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From the heart
NICE, National Institute for Health and Clinical Excellence, have released their guidelines for the care of mums and babies, they are not telling me to do anything that midwives don't already do, their glaring omission is that they don't say how many visits would be ideal, or indeed what the minimum number of visits should be, and there in lies the problem. Trusts are using this lack of advice to reduce the number of home visits to a bare minimum, and certainly less than most midwives are comfortable with.
I've set up a Google alert for Maternity Services, and it's frightening. Hardly a day goes by without some story about another maternity unit closing, and the reasons behind all of them? Funding, or lack of. I expect that if I set up an alert for any other specialist service within the NHS I would receive a similar numbers of responses all telling the same story, money and staff shortages. The answer seems to be lets close units and throw money at a new one, and during this process exceed our existing budget and so be in even bigger trouble next year. Another ploy seems to be alter traditional roles, give paramedics more responsibility, encourage nurses to take over the tasks traditionally carried out by junior doctors, and pharmacists are being encouraged to make diagnosis. There is a certain G.P who rants about this, calls professionals who take on these roles 'Quacktitioners', I am often at odds with his take on matters, and particularly the sentiments he expresses toward nurses, and on occasions midwives, but I have to say that I feel we may be on the edge of enhancing roles too far. I don't feel that distributing some tasks to non-medics is wrong, it is the cheap way it is being done. The training is the minimum necessary and then how well are these 'advanced' practitioners recompensed? I cannot speak for other professions but I do know that within midwifery, if you 'enhance' your practice, you increase your responsibilities and workload, you are not rewarded monetarily. So you see its money saving, reduce the medics workload, don't employ as many, and don't pay the 'pseudo-medics' any more to take over their tasks.
I may regret this blog later. It comes from utter frustration at the terrible state this government is pushing the NHS into, and we are helpless.
Ten days ago my friend and colleague,V , reached the date her first baby was due. We had been planning a homebirth but her blood pressure going up had seen the end of that plan so she readjusted her expectations, and we waited. Then the Consultant decided that induction was necessary. Super calm V was rattled by this, she had been told that baby had a large head, and so she started questioning why baby was late. If it was due to the size of baby's head then was being induced going to get her anywhere, or would she just have hours waiting for her cervix to allow the waters to be broken, difficult breaking of the waters, a day on a drip, and then a nasty forceps delivery, with her perineum looking like a 'car crash', or an emergency section. She put this to the Consultant who felt that we should give it a go anyway. V was doubtful so said that she would go along with the plan, but that if, at any point, things stopped progressing normally, then go straight for section.
The induction process was started on Friday afternoon, by Saturday morning she was ready for her waters to be broken (ARM). I was contacted and in I went. Labour Ward was full, so having called me at 7.30am we then had to wait around until 10.30 before we could get down there and start the process. Thank heavens it was an easy ARM, her cervix was about 2cms dilated, the baby's head was not too high, and the litres of fluid that drained were clear. A swab in pregnancy had detected Group B Strep so she had to have IV antibiotics so I started these running, whilst giving her body a chance to start the contractions by itself. An hour and a half later and nothing had started so the syntocinon drip was put up and V was strapped to the CTG. Luckily the machine was picking up a good reading, so she didn't have to be confined to bed and could stand or use the birthing ball.
After 4 hours of contractions, the last two hours of which had been strong with 4-5 in a ten minute period, I did an internal. Not good news, the cervix was only slightly more dilated, although it had thinned out, but the real down side was that there was caput (swelling) on baby's head. We discussed the situation, my take was that as V and baby were fine at present and there had been slight progress lets continue. V was happy with this, so on we went. Gradually the contractions became far more intense, they were lasting so long that there was hardly a break between then. Baby indicated its displeasure by dropping its heartrate and then increasing it. I watched the monitor, the fast heart rate continued, and continued, the contractions were too intense, I turned the drip off and went in search of the Registrar.
The Registrar looked at the trace, she was not overly concerned, but decided to examine V anyway. It was 2 hours since the last examination, and the news was disappointing, no progress, the caput was increasing. V was very unhappy by this, we all were. Then the doc surprised me, lets get an epidural going so that V can't feel the contractions, which even with the drip off were still practically continuous, and then start the drip again. V agreed, reluctantly. Whilst we waited for the anaesthetist I ran through the next dose of I.V antibiotics, and then the anaesthetist arrived and sited the epidural. It took quite a time to do and by the time he had finished I was watching the trace with growing anxiety, it was totally unreactive, there was hardly any variation in the beats, this is a worrying sign. Whilst I was making V comfortable after the epidural, which was showing no signs of working, another midwife came in to retrieve a piece of equipment, I asked her to invite the Reg back in to look at the trace.
By the time the Reg attended, it was a new one now, the night staff were arriving, it was 2 hours since the last review. She shared my concern about the trace so did another internal, no change. Her view was lets get the epidural sorted, and continue, cautiously. I waited until she had left the room, sat down with V, held her Hubby's hand and started, 'You asked me to be your midwife, that means that I am also your advocate. Before all this started you told me your worst fears, think about this V. If you were the midwife in this scenario, how would you think it was going to end? It's now 9.30 at night, you have made no progress, baby is starting to show that it is unhappy, do you want to carry on or shall I speak to the on-call Consultant? I'm going outside for 5 minutes, tell me your decision when I come back in and we will go from there.' I didn't make it out of the door, ' I want a section, please.'
When I got to the phone the Reg was already on the phone updating the Consultant about the happenings on Labour Ward, I didn't get to speak to him, he had told the Registrar to discuss a Caesarian with V and her Husband, if they agreed!!!! he would come in to do it. A huge weight was lifted, I was practically ecstatic, so was V's Hubby, V was more restrained, just cuddling me and crying, happily.
Conclusion, one 8lb baby boy. He gave us a few scary moments initially as he decided breathing was not on the agenda, but a whiff of oxygen and a couple of sharp foot slaps and he announced his presence. What you can't really tell from the photo is quite how much caput and moulding his poor little head had endured, I'm not exagerrating when I say he has a head like E.T.
I got home at 1am, shattered, but thanking my lucky stars for a happy outcome. In October my friend expects her baby, she already has problems, placenta over the cervix, cholestasis, irritable uterus, I shall see this baby out and then, apart from daughters pregnancies and births, I shall confine myself to only my caseload.
New Contracts
Who cares? Well, I used to believe that the good old G.P cared, and I'm sure that many still do, my G.P is brilliant, when you can get an appointment to see him, but the family doctors in the area I work within seem to be really taking full advantage of the perks their new contract offers them. I have, briefly, looked at the new contract and my thoughts were initially 'good for them. They've negotiatiated a good deal here.' Then today I found out that what may be a brilliant deal for them has left the service they offer to their patients lacking. Strange that because the actual wording within the document goes;-
Benefits for patients
The contract would not be credible or supportable if it did not also deliver substantial and demonstrable benefits for patients. Those benefits include:
- allocating resources to practices according to the needs of their patients
- improved quality of care
- evidence-based indicators in the Quality and Outcomes Framework
- better health outcomes
- the Patient Services Guarantee that patients will continue to be offered locally at least the range of services that they currently enjoy under the old contract
- consistent services across the UK
- a wider range of primary care services, delivered near where patients live
- the right to ask to see an individual doctor of their choice
- the use of patient experience questionnaires in the Quality and Outcomes Framework.
How is it then that our local family health providers can decide to stop conducting the routine newborn examination if a woman has had her baby at home or has had an early discharge from hospital? One minute they are happy to attend and ensure that all is well with their newest patient and the next, they have withdrawn their services, so what happened to 'the Patient Services Guarantee that patients will continue to be offered locally at least the range of services that they currently enjoy under the old contract'? Oh, but read further through the document and you find that 'maternity services' come under the additional section so, if they do provide them, they receive extra funding. Should the newborn examination be regarded as maternity service or is it a patient service? Who knows. All I know is that they have successfully decreased their workload, and increased mine, overnight. How's that? Well a few years ago I undertook the study to gain me the qualification which enables me to conduct this examination. Some doctors winge away about how less qualified health professionals are taking over their roles. Sorry, but this is a wonderful example of how some medics are giving away their roles, or using them as a bargaining tool to obtain more monies from an already cash-strapped NHS. Well, no worries because there are 3 midwives within this PCT who hold the qualification, so we can just do them all. What a wonderful cost-saving exercise, don't pay the G.P's, just inform these midwives that, in addition to their already large caseloads, they can now do this as well, but the real bonus is they don't get paid an'incentive' for 'additional services'. Something is going very, very wrong out there.
Change is in the air
We might be moving house. Basically a property developer has, after negotiation, offered us a fair price for our home, subject to planning consent. We really won't know what is happening until around November/December so we are trying not to think about it too much. That's difficult though, this house holds so many memories for all of us and we had really not anticipated this move for another 8 years when we would retire at the same time. I have become somewhat manic about the whole thing, taking loads of photos of my garden, making lists about what the next house must have etc. As long as we can have one last family Christmas here, perhaps even baby 'poppy' might spend some time with her extended family in the house they all grew up in.
Tomorrow Hubby and I are going out to have a look at boots of cars. Yes, it looks as if I might be getting a 'new' car. We have to look at boots because of the amount of equipment I have to carry for work, plus, of course, a car-seat and pushchair. At the moment I have a 2 door Clio, old style, which has a good sized boot for a small car but the 2-doors are a pain, as is the lack of PAS and EW (AC would be nice as well). I want a Rover 25 but everyone else is against it, which, being the contrary creature that I am, makes me want one even more. I know, difficulty with getting parts etc. but you really get a good deal on them, loads for your money. It's just exciting to be looking, thats how sad my life is!
False alarm
Nearly bought a car today. Went looking at luggage compartments (boots) and saw a Skoda Fabia, good sized boot, diesel, seemed right, so right that on the way home Hubby said we should pick my car up, go back to the dealers and buy it. I was shocked, this is totally out of character, but thats what we did, well part of it. We returned, in my car, tried to haggle, no luck, I sat in the Skoda, and then realised, no electric windows or sun roof, 'Don't want it', I winged like a cross between Matt Lucas and a spoilt brat. The search goes on, but the options are narrowed, Skoda Fabia, Ford Fiesta or Renault Modus. Personally I love the Renault, high seating position, triptically folding rear seats(????), in floor storage and amazing all round vision. We'll see.
Saw Sister and IanB yesterday. Scrummy curry (Hubby has just eaten the leftovers) then an alcohol fuelled rendition of all our favourites from Sound of Music on the way back from the restaurant. They very kindly gave me a replacement monitor, mine has been treating me to extremely jaundiced images for the last couple of weeks, switched it on this morning...........and it's functioning perfectly. How is it that inanimate objects do seem to know when you are about to replace them?
That's scary. I publish my blog and immediately the Goooooogle Ad is for Skoda.
Daughter - 'I feel really calm. It's as if silk has been poured over me.'
Her sister took one look at the scan photo and said it looked like an alien, that's a nice way to talk about your niece/nephew. Daughter does know what sex it is, I don't want to know but can take an educated guess. Hopefully it will now all be plain sailing regarding her pregnancy, her partner goes in on Bank Holiday Monday to have his bowel resection, lets hope that is plain sailing as well.
Work has eased slightly in that we are not having to incorporate shifts on labour ward into our lives, but the pressure remains high elsewhere. Postnatal visits have been cut drastically and the women are still expected to attend the hospital if they need seeing over the weekend. Some local G.P's have re-thought their refusal to conduct newborn examinations, discussing the situation with the senior partner at one of the surgeries I work from lead him to comment about his abstaining colleagues 'awkward bastards'.
I'm trying to reduce the number of 'specials' I'm involved with. These are women who are not my caseload, usually family, friends and colleagues. It's really difficult to say no though so, having just seen V's baby into the world and announcing that I was stopping my extra's after friend with cholestasis and daughter have given birth, another colleague, who I cared for last year, and one of daughters friends have asked me to provide care. After them I really am stopping.
This morning I decided to listen to Led Zeppelin. Immediately I was back sitting in friends bedrooms, lava lamps sluggishly erupting, joss sticks giving off a sweet, sickly smoke (hoping to mask the smell of grilling banana skins and Players No6), everyone liberally daubed with patchouli oil and drinking cider or Double Diamond. Those were the days!