I know I’ve been quiet for a couple of days but I have been reading NHS Blog Doctor and specifically his entry ‘The Independent Midwives of Kent’. I’m not the only person to have been reading it as last time I checked it had 200, yes 200, comments, obviously a provocative entry. Now, Dr Crippen is an old adversary, I like to consider it a love/hate relationship, he hates ‘madwives’ and loves to rant about them, on this occasion though he does have, more or less, my support. His entry was a comment on a birth story, Sharon’s story, published on the Independent Midwives of Kent’s website. The link is to the Google cache as, last time I checked, the original story had been removed, more on that later. I’ve read the story and, as a midwife who has a role encompassing homebirths, I have to admit that I felt quite tense at several points throughout the narrative, especially when polyhydramnios entered the equation. Polyhydramnios, basically too much fluid around the baby, may have no cause but it can be associated with several serious abnormalities in the baby, as I learned the hard way. Several years ago I was caring for a friend, J, in her second pregnancy, I had also cared for her during the first where there were no complications and she gave birth to a healthy baby girl. This first experience decided J that she would like a homebirth this time round so that is what was planned, until 32 weeks, when I was doing a routine antenatal and thought that there may be too much liquor, polyhydramnios, so I asked for a consultant opinion and ultrasound. This was done, nothing abnormal detected but due to the polyhydramnios we were no longer considering homebirth so we just prepared for baby being born in hospital. J was also a midwife and I don’t remember there even being a discussion about whether we should go ahead with the homebirth, we were both just aware of the risks associated with too much fluid; cord prolapse, haemorrhage before or after baby is born, malpresentation so the hospital would just have seemed more appropriate. J was induced at 37 weeks as she had become so huge, when the membranes were broken the room was awash with liquor, quite spectacular, but nothing untoward happened and labour progressed uneventfully. As is practice with an induction of labour J was monitored continuously, baby was a happy bunny, and so when he was born after 4 hours of labour we did not expect a problem but there was, a major problem, he couldn’t breathe. As he took his first breathe his little chest collapsed, he tried again but with the same result. Some babies will have chest recession, this is where their chests will go inwards as they try to breathe and this may be a sign of respiratory distress, but J’s baby’s chest was concave, it was an horrific sight as he battled to breathe. The paediatricians were there immediately and he was rushed round to NICU where he was X-Rayed and ventilated. I have to admit now that everything after that was a blank, according to J’s husband I was brilliant, apparently I didn’t panic, I was very calm and I just carried on delivering the placenta and helping J to wash and get ready to go round to special care to see their baby. I’m pleased I was so in control, it must have been an automatic response. When I finally left the hospital they still had no idea what was wrong with baby, I was certain that it was my fault, I must have missed warning signs, something should have alerted me during the labour. In the middle of the night J’s husband phoned me, baby had been transferred to a high level NICU, he had a severe, right-sided diaphragmatic hernia, nothing could be done, his lungs had never been able to develop, his ventilator was switched off after 48 hours. Why am I recounting this? If I was that Kent Midwife I would have gone ahead with a homebirth, the outcome would have been the same but, supposing that the hernia had not been as severe, having been born at home would certainly have jeapordised him. How would J, her husband and I felt if the same scenario had happened at home, would we ever have been able to come to terms with the sad outcome, would we not be saying ‘what if…’? An ultrasound had been performed when the polyhydramnios was discovered, the sonographer failed to see the hernia, unfortunate, but right-sided are unusual and more difficult to visualise, even so there on the report was a tick to indicate that the chest was normal, we believed that baby was fine, our only worry was the polyhydramnios causing problems, not a problem causing the polyhydramnios, the Kent midwife could have believed it just as we did. So, after tensing myself throughout her description of the labour, her only doing a vaginal examination because Sharon asked (supposing a cord or shoulder was presenting), I was relieved when baby, huge baby, was born without any problems and I relaxed, only to be bought up short by the haemorrhage and the management of it. 1500mls, that is a large bleed, not one that you just sit around observing, keeping a paramedic unit with you for 2 hours, and then finally go into hospital to ‘cover your back’. Supposing the woman had continued to bleed, there had already been one episode where “She then vomited and at the same time passed a huge amount of blood and clots”, this was after 2 previous ‘large’ bleeds’, how much more evidence of the advisability of medical support did the midwife require? All was well, thankfully, but to publish this story on the website, with such detailing of her minimising the risks, was sure to precipitate a reaction from many homebirth detractors, whilst giving them plenty of ammunition.
The story disappeared from the web-site after about 24 hours, hence the Google cache, the midwife has now been reported to the NMC, she has done nothing to dispel the caution with which Independent Midwives are viewed and helped reinforce some commentators opinion about homebirth.
Ahhhh
But you are not a madwife!
John
Dr C – Perhaps, but I have to admit that if it were possible to get insurance, and hospitals would allow them to practice within them, then I would become an Indie. Shock, horror but that is the only way I could provide the midwifery care I would like to. It is doubtless the same for most medical practitioners but I do find the gap between women’s expectations and the care I can actually provide hugely stressful and de-moralising.
Management aside, what saddens me about this whole story is the poor reflection on midwifery and homebirth: what kind of role models are we being to students and health consumers http://tinyurl.com/5wqu29
Sarah – I think that the midwife involved was attempting to advertise her competance and reassure prospective ‘clients’ and, until Dr C discovered it, I would imagine that it served it’s purpose, after all it had a happy ending. I would guess that her career will not suffer. I think there will be a ‘slapped wrist’ and scrutiny of her records by the NMC, she had contacted her supervisor re. the PPH and taken the woman in, all the other slightly questionable decisions had been initiated by the woman or her husband. Many will see her as the woman’s advocate.
Sorry , I think I should clarify what I mean about bad behavior – I am not talking about the original midwife but about all the abusive comments in Dr Crippins blog following his post. I just think its a shame we cant discuss these issues without getting all abusive with each other. Its such a shame that this story cannot be used as a teaching discussion for midwives – here is what I did – what do you think-what do you think I should do differently next time, if at all.
Sarah – Most of the abusive comments were left by anonymous commentators, I think that says a great deal!
I have read Dr Crippen’s blog, as a midwife surely you should know better than to victimise someone purely on his opinion. Had you not read his opinion wouldn’t think a hb of 10 was ok? If a woman fainted her bp would obviously be low so with or without a machine wouldn’t you make a decision based on her condition? I don’t think she mentioned polyhydramnios just lots of fluid and in the story I read she didn’t mention a high head at the time of labour. Oh and the baby was born just fine. Your opinion without knowing the facts may damage that midwife’s career. Do you know if she has been reported to the NMC? It appears to me you have used your near miss homebirth experience to colour your opinion of a birth that you know very little about. Midwives like everyone else are innocent until proven guilty. Now Dr Crippen has moved on to Jane Evans will you do that too? Thank god for madwives to provide choice. Surely better than medwives who create control.
The birth happened a few years ago. Looks to me like Dr Crippen had an agenda to try and discredit this midwife as she has been in the public eye lobbying for women’s choice.
Lisa – Hi Lisa. When I read your comment I was bought up short with a jolt, so have re-read, again and again, my entry, my comment on Dr C’s blog and Sharon’s birth story and from doing this I can only assume that it is my entry here that you believe ‘victimises’ the midwife involved. As you have pointed out this was not just about this Indie’s case but also me reflecting on a case which is never far away from my thoughts. We learn from experience, or I do anyway, and yes, obviously my thoughts on polyhydramnios are now always coloured by my own experience. Polyhydramnios was mentioned by term in the original account, initially as ‘gallons of fluid’ but then by it’s medical term and this is possibly what stirred me into this blog entry. No, a high head at the time of labour was not mentioned, in fact following the vaginal examination the head was observed as being low but, with gallons of fluid, but, even following membrane rupture it can be difficult to assess descent and will always be impossible to exclude cord prolapse, presentation externally so in order to rule out these problems I would favour an internal examination following spontaneous rupture of membranes. Yes, the baby was born just fine, as I said (I hardly think we would be having this discussion if it hadn’t as this story would not have been published on the web). I didn’t comment on the loss of the sphygmomanometer, we are all human and misplace things. The Hb of 10 was a result after the event and even with this the midwife involved commented that in reality it was probably lower. Yes, I would make a decision based upon the woman’s condition and the on-going events which were ‘Sharon birthed the placenta with quite a huge blood loss’………..’About an hour after her birth Sharon had another large blood loss and felt slightly clammy……… She then vomited and at the same time passed a huge amount of blood and clots…….the large loss which in all I estimated at 1500mls’, plus she had been infused with 1500mls of fluid and had syntometrine and ergometrine, as I had said ‘ supposing that it had continued’. Any blood loss over 500mls is regarded as a postpartum haemorrhage, Sharon had lost 3 times that amount even another small loss could severely compromise the woman. What I didn’t say in the entry was – For how long were the paramedics expected to be in attendance to monitor Sharon’s vital signs? By having paramedics in attendance the midwife was demonstrating that she believed the woman was in need of transfer to hospital, you do not summon paramedics just to support you at a homebirth. At this point I would muse on whether it was the parents, not the midwife, who were resisting transfer in, this is not mentioned but the phone call to the supervisor is, I will contact my supervisor if I find myself in a situation where the proscribed/accepted course of action would be my choice but the woman, and/or her partner’s choice, is another. At the time I wrote the entry I did not consider this option, I will amend this, perhaps it was the ‘covering one’s behind’ that made me feel this was the midwife making all the decisions.
My lament about this whole situation with NHSblogdoc was, as I said “she has done nothing to dispel the caution with which Independent Midwives are viewed and helped reinforce some commentators opinion about homebirth”.
If you read comment 4 above you will see that I don’t condemn this midwife, in fact I do say that she was the woman’s advocate.
With regard to Jane Evans, read my ‘Midwives in the News’ entry, just click on the Midwife tag and you will find it, and also read NHS blogdocs entry about her, and my comment, which was made before you left this, and you will see with what high regard I hold Jane, and always have.
Thanks for the reply midwifemuse:
You actually said many people will see her as the woman’s advocate not that you did. I did read your blog entry about Jane so I was being a little facetious. I’m sorry, it was needless.
It did feel from the comment you left on the other blog and this entry that you were condemning this midwife. She hasn’t defended herself, maybe she thought it would just go away, after all it had been there for 2 years. I took the time to ask the midwife in person about the woman’s condition and offer her support. I for one would be very upset by reading this about myself. (I am in Australia, from Wales, trained and worked for many years in the UK) She said the woman picked her children up from school that day. This implies that the whole story wasn’t relayed on her website and she problaby should have used a little more thought before hand.
There is also a direct opinion from yourself “She then vomited and at the same time passed a huge amount of blood and clots”, this was after 2 previous ‘large’ bleeds’, how much more evidence of the advisability of medical support did the midwife require? This just lead me to believe that you were of the opinion she did totally the wrong thing. I think that this type of miscommunication could happen to any of us and I would hope for more support from my midwifery colleagues than it appears she has been given.
I also assume she would have been supervised at the time of the birth.
I would be worried if Dr Crippen didn’t think I was a madwife. ;)LOL
I am all for reflection and growth. There is enough persecuition out there without us joining them.
Hi Sarah, I am sadden by all this criticism of midwives. I have followed the NHS Blog Doctor’s story and am equally horrified at the unprofessional comments made. I feel that the Blog Doctor’s site is midwife / nurse unfriendly and this is not to say I support any view points, it is a comment I make as a generalisation of his site. I would make a comment on the site except that I feel it would be torn to pieces, comma in the wrong place or spelling incorrect etc – I could liken it to a lamb to the slaughter. It is a sad day when you feel your freedom of expression would lead to you being attacked for being a midwife especially on that site. I feel our place is to work together, you know that famous word we use so often collaboration, not condeming each other but supporting, not judging when we do not have all the facts and we are not there. I mean this for all health professionals and we should be mindful of what we write in the public forum as it can so easily be misconstrued.
keep the comments coming.