Day 1: could have flirted

"I restore myself when I'm alone" Marilyn

So yesterday I met my dear friend for dinner, who also happen to be a midwife but we have actually known each other since our pre-midwife days. So sitting in a restaurant eating and drinking wine whilst talking shop is not very conducive for flirting. Of course that is not all I did that day, besides blogging. I shopped for clothes, but was in a dace and anyhow the only men you see in women’s clothes shops are either gay or boyfriends. So what about my journey there?  I took the bus but had my head in a book, so from now on my books stay at home. Journeying home though I finally did have the opportunity to flirt, I noticed that the man I was sitting next to was also engrossed in his phone playing a card game. Now, if that isn’t an opportunity to flirt, what is! Unfortunately I did not find him remotely attractive, hence I could have flirted but wouldn’t.

My action plan for flirting today is to seize every opportunity; no books, card games are off limit, definitely spend some time at the actual bar counter (have found this productive before), and before any of that I will log into the dating site I’m signed up for but never spend much time on (which is probably why it is not very productive in terms of me finding a date to flirt with).

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Single woman into the limelight

Worked the holiday and now time for Single Woman to step into the limelight. So I have had a couple of days off and another couple to follow. I have been cavorting with the opposite sex but not really putting much effort into flirting or following through on the little flirting I did do.

I operate on the assumption that love will just land in my lap, this did actually happen to me once. Well actually, after he literally landed in my lap, he turned out to become a bit of an obsession of mine but that is another story. By this though you would have thought I would have learned my lesson there and then, that love just don’t land in your lap willy nilly.

I need to putting some effort into my flirting and to follow it through too. Rather than rolling over when other flirty flirts squeezes into my spot. I have found this blogging business to be a fun way of gathering tried and tested ways of conducting a flirt amongst other things of interest such as baking, cooking, midwifery, parenting, etc. So here is one blog on flirting step-by-step that I thought seemed easy enough to follow and will try out for the next coming two weeks: http://everythingloveandlust.wordpress.com/2012/04/07/a-lesson-in-flirting-with-everthing-love-and-lust/

I will regularly report on my successes or non-successes in this. Wish me luck!

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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.

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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.

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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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Birth Pause (inspired by Talk Birth)

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”.

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Physiological third stage and the benefits

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);

http://www.sciencedirect.com/science/article/pii/S0266613811001823

Image    Placenta: our tree of health

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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.

Benefits:

  • 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

Risks:

  • infection risk to both baby and mother

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