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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.

previa.gif

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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I have been asked by Alice to do a piece about ‘placenta papyrae’, I think she is referring to something variously called the vanishing twin, fetus papyraceous, or fetus compressus, my Mother had an example of this in a kitchen cupboard at home! Firstly, my Mother was a midwife, an early incarnation of a community midwife, bike and all. Secondly, our home was not cluttered with jars containing interesting specimens, just wonderful midwifery and obstetric textbooks with images guaranteed to stimulate a developing mind, this was the only pathological example I can remember. Her story goes that she attended a twin birth, at home, and when examining the placenta found this little ‘mummified’ fetus which she then kept in the bottle with some preserving fluid at home. As you can imagine I found this hugely interesting, I can remember from quite a young age climbing on to the kitchen work-surface to open the wall cupboard so I could sit and marvel at this strange little ‘alien’. It must have been about 3 inches long, it was a creamy colour, my recollection is that it looked like bone and was almost completely flat, with a large bluish dot where the eye should have been. I have no idea where it is now, I just hope it wasn’t left in the cupboard when she moved!What is it then? Well the first name I wrote gives a clue, a vanishing twin. As people are aware a great many more pregnancies begin as a twin one than end as one.  S. Levi, who studied over 6,000 early pregnancies sonographically, found that of the 188 sets of twins identified, only 86 sets were delivered as twins. From this it was inferred that the others had “vanished.” also   “Review of the sonographic findings of 1000 pregnancies with viable gestations in the first trimester revealed a minimum incidence of twinning of 3.29%. Of these, 21.9% demonstrated the “vanishing twin” phenomenon,” (Am J Obset Gynecol 1986;155:14-9.) Not all vanishing twins will become a fetus papyraceous as this ‘mummifying’ of a dead fetus is most likely to occur if the pregnancy has reached between 15 – 20 weeks.

How does it happen? Basically one, or more, of the feti in a multiple pregnancy dies and the fluid component of their body is absorbed, resulting in the mummification, but due to the bones being reasonably well developed by this gestation the fetus continues to maintain a recognisable shape, it is then compressed by the growing twin leading to the flattening. Hereis an interesting case, with picture, where one live baby was born and two fetus papyraceous were found, originally a triplet pregnancy.

Does this cause any problems for the surviving twin? There is evidence that it may, in some cases. The problems are not generally caused by the development of a fetus papraceous but by the death of the other baby. It may be that there were placental issues and in the case of identical, or uniovular, twins these would then have repercussions for the surviving twin. The change in the blood flow dynamics may also affect the twin that remains, studies have indicated that there is an increase in the incidence of cerebral palsy in the surviving twin, generally though this seems to be more prevalent if the death had occurred after 20 weeks of pregnancy(http://findarticles.com/p/articles/mi_m0CYD/is_17_35/ai_65538238). I have also found reports of a case where the mummified twin is blocking the cervix and so obstructs labour, my comment on this would be that the placenta must have been quite low-lying in the first place so this was a fortuitous event! There are other problems which may affect a surviving twin, the link to Early Path Medical Consultations (below)is quite informative about these.

I have only ever found one fetus papyraceous when examining a placenta, and it looked nothing like a fetus, it was almost discoid and at first I thought it was an area of calcification, the surviving twin was healthy, the parents were told about it and since the woman had experienced a bleed at 14 weeks they felt that this gave them an explanation.

papyrus-c.jpg Scanned from an old copy of ‘Obstetrics and the Newborn’. Beischer and McKay. This is a far larger fetus than generally seen and less mummified.

fetus-pap-with-text.jpg   This is far more representative but is as the result of ‘feticide’ in a multiple pregnancy so in fact is not a ‘vanishing twin’. The text accompanying this can be found here, Early Path Medical Consultations.

Alice asked two specific questions:-

Is it current practice to inform parents? Yes. Parents should be informed as there may be implications for the surviving twin. Also, the discovery of the vanished twin would be recorded in the clinical notes which the Mother would have access to, so it would be better that had been previously discussed with her and her partner.

What is the incidence? Rates quoted appear to be worldwide where articles I’ve read suggest that it ranges from 1:17,000 – 1:20,000 live births. With regad to the UK, the only reference I could find within UK statistics was 1 occurance in the CESDI 2001 report. 

If anyone wants to know more I would recommend this page on the FetusNet website.

Hope this has been of interest. If anyone would like me to ramble on about anything else midwifery related I would love to hear from you, especially over the next few weeks when I shall be kicking my heels until I am fit for work!

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Twin trouble

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I love this photo. I found it whilst trying to discover how so many people are tracking down my ‘Placentae’ entry. It was on this website and came originally from the Daily Mail, if you like seeing the most amazing images on a wonderful ‘blog’ site, then this is the place for you. ( Gosh I’ve just re-read this and it could be interpreted as me saying my blog is wonderful and the place to see amazing images. That’s not what I was saying, the earlier link was the place to visit for that!)

The twins, oh bless my daughter, they are hard work. Yesterday she and her little brood came to see me, and by the time they left I was shattered and emotional. Amy bought Nanny a pink polyanthus and we had lots of snuggles and story-telling, whilst in the back-ground Louis was the most upset baby, ever. He was inconsolable, daughter thinks that the boys may be teething, all I know is that little Lou was sobbing as if he had just been brutally beaten the whole time there were round, about two hours. I felt totally useless as I couldn’t pick him or Jamie up, I couldn’t even cuddle them as my abdomen is still too sore. My poor daughter was on the verge of tears and looked exhausted. I remember, when Jack was born, feeling really cross with him when he wouldn’t breastfeed as it was upsetting my daughter. Yesterday I didn’t feel cross in the same way with Louis, as he sounded so sad, but I did feel annoyed with him and cross with myself for being a useless ‘blob’ and I felt enormous frustration at not being able to ease the burden for daughter. I spoke to her this morning and she sounded more positive but, as she said, she spends most of her life at the moment ‘clutching at straws’. It has to get easier. When Hubby and I were in Jersey last year we met a lovely couple who had a toddler and twins, they told us that life was ‘hell’ until the twins were 7 months old, well if the Boys follow that then in about a months time things should get easier. All I’m wondering is, should we add on another month as they came 4 weeks early?

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Placental interest

WordPress provide a ‘stats’ service which allows bloggers to observe which posts receive the most traffic, my stats are showing me that there is an huge interest at the moment in my ‘Placentae’ post. Why this surge in interest? I have absolutely no idea, I can only hazard a guess that a cohort of student midwives must be doing an assignment on the Third Stage of Labour or on the structure of the placenta and when searching they have happened upon this entry. Musing on this I realised that they may be using the photos of the twin’s placenta. I haven’t got a problem with this, especially if it is being used in the learning process, but I would like to know if photos are being used elsewhere on the web so have put a little message on my side bar, hope people read it!

On the ‘stats’ page we can also see what search terms people have used on the way to our blogs and this is now giving me an idea for entries. I’m thinking that once a week, or so, I will pick a search term that seems particularly popular, interesting or poignant and write an entry based on it, I’m quite excited about it as it could make me expand, review and revise my current knowledge base.

Clips out today, virtually painless. Not surprised that there is a section that is not healed, ‘gaping’ is how the nurse described it, and then promptly covered it with a dressing. I never heal particularly well so I’m not particuarly worried, just fed-up that I can’t shower for a couple of days. I also saw the G.P who reassured me that my ‘slow’ recovery was not in fact ‘slow’, it is just that I am impatient ( I think he really wanted to say that I am not a ‘good’ patient).

Job-share partner has been a gem, keeping my spirits up, updating me on how my women are doing and reporting back on ‘happenings’ at work. The other day she popped into one of the units and looked through the labour ward delivery book and was horrified at the number of PPH’s, she chatted to one of the labour ward managers about the high rates, the manager believes that it is pressure of work, i.e not enough midwives, which is contributing to the problem. Anyway, it has got me thinking so I think there will be a Third Stage Management entry coming very shortly.

I saw Jack and Izzy today for the first time since my op, it’s only 2 weeks but they have changed. With Jack it was his widening vocabulary, he now sounds so grown up and as for Izzy, well her walking is so confident now, she is even incorporating little dances and hand-clapping, last time I saw her she was a baby, now she’s a toddler. Tomorrow I see Amy and the boys, I love being a Grandmother!

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