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 

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

but that's just silly!......

Last week, and with my home-educating mummy hat on, I ran a 'morning with a midwife' workshop.  12 bright eyed children aged between 9 and 15 arrived at my home for a two-hour interactive workshop.

We started of by covering the role of the midwife, and what kind if checks we do; they played with my sonic aid and listened to each others hear rate; they guessed if one of the mum's BP would be high or low, and they giggled as they 'explored' their own pelvis - finding their coccyx and poking around their bottoms!

Children are brilliant (well mostly brilliant, unless they are annoying or I am having a bad day), but on the whole brilliant.  They see things so clearly, and haven't been dis-illusioned by adult-hood, and are still naturally thinking out-side the box - this, I am delighted to say, made teaching them great fun.

After they had labelled up some large pregnancy charts, we looked at the physiology of how the cervix opens, how the baby descends through the vagina and how the baby rotates and fits (perfectly) through the pelvis.  Having tired of the poor messages passed to children (and adults) about birth, I used positive language: I talked about the intensity of birth, and how women cope really well with this and can rest between surges, I talked about how the baby is squeezed and 'cuddled' by the uterus with every surge, I talked about how the baby is pushed out and it feels like a huge urge to pooh!  They got it, and accepted it, and asked about it, and then there was this Eureka! moment: to help the children visualise the size and weight of a growing baby, I had created a basket with different items weighing approx weights at different gestation.  I had an orange for 20 weeks (200gms) and so forth, with the final weight of the basket about 3200g (7 1/2 pounds ish in old money).  Using the pelvis, I showed how easy it was for the orange to get through when the 'mummy' was kneeling or on all fours, then I turned the pelvis into semi-recumbent and......... the Orange just sat there.  Eureka!  

..."but that is just silly!  why would you do that?!....."

asked a 9 year old.  Why would you do that?  Why would a woman give birth in the most physiologically challenging position you could choose? Why would a woman shut her pelvis and work against gravity?  Why would we do something so silly?  Well if a 9 year old can get that, then why are the vast majority of women giving birth on their backs?  Why are student midwives qualifying having NOT supported women in 'alternative' (don't get me started on that phrase) positions? Why why why? 

One for Mr Marr!

I feel there are many reasons (sadly) why this continues; the medical mode of birth, the use of pharmacological pain relief, ease for the midwife, the images of birth that are portrayed in the media?  None of these of course make it OK, or acceptable, but I do think the latter is a huge influencing factor. It's almost as if women expect to birth in that position - the children did, as that is what they have seen - until shown otherwise.  So perhaps then, it is the Film and TV producers of the world we should be talking to?  Certainly, in the opening issue of Andrew Marrs' History of the World (a brilliant programme I might add) the ancient African homosapien is seen to birth in the 'typical' semi-recumbent position.  Historically, women birthed upright; using trees, kneeling, squatting to give birth; not sitting with their bums and vagina's in the dirt.  It would have been much cooler Mr Marrs if your production team had shown that!

Perhaps it's time to remind ourselves of the Wonderful Female Pelvis, to remind women, doctors, parents, teachers, children, and the Film Industry of how perfectly designed we are to birth and how women - when well supported - will adopt the 'alternatively brilliant' birth positions that aid birth naturally.  Perhaps it's time for a new slogan:

'don't take it lying down!'..... 'knees for ease!......'using the (all) fours of gravity!......  suggestions please!

and here is a little something to share: (catch it here too http://www.youtube.com/watch?v=MswFqXdOq2U)

Enjoy!

angela xx

Feel the fear............. and do it anyway

This week has seen the launch of the Freedom For Birth DVD; over 1000 hostings of the film, across 17 countries were simultaneously held on Thursday 20th.  I was quite late to the proceedings in terms of organising, but I had a small, yet perfectly formed (!) group, attend my home on Thursday evening (including my 13 year daughter).

Within a few minutes of the start of the film, tissues had to be shared.  It was a hard and sad film to watch, to see how far some country's will go to control birth and to 'manage' birthing women; a violation of human rights.

In my small (but perfectly formed) group, we spent time after the film discussing, sharing ideas and thoughts, trying to understand where we could perhaps make a difference, what we could do on a local level, how we could encourage women to take charge of their own choices and bodies, and how we can protect midwifery in its own right.  The thread - as in the film - that kept emerging, was the FEAR that prevails in and around birth; of course, this is not a new topic in childbirth, fear, for a variety of reasons, has been part of childbirth for millennia, but we seemed to have reached an all time high - from both women and health professionals.

So what exactly is it we are frightened off?  Trying to answer this question is like trying to capture moonlight in our hands; you can see it, it's in front of us shining like a beacon, yet it moves around, changes, and although it is can be bright as day and pulls us in many ways (even if not scientifically proven), moonlight is not tangible.

Following the evening, I invited a lovely third year student to come out with me.  This student should be counting down to the end of her training, but at the moment she is so disillusioned with her journey, she is not sure how she will make it through this final year.  This intelligent, questioning, reflective woman who is following her vocation and who clearly has the potential to become a 'with woman' midwife, may become another statistic of those students who don't make it to qualify.  We shall call this student Sophie:

Sophie accompanied me to a consultation with a couple who would like to book me as their midwife.  This professional, well-informed, capable couple have already made many decisions around their pregnancy, including choosing, amongst other things, not to have routine ultrasound.  Sophie and I spent time reflecting the consultation; she wondered if I worried about attending a birth where no ultrasound could reassure me baby was 'well'; she wondered if I worried that if a women who chose not to have routine bloods might be anaemic; she wondered if I worried that a women might refuse to take clinical advice I offered.  She did a lot a worrying.  Underneath all this however, it was apparent that Sophie's trust in nature, in women, in birth is being slowly eroded; she has been 'taught' to have a deep fear of the pathological - instead of a deep respect and acknowledgement that

 "Some births in some circumstances sometimes need some help", Mary Cronk.  

As for me, being questioned and exploring these questions enabled me to reflect on my practise; and what emerged for me was that as a midwife offering continuity of care, a relationship of trust emerges with  women, we have time to explore their health, nutrition, and self-care.  Concerns around the 'motherbaby' well-being can be picked up quickly as listening to the woman, feeling her baby grow, and being involved in all aspects of her care enables you to identify changes that (as a registered health-professional) you respond to.  Supervision is also a big part of my practice, as I will talk to my SoM about putting into place plans and documentation for women who may be making choices that challenge the 'status quo'.

So how do we work in a culture of fear?  How do we empower women to trust their bodies? How do we inspire the next generation of midwives to practise autonomously - and without fear, but with respect?

In all honesty, I don't know!  But, I plan to - as long as I am capable - try my best to work towards answering those questions; to protect birth; protect women; and to protect my profession as much as I can.  Burn out is high when you are passionate, so of course this needs to be balanced with protecting me (and my family), but I find it hard to sit still for long, or to ignore what my heart and soul is shouting.  I shall, as long as I can, feel the fear...... and do it anyway!

“The best thing you can do is the right thing; the next best thing you can do is the wrong thing; the worst thing you can do is nothing.” -Theodore Roosevelt

angela x

How it feels to be a midwife

Sometimes, I hate being a midwife, and consider on a fairly frequent basis that I might leave the profession.  My problem is however, that midwifery is an intrinsic part of who I am; it is my calling;  my vocation; my life.  And as much as I hate it, I also love it passionately and I know there are midwives out there who will be nodding in agreement to these thoughts.

I remember so vividly the day I actually qualified as a midwife and the day my NMC Pin number dropped through the letter box.  I spent the next few weeks like a small child telling anyone who would listen that 'I'm a midwife'; I sang it round the house (albeit out of tune), I danced around my garden, and I posted it on facebook.  I really wanted to skip down the road shouting it too, but managed to restrain myself from actually doing that.  Still, there's time.

Anyway, after three years of blood, sweat and lots and lots of tears (a bullying NHS culture and colleagues ensured that) I had finally made it to the other side.  Alive, sadly not well (it took a long time to recover emotionally), but I had made it!!

I never practised in the NHS, but chose to go straight into Independent Practice; I had a midwifery partner and mentor to support me, and despite others doubts, I felt confident and competent to practice autonomously.  I had ensured throughout my training that I had gained a good understanding of the knowledge and skills I wanted under my belt (suturing, home birth, water birth, physiological third stage) etc..  Not always easy, and one of the few in my cohort qualifying with such experiences (that's a whole other issue in it-self!), but with some fantastic mentors and a lot of effort on my part, it had paid-off.

Midwifery is such an amazing profession; but there are so many politics involved, so many issues, so much angst that, at times, it's hard to remember that.  I can only write about midwifery from my view point as an IM; I have a deep respect for my NHS colleagues who work to be the best midwife they can, often under difficult conditions, and although I have worked a few 12-hour shifts on a busy labour ward, I am not in a position to comment about how it feels to be part of the system.

So, how does it feel to be a midwife?...........

When you are invited to care for a family during her pregnancy and for the birth of her baby, you are given a great gift: you are given the gift of Trust, of Respect, of a deeply personal Relationship at a vulnerable time in a woman's life.  You are asked to ensure the well-being of the Mother and her baby, to work in partnership with her, to empower her to make decisions and choices that will affect her health, her baby's health, and eventually her potential to labour and birth with confidence and self-belief.  

This feels like magic; like warmth filling your every cell; like the last piece of chocolate cake nestled on your plate.  It feels like a weight on your shoulders; have I done enough? have I put into place the appropriate advice, plans of care, evidence based information? have I documented it?! Do I convey my belief in her and in birth at every given opportunity?

When you are called to a birth, there is no feeling like it; the wait is over; but the work is just beginning.  Finally, she is labouring; you have put your life 'on-hold' for the past few weeks, you have kept your phone by your side, you have turned down that glass of wine, the invite to a trip that is just a little too far away in case 'the call' comes.

This can feel like coffee when its been burnt - looks amazing but the taste that lingers can be bitter.  It can feel like being invited to the party of the year, but then being grounded when they day arrives! It can feel like your life is passing as you watch from the side; like you are present but not fully participating; like a small shadow lingering over your shoulder.   

In the dark, small hours, I stumble from my bed to reach for the phone; I know it is my client and I hear her husband speak to me: "she want's you to come".  I check she is well, baby is moving, any concerns?  All good, her husband confirms.   I prepare.  Wash, brush teeth, dress - I pretend I am quiet, my husband tells me other-wise.  I breathe.  Deeply. And centre myself before I climb into the car.  I know where I am going as I have been there many times, my equipment is already in the car - always ready in the car.  I think; what do I need to be aware off, will my children be OK, how long might I be gone?  I hope and trust all is well.  You never stop thinking as a midwife; it's just you learn to do it quietly and calmly - that art of 'drinking tea intelligently'.

As labour unfolds, you appear calm, confident and relaxed.  You trust in the process - this is essential: if you do not trust the mother, her labour, her body, then your emotions will affect the birth and the potential outcome.  Without this innate belief you can not be a midwife.   Inside, you are quietly noting where she is in her labour, what you might need to do - or not do - to help and support.  Birth approaches; you breath.  Deeply.  Emergency equipment to hand (just in case); you watch.  Patiently.  And you lovingly encourage the mother to work with her body; you do not tell her what to do.  Her body knows, her baby knows.  As her baby enters the world, and the mother reaches for her child, you calmly, quietly check all is well.  You breathe. Deeply.

And you remember; you remember why you love midwifery, why you answered the calling to be 'with woman'; why birth is the most amazing event to witness, and why women are courageous and inspiring.  You remember why you do this.  It feels like Christmas morning; like the first sparkling frost of winter; like tasting your first bubbles of champagne; like nothing else on earth.  It fills your heart and soul.

A mother meets her baby after an emotional birth;
I was honoured to welcome two of her babies into the world

Midwifery is a roller-coaster of feelings; it is good, bad, beautiful, challenging.  It is rewarding beyond belief, and frustrating beyond measure.  It is a battle of wanting to be the best that you can, in a climate of fear and control and politics.  Midwifery is a way of life; it's not a job to come into because you like babies, or because you're good with people, or because you need a change.

Sometimes, I hate being a midwife, and as much as I hate it, I also love it passionately;  so, for as long as I still love it, and the women I serve, I shall continue on my midwifery journey.




Ask yourself this; how do you feel about midwifery?


angela x

What we do.....

I was thinking about the question "what do you do then?" in response to IM's not reflecting some of the midwives seen on current TV programmes.  Taking time to reflect on that question, I realised its more what we DON'T do.....

• We don't tell women what they should or should not do; we explore, discuss, share and come to a (mutually made) 'trusting' decision.
• We don't subject women to unnecessary intervention such as routine VE's, ARM's, directive pushing or managed 3rd stage.
• We don't assume we know best simply because we are the 'professional'; women know their minds, bodies and babies.  We learn as much from them as they from us.
• We don't apply time frames to labour and birth; we wait respectfully, 'drink tea intelligently' (Anderson) and gently support birth as it unfolds.  We do not (on the whole) need to hasten this process.
• We don't  'normalise the abnormal'; we approach every woman, every pregnancy and every birth as an event that is 'uniquely normal', working with evidence based practice, within our midwives rules and code of conduct, and in the woman's best interest

Angela xx

Parents and Students

Last night I worked at a Mother Care 'baby&me' event; I was the 'guest' professional, on hand to offer information and advice to expectant parents.  I was feeling a bit nervous before hand, but I actually really enjoyed the event.  I chatted to lots of parents about home-birth; water-birth and choice of care.  Many parents had not had any options explored or suggested to them - and this is sadly because the brilliant NHS midwives just don't have the time!

I have been invited to come back next time (the staff were really excited I attended, and I gather that they struggle getting health professionals sometimes); I will of course attend and feel better prepared on what to take for next time.

This week I also met with my SoM for my annual supervision, and have some targets for the next year.  I really appreciate talking to other midwives - there is so much to learn and absorb (we never stop learning) and getting thoughts and ideas from another perspective is very enriching; hence my love for working with students!  I get lots of applications from students to work with me and I have my own rule of only taking 3rd year students out with me, as I physically could not accommodate more.  To make up for this I am starting to develop workshops for aspiring students and current students.  I have run two aspiring student workshops and received excellent feedback so am now keen to run more!

Angela x

The Art of Waiting.... (patiently)

There are many skills that a midwife needs to acquire, but the one that has perhaps challenged me most is the art of Waiting..... and waiting..... and occasionally waiting even more! This is what I have learnt:

1. A watched kettle (bump) never boils


2. 'Switching off' is essential in order to lead a 'normal' life on call


3. Projects are a great way of distracting the mind


4. Family and friends have to be 110% understanding


5. It's worth the wait

Currently I am waiting for a friends baby, whilst my family are enjoying the last of the sunshine at the coast; a planned short break, but of course baby has other plans! My house is now incredibly tidy; the washing is up to date; the gardening is done; my hair has been cut; I have spent some gift vouchers that I received in July; my knitting project is well under way........ and I am still waiting. 'Tis the life of a midwife - and one I wouldn't change!
Angela x