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Archive for February, 2008

Do not press the link if you are squeamish!

BBC three, last night, just by chance I started watching this programme and was entranced. It is advertised as ………

‘Journalist Dawn Porter goes in search of the truth about childbirth. Like many young women, Dawn terrified by the prospect of childbirth. As well as from the pain, she worries that her body will be damaged beyond repair and the prospect that sex will never be the same again. Finding her friends unwilling to spill the beans about what it’s really like to give birth, she seeks out a first-time mum who will let her witness a birth firsthand.’

I am so frustrated at not being at work because I can’t recommend this to the pregnant women. Dawn went right to the ‘nitty gritty’, it was all those questions you don’t know the answer to, all those things that you haven’t even thought about in down-to-earth, humourous at times, but a very honest 60minutes of gems for 1st time Mums. From scooping poo out of a birth-pool,  gas and air, a pool birth, ventouse, forceps, to what a placenta looks like. Yes, it is gory but not gratuiously so. Basically it’s educationally entertaining. 

I also think it would be good for many women who have given birth before and are tremulous about a repeat of their first experience. One of daughter’s friends, expecting her second baby in three weeks, was chatting to me today and mentioned that she had watched it and it had made her think about using ‘Active Birth’ rather than having an epidural the minute she was in hospital. What had made her think this way was not that the women ‘enjoyed’ labour, it was quite obvious that the women found some of it painful (understatement), but how they were immediately afterwards, mobile and catheter free. Obviously not 100% fine but equally not surrounded by, and wired up to, all sorts of medical tubes and gadgetry. Daughters had encouraged her, telling her that I used to facilitate the Active Birth classes so had lots of info. End result is that she and her partner will be coming round next week for a one-to-one on things to do to encourage normal progress in labour and different coping strategies. I’m really looking forward to being midwife me again, even if it is only for a couple of hours!

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G.P’s in demand

Not so many years ago I could phone up and book an appointment to see my G.P that day, or a week in advance. I was never asked if it was an emergency, I never felt that I was an imposition. Fast forward. Last week I saw my G.P and he asked me to see him in 4 weeks to assess my recovery from my op and decide whether I was fit for work or not. Stupidly I didn’t make the appointment there and then. Today I phoned requesting an appointment for 3 weeks time, guess what, there are no spaces. In the end the practice manager has authorised an appointment, 2 days after my sickness certificate runs out, three days after the date I requested. It is all becoming very strange. It used to be that you waited months for an out-patient appointment to see a consultant, and then waited months for your op. Now you wait a month for your consultant appointment and then 6 weeks for your operation. Soon it will be quicker to see a Doc at the hospital than your G.P. Is this the cause for full A&E departments, people desperate to see a Doctor?

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In today’s Telegraph was a piece written by Rowan Pelling who was commenting on the ‘golden hello’ to midwives who have left the profession. I feel that this article explains succintly most of the causes for midwives leaving the profession and then goes on to be realistic about what Alan Johnson is really offering – ‘He offers them a miserly £1,500 (plus up to the same amount in childcare, training days and travel) to re-engage with an even more demoralised and disaster-struck maternity service than the one they left several years earlier.’ The author is employing an Independent Midwife for the birth of her next child and suggests that the problems within the maternity services is her reason. I have no problem with this, it is her choice.

The article invites responses and the first one is from Emily, expecting her second baby in August, who says  – ‘I’ve seen the midwife twice and she seems more interested in ticking boxes and moving on to the next mum than taking time to answer my concerns. The NHS has become a conveyour belt where primary care providers are only interested in treating the issue at hand. Ask anything of them and it is treated like an inconvienence.’  So, Emily is at most 18 weeks pregnant, that’s if baby is due on the 1st August, if it’s due at the end of the month she is 14 weeks, according to the NICE guidelines for Antenatal Care she should be seen prior to 12 weeks and then again at 16 weeks, so twice. Right so far then. At these sessions the midwife will have been ‘booking’ Emily, lots of asking of questions and ticking of boxes, filling in of multiple forms to book scans, have the appropriate blood tests performed, basically attempting to ensure that the pathway is laid for Emily’s progression through her pregnancy. So yes, the midwife is really ‘ticking all the boxes’ at the moment and, unfortunately Emily has it right, the midwife is moving on to the next Mum, and the next, and the next because the way the service is at the moment a midwife’s priority is to give safe care and if she has time to do anything more then wonderful, but becoming increasingly unlikely. If Emily had read Rowans article properly she would have read that one reason midwives leave is that ‘maternity services are so overstretched that a rewarding job has turned into crisis management’ so my message to Emily would be ‘ Your midwife is probably as unhappy with the care she is providing as you are with the care you are receiving. It’s not her fault’.

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Vasa Previa – a midwives dictionary definition is ‘Vessels in front of the presenting part. A rare condition of velamentous insertion of the umbilical cord, usually with a degree of placenta previa, in which the vessels in the membranes are lying in front of the presenting part. When the membranes rupture there is a risk of compression of, or even haemorrhage from these vessels leading to hypoxia or haemorrhage to the child.I would add to this ‘where there is a succenturiate lobe to the placenta’.

Quite a lot of medical jargon here so I’m going to get that out of the way first and explaining all these should go a long way to explaining vasa previa.

Vessels – blood vessels of the umbilical cord.

Presenting part – here they are talking about what part of the baby is coming first, generally the head.

Velamentous – In a normal placenta the cord and the vessels go right up to the surface of the placenta before branching off, with a velamentous insertion the blood vessels branch off before reaching the placenta so are therefore exposed within the membranes.

Placenta previa Placenta previa is when the placenta attaches to the wall of the uterus in the lower portion of the uterus and covers all or part of the cervix. It is found in about 1:200 pregnancies at term ( 37 – 42 weeks). It is observed far more frequently on 20 week scans but on re-scan at 34 – 36 weeks the placenta has moved away from the cervix.

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Different types of placenta previa

Membranes rupture – Waters break, either by themselves or with a little help.

Hypoxia – Baby does not receive enough oxygen due to the pressure on the blood vessels.

Haemorrhage – The blood carried within the umbilical cord is the baby’s. Think of the cord as an extension of baby, rather like the tubes in a dialysis machine or a heart-bypass, and you can understand why a breaking of these would lead to the baby having a huge blood loss, but whilst still inside it’s Mother’s womb.

Succenturiate – the placenta has an extra, separate piece to it. Often this is immediately adjacent,, so is not as much of a concern for vasa previa, but it can be some distance away and so have blood vessels which cross over the membranes connecting it to the main body of the placenta.

Photo of Vasa Previa

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So what  is the incidence of vasa previa? Stats vary, as usual, but there seems to be a consensus of around 1: 2,000 – 1:3,000 pregnancies.

How is it discovered? It can be detected on a 20 week scan, but  it can be easy to miss, if the woman is overweight, has a bladder that is obscuring the view or the problem blood vessels are in a position where they can not be seen, so unfortunately some cases are not detected until the waters break and there is blood. When I say blood I don’t mean a very slight pinky tinge, that is normal, I mean when the fluid looks like fresh blood. There are clues though that there may be vasa previa,  a low-lying placenta, a placenta that has an extra lobe (succenturiate), the incidence appears to be higher in IVF pregnancies, women who smoke, multiple pregnancies, and have a previous history of the condition so these cases would be thoroughly investigated

What can be done? Diagnosis is the most important step. Once diagnosed then decisions can be made about time and mode of birth which, studies have shown leads to a good outcome. Recently a surgeon has reported success with treating this problem by laser surgery to the blood vessels. However, this case was where there was an extra lobe to the placenta, not where the problem was a velamentous insertion. Good article to read though for more information.

How dangerous is it? Well, if it’s not detected then the death rate for baby can be as high as 95% but, if it’s found antenatally then, as long as there are not any other problems, the survival rate is 100%.

Wonderful website here, UK Vasa Previa Awareness.

Thank you to Mother of the Bride for suggesting this topic. If anyone else has any ideas for a post please let me know.

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Queuing for a midwife? 

So the maternity services are going to have 1,000 extra midwives over the next year and by 2012 there will be a total of 4,000 more midwives for the hospital and community. Alan Johnson has said ‘midwives’  not maternity care assistants, lets just see if this is what really happens ( cynic, moi ). Good link here for the statement, plus notes to editors, from the Government News Network.

Obvously I’m really happy, ecstatic in fact but…………….Labour has promised that ‘every woman should be supported by the same midwife throughout her pregnancy’ by the end of 2009, how is this supposed to happen when only 25% of the number of midwives required to provide a ‘safe standard’ will have been recruited by then? In ‘Maternity Matters’, the 2007 publication from the DoH, 4 promises are made to women and their families, Choice of how to access maternity care; Choice of type of antenatal care; Choice of place of birth and finally Choice of postnatal care. Hang on there, rewind,  Choice of postnatal care – After going home, women and their partners will have a choice of how and where to access postnatal care. This will be provided either at home or in a community setting, such as a Sure Start Children’s Centre’. Well, well, so Government promised, about a year ago, that by the end of 2009 women (and their partners) can choose to have postnatal care at home. So what is this about polyclinics then and the reconfiguration of primary care where ‘polyclinics will offer access to antenatal and postnatal care’.? Confused? Well I am. Which promises should I believe? Should I, we, believe any promises?

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Men!

Son, who is decorating his bedroom, just phoned. From Hubby’s end of the conversation I gathered that whilst putting the radiator back on he broke the pipe and they now have water gushing out, on to their new carpet and down into their sitting-room. There was much, ‘ I had warned you about using equal pressure ‘, ‘ find the feed for the central heating system, shut it off and then drain the system ‘. I remember Hubby doing exactly the same thing years ago but luckily it was in a bedroom over the garage so we didn’t have to worry about any rooms underneath, so he’s been there, dealt with that. He came off the phone and I fully expected him to high-tail it over to Son’s, but he didn’t. I said why wasn’t he going over there and he said than Son hadn’t asked him to. Men, they are so poor at reading sub-texts. I said he should go over there, he responded that he hadn’t been asked. I said that he should have offered, he said son would have asked. Now, if this had been one of the girls having a problem I had some knowledge about, I would have offered, and if I hadn’t she would have asked. I don’t think they are any less independent or able than their brother, they are sensible and appreciate that sometimes tasks are easier if shared. Men, oh no, they are so pig-headed that they won’t ask and so empathetically retarded that they can’t identify a cry for help.

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Dr C, the conundrum that he is, has had me shouting at my computer screen about one of his pithy entries involving ‘madwives’, and then had me thanking him for alerting me to a wonderful entry by Good enough Mum.

Now he is ranting about ‘polyclinics‘. What do I think? Well, on the face of it, and given the expectations of the public courtesy of this government’s promises, I think that they will be the only way midwives will be able to cover their workload. That is not to say though that they should be way forward in maternity care, they are a centralisation which I fear will lead to a de-personalisation of the care that I am currently striving to provide. Looks like they are the way we will be going though as the definition of a polyclinic states that ‘In terms of the clinical working groups’ recommendations, polyclinics will offer access to antenatal and postnatal care’. So, if the dream (nightmare) comes true it won’t just be pregnant women attending the polyclinic, it will be newly delivered Mums and babies. Combine the 24% caesarian section rate, with the fact that most post-section women are discharged on Day 2 or 3, and then mix in the fact that they will have to access their postnatal care at the polyclinic and I have difficulty seeing anything positive about this proposed reform. It’s not long ago that we would visit all women daily for the first 3 days, twice a day for the first 2, then we would visit at least another 3 times before we discharged Mum and baby, soon the roles will be reversed. I believe that home visits are important, so much can be incorporated. Practical advise, is the room temperature within normal limits? Demonstrating how the baby should be put in it’s crib/cot according to the SID’s recommendations. How is the Mum coping? Easier to judge if she is in her own environment. If a relative is there to help how supportive is s/he being, some can be quite undermining. I am not going to be able to see, sense any of this if I’m not ‘popping’ in for a chat to see how things are going.

I’m going now because I’m just depressing myself. It’s hard being involved with a service which is falling apart around you. 

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