Category Archives: Midwife

Night shifts

I haven’t written for some time now and I like to blame it on something else rather than me being lazy, so I’m blaming it on night shifts. The night shifts are making me unfocussed and ultimately lazy!!

I’ve been doing so many night shifts that my colleagues thinks I have chosen to do so, and that really is not the case. It will have to stop after my big summer holiday which is coming up as it really does play havoc with one’s mind and body.

The comments vary when one mentions night shifts; – that must be tough, – money must be good, – not sure if I could do them. Nobody says – I’d love to do night shifts!

Unfortunately, in my opinion they are a necessary evil to many professions. There are some advantages though:

* The money is a little better but not worth it in the long run

* Usually it’s calmer – no management nor visitors

* Off-peak shopping – but if one does shift work anyhow, it’s not that advantageous

* Able to party late without getting tired as already on the night clock – a real positive!


But the disadvantages are more serious:

* The risk of bad health – tiredness, body clock changes, confusion

* Shorter life span

* Being more accident prone

* Lack of concentration


Here are some tips I’ve picked up online that I think could help:

* Sleep and eat well before a shift – easier said than done

* Most adults need 7-8 hours sleep a day, if difficult try to rest, as still beneficial

* Stay up and sleep before the next shift – this works really well for me!

* Have a short sleep before your first night shift – works if successful in falling asleep

* Have sleep-preparation rituals that promote good sleep hygiene

* Make time for regular exercise

* Don’t eat a huge meal right at the end of your shift, as it can disrupt your sleep

* Don’t go to bed feeling hungry: have a light meal or snack before sleeping

* Drink plenty of water throughout your shift

* Fuel up on complex carbs; these will release energy slowly over a long period

* Protein will fuel your muscles throughout the night

* Time your meals and activities to match your “day”

* Make your home dark during the day as sunlight wakes your body and brain

* Find a hobby you can bring to work which is mentally engaging; knitting, reading, puzzles

* Don’t do randomly scattered night shifts – be assertive and tell this to your scheduling person


Hope this help anyone out there struggling with night shifts! If anyone has any other good ideas – please post some suggestions!



Filed under Midwife, New

One-to-one care

One-to-one midwifery care means different things to different people.

Some take it to mean one-to-one care throughout the whole pregnancy, labour and postnatal period. This is obviously ideal but not practical in all settings or possible; there is usually a back-up midwife who can take over care where the named midwife is not available for any kind of reasons.

Some parents-to-be come into the hospital in labour under the illusion that they will only have one midwife, not understanding the shift patterns or that midwives need breaks. Some think this is not proper one-to-one labour care as parents have to meet and form new relationships with strangers but I would like to argue that it can actually be of benefit to get a new midwife into the mix; either to reiterate what has been advised already or to come in with new energy or ideas to help the woman in her labour.

Some midwives can just walk into a room and say a few poignant phrases and pieces of advice that where there was whaling and disillusion within a few contractions there is calm and ‘yes! I can do this’ spirit. This is maybe a little of an extreme example but I do find that often there is a benefit to have a fresh midwife take over labour care at the end of a long shift, especially if midwife has not had a proper break.

Where one-on-one care really makes a difference  is where the women have supportive partners and birth partners who understands that labour is not an illness but more of a quest that the woman has to go thru. Those partners give encouragement, they make the environment nice with music and lighting, take them for walks, gives them cuddles and kisses, they rub their back /feet /cramps /hands /scalp /shoulders, ensure they hydrate, take snacks and shield them from the world making them feel safe. If this is in place, it doesn’t really matter who the midwife is.

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Filed under Birth, childbirth, labour and birth, Midwife, Midwifery, New

Public holidays; birth on pause

It is funny how during a public holiday our maternity units become quiet, it’s like people don’t have time to deliver their babies – they have much better things to do! And if they do come in labouring they are nearly about to deliver, they have spent the longest time at home with their families and friends before venturing in to the hospitals.

This is often a funny anecdote between midwives but having not practice for too long as yet, was not quite so sure in the truth of this. But having worked this Easter, less than handful of labourers arrived throughout the whole nigh compared to the usual minimum of at least two handfuls. Having also worked New Year I must concurr in that birth is put on pause.

I have actually found a piece of analysis by MacFarlane in 1978 on the variations of numbers of birth during 1970-1976. It was found that a regular cycle of births can be clearly distinguished. This cycle of births repeats itself every 7 days. There is a minimum of births on Sundays and a maximum is reached between Tuesday and Friday. This cycle happens except for when Christmas falls on those maximum weekdays or during Easter or Bank Holiday Mondays. The difference is less dramatic outside of Christmas but it is still distinct. The preceding Friday and the following Tuesdays of Easter and Bank holidays, birth are generally low too. Additionally it appears that before Christmas the three weeks preseeding are often some of the busiest weeks on maternity wards, so I’m guessing the desire to deliver outside of the Christmas holiday brings on the labour. Our bodies and minds interplay are really extraordinary!

 Monday’s child is fair of face,
Tuesday’s child is full of grace,
Wednesday’s child is full of woe,
Thursday’s child has far to go,
Friday’s child is loving and giving,
Saturday’s child works hard for a living.
But the child who is born on Sabbath Day
is bonny and blithe and good and gay.


Filed under Birth, Midwife, Midwifery

Clarifications in my mind about Electronic Fetal Monitoring

Following my thoughts on fetal scalp electrodes (FSE’s) and remember they are only my thoughts, I am no authority on these things but I feel I need to vent them. Writing them down clarifies it in my mind. Input from my followers out there are most welcome!

So following my thoughts on FSE’s I now want to clear it in my mind about electronic fetal monitoring (EFM), or CTG’s if you like.

A little history first: EFM was introduced in the late 1960’s based on the assumption of efficacy but meta-analysis conducted in the 1990’s clearly indicated the use of EFM increased the rate of C-sections and instrumental deliveries. Without improving perinatal outcomes in full-term pregnant women who presented without risk factors for adverse perinatal outcome. So it is now thought that EFM should only be used when risk factors are present for adverse perinatal outcomes or when intermittent auscultation findings are abnormal.

Some of my thoughts around EFM is that although EFM is to be only used on women presenting with risk, this is not always the case; some women still get an admission traces, once an epidural is sited there’s a risk and EFM monitoring is required. These events can then in turn make a fetus without risk seem like being at risk because a long trace > 20mins may display some abnormal or atypical fetal heart rate (FHR) tracings. A healthy fetus can display both transient and repetitive hypoxia in labour. In fact 80% of labours result in abnormal or atypical FHR tracings at one time or another without signifying life-threatening situations (Umstad et al 1994). So where lies the cut off between a trace being suspicious to be considered abnormal and finally pathological.

I was particularly interested in finding out about these differences in second stage labour, this information I found difficult to find but this is what I finally came up with, which clarified it in my mind:

When to wait:

  • FHR and uterine activity is sufficiently clear to determine both (but in second stage this can be very difficult, often a maternal heart rate can be heard instead of the FHR – change position, unfortunately this often excludes the more favourable active positions)
  • Variability is >50% of tracing, never below minimal and not decreasing over time
  • Spontaneous or elicited (with vibroacoustic or scalp stimulation) acceleration every 20-30 mins ( – this is new to me, especially the vibroacoustic stimulation, – also that scalp stimulation is a good sign; in future I will definitely be recording such events)
  • Occasional late decelerations without repetition that are abolished with correction of position change, delayed pushing, hypotension and cessation of oxytocin
  • Variable decelerations that return to baseline abruptly, without persistent late components
  • FHR baseline is not increasing
  • Absence of repeated prolonged decelerations (>3 mins but <10mins)

When to worry:

  • Previously “put on notice” during first stage labour
  • Patterns that qualify as non-reassuring and cannot be corrected
  • Non-reassuring patterns such as:
    • persistent late decelerations (≥50% of contractions)
    • non-reassuring variables, progressively severe with developing tachycardia, loss of variability, or slow return to baseline
    • Sinusoidal tracing
    • Recurrent prolonged decelerations
    • An unusual or confusing pattern that does not fit one of the catagories define above, but does not have elements of reassurance

Corrective management:

  • Change position of woman to improve FHR
  • Discontinue oxytocin administration
  • Bolus of appropriate fluid to maximise intravascular volume
  • Vaginal examination to rule out cord prolapse, imminent or remoteness of delivery (at the same time see what results from the scalp stimulations on the FHR)
  • Consider passive decent if the FHR is amendable and pushing exacerberates the problem
  • Consider pushing only every 2nd or 3rd contraction
  • Decist from pushing and assist to a side-lying position, allow 20-30 mins recovery (unless terminal pattern present)
  • If FHR persistently is non-reassuring – deliver expeditiously

    (Freeman 2003)

All of the above should be in working collaboratory with the obstetric team, and them with the responsible midwife. So as a midwife it is imperative that this is clear in my mind so that I don’t feel that my client is being railroaded into an unnecessary instrumental delivery or c-section.


Additional clarifications for definitions of typical and atypical decelerations according to NICE:

 Typical decelerations:

  • Shouldering before and after, including quick recovery
  • Ok to have these decelerations for 90 mins in >50% of contractions before classified as a non-reassuring feature

(Document as normal per NICE guideline, however to monitor closely)

 Atypical decelerations:

  • No shouldering and deceleration lasts longer in >50% of contractions
  • Late decelerations in >50% of contractions
  • If lasted for >30mins classed as abnormal/pathological

Additional things to think of with decelerations and what they signify:

Early decelerations = head compression

Variable decelerations (typical and atypical) = cord compression

Late decelerations = placental insufficiency

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Filed under Birth, childbirth, labour and birth, Midwife, Midwifery

Birth Pause (inspired by Talk Birth)

Reading this  has put words to my own observations that had not  yet become thoughts. “Birth Pause” sounds very poignant and relevant to what happens when a baby’s birth goes smooth and linear.

As a midwife I try always to check with mums-to-be if they want baby delivered onto their lower abdomen, most do and some want them wiped beforehand. Additionally baby stays there for at least a minute if active management has been chosen for birthing the placenta, which allows for the birth pause. But maybe to leave baby there in future, even once cord is cut instead of moving baby towards the breast would allow the mum to further inhale and exhale until she is ready herself to reach for her new baby (we are all different and our birth pauses will differ in timing for each individual and for each birth). This happens quite naturally when physiological management is chosen, as there is no reason for me to be moving baby unless asked or cord is short.

Additionally babies are known to crawl by reflex to the breast, this I have seen and it is quite amazing! So my new mantra will be “leave baby be for birth pause”.



Filed under Birth, childbirth, labour and birth, Midwife, Midwifery, skin-to-skin

Three cases to make one think; this time about fetal scalp electrodes

I have found in my practice that things come in three to make me reflect on my practice, this time it is the use of fetal scalp electrodes (FSE) – the lesser of evil perhaps than rushing labour with an instrumental delivery because the fetal heart cannot be heard properly or at all.

I was in three delivery rooms today of three quite varied cases and reasons. First the woman whom I was caring for; initially loss of contact on the continuous electronic fetal monitoring (EFM) due to the position of the woman who was standing in second stage labour. A clear case for FSE so that woman could continue to labour in the position that suited her. In my opinion it was felt that the doctor was being too trigger happy to deliver the baby as baby came out in excellent condition following a ventouse delivery which in turn had required a small episiotomy cut. The fetal cord bloods taken showed that this baby was not a distressed baby at all.

The second delivery I attended was when I answered an emergency bell. Fetal heart rate was not being heard at all on the EFM as very small and the baby was actually coming down the birthcanal. It had apparently been hard to get a good trace throughout, so again a clear case for an FSE due to the difficulty of the EFM. Again a ventouse delivery and episiotomy possibly unnessesary as baby came out in excellent condition.

The third delivery I attended happened very quickly and as there was a lot of very loud screeming I thought I should see if the midwife needed some help in calming this very distressed woman. In this particular case there was no need for a FSE but had it gone slower then maybe it would have been justifiable, as there really wasn’t much of a trace to go on as it were.

The failure to use them is probably due to a history of not enough equipment in general and a continued lack of all equipment actually offering FSE monitoring. Because of this we are in general not very good at siting them, and in my experience it becomes a very stressful intervention due to the need to run around finding and puzzling together the equipment needed, but I think it may be time to address this issue to improve to the practice in the unit, maybe it would reduce what seems to be unnessesary instrumental interventions. The lesser of two evils I think perhaps.


  • more accurate fetal monitoring help make better clinical decisions (rather than make them blindly)
  • active positions for mother can be encouraged as there will be no loss of contact when secured


  • infection risk to both baby and mother



Filed under Birth, childbirth, labour and birth, Midwife, Midwifery

Some external signs for reaching full dilation, or not?

As a midwife I use many external signs when making judgements weather a mum-to-be is reaching full dilation/2nd stage labour, here are some of them:

Transition (sudden behaviour change; sleepy, talkative, had enough, want to go home, want a c-section or epidural, aggressive, hungry, etc)

Pressure in bottom (can be deceiving with a first-timer)

Urges to push/involutary pushes (again deceiving in primips)

Vomitting (can happen anytime, but often once 2nd stage is reached)

If using gas & air; either sucking harder at it or stop using it

Purple line visible high (harder to see on darker skin colour)

Cold lower legs (just started comparing with dilation noted, seems hit and miss to me at present)

Bloody show

Stretching of perineum

Anal gaping

Vaginal gaping


Presto…here comes the baby!


Any addition to the list welcome!


Filed under labour and birth, Midwife, Midwifery