Shiney New Blog

I am so excited to feel my bloging fingers return to the keyboard, and am bursting with new ideas for midwifery and birth related posts!  It's been too long.....

I am planning to start 'what I have been reading' posts, sharing what's on my book shelves with you, as well as 'how to 'posts on midwifery skills (primarily aimed at students) and of course my usual reflections on current topics.

Speaking of which, we are in October.  October.... the impending end of Independent Midwifery as we know it.  Of course, as with all things in life, the goal posts have changed and the NMC confirmed this week that there is a delay in the implementation of the new legislation and we now have until February.  In the meantime, IMUK, who have been working incredibly hard over the summer months and have found a product that is a solution to the insurance fiasco, continues to beaver away at getting insurance in place long before that deadline (we very much hope that the dear DoH do their bit and help us on our way) .  You can keep up to date here.

Pretty knitted things

Exciting, turbulent, history changing times lay ahead; and it is down to the passionate and strong midwives and supporters that there is light at the end of the tunnel.  Women have always had a strong influence in the course of history; this year was the 100th anniversary of the death of Emily Davison, the suffragette who threw herself under a horse; I feel I am part of a modern suffragette movement (although I am not throwing myself under a horse), not one working to get the vote, but one to get a basic human right to know and choose your midwife as a normal part of the childbearing continuum.  I am a feminist - and rightly proud.  Okay, I am a knitting feminist, and rightly proud.  Okay, I am a knitting, mascara wearing, girl-who-likes-pretty things feminist, and rightly proud.

Mascara wearing midwife on a mission

Anyway world, watch out.  Or you may have a bunch of media wielding, modern suffragettes playing havoc with your his(her)story; and it might not be pretty or knitted.

angela x

Why I Campaign.....

Oh how I have missed blogging: I have so many ideas I want to share, so many thoughts I want to get down, so many words that need to be committed to the page.  I just don't have the time or space to do it at present..........

.....so instead, I recently made a 'vlog' - which I share with you now.  Hopefully this will help you see why blogging has had to slow for a bit; but hang in there with me - I will be back to blogging as soon as I can!

angela x

fear + loneliness = Brave?

I have often been told that I am 'brave' for choosing to be an Independent Midwife; I wrote about this a long time ago and can honestly say I have never felt brave, or really understood why fellow midwifery colleagues consider me such.  I am just a midwife, working to support women, some courageous and strong, some needing support to find their inner strength, but all who wish to have the bulk of their care outside of the NHS system, with a midwife they know and trust.

I attended a beautiful home birth this week; I was not anticipating to be the primary midwife, but the woman's own midwife was caught in Jury service and unable to attend. I gathered myself together and headed off to the birth - I knew the woman and her family having supported them as the second midwife with their first baby.  As always, I mentally prepared myself, and drew inner strength and calmness into my being.  I was not aware that I would be doing that many times in the course of the woman's labour..........

Birth works: if you follow my blog you will know that this belief is deep in my inner core.  BUT, and there is always a BUT in nature, sometimes birth changes and sometimes nature will challenge us, humble us and remind us that she is a force that we cannot always control, always predict, always guarantee.  After the baby made its way earth-side (a beautiful, calm, wonderful HVBAC), the woman's body was not (for whatever reason) willing to release the placenta; I was concerned.  Too much bleeding necessitated a decision to transfer; a serious maternal obstetric haemorrhage occurred,  a wonderful team of NHS staff worked very hard to save a very compromised mother.  And a very shaken midwife was left holding the baby...... until he was safely tucked back with his mother later on that day.

So, back to my 'bravery'; it was with a sudden clarity that I understood why people believe me to be brave - and it has nothing to do with me.  As I watched the team work around the woman (and I was in total awe of the NHS staff and so very, very grateful that when obstetric care was needed, we had access to it), as I supported her, reassured her, even prayed for her, I have never felt so alone in all my life; the safety net of the NHS is a strong one.    Perhaps this is the reason midwives do not challenge guidelines, or policies not based on evidence; perhaps this is why the vice on midwifery is so strong.  Not that I am brave, but because the 'safety' of working within the NHS is so strong - and watching that team, I think I understood why people would not want to 'risk' that.  Being the lone voice, choosing to leave that safety net, to be fully autonomous, to accept full accountability..... can be very lonely indeed.  The fear of loneliness is why people believe I am brave.

I am not 'brave' for choosing to be an Independent Midwife; it is a wonderful way of working.  It is 'the gold standard of care'.  It is rewarding, challenging, exciting, scary, bumpy, amazing, tiring.  It is working to keep birth normal - and safe. I am not brave...... but if more midwives were given the support to work outside of the NHS, if the government fully supported choice and continuity, if the RCM would acknowledge a group of midwives who work outside of the system, it might be a little less lonely.

angela xx

He who is brave is free. 

Lucius Annaeus Seneca 

Read more at http://www.brainyquote.com/quotes/quotes/l/luciusanna121145.html#vPE1uJcEvV29CUTm.99 

One Born Every Minute

Last night, for the first time in very, very long time, I sat and watched 'OBEM'.  It wasn't a concious choice - we had watched the great classic movie 'Stand by Me' (oh River Phoenix, what a loss) as a family, and when the DVD had finished the TV returned to OBEM just as it started.  And I was hooked; mesmerized; drawn-in and unable to move despite my intentions to get to bed as I am feeling quite unwell of late.  But there I was, one hour later, as the credits rolled.

There are lots of reasons I don't watch programmes such as this one; firstly, my family don't allow it.  They feel it's detrimental to my health as I am unable to watch without large amounts of steam coming from my ears.  Secondly, it reminds me of the fact that the way I practise as a midwife is at risk, and frankly the thought of returning to work in a large, consultant unit, fills me with dread and fear.

So what was wrong with last night's programme?  Let's start with the fact that both labours, both healthy, first time mothers, both considered 'low risk' (hate that phrase), ended with unnecessary intervention:

'Mother one' was already in early labour; as she was 12 days over, she requested to have her labour 'induced' and just get on with it.  "Good news", hails the midwife, "we can break your waters and get you going."  A birth that was starting physiologically is now having a helping hand with an intervention that brings it's own risks (which I did not see being discussed), or other options given (such as go home - you shouldn't be anywhere near a labour ward at present) and is presented to an audience of viewers as the norm (which it probably is on a consultant unit).  Mother one did give birth vaginally - on her back, epidural in-situ and an episiotomy.

'Mother two' arrives in spontaneous labour, but she stalls and after a few hours it is decided her labour must be accelerated.  And when I say decided, this was the conversation:
Midwife "You've been stuck at 4-5cms for a while, so I need to talk to the doctors to decide what to do"........  "The plan is the get you going and put a drip up to get some oomph behind those contractions".  Interesting use of language, a really great way of not demonstrating informed CHOICE and decision making - the mother was not even included in that, the midwife and doctor decided - and another birth that needed a 'helping hand'.  It was however really fantastic to see the mother using an 'alternative position' and standing as she birthed her baby.

After watching the programme I am now aware of several things: Midwives are in charge and know best; women are clearly malfunctioning when it comes to labour; physiological birth doesn't work.  I am so grateful to have had those points clarified and to recognise that it must be time to change my practice as I am very outdated in my beliefs that birth is normal; that labour has it's own rhythm; that women should be involved in all aspects of the decision making; that the amniotic sac provides a safe, protective barrier in labour; that vagina's are designed to stretch to birth a baby; that facilitating a safe, warm, quiet, environment aids progress in labour.  Thank you to the powers that be (insurance companies and eu regulations) that foolish midwives like myself, or like Virginia Howes need to be tamed and brought into line and that we are wrong.

I clearly am one of those 'born every minute' that needs to be reminded on prime-time TV that birth does not work and the NHS knows best.

angela x

Home Birth is for Hippies?

This was an original article I wrote a few years ago and felt it was relevant again.....

“I’m planning a Home Birth”. It amazes me that this simple, short statement can evoke such a torrent of emotion and be an area where people feel they have the right to comment on someone else’s choices; the phrase ‘you’re so brave’ springs to mind here. Yet without doubt, the discussions and thoughts around home birth bring to mind many powerful images, not least of ‘danger and emergency’, but for some, the image that the ‘sort of woman’ who may choose home birth, as being a slightly alternative, incense burning, ‘hippie’.

Home birth is not a new concept; home, since the time of (wo)man, has been the place where women birthed their babies. In the beginning, home was most likely to have been a sheltered cave, nestled on a hill-side somewhere, and over time has developed into the style of housing that we now know in the western world. Hospital as a place of birth however, is a fairly recent development in the time line of history and yet it has been culturally accepted as the safe place to give birth, even though study after study, report after report does not uphold this notion. Now, don’t get me wrong here; the advent of technology, obstetrics and the caesarean birth have played a hugely important role in making birth safe for both mother and baby – and we now experience very low rates of maternal and infant mortality and morbidity. However, it is not exclusively through birth taking place in hospital that has lowered these rates so significantly, but the development of excellent antenatal care, drugs for the prevention of haemorrhage and infection, and the development of health professionals’ skills in recognising and managing emergency situations.

In an article in ‘The Times’ newspaper (May 09), journalist Melanie Reid launched a scathing attack on women who had or were planning home births: she labelled them as spoilt and complacent, insinuating that intelligent women choose hospital birth, and only ‘sandal-wearing' women (the hippie word again?) would choose home birth.

True? – far from it;

Factual? – indeed not;

Emotive? – yes and yes again.

Ms Reid is not alone however in voicing her opinion, and this is part of the problem for women who are considering home birth – the emotion that decision causes, the myths around home birth and the presumption of ‘safety’ deter many women from pursuing, what is in fact, a very normal, very safe choice.

I had my third baby at home; it was a well-researched, informed, intelligent decision. I met some opposition along the way, but on the whole felt well supported and confident in this decision. No, it was not my ‘first baby’, but how I wish it had been! I had never truly considered home birth an option, after all I did not know anyone who had given birth at home. I had been born in hospital and I was not a sandal-wearing hippie. Why on earth would I want a home birth? Well after experiencing two less than positive hospital births, I felt instinctively that there had to be another way. And there was, and it was fantastic – hard work – but empowering, positive, and ‘uniquely normal’.

The home birth rate in the UK is around 2%, but in parts of the UK the home birth rate is a staggering 50%! In areas where the home birth rate exceeds the average, there are some telling trends in the way maternity care is delivered: midwives actively offer home birth throughout pregnancy and discuss it in an open, friendly manner; women share positive stories of their home birth experiences - giving other women confidence in their own ability to give birth; and women are attended at home, in labour, by a midwife (they often know) and make the final decision on the big day itself! This gives them the freedom to see how they are feeling and coping, knowing that they will be well supported by the midwife, by family and birth supporters, whatever their decision. I would challenge anyone to categorise all those women as hippies.

The DoH has aims to increase the home birth rates for women to experience real choice within maternity services; of course this is still to be delivered and is an ongoing issue for most women.   Following the inception of the NHS it took national campaigns to persuade women to give birth in hospital, needing continual reassurances of cleanliness (hospitals were previously associated with mortality due to infection – very different from now?), and the influential offer of 10 days rest and food. The stark reality in the UK at present is that hospital birth no longer comes with the benefit of complete rest – women are encouraged to leave as quickly as possible due to the high demand for beds (at home you get your own bed); NHS trusts are stretched to capacity with midwife shortages on the labour ward (at home you get your own midwife); and the caesarean section rate is spiralling out of control (planning a home birth halves the chance of you needing a caesarean section).

Hospital is the perfect place for giving birth for the woman who may need additional obstetric care, who may need paediatric care for her new baby or who may not have the support in place to have her baby at home – and no one ever seems to feel the need to comment on those decisions. Next time someone says to you “I’m planning a home birth”, take a closer look; I expect you will find a normal woman, making a normal choice, planning to have a normal birth in the perfect place for her. And not a ‘hippie’ in sight!

Placenta Possibilites

Smoothie anyone?

This morning I made myself my usual smoothie; rice milk (300mls), a banana and a handful of frozen blueberries.  As the blender whizzed my power drink, I was reminded of the workshop I attended last week on Placenta Remedies, facilitated by Lynnea Shrief from IPEN and organised by midwifery on-line.

I recently blogged on the third stage of labour, and felt it was time to update my knowledge on the choices that women have regarding their placentas; Placenta Encapsulation is something I have heard of, know vaguely about and have read briefly around, but I did not feel I had enough information to really talk to women about consuming their placenta and the perceived benefits of this.  I also felt I had to get over my own queasiness over the idea of eating what is often viewed as a waste product.

The workshop was really interesting; doulas, student midwives and aspiring midwives made up the group of interested women - I was the only midwife on this day, although Lynnea confirmed that midwives often attend the study day.  The morning looked at why women choose to consume their placenta, testimonials from women on the benefits and an exploration of mammals normal instinct to consume the placenta (and the really cool fact that the only land mammals who don't consume their placenta is the Camel!).  Testimonials from women included:

• increase in milk production
• reduced postnatal bleeding
• faster recovery
• more energy
• less depression

These all make sense when you consider that the placenta is a power-house of hormones and an iron-rich food source that has nourished and grown a baby for 9 months.  Lynnea was clear that there is not huge scientific evidence to support placenta consumption, but as she rightly pointed out, there is no money to be earned from women eating their own products so no-one will be putting funding towards an RCT on this area!

Later on in the day we learnt about safe storage of placentas, infection control and reduction, and then had a 'hands-on 'session making placenta tinctures and essences...... and Smoothies.  We made a 'berry placenta smoothie' which looked just like my breakfast this morning.  Apparently it tastes good too! (Placenta Encapsulation is studied at a separate workshop).

As a midwife, I feel much more informed to offer this choice to client, and more importantly, I am convinced that a smoothie would benefit my clients significantly.  Of course, women need to be open to this choice, and within our culture where eating offal is considered 'yukky', this might prove a challenge!  I am however, looking forward to sharing, exploring and learning more about this with the women I care for, and to writing about this further and would be interested to hear your comments on placenta consumption.

angela x

Shhh..... I practise physiological third stage

The third stage of labour feels like a topic that is discussed in secret amongst student midwives and midwives; whispered 'what do you do?' questions and the caginess around what one actually 'does' is tangible.

Practice around third stage came up in a recent conversation I was having, and I felt it was time this subject was explored, caginess put aside, and clarity about the NORMALness of a physiological third stage heralded high and loud.

As a student midwife, I was clear about the skills I wanted to learn; I was also very fortunate to have a mentor who was skilled in facilitating physiological birth, and another mentor whose trust in me enabled us to learn together about the third stage.  I was, however, unique in being one of only a handful of students who qualified having gained this knowledge and developed this skill: most only knew how to 'manage' the delivery of the placenta.  I know this is still happening and frankly I find it worrying.

It is normal within the hospital setting for managed third stage to occur; a reason cited to me is that it takes 'too long' to wait for the placenta.

Q1. How long does a physiological third stage take? 

20 minutes is about average, maybe 30, very rarely an hour or more.  If you assume it will take around 20 minutes, even in a busy unit, this should still be the time that the mother and baby are bonding and shouldn't be 'hassled'.  Plenty of time therefore for the midwife to be quietly and attentively watching.

 Q2.  What about the risk of haemorrhage?

Firstly, in a physiological birth, the risk of haemorrhage is relatively low  (I could reference this, but am choosing to use innate midwifery knowledge here).  The clue in this statement is physiological birth, i.e. spontaneous onset, contractions regular and rhythmic, no pharmacological pain relief (okay, a little gas and air is fine), spontaneous explusive urges, no interference with the mother-baby dyad.  In other words, with absolutely no intervention - just a mother working with her body, oxytocin flowing, adrenalin reduced, trust and patience high. 

Okay, so it doesn't take as long as you might have thought, and mum might not bleed to death, but what about the shift leader who is knocking on the door asking if the placenta is out?  What about the assumption from the woman that she will have the injection?  If the shift leader is knocking, it is our job as midwives to politely, but firmly inform them that we will let them know if we have any concerns, we will update them as and when is appropriate, but will not accept people knocking on the door (you could point out that this is like trying to have a pooh with people hanging around outside, and maybe they would not be comfortable with that?).  Midwifery is an autonomous profession, you have a duty of care to the woman, not the shift leader.

Q3. What about informed choice?

It is currently bang on trend for women to choose 'delayed cord clamping'; therefore half the work is done for you.  You know the benefits of a physiological third stage - if you have supported her in a physiological birth, surely you are just continuing with that?  I'm going to put my neck out here and say why does she need to make a choice?  That would mean you are questioning her body, and getting her thinking brain to respond.  Remember, at this point its all about the oxytocin - and quiet, watchful waiting.

 In The Midwife's Labour and Birth Handbook there is a very good chapter on third stage and a clear explanation of what a midwife 'should' and 'shouldn't' be doing; Elizabeth Davis also offers a clear summary in her beautiful Heart and Hands: A Midwife's Guide to Pregnancy and Birth book (definitely recommend that one).

Q4. What do you do?

I myself have learnt FIVE key skills to supporting a physiological third stage :

1. Keep the woman warm after birth: if she is cold, it affects the physiology of the placental separation

2. Keep the room quiet: too much excitement raises adrenaline and impacts on uterine contractions

3.  Watch carefully and listen fully: you will see the tell-tale trickle of separation and mum normally notices stomach pains

4.  Use gravity to aid delivery: the mother will normally push the placena out herself.  However, toilets are magical here; help the mother to the loo, she will pee and pass the placenta all at once.  Never fails if time is passing! 

5. Do not Fear it - IT WORKS!

“Nothing in life is to be feared. It is only to be understood. “~Marie Curie

What thoughts do you have to share around the third stage?

angela xx

Choice?

Following the FFB Screening, I was going to write a blog about choice and choice for women, however The Mule has written a great blog piece on this, so I am not really feeling the need to re-write that.  So I started thinking about choice for midwives, and choice in midwifery.  Or lack of it.

When I started my midwifery journey, I entered it with this fierce passion and a strong belief that I was going to 'change midwifery services'.  Three years of training knocked most of that out of me, and moving into Independent Midwifery enabled me to start practising the 'midwifery' that I had read and  dreamed about.  My choice to be an Independent Midwife is under threat; insurance issues and EU rulings have seen to that, and within 12 months if there is not a solution found, it seems, that the only choice that may be open to me is to return to the NHS.

Apparently, as a registered Midwife, I am an autonomous practitioner; I am accountable for my actions, the advice I give, the women in my care; I have to maintain my knowledge base and demonstrate that I keep up-to-date; I have to attend study days that are relevant to my sphere of practice; I have to work a certain amount of clinical hours each year; and I have to keep up my registration (and pay my fees) with the NMC.  In short, in order to say 'I am a midwife', I have to work bloody hard at it!  And yet, and yet, my right to choose how to work is not being recognised.  The only midwifery (potentially) that will be 'legitimate' will be within the system of the NHS, and whilst there are amazing and wonderful NHS midwives out there, it's 'the system' that scares me.

So, what about being an autonomous practitioner?  Well, it seems that the rules that govern me as a midwife don't quite fit into the NHS system; I would not be free to choose my working hours; I would not be free to choose who I care for; I would not be free to choose the study days I attend (unless the 'off-duty' enables that); I would not be free to choose what I wear (please - tunics?  talk about putting a barrier between woman and midwife!); policies and protocols would dictate my practice - not the evidence and to support women in choices that would challenge these would, I fear, be a daily battle.    Burn-out in the NHS is high, midwives work long hours with little or no breaks, morale is low, staffing issues create stresses on midwives trying to juggle 2 -3 women at once. Choice?  I don't think so.

If women are going to get the care they deserve (based on the evidence and one-to-one care) and have the chance to 'reclaim birth' then it is essential that midwifery remains an autonomous profession, that midwives have the right to choose how they practice (remember, we are already well-governed), and that all maternity provision is not handed over to 'the system'.

Loosing Independent Midwifery will not just affect women; it has the potential to change midwifery in a way that I can not even bare to think about, it has the potential to remove the woman from the focus of care, and to remove any form of choice - whether that choice is a home-birth, an epidural, a caesarean section..........

What can you do about it?  Tell every woman, every person, everybody that you talk to about Independent Midwives; share this page on facebook, email to it to 10 people you know, and ask them to forward it to another 10 people, and another 10 people, and another 10......  tell them about the brilliant NHS midwives who cared for you, who held your hand, and then tell them that if Independent Midwives disappear, so too might that midwife who 'was so lovely' to you.  Because, if you don't tell people, and we disappear, the real tragedy will be that one day, choice will simply not exist for women or for midwives.

A young girl was walking along a beach upon which thousands of starfish had been washed up during a terrible storm. When she came to each starfish, she would pick it up, and throw it back into the ocean. People watched her with amusement.

 

She had been doing this for some time when a man approached her and said, “Little girl, why are you doing this? Look at this beach! You can’t save all these starfish. You can’t begin to make a difference!”

 

The girl seemed crushed, suddenly deflated. But after a few moments, she bent down, picked up another starfish, and hurled it as far as she could into the ocean. Then she looked up at the man and replied,

 

“Well, I made a difference to that one!”