Kent Midwifery Practice

Taking the baby

2012-02-10T09:52:00.000-08:00

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.

Reflection on a normal birth

2012-02-02T04:21:00.000-08:00

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 membranes.....in 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!!

Labour Ward Rituals

2012-01-07T08:40:00.000-08:00

Why oh why does nothing ever change in the medical dominatedworld of midwifery? Maybe it is changing but it is kept hidden from me and Isee little change in the 13 years I have been away from the labour roomrituals. Is there ever going to be a time when I accompany women to hospitalwhen they need to go for assistance but they are then treated with dignity andthe experience is one of joy ( and good women centred practice) in allrespects?....

Recently I took a client in to hospital with suspected earlylabour at 34 weeks. I went home as nothing much was going on but 24 hours laterwas called back by my client as all of a sudden baby was on its way fast.

When I arrived on thelabour ward I walked into the brightest lit room you have ever seen, every mainlight was on but also a spotlight was beaming down onto a visible head. Twomale paediatricians were in the room arms crossed leaning against the window a bored look on their faces.....doing nothing of course just waiting therewatching the woman in her most private time. There was also a doctor presentand 2 midwives, another person keptpopping in and out but I, and I am sure also my clients, have no idea who itwas. 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 anythingI saw, it would have been inappropriate and far too confrontational, but itreally was awful.

The woman was in typical labour ward position, propped up onher back (this was a woman who wasplanning a home birth and wanted everything natural) . She was being encouragedto use the valsalver manoeuvre of sustained breath holding and pulling back onher thighs. This manoeuvre has been demonstrated to be dangerous practice by theWorld Health Organisation and has been labelled “practice be abandoned” as itcan cause fetal distress.

One midwife was standing next to me and I was able towhisper to her " please consider not cutting the cord if this baby is wellas the evidence is clear that it is beneficial especially for prematurebabies" of course I was ignored and when a healthy pink crying baby wasborn a few minutes later the blood rich cord was instantly clamped, cut, thebaby 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 wascutting the cord all the blood spurted all over her face and arms! She thoughtit quite funny, I thought it quite sad! Shame the blood didn’t spurt into thebaby! If they were passing baby to mumanyway why couldn't they have left the cord? It was what mum wanted and shouldbe common practice...its even in NICE now!

I helped mum to unwrap baby and the baby commenced to nuzzleat the breast, I covered them both and that was where I hoped they would atleast remain, however after about 5 minutes the baby was taken from his motherfor a paediatrician to look at him. You could see he was healthy just bylooking at him in mums arms! All the Doc did was listen to his heart (yes itwas beating he had been pink and crying and breathing for a good while now)andthen the midwife commenced to put a nappy on him (did mum want this? of course the answer is that she didnt knowfor she didn’t ask.... did she even stop to think that the parenst may have looked forward tobeing the first ones to dress their baby?) She then wrapped him AGAIN in 2 towels and finally gave him back to mum withno mention of skin to skin or feeding. As I see it this is nothing more thanlabour ward ritual, this taking of babyfor a paediatrician to look at, it happens at Caesarean sections too yet amidwife is completely able to assess at birth instantly if a baby needs adoctor 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 beautifullyand instantly. Why does this happen ?If I had not been there maybe the mumwould not have unwrapped the baby and would have continued to hold her heavilywrapped baby without attempting to feed or certainly not as early and quicklyas she did. At that point with him being born early, I considered skin to skinand feeding was the most important thing for that mother and child yet themidwives began immediately to pester the mother to stop feeding and hand himover to weigh and get prophylactic antibiotics started. The only thing wrongwith this baby was he was 6 weeks early. He was a good weight, over well over5lb and it was a spontaneous quick labour in a healthy mother. It seems sobizarre that there was such a rush to get drugs into him that he may not needbut that they were more than happy to deny him the blood and feeding that hedid need.

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

http://www.bbc.co.uk/news/health-15736550

Ok on with the struggle to make changes….

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

2012-01-04T11:58:00.000-08:00

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

2012-01-04T11:28:00.000-08:00

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.

Are gloves always necessary during birth?

2011-11-29T01:19:00.002-08:00

As I have nothing to hide about my practice and am confident in what I do and the care I give, I agreed to take part in HOME BIRTH DIARIES which, in my opinion, is the best woman centred and positive programme about pregnancy and birth on the telly....

In comparison to it I hang my head in shame at some birth programs, especially ones that take pride in admitting they are demonstrating conveyor belt like care and that one born every program is more like one extracted every minute. However we wont go there in too much detail but I may just remind you of those type of birth shows after I have had my say....

Back to Home Birth Diaries and in particular the episode showing Sadie, a women from Rochester having her 2nd baby. The birth in that episode is clear, close up and beautiful. A baby being born just how it should be. I also happen to know that it ranks as one of Discovery Health's and viewers favorites yet I have come in for criticism from some viewers, those of which are midwives themselves. I am used to criticism, being an independent midwife, and usually do not rise to it for the reasons I began this blog with, but this particular criticism has been mentioned to me twice in a few days so I thought I would address it.

Why do health professionals wear gloves?

We do so to protect ourselves and our clients against infections and blood born diseases.

I do not, however wear gloves to catch babies......shock horror ? please let me explain.

I do not "deliver" babies or have hands on other than if help is needed or if I have to be invasive in any way. Should that type of assistance be needed I always wear gloves, if I need to perform vaginal examinations I wear gloves, during the third stage of labour I wear gloves, to clear up any mess of any description I wear gloves BUT if a baby is just falling into my hands, as in Sadies birth, I take OFF my gloves just prior to catching the baby. A healthy, clean (maybe a bit wet) baby falls into my hands....what is the difference than when I hold the baby an hour later?

There is no risk AT ALL to a mother, baby or myself if my hands are clean, not cut or have any abrasions and I am aware of both the mother and my own HIV and Hepatitis B status. There is more chance of the latex gloves causing an allergic reaction to the baby. Furthermore how nice that baby is welcomed into the warm, clean hands of, if it cant be its own mother or father, a midwife who so well known to the family that she feels part OF the family.

Please my fellow colleagues and critics do not compare what I do to with what goes on in hospitals where strangers care for strangers, unless you are comparing my outcomes to those outcomes....in 13 years of practicing the way I do I have caused or caught no infections. My clients only have the ones they left hospitals with....My way of working is called individualised care...try it you may like it.

funny breastfeeding video

2011-06-19T01:51:00.000-07:00

Well 7 months of hard work is over and now its just the waiting and seeing. Just before christmas last year a group of us including my good friend Bernie from www.mybirthtv.com thought about making a breastfeeding video. Not an educational one, (not to say they are not amazing because they all are), but a funny, cheeky one that will provoke attention and get the subject talked about. We were looking for a funny modern topical idea and it all gradually came together.....I have written the whole story about the making of it and why etc already so wont go into long detail again but if you want you can read it here. Anyway the video is on You Tube and the response is pretty amazing...both ways....I would say 99% positive but with a few people just not "getting it". Glamorous women saying "we are proud of who we are, proud of what we do, come and do it too its fun", not taking themselves too seriously, poking fun at themselves even and all for a very good reason....feeding our babies in the best possible way. We had lots of mums turn up on the day of filming all looking beautiful in their own ways, all willing to feed on camera...I say to everyone who took part ....very well done...didnt we have fun?
watch it here

breast is always

2011-02-10T02:11:00.000-08:00

Shovels at the ready!

2011-02-10T01:53:00.000-08:00

Restocked my birth box and checked all my equipment again over the weekend. Have some additional items that I was carrying around with me but don't need now, thank heavens. A shovel and a piece of carpet - cardboard works equally well though!

Heavy snow seems to be a fairly routine occurance now but nightmareish for us midwives and pregnant women.

If the snow returns though the stuff will be back in my car. And winter tyres fitted next season I think.

Back sleeping for pregnancy

2009-09-27T06:25:00.000-07:00

I am repeatedly hearing women state that they must not sleep on their backs and are really concerned because they wake up on their back and have somehow harmed their unborn baby. I have been meaning to write about this for sometime but the straw that broke the camels back for me was a couple of days ago when a new client told me her previous midwife had told her not to back sleep or she could suffocate her baby!
Goodness me how on earth did our human race survive this treacherous journey called pregnancy and child birth? In one breathe we tell women they are not ill but going through a life event then we give them a whole list of what they must and must not do, places they must not go, things they must not eat and now which way to even sleep!
Rest assured dear sisters you can sleep how ever you feel most comfortable and you will do yourself or your baby no harm at all. In fact truth be known the worry of trying to sleep in a position you are self imposing on your body and the subsequent lack of sleep due to be less than comfortable will do you more harm.
On thinking long and hard I do believe that this myth has come about through a small grain of fact that has grown into huge Chinese whisper. In my opinion the myth has grown from the early days of dense paralysing epidurals and woman being left for hours alone in labour and on their backs.
It is true that there are huge oxygen carrying blood vessels in the lower back that if squashed by a heavy baby filled uterus did in the past lead to out of breath mothers who, due to the paralysis of an epidural were unable to move and the consequence was oxygen deprived babies. Once it was realised this was happening women were placed on their sides with a pillow wedged under them so they did not roll onto their backs, following administration of an epidural block.
These days epidurals are nowhere near so dense and most woman can move themselves around in the bed once it has been administered and can easy change position with minimal help.
As for a non labouring pregnant women, well that is whole different story because if she does happen to be squashing those all important blood vessels the first thing she will feel is a lack of oxygen which will lead to her feeling breathless and she will wake up and move! The baby will not suffer in any way. The human race has mechanisms to help us survive and will not allow us quietly suffocate ourselves (or our growing babies) in our sleep.
So sleep, pregnant women, however it suits your comfort.

Aquanatal class a huge success

2009-03-12T02:45:00.000-07:00

Another success for Kent Midwifery Practice as last week saw the launch of our new Aquanatal classes. Having spent the previous couple of months learning exercise in water for pregnant women then making posters, distributing them , compiling health forms, registers, dance routines, looking around at venues and talking to pool managers.... phew! I was exhausted just thinking about the actual day. I then started to worry if any pregnant women would even turn up!
I had promised a free lunch as well as the first class free but that meant unless I was fully booked at every session I would make a loss. While I had not intended making a profit I certainly did not want to be actually funding the whole venture too.
A couple of weeks prior to launch I had interest and received some cheques in the post to pre book a group of sessions. I had been told by other midwives who run classes around the country that in their experience initially 6-8 women may come but that word of mouth will make the class grow. By the night before I had 8 women already booked and paid for so I was feeling a bit optimistic.
D day arrived and off I went with my student midwife daughter as my biggest support on the day. Women started to arrive at 10.30 as requested, to complete the health check forms and sort out any last minute fees.

By the start of the class to my utter amazement we had only one less than full capacity of women and I was ecstatic, 14 women turned up and as I was driving to the class another rang and booked for next week. So we now have full capacity for the next 4 weeks.

As for the actual class? Well it was great, we had loads of fun and no-one drowned!!
I remembered my routine and all the women said they loved it. After the class we all sat down with a nice cool drink and lunch and had an antenatal discussion.

The women told me they loved the breathing exercise and references to what will happen in labour as well as the discussion around food and what constitutes a good pregnancy diet.

This week I have music to add to the aquanatal moves and I am planning to talk about the progress of labour.......

I am an Inventor.....Presenting the HOWES birth Mirror

2009-02-05T00:33:00.000-08:00

I am feeling quite proud of myself this morning for two reason. One reason is that I have invented a new product for my profession and it feels like it is going be a success.

Having released the details of my lovely new Howes birth mirror I sold some straight away!

Of course some of my dear colleagues had already ordered one from me, but I was never quite sure they thought it as great as I did and weren't just ordering one to be supportive (or they felt sorry for me), but to get orders from the public via my website Kent Midwifery Practice , and even an enquiry from the USA, had me jumping around like a teenager.

The second reason I feel proud of myself is that the hours, days and weeks I have spent recently learning about public relations have paid off. I know that because, having released the details of the Howes birth mirror through a prestigious press release wire distribution service, I not only got great feedback from them that I had written and presented it professionally, I also had several calls from journalists and publications saying they want to do a feature on me and my new invention. WOW!!!!!

You may wonder why that is important to me? Well, I was voted press secretary of Independent Midwives UK a couple of years ago and I want to fill my obligation appropriately in order that my colleagues can have full confidence in me.

The job has not been without heartache, worry, humiliation and sleepless nights over the last year and at times I wanted to retire and just stick to what I know I am best at (being a mother and a midwife) but, as the old saying goes, "if you stick your head above the parapet you get shot at" and, using the words of another strong woman, "I am not for turning".

So, after a short spell of feeling ridiculously sorry for myself after some public midwife-bashing, I dusted down and took myself off to meet a lovely man by the name of Richard Milton, journalist and writer of 25 years, who runs a PR training course in London. I spent a ridiculous amount of money for a self employed, moderately-paid midwife, but every single penny was worth it. He taught me so much about dealing with the press and getting your message to the right audience.

Midwives can really get a raw deal - most of us are too busy with midwifery to play the politics game, unlike our doctor colleagues, whose skills in debate and satirising their opponents are honed during their training.

This could be because midwifery as a profession - both independent midwives and those working in the NHS - is not well represented in the media.
Things that midwives say - and write - can be misunderstood and misrepresented, and as a profession maybe we all need to work on putting our case more clearly - and carefully!

Now I just have to learn about marketing and selling........

whose risk?

2009-01-23T07:35:00.000-08:00

When my Kent Midwifery Practice blog colleague Eleanor told me the story of her client and their perception of risk, I thought it a really good subject for a new post. Then I was approached by a midwife who is researching the subject and looking at it from a midwife's perception and how she considers risk. I have now agreed to be part of her research and have been thinking about it a lot myself.

Risk and how, as humans, we view risk has been the subject of many studies around countless topics and is a subjective judgement made depending on the characteristics and severity of a risk. The influence of the media on the perception of risk is a clear demonstration of how something which is very low risk but is considered an emotive subject could actually cause a red herring effect. That is demonstrated by the whole "stranger danger " subject , making parents almost paranoid to let their children out of sight as they think the risk is too great.

What could be a more emotive subject to a woman than the baby she is carrying? Given a choice all women would eliminate any risk from pregnancy and childbirth but especially any risk to her child. I cannot think of one mother who I have cared for who given the choice of saving her unborn or new baby's life or taking her own life, would not have prioritised her baby.

One mother said to me "Virginia they could have taken my arm if my baby was in trouble". This woman was recovering from a nasty infected episiotomy which was performed in haste and panic by medical staff who believed her baby's heart had stopped abruptly prior to his birth. However what had really happened was the heart monitor had stopped abruptly.

So thinking about that I considered how mothers think about risk. Can we consider birth to ever be without risk? No, we cannot, but that is not to say birth is a "risky business" unless we consider that life is a risky business or driving our car is a risky business. Both those things we do on a daily basis without giving it any thought whatsoever. Who makes the decision on what is an acceptable risk around all the issues of childbirth and what is not? It should be the mother of course, but it rarely is.

We are just about there in the UK with regards to the safety of homebirth. Studies which demonstrate homebirth as a safe option for most women have just about been accepted by our medical colleagues [1, 2 - refs below]. Except for the most obstinate practitioners who refuse to keep updated despite the evidence having been around for a decade or more, most obstetricians will support a homebirth as long as a woman does not have any risk factors.

Yet all women, even the ones considered as low-risk, have risk factors - for a low-risk woman has a 2.7% chance of an unexpected complication occurring in labour [3] A complication that may need urgent assistance and delay could result in the problem becoming compounded. That is considered a low risk.

Let's consider a woman who has a nuchal scan to screen for a baby to be affected with trisomy 21 (Downs Syndrome). She has a 1:250 or 0.4% risk of her baby being affected and is told that is low. Who made that decision? Some women would consider it a no-risk situation; indeed some do and refuse to have the screen at all.

The number of babies that die unexpectedly following a prolonged pregnancy further than 42 weeks is approximately 2:1000 or 0.2% [4.] but that is considered so high a risk that 20% of UK women have labour induced [5], and that number of women are included in the 1:4 or 25% of women that make up the caesarean section rate in the UK.

When she has a section, the woman faces up to sixteen times times the risk of death, and ten times the risk of emergency hysterectomy, than a woman giving birth vaginally [6]. Yet a woman who plans a homebirth roughly halves her risk of ending up with a caesarean and all the risks it involves, compared to someone of the same risk level planning a hospital birth [2] She also roughly halves her risk of her baby being born in poor condition [2] - so why are some risks considered more acceptable to take than others?

Once the woman has had the caesarean section she is told she now has a 1:200 or 0.5% risk of a scar dehiscence which is considered high-risk and the medical profesion would be highly unlikely to support a decision for a home birth. However that number includes induced and augmented labour and benign dehiscence that is seen at elective caesarean section - most studies find a greatly reduced risk of rupture in spontaneous-onset labours which are not augmented with oxytocin. Maybe if figures were quoted for both actively-managed VBAC labours and for spontaneous, unaugmented VBAC labours, the risk perception would change and the place of birth and labour management would be more open to discussion

The most bizarre I think in the calculation of risk is the 1:10,000 or 0.01% of vitamin K deficiency bleeding. It is recommended that mothers agree to injecting a substance into all newborns because they are, apparently, fundamentally flawed and do not have normal levels of vitamin K at birth. Who says what is abnormal and what is that abnormality measured against? Sara Wickham considers that statistics for Vitamin K are the same risk as wearing a hard hat every time you walk outside your front door in case a roof slate falls off and hits you on the head. [ 7.] I think maybe a little more research is needed in relation to cost-effectiveness if that is the case. There has never been a follow-up study on children whose parents refused vit K. There could be a huge saving for our cash-strapped health service if the Vitamin K bill was reduced.

Key findings from major studies [8]such as Starr, were that the experts are not necessarily any better at estimating risk than lay people. Experts were often overconfident in the exactness of their estimates. I accept that the Starr study may be a very old piece of research but it surely is very relevant in our modern nanny-like society. Starr also found that people will accept risks 1,000 greater if they are voluntary than if they are involuntary. Information if presented in an unbiased way will assist women in their individual perception of risk and may even play a part in women taking responsibility for their choices. It may even reduce the ever growing litigation bill for medical negligence.....

At Kent Midwifery Practice we are clear that the mother is the only person who can decide what risks are acceptable for her family. It is not acceptable for professionals to say that lay people should not make their own decisions because they think that only they, the professionals, understand risk; nobody will care more about the risk to an unborn child than its mother.

The job of the midwife, whether independent or NHS, is to give the woman the information she needs, and to help her to understand how different risks apply to her. We all take risks; it is the pregnant women who should decide which risks she will take.

REFERENCES[1] British Medical Journal No 7068 Vol 313, 23 November 1996[2] Home Births - The report of the 1994 Confidential Enquiry by the National Birthday Trust Fundpub. The Parthenon Publishing Group, 1997. [3] Effective Care in Pregnancy and Childbirth, eds. Enkin, Keirse,Renfrew & Neilsen, 3rd Edition (published 2000, OUP), p360[1a] Chapter 38, section 6. "The probability of requiring an emergency CS for other acute conditions (fetal distress, cord prolapse or antepartum haemorrhage) in any woman giving birth is approximately 2.7%"]. [4] Menticoglou SM and Hall PF. Routine induction of labour at 41 weeks gestation: nonsensus consensus. BJOG 2002;109:485-91 [5] NICE Guidelines on Induction of Labour, July 2008, S1. : "In 2004–05, 19.8% of all deliveries in the UK were induced." [6] BMJ. 1998 Aug 15;317(7156):463-5. Should doctors perform an elective caesarean section on request? Maternal choice alone should not determine method of delivery. Amu O, Rajendran S, Bolaji II. [7] Wickham, S, Vitamin K - A flaw in the blueprint?, Midwifery Today, 2000; 56: 39-41. [8] Social Benefits versus Social Risks by Chauncey Starr, Science ,1969 .
2009/1/23 Virginia Howes <virginia@kentmidwiferypractice.co.uk>

Useful Phrases, by Mary Cronk MBE

2008-12-22T02:56:00.000-08:00

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.
"STOP THIS AT ONCE".
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.

Risk in Midwifery - who decides?

2008-11-30T01:03:00.000-08:00

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. -

Sharon's Story Part 3 - Supervision of Independent Midwives

2008-11-15T16:53:00.000-08:00

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

2008-11-15T16:00:00.001-08:00

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.

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

2008-11-14T08:28:00.000-08:00

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.

2008-11-11T05:12:00.000-08:00

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.

Lesley

2008-11-10T05:59:00.000-08:00

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!

2008-11-10T03:17:00.000-08:00

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

2008-11-10T03:01:00.000-08:00

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.