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Archive for June, 2009

Still feeling that I should alert pregnant women to easyJet’s timing requirement for the fitness to fly confirmation I ‘googled’ the topic, and found this from October 2008.  The summary is that a woman who was 31 weeks pregnant, who had boarded an easyJet flight from Rome, was removed due to not having a fitness to fly letter which had been written within the previous 5 days, she “had flown to Rome from Bristol with the airline six days earlier with no questions asked” though. The woman then ended up being seen by a doctor, who carried out an ‘intimate examination’ and then communicated, via a translator, that the certificate he provided was not valid as she was not a registered patient. Guess what, having spent 300€ on accommodation, when they flew the following day easyJet didn’t ask for a certificate!

Reading the comments following the article came as a revelation to me. Many, many people agreed entirely with easyJet and feel that pregnant women shouldn’t fly. Some hypothesised upon the woman giving birth whilst airborne (hee hee), how it would be for the other passengers (!) if “she’d had a miscarriage, DVT” and I just loved this one from ex-cabin crew “No doubt she and her hubby will be one of those highly annoying types who take their infants on long haul flights and let them screech for hours on end expecting everyone else to tolerate it.” The really outstanding feature of the comments was the highlighting of the increased risk of DVT whilst pregnant and interpreting that as meaning that pregnant woman shouldn’t fly. Well, that’s as maybe but if you follow on from that rationale then women on HRT or those taking an oral contraceptive containing oestrogen should also not be flying. Let’s not confine ourselves to females, exclusion from flying should also be extended to anyone with heart problems, cancer, those who are obese or even just because they are male. All of these factors increase the likelihood of DVT so me thinks we should ban all obese males, and any woman past puberty. On a final note concerning DVT and the minimising of risk by airlines, do easyJet provide free water to passengers? Dehydration increases the risk of DVT.

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All the airlines seem to have different ideas about pregnant women and flying. If one of my women tells me that she is about to depart for foreign climes via an airline, and she is 28 – 34 weeks pregnant, I make sure that she has a letter from me informing ‘whom it may concern’ that, at the time I examined her, I could see no reason to doubt her fitness to be transported by airplane. The G.Ps charge £15 for the same letter, I just do it, I don’t think that I can make a charge.

On Friday I saw someone who had just returned from Portugal. Before she went she asked me for a F2F letter, unfortunately her flight was 8 days away and the airline she was flying with demand that the examination be within 5 days of flying, so I couldn’t issue it and the G.P (earned)gained £15. That wasn’t the end of the ‘taxes’ for flying when pregnant, oh no, the ‘low cost’ airline have got a particularly wonderful little wheeze for the unsuspecting, pregnant traveller, you need another F2F to get back from your holiday, even if it was only for 1 week. Apparently, when you try to check-in for the return journey, they ask for your letter, observe that it was signed over 5 days before, and send you to a local doc. The local doc is jolly thorough, far more than the old G.P or midwife back in blighty, not only does he check blood pressure and urine, he also does a scan. Wonderful service, if totally unnecessary. Oh yes, but it comes at a cost, €96. The local doc must love it, wonder how he got the airline to recommend him, was it Easy?

Having heard this story I decided to see if this is now common practice amongst the airlines, do they all demand a certificate/letter signed within 5 days of flying?

Ryanair –  Once your pregnancy has entered its 28th week, we ask that you carry with you a letter from your obstetrician stating the pregnancy is uncomplicated and confirming the expected date of delivery. In this letter, the doctor should state that you are in good health, that he/she is happy for you to fly, and that in his/her opinion there is no reason why you cannot fly. No timescale for signing here but the stipulation of ‘obstetrician’ may cause problems for women having midwife-led care.

Quantas Medical clearance is only required if you are having complications of pregnancy. International travel is not permitted after the 36th week for routine pregnancies or the 32nd week for routine multiple pregnancies. Very laid-back, dare I say ‘sensible’ attitude!

Flybe – Between 28 and the end of 33 weeks, we require a doctor’s note certifying fitness for air travel. No time specification.

Monarch – If you are 28-34 weeks pregnant, you will need to carry with you a doctor or midwifes certificate of fitness to fly. The certificate will only be accepted if:

  • It is dated not more than 14 days prior to the start date of your trip.
  • It states the expected date of delivery of your baby.
  • Your doctor or midwife states that you are in good health, that they are happy for you to fly, and that (in their opinion) there is no reason why you cannot fly.

(Yeah, ‘midwife’)

BAAfter your pregnancy has entered its 28th week, we ask that you carry with you a letter from your doctor or midwife, stating the pregnancy is uncomplicated and confirming the expected date of delivery. In this letter, your doctor should state that you are in good health, that they are happy for you to fly, and that (in their opinion) there is no reason why you cannot fly.

Checked other airlines and they all, so far, do not have the 5 day rule of  the budget airline.

My advise to any woman travelling after 28 weeks of pregnancy and intending on not returning for 5+days, is to add £100 to the cost of flights as quoted by ‘Europe’s leading low-cost airline’ to allow for satisfying their F2F demands.

I have attempted to contact the company involved by email, I have discovered that this is impossible. I could phone their customer services but I really don’t want to throw more money at them. So, if  anyone from the company in question would like to comment on their policy and why no other airline has the 5 day rule and why an unnecessary scan is performed, I would really love it.

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Two days ago I received a Google alert regarding Independent Midwives, the link provided was to the Nursing Times, and the precis supplied indicated that a recent study had found that there were increased risks of stillbirth or neonatal death in pregnancies and births booked with Independent Midwives. I started reading the article ‘ Stillbirth more likely with independent midwives, says study’ and immediately realised that either the study was intrinsically flawed, or that the author of the NT article, Clare Lomas, had not interpreted the study correctly.  I was certain that IM would have something to say about the study so I made them my next click. As I started reading their response to the study I began to suspect that the sensationalist headline in the Nursing Times had been just that, and that the detail of the study was revealing more than the increased stillbirth rate being associated solely with the care provided by IM’s.

My next click was to the study in the BMJ, “Outcomes for births booked under an Independent midwife and births in NHS maternity units: matched comparison study”. When I read the title I began to argue, how on earth could you do a ‘matched comparison’ and why not compare like with like, NHS homebirths and IM homebirths? As I pondered this I realised that the reason it was NHS hospital was because NHS homebirths are generally low-risk, whereas IMs have a high proportion of women who have been refused homebirth by the NHS due to being considered high risk. An editorial, also in BMJ, points out the shortfalls in the research study eloquently without detracting from the positive aspects.

So, what were the outcomes? If a woman employs an IM for her low-risk pregnancy and birth is she placing her unborn baby at higher risk of mortality? No, there is not a significant difference in perinatal mortality. However, if the pregnancy is a twin or breech birth then there is a higher perinatal mortality rate. There are other factors which were discovered in the study; “Women attended by an independent midwife were more likely to go into labour spontaneously, less likely to require pharmacological analgesia, more likely to achieve unassisted vaginal birth, less likely to give birth prematurely, and more likely to breast feed”.

Sounds pretty positive to me, if you are low-risk, but if you read the title of  The Times report of the study findings “Risk of stillbirth ‘tripled for women who have their babies at home'” you wouldn’t think that, and then just see how the article starts – ‘Women who give birth at home with an independent midwife are nearly three times more likely to have a stillbirth than those who give birth in hospital, a study has found’. The reporting does become slightly more balanced after that but the sound bite has happened and what some will inevitably take from this is that 1) Homebirth is dangerous 2) Independent midwives are especially dangerous. Is this biased or just sensationalist headlining as it’s certainly not balanced or accurate?

Yes, I’m annoyed by Nursing Times and their cheap swipe at IM’s, and I’m saddened that The Times should resort to cherry-picking findings to lure readers. What these publications should have done was to disseminate the findings and realise that accuracy would advise a title like Nursing in Practice’s ‘Study calls for urgent review of  NHS and independent birth care’  or the  BBC’s ‘Urgent’ birth care review needed’. They are honest titles which both report the conclusion the study leads the reader to arrive at.

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Are any other employees who blog, particularly public sector ones, quaking in their shoes and ‘pulling the blanket over their head’? There I was battling with my laptop’s wi-fi connection when Hubby started reading me an article from The Telegraph and as he read I stopped checking my connections and started veering between feeling indignant and considering whether to delete my blog. What was the content of the article? Well it was about NightJack, sorry, no point in linking as he has ceased blogging and deleted his blog. Why has this police detective given up his Orwell Prize winning blog? Well, it’s all down to The Times challenging his right to remaining anonymous and a certain Mr Justice Eady agreeing with them. This member of the judiciary has been known previously for defending a persons right to privacy, it was he who pronounced that Maxine Carr was entitled to life-long anonymity, in fact “The judge’s critics argue that he has introduced his own “Eady’s law” of privacy by repeatedly ruling against newspapers and building up a formidable body of case law on which public figures can rely when they wish to gag the media”. What happened this time then, why hasn’t case law supported this bloggers right to privacy, perhaps because NightJack isn’t a public figure?

This decision is terrible as far as employees who blog about their jobs, especially if their blog highlights concerns and/or criticises the organisations they work in. I am krill in the blogging ocean, NightJack was registering 60,000 hits a day, a positive blue whale in comparison to Midwifemuse. There are still similarities though that both blogs attempt to portray what our jobs involve, to inform the public and to voice the frustrations encountered when trying to perform our duties. Frustrations generated by the public themselves, whether through  misunderstanding the constraints we operate within or deliberately by making unreasonable demands. Frustrations felt as a result of media reporting or, for me, the biggest bugbear of all, bureaucracy. Any similarities end there so I am taking comfort in my microscopic blogging credentials. I wouldn’t say I feel cocooned but I do feel that I am fathoms below the sonar so I shall continue my drifting and not go into a mad panic if I see anyone approaching me with a camera.

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grit

Friday morning was a full clinic, plus one extra. It would have been an excellent clinic for a student to be involved in as it covered many different aspects of a midwife’s role in antenatal care. There were early pregnancies, where the women who have been pregnant before were laid back but those who are in their first pregnancy were anxious +++ and in need of lots of reassurance. Then there was a woman who has a rhesus negative blood group so requires anti-D; the woman who arrived with a list of questions, concerns and different options for pushchairs; the woman who had HELLP in her previous pregnancy and decided to cancel her appointment with the consultant obstetrician and see me instead and 2 women with pregnancy related social concerns, 1 housing and 1 employment. Somewhere along the line midwives have been assimilated into benefit administration, I’m talking here about the Health in Pregnancy Grant. This new benefit is available to all women from the 25th week of their pregnancy and is worth £190. The form needs to be completed by a doctor or midwife, unfortunately the G.P’s at my surgery are unable to fill in forms, unless they can charge for it, so this little task falls to me, another bit a paperwork which eats into time I could spend on clinical tasks and giving advice or providing support. Since I consider midwifery per se to be as important, if not more important than form filling, and more likely to assist with health in pregnancy, the appointments take longer and my clinic runs later, and later. Luckily all the women attending on Friday were, if not happy with the wait, not annoyed either.

Clinic finished at 1.30 pm and then my visits started. It should all have been so simple but my destiny was obviously not to finish on time but rather to encounter delays. First was the Mum and baby who were due to be discharged, the problem there was Grandmother. I needed to weigh baby prior to discharge but the ferocious maternal grandmother was not about to relinquish control of baby. She decided that baby was hungry and that she was going to give baby a bottle before I weighed her. I said that I would like to weigh baby before she fed it, she said I would have to wait, I explained that it would be best if I could put baby on the scales first, her response was that it would be best if baby had it’s milk first. As she started giving baby a bottle it’s Daddy intervened and told her to stop feeding baby and either get her undressed or give her to me for me to do it. Grandmother decided to undress baby, in slow-mo. Gritted teeth.

During clinic I had received a phonecall re a woman with breastfeeding issues requiring a visit. I had visited on Tuesday when it was identified that she had inverted nipples. Obviously this can make breastfeeding problematic but we discussed strategies to encourage her nipples to come out and she had said that she would be going to the breastfeeding clinic, she hadn’t gone, the strategies weren’t working and she was distressed. Baby was inconsistent with latching on to the breast, one of her nipples was very sore and she had been offering expressed breast milk via a tea-spoon. After a quick check of baby to make sure that she was well hydrated and not unwell we set about solving all the issues. Nipple shields were thoroughly washed, Lansinoh was applied to the nipples, Mum was made comfortable and baby was put to the breast by Mum. Immediately a couple of potential problems were obvious; Mum was bringing her shoulder forward as baby was latching on. This alters the angle of baby’s mouth to the nipple making the baby take less areola so making baby suck solely on the nipple. (There is a good picture on the Medela site which demonstrates the poor positioning really well). It also causes the woman to develop shoulder, neck pain as she adopts a stooped position. Once we had sorted out the positioning K reported that it felt more comfortable and baby, rather than fighting the breast and repeatedly pulling, back suckled well for 20 minutes.

By now it was 3.15pm and I had a booking appointment to do 5 miles away but I still had a Day 5 postnatal visit to do. I phoned H who I would be booking and explained that I was running late but that I anticipated being with her by 4pm. A day 5 visit is the Newborn bloodspot screening and first weigh after the birth, plus any other issues which may be identified. Hmmm. Interesting couple who I was aware had been a little demanding during the pregnancy. I had seen them twice before and had not encountered any ‘problems’ so expected a half hour visit. The first minor detour was a request to take baby’s temperature, when I queried the rationale I was told that they wished a ‘professional’ estimation. Bearing in mind the issues my colleagues had encountered I complied, it was entirely normal. Eventually I had finished all my clinical activities and was getting ready to leave when the husband stopped me in my tracks by saying that they were going to be putting an official complaint about one of my colleagues. I sat back down and asked him to tell me why they were dissatisfied with the care she had given them. Half an hour later I had discovered that they had no issues with her clinically but they felt that she was not respectful of their time as she had arrived late once and her clinics always ran late and, that when they had told her they were disatisfied, she had not appeared to take it seriously enough. There were also issues with the time she had, apparently, taken to process some paperwork. I attempted to explain to them the difficulties midwives experience with time-keeping, this did not wash, they, or rather he, were on a roll and were not about accept any other perspective than his own. I let him into a few facts about lack of fax machines, hospital postal services etc., apparently midwives should provide their own fax machines and deliver all correspondance by hand. (Brick wall and head). Eventually I managed to find an appropriate time to take my leave, telling them, through gritted teeth, that I would be back on Monday.

I finally manged o get to my booking apointment with H at 4.45, an hour and a quarter late. How did she greet me? Was she annoyed that I had not shown consideration for her time? No. She opened the door, identified that I was running late and was probably in dire need of a coffee and she set about making me a drink. Yes, midwives are human!

I finished work at 6pm. I had had a 15 minute break since I started at 8.30am and had a bruised jaw from repeated gritted teeth.

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Day of celebrations

10am – civil wedding at Registry Office (15 miles away) just daughter, her partner, me, Hubby and son, he gatecrashed as it was only supposed to be the 4 of us. The bride wore a fetching ensemble of distressed jeans and cream sweatshirt, whilst the groom wore the male equivalent. It was pouring with rain but the extremely basic ceremony was anything but dull as all involved, including the registrar and the superintendent, laughed their way through it all. The two officials were lovely, really friendly and insisted on taking loads of photo’s. Hubby and I then rushed home, calling in at the other wedding venue on the way to check that all the preparations were on schedule and drop off the lunch boxes I had made up for the children, and then got changed out of our casual attire.

12.45pm – Arrived at the Catholic Church, 25 miles away, for Jack and Izzy’s baptism. Jack was perfect, took it all very seriously, Izzy was fine until the priest poured the water over her head at which point she protested, loudly. Hubby and I had travelled in separate cars as I was going back to the wedding/reception venue whist he was transporting the bride, bridesmaid and flower girls to our house for them to get ready for the next part of the day.

2pm – Arrived at the next venue, 18 miles from the last one, welcomed all the guests, decorated the trees, it had stopped raining and then helped SIL with ‘the boys’ as their Mummy was the bridesmaid.

3pm –  The bride arrived and Hubby escorted her to the edge of the woods (the ground was too wet for the original plan of having the ceremony in the woods) and the humanist ceremony took place. It was lovely, exactly what they wanted with all their friends and family joining in and loads of children racing around enjoying themselves and not irritating anyone as this was a far from solemn ceremony.  Outside there were toddler climbing frames, swings and slides, plus a bouncy castle, and inside there was face painting, so plenty to keep the rugrats amused. The food was great, especially considering the last minute change from bbq to buffet and everyone appeared to have a good time, it was like a huge family party.

7pm – All children had to leave so I took Jack and Izzy back to our house, 7 miles. When we got back I gave them a quick snack, bathed them, read them several stories, changed the Mother of the Bride outfit for one I could have a good dance in.

9pm – Left the baby-sitter with a list of phone numbers and returned to the evening celebrations.

1am – SIL drove me and an inebriated Hubby and BIL back to our house, they were staying the night and she was not drinking as she is on antibiotics.

2am – We turned in for the night.

3am – Izzy woke.

Sunday – Soooo tired!

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Overload

 Organising a wedding is traumatic, throw uncertain weather forecasts into the cauldron and you can picture the schizophrenic state daughter, future SIL and I are in at the moment.

Relatives staying with us for the weekend has added just a dash of manic housewifery to the mix.

Amy’s and the Boys Mummy being unwell has embellished the whirlwind that is me, as I am so concerned about her that I have stolen Amy, and she is now accompanying me through my organisational maze.  

It’s a bit like Christmas Eve really as then, once it gets to 6pm, I relax slightly as all the shops are shut. I’m just looking forward to bed-time tomorrow as then if it ain’t done, it ain’t ever going to be done!

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