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Month: March 2017

Differences so far…

Differences so far…

Wow, I’m not even sure where to start here. There have been A LOT of differences so far between American midwifery and British midwifery. Here’s just a small sampling.

First, abbreviations. Some of them are the same, most of them are completely different. In the US, an IUD is an intrauterine device (i.e. contraception). In the UK, it’s an intrauterine demise (stillborn baby). BIG difference there. In the US, taking a medication twice a day is BID (“bis in die”, Latin for twice daily); in the UK, it’s just BD. QID = QD, TID = TD. In the US when I see PE on a chart, I would think Physical Exam. Here it means Pulmonary Embolism. In the US, contractions are measured on a tocometer, or abbreviated as “toco”. Here it’s abbreviated as CTG (meaning cardiotocograph). FHHR is fetal heart rate heard regular, rather than just FHR (Fetal heart rate). Small things like that, but it adds up.

The antenatal visit schedule is very different as well. In the US, pregnant women can get anywhere from 12-14 prenatal visits through the course of their pregnancy. Here, a nulliparous woman (first-time mom) will only have 10 visits total with her midwife, and a multiparous woman (second-time mom) will only have 7 visits total with her midwife. In the US, generally the longest time between visits would be 4 weeks, but here there can be up to 6 weeks between midwifery visits. I can see how this might be a much more efficient schedule and use of resources (and the NHS is all about using resources wisely), but I wonder if there is flexibility in this schedule for the mums that may have a lot of issues going on and might actually needs more frequent follow-up. I wonder how that works with the overall schedule, and I wonder how midwives get around that (extra sonograms in place of visits, maybe?). This will be a very interesting area to learn more about. According to NICE guidelines for antenatal care, the schedule looks like this: Initial booking appointment with the midwife by 10 wks if possible, 10-14 wks: ultrasound for gestational age (but no midwife visit), 16 wks: midwife, 18-20 wks (ultrasound for fetal anomalies/ anatomy scan, but no midwife visit), 25 wks: midwife (nullips only), 28 wks: midwife (nullips AND multips), 31 wks: midwife (nullips only), 34 wks: midwife (nullips & multips), 36, 38 wks: midwife (nullips & multips), 40 wks: midwife (nullips only), 41 wks: midwife (nullips and multips, to discuss postdates options). And that’s it, folks.

The screening schedule is slightly different. For instance, in the US an initial visit usually involves a pap smear and a test for gonorrhea and chlamydia. Here in the UK, these are not routinely offered. Pap smears are done routinely by a GP (rather than OB/Gyn or midwife or women’s health NP) on a different screening schedule (every 3 years), so  there’s no need to try to catch up on smears at an initial pregnancy booking. In the US, since many women don’t have access to routine care, it’s sometimes been years and years since they had a pap smear (and sometimes they’ve *never* had a pap smear before), and because pregnancy is actually a time in a woman’s life when she accesses care, the US system is designed to try to take advantage of this and do a lot of catch-up primary care/ health promoting tests at the same time as the routine prenatal care. But thanks to the beauty of UNIVERSAL health care, routine health promotion practices are already in place, so pregnancy care is exactly that: *pregnancy* care. Also interestingly enough, there is no vaginal/ pelvic exam at an initial pregnancy visit here, and many of the British midwives I have spoken to are very puzzled by the need for one. “Why would you routinely do an invasive, uncomfortable exam at an initial pregnancy booking on all women?” Well….because….well….I don’t really have a good answer to that. Because in the States this is something we’re taught to do: pap/ gonorrhea+chlamydia test/ vaginal exam/ bimanual exam/ pelvimetry, at every initial antenatal visit. But in a healthy, low-risk woman who’s already had access to regular check-ups and care, is all of that really necessary? Paps are routinely screened for in the general public by GPs here, and there is a national screening program for all women under 25 years of age for chlamydia, so again chlamydia is already being routinely screened for in the most at-risk population. There is no mention of gonorrhea testing as a routine part of antenatal *screening*. I guess this means that GC/CT are screened for only if there is an indication through the woman’s personal history? Again, this is something I’m going to have to learn more about. Also very interesting is the fact that Group Beta Strep is NOT routinely screened for in all pregnant women at 36 wks here. Which is rather mind-blowing to me. But in a less litigious, more resource-efficient society, perhaps this makes sense too. And it would drastically cut down on the overuse of antibiotics and antibiotic resistance (not to mention the damage routine antibiotic use is doing to our collective human microbiome on a population level). Again, this is something I’m going to have to learn a lot more about.

And finally, ANATOMY is different here. I kid you not! I thought surely the Latin names for muscles and bones and organs and structures would be the same. But no, lots of new names I’ve never heard of before. For example, I would call it the rectouterine pouch. Here it’s call the Pouch of Douglas. What I would label the pubococcygeus muscle (in the levator ani), the Brits call the pubovisceral muscle. What I would call the puborectalis (again in the levator ani), the Brits call the puboanalis. Lots and lots of little things like that. Very similar, but not quite 100% the same. Which means that even though a lot of this material is familiar, I can’t assume that I know it. I don’t know it (and I had forgotten most of the names of all of these muscles anyway). So I am having to study it all again as if I’m learning it for the first time. Time to hit the books!

 

Sleep and “Self-Soothing” Roundup

Sleep and “Self-Soothing” Roundup

There is so much conflicting information out there on sleep, and so many messages you’ll hear on why having your baby “sleep through the night” is the holy grail of parenting and that if your baby isn’t hitting this milestone by (insert whatever age you like here), it’s a disaster or they’re not a good baby or you’re not a good mother or you’re allowing them to create bad habits etc. etc.  But the truth is that every baby is unique, sleep needs vary tremendously between kiddos, and learning to “sleep through the night” is a developmental milestone that you can’t really force a baby to hit before they’re ready, just like you can’t force them to sit up or crawl before they’re ready. Also, it’s important to remember that even as adults we wake up several times in a night (because we’re thirsty, or hot, or cold, or have to use the toilet, or had a bad dream, or heard a loud noise, or are stressed about something, or uncomfortable, or or or…), but the difference is that as adults we have learned to roll over, self-soothe and go back to sleep. Babies are still learning this skill.  It takes years for them to fully master it, and until they do, they often still need our help, input and reassurance to fall back asleep. Meeting a baby’s needs is not “creating bad habits”; it’s being responsive and attentive to the baby’s needs, which in the long run will create more security and independence.

Strangely enough, discussing sleep and self-soothing is a very “controversial” topic. On parenting boards and facebook groups and public forums, there are strong advocates for sleep training, using either “controlled crying”, “gradual extinction” or “crying-it-out” (CIO) methods as a way of teaching a baby to sleep through the night. There are equally strong advocates against these methods. Because every parent is exhausted (EXHAUSTED!), there is an unending market for books, sleep gurus and training methods as desperate parents (understandably) look for ways to get more sleep. And not surprisingly, the message you get from mainstream sources, news articles and “how to get your baby to sleep” books suggest that a baby who isn’t sleeping through the night by (insert whatever age you like here) is a problem that needs to be fixed. But what I am more interested in looking at is the actual science behind these differing approaches. Research into sleep, such as what Professor Helen Ball at the University of Durham is doing through the Infant Sleep and Information Source, is still a relatively new field, but there is a growing body of evidence which is beginning to refute the claims of the many (insanely popular) sleep experts and authors and gurus who recommend this or that sleep training technique.  The following is a round-up of some of these articles.   

First, Sarah Ockwell Smith has a great article on realistic sleep expectations for babies. As you can see, there is A LOT of normal variation in this, and even if one baby is ready to sleep through the night at 8 months, another baby might not be ready to do so at all. Each kiddo is unique and has different needs. 

Sarah Ockwell Smith also has a good article on what’s really happening when you teach a baby to “self-soothe”. Unfortunately, sleep training methods don’t really teach our babies to self-soothe. This is a developmental skill which they can only learn with time and maturity. Instead, it teaches a baby to stop signaling her distress. Babies are smart and they very quickly learn that if crying doesn’t bring a response, it would be better to conserve their energy instead and not use a method that doesn’t work. A study done in 2012 by Middlemiss et. al. monitored the cortisol levels (i.e. stress levels) in 25 mom+baby pairs and found that at the beginning of the study, the mom and baby were synchronised in their stress response, meaning that when the baby was stressed and signaled this to the mother, the mother responded to this with a rising cortisol level of her own. In other words, if baby was distressed, mom was distressed, and their cortisol levels were in sync. By Day 3 of the study, after using a gradual extinction sleep training method, the researchers found that the baby was no longer exhibiting stressed behaviour, but the baby was still distressed (as demonstrated by high cortisol levels). Meanwhile, because the baby was no longer signaling its distress, the mom’s cortisol levels had decreased, indicating that she was no longer in sync with her baby (at least in terms of cortisol levels).

Calm Family wrote a very detailed response to the BBC One’s recent airing of Panorama, Sleepless Britain, which addresses many of the ways “sleep issues” are portrayed in the media.

The Analytical Armadillo, another IBCLC blogger, has also written a good analysis on what happens during self-soothing, and that even though it works (and it does work), it’s not necessarily harmless.

Evolutionary Parenting looks at the science behind exposing our kids to stress, and what’s actually going on neurochemically in their brains when this happens. 

Uncommonjohn also looks at the science behind self-soothing

The Milk Meg writes about the many reasons our babies wake so frequently in the night.  

And while this doesn’t actually get into the science behind it, Mama Bean Parenting documents quite…succinctly…the many, many, many messages we receive in our society which tell us that a baby that doesn’t sleep through the night is a “problem”.

Finally, Dr. Sears has some good suggestions on ways to get more sleep without using CIO methods, as does Dr. Jay Gordon in this article. The Milk Meg also has some ideas on ways to gently night-wean breastfeeding babies.

And one final disclaimer, since I know this is an incredibly sensitive subject for many parents. I understand the desperate need, the overwhelming desire, to somehow find a way to get more sleep! We’ve all been there. Many of us are still “there”.  Parenting is exhausting, and waking frequently with our babies in the night is not at all conducive to our modern lifestyles. I absolutely get it. And I have many clients and friends who have used sleep training methods, sometimes with very good results–hell, I’ve attempted a few of these methods myself with my first son out of sheer desperation (but wasn’t able to follow through with them). I am in no way judging the reasons why parents might turn to these methods, and I have nothing but empathy for the desperate exhaustion that makes these methods seem like the only answer. Getting more sleep is a positive thing for everyone involved, and allows us to be better parents, and in our bleary, sleep-deprived states figuring out how to get more sleep seems all-consuming and anything promising a quick fix seems like mana from heaven. But it’s important that we as parents do careful research and make informed decisions before deciding on a parenting course of action. Our media and society is saturated with messages about sleep and ways to “fix” it, and nearly all of these messages usually recommend some form of sleep training. That is one side of the debate. All of the articles I have posted here are the other side. It’s important to understand both sides before making an informed choice.

As a midwife, asking “Is your baby waking regularly and feeding regularly?” is a much more supportive and useful question for new parents instead of “Is your baby sleeping through the night?”. Most likely, a normal and healthy baby who’s feeding regularly and growing well will NOT be sleeping through the night, so rather than make parents feel like there’s something wrong, it’s much better to emphasise what’s absolutely right about this scenario. And then look for other ways to support exhausted parents to sneak a bit more sleep into their lives.