Monday, 22 December 2008

Useful Phrases, by Mary Cronk MBE

Mary, an internationally-respected midwife who will no doubt be known to many readers, has this advice for women who are worried that midwives or doctors will not treat them with due respect:

I am sure that many others will explain your absolute right to refuse any procedure for any or no reason. The law, and good practice, is quite clear. A sensible person will listen carefully to any explanations to why a procedure is proposed, and then should she choose not to have XY or Z she just says "no" or "no thank you". The "allowing" is done by YOU.

An asssertive approach is worth cultivating. You may care to commit the following phrases to memory and practice them frequently in front of a mirror.

  • "Thank you so much Midwife Sinister/ Mr Hi-an-my-tee, for your advice. We will consider this carefully and let you know our decision." Sweet Smile!
    This one is most useful in the antenatal stage, though it can be used in labour. It can just take a minute to consider what you either want to know, or what you decide.
  • "Would you like to reconsider what you have just said!" Fierce glare.
    This is useful and, for example, applies to the misuse of the word "allow".
  • "I do not believe you can have heard what I have just said. Shall I repeat myself? "
  • "I am afraid I will have to regard any further discussion as harrassment."
    This is used if the person does not respect your decision or persists in pressing the subject.
  • "What is your NMC or GMC pin number?"
    This is used if the last one is ineffective. If the person asks why you want their pin number, inform them that this is something they might like to consider.
    This to be used in extremis. I am delighted to tell you that this was used AGAINST me by a woman to whom I had taught it. I was doing a difficult VE and was being too persistent. I stopped at once and learnt a lesson.

Do not argue; learn the phrases and keep them or similar for use if necessary. I am informed that it is usually only necessary to be assertive once or twice to have a much more respectful attitude from the people who are actually your professional SERVANTS.

Sunday, 30 November 2008

Risk in Midwifery - who decides?

Risk is an interesting issue in midwifery and obstetric care. Risk is discussed all the time with women, but it often means different things to different people. Who decides what is high risk? High risk to whom?

This reminded me of a hospital appointment I attended with a client, her husband and their consultant. They were discussing risk in relation to their impending twin birth. The consultant, whom I trust and respect, was saying that he recommended an epidural for twin labours because of the high risk that the second twin might need to be born quickly by cesarean section or assisted delivery. My clients husband asked what he meant by high risk – the consultant replied that about 5% of second twins are born by emergency cesarean section. The husband laughed and said that 5% was nothing and as a racing driver, he faced death or serious injury every weekend – somewhere in the region of 50%! From his perspective, a 5% risk was minimal, but from the obstetrician's view point, this was a huge risk! The couple therefore decided that 5% was an acceptable risk of an unplanned caesarean for them and so declined epidural anaesthesia.

From their viewpoint, the benefits of mobility in labour outweighed the small chance that the mother would have to have an emergency general anaesthetic if she needed a caesarean section and there was not time to administer regional anaesthesia.
NB The risk of the second baby dying in labour was much less than this - around 3 in a thousand for term second twins - second twins have a higher mortality rate than first twins or singletons. See for instance Birth order, gestational age, and risk of delivery related perinatal death in twins: retrospective cohort study. - Smith GC, Pell JP, Dobbie R. in BMJ. 2002 Nov 2;325(7371):1004. -

Saturday, 15 November 2008

Sharon's Story Part 3 - Supervision of Independent Midwives

This post continues the discussion of Sharon's Story.. the previous two posts described the birth and postnatal transfer. Now I want to look at the Supervision angle.

Virginia, in the story you say that you consulted with your supervisor before transferring Sharon to hospital. What is the relationship between a Supervisor and an independent midwife? When do you consult her, normally?

Midwifery is the most regulated profession under the health umbrella. We are more regulated than nurses and doctors. We are obliged to keep updated and can be called upon at any time by our regulatorybody, The Nursing and Midwifery Council (NMC), to prove we are keeping updated. Midwives keep portfolios as proof of updating.

We have a system of promoting excellence in midwifery care and that system is known as Supervision. It is not supervision as most people understand the word, where the midwife is policed or told how to practice. Rather, it is a support system to enable midwives to practice with confidence, therefore preventing poor practice. Each Midwife will have her own personal named Supervisor of Midwives (SOM). If a midwife has a practice issue, she can talk to her SOM in confidence for guidance and support. The Supervisor has a duty to help the midwife in order to ensure good practice, but also to fundamentally protect mothers and babies. A SOM has a duty to promote normal childbirth and to support women’s informed choice.

You can read more about the supervision system on the Nursing and Midwifery Council website, under the Midwives' Rules and Standards.

If carried out to its full potential and aim, Supervision is an amazing support system. It is not an hierarchical system. A supervisor of midwives could be a head of midwifery, but she will also have a named SOM herself. If any accusation of bad practice is made about a midwife, supervision is used to address the issue and determine if it has foundation or not. There are correct procedures to follow.

As in all walks of life, sometimes ideals and intentions are not met and the same can be said of supervision. Midwives may, perhaps due to previous bad experience, see supervision as a punitive system. That is not how it should be. My career and experience has shown me both sides - but not equally so, I am pleased to say. Luckily (!) I experienced poor Supervision early on in my career many years ago, and so my learning curve about it was very steep. Now, and since becoming an independent practitioner, supervision has been excellent for me. It comes from the top down and the Local Supervising Officer, Helen Odell, follows the guidelines for supervision as they should be followed and actively supports all midwives in her geographical area.

My own named Supervisor of Midwives is a constant support and sounding block for me and I am often on the telephone to her discussing issues of practice. It is not easy for her as she needs to approach our relationship a little differently as I work differently to the other midwives she supervises. I will always call her in the event of a dilemma, difficult situation and even when an unusual yet fantastic situation occurs.

I am very passionate about my profession. This passion has not gone away since the day I started. In fact it gets stronger as my knowledge grows. Yes, my knowledge continues to grow, as no matter how or what your professional status is, there is room to learn more and improve. Someone could be in a profession for 30 years but if they continually repeat practice over and over it does not necessarily make them experienced. Experience can be measured in type, not quantity of time. If the passion and commitment ever goes then that is the time I will get out. If ever I am bored with it, I will not be giving women a good service.

Did you have any further discussions about this case with your Supervisor? Did she review the case? Were any issues raised about your practice?

As I put this story on my website and it was unusual, it was drawn to the attention of my supervisor and the LSO, Helen Odell, and quite rightly procedure was followed whereby the case notes were reviewed. The case notes demonstrated a much fuller picture than the brief story which was originally put online. I was commended for the care I gave.

You wrote the original article in a very candid and open way. Can you explain to us the difference between a midwifery reflection and a case study? It sounds to me like a midwifery reflection is opening your heart, and a case study is covering your back!!!

Midwives reflect, midwives question. We reflect on ourselves on what we did what we could have done better and what we may do again should the same situation arise. Unless you can see where you go wrong how can you strive to improve. When we reflect we are critical about ourselves, we admit to failings, we even admit to others failing or how we felt towards others. However, if we write a case study then it is fact and will include everything but not the feelings or thoughts of the person writing it. A case study is a detailed analysis of a person, a collection and presentation of the facts. A story, however, is a bit of both, but aimed at a certain audience and written in a way to make something interesting.

Weren't you a bit naive, putting what was, really, a simplistic summary of a complex case online in that format? Surely it would leave you open to criticism from those who did not know the full facts of the case. If you don't mention all of the factors you considered, some people may, also naively, assume that you did not actually know about them!

Yes, I was naive. I was trying to write a representative, descriptive story that emphasised my commitment to woman-centred midwifery. It was aimed at women looking for a midwife. Women who may have had similar bad experiences, or who were going through some of the issues now. Women who may have no or limited knowledge on the subjects concerned. I wrote it in an attempt to empower women. If I had been writing for a professional audience, the emphasis and level of detail would have been quite different.

Well, I'm glad you published the story, as it has raised plenty of issues for discussion. Thank you very much, Virginia; I'm looking forward to dissecting some other unusual stories at a later date!

Sharon's Story Part 2 - The Third Stage

In 'Sharon's Story', Virginia described the home birth of a baby weighing 12lbs. The labour and delivery of the baby was straightforward, but the third stage somewhat more complex. In this section, Virginia describes management of a postpartum haemorrhage at home, and subsequent precautionary transfer to hospital.

Forty minutes later Sharon birthed the placenta with quite a huge blood loss. All was well at this point so we all went into the lounge and Sharon breastfed her baby.
She had not breastfed any of the others and really wants to succeed this time. About an hour after her birth Sharon had another large blood loss and felt slightly clammy so I lay her down on the sofa, gave her some syntometrine and looked for my blood pressure cuff. It was nowhere to be found! I had it during labour but now it was lost. ...

I was concerned that I might have a woman who was compromised and so I called a paramedic.They arrived within 3 minutes and were the best guys I have ever met in the job. They got their BP machine, which recorded observations at 5 minute intervals.

Sharon’s observations were all normal. She then vomited and at the same time passed a huge amount of blood and clots.I felt it was appropriate to give ergometrine IM and commence 500ml gelifusin and then 1000 saline.
Sharon felt fine and all her observations were fine. The Paramedics remained for nearly 2 hours. They helped without taking over and were a pleasure to have around.

Would it be usual for a midwife to take blood for cross-matching at this point, or is that something the hospital would prefer to do themselves if necessary? My understanding is that transfusion of actual blood would not be done in a rush anyway...

Correct. If a woman was compromised they would not rush the blood in rather that she would receive fluids first and that is the first thing one would do. Bloods for cross match can be done later. We did not leave the house for 2 hours approximately - why would I be rushing to take blood? I might do that only in a dire emergency, but not in a non-urgent situation like this. Paramedics don't take blood following a crash, do they??

I felt that Sharon did not really need to transfer and instinctively felt that the large loss which, in all I estimated at 1500mls, was due to the large placental site and yet again normal for her as she was not compromised.However having discussed it with my supervisor I transferred her. I think covering ones behind was discussed!!!

- In the reflection, you say that Sharon lost an estimated 1500 ml of blood and yet was 'fine' - how could this be, when 1,500 mls would be a very serious loss? It sounds like you were erring on the side of caution in your estimate.

The issues around the third stage were a catalogue of unfortunates that stacked up. She had a large placenta, which was to be expected having had such a big baby, and so the blood loss when she birthed the placenta was on the higher end of normal, but she was fine.

My experience of physiological third stages is that blood loss is initially higher than in managed 3rd stages (which the evidence backs up), but that a woman often has another gush of blood following breast feeding, often when she stands up to go to the loo for the first time having been resting for a while. I always put protection on the floor next to where she will stand in anticipation of this. She then will pass urine and the blood loss settles. I always tell women that they may also feel faint and woozy when they stand for the first time too. This happened to this client exactly this way, but in consideration of the higher blood loss I acted as per standard practice and administered syntometrine. This was, as already highlighted, my “think ahead philosophy” of not wanting to interfere, but also not wanting to wait till I may have a compromised client. It is correct practice to check a client's observations in this instance.

Following the birth I had taken Sharon's blood pressure and the observations were normal but I wanted to re-check now. I was gobsmacked that I could not find my BP cuff because I had it an hour earlier. (I found it a week later rolled up in my fetal monitor bag; I had been tidying up my equipment in preparation for when it was time to go and must have put it in by mistake)

My only recourse was to call an ambulance. I HAD to presume abnormal. However, when they arrived all obs were normal and that was a very short time after.

Sharon vomited - does that mean that she was really ill?

Syntometrine has a common side effect of vomiting and that is why Sharon vomited. If she was critically ill, her observations would not have been normal, but again, when she vomited some blood clots were pushed out. As a further precaustion I gave ergometrine. In all honesty I think I gave more oxytoxics than she needed.

So now I had ambulance guys there. It just adds to the story to make it sound dramatic, but there was no panic - the client was chatting with us all and the fluids we gave were making her feel fine. Just because fluids were administered does not mean we were seriously worried - after all, they are put up at the drop of a hat in labour wards everywhere. The ambulance guys would have tried over-riding me if they thought I was acting irresponsibly as they deal with abnormal all the time. They would more likely presume abnormal than otherwise. Yet they were laughing and joking and quite happy to wait around while we deliberated.

Sharon did not want to go to hospital and I, in my heart of hearts, did not really believe she needed to. However, I spoke to my supervisor of midwives as is the correct thing to do in any case where events are unexpected or "different" or worrying or for support for me. My supervisor of midwives, despite agreeing with me that she was probably fine, thought I should protect myself from medical criticism and get her checked over.

The baby was much bigger than anticipated, and one of the risk factors for post-partum haemorrhage is a large baby and so of course that was in my mind.The evidence suggests that blood loss is vastly UNDER estimated, on average. It is hard to estimate blood loss when some is going down the loo with the placenta (to be fished out later), some is in the water and some on sheets and towels. I tend to overestimate to compensate for that . It was certainly overestimated in this case as the HB dropped from 11.5 at the last FBC in pregnancy to 9.8 following birth. Therefore the total blood loss was probably around 1000mls.

[Ref for blood loss usually being underestimated: there have been a number of studies on this, but one of the most recent is:Improving the accuracy of estimated blood loss at obstetric haemorrhage using clinical reconstructions by Bose P, Regan F, Paterson-Brown S, in BJOG. 2006 Aug;113(8):919-24.]

- Some midwives say they prefer to look at the mother's condition before diagnosing PPH, and not just the measuring jug - what do you think?

PPH needs re-evaluation in the UK in relation to the definition of PPH. 500mls of blood is not a realistic amount to give such a serious label as 'post-partum haemorrhage' and all that label tells you. PPH written in a woman's notes could have serious consequenses for her - that is why so many underestimate. The woman shoud be loooked at to identify if she has been compromised by blood loss rather than just looking at the written notes. We give almost that amount when we give blood and are sent on our way with a cup of tea. In Holland the definition of PPH is 1000mls of blood. Women are able to withstand quite large blood losses due to haemodilution in pregnancy. Moreover, everything is relative to the size of the baby. This woman would have had a higher blood plasma volume due to the larger placenta needed for the larger baby, therefore could withstand a larger blood loss. What would be a better definition of PPH would be any amount that compromises women. Again you can only use that definition if you are looking after women as individuals and of course large organisation like the NHS can't do that. There has to be a threshold for a definition of PPH, but the UK one is too low.

When I was an NHS midwife I observed that many women's notes had a written estimated blood loss of 450mls; obviously it would be very difficult for the midwife to discriminate between estimated blood loss of 450ml and 500ml, but they did not want her to have the PPH label on her notes. If a woman is defined as having a PPH it has implications for how they are viewed postnatally and for future pregnancies. I do not have to consider this as I make individual decisions based on individual cases. I always look at a mother’s condition as well as the total blood loss.

When we arrived the same midwife was on duty and Paul quite firmly ordered her out of the room! Sharon was then cared for by a lovely midwife. However yet again that medical model reared its ugly head and they wanted to do tests on the baby. Blood sugars and IV antibiotics!
Sharon declined and stated that she had come in to be checked over not the baby and please hurry up as she wanted to go back home. She was all perfectly normal with a well contracted uterus, normal observations and lochia. She had a couple of hours of syntocinon as a precaution and then we all went home.

She has a haemoglobin of just under 10 (so probably a bit lower in reality) but is feeling great and tucking into steak and broccoli. Her big beautiful baby is named Tulah and weighed in at a whopping 12lbs. Tulah is feeding on demand, 3-4 hourly. Perfect. Sharon is giving up having babies now.

In this case, as I understand it, Sharon transferred to hospital to be checked over:

"She was all perfectly normal with a well contracted uterus, normal observations and lochia. She had a couple of hours of syntocinon as a precaution and then we all went home. "
So, if Sharon was checked on arrival and found to be OK with her uterus already well contracted, why was she given Syntocinon?

The doctors who saw Sharon at the hospital wrote in the notes that all was well, everything normal etc etc, but I had reported a 1500ml blood loss and he could see a large baby so I think any doctor would do the same as they always err on the side of abnormal and follow a medical model of care. Syntocinon is usually given in that instance. The underlining principle is that the uterus may relax and the woman may bleed again.

If I had not mislaid the BP cuff maybe I would not have transferred her and then the “story” would not have read like it did....More likely it would have said “the client had a large blood loss, as to be expected, that settled with precautionary oxytoxics with no compromise and all was well”

- Sharon declined to have her baby's blood sugars checked when she went to hospital. Can you explain why a blood sugar test might be suggested for a large baby? If you don't have the test, how do you know the baby's blood sugars are OK?

Big babies born to diabetic mothers are at risk of neonatal hypoglycaemia. If a woman has diabetes she will more likely grow a big baby who gets used to high sugar levels in utero, then when the baby is born the blood sugars plummet and the baby can become hypoglycaemic. A big baby is often presumed to come from a woman with diabetes, but our client had been tested and did not have it during pregnancy. Big babies from nondiabetic mothers are not a high-risk group; in fact, one of the highest-risk groups is premature babies and those which are of low birthweight.
Symptoms of hypoglycaemia are primarily a sleepy baby, irritability, jitteriness, feeding problems, and floppiness, amongst others. The baby showed no such symptoms, and the client did not want her baby subjected to a blood test for no reason. Furthermore, initial treatment for low blood sugars is regular feeding; we knew the baby had received a long recent breast feed and was alert and well. Therefore, apart from ticking a box, what was to be gained from taking blood from the baby?

[Readers wanting to know more about neonatal hypoglycaemia may find the following sources useful: World Health Organization review on Hypoglycemia of the newborn, 'GP Notebook guide to neonatal hypoglycaemia, and Babycentre UK's info for parents on low blood sugar in the newborn. ]

Thanks Virginia.

This story continues in the next post, on Midwifery Supervision and Independent Midwives, where we discuss Virginia's consultations with her SOM over this case.

Friday, 14 November 2008

Sharon's Story Part 1 - normal birth of a 12lb baby

Virginia originally published this story on the Kent Midwifery Practice website. It attracted my interest - who wouldn't be surprised to hear about the homebirth of a 12lb baby? The pregnancy and birth were straightforward, but the mother lost sufficient blood to be classified as having had a postpartum haemorrhage. The bleeding was stabilised at home and the mother remained in good condition throughout, but given the quantity of blood lost and size of the baby, she transferred to hospital for a check-up. When I read Virginia's original story, there were many more questions that I wanted to ask. Virginia has agreed to re-publish the story here, and to elaborate on some of the details. The original story is quoted below, in arial font. Questions and comments from me are in italics, and Virginia's additions to the original story are below them - Angela Horn.

Sharon's Story - an Unusual Normal Birth

I remember the first words I heard when Sharon rang me at the beginning of her pregnancy “I would like a home birth but my husband wouldn’t like it”. Well, I hear that a lot and feel that is only a minor hurdle to cross. If a woman really wants a home birth then getting husband on board is usually easy. I went to visit Sharon and Paul and gave them a DVD of another client of mine who had recently been featured on the Home Birth diaries series on the Discovery Channel. I chatted to them about the safety of home birth, risk factors and Sharon’s previous 3 hospital births.
Sharon and Paul felt that the births of their first two daughters were OK, although medicalised with induction of labour, continuous monitoring, episiotomies, managed third stage etc. However, the birth of their last daughter and then the poor treatment they received during a late miscarriage made them lose their faith and belief in the local NHS maternity services.

Sharon had birthed 3 big babies; the largest was the second baby at 9lb 13oz. The third baby had been induced at 37 weeks following a diagnosis of polyhydramnios and an estimated weight of nearly 10 lbs. The actual weight at birth was 9lbs. There had never been any diagnosis of diabetes or any other maternal or fetal problems.

This client had a history of polyhydramnios in a previous pregnancy.
Was an explanation ever found for that?

No explanation was ever found for the polyhydramnios in the previous pregnancy. It was classified as mild and therefore standard recommendation is that it is treated with expectant management.

However her last pregnancy was not treated with expectant management the client had been induced at 37 weeks. Effectively that baby could well have been 5 weeks early and suffered from respiratory distress syndrome however the client had been led to believe her baby was at real serious risk and that she had no choice. Induction of labour is not without risk. The client found the experience traumatic and therefore did not want to take that route with this pregnancy unless a clear benefit to her baby and/or herself could be demonstrated. She employed me to respect her choices and be honest with her.

This pregnancy never received a confirmed diagnosis of polyhydramnios. She had an upper-end of normal amniotic fluid index.
Back to the story:

We deduced that Sharon therefore grew big babies as normal for her. We decided that we would expect a big baby and not be concerned. Easier said than done during the first trimester!!

Editorial note: Your conclusion was that big babies were 'normal' for Sharon - as a lay person I assume that means that no medical problems were ever found, Sharon and her babies were healthy, so it wasn't the case that her babies were big because of gestational diabetes or anything else 'wrong' - it was just their growth potential.
Back to the story:

All went well. Ultrasound scans and routine bloods all showed a normal pregnancy. Sharon had some episodes of dizziness that were unrelated to anything.

Virginia, do you mean the dizziness was unrelated to anything in the pregnancy?
I mean that she did not have low haemoglobin or blood pressure, no ear infections, other infections etc so we put it down to a “pregnancy ailment” as all the usual explanations have been eliminated. We know women sometimes feel symptoms that will eventually go and have no underlying reason. Woman can have vaso-vagal episodes; I have looked after many who have (I also had them). Dizziness is a common pregnancy complaint and it would not normally be referred to a doctor unless it was severe or chronic.
Sharon's observations and haemoglobin all remained normal and the dizziness stopped with rest. I continued to advise her about diet and encouraged her to reduce her carb intake and increase her protein, calcium vitamins etc.We had hours and hours of discussion. Sharon had so many questions. We discussed every aspect of normal and abnormal birth. We discussed the whys and wherefores, the if and might be of every test and possible happening imaginable. We discussed the medical model of care, the history of childbirth even evolution and natural selection. Sharon was taking an anatomy and physiology course and so the physiology of birth was of great interest to her. Sharon was like a sponge and soaked up everything we discussed. I never at any time felt that Sharon was not making a truly informed choice about any aspect of her care.At 34 weeks I concluded that once again Sharon was growing a large baby and had gallons of liquor on board. The baby was also breech.
We discussed a scan and other investigations and Sharon declined as she wanted to stay away from the hospital as much as possible in order not to “open a can of worms” (her words) as had happened before.

I asked my partner Kay to visit Sharon at 36 weeks to assess presentation and overall health. I had always visited Sharon in the calmness of morning when the children were at school however Kay’s visit was in the evening on a particular stressful day. It was not surprising therefore that Kay found Sharon with an elevated blood pressure. She was also unsure of the presentation and therefore a referral was made to the local hospital.

While at the hospital Sharon had blood taken to assess for pre-eclampsia, as we expected.

If you expected this, why wasn't blood taken beforehand?

That would be just plain silly as she was going to the hospital. Why would one take blood prior to transferring to hospital? In this situation it is standard for blood to be taken at the hospital. We have blood forms and bottles for some trusts but we cover about 7 different hospitals and each has its own different protocols, so there was nothing to be gained by taking the blood before arrival.

Did you do a urine test at the same time as the raised BP was found?

Yes, of course, we always test urine at antenatal appointments, and in this situation, as with all her other tests, no abnormalities were detected.

However [the hospital midwives] also had her previous history and did a blood glucose test [for gestational diabetes] which was normal.

Did Sharon have any earlier glucose tests this pregnancy?

She was tested for glycosuria (glucose in the urine) at every antenatal visit. [urine analysis in the first two trimesters is a valuable screening tool for women at risk of developing gestational diabetes - (Gribble RK, et al. The value of urine screening for glucose at each prenatal visit. Obstet Gynecol 1995;86: 405-10.) ] She had never shown any glucose. In previous pregnancies she had routine glucose blood testing and all had been negative. She was reducing carbs and so I felt no reason to suggest a glucose tolerence test, especially given the research concerng the test's unreliability (Enkin 2000). Moreover, Sharon declined the test.

Sharon had taken our notes with her and so the midwife who cared for her could read them and was well aware of the amount of discussion we had over the previous weeks. Despite this midwife felt the need to shroud wave and talk about the risks of big babies and advise against a home birth. She said that babies who have large volumes of liquor needed to be in hospital in order to be suctioned. In fact she went on so much that in the end Paul had to tell her to be quiet as she was upsetting his wife!

I happened to call the hospital to find out how Sharon was and the midwife caring for her spoke to me. She said that Sharon’s bloods were normal but they had advised her to stay as she was “tightening”. I think I laughed and said I hardly think that was a reason to keep a woman in hospital, especially in view of the fact that she was having a home birth and it was probably Braxton Hicks contractions anyway.

The midwife then went on to tell me she had looked up Sharon’s history and between baby 1 and baby 2 an incidental swab had detected group B strep and therefore they recommend a hospital birth with IV antibiotics. I quoted the RCOG Green Top guidelines to her that this was not a risk factor and said Sharon had not had IV antibiotics during her last labour.

Later Sharon told me that the same midwife had tried to undermine her confidence in me by asking Sharon if “her midwife” knew what to do if her baby’s shoulders got stuck. She also scared them about cord prolapse.
She “informed" Sharon and Paul that I practice without insurance.

The insurance issue is something I discuss at the consultation visit long before I book clients and so they were fully aware of all the issues [- of course they didn't need to be 'informed' about this - they already knew].

I was very offended by the midwife's comments and angry at her scaremongering. I wrote to her asking for an explanation, quoted our Code of Conduct about respecting our colleagues and asked for an apology. I did not get an answer.

Why were you so offended by this midwife's comments?

Because she had the client's notes and could see, if she read them, that Sharon had discussed all of these issues in detail with me. I felt that this 'shroud-waving' approach was coercive and hostile, and was not taking into account the woman's full medical history, or her individual circumstances.

The Midwives' Rules state that:

A midwife..
  • Must make sure the needs of the woman or baby are the primary focus
    of her practice
  • Should work in partnership with the woman and her family
  • Should enable the woman to make decisions about her care based on
    her individual needs, by discussing matters fully with her
  • Should respect the woman’s right to refuse any advice given

Generally I am fortunate to have an excellent working relationship with local NHS midwives, but in this case I had a personal history with this particular midwife and I felt that this influenced the way she approached my client. On reflection, this probably also affected the way I reacted to her comments.

Sharon stayed in overnight and had a scan the next day. The baby was cephalic and an estimated weight showed between 8-9 lbs. Her blood pressure settled and she came home. She was asked to return for a consultant assessment and GTT test, which she declined.

She accepted a repeat scan one week later which estimated the fetal weight as between 9-10lbs. They also diagnosed polyhydramnios. No surprise there then! The baby was cephalic with the head deep in the pelvis. The Sonographer concluded no abnormality seen to account for the increased fluid. A second opinion agreed and concluded that it was probably due to the size of the baby alone.

You say Sharon had 'gallons of liquor' in this pregnancy. Did that worry you?
-When I said she had gallons of water I was not saying it in a negative manner, rather an observation and ever mindful of the audience of women I was writing for. I would suggest that any midwife who knew a woman had previously birthed large babies would expect this one also to be large and therefore also have plenty of water around the baby. The two go hand-in-hand. Just as you would expect a larger placenta for a larger baby.

I did not prepare for the birth any differently based on my clinical findings of “gallons of water”. It was at 34 weeks when I said there was “gallons of water” It was later at 37 that an NHS scan suggested polyhydramnios. The client, on my advice, went for a private scan for a second opinion. I suggested the repeat scan as despite the word “polyhydramnios” being written on the scan report, it was contradictory - the measurement was below the usual threshold for polyhydramnios. MILD Polyhydramnios, calling for expectant management, is defined as a deepest pool of 8cm. This pregnancy showed a deepest pool of 7.5cm, hence my advice to seek a second opinion. The second opinion could find no problems.

Despite the reassurance that all was normal and despite me knowing that 40% of babies with shoulder dystocia are less than 4 kg, I could not stop all the shroud waving of that hospital visit having an effect on me and against my usual practice I suggested membrane sweeps prior to 40 weeks to encourage labour and planned to ask Kay to attend the birth.

What's the significance of 40% of shoulder dystocias being in babies under 4kg?

It means that we can’t presume that all big babies are a risk or that smaller babies are not; a midwife always needs to be alert to the possibility of shoulder dystocia. It also means that most large babies DO NOT have shoulder dystocia. There are other risk factors for shoulder dystocia such as recumbent position, oxytocin augmentation and assisted delivery, so it is even more important that a woman with a risk factor avoid those things.

The RCOG Green-Top Guideline on Shoulder Dystocia (Guideline No. 42December 2005) says:

"The large majority of infants with a birth weight of >=4500 g do not develop shoulder dystocia and, equally importantly, 48% of incidences of shoulder dystocia occur in infants with a birth weight less than 4000 g."

What training have you had in management of shoulder dystocia? Have you ever had to put it to use?

I have regular training in the management of shoulder dystocia. Independent midwives are not exempt from updating their practice or from Supervision. At Kent Midwifery Practice we are luckily very supported by our local trust, and are invited to all emergency skill drill training days.

Shoulder dystocia, although very rare, is a life-threatening emergency for baby. Emergencies in labour is something I discuss with women in the antenatal period and I have even been seen to lie on the floor and demonstrate the position I would quickly ask the woman to adopt should a problem occur, much to the amusement of some. However, a shoulder dystocia is dealt with in the same manner no matter where the woman gives birth - hospital or home. I have dealt with shoulder dystocia at home on one occasion. It was rectified using the procedures I am trained in and the baby was fine. It was an unexpected situation. It has not occurred during the births of the biggest babies I have attended, when I most anticipated it.

This baby was predicted to be about 9-10lbs by scan, so the predicted size was larger than average, but not enormous given Sharon's past history. Why did you recommended membrane sweeps prior to 40 weeks?

I do not recommend membrane sweeps as a matter of course, rather than on an individual basis. During discussions I raise it as an option as per NICE guidelines on induction of labour. It is important we use the ”think ahead philosophy” and put an action plan in place if there are any doubts or niggles. Of course there were issues and things to discuss in this pregnancy and the story tells of hours and hours of that discussion, but when I wrote up the original story for my website, it was just a summary. The medical model definition of 'normal' is much narrower than the evidence-based definition. We know that many women who are categorised as high-risk come to no harm at all; that's the nature of 'risk', after all.

In the NHS they have to apply guidelines for large populations of women; the practitioners may not have time to spend hours investigating each client's history and preferences, and working out her individual risk profile. It is much quicker to tick a box saying 'large baby' than it is to investigate whether the risks which are increased for large babies, are actually increased in this case. However, I have the time to care for women as individuals, apply the evidence to her, including, and prioritising, her informed choices.

It is very hard for women, and midwives, not to be influenced by the “what if " syndrome. Doctors usually work to this rationale. They see a compromised baby following a long labour and they worry that every long labour will produce a compromised baby, yet there is no evidence it is the case.

I resist that way of thinking most of the time. There is a quote from Denis Walsh [in Evidence-Based Care for Normal Labour and Birth- A guide for Midwives (2007)], that I try to adhere to, “The ability to not necessarily adjust one’s care because of a sub-optimal outcome takes experience and a supportive environment”

I have confidence that, in the vast majority of times, nature does a better job than mankind, not the other way round. My logical, confident brain was saying “we have found no abnormality, therefore we can presume normal, this woman has had big babies before, so can have another big baby”

If the average size baby is 8lbs then it is obvious the range is from 6-10 lbs yet the medical model of care would have women believe that a 10lb baby is a huge baby and IS therefore a high risk regardless of other factors. I did not want any of these considerations to impact on the woman’s chosen plan of care. The longer she was pregnant, the longer the considerations had potential to impact on how we all approached the labour. Even in a very straightforward pregnancy with the most confident of women they start getting outside pressure from care givers, magazines, friends, family etc to be induced once they are past 40 weeks and that pressure increases with every day. I did not want that to be added to the equation.

The evidence suggests membrane sweeps at or around term reduces the incidence of formal induction. In this instance I thought that a membrane sweep was a consideration to prevent a post-term pregnancy adding to the equation.

So were you worried about the fluid or the size?

I was not worried either about the fluid or the size. I thought the scan was about right; on my clinical findings I guessed around 10lbs and she had birthed big babies before. As for the fluid, well, the head was deep in the pelvis so there was no concern regarding the mechanics of it. Although a percentage of babies with increased fluid have abnormalities, most do not and this was one of them as far as we knew. The scan demonstrated that the liquor level was below the thresholds for polyhydramnios, both for the single deepest pool and the highest recommended AFI [amniotic fluid index].

Why aren't you in favour of routine vaginal examinations?

Vaginal examinations are an intervention in normal labour. There is no evidence that they should be done routinely. I do perform vaginal examinations if I think the findings will help to plan the care of the woman, change the plan, improve the care, or that the information I will receive cannot be obtained in another way.

Vaginal examinations are not without risk. They can introduce infection, cause disappointment for the woman if she is not too far dilated, accidentally rupture membranes, which in turn increases risk to the baby of infection and heart rate anomalies, or allow the midwife to see meconium which maybe merely due to a term, healthy baby but could cause worry and a change of plan.

On this occasion I had done a membrane sweep, feeling a head deep in the pelvis, the client had recent scans and I was confident in my palpations. I had no reason to think there was anything other than a vertex presentation. In my professional opinion there were no health benefits to doing a vaginal examination. The only reason for doing one in this situation would be to determine her progress in labour, but it would be unreliable. The information I would have received could be obtained by waiting. Progress in a multip can not be determined by a vaginal examination as a woman could be 4cm dilated one minute and her baby born 10 minutes later.

On this occasion I examined the client at her request. She wanted to be reassured labour was underway and this was her experience in past labours. Without all the “issues” I may have been more encouraging in telling her to wait and discouraging the vaginal examination; I rarely perform them on multips and definitely not just to assess progress as it just doesn’t work.

Many a story has been heard of a women having been examined and told she had a while to go then immediately gave birth to her baby. There is always a chance that a midwife could get caught out and the presentation be different to that she had felt it was, or was on a previous occasion, but again I go back to that wonderful quote by Denis Walsh.
NB Readers may also be interested in this article questioning the value of routine VEs, by Chris Warren - Invaders of Privacy - originally published in Midwifery Matters, Issue No. 81, Summer 1999

In this case, you did not do a VE for 5 hours after the waters had broken. Clearly you must have been sure that there was no cord prolapse, but for the non-midwives reading, can you explain how you'd know this without doing a VE?

The membranes ruptured before I had arrived. The fetal heart rate was normal when I arrived, the baby active since the membranes ruptured, and so cord prolapse could be eliminated. Using eliminating cord prolapse as a rationale to perfom a vaginal examination is very old-fashioned and outdated. It is an intervention that has the potential to cause more harm than good. Moreover, this case was low-risk for cord prolapse because the head was deeply engaged. If a head is deeply in the pelvis then it is unlikely there is room for a cord to slide out. Even more so with a big baby.

[Editorial note: the RCOG Guidelines on Umbilical Cord Prolapse state that:
"With spontaneous rupture of membranes in the presence of a normal fetal heart rate patterns and the absence of risk factors for cord prolapse, routine vaginal examination is not indicated if the liquor is clear."

There were no risk factors for cord prolapse in this case, as polyhydramnios had been excluded, the head was deeply engaged and the baby large. The most important risk factors for cord prolapse are a poor fit between the presenting part and the pelvis, allowing the cord to slip down past the presenting part.]

Sharon laboured normally and well. She asked me to examine her after 5 hours and again against my usual practice, I agreed. Normally I would reassure women that this was an intervention unproven in its benefits, but that shroud kept rearing its ugly head and influencing my practice.

Sharon was 8 cms and the head was low. A couple of hours later and Sharon was pushing. The head was large and Sharon was having difficulty pushing it out underwater and so I suggested she stood up for gravity to help. This was all it took and the head was born. The body was born with the next contraction with absolute ease. However, because she was now standing in the pool I had to lean over the pool to catch the baby. As the baby rotated I called Kay closer to help I said “don’t worry - the shoulders are free; I just need help in case I drop it”! Both of us caught this huge beautiful baby girl and passed her to her brave confident mum.
The story does not end there.

Apart from the third stage, which we'll discuss later, was there anything difficult about this birth?

There were no problems whatsoever with this labour or the birth of the baby. The client pushed her baby out with no problems whatsoever.

Thanks Virginia. We'll continue the story about the third stage and beyond in a separate post, followed by a discussion of Supervision of Independent Midwives.

Tuesday, 11 November 2008

I was reflecting on a reflection earlier on and I condsidered the word "passion". I was describing my comitment to midwifery and said if I lost the passion then it would be time to leave. The definition of the word passin is "strong powerful emotion like love joy anger and hatred". Well yes, I do love midwifery and it does bring me joy, but can those both be achieved without involving the others? I don't like the other negative word; I don't like me when I am angry or anyone else for that matter and I certainly would not agree that I hate anyone. So do my displays of passion ever come across to others as anger? I hope not. But maybe love and joy and anger and hatred all are interwoven.

I want to expereince the joy of helping women to achieve the best possible childbirth experience. Because it is amazing to see HER joy. I want to feel powerful because I have empowered HER, not that I have claimed power over her. Maybe, just maybe, when that feeling is threatened it makes me feel angry. I can't remember feeling angry but I do remember feeling passionate. Or maybe that is the same thing.

Monday, 10 November 2008


Congratulations to Lesley who had a lovely baby boy this week. We were never quite sure if she was going to go ahead with her plan of a natural home birth and no intervention until 2 weeks prior to labour starting. Lesley had a low-lying placenta that stayed in the lower segment till almost term then moved out of the way over the course of a week. Definitely a case where the scan caused worry than peace of mind... Or was it? The placenta was anterior and on the left. But that is where baby should lay isn't it? Babies face their placenta don't they? yes! So now we know we have a baby laying on the right and therefore if we agree with optimal fetal positioning then this little one is more likely to turn posterior.

On day of labour memranes ruptured prior to labour starting and yes, as we thought, baby was posterior and laying on the right. Lovely quick and straightforward labour as baby was small and therefore deep in the pelvis, despite the wider dimensions of a posterior presentation. However, a long second stage while waiting for baby to rotate. Eventually we had a relaxed transfer to hospital. Lesley walked in fully dressed with her handbag over her arm looking as less like a woman fully dilated than you can get. The very helpful NHS staff were surprised I am sure to see us arrive all smiles and relaxed. The result was a ventouse birth but a very happy mum and baby none the less. So ok we did have a few unnecessary concerns re the low placenta such as will or won't it move, but at least we were prepared for the OP labour and Lesley had someone (thing) firmly to blame.....she is composing a complaint letter to her placenta as I write.....

We want to give you free midwifery care!

Although Independent Midwives have chosen to work outside of the NHS there is currently a National, Government-supported campaign to make independent midwifery FREE to all women. Local Primary Care Trusts have the authority to commission an independent midwife to care for women under the NHS. If we can raise awareness of this possibility, and of the demand for it in your area, then maybe one day all women will have access to a personalised midwifery service.

So if you would like to be able to choose your midwife, get to know and trust her, have plenty of time during appointments and know she will be with you when you give birth in the place of your choice FREE, please fill in our online form. It's a letter to the Chief Executive of the Primary Care Trust, asking them to commission the services of local independent midwives who offer individualised, woman-focussed care. Once you've filled in the form, including your address, we'll forward it to your local Trust.

Introduction from Virginia Howes

Welcome to the Kent Midwifery Practice blog. Kent Midwifery Practice is a partnership of independent midwives, Virginia Howes and Kay Hardie. You can read more about us on the Kent Midwifery Practice website.

We are Independent Midwives who practise in Kent and South-East London. An Independent Midwife is a fully qualified midwife who works in a self-employed capacity, outside the NHS. Like NHS midwives, we are closely regulated and supervised (our supervisors are NHS Supervisors of Midwives), but unlike most NHS midwives, we can provide one-to-one care for a woman throughout her pregnancy and birth.

We'll be using this blog to muse on various pregnancy and birth issues which our clients ask about, and which we thought other people might find useful. We'll also use it to keep friends up-to-date with news about our practice.