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Archive for October, 2010

I’ve just finished a run of working days, hell and heaven would be the words to describe them. Heaven were the weekdays, hell was the weekend.

Heaven = Visiting new Mums and babies on their first day home, listening to their birth tales, reassuring them that baby is fine, helping them out with breastfeeding and then going back on day 5 to be greeted with a smiley face and thanks for the advice and help I had given previously. Heaven is also seeing my women at antenatal clinic, listening to their woes and then making them laugh, answering their questions and giving advice. Meeting ‘old’ patients in the waiting room as they queue for babe to have his first jabs and being treated as an old friend, even hugged by some. Heaven is feeling that I must be doing/have done a ‘good’ job, that I have fulfilled my role to those womens satisfaction and/or expectations.

Hell. Hell is the weekend, working with a truly skeleton staff, unable to provide any sort of individualised care, the women are on a conveyor belt and I am an operative. Hell is arriving at the midwives clinic to discover that 2 of the 5 midwives scheduled to be working were out at a homebirth all night so are not working that day, then the phone ringing alerting the 3 remaining midwives that another homebirth is ‘brewing’. Hell is looking at the clinic list and seeing that there are 30 women attending and then reviewing the home visits to discover that 10 women need a visit. Hell is phoning those women who are expecting a home visit to explain that this is an impossibility and ‘inviting’ them in to the clinic to be responded to with ‘this isn’t my problem, it’s yours’. To attempt to reason with the shouting woman at the other end of the phone, tell her that there is a homebirth happening, that unfortunately these take priority, and that there is now only 1 midwife covering all women requiring postnatal care over an area of 400sq miles. To then be replied to, in words containing many expletives, that she is your priority, that your job is to provide her with care where she wants it and that YOU shouldn’t put a homebirth before her (where are the decision makers at times like this?). Heaven is when 1 of the midwives who has been out all night with a homebirth turns up at the clinic and works all day with you, although it must have been hell for her, sleep deprived as she was.

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Honesty and the NHS

Lots in the news at the moment about how NHS employees are being suspended on full pay. What have they done to warrant this? Are they suspected of professional misconduct or of gross negligence? No. They had the temerity to speak out about areas of NHS care, or highlight examples of poor management, which concerned them.  So much for the guidelines which were issued to encourage and protect staff who ‘whistleblow’. There is a hope that things might change as the Department of Health are just issuing new guidance on best practice regarding how to encourage a ‘culture where staff feel able to raise concerns about malpractice or potential risk to patient safety’.

I’m not convinced on this one, I have observed two examples recently of how staff are intimidated by management for breaking a code of silence. In the first case a report about local services closing appeared in the press, no one knew the origin of the information. A meeting was called and any staff who knew about the proposed service change were summoned and questioned by a manager, the rationale being that they needed counselling (?) No one admitted to leaking information. It certainly sent out a message though, keep quiet because to speak up is to require treatment, and a treatment which would doubtless appear on your employment record, allowing you to be labelled as a problem. The next example involves the ‘super-highway’ and people exchanging information on social networking sites. Those concerned may have been misguided, but my attitude is that if their working conditions were appropriate and they were happy with the care available then their comments would not have been made. All those who took part in the on-line chats have been spoken to by the HR department and have been advised not to broadcast how discontent they are with how care is provided (or not).

We are not talking here about national security, we are talking about a public service, something which the majority of us have an involuntary financial commitment to and which all of us will use at some time or another. The NHS administrators have been compared to the Stasi, certainly their attitude to ‘whistleblowing’ appears to validate this but why smother the truth, what is wrong with honesty?

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Mutually agreed resignation

So, it’s starting. ‘ …..our organisation faces significant financial challenges……..In order to respond to these challenges we must implement cost savings and efficiencies and begin to restructure the shape and size of our workforce. The Mutually Agreed Resignation Scheme (MARS) is a scheme ……..which an individual employee………chooses to leave employment in exchange for a severence payment’. In other words ‘Jump before you are pushed’!

Now, the scale of payments, if you’ve worked continuously for the NHS for a year – 3 months basic salary; 8 years – 4 months basic; 12 years – 6 months and if you make 24+ then it’s 12 months. Personally, I think that you do rather well if you only worked for 1 year but it’s rather an insult, where’s the pro rata here if you’ve served for 25 years?

There is a real sting in the tail though. You can’t qualify for the payment if you have secured another NHS post at the time of leaving and you can’t start NHS work within a month of the MARS payment.

I’m finding this really scary, I feel that I’m scrabbling to cling on to my post. My angst is increased because I had a cryptic message from a colleague telling me that she needed to speak to me. My first reaction was ‘what have I done wrong’, she’s a Supervisor of Midwives, but she messaged back to reassure me that it’s not practice related but due to her desire to contact our ‘union’ (RCM) rep about the ‘changes that will be happening’. What now? More changes and obviously not for the good otherwise the colleague would not be thinking union representation. How much more can they decimate the maternity services? Anyway, I thought that the NHS was ring-fenced.

The timing is just slightly wrong. I need another year.

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Checking my stats I discovered that ‘Risk factors for a home birth with twins’ was a search someone had started which had caused them to visit my blog. It’s interesting how these things must function as individually ‘risk factors’, ‘home birth’ and ‘twins’ would definitely all feature in my musings but I feel sure that I haven’t ever put them all together, and definitely never in a format suggesting that I would encourage a home birth for twins.

  • There are midwives who will disagree with me on this one, they are brave, I am tremulous. I look at the risk  factors during and following the labour and plump firmly for the ‘birth units attached to an obstetric unit are lovely’ attitude.
  • There are midwives who will disagree with me on this one too, they would rather the obstetric unit.
  • There are midwives who will disagree with them on that one, they would rather an elective caesarean section.

So, there are 4 viewpoints on how the birth of twins should be managed. How would each group have reached their opinion? Most often the answer is experience, a bad experience of one method and a good outcome with another. To be honest, there are very few, currently practising, NHS midwives who will have experienced a planned homebirth of twins therefore we haven’t got any experience, be it positive or negative, on which to base our judgement. What we have to do is consider the twin births we have witnessed in hospital, read any evidence about outcomes at twin home births and weigh up the risk factors (I’m not even going to include Trust guidelines, policies and protocols here as they would completely bar a homebirth of twins). 

Let’s consider the risk factors during labour. Immediately there is a difference between identical, one egg, twins and fraternal, two egg, twins. This arises because the identical twins will share a placenta and sac, whilst the fraternal each have their own home and placenta. I could scribe for ever if I muse about each so I’ll mention it when pertinent. So, Mum has gone into labour, twins will often come early, has the pregnancy reached 37 weeks? Before that there is a risk of one, or both babies, having breathing difficulties. I think  that everyone would agree here that the birth should be in an obstetric unit purely for the paediatric support. Then, how are babies lying? Are they behaving themselves? Ideally both babies will be coming head first, if they are then risk regarding the birth immediately decreases, this is when I muse about a birth centre environment, as long as it stands along-side an obstetric unit. 

First one, head down (cephalic) with the second breech? Gosh. How big are these babies? Is the first one larger than the second? Even though the research on vaginal breech births being a no no has been rubbished obstetricians, and midwives are still hugely wary, at this juncture many professionals would advise an elective caesarian section. I say many, not all. If one of my women was pushing for a vaginal birth with T1 cephalic and T2 breech I would have a long discussion about the problems which may be encountered due to breech presentations but, if they were fraternal, ultimately I would support her with her desire for a vaginal birth in an obstetric unit. Identical twins, more problematic, it’s that one placenta worrying me, is it going to start separating before the 2nd baby is born? The breech may deliver with no difficulty, so hopefully there are only a few minutes between babies, it may take it’s time though, or decide to stick a leg down and then require more manoeuvres to help it out or the cord may snake down, I’m weighing it up, placenta might separate = lack of oxygen, baby might take longer to be born, certainly there is higher risk for a poor outcome with the second twin, my feeling, obstetric unit and possibly an epidural. Many, many people and some midwives would disagree with me, I’ll put a couple of links here, Emma Barker’s twin birth and Homebirth org which have a more relaxed stance than me. Both babies breech, obstetric unit and, in my world, whether fraternal or identical, elective caesarian section.

Why all this worry? After all it’s just giving birth to two babies rather than one. Unfortunately it really isn’t that simple, and the second baby really does fare less well than the first baby. Several reasons, mainly due to the extra space available once number one has been born. Even if the second baby was coming in a good position, be that cephalic or breech prior to its sibling leaving the womb, that can change as soon as room has been created for it to move around. Routine at twin births is stabilising the second twin as soon as number 1 is born. An assistant will, externally, attempt to ensure that wriggly twin 2 doesn’t perform celebratory gymnastics. There is also the risk that the cord will present before baby, someone will check this and, if it there and baby is in a good position plus already striving to come out s/he will be assisted in their endeavours but, if baby is still high, or the part the examiner is feeling is a leg , shoulder or arm then the safest way forward is a caesarean. If T2 is behaving then generally, after a short rest, contractions will continue. This isn’t always the case though and, due to the uterus contracting down following the 1st baby, there is a risk that the placenta will start to separate, causing number 2 to suffer with a lack of oxygen so some units will routinely put up a syntocinon IV to ensure that contractions can be stimulated if necessary. It’s also handy to have the syntocinon hanging around for the third stage, that time when the placenta, or placentae are coming away. There is much talk in this entry about the uterus, and it’s size and during the third stage is when it can cause the mother more problems. With one baby there is a much smaller area where the placenta was attached, with two it is really quite large, and in essence this is an open wound which can bleed quite impressively if the uterus doesn’t contract down really quickly, and then stay contracted down. Following a twin pregnancy all the associated tissues and muscles have been hugely stretched so the chance of an atonic, non-contracted uterus, is more probable, therefore the strong  possibility of a postpartum haemorrhage is something to be kept in mind. This is where the syntocinon IV comes in handy as it may well be required to help a reluctant uterus to contract.

Ultimately the choice of where a woman gives birth to her baby, however many, is her decision. That choice should be informed though. There are risks with a twin birth, and they are higher than for just one baby. The highest risk, prematurity has been passed with a planned home birth but there is still risk at term, particularly for the second baby. Professionals can advise, and on the whole we err on the side of caution so, if you are expecting twins and want to really know your options and the risks, read, read, and then read some more but make sure that what you are reading comes from safe sources.  

Great article about twins – e.Notes.com

American discussion about twin births with international references

Postscript – (declaring an event which may make me biased)

My daughter had twins, by an elective caesarean section at 36 weeks. This was her 2nd pregnancy. The first ended with an induction of labour at 41 weeks and 4 days, failure to progress, cervix never more than 4 cms dilated after 15 hours on syntocinon, progressed to caesarean section and the birth of a 9lbs 12ozs baby girl.

The twin pregnancy was identical twins and was uneventful. Daughter was happy with the plan to deliver the babies at 36 weeks, I concurred as T1 was cephalic, T2 was breech, the history of the previous section and a close family history of twin-to-twin transfusion resulting in both babies dying. The babies weighed 6lbs each but T2 suffered breathing problems and spent the first 2 days of his life in NICU, he is fine now. In retrospect I would have encouraged waiting until 37 weeks, but hindsight is a wonderful thing.

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I’m fed-up with constant repetition, my constant repetition. I’ve lost track now of how many times I’ve blogged about the reduction in postnatal care and how potentially damaging that I believe it is – Two minds; Do women have a right to a homebirth? ; The Demise of Community Midwifery  – part 2 and, perhaps the most pertinent and written nearly 3 years ago, ‘An embarrassment’ .

Well, now it’s official and it’s in the news – ‘New Mothers let down by postnatal care’ (BBC). The NCT have completed a survey and have discovered that women feel unsupported following the birth of baby and have summed up the lack of care in one word, ‘shocking’. They go on to say that ‘ Many of these problems the women highlight seem to be due to staff shortages or lack of visits once they have left hospital’. Actually NCT it is not 2 problems but one, the staff shortages cause the lack of postnatal visits. Sorry, repetition as this is one of my familiar themes and, rather than conduct a survey,  all you needed to do was read my blog. I’m just a midwife though, what do I know? But you do know my thoughts as we had a brief email exchange, it was exactly a year ago, I published the mail from the NCT and my response in An email to the NCT and  ‘NCT – A reply’.

I am a Cassandra, ‘ no one would ever believe her predictions’. I’ve got another prediction, it’s going to get worse unless there is a step back and an honest consideration of what is really important in maternity care. Times are hard and the approach should be to consider what part of the maternity services should not be ignored, can we really afford to be touchy, feely? Should monies be spent on staff or surroundings? Homebirths or home visits? If the finances do not routinely allow for both what is important, a live and healthy mother and baby or an empowering experience?  

Other sources which report on the NCT survey – Sky News, Telegraph (the comments are incredible) and the Observer.

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