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Life has recently become extremely hectic and there is now much more juggling with commitments. Family life has been full, June has 2 birthdays and, in our household, that always heralds family meals so we all mustered the other weekend to celebrate Joshua’s 1st birthday (time has flown), his Mummy’s birthday, Father’s Day, son-in-law passing his electricians course (3 years hard graft after a working day at evening college) and me getting a new job. June also appears to be the month when our ‘children’ need a weekend away, so Mum and Dad end up having the grandchildren and not enough sleep.

The new job, well I’m still doing my old one as a community midwife but I have now also taken on another role, within the same Trust, midwifery related but not clinical. I know, I’m always wittering on about wanting to retire so what on earth has possessed me? Two things have prompted this, firstly it is a role that has always really interested me, and secondly, due to the bankers and the politicians I am one of the select group of women who find themselves most disadvantaged by the changes to pensions, state and NHS. I was amazed to be selected for the job as on the day of the interview I had some nasty virus which was causing me to appear grey, subdued and huddled and the interview was at the end of a particularly busy working day. I knew one person on the panel but the other 2 were entirely unknown to me so either the other candidates were totally unacceptable drop-outs with no grasp of the language or the one person I knew bribed the other interviewers!

Community is plodding along, this month has on the whole been quieter postnatally but I have managed to squeeze in 2 homebirths and a birth at the midwife-led unit. One of the homebirths set my adrenaline soaring, all my own fault really as I was being too relaxed, so was the woman in labour, and didn’t phone the 2nd midwife in time, in fact I didn’t phone her at all as my hands were full. I had to ask the woman’s husband to phone her and request she come PDQ, unfortunately it wasn’t PDQ enough as baby arrived 15 minutes before the 2nd midwife, luckily all was well though. There was still a slight frisson when I realised that baby was on her way out and I hadn’t got another pair of hands if needed, all the adverse scenarios started racing through my mind, but then I banished them and I concentrated on welcoming baby into the world.

I wrote all of this yesterday but when I ‘published’ it all that appeared was the title, the body of the text had vanished, for good, and this is the second time that has happened, is anyone else experiencing this?

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I would like everyone who reads this to remember that on two seperate occasions I  have expressed my concerns to the doctors about the size of the baby and DIL’s ability to give birth to a baby bigger than Evie.

DIL’s waters broke at 16.45. They bought Evie around to us at 17.30 and, since there were only tightenings, they went off to the hospital whilst I stayed at home and gave Evie her dinner. At 18.20 son phoned and said that I should get over there soon as the contractions had started. Off I flew and, of course, encountered every super-cautious driver ( the ones who need an all clear from 2 miles away before they will pull out at a junction) I got to the hospital just before 19.00 hours.

I walked in to hear the midwife encouraging DIL to push, whilst the labouring Mum was inhaling deeply on the entonox. Gosh that was fast, nothing to pushing in an hour! Baby was moving down slowly, very slowly. The midwife and I exchanged glances. Baby’s head started to appear, and then stopped. Much encouragement and his head was born, just. Another contraction and baby didn’t advance at all. The midwife pulled him, he didn’t shift. Whilst the midwives lifted DIL legs back (McRoberts) I dropped the back of the bed and pulled the emergency buzzer, we had a shoulder dystocia.

Within 20 seconds the room had filled with midwives, obstetricians and paediatricians. After a tense few minutes, felt like 10, was really only 3, out came my new grandson, very shocked but after a minute he opened his mouth and let us know that he was fine. DIL didn’t seem to realise anything much untoward had happened, son was quite stunned.

Labour ward was full to bursting, 18 rooms of women in labour or who had recently given birth. Both the on-call community midwives had been called in but even so staffing was not covering the influx so I got on with weighing baby, 8lbs 9ozs, and measuring his head circumference, 37 cms. When DIL started bleeding rather more than we would wish I was left to observe and react. The bleeding slowed down to normal levels by 22.30, DIL was fine and baby had breastfed almost constantly since he was born. I bid them all farewell and returned home.

At 23.30 son texted to let us know that our grandson now had a name, William Joseph, and that Mother and son were doing well.

Evie had gone off to sleep well for grandad and didn’t wake until 5.45am. Unfortunately I had not gone to sleep well, my brain was churning over the evenings events, alternately thanking god for a positive outcome and plotting retribution on the doctors who had dismissed my concerns, so I had managed about 2 hours sleep before Evie woke me from my slumbers.

It is Thursday, so round came the boys to join Evie in the chaos of my sleep-deprived home. Son came and collected his first born at 11 so they could introduce her to her brother, who was now called Joshua William. Unfortunately I had spent the previous 5 hours teaching her to say ‘William,’ so there is definitely going to be some confusion there! The staff had advised DIL that she would not be able to leave until Joshua had been thoroughly checked by the paediatricians to ensure that there was no nerve damage or fractures resulting from his dramatic birth but they were hoping to be home by mid-afternoon.

At 16.30 son phoned to say that the docs had checked baby and he had not suffered any damage, but he does have a heart murmur so they can’t go home. I contacted Hubby who abandoned the golf course in favour of visiting his new grandson, I was stuck at home with the boys and Amy, tired and weepy, me not them!

At 18.30 Hubby arrived home, with Evie, her Mummy and Daddy were waiting for Joshua to be reviewed again. Thankfully I had been blessed with a second wind so we had a lovely time, dinner, bath and much chatting. Then the phone rang, it was son saying that the paediatricians had reviewed baby and……..he was fine so they would be leaving the hospital imminently and would pick Evie up on the way home.

That’s it then, the birth and first 24 hours in the life of my seventh grandchild. DIL appears well and oblivious to how much of a scare she and Joshua gave us. Her coccyx has been displaced again so sitting is painful and it’s very early, pre-baby blues days but presently she regards this labour as a better experience and ‘less traumatic’ than Evie’s labour and birth!

Joshua William, born at 19.19 hours on 23.06.2010

Joshua William – born at 19.19 hours on 23.06.2010

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I’m going to have a new grandchild, all being well, some time in June. I’m being non-committal about dates as there is some disagreement between scan dates and EDD by first day of last period. This situation is not unusual, the majority of my women will arrive at clinic following their dating/nuchal scan with a date a due date a few days earlier or later than the one arrived at by naegel’s rule. There in lies the first dilemma, the scan date is 3 weeks later than calculated using an obstetric calculator. At this point I generally discuss longer cycles with the parents, I started out doing this but was cut off at the pass by son pointing out to me that all the measurements were indicating a fetus whose size was above the top line. We waited for the 20 week scan, same story, big baby estimated as being due 3 weeks later than DIL’s dates. Due to DIL’s low BMI there was another scan at 28 weeks  just in case baby was not growing well. No worries there though as baby was once again on the top line. I’m a little piggy caught in the middle. I know that scans are generally accepted as being more accurate than LMP, however they can be wrong and it’s not surprising really as the measurements used are so small initially that a slight malpositioning of the probe could make days of difference. I’m torn because of several little things,their first baby, Evie, was 12 days late and only came because of induction and even then had to be helped out with the ventouse, dislocating her Mummy’s coccyx on the way.  I rationalise the lateness of Evie by factoring in that DIL was stressed due to son’s illness so her hormones were not behaving optimally for  labour to start spontaneously. Perhaps that wasn’t the cause though, was it because baby was too large for DIL? Now supposing that this baby is also late. DIL’s dates indicate a due date of 5th June, 2 weeks over would mean induction round about 17th to 19th June but the scan says that baby is due on 25th June and allowing DIL to go 12 days over would mean the pregnancy could be 5 weeks over. From another perspective, if the scan dates are correct then this baby is big, very big, will DIL be able to get it out? 2 days I did an antenatal examination, all well until I palpated. Baby feels ‘a good size’ and, at 32 weeks, is measuring in at 34 weeks.

This feels like deja vu. Amy’s Mummy had a large bump with her. I referred her in with polyhydramnios and a large baby at 32 weeks. I was right, but that didn’t stop the consultant allowing daughter to go 10 days over and to end up with an emergency caesarean for failure to progress in labour with a 9lb 12oz baby.  I’ve highlighted the discrepancies between dates, scans and size in the notes, had a word in clinic sister’s ear and eagerly await the consultants thoughts next week.

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Previously in ‘The Demise of Community Midwifery :-

The PCT’s, in some areas, are with holding the government monies which were supposedly ring-fenced for the improvement of the maternity services. The result is that the maternity care providers, the hospital trusts, have increased consultant availability, improved facilities and employed (in some cases) more midwives in line with recommendations but the promised monies have not been forthcoming from the PCT’s, so they are now having to make cut-backs.

Next on my list of ‘those responsible’ are the ‘user’ and ‘interest’ groups. Within maternity care the focus, their focus, is on the birth itself. Fair enough, that is what is most important, a healthy baby and Mum. Childbirth is not an isolated event though, there are 40 weeks leading up to the birth of a healthy baby, the antenatal period. Traditionally this care is provided in a variety of ways but, within the NHS, the majority of care options will involve a midwife to a greater or lesser extent. G.P’s may also be involved, if the G.P is registered as providing maternity care s/he will receive extra funding from the PCT for each of his pregnant women, regardless of how much input s/he actually has and, surprise, surprise, the PCT’s are still paying G.P’s this.

Back to the interested parties and why I point a finger at them. They lobby, they lobby for women’s choice. Women’s choice in where they give birth. Nothing against this, in theory, but everything against it when it appears that they place more emphasis on this than on antenatal and postnatal care and so this is where the money and focus is. Wonderful for a woman to give birth in a friendly, tastefully decorated, home-from-home room, littered with birthing balls, fully equiped with a birthing-pool and aromatherapy diffusers. Is it still wonderful though if, after the birth of her choice to a healthy baby, baby fails to thrive, develops jaundice and is, eventually, readmitted to hospital for IV fluids and phototherapy? This happens now, how much more often will this happen when community midwives no longer visit? G.P’s will see an increase in visits by, or to, newborns and their Mothers. Why the Mothers? Well, wounds become infected. Presently a midwife will visit, suspect an infection, take a swab and then phone the G.P to request that a prescription be issued for antibiotics. The infection will be caught early and the wound will, in most cases, heal well. If an infection is not treated promptly then it will ‘break down’ leading to a longer healing period or a readmission to hospital for re-suturing. I’m not even going to discuss the effect that reduced domiciliary visits will have on breastfeeding rates, all at a time when WHO are emphasing the importance of community support. Much is written about the detection of postnatal depression, as a community midwife I may suspect that a woman is likely to suffer PND, but serious PND generally shows after I have finished visiting. My role in this is to ensure that women know where to access help and to not  be ashamed, as many women are, of admitting that she is suffering from depression. Then there is an illness which does present whilst community midwives are visiting, puerperal psychosis, yes, it is rare but when a woman does begin to suffer from it early detection is beneficial as this illness can have tragic outcomes, as recognised in Why Mothers Die.

The essence of my argument with the ‘interest’ groups, who concentrate so single-mindedly on the ‘birth day experience, is ‘what point an ecstatic birth if, as the result of poor follow-up care, the mother and/or baby are unnecessarily ill, or die?’ It is wonderful that there are groups out there who apply pressure to government and care providers to improve care within the maternity services. Come on though, widen your focus from the glamour, headline catching time of birth and acknowledge the importance of good care before and after birth

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Spotty babies

There you are, proud new parents of a tiny, pink little person and just as you are ready to show your beautiful creation to the world baby’s skin erupts, and or peels off. Everyone has heard of milia, or milk spots, which babies may be born with or develop soon after birth and may last several weeks. They are tiny and are generally clustered on and around baby’s nose. They are just where the tiny glands which lubricate the skin are just not flowing freely yet so tiny cysts form and as the name implies they are creamy-white. Leave them alone apart from normal, gentle cleansing with plain water.

Another really common rash a baby may develop is urticaria neonatorum or erythema toxicum, parents will often see this noted by the person who examines baby and it can occur anywhere on the baby. Sounds impressive but is really nothing to worry about. It looks a bit like a heat rash, a few little red spots clustered together, and often this is what professionals will call it when reassuring Mums and Dads. Sometimes the spots do have very small yellow heads on them, they are not infected though and are totally harmless. They do disappear very quickly, only to reappear somewhere else, so often I will visit and the parents will ask me to check the spots out, only to discover that they have gone or magically moved! We have no idea why some babies get it and some don’t. I have my own theory, baby has been wallowing around in a sterile, fluid environment with nothing irritating it’s skin but once born it has different materials rubbing its skin; the skin is exposed to chemicals from washing powders and parents toiletries plus all the tiny fibres and hairs in the environment and the baby is now having to compensate for rapidly changing temperatures. Just my thoughts but worth taking in to consideration when chosing washing powders,  fabric conditioners and deciding whether or not you should use that cream or those baby wipes for your little one. Anyway, it’s usually quite a short-lived rash, generally appearing within a couple of days lasting to 10 days after birth.

Neonatal acne, much like the teenage version. Looks horrid, lots of red pimples, sometimes all over baby’s face but most common on his/her forehead and cheeks. It usually shows up just as you are really starting to socialise, when baby is around 1 – 3 months old and it can last for weeks. It usually requires no treatment, just use clean water and no prodding or squeezing! If too much attention is paid to these angry looking eruptions then, the same as in older people, scarring may occur.

Neonatal acne

On the whole the advice regarding spots is ‘ Don’t worry’ BUT if your baby has spots AND appears unwell, is overly sleepy and not feeding well please contact your G.P as s/he may have an infection.

A doctor specialising in skin disorders has corrected me on some details in this entry so I’m posting his comment here –

MWM, I am a bit confused by your comments. I am a 2 yr qualified GP undertaking advanced dermatology with Cardiff University. May I explore some themes with you?

Firstly, I have discovered that milk spots and milia and are actually not the same thing.

Milk spots are simply areas of sebaceous gland hyperplasia (or enlargement..for any other readers) which appear in the neonate (<4 week old…) and apparently generally go after a few weeks. They are white-yellow in appearance. The enlargement is thought to be related to maternal androgens transferred to babies, hence the term ‘milk spots’. They classically appear on the nose and forehead.

Milia on the other hand are only white, up to 2mm in size and are due to keratin (skin’s epidermis cells) cysts (fluid sacks). Seen in up to 50% of neonates. Usually rupture within 2 months of birth. Also appear on the face/forehead.

You say neonatal acne (or acne neonatorum) occurs between 1-3 months of age. Where does this info come from? Literature states it develops between the 3-6 months. I have yet to see it myself. At a glance, I am not convinced that your picture actually is acne..it looks more like sebaceous gland hyperplasia to me. Worth showing a dermatologist to confirm?

So what has Marsi’s baby got? I do not diagnose over the net as a disclaimer to all readers. It maybe mildy inflammed milk spots that probably do not need much at all but a full history and examnation is required by her GP firstly. A differential could be the papules (spots) of erythema toxicum which up to 50% of babies get some form of in the first 12m. The baby should be seen by the GP to exclude septic pustulosis if mum says it is nasty. Incidentally Marsi could be worrying unnecessarily here about neonatal acne perhaps?? Unlikely at 1m old apparently.

If there is one thing I have relearned about dermatology is that there is no replacement for actually seeing the lesion in the flesh. I guess we all need to carefully validate what we write for patients on the old ‘net so that we are firstly safe and secondly do not overworry mum’s.

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