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Yesterday one of my women failed to attend her clinic appointment, annoying as it wasted an appointment and all the more so as she is a Doctor in the Health Service, but these things happen. When I had finished my days work I returned to the unit to check up on one of my women, Kim, who had her baby on Monday, This is a complicated case, her children had previously been on the child protection register but this had ceased a year ago when she had stopped using heroin. When she became pregnant again my colleague wrote to social services requesting advice from them, they replied that they had no interest in the family and would not be involved. I was then contacted by the Health Visitor and G.P saying that they believed she was 'using' again. When I saw Kim I asked her about this, she admitted that she had been using again, but only whilst a relative who was an addict was staying and had now stopped. Then information came, she was on a Methadone programme, that on a recent test she had shown positive for cocaine and cannabis. Kim was now missing antenatal appointments, my Manager was informed, contact Social Services again was her advice, person who knew the family was on a course, there was no one else who I could talk to. All this was put in her notes. Then the Health Visitor contacted me again, the partner was dealing, she had contacted Social Services, not interested. Well, now we have a baby who was born 5 weeks early but seemed to have no withdrawl symptoms. The staff in the hospital contacted Social Services as they were sure Kim was still using illegal drugs, same old, same old, not interested. Anyway, Kim was discharged from hospital yesterday evening and we shall be acting as watchdogs, fingers crossed.
Back to my non-attending lady, visting Kim I looked on the board that has all the patients names, and there was my non-attender, that answered that question, she wasn't at clinic because she was in hospital. Before I went in to see her I looked at her notes, forewarned is forearmed, and they told an interesting story of someone who didn't want to be in hospital. Her records were full of notes she had left on her bed explaining where she had gone, and there were several instances where Registrars and Consultants had come to examine her and she had gone off somewhere, often to her office. She was in hospital with a Grade 3 Placenta Praevia, a potentially life threatening condition, for her and baby. I went had chatted to her, she was about to go home on weekend leave. I was bomdarded by questions concerning how the Consultant was managing her case. Next to her bed were a couple of obstetric reference books and a sheaf of research, she had been reading up about her condition. The gereral jist seemed to be that she didn't want to go home, she didn't feel the consultant was being cautious enough, there was more but everything ended up with her not being happy about the management. I remained as on the fence as I could but told her I would try and have a chat with the consultant. Off I went, had a chat with the midwife who was caring for her, as I suspected she was driving them all batty and then found the consultant who was discussing this lady with the senior obstetrician. I told him what had been conveyed to me, he was flabbergasted, she had been pushing him to be allowed home. Knowing her previous history, and how she had distorted facts, I warned him, he seemed at his wits end. Careful, precise record-keeping is a must in this case.
Last night I was called in to the unit as they were over-run with difficult cases. I took over the care of a young girl, 30 weeks pregnant, and....Grade 4 placenta praevia. . She has been in hospital now for 4 weeks, she does everything she can to follow advice, so different to my woman, but has had several bleeds, the one last night a large bleed, but baby is still fine, it's really just a case now of timing the CS right to give baby the best chance but getting there before a devastating bleed happens.
Having rambled on about placenta praevia the other day I thought I should explain the 'Grades', but whilst 'googling' I found this which does a better job than I could do, it has illustrations.
Sunday found me shopping with Amy and her Mummy, if it was supposed to be for Christmas presents I failed miserably as I only bought a tube of toothpaste. It did give me some ideas though but all thoughts of Christmas are overshadowed by the fact that it is Hubby's birthday a week today, and I have no idea what to buy him.
My methadone addict is home and doing well. Baby is a tiny little thing, a pocket-sized baby at only 4 and a half pounds but is feeding well and is very alert.
Yesterday I had my meeting with Head of Midwifery, daughter elected to join us as she wanted to be able to have her say. It turns out that the meeting she had 6 weeks ago with the Supervisor of Midwives was a pointless exercise as the SOM has not written the promised precis of what was discussed, or talked to the Head of Midwifery, this being the same SOM who, with my manager, accused me of being a poor communicator. The meeting yesterday started off with the H of M being quite forceful and it looked as if there was going to be a battle, especially when she said that she would not stop me being there as her Mother! Her main arguement seemed to be that I couldn't be a midwife and a mother. Daughter put it to her that I would not be able NOT to be a midwife, particularly if things were not going well, and that if I didn't do anything then that would cause more of a problem between us than if I had at least tried. After throwing several 'what if' scenarios of the cord tightly round neck, 'flat' baby, and daughter having a massive bleed and then daughter retaliating by saying that she trusted me more than anyone else she either gave up or suddenly realised what we were saying, I would like to think that it was the latter but who knows. Anyway, daughter has her wish, I can be there as second midwife.
So, the plan is that when she goes into labour she lets me know and then phones the hospital to send the 1st on-call midwife out to her. If it is during the day I either find someone to cover my workload, or if it's an Amy day then I phone her Mummy to come home from work and take over, then off I go round to Daughters, followed by Hubby who will take Jack out for a few hours. Let's just hope it is at night, that will be so much easier. This is all assuming that she has reached 37 weeks, there can be no homebirth before then. At the moment though she is only 33 weeks and is presently rocking around on the birthing ball in my sitting-room, baby is so low that anything else is too uncomfortable. Daughter is also complaining of period type pains and is constantly going to the loo. When I prodded Poppy around earlier her head was so deeply down in the pelvis that I could only feel one fifth of it. In someone having their second+ baby this is quite early for the head to engage. Jack was three weeks early, I'm just wondering if this early descent by Poppy is indicative of another early appearance. I've asked her to pee on a urinalysis stick so I can assess whether she may have a UTI (urinary tract infection) as this may, in part, be contributing to her discomfort.
Off now to make daughter lie down with her posterior raised, might encourage Poppy to shift her position and let her Mummy be more comfortable.
Balls
Its that time of the year again. The time when I start beating my chest about my wardrobe. For a midwife who wears 'civvies' to work its not too bad, a good selection of smartish, easy care trousers and tops, equally it passes muster for an active, casual Grandmother, but for a party-going, middle-aged woman it is sadly lacking. It is only very occasionally during the year that I attend an event that requires me to dress-up, then the festive season arrives, and every year it finds me lamenting my lack of style. In the last 10 days there have been 2 events where I needed to raise the bar, not by a huge amount, but they required just a touch of class and I think I just about pulled it off, on Thursday though I have an evening which demands panache, and I'm stumped. Ball gowns have been hinted at, feather boas, long gloves have been mentioned and I'm now frantically trying to put together an outfit that will fit the bill, or rather fit, and suit, a middle-aged lady, with vivid orange hair (yes the dying went so wrong as to be almost right), who is only 5ft 2.5 inches, with a somewhat rubenesque physique, frankly all the images I keep conjuring up err towards burlesque not rive gauche. The theme is Casino Royale, Hubby was a huge help when he suggested I just wear a man's black suit. Brilliant suggestion, I'll look like a dwalf version of Malcolm McClaren and, where do I get this classy suit from, Hubby is 6ft 2 inches and all the other men-folk in the family are at least 6 inches taller, and slimmer, than me. Oh, woe, woe and thrice woe, or Balls to the Ball.
Balancing
The sounds of 'Wind the bobbin up, wind the bobbin up', accompanied by frenetic splashing, are filtering down the stairs. Jack and Amy are in the bath, it's the end of another long day in Midwifemuse's house. Amy and her parents are still staying with us, 3 weeks so far, rumour has it that they may well still be here at Christmas. Years ago I used to love Little House on the Prairie, I am now beginning to feel as if I have been relocated to live the life of Mamma Walton, only I can't be as amazing as she was. I used to think I was pretty good at multi-tasking but I think I may have reached overload. Every hour, of every day, is taken up with toddlers, housework, laundry, cooking, shopping and/or work, I am having to write myself memo's so that I don't forget something. The singing has stopped and instead I can hear Jack plodding down the stairs calling 'Nanny, Jack coming'. Please just half an hours respite, I have shut myself away with the light off so hopefully he won't track me down. My Mother phoned on Thursday evening just as I was trying to give Amy her dinner, put the shopping away, tidy up the toys, and get ready for my work Christmas function. She announced that she was coming over the following morning, when I told her I would be at work she sounded put-out. Normally I would have explained why it would be impossible to stay at home, instead she had a verbal slapping. As it was I summoned the clan so she had all the Grandchildren, even son, and the Great-grandchildren to listen to her latest triumphs over the plebs that inhabit her locale (her viewpoint on anyone who has a different opinion to hers).
Hubby is really down at the moment. He has his own company which has been going for 24 years now, there have been down times and up times, but recently he has been having more difficulty getting work in, we've been there before though so we were just waiting for the tide to turn. Since September he has been owed £35 thousand for a job on which he has paid out for the labour and all the materials, so the real cost to the company would be thousands more. The company he carried out the works for have been coming up with excuses as to why payment hasn't been forthcoming, and he has just discovered that the M.D is basically a conman who has has pulled this before. When someone finally serves him with legal proceedings he just folds up the company and starts all over again under a different name. For our business it could just mean the end, there is no way that the business, or us personally, could recover from that sort of loss so, understandably, there is worry ++.
On a happier note it is Hubby's birthday on Tuesday so tomorrow we have the command performance of a family meal, no excuses accepted. Roast beef and all the trimmings, Apple Strudel, an extensive cheese board and a couple of bottles of wine to help it down, and our spirits up!
Food for thought
I can't say that I have found this to be evident, but I shall certainly start watching out for it. Midwives have observed for a long time now that epidurals adversely affect the progess of labour and increase the need for intervention, and there has been evidence that the fentanyl does cross the placenta. Interesting to see if this research affects the advice by some antenatal class providers about the use of pethidine and it's effects on breastfeeding.
Selective closures?
For me, and I would think any prospective parents, this is a cause for concern.
This is really scary, and something I am embarrassed to admit to but, I agree with Blog Docs latest offering, especially as it is something I have blogged about on numerous occasions.
It is 9.30pm and I am sitting here, on a day off, trying to get up to date on a mandatory on-line training package. It should be done during working time, thats a laugh, 'Sorry, I have cancelled clinics this week so I can sit at a computer' the women, and the G.P's, would love that one. Anyway, where am I supposed to do this at work, despite what you read in the press about the NHS and computers we don't have the available computers for us to faff about doing simulations etc. Then there are the times that my day is so full that trying to set aside time to liase between disgruntled pregnant women, managers (who only work 9-3), and Directors of Midwifery would mean that urgent clinical work can't be fitted in, so I end up spending mornings on the telephone when it's really my day off. I am on overload at the moment, complete this audit, conduct another audit, audit these notes, attend this study session, sing the national anthem and do the can-can. No wonder there are staffing issues in the Health Service, we all spend more time sorting through reams of paper and filling in forms than we spend 'interfacing' with the people we are supposed to be caring for.
Then I have the disgruntled pregnant woman. On a woman to woman level I not only see her point of view but I also agree with her, on a professional level I want to shake her and/or bury my head in the sand. Well, not just my head but my whole body really. It doesn't help that she is bombastic and obviously used to getting her own way, quite like me I suppose, and although I remain super-calm during our little tete-a-tetes she has a heated arguement. The problems arose when she decided upon a homebirth but she lives in a different county, within another PCT, served by a Trust and under a different Health Authority. Midwifery Services are an odd financial set-up which is not usually a problem unless you live by a border, it could be any old border, County, PCT whatever, it just potentially means trouble. Back to DPW, I explained that it wasn't that I had an issue with her wanting a homebirth but due to her address I needed to check with my manager if we could attend her at home, or whether she would need to be transferred to the care of the midwives from a different maternity unit. I did this and my manager said that we could not conduct any care in her home. I wrote this in her hospital notes as she was seeing the consultant next, and also conveyed the news to the DPW, not very happy. Next thing I see her for a routine appointment at clinic, she reports that the Consultant has suggested that a hospital birth, with an early discharge, would be favourite but also the consultant said that we should leave a 'delivery pack' with her. What? Why? 'Well, in case I progress quickly and call you'. I, mentally, took a deep breath and explained that as Community Midwives we always carry everything we need for a homebirth and that we don't go leaving that sort of equipment at peoples houses on the off-chance. 'So when I call you you will have everything with you?'. 'Why would you call me, you are going into hospital, and anyway my manager has said that we may not cross the border, and you are over the border.' I was then told that the Consultant had said that we were to cross the border. Under my desk I had clenched fists as I once again attempted to explain that this was not up for negotiation, policy was dictating our course of action. In a attempt to deflect the anger which I felt was directed at me I then hit upon a cunning plan, 'Here's my managers phone number, why don't you give her a ring?' That ploy failed, I was basically told to sort out the mess myself, but that it all had to go her way. I did try, I spoke to my manager, but she had already discussed it with the Director of Maternity Services, and the answer was still 'NO'.
I see DPW's point of view, we have provided her care throughout this pregnancy and she see's no reason to change, she doesn't want to change and, after all, choice is supposed to govern care. However, I see my managers etc perspective that if we set a precident everyone will demand the same and apparently, due to the geography, we receive no funding for DPW. I have a prediction though, DPW will give birth at home, she will leave it too late to get to the hospital, she lives 25 minutes away. Hopefully a midwife and/or ambulance will get there in time, otherwise it will make the papers, she will make sure it does.
Right, back to work.......