Elena Basteiro: “Many women are surprised that only a midwife attends the birth”
The Hospital Clínic – BCNatal aims to offer childbirth that is minimally medicalized, respected and as physiological as possible. In 2021, a total of 2,993 births were attended, 23.6% of which were caesarean sections, and only 5.37% were instrumental deliveries. Through the PART programme, families are involved in decision-making in most aspects of the birth, taking their needs and preferences into account.
Since 2010, she has been a member of the team of professionals at the Hospital Clínic Barcelona, at the Maternity Hospital Centre. She has been tutoring residents in the speciality since 2021 and teaching the theoretical training programme for the speciality for the Ministry of Health of the Government of Catalonia since 2014. She is also a breastfeeding consultant and co-author of the Ministry's guide for pregnant women, published in 2018.
Yes, it has changed a lot. I began training in 2008, and since then our role has evolved. My work is to accompany women during the birth process or, if it is an induction, to accompany her during the labour induction process and up to one hour after the birth. I am responsible for the women who are in labour but not at risk. Those who are at risk must be monitored by a gynaecology specialist. In these cases, I am also present, I accompany them, although the doctor is responsible. We monitor the dilation and accompany the woman.
Before, the midwife was in charge of the dilation and the doctor came for the birth. And now, in recent years above all, in low-risk births the midwife is the person who is always with the woman and who attends the birth. Many women are surprised that a doctor does not come and that the birth is only attended by a midwife. But the recommendations are increasingly along those lines. In fact, births attended by a midwife end up being less instrumental, less medicalized, but as long as they are low risk.
"We were one of the first hospitals to allow the partner or companion into the operating theatre."
Yes, when I began, the dilatation stage of labour took place in one room and the woman gave birth in another. Moreover, we have been able to ensure women have been more accompanied during the entire process, and that her partner can be with her in both instrumental and caesarean births. We were one of the first hospitals to allow the partner or companion into the operating theatre. It was hard to get a non-professional to be present in the operating theatre, but we gradually managed to do this.
I trained as a midwife along the lines of less medicalized childbirth. The aim was to humanize childbirth and to make it less medicalized. In fact, there was already a major movement of women calling for this. Older midwife colleagues were trained in a different way, and this was a considerable change. But we still have a long way to go and we are not on a par with other countries such as the United Kingdom, because here there are not enough midwives in the delivery room. In fact, there is a lack of midwives both in Catalonia and in the rest of Spain. There are other countries in which each midwife cares for one woman in labour at a time. This is what is called “one-to-one care” and here it is a reality that often does not exist. There are days when the midwife can provide more personal support, but not always.
In theory, the PART programme was created for women who wanted a natural birth without medication, without interventions, which was as physiological as possible. We gradually adapted to the woman’s needs. At the start, it was only for women who were at low risk. However, the reality is that our hospital is a third-level hospital and we have a lot of women who are at risk. Finally, it became about trying to respect the woman’s decisions bearing in mind her circumstances. We have the knowledge, but the decisions are up to the couple. The aim is to provide the tools so that the woman is informed, can decide and, irrespective of whether she is low risk or high risk, she can have a respected childbirth, since it is a unique and vital moment for her and it is important that she feels that she has the power and control.
Exactly. The birth plan explains the things we can offer. It is a realistic birth plan, because if there are things we can't offer, they don't appear. That’s why each hospital has its own birth plan.
In reality, it is very useful because many couples do not realise that there are different possibilities and when you give them the birth plan and they read it they say “I hadn’t thought of that!”. When the woman is in labour, it is not the time to decide what she wants or doesn't want. It doesn’t mean that there can’t be changes of opinion, because due to circumstances this may happen. But it gives us a general idea of what the patient wants, because a woman with contractions really can’t explain a lot.
I think it's important, yes. If anyone comes along without a plan, that’s fine, but I think it’s a good idea because it also makes the woman who is about to give birth think.
"There are other countries in which each midwife cares for one woman in labour at a time. This is what is called “one-to-one care” and here it is a reality that often does not exist."
On the one hand, humanized birth means trying to medicalize as little as possible. Sometimes it is necessary and, if it is, we will explain why and always weigh up the different options. We also try to humanize the induction of labour. We try to ensure that the woman can start the induction in a more familiar environment such as her home, where it is easier for the labour to progress. A woman must feel safe during labour, because this avoids her secreting hormones that may alter the process. Anything that makes her feel more comfortable is good. The atmosphere in the delivery rooms should be as pleasant as possible. We always offer woman the opportunity to visit the delivery rooms in advance, so that they can familiarize themselves with them and see what they are like. We try to ensure the decisions are made by the mother, we try to minimize medicalization, and make sure that after giving birth they can go home as soon as possible to be in a more familiar environment, so that they can adapt better.
In reality, many people want a natural birth because it is more physiological. In 2022, we attended almost 400 births without anaesthesia. It is true that we do not live in a culture that is used to enduring pain. So, one thing is the idea you have, and then when it comes to labour there is the real situation that you might face. It all depends on the expectations you have. I think it’s better to go with the flow. You can try to have a natural birth, and that's fine, but it's also fine if you end up using anaesthesia, for example.
At the Maternity Hospital Centre we have baths in the delivery rooms. However, they are only used to help with dilation, we do not have water births in the bath. We have balls to encourage mobility and the birthing beds can be adjusted and put in different positions. Moreover, we have birthing chairs and use local heat. We also have nitrous oxide, which is medication, but does not have as many side effects. Then there is the epidural anaesthesia, which most people are familiar with. Low-dose epidural anaesthesia is also used, which allows more the woman to move more, to sit up and adopt a more upright position that favours the birth process.
An instrumental delivery is when forceps, a spatula or a ventouse suction cup are used. It is different from a caesarean, which can be chosen for maternal or foetal indications, either because it is not possible or because there are problems with the dilation, for example. Instrumental delivery occurs when a normal vaginal birth is not possible. The mother’s cervix has to be fully dilated and the baby must be in the third or fourth stage of labour at very least. We talk about four stages of labour. If the woman’s cervix is fully dilated, but the baby is in the second stage, for example, an instrumental birth is not possible, because the baby is very far up and it will end up being a caesarean section.
"The parents can choose key aspects of this intervention to encourage the mother-baby bond, always maintaining the safety measures required in a surgical intervention."
In the case of a caesarean section, if it is not an emergency caesarean section in which the life of the mother or baby is in danger, the woman can be accompanied. This allows her to remain calm and helps with everything else. If you go into the operating theatre and are accompanied by the person you love, it is fundamental. And afterwards, what we try to do is to ensure skin-to-skin contact. For a few years now, we have had the pro-bonding caesarean, which is a little different. The parents can choose key aspects of this intervention to encourage the mother-baby bond, always maintaining the safety measures required in a surgical intervention. In this case, it is necessary to control the woman’s heart rate, blood pressure, etc., but we try to keep the thorax free so that when the baby is born, it is the mother herself who receives the baby and can place him/her on her chest in order to begin skin-to-skin contact.
We have skin-to-skin caesarean sections when no complications are envisaged. For example, in the case of a caesarean that is carried out because the baby is breech. In these cases it is possible. However, if any complications are foreseen, it is the midwife who picks up the baby and places him/her on the mother.
The truth is that women who have been able to have skin-to-skin caesarean sections find it a positive experience. But it must always been done safely. In the operating theatre, we always raise the temperature a little, because the operating theatre is a cold place, so when the baby is in contact with the mother he/she is in a warmer environment. We also need to make sure the mother is doing well and is not on any medication that puts her to sleep. There always needs to be someone to check the baby’s skin colour, to make sure he/she is breathing properly, that his/her nose and mouth are clear, etc.
Whenever possible, yes. When a baby is born, it needs to have contact with the mother and we encourage the skin-to-skin contact whenever possible. In a vaginal birth, the mother receives the baby and he/she is placed on her chest. In a caesarean section we also ensure skin-to-skin contact unless the mother is not well, in which case it can be done by her companion. This helps regulate the baby’s temperature, breathing and also encourages the start of breastfeeding, which is also essential, and the creation of this bond is generated.
We even encourage skin-to-skin contact in babies who require treatment, such as premature babies, and if they need more special care, and have to go to the ICU as well. The Neonatal Unit is also open to parents 24 hours a day.
When I started my training, women were already supported during childbirth, by one person, normally the partner. Then the figure of the second companion began to be introduced, because some mothers needed someone to come and perform acupuncture for example, or wanted their doula to be there. For them it was very important, and that is why the figure of the second companion began to be introduced in vaginal births. In the case of caesarean sections, it was more complicated. The introduction of a companion in the operating theatre had to be agreed on by the whole team, and sometimes it is not so easy.
"Like other mammals, need this, a safe environment in which our body recognizes that it can give birth and that it will be OK."
Exactly. Humans are still mammals and we need a safe environment to give birth in and to be calm. Mammals normally go far away, they hide away and they look for a safe place and give birth there. And we, like other mammals, need this, a safe environment in which our body recognizes that it can give birth and that it will be OK.
Really, the hospital does offer resources, but each woman must bring her own resources for childbirth. The way in which a woman deals with things in life is how she deals with childbirth. Therefore, not everything depends on the hospital or the centre, some parts depend on the individual woman. We also have a phone number that women can call us on. We can guide them and they find this very reassuring, since they know that at any time, 24 hours a day, they can call up and speak to a professional.
I think it is essential that the woman goes to a place she trusts. That is why we always try to show her the facilities as far as possible. We also have videos, and our Instagram page, where we provide quite a lot of information. We try to ensure the woman gets to know the facilities, the birth plan and can tell us where she wants to go. Because in the end you have to trust the people who will be with you.
I think that Spain should move towards the “one-to-one contact” approach. In countries in northern Europe they do this, and there is a midwife for each woman in labour. Communication between primary care facilities and the hospital must also be improved, and there must be good coordination. Although we have improved over the years. Today, when a woman leaves here with an early discharge, the primary care service is informed, but all of this can be improved further.
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