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Archive for the ‘Pregnancy’ Category

I’ve just had Jack, Amy and Izzy for 2 days, and I’m shattered! I had forgotten how non-stop 3 little ones can be, especially when the 3 and 4 year olds are starting to demonstrate their independance. Izzy, who’s 17 months, was really no problem, especially as last night she fell asleep whilst I was bathing her, stayed in the land of nod through getting her into night clothes and didn’t wake until disturbed by the other two at 7.15am. Jack and Amy were a different a matter, I was up with them first at daybreak, about 4am, I convinced them to go back to sleep at about 5.30am (they took a lot of convincing) and then they awoke again at 7am. Anyway, as a result of my lack of sleep I have just been slobbing for the last hour in front of the telly and I caught an advertisement for 1st Response, the pregnancy testing kit which can detect pregnancy 5 days before a woman misses her period. We live in a strange old world really. Morning after pills for those who had a quick shag without taking precautions, lets just hope that not using a condom doesn’t result in chlamydia; terminations of pregnancy on demand; embryo research and cloning on the one hand and IVF, ICSI, egg donation, surrogacy, overseas adoptions and life saving surgery on a fetus in the womb on the other.

Off I just went on a little deviation, what I really wanted to muse upon was the effect of these early pregnancy tests. It’s known that many pregnancies, up to 10% for women in their 20’s and up to 50% for those over 40, will end in miscarriage, the majority of which will be before 12 weeks of pregnancy. However, I was contemplating whether these figures would be higher with the advent of these early, early tests and I came across this “But the actual rate of miscarriage is even higher since many women have very early miscarriages without ever realizing that they are pregnant. One study that followed women’s hormone levels every day in order to detect very early pregnancy found a total pregnancy loss rate of 31 percent.” I think this is really sad on the whole. I meet a significant number of women who have experienced a miscarriage, a few are philosophical about it, but the majority are hugely affected by losing a baby. For those who miscarry after 8 weeks they have lost a ‘fetus’, or foetus as some would prefer, those who discover a pregnancy at 14 days, as these pregnancy tests allow women to do, may start to bleed a few days later and in reality they will have lost a blastocyte, but to them they will have lost their baby and this grief is the aspect that troubles me.

I would envisage that the majority of women using these tests will be those hoping to conceive, I know that it is important that women are aware that they are pregnant as early as possile so that they can alter their life-style, if necessary. But to be honest, if they were planning a pregnancy they should have taken steps to reduce the risks caused by smoking, drinking, diet and medication, prescribed or otherwise, prior to the conception, not leave it until an embryo is already developing.

The whole fertility, pregnancy, childbirth scenario is becoming so high-tec, it may give the impression that it is controllable, and it really isn’t.

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I’ve just finished reading this thought-provoking book. It’s an intricate work of fiction with several twists and turns, daughter was disabled, she had Down’s syndrome, here is a review.

At the end of the book the authoress is interviewed and she states that the attitude toward those with disabilities has changed, has it? I question that at it’s root, if it had changed why do we offer screening on the NHS for abnormalities like Down’s syndrome and spina bifida? Back in the 1960’s, when the book was set, routine screening was not available, parents were faced with the situation when baby was born and some would have reacted as a parent did in this book, but the fact was that every parent accepted that their baby may be born with a disability. Nowadays parents have the opportunity to be given a risk factor for Down’s syndrome, whether by nuchal scan, combined, integrated or the triple test. I have a high uptake within my caseload for the nuchal and blood biochemistry test, it approaches 100% , I impress upon my women that these are screening, not diagnostic, they give a risk, an odds, you can not make a decision to terminate the pregnancy based solely on that result, a diagnostic test, amniocentesis (amnio) or chorionic villus sampling (CVS), is required. How reliable is the nuchal screening? Locally (NHS) we quote the reliability as being 80%, whilst Fetal Medicine Centre quote their detection rate as 90%, good, but is this good enough?  The aspect I find problematic is that you are given a risk factor e.g 1:250. Now, if you receive this result you are offered an amnio or CVS, diagnostic tests which also contain a 1% risk factor of their own, miscarriage. Supposing the risk factor given following the nuchal were 1:12,000, is that good? Well, I’m not a gambler, 0:12,000 sounds good to me, 1 in anything is leaving room for doubt, why shouldn’t I, or my baby, be that 1? I am in a minority though, most expectant parents appear to regard the test as providing an assurance that their baby will not have Down’s syndrome. I have cared for a family who had been given a risk factor of 1:10,000 but when baby was born it was apparent that she had Down’s syndrome, they were shocked, horrified and rejected baby immediately, much as the parent did in The Memory Keeper’s Daughter, the baby was taken into care.

So, we have come full circle. Are we more tolerant of disability, or are we just more tolerant if it doesn’t affect us personally?

The above is a personal perspective, I must never influence a couple’s decision. I provide the information and then support them in their decision.

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Booking paperwork or, why I don’t have enough time for my women –

  1. Complete a Registration form. Name, Address, Phone numbers, DOB, NHS number, LMP, EDD, G.P, Practice number, Named midwife, Hospital booking at, Lead professional, Obstetric history, Medical history, BMI.
  2. Fill out green notes. Name (on every page), Address, Phone numbers, DOB, NHS number, LMP & EDD (on 3 pages), Next of kin, Emergency contact, Lead professional, Hospital booking at, G.P, Named midwife, Contact numbers for hospital (Switchboard, antenatal clinic, labour ward, community midwives office). That’s the 1st page completed! Personal details, Partners details, Ethnicity, Full medical history, Family medical details, Previous pregnancies, parity, Blood and screening tests checklist and consent obtained, Summary of timings of scheduled antenatal appointments, blood tests, ultrasounds. Height, weight, BMI, record of booking blood pressure, special features. Name of booking midwife & signature x 3.
  3. Complete NHS Family origin questionnaire form (triplicate, copies to be attached to notes & blood forms). Name, address, DOB, NHS number, G.P, EDD, Hospital.
  4. Complete blood request forms x 5. Name, address, DOB, NHS number, Phone number, G.P, Practice number, Hospital booked at, EDD, parity, gestation.
  5. Complete maternity exemption certificate. EDD, Midwives PIN number & name. Signature.
  6. Complete scan request forms x 2. Name, Address, DOB, NHS number, Phone number, G.P, Practice number, Hospital booked at, EDD, Date of previous scans.
  7. Record in caseload register. Name, Address, DOB, NHS number, Phone number, G.P, Practice number, Hospital booked at, Lead professional, EDD, intended feeding method
  8. Fill out front page of hospital notes Name, Address, DOB, NHS number, Phone number, G.P, Practice number, Lead professional, EDD.

Can anyone see the real frustration about this?

In today’s computer age, where a one off entry could print off everything required, I spend precious time writing out the same information over and over again. What is truly gauling is that one of the sections I have to complete involves an explanation of data protection and how the provided information may be used – ” to monitor health trends, strive towards the highest standards, increase our understanding of adverse outcomes, make recommendations for improving maternity care “. Hang on, what was that last item? “To make recommendations for improving maternity care”. Well I’ve got a really easy suggestion for them, free up the midwives to practice midwifery by cutting down on the paperwork repetition.

Want to see the green pregnancy notes, which are now supposed to be used nationally? Here’s the link.

 

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Listening

A Pinard

Salutary day today. Clinic first, not too bad. One of the pregnant women, 39 weeks with her second baby, told me that after she had last seen me baby had done some massive movements, spending one day lying across her womb, a transverse position. When I palpated I really wasn’t sure what I was feeling. It was obvious that baby was in a posterior position, baby’s back to Mum’s back, but was it head down or bum first, breech, I really wasn’t sure. Out came my Pinards, often that will help me solve my dilemma, not today though, wherever I chose to place it I could hear baby’s heartbeat clearly. Obviously a case for a sonographer. After much bargaining with the hospital they gave in and invited her to go straight there. I phoned her tonight to hear the result, head first, cephalic, with the head deeply engaged, explains why I couldn’t feel it!

After clinic I had a couple of routine, 5 day postnatal visits, weigh and PKU, aka the Guthrie, heel-prick or newborn screening test. Then 2 pregnancy booking home visits. The first was a woman who has now moved to another area but wanted me to book her as I had seen her last year when she had an IUD, intra-uterine death, at 34 weeks. After her loss I stayed in touch until after the post-mortem, during all the process she was well supported by the bereavement midwife so I never heard the full results, just that a syndrome was involved. Today we recapped the whole experience again, so very sad but it is important that K and I are able to communicate well. All her hopes and fears through this pregnancy, which is bound to be sometimes beset by doubts however much screening of baby is done, should be shared openly with me.

Next came a booking where I knew that the woman was booked for a CVS, a chorionic villus sampling. There was a healthy, young boy at home with her and, since she was young, I was interested to learn why she was having this invasive form of screening. Her second child, a girl had been born healthy but by 4 months old had started to exhibit physical signs that she was unwell and a genetic abnormality was diagnosed. Over the next year she deteriorated and a bone marrow transplant was tried, with initial success. Unfortunately the little girl died aged 2 years. There were many photos of her, from a healthy newborn to a toddler showing the hair loss, emaciating effects of the drugs used prior to a bone marrow. It was another emotional chat, the Mum discussed all aspects of her daughters life, graphically describing her last few days, I thanked her for sharing her daughter’s story with me and wished her well with the CVS.

So I had visited 2 women who had previously lost babies, both girls due to abnormality, then came my final visit, a newly discharged Mother of 5. Terrible, a disgustingly filthy house. N greeted me with complaints that the house should have been fumigated whilst she was in hospital but ‘ the f*****g social have only done a deep clean. At least it cost the w****rs 3 undred quid’. Good start. No children, no baby, I had been told that there is an ICO on the newborn. Hmmm. Dare I? Here goes. ‘N. Can you tell me about things. Baby, you, the birth. Why you stayed in hospital so long.’ Out it all came. Baby is with foster parents. 1 of the other children is in hospital following an attack by a relative. 2 others are also in temporary care and 1 is being adopted following physical abuse. I sat and listened to a distressing tale of ‘lost’ children, husband in hospital following an assault, inability to care for children and a total lack of understanding why the baby and 2 of the children had been taken away by social services. She is resigned to never having one of the children back but is fighting for the return of the others. She has the services of a barrister and is going to ‘show them social workers what a**e h*les they are and what they can do with their ICO.’ Whilst I was there a friend phoned and she revealed how desperately distressed she was, how she didn’t know how she would cope. By the time I left I was concerned for her mental well-being and was beginning to feel that they were being unfair, I wanted to speak to her social worker, she gave me the number. Once in my car I phoned the social worker, unfortunately she had left for the weekend and wouldn’t be available until Tuesday. The person I spoke to was not really that interested in the information I wanted to share. Next I went to the surgery and spoke to her G.P, I’m not sure what I expected him to do, I just wanted to share my concerns with someone. I returned to the office and ensured that all my concerns were noted and accessible to N’s midwife who is working tomorrow.

Hubby says that I have had an interesting day, I have found today distressing. My final visit has me behaving like a schizophrenic. I am full of a middle-class ire that this woman and her husband leech off the system, off me the taxpayer. They don’t work, have numerous children they are incapable of caring or providing for. Have a house so filthy that it requires deep cleaning which is paid for by the public purse. Then I just see the person sitting there, bereft, desperate to have her children back, children that I’m sure she loves, and I want to help her. I’m so pleased that I’m not a social worker.

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I’m not going to blog about the abortion debate. We all have our own beliefs. Enough said.

What has everyone been up to recently? Redundant question really as all the pregnancy bookings I’m wading through at the moment answer that question for me! There is a positive glut of newly pregnant women, November, December and January are going to be busy, busy at our local maternity units.

Over the weekend I booked a woman who lives in one of our old homes, interesting to see what they have done with it. H is 11 weeks pregnant and was suffering extreme nausea, luckily not accompanied by sickness but still very distressing. We had a chat about traditional remedies, drink and a biscuit before you get out of bed, ginger biscuits are recommended, as is ginger beer or ginger itself at any time; anti-nausea wrist-bands; frequent nibbling of biscuits, sweets and, for many women, carbonated drinks. I asked if there were twins in the family, as a multiple pregnancy will produce more pronounced pregnancy symptoms, H was having her scan this morning so we would know soon enough! I reassured her that morning sickness is actually quite a positive sign of a healthy pregnancy, so whilst it is quite debilitating it is also comforting and, will hopefully not continue for more than another few weeks. We carried on with the paperwork and chat, no obvious problems so I quite happily booked H for midwife-led care, mentioning homebirth as a possibility if all continued well with the pregnancy.

Today I had a student nurse out with me on her maternity placement. She was an enthusiastic companion and very eager to find out everything that community midwives get up to. I didn’t have a clinic today but took her into one of my surgeries to pick up any messages and drop off a Maternity Certificate for one of my women to collect. The phlebotomist (blood taker) was there and I checked with her that she knew what to do with the new Family Origin Questionnaires we are using. As we were chatting she told me that H had been in this morning for her blood tests having just returned from her scan. Apparently H was excited, she is having identical twins. I immediately phoned H to congratulate her and her husband and check that all the foundations for her care had been established at the antenatal clinic. They had, in fact H was impressed by how instant the response was when the two babies were seen. H said that when her husband had come home after her booking appointment she had told him about my ‘twin’ comment. When they were having the scan, and could see one baby he had, jokingly, said ‘Oh. Is that another one?’, and as they laughed about it the sonographer told them that it was, apparently their laughter became somewhat hysterical after that. That’s 5, pregnant with twins, women on my books at the moment, and all naturally conceived. 

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This morning was my clinic and, as generally happens, it ran late. Luckily my women are quite tolerant of my tardiness, but so they should really since it’s them, or more specifically their needs that mean nearly every appointment overruns. It started off quite well, each appointment is scheduled to last 15 minutes –

10am – 10.20 – 34 weeks. Routine but wanted me look a her birth plan and explain vitamin K.

10.25 – 10.50 – 34 weeks. Routine. Starting to have ‘panic attacks’ at the thought of caring for a baby. TLC.

10.55 – 11.20 – 30 weeks. Requires Anti-D as Rh-ve. Recent blood results not available on screen. Phoned hospital path lab, person answering phone unable to access results, suggests I phone back in 15 minutes. Phone the associated path lab, blood results fine, can give Anti-D. Patient has been taking iron suppliment but it is causing constipation, as haemaglobin is 13.2 I advise her to stop the tablets but ensure that she mantains a healthy diet.

11.25 – 11.40 – 17 weeks. Routine appointment. Runs smoothly.

11.45 – 12.10 – 17 weeks. She describes herself as an ‘anxious primip’, she is right! Basically just wants to talk. Has a cold and is worried about her coughing affecting the baby. Suggested glycerin and honey to attempt to sooth it, reassured her that paracetamol is fine for aches and pains. Took the opportunity to talk about pelvic floor exercises and how to do them.

12.15 – 12.0 – 20 weeks. Routine appointment, 3rd baby. Pregnancy is the result of a condom, and then the morning after pill, failing. Mum is considering the baby a surprise rather than an accident, husband obviously doesn’t as he has done a runner. She is being positive about the situation. Will see her more often than scheduled appointments, she may need extra support. Mat B1 given to her for employers.

So, quite easy to run over, and today was a short clinic, usually there are 10 women. No emergencies, just that 15 minutes is not long enough. To be fair, it’s not just the patients who cause clinic to run late. The appointment system does not allow for computer record input, or the completion of a detailed form which is required by the PCT to check how many women I see, and how long I spend with them. The woman’s name and the times are not enough; address; date of birth, NHS number; G.P; hospital booked at; consultant and……. ‘Uncle Tom Cobleigh and all’.

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Last night I went on a Hen Night and came home bedecked with a fluffy, pink headband which advertised the fact that I am Mother of the Groom. I thought that Hen Nights were supposed to be libacious affairs, this one wasn’t, perhaps 3 pregnant, 2 breastfeeding participants were the reason. Back to work officially tomorrow, can’t say I’m looking forward to it, I can thing of more exciting/enjoyable pastimes on a Bank Holiday. Today son and DIL came round and we had our first listen to baby, how amazing to hear my (fingers crossed) next Grandchild), and how wonderful to share their joy. DIL has asked me to do her antenatal care, I asked her to run it past son and I will run it past my manager. This what their baby looks now!

Amazing. I ‘borrowed’ the photo from this site which also has wonderful videos of 4D scans and images of the developing fetus from conception to term.

My old job-share, she moved away in August, has been telling me about her new post. The lucky midwife is  working in a stand-alone birth centre, 2 pools, a patio, a really relaxed atmosphere, I was so jealous as she was talking about it, and then she went on to tell me about the community midwives and I turned a lovely shade of emerald green, they have caseloads of 70 women. When K first told me I thought that she was talking about ‘real’ caseloading, where the midwife provides true continuity through the pregnancy, birth and postnatally, I was amazed that they have such large caseloads as this type of care provision should entail a max of 35 women per year per midwife. Then she turned the envy dial up by correcting me, they have a 70 woman caseload whilst providing the same model of care as we do with caseloads of 170, perhaps a move to the West Country would be a good idea.

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Expectations

The Old Woman who Lived in a Shoe

I started this blogging stuff back in February 2004 when youngest daughter was expecting her first baby, my first Grandchild. I wanted to keep a diary, organise my thoughts and record this transition from being a part of one generation into a member of another. I had looked forward to becoming a Grandparent but I was amazed by quite how much this forthcoming event was altering my perspectives. My children had all flown the nest, were independent. That had given Hubby and I a freedom that we had never really experienced, the ‘apron strings’ which had held us to the children for so long had stretched to such an extent that they were virtually non-existent. Did I suffer ’empty nest’ syndrome? No. We still saw them all frequently, we all lived locally so someone was always popping round but our time was our own. The advent of a new generation reined me back again. The pregnant one was calling round more frequently wanting support and reassurance and I realised that it would not just be their lives changing, ours would as well. Jack was born and I was overjoyed that the closeness daughter and I had regenerated was continuing, and that I was going to be a ‘hands on Nanny’. It is now 4 years later, I am now a Nanny 5 times over and, although at times spread fairly thinly’, I am still hugely involved with my Grandchildren, when daughter returns to work in August I will be caring for the boys, I am privileged. Yes, my relationship with my daughters has changed, we are now closer than before, we are a support network, I hate saying this as I always used to cringe when I read it but, we are friends as well as being mother and daughter, it’s complex.

Now for the point of my musings, I am going to be a Grandmother again! On Mother’s Day son and daughter-in-law came round and gave us a suggestion for a wedding present, a pushchair! Yes, they are getting married in May, whoops. I was overjoyed, squealed, cuddled both of them and generally made a huge fuss. Yesterday they had the 12 week scan, I was expecting a phone call but no they came straight round to show us the scan photos, my next grandchild, a little smudge nestling in it’s home. A the moment I feel as close to this developing baby as I did to all the others, will this continue as I expect my involvement to be very different. This is my daughter in-law, I shouldn’t think that I will be physically involved during the pregnancy, I doubt that I will be there when baby is born. I was in the room when all my other Grandchildren came into the world, will it make me feel differently when I don’t hear it’s first cry? It is all just so different, I’m frightened that this little one won’t feel as much a part of my mega-family. I think this is going to be a whole new experience in my Grandmotherly role.   

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Do not press the link if you are squeamish!

BBC three, last night, just by chance I started watching this programme and was entranced. It is advertised as ………

‘Journalist Dawn Porter goes in search of the truth about childbirth. Like many young women, Dawn terrified by the prospect of childbirth. As well as from the pain, she worries that her body will be damaged beyond repair and the prospect that sex will never be the same again. Finding her friends unwilling to spill the beans about what it’s really like to give birth, she seeks out a first-time mum who will let her witness a birth firsthand.’

I am so frustrated at not being at work because I can’t recommend this to the pregnant women. Dawn went right to the ‘nitty gritty’, it was all those questions you don’t know the answer to, all those things that you haven’t even thought about in down-to-earth, humourous at times, but a very honest 60minutes of gems for 1st time Mums. From scooping poo out of a birth-pool,  gas and air, a pool birth, ventouse, forceps, to what a placenta looks like. Yes, it is gory but not gratuiously so. Basically it’s educationally entertaining. 

I also think it would be good for many women who have given birth before and are tremulous about a repeat of their first experience. One of daughter’s friends, expecting her second baby in three weeks, was chatting to me today and mentioned that she had watched it and it had made her think about using ‘Active Birth’ rather than having an epidural the minute she was in hospital. What had made her think this way was not that the women ‘enjoyed’ labour, it was quite obvious that the women found some of it painful (understatement), but how they were immediately afterwards, mobile and catheter free. Obviously not 100% fine but equally not surrounded by, and wired up to, all sorts of medical tubes and gadgetry. Daughters had encouraged her, telling her that I used to facilitate the Active Birth classes so had lots of info. End result is that she and her partner will be coming round next week for a one-to-one on things to do to encourage normal progress in labour and different coping strategies. I’m really looking forward to being midwife me again, even if it is only for a couple of hours!

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In today’s Telegraph was a piece written by Rowan Pelling who was commenting on the ‘golden hello’ to midwives who have left the profession. I feel that this article explains succintly most of the causes for midwives leaving the profession and then goes on to be realistic about what Alan Johnson is really offering – ‘He offers them a miserly £1,500 (plus up to the same amount in childcare, training days and travel) to re-engage with an even more demoralised and disaster-struck maternity service than the one they left several years earlier.’ The author is employing an Independent Midwife for the birth of her next child and suggests that the problems within the maternity services is her reason. I have no problem with this, it is her choice.

The article invites responses and the first one is from Emily, expecting her second baby in August, who says  – ‘I’ve seen the midwife twice and she seems more interested in ticking boxes and moving on to the next mum than taking time to answer my concerns. The NHS has become a conveyour belt where primary care providers are only interested in treating the issue at hand. Ask anything of them and it is treated like an inconvienence.’  So, Emily is at most 18 weeks pregnant, that’s if baby is due on the 1st August, if it’s due at the end of the month she is 14 weeks, according to the NICE guidelines for Antenatal Care she should be seen prior to 12 weeks and then again at 16 weeks, so twice. Right so far then. At these sessions the midwife will have been ‘booking’ Emily, lots of asking of questions and ticking of boxes, filling in of multiple forms to book scans, have the appropriate blood tests performed, basically attempting to ensure that the pathway is laid for Emily’s progression through her pregnancy. So yes, the midwife is really ‘ticking all the boxes’ at the moment and, unfortunately Emily has it right, the midwife is moving on to the next Mum, and the next, and the next because the way the service is at the moment a midwife’s priority is to give safe care and if she has time to do anything more then wonderful, but becoming increasingly unlikely. If Emily had read Rowans article properly she would have read that one reason midwives leave is that ‘maternity services are so overstretched that a rewarding job has turned into crisis management’ so my message to Emily would be ‘ Your midwife is probably as unhappy with the care she is providing as you are with the care you are receiving. It’s not her fault’.

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