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 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
Quote for all maternity units tea-room’s:
“You are a midwife. You are helping 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 lead, lead so the woman is helped, yet still free and in charge. When the baby is born, the women will rightly say, ‘we did it ourselves.’” –from The Tao Te Ching
I thought I might have posted more blogs than this in my first weeks but had some gruelling hours and then just needed to switch off for a few days. My batteries are now recharged and thinking back to my long hours what stands out is a waterbirth I attended and a disagreement. I will tell you about the waterbirth as the disagreement is rather a sad and uncomfortable affair.
This first-time mother had been in for an assessment at 13.00 in the evening and she was sent home as in early labour. Arriving back again at 20.00 she was again assessed and she was now in established labour and 4-5 cm dilated. She started using the gas & air and had no plan for her birth, happy to go with the flow. Showing her the room where she would labour and birth in, and further discussing her option she was keen to try hydrotherapy (the waterpool). After entering the pool she first became very relaxed and then started to contract strongly. She requested for stronger pain relief and decided on having an epidural but she didn’t want to get out of the pool. So she stayed in the pool. Half an hour later she was involutary pushing, that is at 23.15. Decision was made to examine her early but for me to just visit the ladies room and grab a snack beforehand. I suspected she was probably close to delivery hence it was important to be ready on all fronts. I only got as far as to sit on the toilet seat when I heard the student shouting in the corridor – Vertex visible! Well I quickly finished and ran back to the room and sure enough vertex was not only visible, baby’s head was nearly crowning. We all got ready and baby delivered within 20 mins. Baby did it’s little swim and was then handed to mum in great condition. The tears and laughter of both mother and father were so heart-warming! There was kisses, hugs and hand squeezes all round.
I love to see all that emotion that the birth of a child brings to the new parents, it often brings me a little tear of joy myself. Speaking to very experienced midwives with more than 20 years experience they say this never changes. As another friend of mine would express it – We are truly blessed!