Sharing the Skills: The Pinard

I have two expectations when a student comes to spend some time with me:

1. That they have read Ina May

2. That they are prepared to learn how to use a Pinard (if they are not already practised)

When we think of all the technological advancements that have been made in pregnancy and childbirth, it is often assumed that the beautiful Pinard Trumpet is better placed way back in the 'olden times', but this little piece of midwifery equipment is (and should be) a staple part of midwifery practise - where-ever that is taking place.

Firstly, lets look at what National Guidance says about the Pinard: intermittent auscultation is the national recommendation for the 'low-risk' (that's another blog in itself) woman in labour.  In these guidelines it recommends the use of a Pinard or a doppler (sonic-aid).  It also states that when there is a concern with a low base-rate foetal heart on continuous monitoring, it is important to ascertain that it is not the maternal heart that is being recorded.  The Pinard is essential in that clinical scenario is you can not pick-up the maternal hear beat when using one.  So, the expectation is that a midwife should know how to use a Pinard.

Secondly, let us think about the routine use of a doppler (sonic-aid) to auscultate the baby's heart rate.  The little sonic-aid is a wondrous invention; it enables midwives to hear that rhythmical heart rate, reassuring that all is well, and enables parents to hear their baby's heart from very early in pregnancy.  I always find it completely heart-melting the first time parents hear that sound and they are full of bare emotion.  BUT, when we use a doppler, we send a high-wave frequency through the uterus that resonates with the baby (again, that's another blog post).  Although National Guidance no longer recommends routine auscultation at an antenatal appointment, many mothers find this a reassuring and exciting element of their care.  Around 2 years ago, as I reflected on my birth statistics, I realised that I had a relatively high number of 'compound presentation' births (this is where the baby is born with it's hands' up by its head).  Whilst this is not usually a problem, it can sometimes make birth a little longer or potentially cause more perineal trauma for mum.  I pondered

A foetoscope

on this for a while, and recalled a very wise, older midwife once saying that she felt we had more compound presentations since the introduction of routine sonic-aid use, and perhaps the baby's were "'covering their ears from the high frequency sound".  So I started my own little trial and I no longer use the sonic-aid in the last trimester or pregnancy: instead I show the women my little Pinard (they love it!) and use a foetoscope (see picture) so that they too can listen to their baby.  And yes, in that time I have had NO babies with hands up by their heads.  Maybe a coincidence?  But one I am not tempted to test!

How to use a Pinard
You can only really use a Pinard or fetoscope successfully from around 28 weeks of pregnancy - before this the baby is just too small and you have to place the Pinard directly over the baby's heart or shoulder, so you need to be able to palpate where the baby is lying.  Antenatally, its relatively easy to use once you've become skilled at palpation and 'listening', so as a student midwife this is the best time to hone your skills!  It is usually easier to start with a plastic Pinard and progress to a wooden one.  The ARM sell beautiful beech Pinards.

Using a pinard in labour can however be a little trickier -especially if the woman is planning to use water in labour, unless you are prepared to wear a get-up like this!   The expectation will be for the woman to lift her bump in and out of the water which can be very disruptive to the flow of her labour!  A water-proof sonic aid is a God-send as you can easily monitor her baby's well-being and work around her by reaching down into the pool and under her bump as unobtrusively as possible.



Sara Wickham has written a lovely explanation on how to use a Pinard (saves me re-writing it!) and Kay Hardie, from Kent Independent Midwives has made an excellent you-tube video on how to use a Pinard.  Read and watch to learn - and then practice, practice practice until you are confident and able to use one!

The Pinard Trumpet may be an 'old fashioned' peice of equipment, but its place is just as relevant in 21st century midwifery as it ever was.  What do you think?


 angela xx

"Knowledge is of no value unless you put it into practice."

Anton Chekov 

Reflections: Postnatal Care

Tami

This post is by Tami: Tami joins Angela at North Surrey Midwives and this is her first blog post.  






So first things first, I am not Angela! I am Angela's practice partner, Tami, and I joined North Surrey Midwives last year as an independent midwife. It's been a year now since I spent a week living and working with Angela and getting to know what being an independent midwife (IM) was all about, and this seems like a good time to reflect on everything I have learnt during that time. I've tried to write this blog a few times now though and it seems I've already learnt enough to fill a book (a project for the future perhaps!?) so I am going to focus my first post on postnatal care. This may seem like a strange choice; I mean, I attended few home births during my midwifery training and have attended many more during this first year of independent practice, surely I should want to write about that! Well, I do. But interestingly, I have found that the biggest learning curve for me has been caring for my independent clients in the first 28 days after their baby is born.

Working within the NHS setting on a community team, we saw most women three times postnatally: the first visit the day after they returned home from hospital (so usually day 1 or 2 for most women), the second visit on day 5 when we would do the bloodspot screening test, and finally a visit on day 10 to discharge the woman and her baby to the care of the health visitor. I never thought much of the fact that we didn't routinely see women on day 3 or 4, despite knowing that these days are often the most difficult for new mothers.

A woman's milk usually 'comes in' around day 3, sometimes causing engorgement and her temperature to go up a bit, and it is around this time that the 'baby blues' can take hold. The first few days with a new baby are a bit of a whirl wind, and day 3 can be (this isn't always the case of course) the day that exhaustion really hits you - loving care, support and reassurance are vital during these days. It wasn't until I became an IM that I really saw all of this though - and learnt how vital postnatal care really is. I saw changes in my usually strong, outgoing clients - they were suddenly uncertain about following their instincts as they had done antenatally and during their labours.

At first I felt like I should have some intelligent solutions for them, something they could do or take to relieve the exhaustion and anxiety they might be feeling. But I soon came to realise that the most important thing is being able to talk about these feelings and be reassured that they are entirely normal at this stage after having a baby. Whether this is the first baby or the fourth, having someone come over for a cup of tea (but don't worry we make our own!!) and a good chat about everything you are feeling during those first few days really can and does make a difference. When I initially

met and worked with Angela, I remember being a bit shocked at her telling a client whose new baby was cluster-feeding every evening (ie. feeding more frequently than usual) to put a box-set on, put her feet up and have a glass of wine and settle in for the evening with her baby skin-to-skin. What was she doing - promoting wine while breastfeeding!?! Well, I visited the same woman with Angela a few days later and the change in her was immediately apparent: reassured that this behaviour was normal for her baby and then having a plan to cope with it (plus a little stress relief via the wine) made all the difference for her. And I have given that advice a few times myself now with similar effects!

One of the biggest learning curves when making the move from an NHS setting to independent midwifery has been not relying on hospital protocols to guide practice, but instead using the best evidence, collective wisdom of the very experienced midwives I work with, parent's intuition and the full clinical picture to make decisions about care provided. For me, I have felt this difference most in the postnatal period, and particularly around expected weight gain of the newborn. Most hospital policies state that a baby who has lost more than 10% of her birth weight at day 5 should be transferred back into hospital for further checks. But is this really the best course of action for a baby that appears clinically well in every other sense (plenty of wet and dirty nappies, pink, active, alert, waking for feeds and perfectly latched when breastfeeding) and a mum with an absolute fear of hospitals? Transferring mum and baby into hospital in this case could potentially make the problem worse: mum will be anxious which will affect her milk supply, and baby may undergo invasive tests

which could disrupt breastfeeding. In this case, lots of skin to skin contact and intensive support with breastfeeding and expressing, while keeping a close eye on the baby in the following days meant that mum and baby could stay at home and the baby quickly began to put weight on. For this baby, it was 'normal' to lose a bit more weight than usual in the first few days of life. For another baby it might not be - and this is the challenge of independent practice compared to working from guidelines.

Although I didn't expect postnatal care to be an area in which I still had so much to learn, I have really enjoyed gaining all of this amazing knowledge from both the mums and babies I have cared for, and the midwives I have worked with over the past year. Midwifery is a career in which you are continually learning, and so I am sure this is just the beginning!

Tami x

"We mother the mother after birth."

 unknown