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Archive for the ‘Breastfeeding’ Category

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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Maternity funding still not being delivered, British midwives claim

Millions of pounds of government funding intended to improve maternity care is still not reaching front line services, midwives say. Despite a rising birthrate, nearly a fifth of the heads of midwifery said that their budget had been cut, and almost a third had been asked to reduce their budgets. Last year the Government promised £330 million of extra funding for maternity services, but this has not been ring-fenced.

The results, from a survey across Britain by the Royal College of Midwives (RCM), come as the Health Secretary is due to speak at the union’s conference in Manchester. Andy Burnham will today announce a new “Start4life” campaign highlighting the importance of breastfeeding and healthy eating from infancy.

The RCM said that 5,000 more midwives were needed to provide safe and quality care to new mothers. Ann Keen, a health minister, said that it was up to NHS trusts how to invest the additional money. “Where funding is not reaching maternity services I call on Heads of Midwifery to challenge their PCTs,” she said. “We recognise there are concerns around staff morale and attrition rates and we are working with the Royal Colleges and the NHS to address these areas”. From Times Online November 27,2009 & Socialized Medicine

When I first worked on the community we all wore a uniform, when we were instructed to be in ‘mufti’ I was uneasy, I liked the fact that that as soon as a door was opened to me I was identifiable as ‘the midwife’. It’s been nigh on 10 years since I donned my uniform, other than odd days when I have been irritated by edits from above advising us to dress like office workers, so I protest by squeezing into my uniform, after all I’m not an office worker, I need to wear outfits which allow me to drive comfortably, plod across muddy fields, crawl around floors and lean over birthing pools. Do I miss my uniform now? No. That’s the thing about change, at first it’s disturbing but eventually it becomes normality.

There, aren’t I the philosopher, quite rational really. Well that stops now, a change is looming which has me seriously concerned, a change which doesn’t just affect how I dress as a midwife but how I deliver care as a midwife. So, what is the association with the quote from ‘The Times’ and my disquiet? My Trust is one of those affected by the PCT with holding government funding intended for maternity services, and what can be done about it? Nothing apparently, and the result, oh the result is fine and dandy, for the PCT, they keep the money but the providers of maternity services, well they have to make cutbacks. Does that suggest that maternity care will be improved?

The cutbacks, or evisceration, are fairly comprehensive. Our antenatal clinics will be moving out of  G.P surgeries and into Children’s Centres. Actually this is a suggestion within ‘Maternity Matters’ , I was going to put a link here, but fittingly the ‘website was unavailable’ since a quick read would reveal quite how loosely the recommendations (promises) are being implemented, the culling continues further though. Women will only receive a home visit from a midwife the day after they return home with their newborn, after that, well its back to the afore mentioned Children’s Centres. Sorry, I fibbed, not all women will have to travel to these centres, those assessed as requiring more ‘assistance’ will have a home visit. Oh, I forgot to say, no visits on a weekend, no clinics either. We won’t be able to do that, well midwives are expensive at a weekend, so it will be a skeleton service, so skeleton that there will have to be 2 midwives ‘on-call’ for the weekend as, if there is a homebirth, there will not be any midwives left. Incredibly cost-effective really as those 2 ‘on-call’ will only be paid £15 each to put their lives on hold for 24 hours, over a weekend, and be at the Trusts beck and call. Real value for money.

Am I blaming the PCT? Yes, but there are also other culprits, they will be in Part 2.

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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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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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I’ve been musing, and I’ve come to an earth-shattering decision, early discharge from hospital after giving birth should not be encouraged. I can sense much sharp in-taking of breath, I know, it’s pretty radical stuff, now I’m going to explain myself.

Recently I made a day 5 visit, that’s the day we reweigh baby and take the neonatal blood screening test (aka heel prick; guthrie; PKU). This was the couple’s first baby, born by emergency CS, 2 day hospital stay, second visit by a community midwife. They had phoned before I left the office to ask what time a midwife would be visiting  as they had seen some ‘blood’ in baby’s nappy and were worried, I told them that I would make them my first visit and asked them to save the nappy. Mum and Dad had been to NCT classes so, when having looked at the nappy, I told them that it was normal and was urates from his urine they then produced an A4 handout they had been given, which showed photos of what they may see in early nappies! Having addressed the blood in the nappy worry I had a look at her notes, useless, the hospital had kept her inpatient notes so I had no idea how things had gone for either of them whilst in hospital. The midwife who had visited before me had recorded that Mum as recovering well, her scar was clean and dry, baby was breastfeeding, passing urine and meconium. I glanced at baby and saw a ‘worried’ looking baby. Worried. This is my description of an underfed baby, they do all seem to have this little sad expression, a furrowed brow, very difficult to describe but when I see it it makes me worried. I decided to examine his Mummy first and remove her suture  before I had a good look at, and weighed him, I had a feeling that she may be somewhat agitated after I had examined her little baby. I should say more agitated as she was extremely anxious about having her suture removed, but my incessant talking worked it’s usual magic and the stitch was out before I could finish my life history. As I undressed baby I asked her about feeding, she was breastfeeding, basically when she thought that he should feed, this was equalling about three times a day. I gave them my usual spiel “It’s normal for babies to have lost up to 10% of their birthweight ……..we plan what happens next on how baby is, what the nappies are like etc. might just come back in 48 hours if all seems well and re-weigh then to make sure that baby is putting on weight but we might ask them to go into hospital to have baby checked by a paediatrician”. Baby’s mouth was very dry, his skin was like an old persons, there was no elasticity, his poo was sticky and green. He really wasn’t bothered about me undressing him, a floppy little boy. As I put him on the scales he showed his startle reflex, little arms and legs shot out star-like, his eyes opened wide, even those seemed dull, and his cry sounded as if he had been screaming for hours, it was hoarse. The results of the weighing were not good, he had lost nearly 20% of his birthweight. I explained to the concerned parents that I would be happiest if he were seen by a paediatrician but, first things first, get some nourishment into him. He was awake and trying to latch onto my arm so I asked Mum to get comfy and we would put him to the breast, once he was feeding I could then contact the hospital he was born in, not one I work for. Basically the attempt at feeding was not a success, Mum obviously had no idea how to breastfeed and it really didn’t help that baby was so malnourished that even hunger was not going to keep him awake. I showed her how to hand-express into a sterile syringe and I went through the long process of referring him to the hospital. I nearly lost the will to live at one point, I considered hanging up on the officious, series of people I was put through to and just send them to the hospital I work for. In the end I resorted to the unspoken threat,’ Since you can’t seem to help, can you put me through to the head of midwifery?’ Works a treat, I was told that baby would be seen on SCBU.  On admission he was found to be severely dehydrated with dangerously high sodium levels; he was immediately put on an IV and a tube was passed into his tummy so that he could be fed easily. He remained in hospital for 8 days.

Following their second discharge from hospital I visited again. By this time baby was still not back to his birthweight, but was a different little man, alert, bright-eyed and peachy skin. His Mum was still anxious, and no wonder, she had spent over a week in a Special Care Baby Unit watching her newborn be jabbed, infused, and tube fed.

That’s the background to my desire to encourage women to stay in hospital for longer after giving birth. My concerns about this ‘early discharge’ culture has been growing gradually over the years, every week I come across examples of where a longer stay would have been beneficial but this latest one has been the most extreme. The couple involved were educated, one was medically qualified. They had attended NCT classes, hospital antenatal classes and breastfeeding ‘workshops’  but none of this theory had adequately prepared them to successfully nurture their first baby. The ward the woman was cared for on was safely staffed but this does not necessarily mean that there was time for staff to ensure that baby was feeding well, or time to reassure anxious first-time parents. The short stay meant that it was not evident prior to discharge that baby wasn’t breastfeeding successfully. WHO wish to promote exclusive breastfeeding, to be successful some women require more support than ‘workshops’ during the antenatal period, they would benefit most from a slightly longer stay in an establishment where there are enough staff to provide assistance and reassurance.

Guess what it is that has caused the early discharge culture? It’s staffing levels, the closure of smaller maternity units and the resultant loss of ‘beds’. What causes all this? Cutbacks. It’s a false economy though, I’m not talking the small cost here of re-admissions, like my example above, I’ll just reproduce the opening paragraph from WHO’s ‘Promoting proper feeding for infants and young children’ and it’s easy to see that a cutback in the maternity services has lifelong health implications.

‘Nutrition and nurturing during the first three years are both crucial for lifelong health and well-being. In infancy, no gift is more precious than breastfeeding; yet barely one in three infants is exclusively breastfed during the first four months of life’. (World Health Organisation)

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