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Author: Ali Monaghan

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.

 

 

Holding Space

Holding Space

Recently, a good friend of mine, Elizabeth Purvis, who works in a magical, nurturing, life-coaching space (she would term it manifesting, I’m pretty sure) posed a very simple, but pithy, question: “What does it mean to hold space?”  And just this very evening, I was tagged in a post giving compliments and shout-outs to beloved midwives, and the idea of holding space bubbled to the surface again in my response. I’m taking it as a sign that the Universe is telling me I really need to write a thing or two about this idea of holding space, so here goes!

What DOES it mean to hold space for someone?

In one of the best articles I’ve read about this to date, the author, Heather Plett, defines it in this way:

[Holding space] means that we are willing to walk alongside another person in whatever journey they’re on without judging them, making them feel inadequate, trying to fix them, or trying to impact the outcome. When we hold space for other people, we open our hearts, offer unconditional support, and let go of judgement and control.

Heather then goes on to explain eight things which a person does when they’re “holding space” for someone, including giving people permission to trust their own intuition and wisdom, only giving as much information as the person can handle, ensuring that they keep their power through the process (or in other words, not taking their power away from them), keeping our own ego out of it, making them feel safe enough to fail, giving guidance and help with humility and thoughtfulness, creating a container for complex emotions, fear, trauma etc., and allowing people to make different decisions and have different experiences than we would choose for ourselves.

Which means, to my way of thinking, that midwives are the original space holders! (And, for the record, although I am writing this post with midwives in mind, holding space at a birth is in no way the sole purview of midwives! Doulas, nurses, doctors, partners and family members can also be exemplary space holders! The pictures for this post are taken from my first labour, and the woman seen in each of these photos–watching, murmuring, encouraging, pouring water over me, massaging hour after endless hour–was my good friend and beloved doula, Kristen, who held space for me like no one’s business through fifty. six. hours. of labour. I would have been lost without her, and still to this day cannot thank her enough for what she did for me.)

Holding space is what midwives do, day in and day out. When I read a woman’s birth plan, I’m always very conscious of the fact that I’m holding a woman’s hopes and dreams in my hand, which is no small thing to be entrusted with. We all know that birth plans don’t always go according to plan, but as a midwife you’re a facilitator, keeping the woman’s desires and expectations foremost in your mind while helping her to navigate the journey that she’s on. You’re the guide, the translator, the sherpa. You can read the environment and terrain, you have a map, and as you’re traveling with her, your job can include any of the following: reassurance, support, course correction, managing expectations, cheerleading, nonverbal cues, preventing interruptions, creating silence, actively listening, validating, explaining, teaching and demonstrating.  If the birth veers away from the hopes and dreams and expectations, the manner in which you support a woman through the transition has a resounding, life-long impact on her. Research has demonstrated this again and again: if care is delivered in a compassionate and respectful way, if a woman feels like she was listened to and was part of the decision making, if true informed consent is given, then the woman can come away from a birth still feeling empowered and whole even if none of it went according to “plan”. If respect is lacking, if imbalanced power-dynamics are at play, if decisions are made without input, if actions occur without explanation afterwards (not to mention thorough, supportive debriefing), then a woman often comes away from her birth feeling disappointed (at best) or traumatised (at worst). And we know these feelings carry into the immediate postpartum period, which not only increases the risk of postnatal depression, but also shapes the woman’s identity as a mother, and impacts her agency and her belief in herself, which in turn has a knock-on effect on her children as well. Again, no small thing to be entrusted with! Doing this well means choosing your words very carefully. Planting seeds without being proscriptive. Breaking news at just the right moment, in just the right way, without overwhelming the couple. It’s constantly walking a tight-rope, a balancing act of myriad pushes and pulls–energy levels, personalities, non-reassuring fetal heart tracings, medical realities, hospital policies, staffing levels. It’s knowing that every room in the birthing center is full, so best not to mention the birthing tub that she can’t have. When you start to think about the complexities, it all begins to feel quite daunting, and yet the best midwives I know feel like their work is a calling rather than a job, and love their work so fiercely that (almost) they would do the work for free (and to be honest, I think this is something the NHS is well aware of, and takes advantage of to the fullest, which is not a good thing by any means).

And you’re holding space not just for the woman, but for the partner as well, who is on their own journey from partner to parent, and often needs encouragement and guidance on how to better hold space for the woman too.  It’s hard to watch someone you love going through pain and doing something so difficult, and this can sometimes make partners feel helpless, scared and even guilty.  I’m sure many other birth workers can speak about births they’ve been at where the partner wasn’t holding space in a helpful way, and how a simple word–maybe try rubbing her like this…I don’t think she can answer those questions right now…why don’t you sit here and then she can lean back against you in between contractions…would she like a sip of water [handing water bottle to partner, so that they can then offer it to the woman]…speaking in whispers if peace and quiet is called for…demonstrating through your own example how best to support her–can make a big difference in a partner’s ability to more optimally support their loved one. And then, of course, there are those moments when the love is so beautiful and present in the room that you feel privileged just to be able to witness it, and no input from you is even needed. I can think of many such moments at births which even now can bring tears to my eyes when I recall them. A toddler telling her mother that she’s doing great. A partner making his girlfriend laugh in between contractions which otherwise have her crying in pain.  A husband telling his wife that her vulva is every bit as beautiful now as it was before the difficult repair she just had (I kid you not, this is actually something I overheard at a birth; talk about knowing just the right thing to say at just the right moment!).

Holding space as a midwife means creating an environment where the woman in labour feels safe, able to do or say whatever she wants, growl or pace or moan in whatever way feels right, but also an environment where she feels protected and contained (and hopefully in such a way that this protection and containment is invisible and completely non-intrusive). If I’m doing my job well, I’m the safety net, the life-guard on duty, watching and observing but for the most part doing very little.  If I’m doing my job well, I can create an environment where the woman feels free to listen to her body, to follow her own instincts and labour in the way that seems best to her, ideally supported by her partner and support team more than by me.

Holding space also means seeing the big picture for the woman. She is lost in her labour, moving from one contraction to the next, unable to see in front of her, or behind her. It means supporting her in the moment when she is convinced that she can’t do it–even when you know she still has a long way ahead of her, and things are only going to get harder. It means telling her, sometimes again and again, after every contraction, that yes, she can do it. Yes, she IS doing it. Yes, she can. Yes, she IS. It means having faith–faith in the woman’s body, faith in normal birth, faith in her strength, in her perseverance, in her ability to push her baby out–and holding that faith for her even in the moments she she has lost her faith. It’s like shining a torch for her, a light in the distance that she can walk towards, a voice calling her when she’s lost in the maze of labour. It’s knowing that YES, she can do it, and never wavering in that belief, even when she is convinced that she can’t. You can’t do the work for her, but you know that she can do the work for herself. You give her the gift of that faith, and when the woman does climb the impossible mountain that she was convinced she couldn’t climb, afterwards she feels like she can do anything. The faith you held for her becomes a truth that she believes about herself. That is what you’re holding.

Holding space is also protective. Birth is wildly unpredictable, and uncontrollable. Birth plans don’t always go to plan. Hopes and desires for specific outcomes can be trampled. The baby sometimes has very different ideas about the manner in which s/he would like to be born! And sometimes there are true emergencies which require quick, focused action with very little time for communication until after the fact. Sometimes holding space is about preserving a woman’s dignity through the chaos. Sometimes it’s about literally giving her something to hold onto–a hand as you race back for an emergency cesarean, a familiar voice that she can hear through the beeping machines and commotion. Holding space means giving a woman time to grieve and process (after the fact) and a warm, non-judgemental listening ear to allow her to debrief. Postnatal listening and letting a woman tell you her birth story (and sometimes she needs to tell it over and over) can help her to understand and contain the experience.

Which brings me back to two of my favourite quotes about midwifery (and about holding space), from the Tao te Ching, written by Lao Tzu in 5th Century BC China:

The midwife completes her work by doing nothing. She teaches without saying a word. Things arise and she lets them come. Things leave and she lets them go. Creating, not possessing. Working, yet laying no claim. And when her work is done she forgets about it, and it lasts forever.

 

Imagine that you are a midwife.  You are assisting at someone else’s birth.  Do good without show or fuss.  Facilitate what is happening rather than what you think ought to be happening.

If you must take the lead, lead so that the woman is helped yet still free and in charge.  When the baby is born, the woman will rightly say: “We did it ourselves”.

What does holding space mean to you?

 

The Pinard Stethoscope

The Pinard Stethoscope

So here’s something that will be pretty mind-boggling for my UK readers: in the US, the Pinard stethoscope doesn’t really exist, at least not in any of the midwifery circles I travelled in.  NO ONE used it.  I’d never seen one or even heard of it until I moved here and started midwifery school (in fact, the only mention I can find of it in any of my American midwifery books–including my American midwifery textbooks–is a brief mention of it on page 112 in Ina May Gaskin’s Birth Matters, where it’s called the Pinard Horn rather than the Pinard stethoscope).  So you can imagine my surprise when I discovered that here in the UK, the Pinard stethoscope is a beloved midwifery tool, so much so that it serves as the logo for the Association of Radical Midwives, and beautiful wooden models are often given to newly qualified midwives as graduation gifts. Nearly every UK midwife owns a Pinard stethoscope–many of them even own several–and if that doesn’t convince you of its importance, it’s one of the first things Jenny pulls out of her midwifery bag during her visits on Call the Midwife.

All of this was news to me, though, as the closest thing we have to the Pinard stethoscope in the US is a fetoscope, which looks like this:

And you can see America’s most famous midwife, Ina May Gaskin, using a fetoscope here:

However, when I brought my American-style fetoscope to antenatal visits to show to my mentor, she was rather shocked, as she’d never seen one before. We then spent the afternoon experimenting with the Pinard stethoscope v. the fetoscope for auscultation of the fetal heart. I found that I could hear the fetal heartbeat more clearly with the fetoscope, while she preferred the Pinard. Go figure! But it was a very interesting experiment, and generally the pregnant women who so graciously allowed us to practice auscultation on their beautiful bellies were amused by the whole thing.

Since I knew virtually nothing about the Pinard stethoscope, and since as a student here in the UK we’re required to become proficient with its use as per the standards for pre-registration midwifery education (NMC, 2009), I thought it would be a good topic to write about for my first midwifery school essay assignment (which, interestingly enough, are called “assessments” here, rather than “essays”, just for the record). So, having written 15 pages on the subject now, and having tried my hand at it multiple times in the clinical setting, I have a bit more of a clue with regards to this ancient and much-revered midwifery tool, which I’m going to share here (you lucky devils, you!).

The Pinard stethoscope is a small 6-8” hollow, funnel-shaped tube often made of wood, metal or plastic, with the larger end placed against the woman’s abdomen and the auscultator’s ear placed against the smaller end (Harrison, 2004). In pregnancy, the Pinard stethoscope can be used from approximately 24 weeks onwards to auscultate the fetal heart during antenatal visits, and can be used in labour as a tool for intermittent auscultation (Johnson & Taylor, 2016). The very first monoaural stethoscope was invented in 1819 René Laennec, and was basically a long wooden tube which the auscultator would place against the patient’s chest wall, with his/her ear placed against the other end (although who’re we kidding…in 1819, it was most likely a man’s ear on the listening end).  Prior to Laennec’s invention of the monoaural stethoscope, fetal auscultation was performed by the examiner placing his (or her) ear directly against the woman’s skin and listening through her abdomen, a practice which required a large degree of intimacy between patient and practitioner, and which (you can imagine) may have been particularly discomfiting to 19th Century sensibilities (Montagu, 2008; Blincoe, 2005). The Laennec stethoscope afforded a measure of distance between patient and practitioner, helping to preserve the dignity of both, and in 1821, Laennec’s colleague, Jacques Kergaradec, applied the newly invented stethoscope to fetal auscultation for the very first time (Pinkerton, 1969). John Creery Ferguson brought fetal auscultation to the British Isles after studying in Paris with Laennec and Kergaradec, where the practice quickly took root at the Rotunda Hospital in Dublin, gradually spreading to the rest of the UK from there (Pinkerton, 1980; Harrison, 2004). The Laennec stethoscope underwent modifications by Holh in 1834, and was finally refined by Adolfe Pinard in 1896 into the current model (Harrison, 2004; Dunn, 2006). The Pinard stethoscope transmits fetal heart sounds more clearly through the long bore of the tube than the more ubiquitous binaural stethoscope which we commonly see slung around practitioner’s necks, which is one of the reasons it still remains in use as a modern obstetric tool today (Montagu, 2008). And, since the advent of the Midwives Act in 1902 here in the UK, proficiency with the Pinard stethoscope been taught to midwives in the United Kingdom for over a century now.

So why use a Pinard stethoscope? What are the advantages to it, versus the more common doppler (which uses ultrasound technology)? And how does Pinard use slot into general antenatal and intrapartum care here in the UK? Good questions, and as luck would have it, this was exactly what I was writing about in my essay!

At its most basic level, the rationale underpinning fetal auscultation is to confirm the presence or absence of a fetal heart rate (FHR) and to assess fetal well-being (Johnson & Taylor, 2016). According to the National Institute of Health and Care Excellence (NICE) Guidelines (sort of the US’ NIH equivalent), there is limited benefit from routine FHR auscultation during antenatal visits, particularly in the presence of fetal movement, since “auscultation of the fetal heart may confirm that the fetus is alive but is unlikely to have any predictive value, and routine listening is therefore not recommended” (NICE, 2008). Nevertheless, NICE supports antenatal FHR auscultation if the mother requests it, and for better or worse, FHR auscultation has become an expected and routine part of antenatal care these days–I couldn’t imagine an antenatal visit in which a mother didn’t want to hear her baby’s heartbeat (once the pregnancy had advanced to the point that this is possible). In labour, FHR auscultation is recommended throughout in order to monitor fetal well-being and the fetal response to contractions (Johnson & Taylor, 2016). The NICE Intrapartum Care for Healthy Women and Babies Guideline (2014) recommends intermittent auscultation every fifteen minutes in the first stage and every five minutes in the second stage for all low-risk women in labour, with continuous cardiotocography (CTG–i.e. electronic fetal monitoring, in US speak) used only in high-risk women, or in situations where intermittent auscultation reveals a non-reassuring FHR pattern or other emerging risk factors (NICE, 2014).

The use of the Pinard stethoscope as a primary tool for fetal auscultation is supported by both NICE and the Royal College of Midwives (RCM). In its 2012 guideline on intermittent auscultation in labour, the RCM recommends that the Pinard stethoscope be used to initially auscultate the FHR before switching to hand-held Doppler or CTG (i.e. electronic fetal monitoring) in order to ensure that the fetal heart is being recorded accurately (RCM, 2012).  This is because unfortunately the Doppler is capable of picking up “artifact” and doubling or halving the maternal heart rate by mistake, and in many tragic situations Doppler ultrasound can falsely reassure both parents and practitioners that the baby is alive and well, when in fact that’s not the case (and many UK stores recently banned the sale of hand-held dopplers to customers because of this very thing).  Using a Pinard stethoscope first to confirm the presence of the fetal heart helps to limit this mistake, and in fact, the Medicines and Healthcare Products Regulatory Agency here in the UK has issued an advisory on CTG which calls for the Pinard stethoscope to be used initially and at any other point when a change in FHR or concern in labour arises, in order to prevent monitoring the wrong heart beat (MHRA, 2010).  NICE also specifies that either the Pinard stethoscope or Doppler ultrasound be used for the initial assessment of a woman in labour, rather than CTG, and that the Pinard is a valid tool for intermittent auscultation throughout labour (NICE, 2014).

There are many advantages to using the Pinard stethoscope. First of all, as mentioned above, the Pinard stethoscope allows the midwife to listen to the FHR directly, unlike Doppler technology which uses ultrasound technology “to evaluate changes in sound waves caused by the direction and velocity of blood flowing through vessels and the heart” (Blincoe, 2005) and which can sometimes get it wrong and pick up the maternal heart rate by mistake.  Many experienced practitioners also find that they are able to hear not only variability with a Pinard, but also differences in tone and rhythm which can be ascribed to differences in individual babies (ARM, 2000; Wickham, 2002a; Cronk, 2002), and in fact there have been reports of midwives being able to pick up congenital heart defects through the subtle changes in rate they were able to detect with the Pinard (ARM, 2000). The Pinard stethoscope may also help support the woman in her role as the expert on her baby (Young, 1999; Montagu, 2007). “The current fashion for selling Dopplers to pregnant women implies that artificial monitoring is in some way protective; instead, it disempowers women and casts implicit doubt on their ability to be conscious of their own baby’s well-being through …awareness of the baby’s movements” (Montagu, 2008, p. 3). In other words, we should all be working harder to support and empower women to feel like THEY are the experts on their babies (because they are) and reaffirming again and again that the biggest predictor of fetal well-being is fetal movement. If you can’t hear the FHR because the baby is moving too much–no problem! You know that the baby is absolutely fine, in that situation (although, unfortunately thanks the to the pressures of litigation, as a midwife these days you would still have to find and record the fetal heart rate, otherwise your care will be deemed sub-standard, and certainly wouldn’t hold up in a court of law).  The low-tech Pinard stethoscope exemplifies the art and essence of midwifery care, and is particularly valuable in the developing world where resources are more limited (Mahomed et. al., 1994). Similarly, there will always be women in the developed world who will decline ultrasound technology, and since it’s imperative that midwives respect a woman’s choices as per the NMC Code (2015) and the Better Births Initiative (National Maternity Review, 2016), the Pinard stethoscope offers a much needed alternative to the Doppler!

However, in practice, the Pinard stethoscope has several disadvantages as well.  First, it’s not easy to use in labour, particularly if the woman is moving around or assuming different positions, such as on hands and knees (Blake, 2008; Harrison, 2004). Second, the Pinard stethoscope can only be used from 24-28 weeks onward, whereas the Doppler can detect the FHR as early as 10 wks (Blake, 2008), which is a big advantage to the Doppler in many women’s books, since naturally many women want to hear their baby’s heart beat as early as possible. There is also concern that accurate FHR auscultation can only be achieved by a highly-skilled practitioner who is expert with the tool, and that the average user is not as accurate (Blake, 2008)–and I can certainly attest to that, as the Pinard stethoscope is quite tricky to use in the beginning.  Additionally, a randomised control trial (RCT) comparing Pinard stethoscope to Doppler or CTG found that the Pinard was the least successful in identifying abnormal FHR patterns (Mahomed et. al., 1994). You can’t use the Pinard stethoscope in the water, which means if you’re monitoring a woman with Pinards alone, she’d have to get out of her birth tub every time you needed to listen, which isn’t very practical.  Finally, women have reported that the use of the Pinard stethoscope in labour is more uncomfortable than the Doppler, particularly if you can only use the Pinard while she’s on her back; additionally, you sometimes have to press quite firmly with the Pinards in order to be able to hear the FHR, which again can be very uncomfortable in labour.  Overall, studies have shown that women tend to prefer Doppler or CTG monitoring instead of the Pinard stethoscope, as being able to hear the heart themselves provides them with more reassurance (Garcia et. al., 1985; ARM, 2000).

And in practice, what is it actually like? Well, rather tricky. It took me several tries with it before I could finally hear the fetal heart. It’s often a very faint sound, and in many cases I don’t really “hear” it at all, but instead almost “feel” it against my ear as a vibration, something which Mary Cronk has written about as well (Cronk, 2002). It also requires that you’re SPOT ON with your abdominal palpation, as you really have to be right on top of the fetal heart in order to be able to hear it (whereas the Doppler is a bit more forgiving, and can allow you to pick up the heart rate even if you’re not exactly in the right location).  This means that the Pinard is a lot more difficult to use in situations where the baby is fully engaged, breech or posterior, as well as in situations where it’s difficult to determine the baby’s position due to the mum having a higher BMI. On the flip side, however, because precise abdominal palpation is a prerequisite skill for using the Pinard stethoscope, many midwives will use the Pinard to help confirm that their assessment of fetal position is correct, and sometimes see this as an advantage to its use (Cronk, 2002; Montague, 2008; Wickham, 2002a).

All in all, there’s something really special about the Pinard stethoscope, and I’m very glad that I’ve had the opportunity to learn how to use it.  I like it because of its historical significance, as well as its low-tech simplicity. I also like that there’s a real art to its use that only comes from experience and continued skill development. To me it represents a true skill that must be learned and practiced many, many times in order to attain mastery, and is something I’ll have to continue to practice and refine for the remaining years of my career.  Now that I’m on my rotation in the Birthing Center, I’ve been relying on the Doppler more, particularly as we’ve been using the pools a lot and it’s impossible to use the Pinard in a pool, but I would absolutely like try the Pinard in labour as well. I would like to someday be as comfortable and proficient with the Pinard as I am with the Doppler–it’s worth aspiring to, at any rate!

 

References:

Association of Radical Midwives (ARM). (2000) ‘Hearing Variability’, Midwifery Matters, (84) [no page numbers].

Blake, D. (2008) ‘Pinards: out of use and out of date?’, British Journal of Midwifery, 16(6), pp. 364-365.

Blincoe, A. J. (2005) ‘Fetal monitoring challengs and choices for midwives’, British Journal of Midwifery, 13(2), ppp. 108-111.

Cronk, M. (2002) Me and my Pinard’s. Midwifery Matters, (94), pp. 3-4.

Dunn, P.M. (2006) ‘Adolphe Pinard (1844-1934) of Paris and intrauterine paediatric care’, Archives of Disease in Childhood, Fetal & Neonatal Edition, 91(3), pp. 79-85.

Garcia, J. et al. (1985) ‘Mother’s Views of continuous electronic fetal heart monitoring and intermittent auscultation in a randomized controlled trial.’ Birth, 12(2), pp. 79-85.

Harrison, J. (2004) ‘Auscultation: the art of listening’, RCM Midwives, 7(2), pp. 64-69.

Johnson, R. and Taylor, W. (2016) Skills for Midwifery Practice. 4th Edition. London: Elsevier.

Mahomed, K., Nyoni, R., Mulambo, T., Kasule, J. and Jacobus, E. (1994) ‘Randomised controlled trial of intrapartum fetal heart rate monitoring’, British Medical Journal, 308(6927), pp. 497-500.

Medicines and Healthcare products Regulatory Agency (MHRA) (2010) Fetal Monitor/ Cardiotograph (CTG) – Adverse Outcomes Still Reported. Available at: https://www.gov.uk/drug-device-alerts/medical-device-alert-fetal-monitor-cardiotocograph-ctg-adverse-outcomes-still-reported (Accessed: 11 May 2017)

Montagu, S. (2008) In defense of the Pinard. Midwifery Matters, (118), pp. 3-4.

National Institute for Health and Care Excellence (NICE) (2008) Antenatal Care for Uncomplicated Pregnancies. (Clinical Guideline CG 62). Available at: https://www.nice.org.uk/guidance/cg62/chapter/1-Guidance (Accessed: 19 May 2017)

National Institute for Health and Care Excellence (NICE) (2014) Intrapartum Care for Healthy Women and Babies. (Clinical Guideline CG 190). Available at: https://www.nice.org.uk/guidance/cg190 (Accessed: 11 May 2017)

Nursing and Midwifery Council (NMC) (2009) Standards for pre-registration midwifery education. Available at: https://www.nmc.org.uk/globalassets/sitedocuments/standards/nmc-standards-for-preregistration-midwifery-education.pdf (Accessed: 11 May 2017)

Nursing and Midwifery Council (NMC) (2015) The Code. Available at: https://www.nmc.org.uk/standards/code/ (Accessed: 15 May 2017)

Pinkerton, J.H.M (1969) ‘Kergaradec, Friend of Laennec and Pioneer of Foetal Auscultation’, Proceedings of the Royal Society of Medicine, 62(5), pp. 477-483.

Pinkerton, J.H.M (1980) ‘John Creery Ferguson: Friend of William Stokes and pioneer of auscultation of hte fetal heart in the British Isles’, British Journal of Obstetrics and Gynaecology, 87(4), pp.257-260.

Royal College of Midwives (RCM) (2012) Evidence Based Guidelines for Midwifery-Led Care in Labour: Intermittent Auscultation. Available at: https://www.rcm.org.uk/sites/default/files/Intermittent%20Auscultation%20%28IA%29_0.pdf (Accessed: 11 May 2017)

Wickham, S. (2002a) ‘Pinard wisdom: tips and tricks from midwives (Part 1)’ Practising Midwife, 5(9), pp. 21.

Wickham, S. (2002b) ‘Pinard wisdom: tips and tricks from midwives (Part 2)’ Practising Midwife, 5(10), pp. 35.

Young, G. (1999) ‘The case for community-based maternity care’, in Marsh, G. and Renfrew, M. (eds.) Community-based Maternity Care. Oxford: Oxford University Press, pp. 7-26.

Safe Co-Sleeping

Safe Co-Sleeping

Unfortunately, there is a very sad article making the rounds on Facebook and several of my news feeds at the moment about a 7 week old baby who tragically died while bed-sharing with his mother. I don’t want to minimise this terrible loss in any way whatsoever, and I completely understand this mother’s desire to share what happened to her child with others as a way of trying to prevent such a tragedy from occurring again (and I can’t even imagine her heartbreak she must be feeling).  However, a lot of the information in this article is not evidence based, and it’s piling a whole lot of fear onto the words “bed sharing”, which isn’t helping when there’s already so much fear and misinformation out there in the first place. (I’ll put a link to this article at the bottom of this post so you can read it for yourself if you want).

First, the article doesn’t mention if this mum made a deliberate choice to co-sleep with her baby, and had therefore baby-proofed her sleep environment with that in mind, or if instead she had accidentally fallen asleep with her baby in her bed. We know that accidentally falling asleep with a baby in an unsafe sleep environment is much more dangerous than making the sleeping environment safe, and planning on sleeping with your baby in your bed. The mum doesn’t say that she was co-sleeping or bed sharing. She says that she fell asleep with her baby, and the baby slipped off the breast.  These are two very different scenarios.

We don’t know if this mum was exclusively breastfeeding or not. The recommendations we do have make it very clear that co-sleeping should only be done in an exclusively breastfeeding relationship. Even one or two bottles of artificial baby milk a day can put babies into a deeper sleeping pattern that is harder for them to rouse from, and it also weakens the mum’s instinctual awareness of her baby in bed with her.

Waking up repeatedly to breastfeed a baby and accidentally passing out from exhaustion in a chair or on a couch is actually much more dangerous for your baby than deliberately planning on co-sleeping safely with them.  There are hormones released during breastfeeding which are designed to help both you and your baby to fall asleep, so it’s very common to nod off while breastfeeding. It’s better to plan for this occurrence to happen in a safe environment, rather than fighting against sleep (and most likely losing the battle) propped up in a chair or on a couch.

Also, the title of the article itself makes it sound like *breastfeeding* was the reason that this baby died, when actually it wasn’t the breastfeeding, it was unplanned bed sharing. In reality, all the evidence we have tells us that exclusively breastfeeding is some of the best protection we have against Sudden Infant Death Syndrome (SIDS).

The article keeps linking to a parents.com article as evidence, saying things like “experts have found…”. Unfortunately, parents.com are not experts on co-sleeping, bed sharing or breastfeeding. Professor Helen Ball and Dr. James McKenna are experts on co-sleeping.

And finally, we need to remember that co-sleeping is not a “trend”. Parents aren’t doing this because it’s cool. They’re doing this because it’s the biological norm for our human species, and the way that we’re supposed to feed our human babies. It’s also the best way to get more sleep as an exhausted new parent, IF you’re exclusively breastfeeding, and IF you make the sleeping environment safe.

So how do you safely co-sleep?

In a nutshell: you need to be exclusively breastfeeding, make sure the mattress is firm and not something you sink into, and that any cracks between the headboard and wall are packed with rolled up towels or clothing so there are no gaps. Duvets and pillows need to be kept well away from the baby (including snoozepods and snugglers and sleep positioners), and the baby should zipped into a sleep sack rather than swaddled, with their head uncovered (and their arms free) The temperature of the room should be about 18 degrees Celsius, and the baby should be dressed appropriately so that they don’t overheat. The baby needs to have been born at term, and should be placed on his/her back to sleep. And obviously, mum and dad both need to be nonsmokers and sober.

Want better evidence than my word alone? Professor Helen Ball’s research from Durham University is one of the best places to start. She has a fantastic website you can visit which talks more about where babies sleep, and how to make their sleeping environment safe.

La Leche League has a check-list you can use as well, called The Safe Sleep 7.  La Leche League also has great article called Safe Sleep and the Breastfed Baby.

Dr. James McKenna, director of the Mother-Baby Sleep Laboratory at the University of Notre Dame, also has an excellent guideline on how to make the sleeping environment safe.

And finally, if you are an exhausted new parent who is combination feeding (i.e. breastmilk and artificial baby milk) and wanting to co-sleep but unable to do so because of these guidelines, putting the baby in a side-car cot that attaches next to the bed (so that they have their own separate sleeping environment while still being very close to you) is a good option, or else a bassinet close to your bed. You could also look into using a baby box in your bed with you, which research from Finland is supporting (although if you’re going to use a baby box, there shouldn’t be any extra padding, blankets, bumpers or pillows with the baby, just a baby and a zippered sleep-sack).

(And finally, the article in question can be found here.)

Two Beautiful Births

Two Beautiful Births

We finished our community rotation about 3 weeks ago, and while I enjoyed community very much, I’ve been counting down the days until my placement in the Birthing Center at our hospital. It’s been a long time since I’ve had a chance to attend a birth, and while I was keeping my fingers (and toes!) crossed during my community placement for the opportunity to attend a home birth, unfortunately my mentor was never called away to a birth during her on-call shifts. So no births…until today, which was the first day of my new placement in the Birthing Center! Except it wasn’t really the Birthing Center, as my  mentor was working on Labour Ward instead.  So Labour Ward! And remarkably, I was lucky enough to witness (and even help catch) two surprisingly normal (for Labour Ward) spontaneous vaginal deliveries today. In both cases they were multips, so their labours progressed very quickly, and in both cases there were no other interventions aside from etonox (gas & air) and in one case, artificial rupture of membranes.  Which was a very pleasant way to kick off my new rotation! And it was glorious (glorious!) to be around labouring women again–the quiet touches, the soft words (“beautiful!” “you’re doing great!” “SO strong!”), the sweat on the brow, the hard, hard work, the smell of amniotic fluid, the holding of legs, the offering of sips of water, the thumping of fetal heart rates as the constant background noise, the partners leaning in and holding hands and stroking their partners (the love–did I mention the love??), the babies’ wet and curly-haired heads coming into sight for the very first time, the first looks, the lusty first cries, the rosy glow of newborn skin (and ALL the skin to skin), the laid-back breastfeeding, the relief, the amazement, the joy, the MIRACLE. I am absolutely thrumming with excitement now, even 3 hours after my shift ended.  And we even had time to eat our lunch, orientate me to the unit, go through the paperwork, and even go through some of the equipment set-up for the warmers and resuscitaires. All in all, a fantastic first day!

Ovulating While Breastfeeding

Ovulating While Breastfeeding

A friend of a friend recently asked me a question that I couldn’t answer. She’s in her late 30s, has a two year old daughter, and has been breastfeeding on demand for the past two years. She and her husband have been trying to have another child, but she just recently learned that she miscarried after their first attempt. She has only recently started getting her period again, and was wondering if the breastfeeding could negatively impact her body’s ability to get pregnant again. I speculated that the high levels of prolactin which occur during breastfeeding might inhibit ovulation, just as high levels of oestrogen inhibit breastmilk supply by competing with prolactin for binding sites in breast tissue, but I told her I wasn’t really sure and that I would investigate. I thought that somehow oestrogen and prolactin were counter opposites: one could not exist in high levels while the other was around. Turns out I was waaaaay off base. Here’s what I found:

During pregnancy, the corpus luteum, acting on instructions from the placenta, secretes the oestrogen and progesterone necessary to maintain the pregnancy. These high levels of steroid hormones simultaneously suppress Follicle Stimulating Hormone (FSH) and Leutenizing Hormone (LH), the two hormones most responsible for ripening an egg and then triggering ovulation—after all, if you’re already pregnant, there’s no need to ovulate. After delivery, once the placenta is removed, the high levels of oestrogen and progesterone no longer exist, and the levels of FSH and LH gradually begin to rise again, preparing the body for ovulation. Eventually, as the levels creep up, the pituitary takes notice again, and begins to release more FSH and LH through a negative feedback loop, which eventually will trigger ovulation.

“Most nonlactating women resume menses within 4 to 6 weeks of delivery, but about one-third of the first cycles are anovulatory, and a high proportion of first ovulatory cycles have a deficient corpus luteum that secretes sub-normal amounts of steroids. In the second and third menstural cycles, 15% are anovulatory and 25% of ovulatory cycles have luteal-phase defects…Lactation, or breastfeeding, further extends the period of infertility and depresses ovarian function. Plasma levels of FSH return to normal follicular phase values by 4 to 8 weeks postpartum in breastfeeding women. In contrast, pulsatile LH stimulation is depressed…in the majority of lactating women throughout most of the period of lactational amenorrhea.” [1]

In other words, after not menstruating for so many months, it takes the body a few tries to get the delicate hormone balance back up to speed again. The first few cycles either don’t release an egg, or if an egg is released, the corpus luteum, which is responsible for secreting enough progesterone to maintain the pregnancy until the placenta can take over, isn’t quite up to the task. This is called a luteal phase defect, and it’s a very common cause of early miscarriages. In women who are breastfeeding, the process of returning to normal ovarian cycles takes even longer.

In breastfeeding women, FSH, the hormone responsible for ripening an egg, returns to normal pre-pregnancy values fairly early, but LH, the hormone responsible for triggering egg release, continues to be suppressed due to the breastfeeding. (However, contrary to popular belief, prolactin is not at all responsible for this suppression. It’s the constant suckling and stimulation of the nipple itself which actually suppresses ovarian function, which is why on demand breastfeeding is so essential to maintaining lactational amenorrhea.)

So, there you have it. To answer the question: it will probably just take a few more cycles for your body to get back into full swing in terms of ovulating, but continued breastfeeding did not contribute or cause the miscarriage in any way, and will not prevent conception. Most likely, the miscarriage was caused by a short luteal phase or corpus luteum that just wasn’t quite ready to maintain a pregnancy, and this will no longer be a problem once your body goes through a few more cycles and gets used to ovulating again.

[1] Hatcher, R.A. et. al. (2011) Contraceptive Technology, 20th Revised Edition. Ardent Media, Inc.: New York.

Gentle Mother-led Weaning

Gentle Mother-led Weaning

 

 

Letting Go

First you hold them like a secret
you only suspect is true.
Then soft knockings from within
tap out messages for you.
Slowly the body allows escape,
you hold them in your arms,
dazed and milky, full of love,
pledged to defend from harm.
Then you  hold them to your heart
and put them to the breast.
but they learn to walk away
like any other guest.

Angela Topping, Musings on Mothering (2012)

When IS the right time to wean?  Before I even start, I need to acknowledge the fact that MANY women wean before they want to, without having met their breastfeeding goals, and often feel like they didn’t have a choice in the matter. This is usually due to a lack of breastfeeding support when they most needed it, and I can understand how articles about women choosing to wean when the breastfeeding is going well might be difficult to read. As a lactation consultant, I hear so many stories from heartbroken women who wanted to breastfeed, but weren’t able to for so many reasons, many of which might have been preventable if they had had the right support earlier in the process. In January 2016, the Lancet published a chilling review of breastfeeding rates around the world, and sadly the UK was at the very bottom of the pile, even worse than the US (which is rather astounding, given that many women only receive six weeks of maternity leave in the US, versus the much more humane 6-12 months that most women get in the UK). In the UK, 81% of women want to breastfeed at the start of their postnatal journey, but by 6 months, the numbers of women successfully breastfeeding have already dropped to 34%, and by 12 months only 0.5% of all women in the UK are still breastfeeding. Which partly explains why extended breastfeeding is viewed as such an aberration in this country.

BUT, if the breastfeeding has been going well, and you’ve been enjoying it and carrying on past the 12 month mark, then at some point the question will arise: when IS the right time to wean? To help answer that question, we can turn to the data. The World Health Organization recommends breastfeeding at least through the first two years of life. Numerous professional organizations, including the Royal College of Paediatrics, UNICEF, the Royal College of Midwives, the American College of Nurse-Midwives and the American Academy of Pediatrics all recommend breastfeeding for at least the first year of life, and then carrying on for as long as desirable for both mum and baby.  New research suggests that there is a link between gut health and brain development, and that nursing well into toddlerhood gives your children a boost in cognitive development and mental/ emotional health. The advantages of extended breastfeeding are numerous and well documented, and carry on well beyond the first year of life. From primate research and indigenous cultures we know that the natural age of weaning for human mammals is probably between 2-5 years of age. If the breastfeeding is going well AND you’re still enjoying it, there’s no reason to stop, and I personally know many, many people who have happily and joyfully breastfed their children until they were 3, 4 or 5 (or even older). I’ve also read and heard so many beautifulbeautiful stories about women who were able breastfeed until the point that their child was ready to stop, a process often referred to as natural term breastfeeding, or child-led weaning.

But what happens if you’re no longer enjoying it? And what happens once you get beyond two years of age? I doubt there’s a standardized answer to that question any more, and I’d imagine that, as with everything, it varies from nursing dyad to nursing dyad. Since I’ve found many accounts of child-led weaning online, but relatively few (if any!) examples of gentle mother-led weaning in toddlerhood, I thought I would share my experience here. The course my son and I ended up charting was a bit different than the one I had originally expected for us, but I am finding a way to make my peace with it.

So, this is the story of how I weaned my second son.

With my first son, I stopped breastfeeding at 15 months. At the time, I had just started a new job as an independent home birth midwife in New York City, and I was convinced that I wouldn’t be able to keep up with the breastfeeding while also being on-call and away at births for hours at a time. Looking back now, the flaw in this thinking seems so obvious to me. OF COURSE I would have been able to continue to breastfeed if I had wanted to, especially as he was only feeding a few times a day at that point, and was fully night-weaned. He would have been fine with a cup of cows milk at bedtime now and then if I was away at a birth, and happy to have a nurse and a cuddle whenever I finally made it home. But at the time, my breastfeeding goal had been to make it to 12 months.  After 12 months, anything beyond that felt like icing on a cake–nice to have, but not really necessary.  So at 15 months, I figured I had breastfed enough, and my (rather self-imposed) perceptions about work pressure convinced me to stop. I weaned him abruptly because I really didn’t know any better.  My husband and I went away for a weekend wedding, and he stayed behind with the grandparents, and when I came back, I didn’t resume breastfeeding him again.  And he rolled with it, of course, because he was only 15 months and couldn’t even talk yet, let alone protest.  But I’m sure he missed it, and I’m sure he would have happily carried on if I had let him, and I’m sure that if he had had a say in the matter, he would have wanted to continue. I was a midwife at the time, but had not yet started down the path towards becoming an IBCLC. I didn’t even know how little I knew.

“Do the best you can, until you know better. Then when you know better, do better.” –Maya Angelou

With my second son, I wanted to do things differently.  I was an IBCLC by the time I was pregnant with him, and I had a much better idea about exactly how important breastfeeding is into the second and third year of life. My goal was to make it to 2 years this time, minimum, and perhaps continue until he was 3 (or maybe even older). I had lots and lots of friends who were “positive deviants” (in the words of Allison Dixon from Breast Intentions), i.e. people who were still breastfeeding their two and three year olds (and in some cases four and five year olds) despite our rampant anti-breastfeeding culture.  Breastfeeding a two year old didn’t seem like a strange idea to me any more. And my attitude had changed as well. Things that I used to worry about with my first son–getting him on the “right” schedule, getting him to sleep through the night (as if this was actually something I could have controlled!), not creating “bad habits”, not letting him “use me” as a dummy/ pacifier–didn’t really stress me much at all with my second. He wasn’t fully night-weaned until 18 months, whereas my first son was night-weaned by 6 months (granted, this was because I was working as a midwife again at 4 months, thanks to the completely INHUMANE maternity leave policies of the United States of America, and I was terrified that I would make a mistake or dangerous decision during a shift because of exhaustion, so the night feeds were phased out quite early). My second son co-slept with us from the get-go. He was in and out of our bed for many months even after he had begun to sleep in his crib. Things were just a lot more relaxed, and he was (still is) one of the most chilled, easy-going and confident kids I know. Of course, I can’t prove that this is because of our more easy-going attitude, or the extended breastfeeding, but in my mind they’re linked.

And then we made it to two years old–huzzah! And the breastfeeding was still going well, and had become a very easy thing to do. As Sarah over at Nurshable points out so eloquently, nursing a toddler is very different from nursing a baby. As the amount of solid foods he was eating began to increase, he began to nurse less frequently throughout the day, and I gently encouraged this by offering liquids, snacks and cuddles during the times that he might otherwise have wanted to nurse. By around 22 months, he was only consistently nursing about twice a day–when we first woke up in the morning and right before he went to bed–plus the occasional emergency nursing session when he had hurt himself or was otherwise having a really difficult time.  But also right around two years of age, there was a change in the way that he nursed which suddenly made things a lot more unpleasant. First, there was a change in his latch. I’m not sure why or how–perhaps it had to do with the changes that were occurring as his speech developed–but suddenly the latch became incredibly tight and clamped. No matter how wide the latch was initially, he invariably changed the shape of his mouth to a very narrow and shallow latch. I tried all kinds of tricks to encourage a wider latch. I talked about it with him, I explained that it hurt, I would take the breast out of his mouth when he did it and re-latch again (and sometimes resorted to just taking the breast away altogether, especially if he had bit me), I switched positions, I used the nipple flip when latching, at one point I even gave nipple shields a try, but as the weeks dragged on, it seemed like this new change was becoming a permanent fixture in our nursing experience. Whenever we finished nursing, I always had a tight little ring of teeth marks around my nipple. He also began the usual (and very normal) nursing tricks that lots of toddlers play–nursing gymnastics where he wanted to nurse upside down and from every conceivable angle, or have his legs on my shoulder while nursing, or his feet in my arm pits. He began twiddling the other side, which I know from my nursing friends and online forums is a very common thing that many women experience and often find incredibly aggravating, and I could usually prevent this by covering my other breast with my hand whenever he was about to reach for it. He did the popping on and popping off game, and talking with a breast in his mouth (ouch!), and ultimately began to want both breasts out at the same time, so that he could switch rapidly between them at his own pace, five sucks from one side, four from the other, then back to the first side again (I suspect my supply must have been dropping a bit at this point, so that he had begun to instinctively switch nurse, which is a great way to boost supply).

Maybe one of two of these changes on their own would have been easier manage, but somehow all of these changes combined meant that I began to approach nursing sessions with dread, and found myself counting the milliseconds until they were over. It wasn’t that it was awful, but it was no longer the cuddly, lovely, snuggly breastfeeding that I had been enjoying prior to this. I began to think that maybe something was wrong, especially as I kept hearing stories from my positive deviant friends about how much they still loved breastfeeding their three or four year old, and how snuggly and comfortable it still was. I began to wonder if maybe they were just having a very different experience to what I was going through, as I usually came away from a nursing session feeling as if I had just been used and pummeled; I often felt annoyed by it, and sometimes I even felt a bit resentful about it, and this was not at all how I wanted to feel towards my child! I also felt a sort of secret shame about these feelings. How could I feel this way, when as an IBCLC I was supposed to be a breastfeeding guru? How could I dread nursing myself, when one of my favorite things in the world was promoting breastfeeding and helping others achieve their breastfeeding goals?  I knew that for many mothers a nursing aversion can be a phase, so I resolved to grit my teeth and carry on as long as I could–in part because I felt like I should be doing natural term breastfeeding, like any good IBCLC would.  If it was a phase, though, we didn’t seem to be coming out on the other side of it, and the months kept dragging on.  I also began to recognise that I was putting a lot of pressure on myself because of the ‘shoulds‘.  If a client had come to me with the exact same situation, there wouldn’t have been any ‘shoulds’ involved at all! I would have been incredibly supportive, and advocated that she listen to her heart and do what felt right to her. And yet, when it came to myself, I had a much harder time letting go of my own (self-imposed) expectations to nurse to natural term.

At about 27 months, I met up with a good friend of mine who was still nursing her five year old son, and in the midst of setting the world to rights, breastfeeding came up. I spoke with her about my aversion towards nursing, and how I was carrying on through the aversion with gritted teeth but not at all enjoying it, and she talked about how she had certainly gone through many phases like this during her long breastfeeding tenure (though never quite as long an aversion as I had experienced at that point). It was lovely because she was able to normalise the experience for me, so that I no longer felt like I was alone in feeling touched-out and resentful towards my child instead of feeling loved-up and oxytocin-blissed out after a feed. But she also said something which I had never really thought about quite in those terms before: nursing is a relationship.  Well, duh!  I was very well versed in all the ways that the breastfeeding relationship is incredibly important to a baby’s bonding and emotional and psychological development and attachment, but I had somehow forgotten that there are always two people in a relationship. I had never quite stopped to think about the ways that my own needs and desires factored into the equation as well. I began to think that I had a say in the matter too; that maybe the right time for us to wean wouldn’t just be when he was ready to stop, but at a point where I was ready to stop, and when stopping wouldn’t be too detrimental to him.  I began to think of it as a compromise between the two of us–I would carry on through the aversion until we came to a point when he could at least be gently persuaded to cut-down and/or stop.

And thus began our very slow and gradual weaning process. I began to think of the entire process as nudging, rather than weaning. I was gently nudging him towards less and less breastmilk, bit by bit, but doing so very slowly, and as gently as possible. For the record, though, this was definitely my idea, not his, i.e. mother-led rather than baby-led.  He would still be nursing right now, if I had been willing to continue. I had to find a middle ground between his desire to continue to breastfeed, and my desire to stop, and hopefully do so in a way that was gentle and respectful of his desires (while still honouring mine).

We began by cutting down the bedtime nursing first, helped by the fact that we have an older child who drinks cow’s milk at bedtime.  It was easy to offer him a little bit of mommy milk first, and then slowly cut-down the amount of time we were nursing, and finish with cow’s milk and books, just like his older brother. There were also a few nights when I was away from him, and he was perfectly happy to have cow’s milk and books with his grandparents or babysitters. He no longer nursed to sleep, and was able to go to bed without me there, so the nursing was no longer the nightly fixture that it had once been. Over the course of a few months, the night nursing became a cuddle and a minute or two of mommy milk, and then occasionally there was a night or two when he didn’t even ask for mommy milk in the first place (and I was operating under the ‘don’t offer, don’t refuse’ policy), so he began to go to sleep with cuddles and cow’s milk, just like his older brother.

The morning feed was a bit more difficult to cut down on. My supply was much larger in the morning than in the evening, and he was in the habit of waking up and coming to crawl into bed with us and having his mommy milk then.  Slowly, though, I began to gradually shorten the length of the feeds, making it up with lots of cuddles and persuading him to come down to the kitchen with me for a drink of almond milk or cow’s milk while continuing the cuddles. Over time the morning feeds became shorter and shorter affairs, finally down to about 5 minutes in the end, but I began to realise that he wouldn’t voluntarily give them up.  I decided I would probably just need to pick a date, and work towards it. Knowing that he couldn’t keep more than a week in his head at one time (his concept of time is still rather shaky), I began to count-down the days with him. Every morning, as we were breastfeeding, I talked with him about how much bigger he had gotten. I talked to him about all of the things he was capable of doing now that he couldn’t do when he was a little baby. I talked to him about the foods and drinks he could enjoy now that he was so much bigger.  I talked about how his older brother had had mommy milk for a long time too, but that eventually as he got older he began to drink cow’s milk instead of mommy milk. And I talked to him about how much I had enjoyed breastfeeding him, and how special it was to me.  And at the end of these little conversations, I explained how we would be stopping the mommy milk in six days…four days…two days…tomorrow. He took it all in stride, and began to count down with me (“no more mommy milk tomorrow” etc.), but of course I wondered how much he actually understood what that meant.

And then, the day finally arrived. “Tomorrow” became “today”, and when he crawled into bed with me in the morning, I explained that the mommy milk was finished. He cried, of course. We both cried. But I held him and talked to him again about how much I had loved breastfeeding him, and about how sad I was that it was over, and about what a special time it was for both of us. And then I talked about how much I love him, and all the ways that I can still comfort him, with cuddles and snuggles in bed, with hugs during the day, with stories on my lap, with kisses when he hurts himself, with tickles and sniffs and rough-housing. And he was comforted, in the end, and we went downstairs to get him some almond milk or cow’s milk, cuddling all the while.

That wasn’t it, of course. He continued to ask for mommy milk in the coming days, but there were fewer and fewer tears involved. We had the same conversation many times, about how lovely the breastfeeding had been, and how it was sad that it was over, and all the ways I could still comfort him, and how much I loved him. And we had lots and lots of cuddles, to try to make up for it, but I have to admit that he was a lot clingier than he normally was for the first several weeks. I felt incredibly guilt-ridden about my decision. Also, in retrospect, I realize now that I could have picked a better time to do this, as I ended up weaning him about 2 months into starting my midwifery course, which meant I was no longer around as much as I had been before. It was a big adjustment for him—to end our breastfeeding relationship at the same time that I was also away from him for the first time—and it would have been an easier transition if I had held on for just a little while longer, giving him the comfort of nursing through my transition to school.

But, after these first few weeks, he did begin to find his equilibrium again. He sometimes cheekily asked for mommy milk at random times throughout the day, even asking for “bonus milk” at one point, which I think was a way of testing me to see if there were any loopholes in our new relationship. And one morning many weeks after the weaning, while I was getting dressed in front of him, he plaintively asked if he could try one more time, and without giving it much thought, I let him. I was curious to see what would happen. He was amazed and delighted that I had relented, and gave it proper go (he still had his latch, for the record), but the milk was no longer there. After a few sucks on one side, then a few sucks on the other, he declared that “the milk was all gone.” And since that day, he’s asked for it a lot less (although he has also suggested that we should have another baby, so that the mommy milk will come back). He’s also asked to put his hand on the “milks” a few times when he’s snuggling me and wanting comfort, which I’ve let him do.

And so, at 31 months of age (2 years and 7 months), we ended the breastfeeding chapter of our relationship. Even preparing for it as I have been, even talking about it and cherishing the last few weeks of it (amidst the gritted teeth and sore nipples), even wanting it to end, I have been amazed at the mix of emotions this has caused in me. It’s been incredibly bittersweet. I have been simultaneously incredibly proud of him, and also crying inside, particularly as he’s my last baby, and I’ll never breastfeed again. In some moments, I feel inordinate relief that it’s over. In other moments, I feel incredibly guilty about it, particularly in the moments when he’s being clingy. Like so many things with motherhood, there is a lot of self-doubt and uncertainty. I wonder if I made the right decision, I wonder if I should have held on for longer. These things keep me up at night, sometimes. But by and large he seems to be taking it all in stride, and aside from the initial clinginess, he’s returned to his normal, happy, relaxed self. We keep having lots and lots of cuddles, and still talk about it now and then. It was a beautiful, magical time in our lives, and I knew, even as it was happening, that it wouldn’t last forever. Now that it’s over, we’ve moved on to the next beautiful, magical time in our lives (as these toddler years are also way too brief). Our relationship continues to evolve and grow, as it always will, and I will weather these changes as he grows up and needs me less and less. But for now I still sniff his head (which still has that sweet, intoxicating baby smell now and then) and watch him when he’s asleep (he still looks so small) and marvel at all of the new things he’s learning and doing every day (he’s begun asking about using the potty like his older brother, so I can guess what’s coming next). The days are long but the years are short, and the seasons of motherhood continue on.

Notes to Self

Notes to Self

We’re beginning the clinical portion of our midwifery education now, after a very intense, action-packed 8 weeks of theory and classroom work. For the next 8 weeks, we’ll be in the clinical setting, on our placements, learning by doing, helping and shaping the antenatal, birth and postnatal experiences of the women we meet.  I’m SO EXCITED to begin actual midwifery work again! But on the eve of my clinical placement, it seemed like a good time to write a few notes to myself (and my fellow students on the eve of this exciting milestone):

Clinicals are going to challenge you in ways we can’t even imagine yet–even though you’ve done parts of this before, it’s still going to be challenging, and new. You’ll need your mind, your ability to think, your ability to feel, your ability to see clearly, to watch and wait, to put 2+2 together, to use all of this knowledge we’ve been working so hard to acquire.

But remember that birth isn’t in the textbook. It’s in the mother, sweating with exertion, it’s in the partner, whispering words to encourage her, it’s in the baby, liminal and waiting.

Remember that wherever you stand in that labour room, no matter how chaotic, you stand in a holy place. Your heart has called you to this profession, this path, this work. Let your heart shine–your wisdom, your strength, your love.

 

 

Differences so far…

Differences so far…

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

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

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

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

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

 

Sleep and “Self-Soothing” Roundup

Sleep and “Self-Soothing” Roundup

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

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

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

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

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

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

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

Uncommonjohn also looks at the science behind self-soothing

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

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

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

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

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