Reflections: life as an on-call midwife

Right now my head space is completely caught up in midwifery and work.  I have two clients who are 'over due' (I will address the EDD in another post) and heading into week 42 and beyond  and this is taking energy and focus in keeping them positive and myself positive as we wait for their baby's.

I try to pretend that I am not 'on-call' and live my life as normally as possible, but it can be difficult. Recently I have turned down dinner dates, nights out with friends, cancelled last minute arrangements that have been in the diary for ages and this is not because I am at a birth, but in-case I am called.   Never quite being 100% sure if you will be called out in the middle of the night and needing to be on the ball means that if you are feeling a bit tired or a bit run down the priority has to be rest.  I may not get the luxury of catching up from a late night the following morning!

I know that not all Independent Midwives feel like this and sometimes I truly can and do live my life normally, but when I hit a busy period, or I am having to support a slightly more complex client, it can take it's toll.

I wrote about life-on call in 2013, so I revisited it today to remind me why it works, how to make it work and why overall it is a blessing.  Here it is again for you to enjoy - and for me to remind myself why I work in this way.  In the meantime I am lining up the wine for when these babies finally arrive!

Enjoy x

From March 2013: Life 'on-call' - making it work

I have worked on call since October 2007; I have taken periods off, I've had periods where I have been on my knees, I have missed some family birthdays, I have even missed a family break.  There have been times I have totally resented it (and even tried to side-step for a bit), however the freedom to manage my working life, the autonomy I have as a midwife, the joy of seeing a family grow as you support the mother and empower her, outweighs the days when being 'on-call' can feel too much.

Working Hours
Developing my own self-imposed 'working times' was one of the first things I had to learn: initially I didn't do this as I was just so excited to provide the care I was offering.  What I quickly learnt was that not having my own 'boundaries' made me tired and resentful.  So now, I never work Sundays unless I am at a birth or it is early postnatal days; Sundays is family day, TV day, reading day; I won't answer texts (unless urgent) or check facebook / emails or make routine appointments.  I stipulate this to clients at booking and I have found that most women fully respect this.  My working 'hours' are 8am - 8pm, and only women in labour or urgent issues get my attention.  I home educate so most of my appointments are late in the afternoon so I can be there for my family.

Switching-Off
This is a real skill that takes time to develop; early in my IM career if a woman was 'imminent', getting to sleep was a problem.  What I have learnt in my time on-call is interesting; if I have not been called by 10pm, then I am very unlikely to be called out in the middle of the night.  I may get an early morning call, or a late evening call, but, in almost 6 years and caring for over 50 women, I have only been called out in the middle of the night a few times.  So if I go to bed without a call, I feel quite confident that I will get a full-nights sleep.

I have also learnt to tell women the days that are really inconvenient to me.... always spoken light-heartedly and with a smile, but since doing this women seem less likely to birth on those days.  I put it down the Oxytocin Factor - if they are worried about me not being there they release adrenaline and don't labour!  I only do this for really important things, like family birthdays and so forth - and of course I will be there if the baby decides otherwise anyway!

Having a Social Life
This was something else I struggled with; frightened to make commitments in case I got 'the call'.  Now, I just live life 'as usual'; I tend to drive myself places so I have the car if needed, women are asked to let me know if they think things are 'happening' so I can get home / sort my family/ make a decision about whether to go or not.  Generally, I will stay close-ish to home.  My family are really supportive and don't tend to mind too much if I can't make something; they do of-course have times when they feel the pressure of my work, but because there is so much time when I am available, around and participating, they get over it quickly.

Friends also know that sometimes I will cancel things last minute - but I guess knowing their friend is attending a birth must seem quite cool.  They certainly like to hear the birth story later!

Drinking is of course a bit of a no-no; turning up pissed to a birth might not be the safest way of practising.  I do have the occasional small glass of wine, and I like to make up for it when I am 'off-call'; personally I think my liver enjoys the time off.  And it saves me money.

The 'best-bits'
Supporting women and knowing what is important to them; not having to 'quickly' read notes and get to know the woman and her 'preferences'; practising 'hands-off' autonomous midwifery; managing my workload (choosing my hours outside of births); drinking tea and laughing with clients; continuity of care; taking my children to meet the new baby; wearing my own clothes (silly, but I hate tunics - so 'official'); being my own boss; lie-ins - no early shifts for me!; feeling proud of what I do; meeting fellow IM's and sharing stories and skills; meeting students - and learning from them as they do from me; having time with my family when I choose to; not waiting for the 'off-duty' to come out; catching babies with inquisitive assistants.......

The list is end-less.  Working this way is not always perfect, and there may be times in my life when working within the NHS will be the right thing at that time and having 'set' hours will be what I need.  Until that time, I will choose to work in this way.

So I hope this answers the question for you - about what it's really like..... and maybe it might help you answer the question would you work as a self-employed midwife?

angela xx

A week in the life

This week has been a very special week for me as an IM, and I was very honoured and privileged to receive third place in the BJM Community Midwife of the Year awards.

It was a spectacular evening hosted by the British Journal of Midwifery and a real highlight in the midwifery year; a time when midwives from all arenas can be acknowledged for all the hard work they do - and a wonderful opportunity to wash of the placenta and booby milk, get dressed up, and let our hair down!

Being an independent midwife is hard work; there is an awful lot that goes on behind the scenes and being on call 24/7 is not always easy.  It is however incredibly rewarding, and after heading up to collect my certificate on Monday night, I was reminded of some of the really hard times over the past few years when IMUK worked hard to retain independent midwifery and the right for women to choose.  During that time, I made a 'Week in the Life' video to use at an IMUK open day to highlight the work we do and the way we do it.  I am really pleased to share this video with you now:

I love being a midwife (mostly) and do feel very privileged to work in this way.  I am not sure that being on-call will be right for me forever, and I do grow weary of it at times.  However, I think that probably applies to many of the different midwifery avenues that are out there: any job that gives of yourself can lead to burn out and fatigue - which is why it is so important that we look after ourselves - and are looked after (Jeremy Hunt take note).

So thank you BJM for my award, thank you women for sharing your lives with me, and thank you to everyone who supported the campaign to save IM's and kept us going!

angela xx

"Midwives are best placed to make a real difference in the woman's overall experience - and I am privileged when I get invited in by the family to provide that care"

Angela Horler 

The Midwife's Bookshelf: Waterbirth

Currently on my bedside table  Water Birth

Most hospitals now offer water immersion and waterbirth as an option for women. The hospital I trained at even has one available for women to use on its consultant-led labour ward (although I have to say that I hope it is being used more now than it was when I was a student...!). Waterbirth was introduced to the UK in the 1980s, and we have learnt more and more about the benefits of labouring and giving birth in water since then. I am currently reading Milli Hill's new book on the subject, which is an absolute delight to read whether you are a midwife or a pregnant woman considering the use of water in labour. It is made up of stories, many from women who birthed their babies in water, but it also includes some other perspectives: an interesting one for me was a 13-year-old describing her experience of being present at the home waterbirth of her baby sister. All of the stories convey a sense of the birth pool as being a 'protected space' - a place where the labouring woman is completely in control of her own body and experience.

Article of the week  Kathryn Kelly: Raising a quizzical eyebrow: the language of birth (Essentially MIDIRS, March 2015)

Not directly about waterbirth - but a very thought-provoking piece on the use of language in Essentially MIDIRS this month. The article identifies some common phrases and terms used by midwives and doctors which can affect the relationship between birth professional and pregnant/labouring woman - and in particular can subtly undermine a woman's belief in her own body. Seemingly innocent words such as 'allow' ("am I allowed to get in the pool yet?") , 'need' ("she needs an epidural") and 'just' ("I'm just going to break your waters") take control away from women and reinforce professional hegemony. I strive to ensure that the language I use is supportive and not authoritarian, but this article is a little reminder to be aware of the power of the words we choose.

From my personal library  Denis Walsh: Evidence and Skills for Normal Labour and Birth

This book is a must-have for any student or midwife. During my midwifery training, it gave me enough confidence to question certain practices which I knew to be non-evidence based and encouraged me to always question why something is (or isn't) being done. Denis Walsh looks at the available research on everything from place of birth and fetal heart monitoring to second stage rituals and care of the perineum. The evidence on each topic is discussed and appraised in simple terms which would make it easy for a layperson to understand - although it is aimed at midwives, I have lent this book to a few pregnant friends who have found it invaluable. The book includes a chapter on water immersion and waterbirth, and Walsh covers the therapeutic, physiological and psychosocial benefits of waterbirth before moving on to some very practical recommendations for practice.   

Which will you add to your midwifery collection?




Tami xx

North Surrey Midwives Tami and Angela are experienced in waterbirth, and provide birthing pools and liners for our clients to use should they choose a home waterbirth.

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

Sharing the Skills: Supporting birth without the use of vaginal examinations

I have struggled to write this particular post for the past week or so; do I reference, don't I reference. Am I trying to be the 'expert'?  Is this formal, informal.  Argh - round and round I go!  Until a colleague reminded me this is a BLOG post, meaning it's an informal piece of my opinion (see disclaimer thingy).    and breathe........

I can still remember the first Vaginal Examination (VE) I preformed as a student midwife.  I remember two things mainly:

1. I had no idea what on earth I was feeling!

2. That this was a very invasive procedure.

Many units have a 4-hour guideline for VEs to asses the progress of labour; this routine assessment has no real evidence to support it and is still of unproven value in routine midwifery care, despite being recommended by NICE (it is important to acknowledge, that NICE states women should be offered a VE).  VE's can be a very helpful tool in understanding a labour when perhaps midwifery intervention may support the woman in keeping her labour normal, when clarity around labour progress is appropriate, and / or if it will affect the plan of care.  When used as the marker for progress in labour only, VEs can cloud the midwives understanding of what is happening in the woman's birth story and cause the woman to doubt her own body.

The art of Midwifery is the 'big picture', and it is through many different signs that a midwife may recognise where a woman is in her labour.  This awareness is not 'taught', but learnt: learnt from the women as you observe undisturbed birth, learnt from sitting and quietly absorbing the behaviours unfolding in front of you, and learnt from not starting from a place of 'knowing best'.  As a result of this, the thoughts below are not a 'check list' of progress in labour, simply prompts to help you consider the physiology of what may be unfolding before you.  Remember also that all women are different, and every woman and birth can unfold in a way that is unique for them.

Let us consider then, alternative ways of recognising a labour that is progressing:

How low can you go?
When I was a student midwife, I heard the wonderful Jane Evans speak on Breech birth.  In her talk, she described how women get 'closer the the ground' as their labour progressed.  In labour, as those powerful surges increase in intensity, the woman finds it harder to be upright and conserves her energy by moving into positions that bring her down - usually into the all fours, or leaning over a sofa etc.  As a guide, the closer she is to the ground and needs to stay 'grounded', the further along in her labour she is likely to be.

Those wonderful noises
Experienced midwives can often tell where a women is in a labour from those lovely noises she omits; Liz Nightingale wrote an excellent article in Midirs on noises in labour which is well worth getting your hands on. Women, under the influence of Oxytocin in labour, start to withdraw into themselves.  Talking and conversation dwindles (and so too should birth workers!), but the woman will naturally start to moan and groan through those surges; those noises come from deep within her and she has little control over them.

The 'purple' line
If you google this term you will find lots of excellent blogs reflecting on this phenomena, pictures on what you may see and so forth.  My favourite post is in Birth Without Fear which is beautifully written: just read that for a great explanation on the purple line.  I love the purple line; once you recognise it you can't fail to notice it.  Just wish bottoms came with a little gauge - you know, when it's this height the cervix is x-cms etc!

This is a woman who smiled
most of the way through her labour!

Sense of humour failure
When the woman is no longer smiling, then we are in serious business (except for those women who are having serene, orgasmic births - they smile a lot).  Humour can really help a woman in labour as it can ease tension.  If you follow her guide however, the more serious she becomes the less she may appreciate wise-crack jokes from her supporters, and the more likely her labour is advancing well.



It's all a bit sticky down here
Around 8-9 cms, women will discharge a sticky, blood-stained mucousy plug as the cervix really opens. Yay!  Even better still, as the cervix becomes fully open, the waters will spontaneously release if they have not done so already.  There is NO NEED to do an ARM if a women is 9 cms and membranes are intact (and yes I have seen midwives do this, because otherwise how will the baby get out?).

Cold Feet
As the uterus continues to work beautifully, the blood circulation will move more and more towards to uterus: this is why women get cold feet as labour progresses.  A German midwife (when I was a student) also taught me that the heat will move 'up the woman's' legs.  At around 5 cms, the heat will start from just above her knees, 8 cms the thighs feel cold, at 9cms, only a small amount of heat is left at the top of her thighs.  We used to have guessing games by gently placing a hand on the woman's thighs to see 'where she was'.  It doesn't always work, but is gentle and non-invasive.  Use the back of your hand to gently asses the coolness of the legs.

Pushing on through
Why, oh why, oh why on earth do some midwives feel the need to 'confirm' the onset of second stage with a VE?  Really?  As a woman moves into second stage, she will start to make grunting / expulsive noises.  These will intensify as the baby moves further down, triggering further expulsive urges.  The woman's body will start to 'open' as the rhombus lifts.  The purple line will be highly visible and prominent.  She will probably poop.  All of this will happen either quickly (as with the foetal ejection reflex), or for the vast majority of women, s-l-o-w-l-y!  Women can tell when they are 'moving' their baby and will often remark they can feel the baby moving down.  If after a period of time of strong expulsive urges, there are no external signs of descent, then a VE may be appropriate.  That time depends on the whole clinical picture.  And No, 10 minutes is not long enough.


There are many other ways of recognising progress in labour without the use of VEs (and please do share them); these are the ones I use to help me recognise that labour is progressing without needing me to 'do' anything other then keep the mother and baby safe and hold the space for the birth.  Observing the woman in a non-invasive way (i.e. not staring at her and 'drinking tea intelligently') normally enables the midwife to sense if something is not 'quite' right and provide the appropriate care to help the mother birth her baby as she needs to.  And this is usually herself.

Midwife angela 

“There is no other organ quite like the uterus. If men had such an organ they would brag about it. So should we” ― Ina May Gaskin

New Year Pop

A few months ago, a little add popped up on my computer.  I clicked it away without a thought.  A little later it popped up again; again, I clicked it away, thinking nothing of it other than it 'being annoying'.  A few days later, sure enough the advert appeared again.... and again.... and again.  I 'quickly' clicked them away and carried on with my work.  Slowly, over time, these adverts became a regular part of my day, and I stopped really thinking about them.  Just methodically removed them and carried on with my tasks: pop - click - pop - click - pop - click (getting the picture).  (If you are wondering what this has to do with midwifery - bare with me, it will make sense.)

Two weeks ago, my computer needed an overhaul; those annoying little ads had grown so much, that I could no longer log on to my blog (hence no posts for a while), I could not move on the internet without being directed to sites I did not wish to visit  (er, no I do not need Viagra thank you) and my working time at the computer ground to a halt.

Reflecting on this (and here is the midwifery link) made me think about how small interventions in midwifery practise have become a routine part of our care.  Let's take the vaginal examination (VE) for example; these are now so routine that we no longer even see them as an intervention, and yet, they can interfere so much in a woman's birth that they can slow and grind a labour down to a halt (see what I did there?).

As midwives, we are considered 'autonomous practitioners'; this means that we work to evidence base and to the woman's needs.  There is no evidence to support routine vaginal examinations and whilst they can help understand the progress in labour, most women find them invasive and unpleasant.  Encouraging the woman to 'pop' onto the bed, the 'quick' VE, the repeat of this process at routine intervals, in my opinion, slowly interferes with the midwives care and her understanding of 'normal' progress in labour, and most significantly affects the woman's trust in her body, until eventually the labour grinds to a halt and needs an overhaul (or caesarean) - just like my computer.

This year I have been blessed to attended 15 women in labour: only 6 of those women required a VE to support plans around their labour and birth.  I promised to 'share the skills' previously, but the problems with my computer jaded my work, distracted me from writing and prevented me for being 'with computer'.  Yet it took a real crisis before I addressed and faced up to the problem: it was just easier to keep pushing the problem away.  Sound familiar?

2013 has been a year of facing up to a huge problem: the demise of Independent Midwifery.  Over the past 12 months, I have been involved in the odious task of campaigning to save IMs, to save my livelihood, to save choice for women and to save a group of midwives who believe in true autonomy.  It was a problem I did not want to face up to: it is a problem that many midwives are not facing up to, and it is a problem that the Government does not wish to face (I think they hope we will all  just go away).

If midwifery is to remain a strong profession, then we need midwives to have the choice to work independently.  As we enter 2014, I feel optimistic and positive that this year will herald a change for Midwifery and that midwives will reclaim their profession.  I feel confident that I will be able to continue to practise in a way that supports women without the routine use of interventions, and that working in this way will not 'grind to a halt'.  And mostly, I look forward to not campaigning anymore - but rather to getting back to what I love most.  Being 'With Woman'.

What will your 2014 pop-up for you?