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Archive for July, 2009

Still waiting

First I would like to say ‘Thank you’ to everyone who has left kind comments about my step-father’s accident and the resulting injury.

We visited today hoping to see an improvement, however slight, unfortunately his condition today was the same, possibly worse. At least yesterday he did appear to be aware that people were there, today there was zero response to noise or touch. They are using the Glasgow Coma Scale to assess his level of consciousness, being generous it is around 10 by their assessment, when I do it I can’t give him more than 9. Whatever, his condition is stable and the blood has stopped leaking from his ear. He is still in a neck brace, even though a scan has not shown any damage, but the ortho guys are reluctant to remove it until he can tell them if he has any pain, apparently there is a 1% chance that the scan fails to show damage. I had another long chat with the doc on ITU, who is as disappointed as we are that there are no positive signs, but was at pains to emphasise that if there is to be any recovery it may take weeks as opposed to days. I won’t be able to visit now for 4 days, hopefully when I see him again I will feel more positive.

Mum is odd, but there again she is a strange person anyway. She is a retired midwifery tutor who prides herself on, and flaunts, her ability to diagnose, prescribe treatment and take control. (Take this as you will but I have frequently considered that she may have Munchausen by proxy). You would imagine that in this situation a loving wife would be constantly in attendance, not the case here though, slightest opportunity and she’s off and away. Perhaps it’s too difficult, on an ITU, for her to be in control given the one to one nursing and the complexity of the monitors and electrical equipment. Enough of that b******g as on Thursday we will be celebrating her 80th birthday, obviously this will be a rather subdued celebration, in fact it is just going to be my sister and I taking Mum out for a meal, but we do have to mark such a major birthday.

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A waiting game

I’ve spent the majority of today in an ITU as my 87 year old step-father has a serious head injury as a result of being run over by a reversing car. Apparently the car was being reversed off a drive, the driver failed to see my step-dad who was out walking the dog, he thought that something has fallen over in the boot, until his son looked in the mirror and saw a man lying in the road. On admission my step-dad was conscious, but confused and irritable, bleeding from his nose and ears with a laceration on the back of his head. He was then heavily sedated, intubated and a CT scan was undertaken, it showed a large, sub-dural bleed. Following this they shared the image with a centre specialising in head injuries, who confirmed their interpretation but wanted Ref to be woken up so his condition could be assessed before a decision was made regarding transfer. He was ‘woken’ up, he is now conscious, but not responsive but he is breathing unaided. I had a long chat on the phone with the neurosurgeon at the tertiary referral unit, he explained everything and explained that they would rather not operate due to the size of the bleed, apparently that will be as dangerous as leaving the bleed there.

It’s just a waiting game now to see how much brain function, if any, is recovered.

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Over the last two weeks 3 of my women were due to give birth – at home.

A is a 30 year old who was having her first baby. She wanted a homebirth as she is frightened of hospitals.

B is a 31 year old, also having her first baby. B decided on a homebirth after having an entirely normal, ‘easy’ (her words) pregnancy.

C is a 34 year old, she already has a 2 year old who was born in hospital following ‘an awful experience’, with a cascade of intervention and a ‘control freak of a midwife’.

A’s story

At 41 weeks pregnant, with the birthing pool up and waiting in the sitting room, A had a stretch and sweep. The examination discovered that the cervix was central, effacing and 2 cms dilated with baby’s head -2 above the ischial spines. For a few hours afterwards A reported that she was feeling sightly uncomfortable, but then everything settled back down. 2 days later a second stretch and sweep was performed, with very similar findings except that the baby’s head had descended to the level of the spines. A was now 9 days past her due date, so a date was made for an induction of labour when she would be 40 weeks + 12 days.

At 11am on the scheduled day A, tearfully, made her way to the maternity unit. On admission a cardiotocograph (CTG) was performed to assess the wellbeing of baby. Once it was demonstrated that baby was doing okay a vaginal examination was performed, a Bishops Score estimated and a prostin pessary inserted, it was 1pm. Following a second CTG A went for a walk and tried to relax, nothing was happening. At 7pm the whole procedure was repeated, her partner and Mother stayed with her until 10pm and then left (hospital policy) to await a phonecall. By 2am A was experiencing regular contractions but was coping well using a TENs machine and wobbling on an activity ball. 6am saw A no longer coping with contractions, a vaginal examination discovered that the cervix was now 6ms dilated and baby’s head was now -1 below the ischial spines, an artificial rupture of membranes was performed and A as given pethidine.  At 10am a vaginal examination was performed, hospital guidelines indicate that 4 hourly vaginal examinations should be performed during induction of labour to assess progress, at this time the findings were the same as 4 hours previously. A was very upset by the lack of progress, despite regular contractions, and when told that the next move would be to start a syntocinon infusion she requested an epidural, after an hours wait for the anaesthetist, he was in theatre, an epidural was sited and then the synto was started. 3pm, a vaginal examination by a doctor estimated that the cervix was now 9cms dilated but he detected that baby was trying to come out with it’s back to Mum’s back, direct occipito-posterior, he also believed that baby’s head was not tucked down with it’s chin on it’s chest, instead it’s head was deflexed. He decided that baby was not going to succeed in being born vaginally and so A gave birth to her baby boy, weighing 8lbs 12ozs, by caesarian section.

B’s story   

41 weeks pregnant and the super, heated, filtering birthing pool had been inflated and filled for a week. A stretch and sweep was performed and the findings suggested that labour was not imminent, the cervix was posterior, long and only 1cm dilated, baby’s head was -3 above the spines. An induction was scheduled for 2 days later and all started as with A. The first prostin worked wonders though and 6 hours after it was inserted B was taken to labour ward to have her waters broken (ARM). Within the hour her contractions had started and her TENs was pulsing away, 5 hours later, after much marching, she gave birth to her son who weighed in at 8lbs 10z and 6 hours later they went home.

C’s story

At nearly 36 weeks I couldn’t be sure that baby was coming head first so A went to hospital for a scan, baby was head down so her homebirth was booked. 4 days later A experienced sharp pain in her uterus so self-referred to the maternity unit where they performed a CTG. The doctor who reviewed it felt that it was non-reactive and believed that baby was small-for-dates so, as a result of these two findings, suspected intra-uterine growth retardation (IUGR), an USS and doppler was arranged for 2 days later. C was on tenterhooks. The scan and doppler were performed, plus a repeat CTG, and all was reassuring, baby wasn’t huge but was estimated to currently weigh about 5lbs 8ozs. C was now 37 weeks pregnant, it was all systems go for a homebirth and so…..the pool was inflated.

2 days later and C experienced a few trickles of fluid.  A community midwife visited, performed a speculum examination to try and assess if her membranes had broken, they had, and a vaginal swab was taken to exclude the presence of infection. The following morning the on-call midwife contacted C, there were no contractions and the membranes had now been ruptured for nearly 24 hours so C was asked to make her way into the maternity unit for augmentation of labour by syntocinon infusion plus the administration of intravenous antibiotics as once the membranes have broken there is a risk of infection to the baby. C refused, but did agree to attend the hospital a have a CTG to check that baby was okay. The risk of prolonged rupture of membranes was explained to C, but she opted to return home and await events.

36 hours after her membranes had first started leaking C’s contractions started. She contacted the on-call midwife who came round to assess the situation. It was 4am and when C was examined the midwife found that the cervix was 2cms dilated and long, C was advised that labour was not yet established. The midwife stayed for an hour and, believing that C was only in early labour, went back to bed. C was finding the contractions difficult to cope with so had a warm bath. Within half an hour she decided that, if this was early labour and that there were still hours to go (as the midwife had told her), then there was no way she could do it without an epidural so she, her husband and their 2 year-old son set off for the hospital, 20 minutes away. Halfway there C realised that baby was coming, quickly and told her husband to pull over. He told her to hang on as they were nearly there, with that C felt the baby’s head being born so screamed at her other half to stop, NOW! He did, and their son, weighing 5lbs 7ozs, was born in a lay-by. An ambulance took C and baby to hospital for a quick check over, all was well, and 4 hours later they were driving back past the lay-by where baby entered the world.

Why write about these 3 births. Well, all were booked homebirths, but not one actually gave birth at home. None of the examinations before labour gave any indications of when, or if, labour might start. In fact the examination which appeared to give the most positive sign of readiness to labour was A, who ended up with a caesarian section. What does this show?  That there are no rules, patterns or predictive measures as far as labour and birth is concerned and that birthing pools are very popular!

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What man would be brave enough to suggest that the pain of labour is ‘a good thing’? Dr Denis Walsh, that’s who. Now the doctor title may be slightly misleading as, rather than being a medical ‘doctor’ the title is a PhD, he is actually a midwife, admittedly an extremely senior practitioner, but midwifery is his profession, even if he is ‘not able to provide midwifery care at this time’ (NMC register). He is now also the cause of huge discussions everywhere, ranging from a well-constructed defence of his opinion by Feminist Philosophers to a series of expletives, tempered with some thoughtful comments, on the Mumsnet forum.

What do I think? I think that epidurals are over-used. That they do adversely affect the progress of labour. That they change, what for 70% of women is a normal, physiological process, into a medical event. That the use of epidural anaesthesia increases the risk of an instrumental delivery. That the opiate used in the epidural passes into the woman’s blood stream and so across the placenta to the baby and may affect breastfeeding.

So now I have stated my thoughts about epidurals BUT I would never deny a woman her choice of an epidural, in fact there are times when I actually advocate the use of epidurals in labour. What I do attempt to do is support the woman in normal labour, to encourage her to accept that the pain of the contractions is not a sign that something is abnormal but, if she still wants the epidural, then she gets one.

I get annoyed when I hear women say that they don’t want pethidine because ‘it affects the baby but an epidural doesn’t’. Rubbish. Even before I read the research suggesting that epidurals adversely affect breastfeeding I was only too aware that having an epidural increased the chance that baby would be delivered by a ventouse or forceps, both of which are capable of causing severe physical damage to baby. How about the woman? Yes she will probably have a pain-free labour (not all epidurals work though). Labour will be longer, but that’s not a problem, for her, if she can’t feel anything, might distress baby though. She may not be able  pass urine, her bladder may become overful and obstruct baby’s head descending, no bother though as she can always have a cathater, but that does run the risk of giving her a urinary tract infection (cystitis). It’s more likely that she will need an episiotomy, but at least she won’t feel it, or the stitches, until the epidural wears off. The epidural may cause her blood pressure to fall dramatically, but her feeling faint and sick as a result, like the fall in baby’s heartrate, will be sorted out quickly by the intravenous fluids being increased and rolling her onto her left-side. The woman’s temperature may well rise as a result of the drug used in the epidural, but the staff can’t say definitely that the drug is the cause so the treatment has to be as if there is an infection present. The woman having a raised body temperature may also cause the unborn baby to demonstrate an increase in heartrate, if this persists then the medics will wish to investigate further and fetal blood sampling may be required. Following the birth the baby may well have to undergo investigations to rule out infection or, there may be a decision to use intravenous antibiotics prophylactically.

There it is then. If you hear, or have heard, of a midwife refusing a woman an epidural it wasn’t me, but if the story entailed a midwife trying to encourage a woman to cope without one it may well have been me as I have seen all of the above too many times to believe that epidurals are the innocent pain reliever many would like you to believe they are.

If anyone would like to read more from Denis Walsh about epidurals this  ‘Zephrina Veitch Lecture’ is great.

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Life has been super busy recently, hence no posts. I have had 2 weeks without having the boys so you would think that I’d have an excess of time for relaxation, well that would be the case, if it weren’t for Son moving house last Friday so, as I couldn’t help on the moving day because I was working, I offered to look after Evie on the days prior to the move, those excessively hot days. Their move went well, however since they both have a desire for perfection they concentrate on a specific, wonderful in their work life but rather limiting when moving house and needing to set it up quickly for an 8 month old who is crawling , cruising and into everything. As a result, by Monday the house was still full of boxes, mirrors propped up against walls and totally unsafe for an adventurous bundle of mischief so, I abducted her for the day. Thankfully it worked the trick and by the time I returned her the house resembled a home, rather than a junk yard.

On Sunday Amy, the boys and their Mummy and Daddy came round for dinner as they had only returned from Majorca the previous evening. We were lucky to still have Amy as, on their first day there, she jumped into the deep end of the swimming pool while her Mummy and Daddy were attempting to control her brothers. By the time they had realised that she was not with them she was bobbing up and down underwater. Daddy leapt into the water and dragged her out, blue and, eventually, spluttering. She recovered well, unlike Daddy’s camera and wallet which were in his pockets when he jumped into the pool.

I’ve been having a clutter clear-out and am now a huge fan of ‘Freecycle’ . I have always been a terrible hoarder, mainly because I hate throwing out something which is still ‘fit for purpose’, so having a system whereby you can pass things on to people who want them is brilliant.

Whilst I’ve been on annual leave one of my women who I had booked for a homebirth had her baby, in a lay-by! Whilst I was discussing homebirth with D and her partner she asked me what would happen if she decided that she wasn’t coping well labouring at home, I reassured her that if that were the case then we would transfer her in to hospital. I did point out though that as this was her second baby, and if she were progressing well in labour, the chances were that by the time we had got her to the maternity unit the baby would be very close to putting in an appearance, and it may well be too late for the epidural. I’m so glad that I said this as what happened proved my point. Apparently a midwife had been called out early in the morning, examined D, found that it was still early labour, stayed for an hour observing irregular contractions and then left, leaving D with her phone number for when labour kicked off. Labour did kick off, and D decided that she wasn’t going to bother the midwife as she was finding contractions too much to cope with, so decided to go straight to the maternity unit by car, only they didn’t get that far before baby decided that car travel was interesting and so he would get a better look by being born, in a lay by, on a dual carriageway. Thankfully everyone is well, the car does need valeting though!

For the past 5 weeks I’ve been on-call for a family friend who was having a homebirth. Needless to say this 1st baby was reluctant to start the being born process by himself, so off went his Mummy for an induction on Thursday. Boy was this an awkward little boy, so, so near to being born normally, but, after 14 hours on the syntocinon drip, Mum’s cervix nearly fully dilated, a doctor discovered that baby was trying to come out brow first and so a CS was the method by which the not-so-little – 8lbs 11ozs, baby boy came into the world. Once again though, Mum and baby doing well.

I’ve just managed to get 2 days much needed gardening in, the borders are looking so much better now and the risk from errant brambles has been contained. I must be stronger than I thought as I succeeded in snapping a tine off a garden fork, only 3 months old and with a 10 year guarantee. When I returned it to the store the assistant told me that they had never had one returned, broken, before. Don’t mess with me, I’m obviously a force to be reckoned with.

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