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Author: Ali Monaghan

Midwifery in America

Midwifery in America

I’ve gotten a lot of questions the last few months from fellow students and other midwives here in the UK about exactly what midwifery is like in America. There is a fair bit of confusion about the roles. Some people I’ve encountered think that midwives in the US don’t do any actual baby catching, but they’re confusing the role of US Labor & Delivery nurse with that of the US midwife.  It IS confusing because in the UK, L&D nurses don’t exist. Instead, the UK midwife does both the US L&D nurse’s job AND the US midwife’s job.  I also think the role of the midwife and scope of practice varies a great deal between the US and UK as well, and midwifery in general in the US is so confusing because there are two different standards of midwifery care there (CNM v. CPM). So in conclusion, a post to explain US midwifery and the differences I’ve noticed so far between the US and UK seems like a good idea!

First, here in the UK, a midwifery degree is an entry-level degree (i.e. a Bachelors degree) and the majority of midwives are direct-entry midwives (meaning that their degree is in Midwifery, without first having to obtain a nursing degree before becoming a midwife). Granted, there are some people here who come to midwifery after having obtained a nursing degree first (and there is a handy 18-month program which allows them to become midwives fairly easily), in which case they are both a nurse and a midwife after they qualify (and will have a Bachelors in Nursing and a Bachelors in Midwifery). Crucially, though, the practice of nursing and midwifery are separate fields of study here, and separate qualifications (although there is a lot of overlap in the subject matter, such as basic health skills). The labour wards here in the UK are staffed by midwives (and if there are staff members who are both midwives and nurses working there, they would be working on labour ward in their midwifery role and not in their nursing role). Labour & Delivery nurses do not exist in the UK (although there might be a few specialist nurses who do work on the labour ward occasionally in a nursing capacity) and the majority of the work done on the ward is done by midwives. After completing her midwifery education here, a midwife qualifies and joins the register through the Nurse and Midwifery Council (NMC) and has the title of Royal Midwife (RM). There is ONE standard for midwifery care here, which is defined, set and monitored by the NMC, and there is only one main professional organisation which supports midwives in this country (the Royal College of Midwives) versus two in the US (see below).

In contrast, in the US there are two different routes to midwifery, and three legally recognized titles that you can practice under as a midwife: Certified Nurse-Midwife (CNM), Certified Midwife (CM) and Certified Professional Midwife (CPM). Instead of one national accrediting body for midwifery educational programs, there are two: the American College of Nurse Midwives (ACNM) and the Midwifery Education and Accreditation Council (MEAC). Instead of one national board exam, there are two different exams administered by two different organizations: the American Midwifery Certification Board (AMCB), which administers the board exam to qualify as a CNM/CM, and the North American Registry of Midwives (NARM), which administers the board exam to qualify as a CPM. The acronyms alone are enough to make your head spin!

The ACNM (American College of Nurse Midwives) is the professional organization of Certified Nurse Midwives (CNMs) and Certified Midwives (CMs). Nearly all of the members of the ACNM have a Bachelors level nursing degree first, then go on to obtain an advanced degree in midwifery (usually a Masters degree), and are then credentialed through the ACNM. A very small subset of this group are “direct-entry” midwives, meaning that they don’t have any prior nursing education before beginning their midwifery training, although they do have a Bachelors already, usually in a related field like public health or sociology or biology or chemistry; a direct-entry student goes through the exact same program as her nursing compatriots, and when she graduates she takes the exact same board exam, and is credentialed as a CM, rather than CNM (both CNMs/CMs are credentialed through the American Midwifery Certification Board (AMCB)).  In this pathway, midwifery education is a Masters level degree, and when they graduate, a CNM/ CM is a a mid-level provider. They work autonomously are able to practice in all 50 states, prescribe medications in many of them, and are able to work independently as autonomous providers (although in some States they have to have a written practice agreement with a doctor in place in order to be able to practice legally).

In contrast, Certified Professional Midwives (CPMs) obtain certificates through midwifery-education programs which are accredited by the Midwifery Education and Accreditation Council (MEAC), and when they graduate, they are credentialed through the North American Registry of Midwives (NARM) and become CPMs. Like CMs, CPMs are direct-entry students, with no prior nursing education or experience. And because CPMs are not nurses, nor are they credentialed through the ACNM, they aren’t allowed to join the ACNM. The professional organization which represents the interests of CPMs is the Midwives Alliance of North America (MANA), which seeks to represent the interest of every type of midwife in North America, including CNMs/CMs (even though their interests are already being represented by the ACNM). While some midwives (well, CNMs/CMs) belong to both organizations, I think the majority of midwives tend to pick one or the other, if they even join at all (and just think how much further the profession as a whole could get if every midwife in the country actually joined their professional organization and paid dues, which could then be applied to projects and lobbying which actually benefits midwives and our profession. Sadly, of course, membership is never even close to 100%, which is really disheartening. Membership in the American Medical Association is much higher—I have never known a US doctor who was not also a member—and just look at what a powerful and influential organization the AMA is—i.e., look what happens when a professional organization actually has money! Ahem.)

Are you confused yet?

Now, there are so many problems with this I don’t even know where to start. Someone looking in from the outside could very sensibly say: well, don’t you think you’d have more power and more political clout and be better understood by the public and by other professions if all of you midwives just got together and decided on ONE standard definition, ONE standard credential and ONE professional organization to represent you? And of course, the answer to that would be a resounding YES! In countries around the world where midwifery has a very strong professional presence, and where midwives are not only highly respected but also deliver the majority of the babies in that country, invariably you will find that there is one unified professional organization for all of the midwives of that country, one standardized educational track and one credential. Here in the UK when you say “I’m a midwife”, no one needs to ask if you’re a nurse-midwife or a direct-entry midwife or if you have a Masters Degree or a Certificate. The profession of midwifery has one standardized definition of what midwifery entails, one credential, one professional organization and one standardized scope of practice. I’m sure this must really simplify things, and allow the profession of midwifery to move beyond issues of sorting out its own mess and instead tackle larger goals and issues and missions which are important to the entire profession, as a whole.

In America, because of all of the different credentials and the differing legal status of midwives from state to state, we’ve got an enormous range in our scope of practice. CNMs can legally practice in all 50 states. CMs are legally licensed in 5 states at the moment, and CPMs are legal in 33 states. CPMs most often work in birth centers or homes, while CNMs/CMs can work in hospitals, birthing centers and homes. Depending on what state you live in, a CNM/CM may or may not be able to prescribe drugs, or admit private patients to a hospital. In some states, CNMs/CMs are required to work with a collaborating physician in order to practice legally, in others they can practice autonomously (is this also true for CPMs? To be honest, I’m not sure. Any CPMs who are reading this, please let me know!). The scope of practice for CNMs/CMs can range from primary care to family planning to birth control to hormone replacement to basic gynaecology. To be honest, I’m not sure if CPMs can do all of this as well (CPMs who are reading this, can you? Or is that a state by state thing, too?). In other words, it’s a hodge-podge mess. And maybe that’s just the nature of the game, given that America is a conglomerate of states, and because each state wields so much independent power, laws vary considerably from state to state.

One of the biggest differences I’ve noticed, though, is the difference in power and influence that the profession holds in each country. Prior to the turn of the 19th century in America, there were thousands of traditional, apprentice-taught midwives practicing in America, and most births were still attended at home by midwives as they always had been. “Native American midwives continued to attend women in their tribal groups, as did colonial midwives among the white settlers, Hispanic midwives in their southwestern communities, immigrant midwives accompanying their ethnic groups, and black granny midwives in the American South” (Davis-Floyd & Johnson, 2006). However, starting in the early 1900s, doctors began to move into the lucrative birth business in droves and launched a comprehensive smear campaign against traditional midwives, stereotyping them as dirty, ignorant, uneducated and careless. This was happening at the same time that birth was moving out of homes and into the hospitals, which were portrayed as clean, modern, hygienic, progressive and cutting-edge. In this regard, patriarchy also played a part; it made sense to accept male dominance and authority in obstetrical matters when the cultural norm already viewed men in this role, and male inventors had ushered in the modern age through new technologies such as electricity, railways, cars, telephones, etc.–chloroform in hospitals and forceps deliveries felt like the future in this context (Davis-Floyd & Johnson, 2006).  Mainstream cultural pressure and assimilation also made giving birth with private physicians fashionable and trendy, while cultural, socioeconomic and language barriers made it nearly impossible for traditional midwives of different ethnic groups to join together to collectively fight the physician’s propaganda against them. The end results was a complete decimation of midwifery as a profession in the US; in the 1800s, midwives attended the majority of all births, but by the mid-1900s, midwives attended a tiny minority of births, often illegally (Davis-Floyd & Johnson, 2006).

Nurse-midwifery in its modern incarnation first appeared in the US in the mid 1920s, after Mary Breckenridge, a public health nurse, travelled to the UK and trained there as a midwife, returning to rural Kentucky to found the Frontier Nursing Service (FNS), which brought the UK midwifery model of care to isolated and deeply impoverished Appalachian communities. This model of care was also adopted in New York City through the establishment of the Lobenstine Clinic in 1930, which began to train nurse-midwives to care for the underserved communities in Harlem, Hell’s Kitchen and the Bronx, tending to “populations in dire need that physicians were not attending [to], and did not wish to attend [to]” (Davis-Floyd & Johnson, 2006). During the World Wars, nursing had established itself as a profession and organised itself as a professional body, and America’s earliest modern midwives were able to use the legitimacy of the nursing profession to overcome the negative stereotypes surrounding midwifery; in this way, modern midwifery in the US has been associated with nursing from the very beginning, despite the fact that midwifery is its own profession, separate from nursing. The growth of nurse-midwifery was very slow through the fist half of the 20th century as nurse-midwives still had to fight against the negative stereotypes of ignorance and unprofessionalism, but little by little, gains were made. The first graduate-level midwifery education program was opened in 1956 in Yale’s Department of Nursing (again linking midwifery to nursing in the US), and the ACNM was formed in 1955 after nurse-midwives were unable to create their own niche within the newly created American Nurses Association (ANA). The post-war baby boom also opened up new opportunities for nurse-midwives as over-stretched hospitals in New York and Baltimore began to rely on them to cope with the increasing numbers of women giving birth (Davis-Floyd & Johnson, 2006). This resulted in nurse-midwives moving into hospital-based practices in greater numbers, which decreased their autonomy but increased their knowledge base and ability to deliver care to a larger number of women. However, nurse-midwives’ adaptation to hospitals and adoption of hospital norms was so complete that by 1973 the ACNM actually issued a Statement on Home Birth which declared that giving birth in a hospital was the preferred location due to increased safety (in 1980, ACNM retracted it’s original statement on homebirth and instead endorsed nurse-midwifery practice in all settings, but to this day, the majority of CNMs still practice in hospitals) (Davis-Floyd & Johnson, 2006). The ACNM continued to develop a national certification process and education programs, and by the end of the 1970s there were 19 nurse-midwifery education programs, nurse-midwives could legally practice in 41 states, and combined they attended a little bit more than 1% of all births in the US (Davis-Floyd & Johnson, 2006).

And then along came a midwifery renaissance in the US, spear-headed by one of the world’s most famous midwives, Ina May Gaskin. This renaissance was fueled by the turbulent cultural changes occurring in the 1960s and 1970s through the counterculture and feminist movements, as well as in response to the rampant over-medicalization of birth. Hospital birth from the 1930s – 1960s was increasingly restrictive and technocratic, with women disempowered recipients of authoritarian care, where the doctor was the “expert” and the woman was the”patient”, combined with restrictive practices like routine pubic hair shaving and enemas, routine episiotomies, routine use of forceps and common use of twilight sleep, which was a combination of morphine and scopolamine, a psychedelic amnesiac designed to take away the memory of the birth–which it did in spades, but it also transformed women into wild animals during the delivery (Davis-Floyd, 2003). Women receiving twilight sleep were often out of their minds and hallucinatory, strapped down to beds, left alone to scream, or put in padded rooms, only to wake up afterwards with a baby in their arms and no true memory of the birth experience except for scary flashbacks and nightmares which would haunt them for the rest of their lives (the TV series Mad Men did an excellent job of portraying this in Season 3 when Betty Draper gives birth to their third child). In the 1970s, giving birth became a feminist issue, with women clamoring to reclaim birth and humanise and personalise the birth process (NEWSFLASH–respecting basic human rights during birth is STILL an issue we’re battling today!) and midwifery care became a hallmark of this movement away from a disempowered, technocratic birth experience towards a more natural, woman-centered birth experience (Davis-Floyd, 2003). In the hospitals, the use of twilight sleep died out, routine shaves and enemas were no longer performed, and nurse-midwives in the 1970s and ’80s worked to include partners at births and to begin to remove barriers to natural childbirth like routine lithotomy position, routine forceps and episiotomy, and sterile drapes separating moms and babies, as well as promoting unmedicated birth and breastfeeding (Davis-Floyd & Johnson, 2006). But there was also an increase in the popularity of home births during this time, and more women became interested in providing and receiving midwifery care outside of the hospital paradigm, which increased the number of grassroots direct-entry midwives practicing in the country. These direct entry midwives (also called “lay midwives”), like Ina May Gaskin, Raven Lang and Anne Frye, were apprentice-trained and not formally educated like nurse-midwives, and by the end of the 1970s were also attending approximately 1% of all US births.

At first, these small clusters of lay midwives were unaware of each other, but because of growing interest in their counterculture message, the publication of books like Spiritual Midwifery and The Birth Book, and the media attention this brought, lay midwives began to band together and organise themselves. According to Robbie Davis-Floyd’s (2006) anthropological documentation of midwifery in the United States, there was probably a period of time when direct-entry lay midwives could have been folded into the ACNM, if the ACNM had been willing to drop the nursing requirement from its educational pathway and addressed some of the philosophical concerns of the lay midwives. But instead the ACNM affirmed its belief  that midwifery in the US required formal education and a nursing background (the ACNM later changed its mind about the nursing requirement, and went on to develop its own direct-entry pathway for non-nurses to become midwives, hence the credential of Certified Midwives (CMs)). Therefore, since lay midwives were not welcomed into the ACNM, in 1982 they decided to form their own professional organisation, the Midwives Alliance of North America (MANA), later going on to create the credential Certified Professional Midwife (CPM). As CPMs and MANA continued to evolve, they began to develop their own knowledge base, values and philosophy of care based on their greater understanding of unmedicated birth in homes, and went on to create an educational pathway that would teach and support this knowledge base without being incorporated into the more “medicalised” hospital environment. As it stands right now, CPMs can legally practice in 33 states, and The Big Push for Midwives continues to advocate and lobby for further legalisation in the remaining states (whereas CNMs can practice in all 50 states).

Thus through the history of modern midwifery in the US, we can see why there are two midwifery organisations, two educational pathways, two accreditation programs, and three different midwifery credentials you can obtain! And unfortunately, it seems like the chances of MANA and the ACNM actually getting together and coming up with one unified plan for midwifery in the US are very slim. There have been many attempts in the past to align both groups, most notably during the Carnegie Meetings sponsored by the Carnegie Foundation in the late ’80s through the mid-’90s, and subsequent MANA/ACNM Bridge Committees continue to keep a dialogue open between the two organizations (Davis-Floyd & Johnson, 2006). However, it seems unlikely these two organisations will be joining together any time soon (and I’m sure there are many midwives who would argue that that’s a good thing). Part of the problem is that the interests of these two groups are now quite distinct and it’s hard to find common ground. Many CPMs who are trained through apprenticeship view apprenticeship as a key component of their education, and therefore MANA is unwilling to give up apprenticeship training as a viable route to midwifery, whereas the ACNM has a long history of valuing graduate-level university education and is unwilling to accept apprenticeship as an equal educational pathway. There’s also an undercurrent of disdain between some members of both groups, unfortunately. I think that *some* CNMs/CMs (certainly not all!) have a tendency to look down on CPMs as being under-educated, unacademic, tradition-based rather than evidence-based, and not very clinically well-informed, while *some* CPMs have a tendency to look down on CNMs/CMs as being too interventionist and technocratic (“medwife” v. “midwife”), too quick to view pregnancy from an medical/obstetrical lens, too eager to suck up to the American Medical Association (AMA) and/or the American Nursing Association, and having lost touch with the heart and soul of midwifery. There’s really no point in arguing which point of view is right; they’re both flawed, and so long as this continues, the profession of midwifery in America will continue to struggle. The bigger picture is that right now midwives (of whatever credential!) in the US only attend 8% of all births, while in the UK midwives attend over 50% of all births!

In the UK midwifery took a much different route. Midwives in the UK were able to organise as a profession as early as 1881, and the first legislation legalising the profession was passed in 1902 through the Midwifery Act for England and Wales. Therefore in the UK, midwifery has always been its own profession, separate from nursing, and midwives have consolidated and maintained their position as the primary caretakers for pregnant women. In fact, the power of midwifery is so strong in this country that even in high risk cases, where women are very much being cared for and managed by obstetricians, they are still collaboratively managed and still have visits with midwives as well os OBs during their pregnancy in order to preserve some pregnancy normality for them. At the hospital where I am currently doing my clinical placements, midwives manage the majority of labours (doing both the US equivalent midwifery role AND the US equivalent Labor & Delivery nurse role combined) and call the OBs in for assistance when needed, but are very much autonomous practitioners. It’s true that the scope of midwifery practice is more limited here in the UK than my scope was as a CNM in New York (and as you can see from above, my experience in New York was quite specific to that state, and by no means an similar to other states). For example, I was trained in gynaecology as well as primary care and midwifery; many of the women I saw in the clinic weren’t even pregnant, but were coming for routine gynaecology appointments, such as contraception (in NY state I could prescribe all forms of contraception, as well as insert intrauterine devices/ coils), STI screening and treatment, fibroids, or abnormal uterine bleeding; I would often order initial work-ups such PCOS lab tests or basic fertility lab tests and then refer them on to my physician colleagues for further care. I occasionally saw women who were menopausal or had issues with prolapses, and of course took care of pregnant women through their pregnancy, births and postpartum period. However, in my experience midwives enjoy a much greater degree of respect, recognition and empowerment here in the UK. There are often campaigns designed to thank and recognise the midwifery role, such as the Pampers ‘Thank You, Midwife’ campaign, and I still get such a kick out of not having to explain to people what a midwife IS when I tell them that I’m in midwifery school…here in the UK, everyone knows what a midwife is, and most people I talk to have a great deal of interest and admiration for the work midwives do.

So perhaps this helps to clarify just a little bit the ways that midwifery is different in the US versus the UK? (And of course, if I’ve misrepresented anything, or gotten anything wrong, please let me know–especially with regards to CPM legislation and scope!)

 

Davis-Floyd, R. (2003) Birth as an American Rite of Passage. London: University of California Press.

Davis-Floyd, R. and Johnson, C.B. (2006) Mainstreaming Midwives: The Politics of Change. London: Routledge, Taylor and Francis Group.

 

Student Midwife Life: The Forest for the Trees

Student Midwife Life: The Forest for the Trees

I had other plans for my #70midwifebloggers post. Something better researched. More topical. Some lovely commentary or analysis on what’s currently happening in the world of midwifery today. Oh, and did you hear that there was a royal baby born recently too?

But no. Today, managing to write a blog post, ANY blog post, in my currently-overwhelmed student midwife existence is enough. More than enough.

So what I’m going to write about is the overwhelm. I don’t really have any answers for it, but for me, writing always helps.

It’s hard to be a student midwife. Having been on both sides of the equation before, both a student and qualified midwife, I can say with confidence that once you qualify, it’s easy to forget just how hard it is to be a student. There is a sort of misty, rose-tinted glass effect that happens once you qualify where you start to look back on your student existence fondly–you may even start to think that you had it easier as a student. I think that’s because once you qualify, the sudden weight of responsibility that sits so firmly on your newly-qualified shoulders feels so stressful that it’s only natural to want to return to your more familiar student existence before you had so much responsibility, and to therefore view your student existence as the easier of the two.

But being a student again, currently, reminds me of just how difficult student life is. Learning is hard. Becoming something new is hard. Being in a nascent, in-between place is always challenging–no longer a layperson, but not yet confident in your role and knowledge as a clinician, not yet fully-formed in your opinions or identity, not yet having acquired all of the skills and experiences you need to be competent. Uncertain in so many situations. Wobbly and tentative, and constantly being presented with new situations and new experiences you’ve never encountered before. It’s an uncomfortable place to be.

Then, add to it this the demands of student existence. Students work 12-hour shifts, sometimes with no lunch breaks (and sometimes not even a chance to wee), just like a qualified midwife does, except that once you return home from said shift, the expectation is that you’ll be studying and researching and writing papers during your down-time, instead of vegging on the sofa and watching Netflix all day. (And trust me, after some of these shifts, vegging on a sofa is all you want to do, and is just about all that you’re fit for!). Down-time when you’re a midwife is essential for replenishing your stores. There is endless research detailing exactly how important this is, especially in caring professions where you give so much of yourself at work. If you don’t recharge your batteries, you burn out, it’s as simple as that. And as students, we need this just as much as any qualified midwife does. EXCEPT we have even less time for it.

The to-do list is intimidating. I have a massive assessment due in 10 days which I should be writing right. in. this. moment (except I’m not, I’m blogging instead, to take a break and recharge said batteries). I have physiology modules to complete that I am WAY behind on. I have case study scenarios to be writing up. I have a presentation on varicella which I should be starting to think about at this point, but I’m not because I’m still too snowed under by my more pressing assignments. Oh, and don’t even get me started about the OSCEs, yet. I am an ostrich with my head in the sand about those–la la la la la! Year Two is seriously intense! (Brief shout out to all my fellow Year Two compatriots out there–man, I feel you!) And on top of this I am currently on-call for three women whom I have case-loaded and who are due any day now (and I have heard nary a peep from them yet), so I could be called to a birth at any moment. Just like qualified midwives, students also live their lives on tenterhooks, always thinking “maybe I should nap now, in case I’m up all night”. It’s always in the back of my mind, the maybe-I’ll-have-to-drop-everything-and-GO. And if you have kids, like I do, that feeling combined with the what-in-the-world-will-I-do-for-childcare-if-I-get-called-rightnow-? feeling is pretty stressful.

And then there are the mentors. Nearly all of whom are LOVELY. But even with the nicest and most supportive mentor in the world, it’s still exhausting to have to work with and prove yourself to new mentors again and again. To have to build a rapport, not just with the woman or couple that you’re caring for, but with your mentor as well. To have to build a rapport while simultaneously being evaluated and assessed by your mentor.  And to also have to constantly adjust yourself to different people’s approaches and philosophies and styles of care, while simultaneously trying to form your own, fledgeling philosophy and style of care in the process. And sometimes the mentors forget how hard it is to be a student. Sometimes their expectations are too high. Sometimes your personalities don’t quite mesh. Sometimes they’re having a bad day. Sometimes you’re not nearly as well supported as you were hoping to be.

Finally, let’s not forget the work itself. This is demanding, all-encompassing heart work. This is physical, 12-hours-on-your-feet work: lifting, pulling, stretching, leaning, walking, running, pushing gurneys work. This is emotions so big you sometimes think you’ll burst. This is balancing a myriad of conflicting demands, coursework and motherhood and busy schedules and shifts, hospital policies which don’t align with birth plans, feathers that need to be smoothed, bad news that has to delivered with such sensitivity and care, personalities that have to be carefully navigated, emergencies that are terrifying and heart-rending, beauty so raw that it will sometimes make you cry, and sometimes sadness so raw that it feels too heavy to even hold. Mothers who need more time and support than you have to give. Resources that aren’t available, so you cobble solutions together, piece together equipment with tape (literally and figuratively), think fast on your feet, and sometimes fill needs from your own stores (which then need replenishing).

It’s daunting. And yet, every day, from this scary, in-between, uncomfortable place, students bravely get up every morning and put themselves out there again. That’s what the course requires of you: dedication, commitment, time, energy, focus, love, and putting yourself out there again and again and again. Making mistakes, and picking yourself back up, again and again and again.

It’s easy to forget why you’re doing this. It’s easy to lose sight of the forest for the trees. The big picture is vast, and you get so bogged down with the minutiae–why does preeclampsia cause proteinuria, what are the warning signs of obstetric cholestasis, how many weeks into the pregnancy before you start to measure the symphysis to fundal height, why does diabetes increase the risk of macrosomia, what are the diameters of the pelvic inlet–that you lose sight of the horizon. You find yourself wondering why you’re away from your family SO MUCH. Why you’re so tired all the time. Why you thought this was a good idea. Most of the student midwives I meet are so passionate about midwifery care, about making positive change in people’s lives, about making midwifery care better. But if the candle flame isn’t fiercely protected, it’s easy to accidentally blow it out. This is why so many students midwives leave the course, and given how desperately the NHS, and the UK, need midwives right now, we honestly can’t afford to lose a single one.

So what helps you stay the course? What helps to keep from losing sight of the goal? What ensures that your flame continues to burn brightly? I don’t have all the answers, not by a long shot. But what helps me is community. Knowing that I’m not alone. Talking with my friends and student peers who are on the course with me, who totally get it. Being part of online student groups and Facebook groups and the chaotic, messy twitterverse.  Leaning on my family and friends. Having dinner out with my friends (who I really wish I got to see more often). Laughing. Watching Game of Thrones (even when I know I should be studying). Cutting myself some slack (easier said than done!). Exercising–even (and especially) on the days when I think to myself: I’m just too busy to go for a run today (those are the days I most need to run)! Hugging my kids, kissing my partner, sucking up oxytocin whenever I can, and reading an extra bedtime story to my kids just because I want to. Cooking good food for myself (and then eating said food)!

This pin board helps me as well. It’s a silly thing, I know, but it sits over my desk and I find myself looking at it a lot while I’m studying. When I forget why I’m doing this, these pictures are a visual representation of my answer. This is why. Women and their families deserve this type of care, and it’s my privilege to be able to provide it.

So, I’ve used up an hour that I should have been using to write my essay on HIV in pregnancy. But maybe this post will help other students remember that they’re not alone either. And if that’s the case, that’s an hour well spent, and a good reason to blog.

What in the world is a Lotus Birth?

What in the world is a Lotus Birth?

A Lotus Birth is the practice of keeping the placenta intact and attached to the baby for the first few days of the baby’s life, until the cord dries out and naturally falls off on its own, just like a cut umbilical cord would, usually within 3-10 days of the birth.  When I first heard of this practice, back in 2002 as a nursing student, I was completely aghast. Why in the world would anyone want to do something like that?? What do you do with the rotting and mouldering placenta that’s still attached to the baby? How do you dress the baby and care for the baby with the cord still attached?? I had a million questions, and the entire concept seemed completely alien.

(Photo courtesy of Danella Jade, 2018)

Further research into the subject, though, has changed my mind. It turns out many indigenous and aboriginal cultures honour the placenta, which makes a lot of sense when you think of the placenta as a guardian that has nourished and supported the baby in utero. Moari tradition buries the placenta on tribal land to help foster a connection in the child to that land. In the Hmong tribe in South East Asia, it’s believed that the placenta must be retrieved by the spirit after death, in order to ensure physical integrity in the next life, and therefore the placenta is always buried under the house where the baby was born so that the spirit will know where to find it (Buckley, 2003). In Zimbabwe, the placenta is buried by the family home to ensure that the child will always want to return home, and in Cambodia people believe that the child will stay safe so long as they are always near to their placenta (Buckley, 2010).  In Bali, the placenta (as well as the cord, amniotic fluid and blood) are called ‘Ari-Ari’, which means “younger siblings”, and these tissues–and in particular the placenta–are treated with the utmost respect, often bound in a coconut shell or placenta bag with herbs and flowers and buried outside the home (where it’s marked with a stone and then later a prickly bush is planted on top to help protect it).  A Balinese child will greet their placenta in the morning, and pray to it for protection at night, and the spirit of the placenta is thought to live on as the child’s guardian throughout their lifetime (Buckley, 2010).

(Photo credit: Nick and Vanessa Fisher)

In Western culture, the placenta is mostly seen as medical waste, and is often collected into biohazard bags and disposed of or incinerated by the hospital. The newer trend of placenta encapsulation, as well as some couples wishing to follow more traditional practices such as burying their child’s placenta under a tree in their garden, has led to more placentas being requested and brought home from the hospital than ever before.  Lotus Birth was first documented among chimpanzees, but was never practiced by humans until Claire Lotus Day (inspired by some of Jane Goodall’s research) sought an alternative to the routine cutting and clamping of the cord in 1974 and found an obstetrician who was willing to honour her wishes and leave the cord and placenta intact until they fell off naturally (Buckley, 2003; Lim, 2001). Since that time, Jeannine Pavarti Baker, Shivam Rachana and Dr. Sarah Buckley have all been proponents of Lotus Birth, and more recently Michel Odent has also spoken about the advantages of it.  While I can completely understand that this practice might not be for everyone, there are many good reasons to at least consider it.

First and foremost, a Lotus Birth would ensure that optimal placental transfusion occurred. At birth, one third of the baby’s blood supply is located in the placenta, and this vital supply of blood, oxygen, nutrients and stem cells rightly belongs to the baby (and is not waste!).  Left undisturbed, Mother Nature will gradually perfuse the baby with the remaining blood over the next several minutes while the placenta is still attached to the uterine wall; eventually, the cord will stop pulsing and the perfusion will end, often heralding signs of placental separation, followed by the delivery of the placenta. (I’ve written a lot more on physiological management of the third stage of labour in a different post). In hospitals right now, there is a big push to better support optimal cord clamping as we learn more about exactly how important this blood is to the baby. Recently, both NICE and WHO changed their guidelines to reflect the new research on this topic, urging practitioners to wait at least a minute before cutting the cord to allow placental transfusion to occur (a practice known as ‘delayed cord clamping’). However, other clinicians like Amanda Burleigh, founder of the “Wait for White” campaign, argue that a 1 minute delay isn’t nearly long enough to allow full placental transfusion, and believe that we need ‘optimal cord clamping’, which involves waiting until the cord has turned white before cutting it (more information on this can be found at Blood to Baby and in this fabulous podcast with Amanda). Unfortunately, there’s still a lot of room for improvement in this area, and lots of cords are STILL getting cut way too soon. But opting for a Lotus Birth would ensure that this would never even be a question, as the baby would receive their full portion of blood and the cord would never be cut (too soon, or otherwise).

Additionally, a Lotus Birth helps preserve the mother-infant bond, and helps enforce a “lying-in” period, or a “breaking-forth”, as Dr. Sarah Buckley calls the time between when the baby is born and when the cord naturally falls off (Buckley, 2010).  It’s hard to get out and about with a baby who’s still attached to a cord (although not impossible, as placenta bags are portable and easy to use), and the practice ensures that the first few days unfurl at a slower, more gentle pace, with the mother taking it easy and spending the majority of her time resting and bonding with the baby. A baby who’s still attached to the cord is a visual reminder to visitors that the baby is still new and needs to be protected, and also helps prevent the baby being passed from one excited relative to the next (potentially to the mum and baby’s detriment). It’s also a bit harder to fully dress a baby who’s cord is still attached, which gently encourages skin-to-skin bonding to keep the baby warm, rather than dressing, and we know how important uninterrupted skin-to-skin is when it comes to establishing breastfeeding.  Anecdotal reports have emphasised the calm and peaceful transition Lotus Birth allows for, as well as the calmer and more relaxed temperaments of babies who are still attached to their cords (although this might be influenced more by the uninterrupted bonding and attachment fostered by a Lotus Birth, rather than the actual physical presence of an intact placenta). Author Shivam Rachana has written about how babies seem to automatically flinch or cry out or grab their cord as it’s being cut, and Robin Lim, international midwife and founder of the Bumi Sehat birthing center in Bali, reports on a Lotus Birth where the placenta was seen to pulse at the same time that the baby was breastfeeding (Lim, 2001). The father of that baby, himself a PhD biochemist, was amazed by this discovery, stating: “I am certain that something here is being communicated. I am not fooled by the dry appearance of the cord, deep in the center there is life. Something essential is being provided to my baby by his placenta,” (Lim, 2001). In the same article, Robin Lim beautifully sums it up:

Midwives are the guardians of normal birth. Yet in these times we may have forgotten what normal is. We are certain that a close bond between mother and child is normal. My experience is that Lotus birth facilitates that bond. Yes, it is inconvenient to move around with the baby attached to her placenta. So mother lies in, close to the baby and placenta; breastfeeding is established in this sacred circle of quiet, restful seclusion. Yes, few visitors feel welcome while the placenta is still attached. It is during this space out-of-time that family may be invented, and that the new mother reinvents herself.

 

(Photo credit: Veronika Richardson, Fox Valley Birth & Baby, “Tranquility”, 2018)

So what about the practicalities? How does one actually have a Lotus Birth?  This article is great for answering many frequently asked questions (with lovely images of Lotus Birth to boot).  According to Lotusbirth.net,  first you wash the placenta in warm water after it’s been delivered (and after it’s finished pulsing/ transfusing all its blood to the baby) and then pat it dry. Then place the placenta in a sieve over a bowl for about 24 hours to allow it to drain. After this, the placenta can be placed in a nappy or cloth and covered with salt and herbs like dried goldenseal, lavender, turmeric or sage, with more salt and herbs added daily and the nappy changed daily (if you have a placenta bag, the nappy can be placed inside the bag). There are no reported cases of infections being transferred from a degenerating placenta to a baby, although RCOG states that there is the potential for infection and advises that practitioners should act quickly if any signs of infection in the baby are noted. Many anecdotal reports state that the placentas dried out and remained surprisingly odourless for days when salt was used to preserve them.

Naturally, Lotus Birth won’t feel right to many women, but if this appeals to you, don’t hesitate to ask for it. As midwives, we need to be able to support all women’s birth choices, including Lotus Birth.  As quoted from a Guardian article on Lotus Birth: “Unsurprisingly, lotus birth is a minority home birth activity, says Mervi Jokinen of the Royal College of Midwives, although there is no reason you couldn’t ask for it at a hospital birth. “The people who do this are happy to see the experience as a life event and a natural thing. It’s difficult to make a clinical comment on this because there are no studies.” Which is all just to say that even if it’s an unusual practice, it’s absolutely something that midwives can (and should) support. We didn’t have a Lotus Birth with either of our home births, but looking at all of this information now, part of me wishes that we had!

 

Buckley, S. (2003) ‘Lotus Birth: A Ritual for Our Times’, Midwifery Today, 68 (Autumn 2003), pp. 36-38.

Buckley, S. (2010) The Amazing Placenta. Available at: http://www.mothering.com/articles/the-amazing-placenta/. (Accessed 8 March 2018)

Lim, R. (2001) ‘Lotus Birth–Asking the Next Question’, Midwifery Today, 58 (Summer, 2001), pp. 14-16.

Student Midwives Need More Exposure to Continuity

Student Midwives Need More Exposure to Continuity

(I wrote this post for the Continuity Matters campaign being run by the very inspiring Michala Marling–something which is very dear to my heart, and the gold standard for midwifery care.)

What if I told you that there was a new, magic intervention that was guaranteed to lower the rate of epidurals, cesarean births, instrumental deliveries, preterm births, miscarriages and even neonatal deaths? Sounds too good to be true, right? This intervention is so miraculous, though, that not only does it reduce all of those risks above, but it also increases the likelihood of having a normal, uncomplicated vaginal delivery. It even shortens the duration of labour, and women across the board not only feel more positive about their births, but also more satisfied with their care in general. Sounds incredible, right? If you were a pregnant woman, you’d definitely want to make sure that you received this intervention, right? You would be clamouring to get your hands on it!

But here’s the rub—this intervention already exists. It isn’t new—it’s been studied for decades, and all of the evidence is quite clear. It’s even something that the RCM and RCOG both agree on! The magic intervention? Relational continuity with your health care provider during your pregnancy, labour, birth and postnatal period. That’s it. Continuity of care and carer. Meaning that every time you have an antenatal appointment, it’s with the same midwife. When you go into labour, the midwife you know and trust is the one supporting you at your birth, and she continues to care for you during the first several weeks after the delivery as you weather the normal postnatal ups and down during your transformation into a mother. Continuity of care and carer. That’s all we need for better outcomes across the board. That’s the magic bullet.

And women don’t just need this, but midwives need this as well. Study after study has shown that when midwives are able to provide continuity of care to women (known as case-loading midwifery here in the UK), there is less burn-out, more job satisfaction  and more autonomous practice. Continuity of care is the one magic intervention which will improve maternity services across the board, in all areas, for women AND midwives. It really is that simple.

Except that it’s not. Very few NHS trusts provide a case-loading model of care for their maternity services. In fact, unless you’ve hired an independent midwife or a private midwife through a company like Neighborhood Midwives, chances are good you won’t receive continuity of care in your NHS trust. Which means that the majority of women in the UK aren’t receiving this amazing, life-changing, magical intervention. Because of this, increased continuity of care is a priority in both Midwifery 2020 and the Better Births Initiative.

I first experienced continuity of care as a brand new midwife working in Brooklyn with some of New York City’s most vulnerable women who were attending a Medicaid-only public hospital for their care. It wasn’t complete continuity of care and carer, but it was pretty close. In the antenatal clinic, when you did an initial booking visit with a woman, she would then follow-up with you for all of her future visits (assuming she was appropriate for midwifery care; any women in need of obstetrical care were transferred to the obstetrical team). Which meant that as her pregnancy progressed, you really got to know her, even though you only had 15 minutes per visit. In many cases, towards the end of the pregnancy, when you were seeing her on a weekly basis, you knew her so well that you recognised her name on sight, and knew all of her history without needing to consult the notes. You knew her birth plans, her hopes and desires for her birth, as well as her concerns and fears. You often also knew the names of her older children that she always brought with her to the visits, and in many cases, you knew her partner too. You could greet her with a familiar smile, answer her questions, and pick up conversations that you had left off the week before. It also meant that there was time for the relationship to grow and for trust to develop between you. In some situations, this meant that as she got to know you, she would finally feel comfortable enough to confide in you about domestic violence, substance misuse or other issues going on in her pregnancy—things she hadn’t been comfortable discussing at the earlier visits, and things she probably would never have mentioned if she was seeing a different provider for each antenatal appointment.

It wasn’t a perfect system by any means—the visits were still too short, and while there was continuity in the antenatal and postnatal setting, there wasn’t continuity on labour ward, which meant that we worked shifts on labour ward and delivered whoever happened to be in labour that day, rather than being called in for our own clients when they went into labour. However, sometimes, when I was lucky, one of the women I’d cared for in the antenatal clinic would be in labour during my shift, and then I was able to provide her with complete continuity. The look of joy lighting up her face when I would first come into her room as she laboured was always priceless—and it was a look of joy that was always mirrored in my own face as well, since it was an absolute pleasure to be able to care for women that I knew well and had formed a relationship with. In fact, many of my clients would inquire about my schedule during the weeks around their due date, and in some cases would try their best with acupuncture and spicy food and lots of sex to go into labour on the same days as my shifts.

I also had an opportunity to provide complete continuity of care briefly during a 5-month stint as an independent home birth midwife in Brooklyn. I was a younger midwife joining the established practice of an older midwife who had been providing continuity of care on her own for years. Unfortunately, she and I never really gelled as a team and the partnership was very short-lived, but the experience of providing care for women that I had an opportunity to really get to know well during (luxurious!) hour-long antenatal visits at their homes was indelible. As each woman approached her due date, at each visit, there was growing anticipation leading up to the birth, and when the phone call finally came that she was in labour, my first thought was often excitement and joy for her, rather than disappointment that I would have to leave my warm bed or whatever activity I was currently doing. This made the on-call slightly easier to bear, despite the fact that it was pretty brutal (we had to take on six births a month in order to be able to cover our salaries and our indemnity insurance, which, trust me, is A LOT of work in a month). I missed Thanksgiving, Christmas and New Year’s that year, and was sometimes away from my 1 year old son for up to 30 hours at a time. It wasn’t sustainable, but the continuity did provide enough joy to almost (almost) balance it out.

I was also lucky enough to be on the receiving end of continuity of care with both of my pregnancies. With my first pregnancy in the States, I knew from the very beginning that I wanted to have a home birth, so this automatically meant that we were going to have to seek out private midwifery services, since home birth is not provided in the US through any hospital-based system. My husband and I interviewed several midwives providing private services and finally settled on a two-midwife team that lived fairly close to us, and who seemed to click with us on every level. Over the course of my pregnancy, my visits were split between the two of them, so that I had an opportunity to get to know both very well, and by the time I went into labour, I felt equally comfortable with both of them. These two midwives took turns with the call, meaning that one of them would always be available by phone at any point in my pregnancy, and while I didn’t have to avail myself of their on-call services much during the pregnancy (except for one really bad case of the flu around 20 wks), it was a tremendous comfort to know that I could speak to my midwives at any point, whenever I felt like I needed them. It was also a tremendous comfort to know that when the big day finally arrived, it would be someone who knew me and my pregnancy well who would be picking up the phone to answer that call. And thank goodness for that! My first labour was a 56 hour marathon, during which time I lost hope on several occasions. However, because I knew and trusted my midwives and had a relationship of trust and respect with them, I believed them when they told me that things WERE progressing, that everything was normal, that we didn’t have to transfer to the hospital (in my labour-haze I had determined that hospital augmentation, or possibly cesarean birth, was the only way I was going to deliver). If I hadn’t known them and trusted them as much as I did, I don’t know that their words would have carried as much weight with me at a time when I was seriously doubting my ability to give birth. And lo and behold, they were right: 56 hours later, I did indeed give birth in my living room, surrounded by this loving circle of support!

With my second pregnancy, here in the UK, I was really excited by the fact that home births were a service provided by the NHS, and something that wasn’t viewed as inherently risky or completely crazy—what a relief to be in a country that valued evidence, had a thriving midwifery presence, and a long history of midwifery care as the norm for all pregnant women! However, when I began to inquire into what the NHS home birth service looked like in my trust, I was very disappointed. Yes, the NHS would absolutely support my desire to have a home birth, but the majority of my care would be provided at the antenatal clinic at the hospital, following the usual schedule (and since I was a multip, this meant fewer visits with midwives than I would have been having as a primip). I would meet the community midwifery team for the first time at 28 weeks for one visit, and then again at 36 weeks, but this meant that I wouldn’t have much of a chance to get to know them at all, or even meet everyone on the team. Since there were 6-8 midwives on the team, chances were good that when I did go into labour, a complete stranger would be answering the call and coming to our house. I also learned that sometimes if the ward was very busy, the on-call community midwives were asked to come help out on the ward, and that when I went into labour, if the community midwife was on the ward at that moment, she would ask me to come to the ward for my birth. Not ideal! Even though it was absolutely within my right to put my foot down and insist that the midwife come attend me at home instead, the thought of having to make a decision like that while in labour (and to selfishly pull a midwife away from a busy ward where she was caring for other women) filled me with dread. Having had a taste of true continuity of care, it’s hard to settle for anything less than that the second time around. So in the end, we decided to hire an independent midwifery team for our second birth as well, and he was born in our downstairs loo into the loving hands of our midwives, whom we had gotten to know and adore through 9 months of unhurried antenatal visits in our home. It was expensive, but we were lucky enough to be able to afford it, and to my way of thinking, it was worth more than every pence we paid for it, especially when my son became very sick with a bout of viral meningitis on Day 5 and we ended up in the hospital with him—being visited daily by our independent midwives, whose familiar faces and support made such a difference to us during such a stressful time in our lives!

Giving birth with someone you know and trust is transformative, and it makes perfect sense: labour strips you down to an incredibly vulnerable place, by necessity, and it’s much easier to remove your armour and surrender to that vulnerability when you’re surrounded by people you trust. Additionally, labour is hormone mediated, which means that the more relaxed a woman is, the more easily the hormones of labour can unfold, without cortisol (a stress hormone) blocking the effects of the love hormone oxytocin (which is responsible for uterine contractions, among many other things). Women are incredibly sensitive and perceptive when they’re in labour; even small levels of anxiety are sometimes enough to disrupt contractions. Many women experience this when they first transfer to the hospital, discovering that their labour, which was booming along in the comfort and safety of their home, suddenly stalls over the journey and admission to the hospital. Continuity of care can help buffer these effects, though. When a woman is with a team that she knows and trusts, the message her labour brain receives is one of safety and security, rather than stress and anxiety, and this encourages the labour to progress without intervention (and is probably one of the reasons that continuity models have higher numbers of spontaneous vaginal deliveries, and lower numbers of augmentation, instrumental deliveries and cesarean births).

Therefore, with all of this in mind, I was really excited to learn that continuity of care would be part of our learning experience as a student midwife, and I envisioned myself giving care to women as part of the community midwifery team and getting to know them over the months of their pregnancy. However, I quickly learned that in the trust that I’m working at, continuity of care is the exception and not the rule. While a new case-loading model for high-risk women is going to be trialled at our trust over the next year, at the moment, the hospital-based antenatal care is often done by a different midwife at each visit—often midwives who are part of the same community midwifery “team”, but still different midwives. In some situations, there is antenatal continuity, especially in smaller satellite clinics which are run by the same midwife every week, but at the main hospital this is not often the case. And unfortunately, there is no continuity between the antenatal team and the labour ward team. When a woman finally goes into labour and comes to Labour Ward, she is greeted by brand new midwives she’s never met before, who are then tasked with the difficult job of building rapport and learning about the woman’s history and birth plans on the spot, while she’s in labour, which isn’t exactly the ideal time to be doing this crucial relationship-building. (For the record, though, the labour ward midwives work exceptionally hard at immediately building trust and rapport with the women when they come in, and are often able to provide exemplary care in spite of this significant hurdle—kudos to them! It’s not an easy task at all!). Additionally, the home birth on-call schedule is shared between the entire community midwifery department, which again means that when a woman calls to say she’s in labour, the community midwife who attends her birth will most likely be someone she’s never met before. If the woman is lucky, she might be cared for in the community by the same midwife for each of her postnatal visits, but again it’s common for different members of the same community team to visit her on different days, depending on which days they’re working.

As a student, we’re required to case-load at least one woman every year of our education, but our programme defines case-loading pretty loosely: one antenatal visit, caring for the woman in labour, and then one postnatal visit is all that’s required, although we’re certainly welcome to see the woman/ family more often than that if we can manage it (and if our schedule allows!). Even this minimal requirement is difficult to achieve, though, because we’re not allowed to give the women we’re case-loading our mobile number due to privacy/ confidentiality/ legal issues. Which means that it’s really hard to know exactly when she goes into labour! There are brightly coloured stickers which we put on the outside of the woman’s chart which have our contact details on them, in the hope that the midwives will call us when she arrives in labour at the hospital, but this doesn’t always happen. In fact, I case-loaded four women antenatally, each of whom I was lucky enough to attend two antenatal visits with, but I was never called by Labour Ward when they arrived in labour (despite the stickers on the front of their charts with my name and mobile number on them)— so I missed their births. In the end, to fulfill the requirement for case-loading in my programme, I “case-loaded” a woman who I saw once in triage in early labour, who was then sent home (this counted as my antenatal visit), who then returned to the hospital later that day and was admitted in labour. I attended her birth and helped catch her baby, and then saw her the following day on the postnatal ward (which counted as my postnatal visit). This isn’t exactly true case-loading or continuity of care, by a long shot! But if you’re a student in a trust where true case-loading doesn’t exist, this might be the best you can do in a less-than-ideal situation. If I hadn’t already experienced case-loading in a professional capacity as a midwife in the States, or as a pregnant woman receiving it, I’m not sure I would understand that continuity of care looks a lot different to what is being offered in my trust. Which is by no means suggesting that the care women are receiving in this trust is bad care–on the contrary, I think it’s very GOOD care, all things considered–but it’s not true continuity of care, and there’s plenty of room for improvement in that regard.

Continuity of care is meant to be an integral part of the student experience, but unfortunately it’s nearly impossible to ensure that students are exposed to this model of care. I’ve spoken to many students who have had the blessing of experiencing true continuity of care—Michelle Marling, the author of the Continuity Matters campaign, was lucky enough to discover this early in her student experience, which she has written about before. Once you’ve had a taste of the joys of continuity of care, it’s a lot harder to settle for anything less! But if you’re never exposed to true continuity of care as a student, you never learn that there is another model of care out there. You never learn to treasure it, to seek it out, to make it happen, to fight for it if necessary. You grow up in the system as it stands, learning how it works, growing confident in your skills and competence within that system, and all the while never know that other options exist. And it all boils down to a chicken-and-egg sort of question. If student midwives aren’t exposed to continuity, they won’t want to provide that type of care. They won’t clamour for creating continuity models in their trust, they won’t be keen to sign up for case loading teams, they won’t want to provide that type of care—and then, less of that care will exist, and even fewer students will be exposed to it. And around and around it will go. This is how systems are perpetuated, and why creating systemic change is always so challenging.

Thankfully it does seem like the message of continuity is starting to seep into the system, with the RCM, RCOG, Better Births and Midwifery 2020 all promoting it (and even the World Health Organization recommending it in their most recent intrapartum guidelines). My fingers are crossed that the high-risk case-loading trial at our hospital will be a rousing success, and we can start to roll this type of care out for low-risk women as well. The evidence speaks for itself. What’s more difficult to combat is the perception that case-loading is too difficult, that case-loading midwives never have down-time or chance to see their families, and that case-loading leads to burn-out. In part, I think burn-out occurs because not enough midwives want to case-load (in part because they weren’t exposed to it), which means that too much pressure is put on the few midwives who do. If the work of case-loading is spread out over many midwives, in small teams or in buddy systems, the work is much more manageable (but again, this is easier said than done in a system that’s already 5,000 midwives short). (Better births tries to help prevent this by suggesting caps for case-loading teams, putting a ring-fence around their work so that they can’t be pulled to different units, and allowing the midwives to manage their own schedule and diary.) Nevertheless, despite these challenges, this is the future I long for: a world where all women can receive true continuity of care and the many benefits associated with it, and all case-loading teams are staffed robustly enough to allow each midwife the important down-time and off-duty she needs to recharge her batteries and return to work refreshed and ready to give her all again. This is the case-loading dream! But if students aren’t exposed to this type of care, how will we know to shoot for it?

Lions and Tigers and Tenaculums, oh my!

Lions and Tigers and Tenaculums, oh my!

Happy new year! You’re negligent, itinerant blogger here. My apologies for being too tired to blog much lately. However, I’m coming up for air (hopefully) as I am now *drumroll*…three weeks away…from being a year TWO midwifery student. Yes, you heard me right: Year One is nearly over, and I have survived!

I wanted to update all of you on what’s been going on in my clinical placement the last few weeks. I finished my postnatal rotation, and I’m now two weeks in to a three week rotation through the Early Pregnancy Unit, Sexual Health, Outpatient Gynaecology and Uro-gynaecology. It’s been fascinating so far! But it’s also reminded me about how much of my practice I’ve been losing since moving here. Here in the UK, midwives only work in maternity, for the most part, and only with pregnant women (for the most part). However, in the US, well-woman gynaecology is within the scope of practice for Certified Nurse Midwives/ Certified Midwives, and doing pap smears, treating UTIs, STIs, discussing the pros and cons of different methods of contraception (and prescribing said contraception), inserting intrauterine devices (IUDs) and managing complaints ranging from heavy periods to painful sex to bleeding between periods was all well within the range of midwifery care. Which isn’t to say that as a midwife you always knew what to do for every issue, but you generally had a good idea of how to at least start to manage the case, when to refer to a gynaecologist, and what tests would be useful/ needed prior to that visit with the gynaecologist. It was never my favourite part of the job (pregnancy and birth was always my favourite part), but I don’t think I ever realised how much I missed it until now.

The Early Pregnancy Unit (EPU) is a very somber place. The waiting room is small, the faces in the waiting room are tense, and a huge amount of discretion and sensitivity is required. This is where women come when they’re having spotting, bleeding or pain in early pregnancy and there are concerns about whether a miscarriage has occurred or not. In many of the cases, everything is fine, and the couple can be reassured. But 1 time out of 5 (statistically, at least), a miscarriage has occurred and the woman and her partner are now faced with heartbreaking choices about how to proceed–whether to wait for the miscarriage to pass spontaneously on its own, or whether to opt for medical or surgical management. There are also concerns about ectopic pregnancies in the EPU, which is when the embryo implants outside of the womb rather than in the womb (this occurs most commonly in the fallopian tubes–called a tubal pregnancy–but can also more rarely occur in other places like the ovary, in the abdomen or even in the cervix). Ectopic pregnancies can be very dangerous, particularly if the growing embryo ruptures, which can cause severe bleeding, shock and even (very rarely) death. It’s a medical emergency when this happens, and if a pregnancy is confirmed by urine pregnancy test but no embryo is visualised in the womb on ultrasound, then it’s assumed to be an ectopic until proven otherwise, since you really have zero chances to miss an ectopic. The level of care that the women received at this unit was incredible, despite the sadness. The amount of follow-up was also breathtaking, and the team was able to move very quickly to provide urgent sonograms for pregnant women presenting in A&E with bleeding and pain . Every woman was tracked, every lab result was tracked, every beta-HCG drawn was placed in a book to be checked on at a later date, and every ongoing case was discussed weekly at a multi-disciplinary team meeting. To be honest, I enjoyed my time in this unit, despite the sadness, and was able to listen, offer tissues, take bloods and explain warning signs to be watching out for etc.

After EPU came Sexual Health, and this is something I also enjoyed very much. The caseload was incredibly varied–anything from people coming in for a routine check-up to those presenting with specific complaints (burning, itching, discharge, smells, lumps or bumps etc.) to routine medical management for HIV positive patients to people seeking post-exposure prophylaxis (PEP) or pre-exposure prophylaxis (PREP), both designed to help prevent HIV transmission after (or before) unprotected sex. The staff was very welcoming, and the clinic I was in was huge and able to manage nearly all of their results on site, even staining their own slides to look for clue cells, monilia, gonorrhea, trichomoniasis etc. We would prepare our own “wet-mount” slides in the US sometimes, and would look at them under the microscope to diagnose trich versus bacterial vaginosis versus yeast etc., but staining slides to look for gram positive or gram negative microbes was something I had never done or seen before, and it was fascinating. I’ve got to admit, though, it was a bit surprising to be taking care of men in a clinical setting again–the last time I had male patients was way back in 2003, when I was training as a nurse!

After Sexual Health, though, I was thankfully plunged back into womens’ health care again as part of my outpatient gynaecology rotation, and to be honest, I think outpatient gynaecology has been my favourite rotation so far. When you think about it, pregnancy and childbearing is an incredibly important part of a woman’s life, but it’s just a small piece of her total healthcare experience. Gynaecology spans the woman’s entire life, and encompasses everything from contraception needs to menstrual issues to peri-menopause/ menopause, and everything in between. This includes hysteroscopies, hysterosalpingograms, polyps, fibroids, cysts, prolapses, dysfunctional uterine bleeding, abnormal pap smears, colposcopies, menopause, vulvar issues, painful sex (dyspareunia) and even sub-fertility/ trying to conceive. It was really heartening to see many of the practitioners taking time to listen to women, explain how their bodies work, discuss their symptoms and options, and in many cases reassure women about what was going on, and why it might be going on. I was also able to observe one of the doctors through her day surgery case load, and it was fascinating to be in the main ORs in the hospital with the OR staff, where I found the experience to be quite different from being in an OR during a cesarean. For one thing, the staff was so efficient at their jobs that they had the entire process laid out like a precision science, with the next woman being wheeled into the OR for anaesthesia prep only a few minutes after the previous woman had left. All of the women were put under general anaesthesia as well, which was also very different from cesareans, which are normally done under epidural or spinal anaesthesia. It was also amazing to watch how relaxed the anaesthesiologists were! There is a point between when the woman has been put to sleep but is not yet intubated during which time she’s not really breathing on her own, and I kept watching with baited breath, waiting for the intubation to occur and then the chest wall to begin to rise and fall again, but the anaesthesiologists always appeared so calm through this entire process. And once she was intubated again and they were using an ambu-bag to ventilate her, again there was never any sense of panic or urgency to it. It made me reflect on how different general anaesthesia (GA) is on Labour Ward. If a woman is under GA during a cesarean, it’s usually because something has gone very wrong and there was no time to put in an epidural. GA is used during cesarean births when seconds literally matter, and in those situations, there is often a palpable sense of urgency and stress through the entire thing. And the same applies to ventilation–I have only ever seen it in the context of resuscitation, which is never a calm or relaxed situation. It was really eye-opening to observe routine GA, with calm, workday efficiency surrounding it, rather than barely-controlled panic.

One more week of outpatient clinical placement ahead of me, and then….I am more or less done for Year One! And I promise I’ll find some time to write a few more blog posts soon!

Options for the Third Stage of Labour

Options for the Third Stage of Labour

I just finished a MASSIVE (29 page whopper!) of a research paper on the management of the third stage of labour, so of course it’s only right and proper that my new, shiny and very-up-to-date knowledge of the subject should be shared here.  I’ve found this topic incredibly interesting because…guess what? The management of the third stage of labour is handled very differently here in the UK than it is across the pond! (Shocker–NOT! After all, this is why I’m back at university–for this sort of thing exactly, right? Right??) Basically, there are two different strategies for managing the third stage of labour: active management, and expectant management (don’t worry–I’m going to get into the nitty-gritty of exactly what all of this means below). Here in the UK, active management is the norm, whereas in the US (at least in the hospitals where I was working), expectant management was the more common practice. I’m still not entirely sure why this is the case–the research on this has been around for awhile, but clearly the two countries have taken very different approaches to it. (Obviously, the follow-up to all of this should be looking into the history of why this occurred, but for now, I’ll just stick to the research and leave that for a different post). Also, interestingly, because of the prevalence and preference for active management here in the UK, many women at low risk of postpartum haemorrhage aren’t being offered true informed choice about the different management strategies available to them–in fact, researchers have found that many women at low risk of haemorrhage don’t even know they have a choice in the matter (again, see below for more on this)! Which all just goes to show that there is a desperate need for women, midwives and doctors to be better educated on this topic, and to understand and be able to support physiologic (i.e. expectant) third stage management. Which brings me to my research paper.

So, without further adieu…

The third stage of labour is the time from the birth of the baby up through the delivery of the placenta, followed by control of bleeding. The placenta is a miraculous and highly evolved organ which is created during the pregnancy and then expelled afterwards. (Just let that sink in for a moment: during pregnancy your body creates and grows a whole new organ solely for nourishing and sustaining a baby, and then, after pregnancy, this brand new organ is disposed of, just like that; talk about amazing!) It acts as a life-support system for the baby, providing an interface for maternal and fetal blood which allows for gas exchange, as well as letting hormones and nutrients pass to the baby. The placenta also provides a barrier for the baby, helping to keep out toxic chemicals, substances and pathogens. It even acts like a gland, producing hormones such as oestrogen and progesterone that sustain the pregnancy, and helps to metabolize various substances that the baby’s tiny, immature liver isn’t ready for yet. The placenta is so good at its job that it keeps maternal and fetal circulation completely separate (this is how babies are able to have different blood types from their mothers, or how a mother can be HIV positive while a her baby remains HIV negative)! And then, after the birth of the baby, this miraculous life-support system peels away from the uterine wall and slips out through the vagina, while meanwhile the uterine muscle fibers clamp down on the open blood vessels and prevent the woman from bleeding to death.

More specifically (in clinical speak), after the birth of the baby, a rush of oxytocin encourages the myometrium (the muscle layer of the uterus–another miraculous and highly specialized part of the body) to contract and reduce in size. As the uterus shrinks around the placenta, the placental bed separates from the uterine wall, and the woman will usually experience a cramp or feel an urge to push, combined with other clinical signs that placental separation has occurred, such as a small gush of blood, a lengthening of the cord, or the uterus rising in the abdomen and becoming globular and round rather than discoid. In physiological management, the placenta is birthed by maternal effort alone. Afterwards, the myometrium continues to retract around the placental site, creating ‘living ligatures’ around the torn blood vessels and ensuring haemostasis (Baker, 2014, pp. 191). An intricate cascade of hormones assists this process, led mostly by oxytocin, beta-endorphins and prolactin (Buckley, 2004). These hormones provide a blueprint for placental separation, maternal and infant bonding, control of bleeding and the initiation of breastfeeding (Buckley, 2004).

The two main management strategies available in the third stage of labour are Expectant Management of the Third Stage of Labour (EMTSL) and Active Management of the Third Stage of Labour (AMTSL) (and no, I’m not making these acronyms up–this is actually how it’s referred to in the literature!). Interestingly, there are NO universally recognised protocols available for either strategy (and arguing over exactly which protocol is superior is the raison d’etre for most of the research on this topic). However, in general, EMTSL tends to utilise a ‘hands-off’ approach that allows the placenta to deliver spontaneously, by maternal pushing effort alone. The aid of skin-to-skin contact, gravity or nipple stimulation can encourage delivery, and early cord clamping, controlled cord traction (CCT) or administration of prophylactic uterotonic agents (i.e. drugs which cause the uterus to contract) are not employed. In contrast, AMTSL involves the routine administration of uterotonic agents after the birth of the baby, and then early cord clamping and CCT to deliver the placenta. These strategies pertain to routine management and not emergency situations where uterotonic agents are administered as a treatment for postpartum haemorrhage (PPH).  And in fact, once you get into it, the evidence on this subject is pretty murky. Reams and reams of papers have been written on various types of active management. Studies comparing the timing of uterotonic administration (should it happen with the birth of the baby, after the birth of the baby, or even after the delivery of the anterior shoulder of the baby but before the entire baby is out), the types of uterotonic agent used (carbetocin versus syntocinon versus syntometrine versus misoprostyl) and other parts of active management (early cord clamping v. delayed cord clamping–and if delayed, for how long?–controlled cord traction v. no CCT, uterine massage v. no uterine massage etc. etc.) is what fills most of the literature on this topic.

The reason so much research has been devoted to various management options on this is because postpartum haemorrhage (PPH) is a real and very serious risk. On a global level, PPH is the number one killer of pregnant women, responsible for 25% of all maternal deaths worldwide, particularly in developing countries where access to medical care and decent nutrition is hard to come by (which leaves women aenemic and much more vulnerable should a heamorrhage occur).  Similar to AMTSL and EMTSL, there is no universal definition of PPH, but many guidelines define it as blood loss greater than 500 mls from the genital tract. The most common cause is uterine atony (ineffective uterine contraction), followed by trauma to the vaginal tract (such as lacerations), retained tissue in the uterus (such as retained membranes or placental lobes) or coagulation disorders (WHO, 2012; RCOG, 2016). However, it’s also worth noting that these definitions are not always helpful. For example, 500 mls is equivalent to a blood donation, and is often an amount of blood loss that women can tolerate well, especially women who live in developed countries, have good nutritional status and who aren’t aenemic (Goer and Romano, 2013). Many of these studies would be BETTER studies if they looked at clinically important outcomes, such as symptoms like dizziness, weakness or tachycardia (fast heart rate), or the clinical need for a blood transfusion, rather than surrogate outcomes such as blood loss. Also, a lot of the studies use Estimated Blood Loss (EBL) as their clinical indicator, which is a visual estimate of how much blood has come out; not surprisingly, EBL varies significantly from provider to provider and is a notoriously inaccurate way of measuring blood loss, particularly as blood is often mixed with amniotic fluid after a delivery, and the amount often looks like more than it really is (Yoong et. al., 2010; Lilley et. al., 2015).

Global guidelines universally recommend AMTSL as the preferred management strategy in the developing world (WHO, 2012; ICM/ FIGO, 2014), which makes a lot of sense given that postpartum haemorrhage is such a risk. In the UK, guidelines also recommend AMTSL in all situations, but acknowledge that if a woman at low-risk for PPH requests EMTSL, she should be supported in that choice (NICE, 2014; RCOG, 2016; RCM, 2012). The National Institute for Health and Care Excellence (NICE) guidelines encourage counseling low-risk women on both management strategies, but recommend AMTSL over EMTSL to help prevent PPH. These guidelines are based on a recent Cochrane Review (Begley et. al., 2015) and the earlier Cochrane Review which preceded it (Prendiville et. al., 2000). However, there is some research which suggests that for women at low-risk of PPH, expectant management may actually produce lower rates of postpartum haemorrhage than active management (Fahy et. al., 2010; Dixon et. al., 2013). These studies are observational studies rather than the randomised control trials (RCTs) used in the Cochrane reviews, but they are well done and hold up under scrutiny.  Nevertheless, over half of all maternity units in the UK still advise AMTSL for all women regardless of risk status (Rogers et. al., 2012) and most practitioners in the UK are more familiar and comfortable with AMTSL than EMTSL (Farrar et. al., 2009; Downey and Bewley, 2010). This has led some authors to question whether women at low-risk of PPH are being offered a true informed choice regarding management options (Selfe and Walsh, 2015), and this is something that my clinical experience in the UK so far would confirm.

The Cochrane systematic review by Begley et. al. (2015) provides some of the strongest evidence on this subject, based on the fact that it’s a meta-analysis which pools together the results of several RCTs and then does further statistical tests in order to provide a larger sample size and greater statistical power. This particular meta-analysis uses seven RCTs examining AMTSL versus EMTSL in hospital settings, for a combined sample size of 8,247 women. The maternal outcomes of interest were severe and very severe PPH (blood loss greater than 1000mls and 2500mls respectively), blood transfusion requirement, maternal mortality, and maternal haemoglobin (Hb) levels less than 9g/dl at ≥ 24 hours postpartum. The authors found that overall AMTSL significantly reduced the rates of PPH, the need for blood transfusions and low maternal Hb. However, for women at low risk of PPH, AMTSL offered no statistically significant reduction in PPH (although there was still a reduction in the need for blood transfusions). Additionally, AMTSL has several disadvantages, including maternal hypertension, nausea and vomiting, increased postpartum pain (afterpains), an increased chance of returning to the hospital after discharge due to postnatal bleeding, and a decrease in newborn birth weight due to early cord clamping. The authors concluded that for women at low risk of PPH, the benefits of AMTSL may not outweigh the disadvantages of it, and advised that low risk women should be counseled on both options and allowed to make their own choice.

There were several strengths to this meta-analysis. Because of the large sample size, the study was able to provide statistically significant results with 95% confidence intervals and low p-values, which indicates that the findings were likely due to the experimental treatment (in this case AMTSL) and not due to chance. However, there was a large degree of heterogeneity between the RCTs analysed, meaning that the populations and experimental treatments being compared were quite different, and therefore may have prevented a true comparison between the outcomes. Only three of the RCTs limited their sample to women at low risk of PPH; the four remaining studies included women regardless of their PPH risk status, which may have introduced a selection bias that weighted the results in favour of AMTSL. Additionally, the studies varied significantly in terms of uterotonic agent used, route of administration (intravenous versus intramuscular), timing of cord clamping, use of uterine massage, and EMTSL protocol observed. Finally, among the seven trials analysed, four of them reported that many women in the EMTSL group received prophylactic uterotonic agents (rates varied from 2.5% to 38% among the studies), which again weakens the findings as many of the women in the EMTSL group were treated with the AMTSL protocol.

In contrast, two retrospective cohort studies examined EMTSL in more detail and found that PPH rates were lower than AMTSL when used in a holistic midwifery model (Fahy et. al., 2010; Dixon et. al., 2013). Fry (2007) and Hastie and Fahy (2009) have both proposed that EMTSL is more than merely a “hands-off” approach during the third stage, but also involves guarding and facilitating normal physiology in all aspects of care. Hastie and Fahy (2009) named this ‘holistic psychophysiological care’ as it considers all aspects of a woman’s experience, including her environment, and is a more sophisticated approach to EMTSL than the limited definition employed by Begley et. al. (2015). This approach requires a physiological labour and birth, a private and warm environment, uninterrupted skin-to-skin and suckling after delivery, plus waiting until the cord stops pulsing before cutting it. Furthermore, a trusting and respectful relationship between woman and midwife is necessary. In their qualitative descriptive study interviewing midwives who were expert at EMTSL, Begley et. al. (2012) found that midwives skilled in this management approach intuitively provided this type of care, with themes of watchful waiting, guardianship and trust in the woman and the process emerging from their study.

Fahy et. al. (2010) designed a retrospective cohort study to evaluate the effectiveness of ‘holistic psychophysiological care’. Using data from the computer-based Midwives Data Set in Australia, the study compared women at low risk of PPH in a tertiary-care hospital receiving AMTSL to women at a midwife-led unit (MLU) receiving EMTSL. At the hospital, women received 10 IU syntocinon intramuscularly within one minute of birth, followed by CCT and then uterine massage, whereas at the MLU, midwives were taught how to facilitate ‘holistic psychophysiological care’ as described by Hastie and Fahy (2009) above. The study found that 11.2% of low-risk women in the hospital setting experienced PPH (defined as ≥ 500 mls blood loss) versus 2.8% at the MLU (95% Confidence Intervals).

These findings were quite rigorous and trustworthy, as they excluded all women in both settings who were at higher risk of PPH. They also used a stronger definition of EMTSL and eliminated women who received mixed management from the EMTSL cohort. The results from this study also provided data from an MLU setting, whereas Begley at. al. (2015) only looked at hospital settings; this provides greater generalisability and transferability to other settings (Rees, 2011). However, the retrospective design prevented complete control over all of the interventions. The data set also used EBL rather than measured blood loss, which could contribute to inaccurate measurements (Yoong et. al., 2010). Additionally, the authors noted that ‘holistic psychophysiological care’ is hard to achieve in all settings due to the extent of its definition, and may be difficult to apply outside of an MLU or home.

The findings in Dixon et. al. (2013) confirmed the findings of Fahy et. al. (2010). Dixon et. al. (2013) designed a population based retrospective cohort study using data from the New Zealand Maternity and Midwifery Provider Organisation (Dixon et. al., 2009; Davis et. al., 2012). It compared 17,514 low-risk women who received AMTSL (51.9%) to 16,238 low-risk women who received EMTSL (48.1%) over a five-year period. Midwives provided continuity of care to all women from booking to six-weeks postpartum, and women could choose to deliver either at home, an MLU or a hospital. Therefore, the midwives in this database practiced in all settings depending on the woman’s history and preference, and were familiar and comfortable with both AMTSL and EMTSL strategies. Similar to Fahy et. al. (2010), the authors found that AMTSL resulted in higher rates of blood loss than EMTSL, regardless of setting (6.9% v. 3.7%, Confidence Intervals 95% and 94% respectively). Women who received AMTSL were also three times more likely to have a retained placenta (0.7% AMTSL v. 0.2% EMTSL, p<0.0001). Women in hospitals were more likely to receive AMTSL, and also experienced the highest levels of blood loss, while women at home were more likely to receive EMTSL, and had the lowest levels of blood loss.

Dixon et. al. (2013) was also quite rigorous and trustworthy. They defined the populations carefully and excluded all women at high risk of PPH. They also had a very large sample size (32,752 in total) and provided data from a wide range of settings, collected by midwives who worked in a variety of settings and were comfortable facilitating both management strategies. Limitations to this study included its retrospective observational design and the use of EBL rather than measured blood loss. There may have also been other confounding factors not accounted for, as women who choose to give birth at home or in a MLU may differ in health, lifestyle or philosophy from women who choose a hospital setting.

So what does all of this mean?? It means that for women at low risk of PPH, who have good nutritional status and (more importantly) a NORMAL, PHYSIOLOGIC birth, expectant management is probably safer than active management, and has a lower rate of PPH, especially when provided in a holistic midwifery model and occurring in a calm, private and undisturbed setting, such as a home or birth centre. However, let’s be honest here….how many women experience normal, physiologic birth in a hospital, without an epidural, or syntocinon to augment contractions? Labours that started spontaneously, without induction? Waters that broke spontaneously, rather than artificially? The sad, grim statistic is that only about 25% of all births occur in this manner…the remaining 75% have been fiddled with in some way. Which means that for the majority of women, AMTSL probably IS the superior choice. Midwife Thinking sums this up far more eloquently than I ever could in her excellent blog post (which I just linked to, and which I highly encourage you to read). She also concludes that for most women, AMTSL is most likely the better option, given how rare true physiologic, undisturbed birth is.

Interestingly, though, my (completely anecdotal) experience in the US counters this somewhat. In the States, the third stage was most often handled in a physiologic manner, although with a few aspects of AMTSL thrown in for good measure. For example, in the hospitals in Brooklyn where I was practicing, pitocin (syntocinon, i.e. artificial oxytocin) was not given until after the placenta was delivered (usually intravenously). The practitioner awaited signs of placental separation, and then, once the signs were visible, gentle cord traction was used to facilitate the delivery (which isn’t quite right for true physiologic management, which should be entirely hands-off until the delivery has occurred). Pitocin given prior to the delivery of the placenta was only used in cases of PPH, and often accompanied by manual removal of the placenta in those situations. The received wisdom behind waiting to give pitocin until after delivery of the placenta was to prevent placental entrapment (i.e. the uterus contracting around the placenta and preventing it from being delivered), but the research on AMTSL doesn’t back this up, as active management regularly employs uterotonic agents before placental separation, and placental entrapment rarely occurs. We generally used physiologic third stage management on the majority of women regardless of whether their birth had been induced, or whether augmentation was used, or whether they had an epidural or not, and I don’t believe our rates of PPH were significantly higher because of this (although it’s worth noting that the US ranks 47th globally in terms of maternal mortality as of 2014, whereas the UK ranks 38th).

If you’re planning a birth in the UK, though, keep in mind that expectant management is a valid option for you, particularly if you’re at low risk of haemorrhage, and you’ve had a normal, physiologic birth. My experience so far has shown that this conversation rarely happens during the antenatal period, unfortunately, and options are most often mentioned after the birth of the baby. Sadly, I have seen “informed choice” offered like this: “Would you like the shot that will bring the placenta more quickly, or do you want to wait for the placenta to separate and push it out yourself?”  That’s not at all what I would call informed choice! Midwives in the UK are more familiar with active management, and tend to prefer it (Rogers et. al., 20120; Farrar et. al., 2009), and as the research by Selfe and Walsh (2015) demonstrates, many women don’t even realise they have a choice in the matter. But you do! And it’s well within your rights to ask for expectant management, as per the latest NICE guideline. If you’re looking for more information on this, I’d highly recommend the Association for Improving Maternity Services (AIMs) publication on this, which you can purchase here (Birthing Your Placenta).

 

References:

Baker, K.C. (2014) ‘Postpartum haemorrhage and the management approaches in the third stage of labour’. MIDIRS Midwifery Digest, 24(2), pp. 191-196.

Begley, C.M., Gyte, G.M., Devane, D., McGuire, W. and Weeks, A. (2015) Active versus expectant management for women in the third stage of labour. [Cochrane Systematic Review] Available at: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007412.pub4/full (Accessed: 25 September, 2017)

Begley, C.M., Guilliland, K., Dixon, L., Reilly, M. and Keegan, C. (2012) ‘Irish and New Zealand midwives’ expertise in expectant management of the third stage of labour: The MEET study’, Midwifery, 28(6), pp. 733-739.

Buckley, S. (2004) ‘Undisturbed birth—nature’s hormonal blueprint for safety, ease and ecstasy’, Midirs Midwifery Digest, 14(2), pp. 203-209.

Davis, D., Baddock, S., Pairman, S., Hunger, M., Benn, C., Anderson, J., Dixon, L. and Herbison, P. (2012) ‘Risk of Severe Postpartum Hemorrhage in Low-Risk Childbearing Women in New Zealand: Exploring the Effect of Place of Birth and Comparing Third Stage Management of Labor’, Birth: Issues in Perinatal Care, 39(2), pp. 98-105.

Dixon, L., Fletcher, L., Tracy, S., Guilland, K., Pairman, S. and Hendy, C. (2009) ‘Midwives Care During the Third Stage of Labour: An Analysis of the New Zealand College of Midwives Midwifery Database 2004-2008’, New Zealand College of Midwives Journal, 41(10), pp. 20-25.

Dixon, L., Tracy, S.K., Guilliland, K., Fletcher, L., Hendry, C. and Pairman, S. (2013) ‘Outcomes of physiological and active third stage labour care amongst women in New Zealand’, Midwifery, 29(1), pp. 67-74.

Downey, C. and Bewley, S. (2010) ‘Childbirth practitioners’ attitudes to third stage management’, British Journal of Midwifery’, 18(9), pp. 576-582.

Fahy, K., Hastie, C., Bisits, A. Marsh, C. Smith, L., and Saxton, A. (2010) ‘Holistic physiological care compared with active management of the third stage of labour for women at low risk of postpartum haemorrhage: A cohort study’, Women and Birth, 23(4), pp. 146-152.

Farrar, D., Tuffnell, D., Airey, R. and Duley, L. (2009) ‘Care during the third stage of labour: a postal survey of obstetricians and midwives in the UK’, BMC Pregnancy and Childbirth, 10(23), pp. 1-9.

Fry, J. (2007) ‘Physiological third stage of labour: support it or lose it’, British Journal of Midwifery, 15(11), pp. 693-695.

Goer, H. and Romano, A. (2013) Optimal Care in Childbirth: The Case for a Physiologic Approach. London: Pinter and Martin.

Hastie, C. and Fahy, K. (2009) ‘Optimising psychophysiology in third stage of labour: Theory applied to practice’, Women and Birth, 22(3), pp. 89-96.

International Confederation of Midwives (ICM) and International Federation of Obstetricians and Gynaecologists (FIGO) Joint Statement (2014) Misoprostol for the treatment of postpartum haemorrhage in low resource settings. Available at: https://www.figo.org/sites/default/files/ICM-FIGO%20Joint%20Statement%20English.pdf (Accessed: 16 October 2017)

Jangsten, E., Mattsson, L-Å., Lyckestam, I., Hellstram, A-L. and Berg, M. (2011) ‘A comparison of active management and expectant management of the third stage of labour: a Swedish randomised controlled trial’, BJOG: An International Journal of Obstetrics & Gynaecology, 118(3), pp. 362-369.

Knight, M., Nair, M., Tuffnell, D., Kenyon, S., Shakespeare, J., Brocklehurst, P. and Kurinczuk, J.J. (eds.) on behalf of MBRRACE-UK. (2016) Saving Lives, Improving Mothers’ Care – Surveillance of maternal deaths in the UK 2012-14 and lessons learned to inform maternity care from the UK and Ireland. (Confidential Enquiries into Maternal Deaths and Morbidity 2009-14). Available at: https://www.npeu.ox.ac.uk/downloads/files/mbrrace-uk/reports/MBRRACE-UK%20Maternal%20Report%202016%20-%20website.pdf  (Accessed: 26 September 2017)

Lilley, G., Burkett-st-Laurent, D., Precious, E., Bruynseels, D., Kaye, A., Sanders, J., Alikhan, R., Collins, P.W., Hall, J.E. and Collis, R.E. (2015) ‘Measurement of blood loss during postpartum haemorrhage’, International Journal of Obstetric Anesthesia, 24, pp. 8-14.

National Institute for Health and Care Excellence (NICE) (2014) Intrapartum Care for Healthy Women and Babies. (Clinical Guideline CG190). Available at: https://www.nice.org.uk/guidance/cg190 (Accessed: 22 September 2017)

Prendiville, W., Elbourne, D., McDonald, S. (2000) Active versus expectant management of the third stage of labour. [Cochrane Systematic Review – withdrawn in 2009 due to publication of new Systematic Review] Available at: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000007.pub2/full (Accessed: 21 October 2017)

Rogers, C., Harman, J. and Selo-Ojeme, D. (2012) ‘The management of the third stage of labour—A national survey of current practice’, British Journal of Midwifery, 20(12), pp. 850-857.

Rees, C. (2011) An Introduction to Research for Midwives. London: Churchill Livingstone.

Royal College of Midwives (RCM) (2012) Evidence Based Guidelines for Midwifery-Led Care in Labour: Third Stage of Labour. Available at: https://www.rcm.org.uk/sites/default/files/Third%20Stage%20of%20Labour.pdf (Accessed: 22 September 2017)

Royal College of Obstetricians and Gynaecologists (RCOG) (2016) Prevention and Management of Postpartum Haemorrhage. [Green-top Guideline No. 52] Available at: http://onlinelibrary.wiley.com/doi/10.1111/1471-0528.14178/epdf (Accessed: 11 October 2017)

Selfe, K. and Walsh, D.J. (2015) ‘The third stage of labour: are low-risk women really offered an informed choice?’, MIDIRS Midwifery Digest, 25(1), pp.66-72.

World Health Organization (WHO) (2012) WHO recommendations for the prevention and treatment of postpartum haemorrhage. Available at: http://apps.who.int/iris/bitstream/10665/75411/1/9789241548502_eng.pdf (Accessed: 27 September 2017)

Yoong, W., Karavalos, S., Damodaram, M., Madgwick, K., Milestone, N., Al-Habib, A., Fakokunde, A., and Okolo, S. (2010) ‘Observer accuracy and reproducibility of visual estimation of blood loss in obstetrics: how accurate and consistent are health care professionals?’, Archives of Gynecology and Obstetrics, 281(2), pp. 207-213.

 

The Nautilus Shell

The Nautilus Shell

I wrote this yesterday, for a dear friend’s Mother Blessing, and I thought I would share it here as well (with her permission):

I give you two beads, shaped like a nautilus shell. The nautilus is very special—it’s one of the oldest known fossils on our planet, but it also tells the story of growth and maturation. It starts as a very small shell to protect the animal inside. Then, as the sea creature outgrows the first small chamber, it has to create a new, slightly larger shell to accommodate its slightly larger body, which it adds to the front of its old shell like an extension on a house. This is how the Nautilus grows, spiraling around and around with each new addition. The Nautilus is all about growth and evolution, and to my mind, the perfect metaphor for becoming a mother.

Your entire world is about to change. Very soon you’re going to find that you’re too big for your old self, and you’ll have to grow and change to accommodate this new person you’re about to become. Growth is inevitable. But every time you spiral around your center, the newer parts of you will strengthen the older parts of you. You will feel lost for awhile—awkward and clumsy, uncomfortable in your new role. You will mourn who you used to be, before you were a mother—we all do, now and then. But gradually you will get used to your new self and how much bigger you’ve become—and how much stronger you’ve become—and how much more beautiful you’ve become. And to your baby, you will be his entire world. His ENTIRE world. And you will grow as big as you need to be, to be the mother that he needs. But at the very center of your larger shell, the person you’ve always been will still be there, too. And at some point, you’ll realize she hasn’t gone anywhere. She will wait for you to find her again, and you will. You will be both—your new, larger self, and your older, smaller self. And you will love him so much. And he will love you like you are his entire world. Because you will be.

I wish you every blessing as you start out on this new adventure. I wish you health, and happiness, but more than anything else, I wish you time. The time goes too quickly—everyone will tell you this. So many people will tell you this that it will actually become annoying. Of course, of course, it goes too quickly, cherish every moment! They will say things like that—old ladies on the bus and aunts and grandparents and random strangers in waiting rooms—and you will think to yourself that there are moments you don’t want to cherish. It’s hard, to be a mother. It’s so unbelievably hard. The old ladies forget this part of it, I think. The work is invisible, and often unappreciated, and not valued by our society, and the worry will etch lines into your face and make your heart feel like a stone, sometimes. There is always so much to get done, and never enough time to do it in. And the days can feel like months, and the months can feel like years. You will wish for the time to go faster—we all do, sometimes.

But at some point you will look back and realize it did pass in the blink of an eye (because it does that, as well; it’s both interminable and lightning quick at the same time). So my wish for you is that every now and then, not always and not constantly, but moments here and there, you can catch the time and hold it with both hands, for just a second. I wish that for you there will be time to do nothing for an entire afternoon except hold him. There will be time to let him fall asleep on your chest. There will be laundry to do, and meals to prepare, and groceries to buy…but there will be time to ignore all of that, and curl up on the bed with him and take a nap together, just the two of you. There will be time to sniff his warm little head, and kiss his nose, and stroke his feet. There will be time to make him laugh. To tickle him and play peek-a-boo. Time to go on walks together, just the two of you, to push a buggy down the street on cold, blustery days, and balmy summer days. Time to look at the leaves in the trees, to watch the way the sunlight catches them or the wind shakes them—he will be fascinated by things like this—and time to do nothing but watch him watching the leaves.

This is what I wish for you. There will be so much to get done, and so many new concerns. But I wish you pockets of time. Little moments, caught here and there.

I wish you lots and lots of time.

Healing from a Miscarriage

Healing from a Miscarriage

Miscarriages are so incredibly common.  Statistically, 1 in 5-7 pregnancies will end in miscarriage, although many might occur before a woman even knows she’s pregnant. I’ve personally had two.  And I’ve midwifed many women through a miscarriage.  In fact, I’m pretty sure if we all started talking about our miscarriages just a bit more, we’d be astounded by how common this is, and how many sisters all around us have been through it, or are going through it.  But that’s just it…NO ONE talks about it. Which is why it’s important to bring it up, especially during Baby Loss Awareness Week. Tonight I’m going to light a candle as part of the Wave of Light in honour of International Pregnancy and Infant Loss Remembrance Day.  It’s so important that we share these stories. These babies were alive, no matter how briefly. They mattered to us. And our lives will never be the same because of it.

It is hard to talk about.  I’ll certainly give you that.  I can’t speak for anyone else’s experience, but for myself there has always been some element of lingering guilt attached to it: if only I’d taken better care of myself, or been less stressed out, or hadn’t gotten into that one argument, or had gotten more sleep.  As if I had had any control over it in the first place.  It’s hard to accept that most miscarriages happen for no good reason at all.  Or actually, perhaps they happen for the very best reason possible.  If you stop to think about it, a miscarriage is the body’s way (or nature’s way, or God’s way, or the Goddess’s way, or [insert spiritual belief of choice here]’s way) of ensuring that more often than not healthy babies are carried to term and delivered.  Think of all of the miraculous, amazing steps which have to go perfectly right in order to form a baby.  If even one of those steps goes wrong in those early weeks, the implications for a living child could be devastating.  While a miscarriage can be absolutely harrowing, I do believe it’s kinder than the alternative.  And those early steps are pretty complex.  It’s not surprising that something goes awry from time to time.

But this is cold comfort.  And since it’s so rarely talked about, knowing what to do to recover and heal after a miscarriage is very rarely discussed. As a provider I’ve often searched for a resource or a guide to give to clients to help them ground themselves afterwards. And as a woman who’s been through it, I’ve found myself staring off into space afterwards, hands on a suddenly empty belly, wondering to myself: what happens next?  I think the answer to that question is so incredibly personal, for each and every woman.  But I did find this fantastic post by Maisie Hill which is certainly worth sharing: How to Recover From a Miscarriage.  It’s worth a read, even if this has never happened to you, if only to allow you to better support a friend or sister who does have to endure this.  And for everyone else who has had to walk this path, what helped you heal afterwards?

If we all start talking about our own experiences just a bit more often, we’ll stop feeling so alone.

 

Deskilled

Deskilled

How has it gotten to October and I have published nothing for all of September on this site?!?  The time is flying, and to be perfectly honest, I am slightly overwhelmed. Being a student is HARD. Being a mom is HARD. Being both of those together is VERY hard. And let’s not forget trying to be a good spouse, friend, sister and all the rest…there’s too much to get done every day, and not enough hours in a day. We’re currently on placement again now, working in the clinical setting, but in two weeks I have an in-class debate to research and prep for, plus a research activity due which involves critiquing a research study and then sharing it with the class. The first week in November our second 15-page(-ish) assessment is due, which I have started researching but have not yet written a single word for. We also have our Year 1 exams in December, focusing on anatomy, physiology and the role of the midwife, which I have started studying for, but again…this is not something you can do in a single cram session the night before. So, yeah, that’s the homework front. Add to that 12 hour work-days, not seeing my kids for entire days at time (because if I’m doing a day shift, I leave in the morning before they’re awake and come home once they’re asleep) and using my days off to try to desperately make it up to them with quality time…and also using my days off to try to get on top of the mound of homework. This student midwife business is definitely not for the faint of heart!

Clinical placements have been challenging for lots of reasons. The work is fabulous, and it has been such a joy to be attending births again, and particularly births in the lovely midwifery-led unit/ birth center that is part of the hospital where I’m at. But it’s been painful to realise how many of my skills I have lost during the long break I took over the last 4 years where I wasn’t working as a midwife. Things that used to come very easily to me are now things that I am grappling with again. Is that really the right position of the baby I’m feeling on abdominal palpation? Is the baby vertex or breech? Is that the baby’s back? Are those the feet and hands? Is that cervix 7 cm dilated, or 8? What is the estimated fetal weight? I used to be really good at this stuff…now I find myself in the dark with it a lot more, much like I was during my first student experience. Muscle memories that have been forgotten and need to be retrained into hands again. How to press just so on the doppler to be able to angle it upwards into just the right position to find the fetal heart. How to get the monitor straps to be able to hold the tocometer/CTG in the right place. (Annoyingly, the straps are very new to me; in the US the women wore an elastic band over their bellies and you just had to slip the monitors underneath the band and they were magically held in place, without too much fiddling involved. We did have straps, too, for occasional use, but again, they were a different design and not at all like the straps in my new trust, which I think require some fancy angling and folding and tying tricks to get them to be angled/ placed correctly, of which I have by no means mastered yet!)  And don’t even get me started on the hospital policies, the documentation, the pro formas that have to be filled out. The new computer system.  There are even things that I murmur and say during deliveries: “Good job”, “you’re doing great”, “you’ve got this” which sound so American to my ears now. My mentor more often says “well done” instead of “good job”. Tiny things like this which I wonder about, and I wonder if my American-ness is helpful in labour, or if I was speaking better British-English, would that be more reassuring? It’s all new. So in SO MANY ways I feel like a complete novice at this again.

But that’s the part that sits uncomfortably with me. I had gotten used to feeling competent after years as a midwife in the US. I knew the system, I knew how my hospital’s policies worked. I knew exactly what documents needed to be filled out, and how to document correctly.  Feeling competent had become part of my identity. Feeling incompetent again is painful. I have to keep reminding myself that I am a first year student, because I AM. There is so much I don’t know. And in fact, there is a term for what’s been happening to me. It’s called being deskilled, or deskilling: losing skills which I had had in the States and had taken for granted, and needing to re-learn these skills again from scratch. Not fun in any way whatsoever! And in some regards, there are even bad habits I had picked up which I need to un-learn as well. And completely new skills which I never had in the first place, like using a Pinard’s stethoscope or estimating how many fifth’s palpable the baby’s head is in abdominal exam. In the States we would say the baby was engaged or floating, but never had to document exactly how engaged (3/5ths engaged, 1/5th engaged etc.) the baby was.

I was painfully reminded of this awhile ago when I experienced my first true emergency as a student on labour ward. A woman had been brought in by ambulance in booming labour, and was barely into a side-room before the baby had been delivered. And then she began to seize afterwards. The emergency bell was pushed in her room, everyone ran in to help (including my mentor), and I was out on the fringes trying to be helpful but not actually able to do very much. Whatever was called for from inside the room, I was one of the task-rabbits running to get it. I put out the overhead hospital-wide emergency call to bring the larger team to the room, which I had never done before, and didn’t even know what room the patient was in without asking another midwife about it. I got a screen to cover the door for privacy. I brought a table and emergency trolley to the room.  Which is helpful, a bit, but that was about as much as I could do, and I was conscious that if this had happened in my old hospital in the States, I would have been in the room, in the thick of it, being a lot more helpful.  And it was scary. In my 6 year career in the US, I had never seen a full-blown seizure like that. I hope I never do again, any time soon.

Midwifery is a highly-skilled job. It takes years to master the skills necessary to do it well. And years of training and experience in a particular setting to know all of the ins and outs of the job. And I am just at the very start of this journey again, deskilling and re-skilling again.

Private Midwives in the NHS

Private Midwives in the NHS

The Sunday Times published an article recently about private midwives attending births at NHS hospitals: “Mothers Take Own Midwives Into NHS Hospitals”. This is definitely becoming more common, especially now that NHS trusts are inviting it to happen by contracting with companies like Neighbourhood Midwives and Private Midwives:

Ten NHS trusts have signed partnership deals allowing one private company to book rooms in their hospitals and centres for women to give birth helped by a private midwife. The mother then pays the company.

I can understand why this is happening, but I have mixed feelings about it. On the one hand, many trusts are under severe financial pressure, with midwifery shortages and hiring freezes, and literally not enough staff to care for the number of pregnant women in their trust. Creating an option for some of that responsibility of care to be taken up by private midwives helps to ease the burden on their over-stretched service. Renting out rooms and equipment to private midwifery companies also generates more money for cash-strapped trusts, so you can see the appeal. We also know, by overwhelming evidence, that continuity of carer produces better outcomes across the board, from shorter labours to fewer cesareans to better neonatal outcomes, as well as increased satisfaction reported by both women and midwives alike. At the moment, though, continuity of carer is hard to come by in the NHS, but is something that private midwives are much better at providing, so it makes a lot of sense that women who are able to are choosing private midwives because this is the type of care they desire.

In 2016, in response to the Kirkup Report which investigated the tragic failures at the Morecambe Bay NHS Trust, NHS England announced a new scheme to give women more options in choosing their maternity care provider, ostensibly as a way to address the shortfalls which led to the Morecambe Bay tragedies, as well as increasing women’s ability to have a named midwife or case-loading midwife (i.e. to have continuity of care and continuity of carer). This scheme is currently being tested in several NHS trusts, called “Maternity Choice and Personalisation Pioneers”, and basically amounts to women being given a £3000 “birth budget” and then allowing them to choose where and how to spend their money–either on NHS services or private services which contract with the NHS, exactly as described in the Times article above. Which all sounds very good on the surface, but I’m worried that this is just a way to privatise the NHS through the back door.

As soon as you begin to allocate personal budgets to women, you’re pulling funds away from the general NHS pot, which is already operating on a shoestring and severely underfunded. If more money is diverted to private midwives and organisations providing private care, there will be less and less available for NHS, which has expenses (such as providing and maintaining actual physical hospitals) not accrued by private companies, who would be using the NHS facilities.  Also, it runs the risk of pulling low risk women (and their funding) out of the NHS pot, which leaves less money available for women with more complicated pregnancies, who would have to rely on NHS services if they weren’t a good candidate for low-risk private midwifery care.  There is a lot of thoughtful commentary out there on why a £3000 birth budget might not be such a good idea. For one thing, in some areas (such as London), £3000 wouldn’t fully cover the costs of hiring a private midwife, and my understanding is that the NHS has put provisions in place which would prevent women from taking the NHS budget and then supplementing it with their own money in order to purchase more expensive care. Also, women using these birth budgets can only use them on private midwives who have been contracted by the NHS, which means that they couldn’t use the budget to help pay for the services of a self-employed independent midwife working outside of the NHS. And in fact, the fate of the self-employed independent midwife (i.e. a private midwife who works outside of the NHS, and works for herself rather than being employed by a private company, such as Neighbourhood Midwives) is very uncertain at the moment anyway, thanks to an incredibly obtuse decision by the NMC (but that’s a conversation for a different day, certainly).

In my mind (and on my wish-list) is the option where the NHS is fully funded, the shortage of 5,000 midwives in the NHS is filled, and women are given true informed choice about the type of care and services they would like to have, including case-loading and one-to-one midwifery care, i.e. continuity of care and carer.  This is something the NHS has struggled to provide, and something that women are clamoring for.  When there is a shortage of midwives and a budget crisis, I suspect there isn’t enough staff to truly provide that kind of care in numbers that aren’t overwhelming to the individual midwife. I’ve already spoken to many NHS midwives in my very brief tenure so far who have discussed how they used to case-load, but over time found it to be too exhausting, so they switched to a different modality. Or about how home birth services that provided case-loading care gradually disappeared when the core midwives who were part of the team became burned out or fed up or too exhausted to continue, and no new midwives wanted to take on the role. Imagine how different a service like that would look if it was staffed in such a way that a midwife could personally attend…I dunno…20-35 births per year, tops, and truly give each woman the fullness of her time and energy and attention through their entire antenatal/ labour/ postnatal journey, while still feeling like she had down-time and time for self-care and time to see her family. Imagine what maternity care in a world like that would look like!

But I know well enough that this is wishful thinking. I’m not sure what the right solution is here. Women want (and absolutely deserve) individualised, unhurried care from the same midwife throughout their pregnancy, birth and postnatal period–and rightly so! If this can’t be provided by the NHS, I understand why women would try to seek out that type of care privately, and also why the beleaguered NHS might think that contracting private midwives to provide it is a good idea. But I also know that there are thousands and thousands of excellent NHS midwives who also long to be able to provide that type of care in the first place, and if they could work in a system that allowed for case-loading and continuity of carer in a humane model that didn’t require each individual midwife to completely drain herself dry, there would be no need to contract private midwives in the first place.  Where do we go from here? It will be very interesting to see how these birth budgets are working out in the pioneer trusts, and whether they can actually create the kind of change their creators are hoping for.