Wednesday, 19 December 2012

Dear Health Minister

Its time to act for in the not too distant future through no fault of my own Independent Midwifery will becme illegal unless some serious consideration is given by the UK Government. Part of the campagin to draw attention to this serious problem is to get everyone to send a Christmas card to the Minister for Health. This is mine and below is the hand written message inside:

Dear Dan
I would like to wish you and your loved ones a very happy Christmas.
I would also like you to give me an amazing gift at this special time, one that will cost you nothing other than that which you do best. I would like you to truly consider the health of the women and their babies in this country and apply your politics in their favour. I am hand writing in this to you in the hope that you will not just return to me a standard template letter saying that the problems facing Independent Midwifery have been solved. A solution has not been found and from October 13th 2013, without true political will from a Government that cares, real choice for women will be a thing of the past.

Please Dan, help me to continue doing what I do best, help me to continue to serve my profession and do my duty. I would like you to help me to continue being a midwife who truly is, as the word means, with woman.

I became an independent midwife in order to give one to one care to women, to give choice to woman and to never leave her side when she is in need, to get to know her and for her  to get to know me. That type of care, which according to your own Government is gold standard has achieved outcomes that the NHS can only dream about until they too implement true women centred care.

As I understand it the piece of EU legislation that will make independent Midwifery illegal can be implemented by each individual country in the way they think best and so it is not outside of the UK Government to find a solution.  Social enterprise and contracting into the NHS is an amazing concept but is neither easy or a solution for it is not Independent Midwifery and will not solve the problems woman face. 

It is believed that the fall-out from this legislation will be illegal midwifery as there will be midwives who will not leave women to birth alone when those women cannot or will not use the NHS. If this comes to pass it will be a sad day for a country that has always had such a strong and respected midwifery profession at the heart of health care for women. If aspects of childbirth go underground how Dan, could this safeguard society or continue to regulate the profession of midwifery?

My plea is from my heart. Please please do not turn your back on us and the women that need and want us. In a few weeks’ time on prime time ITV1 you will see the way I work, you will see the commitment I have to my job, please watch the documentary in which I have taken part in order to  show how independent midwives do their duty and care for women. Please watch and think of me and all the other women who I want to care for in the future. Please don’t throw me away.

Yours  Sincerely

Virginia Howes

Friday, 30 November 2012

Supervisors of Midwives

The life of an IM can be difficult sometimes due, not to the women we care for but to what should be simple things.........

At 0850 this morning I rang a local NHS trust to get some help in getting a woman in to see the phlebotomist in order for them to take antenatal booking bloods. This is something I usually do myself, I am very proficient in taking blood and have rarely failed but having had 2 attempts I thought the experts should do it in this case. Ok, so I have 2 contacts at this particular hospital, one is the community midwifery manager and the other the contact Supervisor of Midwives, (SOM). This SOM always writes me a very nice letter; in response to my booking courtesy letters, offering her help should I need it. Yesterday I rang the community midwifery manager but she could not speak to me due to being in a meeting, other than to say she would call me back. She did not call back, which is ok, she is a very busy lady and as we are friends too she may have though I just wanted a chat and so this morning I tried my other contact the, SOM. For the sake of anonymity let us call this SOM Mary

The Dialogue:
Operator: Can I help you?
Me: Can you put me through to Mary please
Midwife: Hello Triage midwife Anne speaking
Me: Oh sorry I thought I asked for Mary
Anne: No sorry she is off till Tuesday
Me: Oh ok well as you are a midwife maybe you can help me please. I am Virginia Howes IM and I have a client who needs some routine booking bloods done, she needs to see a phlebotomist really as I have tried twice and failed can you arrange that for me please?
Anne: Oh we send the difficult ones to day care they are really good at doing blood so I will put you through to them
Me: Thank you
Midwife: Hello day care, midwife Jane speaking.
Me: Hello Jane I am Virginia Howes IM and I have a client who is difficult to bleed and I have been told you are experts at it can I send her to you please?
Jane: Oh no we send them to the phlebotomists if they are difficult.
Me: Oh ok yes that’s what I originally thought /wanted so can you do some blood forms for me please? (This is a trust not local to me so I don’t carry their forms. Had I succeeded in my attempt at taking the woman’s blood I would have put them through my local trust as I DO have their forms, it’s the same PCT so I have it from the top that the funding is coming from the same place and it’s fine to do this).
Jane: The phlebotomists will do the forms just send her in with her notes.
Me: Well therein lays a problem because she is booked with me an Independent Midwife so the notes will not be NHS notes or familiar to the phlebotomist, it will cause all sorts of confusion so could you not just do the forms for me please?
Jane: It will be fine just speak just to them and explain…I will put you through
Me: Ok thank you
Phlebotomist: Hello can I help you
Me: Hello yes I am Virginia Howes IM and I need to send a woman in for routine booking bloods I have been told that you will do the forms at my request?
Phlebotomist: Oh no we don’t do forms you need to ring day care.
Me: oh no! I am going round in circles here…Can you transfer me back please
Phlebotomist: Ok

The line rang for about 5 minutes and then cut me off………..
I now want to bite my knuckles and have been on the phone for 25 minutes and need to go back to the starting point.  I rang the hospital main line and it rang and rang and rang. I gave up redialled and it was answered in a normal time. By now I am thinking “ok well lets resort to supervision after all a SOM is the person a midwife is meant to contact if she is having issues or problems”.

Operator: Hello can I help you?
Me:  Can I speak to the Supervisor of Midwives on call please.

Now, a Supervisor of Midwives is meant to be on call 24/7 in case of emergencies. Switchboard, all maternity managers and notice boards are meant to know who she is and she should be instantly contactable. The line rang for 3 minutes. I was now beginning to think “oh my goodness this is about a simple blood test but what if I was at in emergency situation, how much time this is wasting”. I gave up and redialled but started making notes of times and conversations.

Operator: Hello can I help you?
Me: Yes I would like to speak to the Supervisor of midwives on call please.
Operator: You mean midwifery liaison?
Me: No, I mean the Supervisor of Midwives on call and it is important she can be contacted as she is someone to contact in emergencies.
Operator: Ok  I will page her

By now I had put the phone on speaker and was recording the event….this was serious and that imaginary situation of me being involved in an emergency and the resulting questions during my investigation of “why didn’t you contact the SOM” was coursing through my mind.

Operator: Sorry but I have paged her twice and she is not answering her bleep I will ring her extension.


SOM on call: Hello can I help you…….phew!

Bloods sorted forms in post to woman so she can go to the phlebotomist when it was convenient for her…job done good result

Time taken?  48 minutes.  Issues raised, ?????





Thursday, 6 September 2012

midwives in the news

Are midwives any different than any other professional when it comes to the press?  Possibly not.  Or maybe we are.  Women, pregnancy, birth,  motherhood, fatherhood , babies ......a potential maelstrom.  And there is the midwife in the middle of it all. So I think that maybe we are a bit different in many respect because we are so involved; after all the meaning of the word midwife translates to being 'with woman'.

So the press love a story about us, good or bad.  But often the reporting in inaccurate, incomplete and sensational.   We all know that. I was recently reported as a 'midwife to the rescue' when my friend gave birth as planned at a local music festival.  No rescuing there in any sense of the word; it was all planned and everything went smoothly.

So as I read today's reporting in the national newspapers about a midwifery colleague, my heart is heavy for the family and the midwife involved. I will wait until all the inquest evidence is considered before coming to any conclusions myself.  And in the meantime be circumspect about what the press are saying.

Monday, 25 June 2012

I am a midwife and my heart is breaking. I have spent 15 years working tirelessly in the career I love serving the women and families I have come to love. My passion for a woman’s right to make her own choices about how, where and with whom she births her baby are as strong as I write this, than they were the day I became a student midwife. For the last 13 of those years I have been working as an independent midwife and it has been the most wonderful time of my life, for I now know how empowering it can be, not only for women, but for the midwife too, to make individual informed choices.
About 5 years ago I received a letter from the Government stating that due to new legislation that was coming from the EU it would be illegal for midwives to practice without insurance within 18 months. It has actually taken much longer than that but despite all that has been done by the Independent Midwives, the law will be in force from October 2013 and I will therefore legally have to stop practicing as I do now.

Choice for women and midwives will legally be no more.  It will be the NHS way or nothing.

This is not something that is directed solely against independent midwives. There are already lots of rumours about why this is coming about but this is not anyone trying to rid the country of independent midwives due to how they practice or because doctors or the NHS want to take control.  We have been caught in an unfortunate situation. The new law will say that all health care professionals should have professional Indemnity insurance in order that the public have protection in the event that human error makes it necessary for them to make a claim against a practitioner. Whilst all other health care professionals such as Osteopaths, Physiotherapists, Podiatrists to name but a few, can purchase insurance on the commercial market, midwives cannot. The insurance companies are about making a profit, they are a business and they can clearly see that a valid claim involving a baby will not make them a profit from premiums collected from 150 midwives or so. So there we are, caught in a situation not of our making.

We started fighting back, we had marches and campaigns, we drew attention to our plight and we had pledges of support from many a high place. The Government pledged to help us; David Cameron said if he came to power he would not let it happen. They said Independent midwives provide gold standard care and are valuable to the profession. So far they or he have not carried out their promises. The solutions they suggested way back when we first had notice of the proposed changes are not viable. We have jumped through every loop they have suggested, we have walked every promised path from every insurance broker who has said they can help, but we are no closer to a solution.

We have put every valid argument forward; that its women’s, choice that we always inform woman of the situation as per our rules, that there has only ever been a couple of personal claims against independent midwives ever, that our outcomes and statistics speak for themselves, that the country is already short of midwives, that it feels to be against our human rights, that it takes away choice for women which in itself goes against Government policy, that it will make women and  midwives go underground and that ultimately it may make women birth without a midwife putting them and babies at risk. As usual woman and babies are at the bottom of any political agenda. This is a woman’s rights issue and not many concerns themselves with woman’s rights or issues.

Collectively we will not give up the fight till the very end and I personally pledge not to ever give up on woman and on my profession even if my profession gives up on me. I will always be a midwife whatever that may cost me but it doesn’t stop my heart from breaking

Monday, 26 March 2012

Who wants a cherry on the top?

Is choosing or knowing your midwife really as important as the evidence says it is? We are informed by studies that knowing the midwife improves outcomes with all variables….you know, less caesarean sections, less babies in special care, more women achieving normal birth, less hospital stays, more breastfeeding, more satisfaction with the process……I am sure the list can go on but already it is clear to see a cost saving, and far less complaints maybe, if all these things were reduced? How much money could be saved by the implementation of continuity of care? The Government know it, the NHS knows it, the trusts know it, the mangers know it and the midwives know it. But do the women know it? Does it matter to women that they get to know the midwife who will be caring for them at the birth or is all they want is a knowledgeable, caring, kind midwife?

Currently Neighbourhood Midwives is trying to make changes to the way maternity services are delivered by setting up an employee-owned social enterprise organization. They state that their primary purpose is to provide an NHS commissioned caseload midwifery homebirth service, based in the local community, “wherever it is required”……

Wherever it is required? Surely the question should be; is it required?

In order to gain the relevant information to answer this exact question, a colleague who is working on the implementation of Neighbourhood Midwives asked this question on the Facebook page “One Born EveryMinute-The Truth”;

 “Does it matter to you that you don't know the midwife who will look after you in labour? If not, why? If you could have a choice and choose a midwife whom you knew and who could care for you throughout your pregnancy, would you choose this option”?

As would be expected on a page that is primarily about evidence based midwifery practice, there were quite a few women raving about having the option of knowing ones midwife and continuity of care.  To be fair there were also a lot of comments from women who had amazing experiences but who did not know their midwife and then some women were saying that it really doesn’t matter as long as the midwife is kind and caring.

I have been thinking about the final comment as I remember having the exact conversation with a mentor many years ago when I was a student midwife. The mentor told me that “all women want is a king caring midwife.” However this was also the same midwife who said “the important thing is a live healthy mother and baby,” when we were discussing birth plans.  Well of course I do not think we could argue either of those points because both are important and any birth would be unbearable without either. But why does anything have to be sacrificed? Why can’t women have it all? Why can’t lots of things be equally important? Why can’t importance have parallels?

 I love really using analogies so I will compare it to going to a restaurant and choosing a dessert…..

OK I really want a dessert the type of which I know is sold in another restaurant and which I absolutely adore.  They do something similar here and I have tried it at this restaurant too but here it’s not quite the same.  It is not a fancy dessert in fact it’s been around for years, including at this place but in the other restaurant it is so utterly special because it is with a fresh cherry on the top. The cherry makes it exquisite to taste. Lots of people want it with a cherry too but as it has never been available they settle for the dessert as it is served here. Despite asking for a cherry I am told by the waiter that sorry I cannot have a cherry. What he knows and everyone else knows is that the fresh cherry has loads of health benefits and is exquisite to taste but according to the restaurant  owner they would have to install an expensive machine to de stone the cherries. Even though they know that people will come to the restaurant from far and wide and rave about it and that in the long run their takings will improve they think “oh well it’s been ok for most people for all this time so we will keep the dessert as it is”.  There are some people that eat at the restaurant who love the dessert as it is, they say it is perfectly good enough and cannot for a second believe that a cherry would make any difference. Some diners say all that matters is that the dessert tastes nice and so let’s just leave it as it is………

But I know the truth, and all those other diners who have tried it at the other place, knows the truth, is that they have never experienced it with a cherry on top, that if only others would try it a different way they would widen their eyes and say “oh my oh my the other way was good I admit but oh how delightful how exquisite and how memorable is this desert with the cherry on the top……and healthy too…. wow we are having it all…..

Who wouldn’t want midwifery care with a cherry on the top?

Friday, 23 March 2012

Meconium stained liquor

In a note regarding last week’s OBEM I asked why it was that a multiparous woman being induced for postdates was being subjected to continuous monitoring,(EFM). It was clear that she had been induced by prostaglandin suppository alone and was not on a syntocinon drip. I had a discussion with an NHS labour ward colleague and was able to rule out that EFM, in this case, was linked to induction process so I was confused. However what I obviously missed and what was subsequently pointed out on Facebook page, One Born Every Minute-The Truth, was that there was meconium stained liquor seen during the birth. (note to self wear your glasses next time)

So I thought I would pose this question; is meconium stained liquor always a reason to constantly monitor a baby in labour? I think I am correct in saying that finding meconium in the amniotic fluid is a reason that is often cited to transfer from a home birth, midwifery led unit or birth centre to a consultant led unit and also to commence EFM (information taken from local trust guidelines). The labour therefore has shifted from a normal one to an abnormal one, from low risk to high risk and maybe the course of the woman’s birth and or birth plan completely changed because of the meconium alone.

There is plenty of information on what meconium is and what harm it can do (Google it) so I want to focus on the changes it brings to the course of labour and whether those changes are indeed always necessary.

According to the National Institute for Clinical Excellence, (NICE) continuous EFM should be ADVISED for women with significant meconium-stained liquor, which is defined as either dark green or black amniotic fluid that is thick or tenacious, or any meconium-stained amniotic fluid containing lumps of meconium. Whereas continuous EFM should be CONSIDERED for women with light meconium-stained liquor depending on a risk assessment which should include as a minimum their stage of labour, volume of liquor, parity and the fetal heart rate. Nice also states that “significant meconium stained liquor” is an indication for transfer to an obstetric unit. It seems that NICE are definitely about defining and describing different categories of meconium which may change the advice given and or choice of care.

We can presume, from reading individual Trusts guidelines, listening to women’s stories and of course watching good old OBEM that labouring women are told that there IS meconium and therefore they need to be constantly monitored due to it being a risk factor for baby, but are they told ALL the details and given a choice?

Are women informed that the meconium in the water is light and that as they are having a 2nd or subsequent baby the labour may be quick and that if baby has no problems with his /her heart rate it is recommended that continuous EFM be only CONSIDERED? Are women told that the need for EFM is not absolute, and furthermore that in her particular case, it has been considered and there is no reason to constantly monitor the baby as long as all else stays well? Her birth plan does not have to change she can remain moving around and being intermittently monitored at home, in a birth centre or indeed in the hospital of her choice?

I have reviewed a very recent research paper (2012) which was published in the International Journal of Paediatrics and reviewed 133,000 births between 37 and 43 weeks complicated by meconium stained liquor. With a bit of mathematics I have changed the percentages into numbers and this is what the study found.

Meconium in the water is a relatively uncommon problem and in this study affected only 8 in every 100 births, and of those babies less than 7 in 10,000 became ill. In terms of mortality rates, the chances of meconium related death in childbirth was 2 in 100,000.

Other studies have quoted different statistics but in all recent evidence the incidence of meconium aspiration syndrome is similarly very low. That is not to say that it is to be dismissed lightly as it can cause extremely serious illness and fatalities in the extreme cases.

The issues once again are informed choice. Some parents would want to act on the chance they could be one of the 2 in 100,000 who child dies or even one of the 7 in 10,000 whose child is ill but equally importantly some would want to make choices based on the likelihood of them being one of the 998,000 or of the 9,993 who could continue with their plan of a normal non-medical birth.

Either way they should be given the facts in order to make a choice

Thursday, 22 March 2012

Medical Help for the few?

I watched OBEM last night mostly with a smile on my face and the occasional “oh no why?” so lets start with what was really good….I thought the story of Cody was a real positive story about pre-eclampsia. As Billie admitted herself whilst most women have heard about it and know it to be a problem, many are not informed about how bad it can be. It’s a shame given what we know about kangaroo care that Cody and Billie did experience it for the first hold as it would have been an amazing example of excellence but again maybe it was done at another time and we just did not see it due to editing.

The same for the story about the baby with the cleft lip. Brilliant information giving. TV has as the ability to normalise situations (which can be a double edged sword) so by seeing the sweet baby, seeing his lip and how well it was repaired, may go a long way to helping women who are also told their baby may be similarly affected. It appears that Carolyn was induced post dates but we know no more so we cannot make presumptions whether or not it was an informed choice. (note to self add stuff about the evidence and risks of induction of labour) However Carolyn was constantly monitored during the birth. Why? Following birth the cord was cut for no apparent valid reason and baby was immediately removed from his mother. Why?

The midwife who was with Tania I felt did an excellent job of support sitting with her (off the bed) talking and encouraging her. She was however being constantly monitored. Why?

However... cushion hit TV when another midwife gave incorrect information by saying women ”should progress at 1cm per hour” There is NO EVIDENCE of this. This is outdated, discredited information that can cause harm. Some woman will progress faster and some slower and as long as all is well, the clock has no part to play in a normal labour. Once again I would like to mention the Royal College of Midwives campaign for normal birth. If the midwives do not want to read complicated and or deep research papers then the RCM make the evidence simple. I got really excited to see Tania have good midwifery support, sitting on a ball, resting for a while on the bed, then all fours for 2nd stage……then it all fell apart when a midwife (not the primary one) said “lets turn you over” and once again constant monitoring, Valsalva and a shouting match. No need for any of it……she would have done just as brilliantly leaving her alone to push under her own steam. The fact the baby was OP (back to back) just adds weight to the argument that she was an amazing woman who was quite able to give birth to her baby without interference.

Amazing stories, lovely babies and a missed opportunity once again to normalise birth for the majority and show medical help for the few.....

Also published on One Born Every Minute The Truth facebook page

Thursday, 8 March 2012

All midwives do is sit around and eat

Since my last blog the, One Born Every Minute- the Truth, Facebook page has grown and grown.... not all of the lively discussion on there has been praise for the page mind you, maybe that is because it has touched a nerve for some.  Understandably I suppose because if I was a midwife who uses, for example, the Valsalva manoeuvre or who has never helped a woman birth other than on the bed (yes they are out there) or who always attaches a fetal monitor, or always cuts a cord, of course I would take all the criticism personally too, (although I may just then look to change my practice).  Tongue in cheeks comments aside though, that is not the intention of the page. The purpose is not to condemn the midwives rather than some of the practices which, if keep on being seen over and over on TV without being challenged, will continue to be regarded as ok and as normal by both women and health care professionals.  It is important to challenge bad or discredited practice, indeed it is part of the midwives rules to do so, or it will never stop and women will always be exposed, depending on who cares for them, to sub-standard care.  
I actually thought last night was pretty ok, with some exceptions which I will come on to later. I thought  it was ok however only because as a midwife who has worked in similar situations and in a labour ward I can see through the editing, where conversation have taken place and things missed out. But can the women who are regularly watching and to whom a labour ward is a very unfamiliar place see it the same way?

I want to first consider how it showed the midwives. It was all very relaxed and calm.....But if I was a midwife working in a consultant unit it would make me reflect on all the days and nights I felt like I was trying to be two people and it may just make me pretty cross.   It showed the midwives sitting, eating chocolates, chatting; talking and getting on lovely.......a true reflection? I do not think so….All midwives know how it is in a consultant unit most of the time. The truth is (I bet) the majority of the time they are rushing around with a million things to do, the office is empty, they are rushed off their feet and hardly get time for a cup of tea let alone a rest and a when it IS busy thus and women for whatever reason are alone in the room, because we know that does happens and at times, is unavoidable, what exactly will those women be thinking? They just might be thinking that the midwife is leaving them alone, vulnerable, scared and wondering how long the labour is going to go on for, in order to eat chocolate and bemoan the size of their thighs! How is this painting midwifery in the NHS in a true light?  What is this doing to the political appeal for more midwives? Some of the midwives who have been challenged enough on, One Born Every Minute- TheTruth, to speak out have argued that it is entertainment only, that most things can be blamed on editing and that what we see is not really happening (non evidence based practices, Valsalva manouvre, constant monitoring, encouraging epidurals, unkind or untrue things being said). Well I tend to agree with you on this one gals......the bit about midwives sitting around chatting and eating choc? That bit I give you really is pure it not?

Tuesday, 6 March 2012

I am so mad at some of the things I see and hear on One Born Every Minute I have set up a facebook page to talk about pleased that in just a couple of days it has over 800 likes!! so here it is and also here is my first bit of ranting on the subject One Born Every Minute..The Truth

Factual or fiction?

The Channel 4 television show One Born Every Minute won a BAFTA in 2010 under the category of Best Factual Series.  A definition of the word factual is:

"The available body of facts or information indicating whether a belief or proposition is true or valid".

Whilst it may be assumed that  the audience knows that editing has taken place, especially those who are aware of the time involved in the labour/birth of a baby, there is no doubt that what is being seen, said, and done is fact for it is happening as we are witnessing it. What is questionable is whether or not these “facts” or the actions and words of the professionals involved are true or valid? Turn that into professional speak and it could be asked if the words and actions are evidence based.   Are they in line with the rules and codes of the governing bodies of the professionals involved? If the answer is no then surely there are further issues to be considered and questions to be asked.

During the Wednesday 29th March episode, Midwife Zoe Leonard was encouraging long sustained breath-holding whilst caring for Vicki who was pushing in the second stage of labour.   This practice is known as the Valsalva Manoeuvre which involves prolonged breath-holding.

With prolonged breath-holding there is an increase of the maternal intrathoracic pressure by forcible exhalation against the closed glottis, which causes a trapping of blood in veins preventing it from entering the heart. When the breath is released, the intrathoracic pressure drops, the trapped blood is quickly propelled through the heart producing an increase in the heart rate and blood pressure and followed by a slowing of the heart rate. All of this disrupts the blood flow to the uterus and ultimately to the baby which then shows up or is interpreted on the fetal heart monitor as fetal distress.

There is no evidence that the Valsalva Manoeuvre shortens the second stage, decreases fatigue or minimizes pain. The evidence suggests that it alters the contractile pattern of uterine smooth muscle, leading to inefficient contractions and failure to progress. Studies suggest that encouraging women to believe in their ability to push the baby out may be as important as the type of breathing. 

Studies published between 1992 and 2009 show that the physiological effects of Valsalva Manoeuvre can include: impeded venous return; decreased cardiac filling and output; increased intrathoracic pressure; affected flow velocity in middle cerebral artery; raised intraocular pressure; changed heart action potential/repolarization; increased arterial pressure; increased peripheral venous pressure; altered body fluid pH, which contributes to inefficient uterine contractions; decreased fetal cerebral oxygenation.  The World Health Organisation, (WHO) concluded that it is a dangerous practice and should cease.

Later in the same programme when interviewed, Midwife Zoe said that babies can, if left too long in labour, "get tired" (labour ward talk for become hypoxic) if the 2nd stage goes on too long.  There is no evidence to support better outcomes when time limits are imposed on any stage of labour. More importantly, Zoe is obviously not aware of the evidence around her practice with efforts to encourage Vicky to birth her baby quickly.  Is Zoe disregarding them the evidence in favour of dangerous practice? Either way she is in breach of her Nursing and Midwifery Council Code, (NMC) as according to Rule 6- Responsibility and sphere of practice, the guidance indicates that practice should be based on the best available evidence and that a midwife must make sure that the needs of the woman and baby are her primary focus.  The NMC code of professional conduct: Standards for conduct, performance and ethics (2010) states that a midwife must keep her knowledge and skills up to date.

This programme needs more editing in order to stop showing bad or dangerous practice. Whilst the programme makers must be delighted in their ability to pull in large audiences, the success of other birth programmes has demonstrated it does not always need sensationalism and car crash births in order to do so.  It must not be forgotten that the viewers may include new and impressionable midwives who may get the message that it is fine to copy what they see and for women to accept as normal what they too may be exposed to or ask to do when they face childbirth.  Questions needs to be asked and they include; why are awards being given for dangerous practice and are the NMC watching?


 Martin C 2009, Effects of Valsalva manoeuvre on maternal and fetal wellbeing, British Journal of Midwifery, vol. 17, no. 5, pp. 279-85

Nursing Times  95:15, April 15, 1999.

WHO (1996) Care in Normal Birth: a Practice Guide.

Friday, 10 February 2012

Taking the baby

Need to have another little rant! Was watching 'One born every minute' on Ipad in kitchen. Anyway, was really cross with events after a baby girl was born with difficulty (a condition called shoulder dystocia) when head is born but the shoulders get struck. When she eventually came out she was floppy and shocked and need resusitation. She responded well and started breathing and crying. She was wrapped up and left under a heat lamp whilst a paediatrician told her parents baby needed to go to special care unit. I cannot comment about that decision; what makes me mad is why that mother did have her breathing, crying baby put into her arms first! Instead, her baby was wheeled away on the resusitaire and her poor shocked distressed mother was left lying on an operating table. It was some time later that she was 'allowed' to hold her.

There is a phrase that midwives use when they accompany a woman to theatre for a caesarean section or instrumental birth; 'taking the baby'. What that means is the midwife is the person that the doctor gives the baby to immediatly after its birth. The midwife then carries the baby to a resusitaire where a paediatrian is waiting to check the baby over. If the baby is poorly then that is the best thing for that baby; it may need lots of care and this will be the safest place for it. Usually babies come out well however. Sometimes fathers hover around wanting to see what's going on. They are often told to sit back down at in the chair they were placed in, so they don't get in the way. When the paediatrician is happy he/she will wrap the baby up and leave. The midwife may then decide to weigh the baby, give it vitamin K and put labels on. Several minutes have now elapsed; the mother is generally craning her head round to see what's going on and is everything all right? When the midwife has finished, she will re-wrap baby up well in towels and blankets and then when SHE is ready, give the baby to it's mother to hold. Sometimes also whilst the woman is being sutured or whatever, the father and the baby are taken out of the operating theatre and have to wait a short while to be reunited with the woman in a recovery/post natal ward.

When will this brutal and controlling ritual stop? As it's so easy to do so! I do it everytime I go into an operating theatre with a woman. We insist on skin to skin. It just requires some cooperation with theatre staff, making room on a woman's upper chest between electrodes and lying a baby with warm towels and hat on. If the woman doesn't want to, then the father can. Weighing and vitamin K can wait. Baby can have labels put on easily in any position. The family can stay together at all times.

These first few minutes after birth are so important to a mother - they can NEVER be re lived.

So as professionals, it is our duty to stop 'taking the baby' and ensure it's the baby's mother who enjoys those first few minutes. It's really not rocket science! Just kind, thoughtful and humane care to a family who especially need it during a heightened stress situation.

Thursday, 2 February 2012

Reflection on a normal birth

I wrote an article a few years ago that was published in The Practising Midwife and I had cause to re visit it recently when I attended a birth complicated by meconium stained liquor. I thought it would be good to include the article in this blog as it covers so many issues that worry both women and midwives alike, things such as long, stop start labours, meconium, long 2nd stages, infection and prolonged rupture of fact if I had not written it myself I would think it a marvelous reflection of normality.....its a bit long but well worth a read if I say so myself

Reflection on a normal birth
Lindsey had a lovely home birth. Not really unusual and certainly not unusual in the life of an independent midwife. However Lindsey’s homebirth was achieved against so many odds and against so many objections that she would have encountered had she been being cared for under a medical model of care, her birth and the woman herself is well worth calling amazing.
Five days after her estimated due date Lindsey called me around 05.30 to say her membranes had ruptured at 0100 but that the baby was very still and not moving much hence her call so early in the morning. I reassured her that she is not usually awake this early so it may be that the baby is asleep at this hour usually but that I would come and see her immediately.
I arrived to find baby well, with a very reactive heart rate and by now movement was evident. The head was very low in the pelvis, hardly palpable at all with the back laying left lateral. Wonderful I thought!! However when Lindsey showed me her liquor loss there was meconium diluted into it. Meconium can be a sign that baby is becoming hypoxic although not necessarily an absolute indicator. It can be that baby is mature enough to open its bowels. It is important to determine between the two possibilities so that the birth is not only a safe one but also that the labour is not interfered with leading to further complications.  I do not automatically advise transfer for a hospital birth where well diluted or old meconium is evident but I do keep a very close eye on the fetal heart and would advise urgent transfer at any deviation from normal. In this case labour had not yet started and we did not know when it might begin and so I advised that a trip to the local hospital for a well being CTG was appropriate.
We arrived at the local hospital where I know many of the midwives and doctors and have good relationships with most. Lindsey had a CTG which was normal, it was reassuring that baby was well and healthy. A Consultant obstetrician on the ward advised immediate induction of labour due to the meconium and ruptured membranes which was no less than the advice we had expected. However Lindsey was aware of the evidence and the risks of induction and so declined and decided to go home to await labour.   The midwifery staff were very supportive of Lindsey’s decision to go home and reassured us both we could return if we encountered any problems.
Having had a similar situation in another area a couple of years previously when a woman and I had to fight our way out of the hospital, having encountered terrible coercion and bullying from the midwives to conform to what the medical team where advising, this now was a lovely supportive beginning to what was to be a very unusual labour. To know welcome help was on hand should she need it at a local hospital is reassuring for both woman and midwife.
Relationships are not always easy between Independent Midwives and NHS staff due, I believe, to a lot of myth and misunderstanding of an IM’s role in the care of women. I have however worked hard on building good working relationships with this particular trust and to a large extent have achieved it.
Lindsey went home, and so did I, with a plan for me to visit her at 1700. When I arrived it was to find Lindsey, her husband Ian and her mum all having tea. Lindsey was chirpy but at last was having mild contractions every five minutes. Lindsey and I had shared many antenatal discussions about pregnancy, labour, birth and everything associated and so when I bought up the subject of vaginal examinations she was well aware of the risks both physical and physiological and the limited benefits to be gained. We came to the mutual conclusion there was no clinical indication for any intervention including and especially an invasive examination. We went on to discuss how she may cope with the coming night. We recapped all the issues surrounding meconium stained liquor, in fact both Lindsey and Ian asked relevant question repeatedly which left me in no doubt that at all times they were making very informed choices. All was well physically with both Lindsey and baby and so I left once again to go home to get some sleep.
At 2300 I received a call from Ian to say the contractions were now coming quite strong and regular. When I arrived it was to find Lindsey lying on her side very sleepy on her large bed with her mum chanting relaxing hypo birthing words in her ear. Lindsey’s contractions were very regular 3 /4: 10. The contractions looked expulsive and Lindsey told me that she felt surges downwards with each pain. It certainly looked liked active labour now and in fact I wondered if Lindsey was fully dilated given the way she was acting. We discussed a vaginal examination again and this time we both felt it appropriate. It was 23 40.
I initially thought Lindsey was almost fully dilated and was shocked at how low the baby’s head was. Literally my fingers were only inserted to my second knuckle to find the head. On closer examination I could feel cervix around the back of the baby head and eventually concluded that Lindsey was around 6 cm dilated. Lindsey was really pleased especially when I told her how low the head was and that could only mean she would not be long before she saw her baby! If I only I knew!!
Lindsay had a nice warm pool of water waiting for her downstairs so I suggested she get into it. At 0030, now around 24 hours since her membranes had ruptured Lindsey started to involuntary push. The pushing went on for about 20 minutes with contractions still 3 /4:10. All observations for both Lindsey and baby were normal and so I sat back and waited for a baby to appear. However after half an hour the contraction began to slow down and space out. I suggested she may be coming to her “rest and be thankful” stage. This spacing out of contractions can occur at full dilatation, when the level of oxytocin in the blood falls due to the lack of the feedback mechanism from a fetal head putting pressure on the cervix. I did not know it at the time but I was quite wrong!
Contractions did not return and so I encouraged her out of the pool to have a little walk around. At 0230 the contractions picked up again in intensity but Lindsey no longer had any expulsive urges. This may have been therefore a positional issue with the low head of the baby stimulating Fergusons Reflex to cause the pushing urge. Who knows for sure but the art of midwifery was telling me this may be so.
For the next 4 hours the contractions continued regular and strong. All was well with baby. I heard lots of variations in the baseline rate, some acceleration and no decelerations. I was very reassured all was well. Lindsey alternated between resting and activity as any labouring women does, she kept well hydrated, passed lots of urine and all her observations were normal. She often had the urge to open her bowels but by now I suspected it was only due to the very low head and not to full dilatation.
At 06.30 once again contractions slowed down. We re visited the subject of vaginal examinations. Lindsey as always looked at everything from all angles and we devised a plan, depending on the findings, prior to any examination. She decided that if she was more dilated than the last time she would continue to be active but if no change then (at my advise) she try and get some rest as the contractions had slowed down. Obviously the other remaining option which I always reminded her of was that we could transfer to hospital at any time for some intervention.
A vaginal examination disappointedly showed no progress, that Lindsey was still 6cm dilated and the position of the baby was unchanged. By now the contractions had all but stopped. Lindsey went up to bed and slept soundly for an hour. From downstairs I heard just 2 small contractions in all that time. I wondered long and hard what was going on here. I knew most woman by now would have been augmented long ago but despite looking hard I could find no real abnormality in either Lindsey’s or the baby’s condition. Lindsey had no wish to transfer to hospital and had the full support of her husband Ian and her mother.
At 0800 Lindsey awoke, got up and started to pace around refreshed and eager to restart the labour. By 0900 the contractions started up again and by 1000 they were back to 3 /4:10. This pattern continued until 1400 when unbelievably they once again started to die off.
By now I was getting to the point where I just could not believe what was happening. I discussed Lindsey’s labour, progress, care and choices with both a midwifery colleague and my very supportive supervisor of midwives. I was careful to do this out of Lindsey’s hearing as I did not want her to think that I was either worried or unsupportive as I was neither. However as most midwives know our practice is sometimes judged by our peers and so I questioned in my own mind what was happening.
At 14.15 Lindsay and Ian were walking around the garden in the sunshine. She looked nothing like a woman in labour and so I took photographs of her. She was smiling and happy. I decided it was time for a very frank and full discussion and to devise a plan of action. The first thing we discussed was another vaginal examination. Lindsey did not want one!!
I told them that in my opinion the choices they had were
1) Do nothing, as long as mother and baby remained well (or otherwise) for I could not make them do anything they did not want to. I would however let them know if I felt I needed to strongly advise them that their choices may compromise immediate safety of either Lindsey or their baby.
2) Have a vaginal examination and depending on the findings devise a time frame for action
3) If the choice is no vaginal examination have a time frame in the short term to perform one i.e. at 1700 and make a further plan then
4) Immediate transfer to hospital
Lindsey was upset at this time and started to cry. Ian suggested that it was not a good time to make any decisions with her being distressed and said it was not urgent due to baby and Lindsey being well. They decided that Lindsey would have a vaginal examination around 1600 and in the meantime would rest. Once again Lindsey slept. No contractions at all for around an hour then a really big one awoke her.
I have never known such a supportive and sensible husband.
At 1640 Lindsey decided to have a vaginal examination. The findings were unchanged. However now I could feel a very large bag of fore waters. Lindsey became very distressed during the examination and asked me to stop. The liquor Lindsey had been draining throughout her long labour had continued to be meconium stained but it was minimal. To now feel this large bag of for waters was surprising.
I suggested that the options now were to
1) Transfer to hospital for augmentation and other interventions
2) To re examine break the bag of for waters which may bring back contractions and then have some pethadine which may relax a now very upset and stressed woman.
3) Do nothing.
Lindsey decided to take option 2.
I rarely perform artificial rupture of membranes as the risks far outweigh any benefits as far as the evidence is concerned. However I felt it was warranted in this case especially as liquor had already been draining, baby was so low and there had never been any cause for concern with the heart rate. I ruptured the membrane and a huge amount of very clear liquor drained. I then gave Lindsey 100 mg of pethadine and the entonox. She rested then for 3 hours cuddled up to Ian on the bed.
At around 1700 contractions returned and although they were only 2:10 they were very strong. At around 1845 some were once again sounding expulsive. I had however been fooled before and so did not get excited. Lindsey continued to lie on her bed but around 2000 the expulsive contractions were very strong and Lindsey felt inside with her own fingers. She could feel her baby’s head. I was not surprised by this as I had always felt it very low. This very low head was the most reassuring thing of all and gave me confidence to support Lindsey in her choices to continue in this very extraordinary labour. 
At 2000 the contractions were all uncontrollable pushes. Another vaginal examination found the cervix to be 8cm dilated and we both felt huge relief and exhilaration.
Squatting beside her bed and pushing uncontrollably at 2100 I caught sight of a baby’s head. It was what we had waited many many hours to see. Once again Lindsey got back into a nice warm pool.
For the next three and a half hours Lindsey pushed her baby steadily towards life. She got out of the pool after a while and used a birth stool. Her baby was born in absolutely perfect condition at 0030……She sustained a very small tear that healed in a few days. She pushed her placenta out herself with minimal blood loss.
Lindsey had ruptured membranes for 48 hours. She had meconium stained liquor. Lindsey had remained at 6cm dilated for over 20 hours. Her labour had stopped and started many times in 24 hours. Lindsey had made all her own decisions based on her knowledge of all the choice available to her. The choices she made were the correct ones. Had she chosen intervention she may have had her baby a day or so earlier but at what cost?? There was no infection, no distress, no bleeding, no incontinence, no disempowerment or disappointment. Her baby had apgars of 10 and 10. Despite having peaks and troughs of feelings she coped amazingly. Following the birth she was neither exhausted over and above what would expected for any mother having just given birth and neither was she traumatized or upset by her experience. She says she had a wonderful labour and birth!!

Saturday, 7 January 2012

Labour Ward Rituals

Why oh why does nothing ever change in the medical dominated world of midwifery? Maybe it is changing but it is kept hidden from me and I see little change in the 13 years I have been away from the labour room rituals. Is there ever going to be a time when I accompany women to hospital when they need to go for assistance but they are then treated with dignity and the experience is one of joy ( and good women centred practice) in all respects?....
Recently I took a client in to hospital with suspected early labour at 34 weeks. I went home as nothing much was going on but 24 hours later was called back by my client as all of a sudden baby was on its way fast.

 When I arrived on the labour ward I walked into the brightest lit room you have ever seen, every main light was on but also a spotlight was beaming down onto a visible head. Two male paediatricians were in the room arms crossed leaning against the window a bored look on their faces.....doing nothing of course just waiting there watching the woman in her most private time. There was also a doctor present and 2  midwives, another person kept popping in and out but I, and I am sure also my clients, have no idea who it was. As the birth was so advanced and in front of so many people there was no way I could make any changes or even comment on anything I saw, it would have been inappropriate and far too confrontational, but it really was awful.

The woman was in typical labour ward position, propped up on her back  (this was a woman who was planning a home birth and wanted everything natural) . She was being encouraged to use the valsalver manoeuvre of sustained breath holding and pulling back on her thighs. This manoeuvre has been demonstrated to be dangerous practice by the World Health Organisation and has been labelled “practice be abandoned” as it can cause fetal distress.  
One midwife was standing next to me and I was able to whisper to her " please consider not cutting the cord if this baby is well as the evidence is clear that it is beneficial especially for premature babies" of course I was ignored and when a healthy pink crying baby was born a few minutes later the blood rich cord was instantly clamped, cut, the baby wrapped in a towel and handed up to his mother. The mother was overjoyed, of course she was, baby was healthy a good size and in perfect health.  The irony of it was that as the midwife was cutting the cord all the blood spurted all over her face and arms! She thought it quite funny, I thought it quite sad! Shame the blood didn’t spurt into the baby!  If they were passing baby to mum anyway why couldn't they have left the cord? It was what mum wanted and should be common practice...its even in NICE now!

I helped mum to unwrap baby and the baby commenced to nuzzle at the breast, I covered them both and that was where I hoped they would at least remain, however after about 5 minutes the baby was taken from his mother for a paediatrician to look at him. You could see he was healthy just by looking at him in mums arms! All the Doc did was listen to his heart (yes it was beating he had been pink and crying and breathing for a good while now)and then the midwife commenced to put a nappy on him (did mum want this?  of course the answer is that she didnt know for she didn’t ask.... did she even stop to think that the parenst may have looked forward to being the first ones to dress their baby?) She then wrapped him AGAIN  in 2 towels and finally gave him back to mum with no mention of skin to skin or feeding. As I see it this is nothing more than labour ward ritual,  this taking of baby for a paediatrician to look at, it happens at Caesarean sections too yet a midwife is completely able to assess at birth instantly if a baby needs a doctor or its mother. Of course as I was there I encouraged the mum to unwrap (again) put him skin to skin (again) and breast feed which he did beautifully and instantly. Why does this happen ?If I had not been there maybe the mum would not have unwrapped the baby and would have continued to hold her heavily wrapped baby without attempting to feed or certainly not as early and quickly as she did. At that point with him being born early, I considered skin to skin and feeding was the most important thing for that mother and child yet the midwives began immediately to pester the mother to stop feeding and hand him over to weigh and get prophylactic antibiotics started. The only thing wrong with this baby was he was 6 weeks early. He was a good weight, over well over 5lb and it was a spontaneous quick labour in a healthy mother. It seems so bizarre that there was such a rush to get drugs into him that he may not need but that they were more than happy to deny him the blood and feeding that he did need.

Why couldn't this baby have been born without an audience? Surely just outside the door is as good as in the room? Why did she have to be born under a spotlight and why wasn't the women in a better position to achieve a more positive birth, help with pain, prevent tearing etc. she could easily have been on all fours, the room dark and everyone waiting outside in case they were needed. Most importantly why was the cord not left to pulsate? They passed him to mum anyway so why not keep the cord on ? Just in case readers are not aware of the overwhelming benefits to leaving cords to pulsate the blood into the baby (rather than over the midwife) you can look at this link: 
Ok on with the struggle to make changes….

Wednesday, 4 January 2012

To push or not to push...that is the question

Attended a lovely birth on New Years Day. In hospital, so I was unable to 'catch' the baby but was able to support my client and her partner throughout. Labour was induced for medical reasons and strong regular contractions quickly ensued. After a short while my client said she wanted to push and it became apparent that she was in second stage of labour. She was told by the hospital midwife not to push but to breathe through the contractions. She started pushing anyway and a lovely healthy baby born shortly afterwards.

This had made me think about lot of issues surrounding the issue of pushing.

Firstly, why women are so often not believed when they say they want to push? I have heard that story too often, even with a woman who have had babies before and the head is visible! Whether the urge signals the second stage of labour or not, being told to suppress those feelings and fight them is counterproductive. Just acknowledging that a woman has those feelings can help her by demonstrating that we believe her and trust in the normal physiology of birth.

Secondly, If a woman's cervix is fully dilated and her baby is moving down the birth canal then she is in second stage of labour and her baby will soon be born. Fantastic! So why tell her not to push for heaven's sake!

And thirdly, if her cervix is not fully dilated there isnt any compelling evidence from research that this will cause a woman or her baby harm.In fact early urges to push are common and in some labours may encourage baby into more a favourable position for birth.

Lastly, women's urges often ebb and flow. So encouraging them to be instinctive and push as they feel inclined will almost always result in strong overwhelming expulsive urges only when baby is well down in the birth canal and about to be born.

So I for one will always believe a woman when she says she wants to push and continue to tell her to do just what she feels she needs to do.

Strong women not good girls

Just wanted to have a moan about a little thing (or maybe it's the tip of a very big one!) ...but its bugged me for years. In fact since I was a student midwife a very long time ago and I noticed one particular midwife saying it. And I would say that midwives say it most, less so doctors, and that it tends to pop up in the second stage of labour.

Telling women that they are '...good girls'. I cringe inwardly and then want to scream and shout at same time. I think it's rude, patronising and infantilizes women.

So why is it said to women when they are doing one of the most strong, grown-up things in their lives?

Power and control may have a lot to do with it. Also the culture of birth, the labour ward etc. Or maybe it's just that as professionals we forget what messages our language conveys and we need to pay attention to it more.