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Settling in
Work is going well, and I remain happy in my new post. The caseload I hold now is similar to my previous one, predominately well-educated middle-class families who present me with few 'social problems'. The women are, on the whole, well-informed and eager for as much information as possible. They rarely miss appointments, the most common problem is their timekeeping as they often get 'held up at work'. I do find this irritating as means that my clinics will often run late even without the help of my verbal diarrhoea and the patients desire for information about everything. Sometimes I find it quite difficult to bite my tongue. An obese woman will sit there questioning me about why her ankles are so swollen, or why she is so out of breath, and then go on to grumble that she is treated as 'high risk' just because she is large and so cannot use the birth unit. I will then visit that same woman after the birth and be told a tale of horror. The staff will have been unable to monitor the baby properly, according to her due to the position of the baby, I just want to say that really it is because that she is so fat that the transducer is unable to make a good pick-up, so then they had to put a clip onto baby's head. Then comes the failure of the epidural to work properly, it's not easy for the anaesthetist to site an epidural well if she cannot feel the vertebrae this is then quickly followed by an emergency section due to slow progress. There is now research out which could provide me with an answer to give them but by the time I see them they are already pregnant and time is running out for them to lower their BMI so it would be a case of closing the stable door after the horse has bolted.
Over the weekend I was covering another midwife's caseload, and this was in a particularly affluent area. When talking about her caseload she says how demanding, and rude the women are, I was dreading the visits. I have to say that however difficult the women may be during pregnancy they were all lovely after they had given birth. Perhaps it was just because I was a stranger to them but I was made to feel really welcome and they all thanked me for my input. I loved it because Molton Brown handwash is obviously a must have and it is wonderful stuff. It has a pleasant scent but more importantly it is kind to my hands. During the day I wash my hands numerous times, generally three at each visit, once before Mum, again before examining baby, and then again when I'm leaving, so by the end of the day my skin can be sore and chapped. Not with this handwash though, they still feel as soft as a baby's bum. Bet it's expensive stuff.
Yesterday I visited a woman who had had a BBA (born before arrival) on Friday. Apparently her first baby had been quite a rapid labour, but this one out did her brother on the speedy front. She had been having twinges through the morning but just carried on as normal. Suddenly though the contractions had come fast and furious. She phoned her husband, a fireman, to pick their son up from school and come home, which he did to be greeted by her, on all-fours in the hallway unable to move. Sensibly he phoned 999, and they sent an ambulance, not a paramedic but a vehicle to transport her to the hospital. Labouring woman announced that she wasn't going anywhere, she couldn't move, so another ambulance, this time a paramedic response was summoned. Ambulance control phoned our office to request a midwife's attendance, got no answer, so left a message on the answerphone. Now the outgoing message says ' The office is now unattended. Midwives are in the office between 8.30 and 9.30. Please do not leave urgent messages but contact Labour Ward on....', so why did ambulance control leave a message? The inevitable happened, baby was born before a midwife arrived, it was the paramedics first birth, but all was well with the baby girl. Mum had to be transferred in though because she had sustained a couple of nasty tears during the birth but when I visited everyone was well and happy with quite a tale to tell.
For me this little scenario has highlighted a number of concerns
- Inappropriate personnel being sent initially. Was this a communication failure between the Husband and the person at ambulance control, or was it policy?
- Leaving a message on an answerphone, not good practice.
- Community midwives not all carrying on-call equipment.
- The decision about who to call. There was a midwife quite close to the scene but she wasn't asked to attend as she wasn't 'on-call' so didn't have any equipment. To my mind though it would have been safer to send her, the on-call midwife was half an hour away. Paramedics were already in attendance and they carry any emergency equipment she might need, with the exception of a couple of drugs, but we all carry those anyway.
There is a community midwives meeting this week. I was going to attend anyway as I have a couple of issues about the unfair distribution of finances between the two different areas which has resulted in lack of resources and sub-optimal equipment in one area, I am now also going to ask for a discussion about the events on Friday. Boy, I know how to make myself popular.
Long weekend
Yesterday I was mentioned in dispatches by NHS Blog Doctor, I was surprised, pleasantly so but then I became suspicious, after all my favourite blog doc is not known for his support of 'madwives'. My mention followed a reference to Tom Reynolds and Maternataxis, we had both blogged about ambulances and women requiring transport when in labour. I whole heartedly agree with Random Reality about the misuse of ambulances by women who are just using them as a free taxi service. If, as in my entry about the unplanned homebirth, events progress with unexpected rapidity and the stage is reached when the labouring woman is unable to move, let alone get into a car, then an ambulance and midwife should be summoned PDQ. However, all too often the ambulance service are summoned to transport a woman who really should use her own transport, whether that be in a family car, with friends or in a taxi. Amongst the comments in Tom Reynolds blog were people bemoaning the fact that haven't got their own transport, they have had months in which to arrange a suitable form of transport, being in normal labour is not an emergency, it is an elective event.
I had a phonecall from my job-share partner yesterday to tell me that she had not been at work on Friday, she had instead spent 7 hours in A & E with atrial fibrillation. In the morning she had woken up with chest pain, a superfast heartrate and difficulty breathing. Scary. After the sojourn at the hospital she was discharged with Aspirin and the promise of a follow-up to investigate the cause of her heart misbehaving. She is putting it down to a late cup of coffee with me and stress at work, is this her way of saying I cause heartache?
On Friday I babysat Izzy so Daughter could take Jack to the zoo and give him one-to-one time, I was confident all would go smoothly, wrong! It all started off really well, Nanny and Izzy went and did the supermarket shop together and Izzy fell asleep on the way home, unfortunately she woke as soon as we got indoors and that's when the fun started. She was a hungry little girl so Nanny warmed up the bottle, pointless exercise really as tiny tot was not having it. The offending item was pushed away and the crying commenced in earnest. This was no heartbroken sob, this was full blown anger and indignation, a latex teat, even if it was a Nuk, was no substitute for Mummy and was not going to be accepted. We called a truce, nappy-free time was declared, always a good move and cause for giggles and gurgling. Once we were friends again I gave the bottle another try with the same result, I admitted defeat and just spent the rest of the day jiggling around until Daughter arrived home and I could pass Izzy to her favourite milk provider. This week I'm going to buy a new Tommee Tippee bottle and see how that goes, we will solve the dilemma, I hope.
Amy and her parents return from Spain tonight, Hubby is picking them up from the airport but I can't go because all of us, plus their luggage and SIL's golf clubs, won't fit. I'm gutted because I haven't seen for what seems like ages, actually it's a week, and I'm working tomorrow so it will be Tuesday, when I have Amy, before I can see how much Van and Lorry have grown. Daughter has her anomaly scan (20 weeks) on Wednesday and the specialist cardiac scan on Friday, another landmark week.
The pain of the childbirth issue.
I am reproducing this article here, in full, as well as linking to it. It is wonderful to know that good old blighty is not the only country to be experiencing high caesarian rates but it is also refreshing to have someone consider the whole pregnancy, birth experience in relation to fashion, culture and expectations. I feel that pressure is being exerted on women by the media, whether it be in magazines with articles telling them how to have the best childbirth experience, newspapers scaremongering one day about normal birth and how dangerous it is for Mothers and Babies, and calling for homebirths for all the next or the Government weighing in with its plans to increase the number of homebirths, producing little booklets which advise women that they have a choice, and initiatives which they proclaim to the public but omit to say that they are on a wish list and not really available. Which way should a woman go? Protect her reproductive tract and have a caesarian, saving money then on having her 'designer vagina' constructed by a surgeon. Perhaps she should just seek out a birth unit, all low lights, soft music and large baths, certainly that sounds like a lovely option but unfortunately they don't offer epidurals so if it is a birth centre it should be close to the consultant unit and that way, once the aromatherapy and the massage has failed to smother the outrageous contractions, a wonderful anaesthetist can come and site the ultimate in pain blockers and instantly double their odds of requiring an instrumental delivery, if not a caesarian.
Caesarean glut not just about too few midwives
Michelle Hamer
April 30, 2007
Other related coverage
CATHERINE DEVENY The great birthing con is taking choice away
The introduction of one-on-one midwife care alone will not curb Australia's soaring caesarean rate; it hasn't worked in New Zealand and it won't work here.
Catherine Deveny (Opinion, 26/4) wants the Federal Government to support independent midwives as a means of reducing our caesarean rate, which at 30 per cent is double the maximum number of surgical births considered appropriate by the World Health Organisation. (But the WHO figure was set more than 20 years ago, and many argue that it is outdated.)
To support her argument, Deveny cites the introduction of one-on-one midwife care in New Zealand 13 years ago - and the huge maternal shift towards it. What she doesn't mention is that despite the switch to midwife-led care, New Zealand's caesarean rate has continued to rise steadily.
In 2003, 23.1 per cent of New Zealand women underwent a surgical birth; in the same year Australia's rate was 27 per cent. Australia's rate has continued to rise in the past four years and there is no sign that the New Zealand figures have done otherwise.
In Finland, which, as Deveny correctly states, has one of the world's lowest caesarean rates of 16.1 per cent, pregnant women are largely cared for by midwives during their pregnancy, but this is often under the supervision of a specialist, and does not continue during the birth, which is managed by an obstetrician. So something else must be contributing both to Finland's reduced, and Australia's rising, caesarean rate.
Certainly in Scandinavian countries such as Finland, childbirth is seen more as a natural, physiological process, rather than a condition to be managed and controlled. It's no coincidence that the countries with the lowest caesarean rates are also those that most warmly embrace family-friendly work and government policies.
If having a baby is seen as a natural part of life, rather than a scary endeavour that will damage your career and cut you off from mainstream life, then it's likely you'll approach it in a more relaxed manner.
But in countries such as Australia, the baby stakes are high. We're constantly reminded of the cost of bringing up children, and we tend to slot baby-making into a calculated position somewhere after paying off a cavernous house and getting as much travel and experience as possible under our belts. Strange that starting new life is often seen as the ending of so much more.
In this culture it's no wonder the thought of having a baby "the old-fashioned way" is less appealing. Making the decision to have a child in the first place often requires so much agonised consideration and strategic planning that mucking it up at the end is not an option.
And this is the way vaginal birth is increasingly being seen: as a little wild and out of control, messy and unpredictable.
Caesareans are certainly safer for obstetricians; no Australian doctor has ever been sued for performing a caesarean, though many have faced litigation following vaginal births gone awry.
For a society that has elevated technology to a new form of religion that offers a more sanitised, controlled experience of the world, a caesarean is often seen as the "new, improved childbirth".
This month the NSW Government weighed into the debate, trying to reduce the number of medically unnecessary caesareans by ensuring mothers are clearly informed of the risks of such a choice - but research shows that just 5 per cent of Australian women are storming into their obstetricians' rooms and demanding to have their child cut out.
Most mothers set out with the best of intentions for a natural birth, but are often swayed when the "risk" word creeps into prenatal discussions. Multiple birth - ooh risky. Breech - let's get out the scalpel. Previous caesarean - sorry love, no choice. The baby's heart rate is too fast; too slow; too loud - what the hell, let's cut.
We're all scared by the what-ifs of childbirth and have been seduced into the idea that a caesarean will be safer, more predictable and manageable, but major abdominal surgery is not a walk in the park.
Legislative support for midwife care may help, but there are many more conversations about the importance of family, about our shame and blame culture and our intolerance of (perceived) risk before midwife care alone will reduce the caesarean rate.
Michelle Hamer is the author of Delivery by Appointment - caesarean birth today (New Holland) and the mother of four children born by caesarean.
I read this on a day when I also discovered that 'postnatal depression', by the way us midwives are not supposed to call it that anymore, it is depression, pure and simple is at an all time high. I wonder, could there be a link here, are womens expectations of the childbirth experience too high?