the birth.’

  Mark forced himself to stay calm and collected. ‘I thought, I’m just like the fifteen-year-old girl – absolutely terrified. I had come from a nursing background where multiple infusions didn’t scare me, but I had no idea that managing the workflow could be like this.’

  At the time the student midwives had to follow a certain amount of women through their care from antenatal to postnatal – and this girl was one of Mark’s follow-throughs. ‘We were monitoring the baby with a CTG monitor, constantly listening to the baby’s heart rate and we had cardiac monitoring on to watch mum’s heart rate because drugs can affect cardiac rhythms. Plus we had the epidural management and other medication, infusion and maintenance going on. Up to this point I’d only seen upright, beautiful natural births on work experience. I’d studied and heard about dramas, but this was the first time I’d gained an appreciation of things going wrong.’

  Mark had never seen so much fear in anyone as this girl and it frightened him. His job was to lessen her fear and not show his. ‘I thought, We have to reassure her. We had to get ourselves over a really complex situation and keep advocating for her. She had moved from a hard-working, active birth to sitting on the bed, quiet and still. Thankfully, things progressed well from there and the baby birthed without the caesarian and mother and child were fine. I followed the mum through and watched her take to early parenting. I had formed preconceptions in my mind – but she made a fantastic mother and did amazingly well considering her young age.’

  It was then that Mark understood the importance of midwifery. ‘For the first time I saw the difference between a midwife and a nurse. It went way beyond what I knew in nursing and crossed into that whole midwifery realm. I still think about it to this day and have since presented the case at a midwifery conference to highlight the value of a midwifery partnership in high-risk obstetrics.’

  Kelly was very passionate about water birth and was instrumental in introducing it to Cairns at the time. Pregnant women had started asking for them. And while there was quite a bit of scepticism from hospital management and some obstetricians, it was all about providing the option. Kelly taught Mark how to do it. ‘To birth underwater is an incredible thing and it’s a great option in hospitals now. In low light, a warm room and warm water, the atmosphere is beautiful. The woman is completely immersed and her partner can hop in as well.’

  Mark completed the qualification process to attend water births and had assisted at one before the opportunity came for him to be part of his first independent water birth. ‘It was a 23-year-old woman, about my age, at the time, and she didn’t want to have a traditional birth. She presented in a well-established labour and hopped into the birth pool. Blanketed and soothed by the water, she really went into herself – almost a meditative state. I knew my role was to be a fly
on the wall as much as possible – an active inactivity. I just quietly checked every now and then that things were going along well. Midwives are encouraged to knit or crochet to keep their hands busy. Nurses are very task oriented, always needing something to do. So sitting and watching and staying in the background can be hard. There’s a real urge to brush hair, wipe brows, provide food, make beds – do fiddly stuff. But the woman is best left alone. The midwife’s role is simply to provide safety and knowledge.’

  In a kneeling position in the birth pool, the woman was working hard and started pushing. ‘And then very quickly she birthed a beautiful baby underwater,’ Mark says. ‘The baby floated to the surface with the guidance of his father. They lifted that baby out and there it was. The mum was totally in control of what was happening. She owned the birth.’

  Coming from southern Queensland, Mark found the patient cases well outside his previous experience. ‘It was my first major contact with the Indigenous population. Thirty-five per cent of women birthing were Aboriginal or Torres Strait Islander women and it was a huge learning curve for me.’ Mark soon realised there were vast differences between Indigenous communities. ‘The girls from the coast are a little more outgoing than those from places further west, like Aurukun. Those that come in from very isolated communities are harder to establish a rapport with. They’re more reserved, quiet and avoid eye contact. They just needed to be left alone to do their own thing.

  ‘The birth suite at the Cairns Hospital looks over the esplanade with stunning sea views. The islanders waiting in the maternity ward for babies would predict the sex based on the tide. I can’t remember the exact detail but it was something like; if the tide was coming in when the baby was being born, it was going to be a boy. If it was going out, they would expect a girl. I think they were right 90 per cent of the time.

  ‘I loved working with the Thursday Island women. The ward would often be packed to the rafters with aunts and older women and was a sea of colour with brightly coloured, tropical muu-muus, dresses and shirts. There would be up to eight aunties in a corner, knitting or sewing. And the families from Papua New Guinea would gather around chewing betel nut. As an outsider both culturally and genderwise, I saw that their approach was tied to the land – and most importantly, to the sea. The young mother is physically surrounded by a ring of women attending her every need. They tap into the power and wisdom of motherhood built through the generations. When it is the birthing woman’s time the women congregate and celebrate womanhood and this rite of passage. It is calm and laidback with all the older, experienced women supporting the younger girl through the experience. Words of wisdom, encouragement, chatting, feeding, watering is all going on and amid the caring everyone is regularly looking out the window keeping an eye on the tide and the weather. Occasionally there is some low soft singing or humming. Always smiles, always touch, a hug and then a stern but warm “get on with it”. I always felt very privileged to be among it all – a rare visitor. We were just there to make sure everything was okay and to complete the reams of paperwork that come with birthing in a hospital. As far as birthing went, we’d just let the mothers do their thing, and the majority of the time, beautiful babies were born naturally and stress free.

  ‘There are some amazing midwives in Cairns, and while it was challenging at times, I learned a great deal. I sometimes challenged the status quo. As a male midwife, there was a reasonable amount of suspicion from the women midwives. Midwives in general can be quite tough on each other.’

  Going out of his way to offset the gender difference meant Mark didn’t have any trouble gaining acceptance by the mothers in his care. ‘Birthing is so rooted in womanhood and women’s liberation and feminism,’ he explains. ‘Particularly with some cultures that believe it’s very much women’s business only. Muslim women and some Aboriginal women stipulate birthing is women’s business and it’s about the spirit of what it means to be a woman going through the experience and it requires privacy. That did present a few challenges and occasionally we had to rearrange mothers and midwives to make sure we respected any cultural sensitivity. But by and large, there are no major concerns with the women I work with.’ The feedback Mark receives is testimony that he is extremely aware and astute when it comes to maintaining a woman’s dignity. ‘Most midwives are naturally at ease with women, whereas I feel I need to go out of my way and spend time to build that relationship. That’s if I have a chance. Often it’s not easy, because when a woman is well into labour anything can impact on the birth environment. It’s in those early labour stages or inductions you can build some trust and respect with the woman and her partner. Then it’s all about maintaining those relationships.’

  Mark’s career in Cairns was cut short when personal tragedy struck. ‘I was 23 and my partner, Alistair Frame, died suddenly overnight. He was 26. My life changed that day when I woke up, rolled over and discovered Ali had died in the night, in bed beside me. All I wanted to do was go home to Mum and Dad, which I did, and I worked in Clermont for the next twelve months. Luckily, it wasn’t difficult to get a job at the hospital and it was comforting to come home and work alongside Marg and all the people I knew working there. I did some antenatal clinics, working with the local doctors’ surgery and a little maternity work at Emerald to keep my midwifery current.’

  Marg said everyone was delighted when Mark came back to Clermont to nurse for a twelve-month stint – and with midwifery under his belt. ‘He was hilarious and brought such a sparkle to the place. He’d organise wheelchair races in the middle of the night up and down the corridor to keep the nurses awake. And he’s a great dancer. His parents ran the debutante balls and when we weren’t busy, he’d teach us to dance.’

  Mark suddenly found himself looking after and caring for girls he had gone to school with. ‘It was interesting to say the least,’ he says, laughing. ‘I got to know them more than I ever thought I would. But that was actually beautiful and now, ten years later, I see some of the babies I helped birth popping up on Facebook. I remember looking after them in postnatal care. We had a really nice group of core midwives for antenatal and postnatal care. We put a system in place to help women return home from regional hospitals a lot faster. Unfortunately, women could no longer birth in Clermont, so we did a lot of transfers in the back of ambulances with women in labour to Emerald, our nearest large centre, an hour south. It was crazy. That’s still an area of contention for me. That part of central Queensland just seems to get forgotten by the Queensland government. You can birth in the bigger centres, but services don’t go into the smaller communities – they have to go without facilities. If you want to have a baby you have to wait at one of the larger centres and birth away from home.’

  Mark remembers a transfer in the back of an ambulance with a woman in labour who had had several babies. ‘I tried to convince doctors to let her stay in town because I didn’t think she’d make it. But we were pushed into a pretty hairy ride driving very, very fast. Strapped in, we were rocketing along the dodgy, potholed road at 140 kilometres per hour and in fading twilight – roo time.’ Mark was imagining birthing scenarios. The woman, strapped down for safety, was squirming around trying to move to a more upright position. She was extremely uncomfortable. ‘All the while I was flailing, grabbing on for dear life and trying to document what I was doing. I was caring for the woman and supporting her through contractions, monitoring the baby’s heartbeat and hoping we didn’t crash! We were both powerless and desperately wanting a normal situation – we just had to ride it out.’ The woman birthed the baby about half an hour after arrival at the hospital. ‘It was a lovely birth and she was back with us the next morning, where we could continue to look after her.’

  On another night the hospital staff had a surprise birth when a woman who was travelling and staying at the caravan park showed up at the door. Shortly after, she birthed the baby and Mark was there to catch him. ‘He was rugged up, cuddling and breastfeeding with his mother when the doctor who had been cal
led raced in sounding out orders and calling for drugs. He was surprised to find the baby already nuzzling at the breast, skin-to-skin, cuddling with mum and dad. They were in low, soft light and it was absolutely beautiful. The baby pretty much birthed himself.’

  In midwifery, the term ‘delivery’ isn’t used anymore because it implies the woman is passive during delivery. ‘Pizzas get delivered, not babies,’ Mark says. ‘They get birthed. And we don’t refer to women as patients – they are women.’

  After a year of healing and spending time with family and friends in Clermont, Mark headed off to Scotland and took a break from midwifery. He had the opportunity to do some maternity-care assistance and shifts in the birthing suites in Edinburgh. ‘I’d worked in much smaller environments and to go to a major tertiary referral centre was a bit of a shock. I kept in mind the first birth I’d seen and compared everything with that. To this day that’s still how I think it should be done – with no bells and whistles.’

  Mark fell into emergency nursing in the Western General Hospital mainly because that’s all that was going. ‘It was a very big change for me. At that stage it was almost impossible to register as an Australian-trained midwife in the UK. To get in as a nurse I had to sit an English-language test at considerable expense.

  ‘When I first moved to Cairns I worked in surgical wards and I had seen a reasonable amount of drug and alcohol related trauma there. However substance abuse in Scotland was a very big thing. It was a great experience working across three big hospitals. I gained a lot of new skills and exposure to different cultures. I knew nothing about Eastern European culture and all that went with that.’

  Mark worked in Edinburgh for a couple of years until the global financial crisis hit and the National Health Service (NHS) stopped renewing visas for foreign workers. ‘There were no more jobs and they sent us all home.’ His long-term plan to get into aeromedical nursing was suddenly on the cards. ‘These days the only real way to practise nursing and midwifery side by side is in aeromedical or to take a placement in a rural or remote area. Mindful of the smaller birthing units closing around the country, I decided the only way to practise the two disciplines I enjoy was to become a flight nurse.’ He applied to NSW Air Ambulance. ‘Being a proud Queenslander and afraid of big impersonal cities, the last place I said I’d ever live was Sydney,’ he says. ‘I had been travelling around Queensland for six weeks with my new partner, David, who had come out from Scotland with me. We were filling in time waiting to hear about the Sydney job before deciding where to head next if I didn’t get it. When I did get it, I thought, I’ll just see how it goes for six months.’ Seven years later he’s still in the job and loving it. ‘I have all the conveniences of living in Sydney while I’m working in the bush.’