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.
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.
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
- 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
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:
- 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)
- 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
Reading this http://talkbirth.me/2012/03/28/birth-pause/ 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”.
I have just read the following blog from fabulous Dr Sloan; http://marksloanmd.wordpress.com/2011/12/16/delayed-cord-clamping-settling-the-debate/ which was re-blogged by another blogger I’m following http://modernmidwifery.org/
I wanted to further share my comment with you my own followers, present and new:
I’m all for delayed cord clamping for the benefit of the baby and to further wait until it stopped pulsating for the benefit of both mother and baby as it is gentler. As long as the cord is pulsating the risk of haemorrhaging from the uterus is minimal as the placenta is still attached. The cord can continue to pulsate for some time, many times for as long as 20 minutes. I also have found from personal experience that the blood loss seems less at delivery when women opt for physiological birth of the placenta which is opposite from what textbooks tells us midwives. Now I have found research to support my findings that there is actually less blood loss when undertaking physiological management of delivering the placenta (Dixon et al 2011);
Placenta: our tree of health
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
So many thoughts going round in my head about the last labour and birth I attended but the main one is that I’m happy about the outcome. Happy that it went so smoothly even though some help was needed to progress the labour. The mum-to-be needed care in the high-risk unit due to her pregnancy-induced condition. Continuious fetal monitoring and certain maternal monitoring were part of the care plan according to the guidelines.On arrival to the hospital she was 7 cm dilated and coping very well.
The mum-to-be appeared to be making quick progress from the external signs but alas when next examined she was again 7 cm. Curiously she had a couple of times wanted more pain as she wanted the labour progress to go faster. She was very anxious about how long it was going to take. I wonder what kind of birth stories she had heard. She hadn’t had any antenatal education but instinctively she mobilised and rocked during contractions and later when sleepy, she rested in between contractions but sat upright during them. She had a birthpartner who rubbed her back and was very supportive but I wonder also if the same birthpartner was putting ideas into her head, they spoke a foreign language so it’s hard to know.
As her waters had already broken during the time she had laboured in the unit, the next step to help labour progress is to give the mum-to-be an oxytocin infusion. As this would increase her contraction pains and frequency, we discussed pain relief options with her and she opted for an opiate injection.
2 hours after the oxytocin infusion had started she had now progressed to full dilation and was having those involutary urges to push that often is a external sign of the same, but not always (the thoughts I have on this I’m sure to pen down in the future and have mentioned previously too). Being that this is her first baby, we let her get on with her own pushing without direction or encouragement to allow for decent of baby’s head. Should she after an hour not show progress, further active pushing is encouraged and directed.
As the contractions after an hour was now shorter and not as powerful, the oxytocin infusion rate was increased. Some direction and encouragenment was given on how to push and within a short time effective pushing was noted, and very quickly baby’s head was visible and then baby was delivered by our new mum!
Part of why I am so happy about this birthstory is that I have been in similar situations where progress has been slow, and fetal distress has been noted and the deliveries have had to be assisted by a cut, or instruments or a c-section. The last woman who did not progress whom I cared for had all three and baby was very bruised from the instruments. The same woman had laboured so well in water and had pushed like a champion but baby just did not come, allthough appeared to be in an ideal position. I know these are quite different cases but one wonders if it is the care that I provide, however how I can even think that when I attend day-in and day-out in so many non-intervention labour and births.