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Archive for the ‘Musings’ Category

Christmas Day came and went. Absolutely frenetic, much wrapping paper, steam, yes steam is my major impression of Christmas Day because of all those pots bubbling away, full glass of red wine over my oatmeal coloured carpet and then peace when all the little people were asleep.

Work was busy and foggy with numerous offers of mince pies. I have been desperately trying to ‘book’ a newly pregnant woman, twice we have made appointments and she has phoned minutes before them to cancel, I almost know her phone number off by heart now as I’ve rung her so many times to reschedule but been met by her voicemail. She has left me a message to tell me that she needs to see me before her scan, I KNOW, but when I return the call guess what, voicemail. Hubby is now getting annoyed with it as I am always phoning her, yes on my days off. Get up in the morning, phone. In the car on the way to the DIY store (we are going to decorate and put down a new floor in the shower-room), phone. Cooking dinner, phone. As I was so desperate to speak to the woman I’ve been leaving my work phone on, bad mistake as I keep having to answer it. Swine flu, that is the number 1 topic. Last year I was quite reticent on advising women to have it, I gave them the info and told them to make up their own minds, this year I am swaying toward the ‘it’s probably a good idea’ stance. In my mind I feel somewhat happier about reinforcing the party-line as the vaccine has been around for a year, babies have been born to Mums who had the jab last year, and so far I have not been made aware of any adverse outcomes as a result of it. Next in the things to phone your midwife about is ‘I’ve got a cough, what can I take?’ Now, presumably these coughing ladies will have to go to a pharmacy to purchase the medications I suggest, how about asking the pharmacist? I have recollections of an ad campaign encouraging people to speak to the pharmacist and chemists now have a ‘consulting room’ for that purpose, why ask a midwife when there is a highly trained person who is far better placed to advise?  One of the phone calls was from Children Services asking me if I had seen someone, who I had never heard of, and who there was a meeting about on Thursday. Oh b****r, my heart dropped. After much questioning it turned out that they were giving me the name of her child, who has a different surname to her, my shoulders relaxed. Yes, I knew her, I had seen her, she was ‘co-operating’ with the maternity services but no, I couldn’t come to the meeting as I don’t work that day and, where usually I will attend these meeting if possible on a day off, that is one of the days when I have the boys and they hadn’t given me enough notice to rearrange childcare. Had they got a creche? No. Now I’m consumed with guilt, female thing, but they really should either give more notice or consult with ALL parties on when is a convenient time.

Homebirths are in the news again, apparently doctors are trying to put women off them. Why are the RCM and NCT suddenly getting hot under the collar about this, doctors have always tried to put women off them. When I say ‘doctors’ I actually mean G.P’s, obstetricians, well the ones locally, are supportive as long as the woman fits the criteria for a homebirth, i.e the pregnancy is low-risk. Cathy Warwick, RCM leader, calls for a ‘seismic shift’ in the maternity services and recognises that midwives are unable to offer choice. Sorry, Ms Warwick but we do offer choice around here, and the rest of the service suffers as a result. Yes, we need a shift, seismic or otherwise, but something definitely needs to happen, and soon and not just to enable more women to have a home birth but to allow that to happen without depriving other women of the care they deserve and putting midwives under so much pressure of work that they leave.

So, on this last day of 2010, I wish everyone a wonderful 2011. My resolutions? To carry on with my diet, I have lost over a stone, and lose the 3lbs I have put on over Christmas! To allocate some ‘me time’. 

HAPPY NEW YEAR

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Midwife wanted

This email arrived in my inbox at work the other day, interesting opportunity for a midwife in the North.

Dear Manuela,

As I explained in our phone conversation earlier I have been commissioned to ghostwrite an uplifting memoir of a modern day midwife for Headline and wondered if you could help me to find a suitable case study whose story I would write on her behalf. The book is to be written in first person narrative and will be uplifting, heart-warming, touching and life-affirming – a real celebration of a modern day heroine.

Ideally the midwife in question would be from the north of England and working in a community. She would be aged between 42 and 53, would have worked as a midwife for at least 15 years and have children of her own. She needs to open, warm and a good storyteller. She will receive payment as the author of the book and will be expected to do PR to promote it. 

My publishers have asked me to come up with a shortlist of suitable midwives for this project and I would be very grateful if there was anyone you could put me in touch with. I’d also be very interested to read the press release about Lindsey Reid.

Many thanks,

Charlotte Ward

Freelance writer

I have a few queries. Why a ghost writer? How much would the midwife be paid? Why the age constraints, especially as that rules me out? Hang on, is that age discrimination ;)? Why the location in the North? Do northerners have more interesting lives and experiences than those from other parts of the UK? Then there is the gender issue, why a female midwife? Male/female, we all do the same job.

Modern day heroine. Tee hee. Read a few parenting websites and you will soon see what the Mums think of midwives, and it’s not as heroines. How exciting though for the chosen sage femme (I just love that french word for a midwife).

She will have to tread carefully though, and I suspect that her every word will be subject to much examination by her Trust. What makes me think that? Well, as an introduction to the forwarded email was an advisory – Any midwife interested in this project should contact their Trust press office to discuss the opportunity. That should be an interesting conversation!

Oh yes, Lindsay Reid is a writer, researcher and midwifery historian.

Well, any midwives reading this who would like the opportunity to become a published authoress should contact Charlotte on charlottefreelance@gmail.com

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I’m about to write an assignment centred around the perspectives of childbearing women, and I could really do with some input from the ‘other side of the fence’. I know what I believe is important, and the area where I think the maternity services should focus but I would really appreciate an honest snap-shot of ‘consumer’ opinion. Where it says ‘Other’ then I hope that voters express themselves and perhaps explain why they rate one aspect more highly than another. If it doesn’t have enough space, or anyone has loads to say then please leave a comment.

It doesn’t matter when, where or if you had a baby. It would be useful though if you could identify your gender in the spare box as then I can identify if perspectives are affected by this. 

Thank you for your time.

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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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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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Sleep problem

Sleep, an action I often have problems with, sometimes due to heaven knows what, often down to restless legs and frequently discouraged by Hubby’s snoring. One of the grandchildren is also displaying a disinclination to sleep but, unlike me who wanders quietly around without disturbing anyone, she feels that the rest of her family should join her in her noctunal wakefulness. This is not going down too well with her parents or brother who are all now becoming rather tetchy due to sleep deprivation. The nicely, nicely approach was tried; a night-light was introduced; lighter, then heavier bedding, no change. A reward system was tried, that didn’t work. Then Mummy and Daddy ceased being lovely about multiple, protracted wake-ups and responded with instant returning to bed, first soothing words, then sharp words, not successful. Next came punishment, toys were taken away. Yesterday the final toy was shut away, and last night they had their first night’s sleep in a month. Daughter was overjoyed and everyone received a joyous text message. Fingers are being crossed that there will be a repeat performance tonight.

Why is she doing this? Three years old and has always slept well. She started 5 half days a week at school at the beginning of the month and so you would think that she would be tired and sleep well. Is it school? On the one hand I think that’s doubtful, she had been doing two half days a week for the past 6 months and she loves it. She appears to be happy to go and is full of chat when you pick her up so I’d be surprised if school is making her anxious enough to affect sleep patterns. But, on the other hand I just wonder if school is over-stimulating her. Does that happen when you are 3?   

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I received this email a few days ago
 
Hi – I’ve just had a terrible experience with EasyJet (which I assume is the airline you refer to in your blog about the F2F certs). They allowed us to board on the way out with a doctor’s letter from 3 weeks previous to the date of our flight, but on the way back denied us boarding, as the letter was ‘out of date’.

Nowhere on their terms and conditions have I been able to find anything to suggest that there was a time-limit for such letters/certs. You refer to a 5 day rule, but I haven’t been able to find that anywhere. Can you point me in the direction of this ‘rule’?

I followed the link I had provided in the relevant post, and soon found that EasyJet have changed their policy and now the low-cost airline are demanding the professional be more specific – 

“When travelling between 28 – 35 (inclusive) weeks a medical certificate issued by a doctor or midwife confirming the number of weeks of pregnancy is required confirming that the passenger is fit to fly. It is important that the certificate covers the date (dates) of your travel.”

Well, as a result I can confidently assure any of my women who are travelling with EasyJet that I wil be unable to provide a cerificate which will be accepted by that airline. I am happy to provide a letter which states that, in my opinion, on the day I examined the pregnant woman she was fit to fly. I will never, ever provide a letter or certificate which says that 2 weeks after I have seen a woman, and following what may be a hectic, tummy bug filled holiday, the situation will remain the same and she will still be fit to fly. In fact, my advice will be to fly with a different airline!

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