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Archive for the ‘Musings’ Category

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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Purple thoughts

Just waiting for the morning sun, yes sun, to dry off the dew from the grass and then I shall be out there giving the lawn (grass, moss and weeds) the first cut of the year.

Meanwhile, back in the weird and wonderful 13th dimension which are the maternity services, a strange calm has descended. So far my manager has not approached me directly about the plans to rip me from my natural habitat. Many others have told me that I am a) to be co-ordinator on labour ward; b) sister on postnatal ward; c) a stand alone midwife on the stand alone birth unit but there is nothing from anyone in authority. Two of the message bearers were apparently told to discuss options with me but, until I have been in conclave with a body in a senior position, I am of the opinion that the consultation has not commenced so that gives me 3 months to consider my next move.

The election. This has given me a wonderful platform to air my concerns about local maternity services. Representatives of the political parties are knocking, innocently, at my door canvassing for my vote. In times gone past I would politely rebuff them, not now though, I have a captive audience. Last night Hubby answered the door and was in the process of saying goodbye to a rosette wearing bod when a tubby little madwoman invited the caller in for a chat. Huge satisfaction and enjoyment, being able to sit one of our local officials down and enlighten him about the troubles within the maternity services, not just locally but nationwide. I know that it won’t make a jot of difference, Hubby’s expression was ‘pi**ing in the wind’, but at least I can express my concerns to someone who may pass them on, even if it is only to warn others about the mad woman!

Years ago my sister told me about a poem concerning a lady of advancing years, Warning by Jenny Joseph. We joked that we would become the person described in the poem and that I was already on the way there as I do ‘ hoard pens….. and  things in boxes’. Well, last weekend, Easter Sunday in fact, was my birthday. I decided that this was my most important birthday…ever. I was now of an age when I could retire and I had achieved this at Easter (symbolism) so I was of a mind to celebrate. The first step toward my ‘rebirth’ was managed by one of my daughters, hair colour, she chose violet, it is really more purple, but it is vivid and it is different. Then my offspring took me to Crazy Bear to educate me in how other, less ordinary people, spend their leisure time. Thankfully they had been there before so were not a fazed as I was by the decor, with which I co-ordinated well, and the cleverly concealed toilets. Sunday saw a surprise meal, children, grandchildren, sister and best friend, fabulous and special. Deviation, back to ‘Warning’. I think I am slowly slipping into the persona, especially with my new found diversion of engaging political cold-callers. As the poem advises-

But maybe I ought to practice a little now?
So people who know me are not too shocked and surprised
When suddenly I am old, and start to wear purple.

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At last, at last, I have 13 days off work. I’m not sure if it is a good time to be absent as a major ‘shuffle’ is being hinted at with relocation plans being decided on Monday. Things are dire, and will definitely get worse before they get better. Midwives are leaving at breakneck speed, every week we hear that another colleague has handed her notice in, it’s scary, scary and infectious. Morale is slithering along, unable to drag itself out of it’s rut and, as the whispering and conjecture increases, morale sinks lower, and more midwives hand in their notice, it’s a rapidly progressing, destructive process. I’ve decided to put my blinkers on and not consider the bigger picture, if I broaden my vision it reveals a picture where so many elements are missing that it’s difficult to identify what the original image was, all there is are fragments.

Enough of that. I’ve been gardening, and it’s wonderful. One of my camillia’s is just coming into bloom, the garden is dotted with splashes of colour where little primulas are welcoming the longer days and rising temperatures, the pond is churning with amorous frogs and the red kite which glides over our house is no longer alone, there are two of these magnificent birds circling overhead nowadays. Spring is definitely in the air.

Last weeks homebirth. I was out in the wilds, just about to perform a stretch and sweep, when my phone rang, K was fairly certain that labour had started, 2 weeks after her due date. We had a chat (question and answer session), by the sounds of it things were still early on but as this was K’s second baby I was not going to be too laid back so I told her that I would finish this visit and make my way over to her, I got there within the hour. K was relaxed when I arrived with contractions coming every 5 minutes and lasting just under a minute, I relaxed and made us both a drink. K asked me to examine her so she would know how she was doing and confirm that this was ‘it’. After examining her I was delighted to confirm that this was ‘it’ as the cervix was over 6cms dilated BUT baby’s head was still high so I suggested that a few minutes marching up and down stairs, followed by some rocking on her birthing ball would  be a good idea. Whilst on the ball K munched on toast and honey which her Husband had prepared and before long the contractions were longer, and judging by K’s reaction, more intense. I phoned the unit and asked them to track down the second midwife, no rush but if she could make her way over within the next hour it would be a good idea. That was at 1pm, 5pm the unit phoned and asked what was happening, had we got a baby yet? ‘Umm, well no. I’ll update you within the hour’, even though we are at a homebirth we are still subject to the angst of the obstetric unit! We had a little conflab and K agreed with us that an examination may be a good idea. The examination was slightly disappointing, and confusing. The cervix was 8cms dilated and the baby’s head was still high and way off the cervix and there was something next to the head. I froze, please, not a cord. Gently I investigated, no, not a cord, fingers. There one minute, gone the next. Was it fingers? Could it have been toes? Was this baby in fact a breech? I told K that I was unsure what I was feeling and would she mind if A, the second midwife, checked. A examined and said she was certain that baby was coming head down and said that she couldn’t feel the fingers (or toes). We discussed the situation with K and said that it would be really good if we could a) increase the contractions and b) encourage baby’s head to come down so it was back the stair marching and sitting on the toilet. The unit phoned and were not happy, in fact the consultant said we should transfer K in for augmentation. Unfortunately I had just put the kettle so I still had to make and drink my coffee, then pack my bag up, not forgetting making sure that my notes were up to date! I went to K and her husband and put my cards on the table, I could delay the transfer for a while, I wasn’t concerned, K was fine and baby was happy but things could change at any moment. Nipple stimulation, that may be a help. I left them to it! Twenty minutes later K was violently sick, and her waters broke, within 15 minutes we were seeing the top of baby’s head. Slowly, slowly baby pushed her way out, with her arm across her chest and her hand on her cheek, I had felt fingers and that was why her head stayed high for so long. Weighing in at 8lbs 6ozs she was 2lbs heavier than her sister but with her shock of thick, black hair was the image of her. I got home at 11pm, really hungry but happy to have been able to welcome baby into the world.

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I’ve had time for musing today and yesterday as I’ve driven between my visits and here’s what I’ve come up with –

  • I really don’t like the drop in clinic. No surprises there. I feel that I’m short-changing the women and that I’m missing out on aspects of the women’s welfare. The clinics are good for the women as they are given an appointment time so they are not left wondering when a midwife will appear at their home, other than that I can’t see a positive for them. For me; I get depressed when I see the long appointment list; it’s difficult to give truly individualised care within an appointment system and in an environment which is alien to both the woman and myself. In most cases the woman is accompanied by her partner/husband and he will come into the room with her, making himself comfy on a chair. This spectator aspect can stultify the midwife and woman relationship, I am not seeing or hearing the real woman, I am receiving the information and impression that the woman wants her husband/partner to receive.

Following on from the drop-in clinic muse I began to wonder if anyone had followed-up on outcomes for women whose care was provided within clinics compared to those whose care was provided my a ‘named’ midwife, in their own home. This lead me to considering the holistic approach, which named midwifery should favour, and if it is beneficial and gives rise to increased positive outcomes.

  • Yesterday I visited a woman, her husband and 15 month old son to book her care in a new pregnancy. I knew this family through the previous pregnancy so there were many questions I didn’t need to ask, in fact it was less like an ‘interview’ and more like a social catch-up. When I left I was remembering her last pregnancy, all normal, in fact at 36 weeks I booked her for a home birth. Things change though an when I took the home birth bag round a week later I thought S looked puffy. I asked her if she was swollen, she showed me her hands and feet, slightly oedematous, but her face looked different. I asked her husband what he thought, he looked at S and agreed that she was slightly puffy. I took her blood pressure and it was slightly higher than usual, nothing unduly worrying though, a trace of protein in her urine, no headache, flashing lights, everything within acceptable limits, but I was still uneasy. I sent her in to our day assessment unit and within a few hours she was being induced for pre-eclampsia. This disease of pregnancy generally, but not always, shows itself with high blood pressure and lots of protein in the urine, if I had relied solely upon these diagnostic determinants I wouldn’t have suspected PET. I’m not super midwife, I’m just a midwife who knew her patient.

Midwives talk about ‘intuition’ and frequently recount stories like the one I’ve just written down. Examples of when we have been unable to robustly support why we have concerns but feel strongly enough to push for a second opinion or diagnostic tests. I know that if I have a ‘feeling’ about something then I don’t ignore it, I have been proved right too often. It would be interesting to see if community midwives working a named midwife caseload have a higher early detection rate for pregnancy complications or even just better outcomes for pregnancy. I wonder if any research has been conducted on this?

  • Research. Is it beneficial? How, why, when and where does it affect practice? It does if it shows that it improves outcomes. It does if it is shown to be economical. What about if it improves working lives, and here I’m talking midwives, is any research being done on this area? 

‘A happy worker is a productive worker’. Come on midwives, are you happy workers? What woud impove your woking life and the care you can provide, we all know increased numbers would be a huge fillip, but what else? What research could highlight practice which would beneficial to you? Please leave any suggestions in the comments section.

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Caring professionals

Snow, lots of it. Luckily I’m not working today so I’ve been able to admire it and marvel at how deep it is rather than attempt to navigate my car through it. Yesterday we received an email from someone within the Trust which informed us that, if we failed to work due to adverse weather conditions, then we would have to take unpaid leave or annual leave. What happened to an employers ‘duty of care’? Norfolk NHS Trust have kindly produced a policy to address adverse weather which demonstrates the same sentiment as the Trust which employs me. Now, little old me interprets these sentiments as saying ‘ you will attempt to get into work regardless of how safe it is to travel and despite the fact that we should be demonstrating concern for your welfare’. The authors of the policy have even paid lip-service to this angle  by ending their document with ‘ Severe weather may have a number of implications for an employers business. Employers should not encourage their employees to travel in dangerous weather, either during working hours or when travelling to and from work and employees should not feel pressurised to risk their safety to get into the office’. (My underlining). I’m assuming that this is taken directly from the Health and Safety at Work Act 1974 and they felt that they had to acknowledge the paragraph even if the essence of their policy is not sympathetic to it. I would really love to see how any Trust, which implements a policy like this, would fare should an employee seek legal advice. There appears to be an abundance of official literature which advises employers about ‘caring’ for their employees safety, my favourite is from ROSPA –

Avoid driving in adverse conditions

Actively discourage driving at night and in adverse weather conditions, particularly fog, very high winds, ice, snow or flooding or where there is a danger of drivers becoming stranded in remote locations.

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Unfair

Very busy at work at the moment, I blame it on the New Year celebrations!  The rumours are still keeping everyone on their toes, brows are furrowed, tongues are wagging and knees are trembling, whilst ears are flapping and teeth are gritted We should enter the World Gurning Competition.

Yesterday I ‘booked’ a young couple who have just gone onto the social housing waiting list. I was discussing the process with them and we got onto the topic of the list of available properties which the housing association publishes. I’ve had quite a number of families who have been going through this process so was passing on some tips about the necessity of acting the minute the list comes through the post when K explained that it had changed, it’s on-line now. I looked around their bedsit and noted the lack of a computer. ‘What happens if you don’t have internet access?’ I wondered. K said that she had told the housing officer that she didn’t have a computer, let alone a printer to hard-copy the list. The reply? You can access the site free at the library. Brilliant. How fair is that. Not at all if you work. K and her husband work, at the time that the list of properties is put on-line they will be earning a living. By the time that they can get to the library it will be too late as all other property seekers will have already expressed their interest to housing. This a wrong approach. All those who have a computer, and or who don’t work have an advantage over this couple who do work but still have limited finances.

The house next door to us is scheduled to be demolished, and a new one constructed. The next few weeks are going to be really interesting. The house is built entirely of asbestos sheets, even the roof is asbestos tiles and the house sits on the boundary. So far the developer has not asked us for access via our land, which they will definitely require but they have informed us that the demolition will start a week on Monday, half-term week. Wonderful, I’ve got the week off but there will be no lie ins for me as there will be plenty of machinery clanking and workmen exchanging pleasantries.

The asbestos concerns me. They can’t help but damage it as it is removed, that will release fibres and my home is only 8 feet away, with no barrier between the houses.

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At the rate things are going I’m going to have to brush up on post-operative recovery skills, not because I’m going to be working back in the hospital, but because my women are being discharged earlier and earlier post caesarean section. Just a few years ago a 5 day stay was routine, then 4 and now it’s day 2, how long before they walk out of the operating theatre and get straight into the car to come home?

C-section is now viewed as just another option in the childbirth choices. It is that but it’s the just  which is inaccurate, it is a major operation. If you are not squeamish then watch the video and appreciate the invasive nature of this major surgery.

In some cases caesarean section is a life-saving procedure, in many it was defensive practice. Over the past 15 years the C-Section rate has more than doubled BUT there has been no decrease in maternal morbidity or mortality, in fact it may even be stationary with researchers in the USA concluding that caesarean section quadruples a woman’s risk of dying.

How much higher is that risk going to be when leaving the hospital earlier and earlier?

Which poses more risk to women and babies, caesarean section or homebirth?

Don’t even get me started on the possible risks to the baby during and following a c-section for non-medical reasons.

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