Browsed by
Category: Labour & Birth

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?

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.

 

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?

 

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!