New Zealand Midwives Practicing Reflection

When is a birth a traumatic birth?

2009-12-28T18:38:00.000-08:00

Defining a reflection in accordance with Raynor et al (2005) it is a process by which a person recalls their experience, thinks about it, mulls it over, and evaluates it in order to lead to a new understanding and appreciation. Reflection must also lead to a changed perspective and not only involve an analysis of events. (Atkins and Murphy 1993). In this reflection I am trying not to get bogged down in self pity, self recrimination and self justification which is why writing within this group I can hopefully find an objective view point on what has occurred.

How is Post Traumatic Stress Disorder defined?

It is the term given to a psychological and physiological set of reactions anyone may experience when something traumatic, scary or bad happens (TABS 2001). In 1980 the American Psychiatric Association said that a trauma had to be outside the usual range of human experience, in 1994 the definition was altered to include events in which a woman feared for her life or bodily integrity and meant as a consequence women who suffered as a consequence of giving birth could be defined as such.

Reflection on the case
A couple of weeks ago I visited the local unit to find a past woman of mine in having an antenatal assessment with another midwife during her second pregnancy. I had been her LMC for the first pregnancy. I was told by the new midwife that I was considered to be responsible for the 'trauma' she suffered during her first birth. I was immediately horrified and couldn't recall anything specifically traumatic about the event. I have spent the last week looking through the notes and for the life of me I cannot find how the said event works in relation to me.
The pregnancy was relatively uneventful there were the usual frequent trips to be checked over at the hospital for 'spotting' and there was some evidence of the primigravida's anxiety but nothing which seemed out of the ordinary.
She was seen by me on labour ward at 2am at term in ?spontaneous labour. The complaint was backacke, with one documented tightening felt in 25mins. On vaginal examination unsurprisingly she was 0.5cm dilated head was -3station and the cx was still 2cm long. I started a CTG for reassurance to her and all was normal. But she didn't want to go home and her mum didn't want to take her home. I telephoned the obstetrician and it was agreed that she could have some pethidine and go on to the ward for reassessment in the morning. At 02.50 Pethidine was given and she was shown to a bed on the ward where the ward midwife took over and at 03.20 I went home. The records documented by the ward midwife show a check over at 03.20, 04.30, 05.00, 05.15,05.35,06.30, 07.00,07.30. I was contacted again at 07.15 to attend. I live out of town a 30min drive in to the unit after getting out of bed organising childcare I made it to the unit at 08.12.
Good labour progress was observed and a decision made with consent to perform another VE. This time she was 7cm, membranes intact head -2. Everything progressed well spontaneously, at 08.45 contractions became expulsive in nature with an urge to push at 09.10. Spontaneous pushing began at 09.30 and membranes became visible at 09.50. At 09.55 there was SROM, clear liquor draining and normal birth at 10.00 in squatting position. Actually I was lay full length on the floor! EBL was 250mls with 2nd degree tear sutured. There was a physiological 3rd stage with ecbolic given 30mins later when lochia appeared to be a little heavy and 2 large clots were expelled from the uterus. She felt faint at 11.30 but following some fluids and something to eat all was well. The baby weighed 3930gms and was a boy. I am convinced had she not been in an upright position and laboured in an upright position then she may have had difficulties with the birth.
She also states I never visited her postnatally. I have again reviewed the notes there are 12 contacts recorded on the notes 9 visits 3 phone calls which I made to her not her to me. I made a referral to the GP on day 5 because I was concerned about her emotional state, the breastfeeding consultant visited and the Plunket nurse saw her in her first week home. She also had support from the Karitane nurse.

I am searching now for a model on how to reflect upon this experience so that I can learn from it and take it forward.

Stress and Burnout

2009-03-24T17:37:00.001-07:00

I`ve been in denial, I denied that I had been suffering burnout prior to my decision not to return to LMC caseloading midwifery following my surgery in October but I can deny no longer.

I completed an assessment the Maslach Burnout Inventory. I scored 66 which is well above the score of 45 which is required to confirm burnout.

“Burnout is a psychological syndrome of emotional exhaustion,
depersonalization, and reduced personal accomplishment
that can occur among individuals who work with other
people in some capacity. A key aspect of the burnout syndrome
is increased feelings of emotional exhaustion; as emotional
resources are depleted, workers feel they are no longer
able to give of themselves at a psychological level. Another
aspect of the burnout syndrome is the development of depersonalization
(i.e., negative, cynical attitudes and feelings
about one's clients).” Maslach et al (1997)

It is only now after speaking to other midwives that I have begun to see it and recognise the symptoms in others.

Burnout is more likely to occur in midwives who

are younger
have more children
Are relatively newly employed serving a high proportion of low socio-economic class families

Beaver et al (1986).

Whilst I can`t claim to be young, in relation to the average age of the midwife in New Zealand being 50 then at the start of my LMC career in New Zealand I was 36yrs old so younger in comparison. I also have young children who at the start of my LMC career were aged 3 and 4 respectively and so I had two of the predispositions towards burnout yet I never identified myself as being ‘at risk’ because I didn`t know about it. Would it have been useful to know? I think that it is worthwhile considering that I may at least have made a more INFORMED CHOICE about entering into LMC caseloading and I possibly at least have been able to implement coping strategies but who can tell no one informed me of the risks and no one gave me the options of support instead I was often made to feel ‘guilty and selfish’ for needing to feel supported.

I am distressed now to hear of midwives still suffering ‘horizontal violence’ Friere (1972) Stories of ‘back stabbing’, medical staff shouting and admonishing midwives in font of the women under their care, undermining their practice and exulting in their parade of power. I am heart broken to hear of midwives struggling, compromising themselves to work in a broken system for which they are not responsible. Why should the midwife feel the stress when she is told that the woman has to have the epidural now, not because she wants to but because the anaesthetist is tired and if he/she goes home then he/she will not come back if the woman changes her mind later on. These elements work hard to drive the midwife to burnout.

This is another idea of how to work in more of a team it doesn`t mean that you have to lose the concept of LMC role and carrying a caseload it is about creating an environment to try and avoid stress and burnout, trying to give people more time off and trying to avoid working dangerously long hours.

Name

Mon

Tues

Wed

Thurs

Fri

Sat

Sun

Midwife 1

COMMUNITY DAY

BACK UP ON CALL

HOSPITAL DAY

OFF

community day

on call

off

hospital day
back up on call

Community Day
back up on call

Midwife 2

hospital Day

OFF

Off
Back up on call

Hospital day

community Day
on call

Community day
On call

Hospital Day
On Call

Midwife 3

COMMUNITY DAY

BACK UP ON CALL

Hospital Day
On call

Community day
back up on call

hospital day

off

Midwife 4

OFF

ON CALL

COMMUNITY DAY

ON CALL

Community Day

Hospital day

hospital day
Back up on call

off

1. HOSPITAL DAYS:- 8AM TILL 8PM LOOKS AFTER ALL OUR P/N AT THE HOSPITAL, TAKES CARE OF ANY HOSPITAL ASSESSMENTS NEEDED AND STARTS OFF INDUCTIONS.

ADVANTAGES INCLUDE NOT HAVING TO LEAVE CLINIC FOR CTGS, ABDO PAINS AND ALSO COORDINATES WITH HAVING ROOM FREE AND CTG MACHINES FREE AT THE HOSPITAL. SOMETIMES THERE IS A TENDENCY FOR AT LEAST TWO OF US TO NEED A CTG AT SAME TIME.

IT SAVES ALL FOUR OF US GOING UP TO THE HOSPITAL TO SEE OUR WOMEN.

IT ALSO MEANS THAT INDUCTIONS WOULD NOT BE SUCH A LONG PROCESS.

2. COMMUNITY DAYS:- SPEAK FOR THEMSELVES I TRIED TO GIVE EVERYONE THEIR CLINIC DAY AS A COMMUNITY DAY SO WE DO OUR OWN CLINICS AND WHOEVER ELSE ON COMMUNITY DOES COMMUNITY VISITS.

3. ON CALL GOES FROM 8PM TILL 8AM

THERE IS ENORMOUS DEGREE OF FLEXIBILITY, THE HOSPITAL DAY CAN HELP UP WITH COMMUNITY BUT HAS TO BE PREPARED TO GO UP TO THE HOSPITAL TO DO ASSESSMENTS.

OBVIOUSLY IF WE HAVE INDUCTIONS ON COMMUNITY DAYS WE CAN EITHER SWAP EVERYTHING WITH SOMEONE ELSE ON HOSPITAL DAY AND THE ON CALL OR JUST COME WHEN IN ESTABLISHED LABOUR AND THEN WORK AS BACK UP ON CALL.

I had to smile to myself when I read the list of things to do to avoid stress build up leading to burnout.

Increased self awareness of being stressed
Develop outside interests become a member of a social group
Regular exercise
Regular Vacations
Relaxation techniques, yoga, meditation.

How as an LMC are we supposed to find the time to do these things? I tried to be a member of a book club but found I couldn`t attend more than twice as I was always called out or in bed asleep. I tried to attend spin class but the instructor told me off for answering my phone in the middle of the session. Regular holidays aren`t enough unless you can take regular days off too. Relaxation techniques thats a laugh as soon as I took a deep breath in I was usually asleep!

Useful Website on stress and burnout

http://www.helpguide.org/mental/burnout_signs_symptoms.htm

References

Evaluating Stress, A book of Resources. Zalaquette, C.P. and Wood, R.J. (Eds) The Scarecrow Press, Inc Lanham, Md & London 1997

Supportive Care and Midwifery Rosemary Mander
Edition: illustrated Published by Wiley-Blackwell, 2001

Audit

2009-01-18T14:27:00.000-08:00

Access Agreement

As self employed midwives we often have an access agreement with the local hospital. This means that we have access to the hospital to take our women there and use the birthing facilities. In our area I and the other self employed midwives I work alongside have worked in the unit and so we are familiar with its workings and routines. When we sign the agreement it stipulates our responsibility and outlines the units responsibilities to us as practioners. One element of this agreement for us is that we will attend the monthly audit meeting.

Who is there?

At our meeting there is all the obstetricians, the unit manager, as many caseloading midwives as possible, the paediatric team and representatives of the hospital management team.

What is the purpose?

The purpose of the meeting is to look over 3 cases which fit a certain criteria, the unit manager has the list of the criteria and so I have no knowledge of it. I know that a case will be choosen, for instance, where the baby has been born with low apgars. The purpose is to identify if any aspect of care needs to be improved upon.
The case is presented to the meeting. The presentation of the case used to be done by the midwife who was incharge of the case, I still prefer to do it, but recently one of the obstetricians have been presenting.

The meetings effects

As a midwife when you are told one of your cases is going to be put into the audit meeting there can be an unnecessary level of anxiety experienced. It is not pleasurable feeling like you are about to be attacked on all fronts and it is always great to look at something with the benefit of hindsight and especially when others may say they would have done something different. I have seen a number of midwives go to pieces during this process and feel swamped.

How I always approach audit.

If I ever have a case which has been choosen to be discussed I always make sure I have read the notes and familiar with the case enough to present the facts with out having to fumble through pages and pages of documentation. I also research the facts behind the case and go into audit armed with text books or National Institute of Clinical Excellence guidelines or examples of research which support the care given. If I have to I will take my laptop with me so that I have every means of reference possible and because it gives me instant access to the internet.
This means that I only make clinical arguments and I refuse to get flustered.
So my advice to anyone who has to be involved with these things prepare, prepare, prepare.

2009-01-13T02:58:00.000-08:00

Ive been keeping an eye on midwifery with our closest neighbors, Just my opinion about the "Australia situation"

"With the federal health minister, Nicola Roxon, already on record as
indicating some sympathy for the midwives’ pitch, specialist doctors
say the Government should first consider what they claim are the
‘‘harmful effects’’ experienced in New Zealand, which moved to a
midwife-led system in 1990. "

What "harmful efects" I don't see our system as being "midwife-led" rather a collaboration of women their whanau, support people, and health professional who bring their specialist knowledge. A partnership.

In December the Government revealed over 900 submissions to the review had been received, most of them from individual consumers.

Releasing the news at the time, Roxon said in a statement that the women’s ‘‘personal accounts of experiences with maternity care sound a strong note of concern that our maternity system has become too focused on medical intervention’’.

It was the push consumers of Maternity services that pathed the way for New Zealand Midwives. I believe It will be the voice of consumers in Australia that will make a difference to the Australian system.

Follow up to Men in Labour

2009-01-06T19:18:00.000-08:00

I was asked by Leigh in the post, "Men in labour" whether I could collect some points of view from women on the subject.
I have designed a questionnaire which reflects the same questions as I asked the men.
Please If you have the time fill in the questions.

Click here to take our Online Survey http://freeonlinesurveys.com/step3_launch_popup.asp?surveyid=530691

Strategies To Support Students Learning Presentation For Interview 2

2008-12-19T18:12:00.001-08:00

This is the presentation I recently gave for my interview to become a tutor with CPIT. Unfortunately I didn`t get the job but hey there`s always another day!

Strategies To Support Students Learning Presentation For Interview 2

View SlideShare presentation or Upload your own. (tags: learning distance)

Men in the labour room. Do they want to be there?

2008-12-14T13:25:00.000-08:00

How it all began.

At the start of my LMC career here in New Zealand, I also began teaching antenatal classes for Parents Centre during this I was also studying for a Diploma in Childbirth Education. I began educating the antenatal classes with definate ideas in mind, one of which was the session with men and women divided. A male educator would visit the session and take the men away and they would cover some aspects of the birth from a male perspective. This bothered me, as an educator I had no idea of the content of the session and I also had the firm belief that the couples should be encouraged to share their communication and be open and honest in the sessions. I held true to this for the first few courses, abolishing the separation of men and women keeping them together and then I began to question myself and I wondered if I was doing the right thing, therefore when it came to my special topic section of my Diploma I decided I should look into the subject and ask a few of the male membership of Parents Centre how they felt about being a part of the labour and birth.

What to look at.

I wanted to look at whether as an educator I did enough to prepare the men in class? Do they want to be present during the labour and birth? Are they the most appropriate person to be adequately supporting women through the birthing process?

I also wanted to know if the men felt under pressure to be present during labour and birth and where did that pressure come from their partners or their peers. I also wanted to know if their intention was to be supportive or was it more about witnessing the birth of their offspring? But whatever the questions I wanted to know if there was more I needed to be doing as an educator and midwife to prepare the men to be more effective as a support person.

In the beginning

Traditionally birth was generally thought of as being 'women's' work, labour and birth took place in the home. In this environment life carried on as normal, women got on with the household tasks during the early phase of labour preparing the household for the imminent arrival of the newborn baby. At the appropriate time the birth attendant was called. During this time the men may have been still at work or busy within the home chopping wood, shooting or fishing or dare I say it maybe even down the local inn having a pint or two. once in attendance the birth attendant would give the man of the house tasks to do as the time of birth drew near, maybe lighting the fire to prepare a warm room, finding warm dry towels to wrap the newborn in and boiling water. The point of this observation is to demonstrate that the men had their role; it was one of practical assistance and one which appeals to their way of thinking. Men are thought of as warriors, hunter providers and enjoyed the practical role during this phase, they were constantly occupied and were just left to pace around the living room at the point of birth itself, to give a sigh of relief once the cry of the newborn was heard and brought out to them wrapped in the warm towels he had provided. He then stayed out of the room until his wife was cleaned up, washed, hair combed and invited to join her in the room once she was presentable.

During this time he was never called upon to give emotionally to the process of labour, he never saw any of the 'gory' bits of childbirth, it remained a magical mystery to him and his wife remained a demure woman in his eyes to once again be able to produce off spring. He had no idea what she had just gone through and had no interest in finding out.

Change begins

In the early 1900's, the process of birth was promoted to be a potentially dangerous one. There was a review of the statistics for maternal death, neonatal death, and morbidity with many women dying of puerperal sepsis. Instead of addressing some of the underlying issues around poverty (many were giving birth in areas of poor sanitation) and poor health, the government looked to providing state hospitals for women to give birth in. It was obviously the cheaper option. 4hrly aseptic washing techniques were employed and the birthing process became sterile and aseptic. The recommendation was made that all women should come into hospital to give birth. The trend continued and by the 1950`s almost all births were taking place in the medical environment. The midwife became a part of the medical establishment and the role of support person came up for grabs as she disappeared to look after more than one woman in labour. In this medical environment women now found themselves in the hands of strangfers, being told what to do and how to behave and became disempowered, lossing belief in their ability to give birth.

Bucking the system

Helen Brew was a person who believe that if they wanted to, 'husbands should be allowed to give comfort and support to their wives in labour'. She began the movement of Parents Centre which fought to allow the husbands into the labour room. The emphasis of this statement should be, 'if they want to'. The problem can now be that it is expected and accepted as part of the 'norm' that the husbands/partners will be present. More than 3/4 of men now attend their childrens birth in the Uk it is 90%. Is this an acceptable pressure to put on men? Is it possible that men can truly be a support to their partners during labour if they have never felt the process of labour and birth and the feeling of empowerment this process gives a woman?

Men in the hospital environment

In the hospital environment the men are now a part of an alien environment, shouted at if they disturb the aseptic area, they are excluded from certain parts of the environment, equipment room, staff tea room, there is nothing provided for them no refreshments, no food nothing to welcome them. Yet they are expected to provide full emotional support, men are hunter gathers, rational and calculating. This seems to be a complete role reversal for them to take on without any preparation or guidance. Where can they turn for advice? Their own fathers may never have been a part of the process and so cannot provide advice or insight, there are very few books and the countless magazines appear to be targeted towards pregnant women. I doubt that any of the men would want to be seen picking up one of these magazines unless he could hide it in his Pig Hunters weekly! Men are not renowned for talking to each other about labour and birth, instead concentrating on what the baby may be up to after he/she is born, quickly it seems turning to the recent rugby team`s performance rather than discussing how the labour was. One article I read which describes a fathr`s experience of birth interestingly pointed out that his wife actually felt less 'connected' to him during labour and she thought it created a distance between them. He felt his role was one of a companion but she wanted him to support her. she saw him as distant, combative and unaware of her needs. Bradley and Lamaze created the role of 'coach' for the father asking him to guide and direct the birthing woman. This can make the fathers role difficult; his tasks can be conflictive with the medical establishment who are trying to 'manage' the labour. Sometimes the early part of labour appeals to the task orientated male, timing the contractions can give him a job to do and commands his attention. As labour progresses some women can then find this distracting and annoying. The men seem to lack the intuitive instinct that other females can have to change to the adapting needs of the labouring woman.

The effects of men in the labour room

Many of the Lead Maternity Carers I interviewed for this special topic, felt that the men seemed uncomfortable and on edge when along side their partners in labour. The men often found it a struggle to see their partners in pain and often influenced the woman`s decision to have medical forms of pain relief. The men appear anxious and afraid and the LMC`s feel that this transmits to the women. They claim to see visible signs of relaxation from the men when the women decided to have epidurals and they often turned back to their magazines and settled into their lazy boy chairs with their feet up to catch up on sleep once she shows no signs of discomfort. Some men have been known to comment, "Well I wouldn`t have a tooth pulled at the dentist without an anaesthetic". Women are also distracted by the obvious discomfort that their partners are feeling and not wanting him to suffer any longer she will opt for strong methods of pain relief. Dr Michel Odent believes that expectant fathers can often cause more problems than they solve and can be partly responsible for the upsurge in caesarean section because they cannot stand to see their partners in pain,

"The baby`s father - a man - is not always the best possible person to help his wife to feel secure."

They can become aggressive in their stance to see what they perceive to be a problem, 'sorted out' and are prepared to push the midwife to call in an obstetrician who then believes they may face litigation if they don`t carry out their wishes. He can often then convince his partner that she should not have to continue with this 'suffering' as he sees it and should opt for surgical assistance.

The National Childbirth Trust believes we should change the culture which means that partners will be there. This statement seems to be in direct contrast with earlier beliefs when they wanted to get partners into the birthing room.

Headlines from the BBC News state that men suffer baby blues as a direct result of witnessing the birth. 4% of UK men nationwide and 10% of Londoners suffer 'postnatal depression'. Most of those men suffering who had witnessed the birth had found it off putting.

Michel odent dares to suggest that in France where men were involved in the process of birth a % were followed a year later by divorce. I think there are many reasons for this and possibly not just due to the birthing process.

Sam Janus, a psychologist in New York, found a high proportion of men were impotent following participation in the birth of their babies. He found the men`s masculinity had been challanged because he could not fulfill his role of protector and he had witnessed the pain of labour something which he felt responsible for.

According to Jon Smith in his book, "The blokes Guide to Pregnancy," there is no information geared towards men and men often feel overwhelmed by the power of contractions and the intensity of birth. Men in unfamiliar surroundings, witnessing medical procedures, feel irrelevant and useless. They can also feel embarrassed and powerless. There can be a sense of failing, failing to make the birth easier. Labour can be a boring process for them, there is a need to hurry the process along. They cannot cope with their partners becoming instinctive in their response to labour and try and keep them from slipping out of a rational, controlled state.

Considering why they should be there

It is considered that men should be a part of the birthing process because he has the benefit of early bonding with the baby. It is an experience which can provide a postitive affirmation of the relationship.

Dr Gita, a gynaecologist in India is now experiencing an increasing number of 'new age' dads who wish to be present during the birth of their children. She believes that their presence at the birth makes the process complete.

" The father also forges a stronger bond with the child if he is present during the birth, and holds the baby as soon as it is born."

Other doctors from the same area believe that it gives the husbands a greater sense of belonging.

Grantly Dick-Read author of, "Childbirth without Fear", values that the couple have to be united in the experience of birth and that it can enrich their relationship.

Andrea Robertson, a leading expert in childbirth education, believes that the man`s needs are often ignored with everyone focusing on the woman and her needs. She believes that they have the benefit of a unique perspective which deserves to be considered, especially if the family unit is to remain strong.

Questionnaire

I decided to take a group of new fathers who had all attended the antenatal classes with Parents Centre and send them a questionnaire. I sent questionnaires to 69 new fathers and received 34 responses.

Only 7 men wanted to write about their experiences of birth.

10 of the men questioned felt under pressure to be present at the birth, 24 felt under no pressure.

All 34 respondents wanted to be present

16 had secret fears about birth, 18 had no fears

When questioned the men felt their main role during labour and birth included, being there, support, reassurance, encouragement, to act as advocate, keep hair out of face, test blood sugars, to assist with crowd control, make her feel strong, understand her needs, provide comfort, keep her calm, to get her there on time, keeping postive and smiling.

only 16 of the respondents were involoved in writing the birthplan, 18 were not involved.

27 men knew there was a birthplan, 7 didn`t know there was one.

5 men didn`t expect their partners to cope with labour, 21 expected her to cope well, 1 respondent had no idea.

13 respondents were surprised at the pain of labour, 17 weren`t surprised.

29 respondents said that the chosen method of pain relief made the job of supporting her easier, 2 said it didn`t and 2 women had no pain relief at all.

When asked what would they teach other men to help them to be a support to their partners during labour they listed,

gain as much information as possible about unexpected outcomes, just be there, don`t get a new job in Australia and be away for the due date, be sure to ask for clarification if you are unsure as to whats happening, stand up to the staff after the birth if you don`t feel they are being helpful or understanding, just do as you`re told, know what your options are, don`t take it personally when you get called bad names, communicate well, be involved, relax, stay calm, be patient, trust the midwife, make sure they have drugs, read as much as your wife does, seem really interested, use the words, "yes dear", "great job", always end by saying, "I love you", ask for epidural early, make your wife wear a hairnet, take responsibility, grow up and bacome the fathers we had or the ones we wished we had. Always maintain a sense of humour, massage, cuddles and verbal support. Only give 2 fingers for your partner to hold.

Conclusion

I can reflect now that men need guidance and support to fulfill the role expected of them during labour and birth. We cannot exclude them from the labour room but we can make certain recommendations. We need to not put men under any pressure to attend the birth. It appears that there is a proportion of men who feel under pressure and that his presence can influence the labour outcome, the woman`s perception of labour and it can aslo influence their relationship following the birth. Interestingly Grantly Dick-Read recommends that there is an assessment of every male prior to the day of baby`s birth. He would then like to place the man into one of 3 categories,

Men, who are prepared, interested and have confidence in the process of birth can stay.

If man cannot overcome their own fears they should be kept out of the delivery room

Those who have done no preparation should definately NOT be allowed in.

Special consideration for Midwives and Childbirth Educators

Antenatal classes should include discussion and information directed primarily at men and provide them with opportunities in the group to share and work together on issues of specific importance meeting their needs.

There needs to be a separate session for men alone with a male group leader.

Men need clear factual information.

Give the men a tick sheet on the hospital visit to make a note of where to get ice, where the toilet is, bean bags, extra pillows, sheets and towels.

They need to know how to dim lights and move furniture.

They need to know where to park and how to access the unit and which door to use.

The man needs to know the midwife and should attend some of the antenatal check ups.

The midwife should acknowledge his feelings during the process of labour and birth.

he should be provided with a sleep area if the labour is taking a long time

He should be able to join his partner in the shower and have the privacy to do so.

He needs clear explainations about what is happening at all times

There should be an opportunity for fathers to debrief following the birth

So yes, reflectively I have changed my practice as a midwife to accomodate the special needs of the partner and I have reverted back to having a session at antenatal class which is divided into men/women only session.

Making Connections

2008-12-06T12:52:00.000-08:00

I`ve been making connections with my previous post, which describes some of the theories by Neighbour, with my practice when looking after women in labour. There are some things I have been thinking about which include, the setting up of a trolley for birthing, challenging the thought process of student midwives I`m working with and how my reactions to the progress of labour are so different on each occasion. I find that I always feel I`m at my best with the woman in labour and I can gain a deep sense of connection. My responder self is at its best, sensing and intuitively working in partnership with her until the moment of birth.

The setting of the trolley.

I have often thought and wondered why I set a trolley with the required equipment and why everyones trolley is set slightly differently. In the past the moving of the birthing process to within the hospital setting to create the aseptic technique of `delivery` was aimed at reducing the maternal death rate from puerperal sepsis and the setting up of a sterile trolley was part of the process. Assessing one day how I felt one day when I was setting my trolley, I realised it was as much about me preparing myself for the imminent birth as it was about maintaining a clean environment. I was in effect getting ready and it was a task that the 'organiser' part of my head felt comfortable doing, staying one step ahead of the process and being prepared. There have of course been those times when I`ve not been prepared at all because I`ve been so tuned in with my `responder` head, emotionally connecting that it is with some annoyance to others they`ve had to set the trolley for me and get some warm towels prepared.

Monitoring of labour

When it comes to challenging student midwives, I`ve often found that some senior student midwives I have worked with have developed some 'routine' task orientated habits when it comes to their assessment of women in labour. This demonstrates to me that the 'organiser', task orientated part of their heads is working well but I am often looking for them to be developing their 'responder', intuitive part. One of the task orientated assessments is the routine use of vaginal examination on admission to the labour ward. When challenged as to why they just want to 'jump' straight in there with the assessment they often explain, "Well how am I to know where she is up to, or if she is even in labour". It is always important to continue to challenge this as not just 'routine' as Sheila Kitzinger says,
"Hospital staff tend to perform vaginal examination far more frequently than is necessary in order for them to assess the mother's adherence to their definition of 'normal' labour, and also because their lack of close surveillance means they are unable to understand what is happening within the mother by more intuitive, non-invasive means. This further increases the risk of infection being introduced into the mother. "
There is plenty of research on the subject of vaginal examinations none more so than a recent article in the NZCOM journal http://www.midwife.org.nz/index.cfm/3,114,279/nzcom-journal-oct05.pdf, in this article Lesley Dixon examines the reasons for vaginal examinations and why it is important to keep them to a minimum.
I often wonder though how much influence cases such as this that are recorded with the Health and Disability Commissioner http://www.hdc.org.nz/complaints/opinions?98HDC13531 cause a midwife to lose a little confidence in herself and do one quick internal check.
I found it easier to challenge the student to just take a thought and observe the woman`s behaviour for a while, when she has been seeing the woman antenatally for a while and is confident with the results of palpating. I always see a look of shock when I suggest that if someone who has been niggly for 3 nights, is having her second baby and has had to drive one and a half hours to come in and arrange a babysitter to do so, she is only gonna come when she knows she is in labour. These are the cases that can be used, I feel, to increase the skill of the 'responder' head, sit back, observe, feel and watch the woman's behaviour. I had a mentor once at the start of my training who used to leave me in the room, make me sit in the corner and she used to say, 'call me when her toes start to curl.'

Different reactions to labour.

In the past I`ve been know to question myself. Where I worked in the UK, in Shrewsbury, there were 4,000-5,000 births a year, there was a consultant led unit and five outlying midwife led units which each took care of 500 of these births each. The midwife led units ranged from 40-90mins out from the consultant led unit. I was mainly based on the consultant led labour ward with the usual story of lack of staff and looking after up to 3 women at different stages of birthing, going from room to room sometimes forgetting that I needed to drink and most of us had learnt to just pee once during a night shift. I started it seemed to develop a sense of what was happening to a woman during labour but then I began to wonder if I was just aiming to get that woman to fulfil my prophecy or was I correctly identifying and anticipating a problem? I therefore requested a move to one of the midwife led units to regain my midwifery roots.
It is that experience I draw on now when I adapt to the individual women in labour. I find that now I am able to follow labour intuitively with my 'responder' head trusting the process of what is happening and then I am able to recognise the need to be more the 'organiser' head, anticipating that there is an impending, developing problem leading to being one step ahead of the game and ready for anything that may present itself.

What have I learnt about how to interact with women and their families.

2008-12-01T18:32:00.000-08:00

The Inner Consultation, Roger Neighbour

Chris, my husband gave me this book to read. It is aimed at GP`s in practice and looking at how they interact and consult with their patients, so you may wonder why he should suggest a midiwfe should read it and I must admit to being skeptical. I did wonder what on earth I could get from a book which is set in a medical context? Chris did reason with me, that as a practitioner in a primary care setting that I may be able to adapt some of the philosophies of which the author describes.

I have to admit that after reading the first section, he is right. So often as midwives we are taught in our training about the practicalities of the job and we are left to our own devices to develop our own intuative style of connecting with women. I`m left to reflect, is there more that could have been done during my training which would have helped?

In the begining

It is important for us to look at and examine how we are taught our consultation style. Often we have learnt our style from our mentors with whom we have worked during our training. These were women who at times could seem infalible, with the huge amount of what seemed infinate knowledge they had and some of us held them in high regard.

Models of consultation can also be looked at to make the skills of connecting seem easier. I like the description he uses for `keeping it simple` and `the consultation as a journey` because I often see the midwife/woman relationship as a `journey` through pregnancy, birth and with her new baby. It is often when considering this `journey` we can look at the models that are used.

The `role model`

In his book, Neighbour describes this model of the patient entering the `sick role` and they hand over partial or complete responsibility for their well-being to the doctor. I liked this role model to the one of the pregnant woman going to see the obstetrician for a consultation regarding her pregnancy. She may assume the role of `sickness` because she has only ever associated the doctor with being sick and during that consultation she begins to partially or completely handover control to the obstetrician and although she had every intention of having a normal labour and birth she ends up before she knows it booked for an elective c/s. I enjoyed reading about the `role signals` which may lead a woman to assume this role. How often have we seen the obstetrician in his clinic, enthroned behind a desk in a white coat with what Neighbour describes as `access rituals`, such as receptionists, appointment systems and the women having to present their urine specimens as gifts to secure the obstetricians attention.

The doctor-centred or patient centred consultations

I was left to reflect how often I have over heard the `midwife-led` consultation, the woman is bombarded by information which must be covered so that a box can be ticked in the box of the careplan with a total disregard for anything that the woman may have wished to discuss and a disregard for whether she has heard it all before or if she has found it out herself. The midwife is happy at the end of the visit having accomplished her agenda. Or on the other hand the `woman centred` consultation whereby none of the essential information is covered at all and the woman is in charge of the visit.

The Task orientated model

This is very much similar to the above model whereby the visit is dominated by tasks that have to be completed and the success of the visit is set with the accomplishment of these tasks.

The Health Belief Model

This is the model that most interested me, especially in the climate which I have worked. In this model he discusses that the beliefs and motivations which the patient (woman in midwifery world) brings into the visit influence the understandings and intentions she takes away with her and passes on to her family. With this model it is useful to consider the ideas, concerns and expectations the woman has with regard to her pregnancy, birth and with her new baby. These aspects I believe, will influence her choices and the information she looks to the midwife to provide during the pregnancy. Then depending on what she has heard and absorbed her health beliefs will influence how she transmits that information to her family and friends.

Talking with two heads

After reading this chapter I was left reflecting how often I use two heads during an antenatal assessment. In his book, Neighbour names these heads as the Organiser and the Responder and he takes us through a couple of examples and I have been left trying to construct a midwifery example in my head. The organiser head is the intellectual part of the brain, is very logical, task orientated, is calculating, likes to anticipate and stay one jump ahead of the game. It sets your goals and `wants` certain things to happen. It deals with the checking of urine, Bp`s, palpation and the documentation of the visit and the checking of the careplan. The responder is the spontaneous head, naive and intuitive and picks up on not only verbal communication but non verbal communication. Have you ever wondered why you connect with some women better than others? Thats because your responder head has been busy reading all the non verbal cues which may be suggesting that the woman isn`t connecting with you, such as lack of eye contact, fidgeting, hesitancy of speech.

The responder head and the organiser head may alternate during a visit with one or the other whispering in your ear as you talk.

One exercise which I found useful is to recall some visits which you have done recently and see if you can remember some of your internal dialogue and then jotting your thoughts down.

Continuing with the two heads theme I was left to reflect on the midwife/obstetrician relationship in the book he says, "Two heads are better than one just as long as they are each working towards the same goal, and each respects the strengths and weaknesses of the other." I was left thinking of the recent signing of a memo by the College of Obstetricians and the College of Midwives to each share the aspiration to work towards the health of the mother and baby and wondered if that would ever be possible if we don`t respect each others strengths and weaknesses.

I look forward to reading the second part of the book and picking out the information which may improve how I connect with women or having the reasons for the times that I don`t.

Interview Reflection - How stupid am I?

2008-11-25T15:10:00.000-08:00

The Interview

Two months ago I applied locally for a Midwifery Educator post within the local unit, it was an eleventh hour decision to apply, I managed to get my application in 1hr before the deadline. I don`t really know what my motivation was but I saw it as an opportunity to explore a different role in an educational capacity. I hadn`t even told my husband that I had done it. Much to my surprise I received a call from the Head of Nursing that evening whilst I was on labour ward, having just had someone birth their baby. She very kindly invited me to interview the following Friday morning and gave me the title of the 10min presentation I had to put together and she also casually dropped into conversation bring your portfolio with you. I was outwardly very calm and confident but inside was thinking, "Oh my god, presentation, portfolio bugger!"

The following week

The following week was spent bringing my portfolio up to date, furiously writing reflections and assembling some order to the folder. I was also concentrating on the power point presentation with some very supportive colleagues input. Needless to say I was so taken up with these two activites I never gave a second thought to the questions that I may be asked or to the panel of people that I would be facing. This was compounded by the fact that I only remembered to look at the job description the night before.

Day of interview.

The day of the interview finally came and I drove the one and a half hours to the venue by which time I had convinced myself that I really wanted the job and I was also a nervous wreck. When I walked into the room I faced a panel of 5 people. Needless to say the interview bombed, my presentation had some sort of fault and it fell apart and some of the questions I faced, I totally fell apart on.

Anyhow the point of this reflection is to look at what I have learnt since being asked those questions and hopefully I will tie it in with what Tania posted in the previous post.

Warm up questions.

I was asked two warm up questions one of which I had no idea on, who are the stakeholders?

I`ve since learnt that this is anyone who has a vested interest in the services that the DHB provide.

How did the Health Practioners Competence Assurance Act of 2003 affect Midwifery?
I was stumped; and I must most sincerely apologise to Jean Patterson of Otago Poly because when I first came to New Zealand 4yrs ago I had to complete a pharmacology and prescribing module to gain registration, well the first module consists of all the legislative and professional framework for the practice of midwifery in New Zealand so all the information I needed was in there but I`d never retained it.
The act was brought about to ensure accountability, health and safety of health practioners which include midwives. This progress for midwives was 30 years in the making, which is the point I wanted to tie in with Tania`s post, Australia has a long way to go and many years of lobbying ahead. It was also with powerful ministerial help that this change was brought about. Helen Clark, love her or hate her she was a strong supporter of midwives, she brought about the ability of midwives to practice independantly in 1990 with the Amendment Act and along with Annette King, then Health Minister who brought us the HPCA Act of 2003 ( I like this woman she is a straight talker who gets things done).
Anyhow the act enabled the Midwifery Council to be formed independent of the Nursing Council and makes them responsible for regulating the profession.
I would also like to mention that to meet the requirements of the Act you need to:

Keep a portfolio
Take part in Midwifery Standards Review
Keep skills updated

There were a few other questions which I stumbled on throughout the interview none more so than the Treaty of Waitangi question. I forgot about the 3 P`s, Partnership, Protection and Participation and instead waffled about communication, trust and giving value to a different culture.

So I advise always before interview prepare, prepare, prepare or have a bottle of wine sit back and enjoy the experience!

Babies deserve the best care

2008-11-24T18:39:00.000-08:00

I read this article: Babies deserve the Best care on my blogs news reel. When I first read it I thought no that cant be right, I need to investigate it further. The thing that irked me was: -

The New Zealand maternity system has moved to keeping obstetricians out of the delivery room until there is an emergency. In 2000 the perinatal mortality rate for both Australia and NZ was 6/1000. The perinatal morbidity has risen to 7.5/1000 in NZ, whilst Australia has fallen to 5/1000. Mother nature can be a cruel midwife and in developing countries with poor medical services, this rate is a staggering 110/1000.

The article encouraged me to do my own research about the statistics quoted. I found the statistics published by the Australian department of Health The figures quoted (made up) in the article are no where near the actual figures. The perinatal death rate in South Australia is 9.5 per 1000 and the overall rate for Australia is about 8 per 1000. NZ is doing better than quoted.

My lesson for today, dont beleive everything on the internet or written in the news paper, especially when the article shows a bias towards one model of care.

Informed Consent

2008-11-23T18:53:00.000-08:00

As a midwife I`ve often been concerned about the subject of informed consent, what it means to me as a midwife and what it means to the woman in my care. I`ve often wondered what is meant by informed consent and actually what that means to the woman.

Role of the Midwife
The NZCOM consensus statement ratified at National Committee in May 1996 is very clear on the role and responsibility of the midwife in getting informed consent and what is to be documented. It also discusses obtaining written consent where either person in the midwifery partnership requests it. I am left to reflect on how often I have within my practice formed a partnership based on trust and how often I trust the women when I don`t obtain that written consent. The documentation part of midwifery practice I find can begin to fall down when a midwife is tired and stressed. it can be the case that there is every good intention to record throughly what is discussed at a visit only to find that one appointment has run into another and someone else is waiting to be seen so you have every good intention of writing it down but before you know it you`ve got home cooked tea, sat down, relaxed and then ended up asleep in bed.

More than one professional perspective
The consensus statement also discusses that where there is more than one opnion on how care can proceed then the midwife has a responsibility to inform the woman that another perspective on care exisits and give her information on how to access that perspective. It is then presumed that the woman can request that opnion or she can request not to.
The dilemma can exist then when she has two perspectives which one does she choose to follow?

Dr House perspective
I am fascinated how House views informed consent in the 3rd episode of the 3rd season. It is often viewed that House has his 3 doctors to represent different aspects of morality on the subject in the hopes of keeping him on the straight and narrow and failing miserably.

Parentscentre
In my teaching of antenatal class for Parentscentre, informed consent forms part of the cornerstone in the class. The organisation which was set up in the 1950`s decided to offer antenatal classes on the basis of giving clear, unbiased information so that women could leave the classes able to make their own choices. During the first session I often spend some time discussing what the class believe informed choice is and how the think they may be in control of their maternity experience. I often use the analogy of getting married. When women are organising their weddings they pour through heaps of bridal magazines choosing the right dress, they visit dressmakers, florists, venues, the ask friends what happened at their weddings and they gain as much information as possible before making the plans for their own wedding. It is rare, although there is always someone in the class who has done this, that they just hand over control to their mothers and mother-in-laws and say just give me the date and I`ll just turn up.
I often end up saying having a baby is a similar experience, you cannot just hand over control to someone else and have them give you their impression of what the birth should be like.

Childbirth Educator v LMC
At the end of class I am often approached by the women under my care as a LMC and they always express the concern that they want to follow my advice as much as possible. I often do explain that my CBE hat and LMC hat are slightly different and in any given situation I would endeavour to give them the benefit of my professional experience but that it is my duty to ensure that they feel in control of their own decisions. I often end up using another analogy for these people and say that if I wanted a professional newspaper article written I would approach a journalist for advice and at that point I could take it work in partnership and have a brilliant article or ignore the advice go it alone and have just an ok article.

Here`s hoping that this hasn`t just been and insane ramble and that this all makes sense!

Powerful influences at work

2008-11-20T17:48:00.001-08:00

Hi,

I`ve been reflecting alot about the influences that some midwives face on their practice and whether it is possible to stay strong and fixed to a philosopy of practice.

Some midwives face the influences of women at booking, so if your philosophy is homebirth but the majority of women you are in partnership with want a hospital birth then you have to ensure you have an access agreement to the local hospital. Once you sign that access agreement the midwife may then be bound to following the policies and protocols of that unit once she steps into it.

What if the midwife`s philosophy of care doesn`t fall in with hospital protocols and policies?

Another influence on the midwife`s practice can be Section 88, the referral guidelines, just how binding are they? There are levels of referral, 1, 2 and 3. Is informed consent obtained if the midwife says, "Well I should recommend that you see an obstetrican but I don`t really agree with it so I don`t think you need to see one."

The hospital routines and those little unspoken, not in writing, rules can influence practice. Such as trying to avoid complications during the night because a theatre team will have to be called in. This may result in an early intervention which may have not been necessary.

Tiredness and fatigue can have an influence, if a midwife has too large a caseload, the pressure to `get them delivered` can force the issue of overuse of ARM, Epidural and syntocinon and can also influence that there are more inductions than are necessary. It can be easy to start in practice with the idea of limiting your caseload but as I know from experience it is hugely difficult to turn women away and before you know it you are swapped.

So how can midwives stay strong to their philosophy of practice?

The dangers of blogging and what it means as Midwives

2008-11-19T13:10:00.000-08:00

Hi guys,

I have been wondering about the possibility of this becoming a `closed` blog, as you can see I`ve removed the previous post its very difficult in the confines of our practice to share our reflections in an open format. I have come across the following link which brings the difficulties into perspective,
http://infomidwife.blogspot.com/2008/10/cyber-talk-and-midwives.html

In this blog it is discussed the implications for our practice to share online reflections in relation to other professions and in matters surrounding confidentiality.

I`m keen to keep this going because I believe it can become a valuable resource but I need feedback as to how we can or whether anyone wants to become more closed and people can contribute when invited.

You guys are stars!

2008-11-15T13:13:00.000-08:00

Just wanted to pop by and say how thrilled I am to see that you've got this blog up and running. I will be really interested to see how you go with it.

Julia & Pam: I have taken away your privileges on the course blog, but you are still able to cut and paste anything on the blog that you want to put here.

I will leave the course blog open to you all. If you want to unsubscribe from the course blog or email group, feel free to do so any time.

I am going to bow out as a contributor because I feel it is really important you own and run this blog - I'm so bossy, I'm afraid I'll take over things. But I will subscribe to the blog and comment all the time. But before I go, just a comment about a couple of things.

1. Be very careful about confidentiality. New Zealand is a very small place, and it would be relatively easy to work out who you are talking about, even if you use false names, so be mindful of that when you are talking about your day-to-day practice.

2. Have a think about how you can share resources, other than linking to them when you come across them. For example, you may all want to get a Delicious account and tag any thing you read about 'reflection' and 'ePortfolios'. That way you can keep an eye on what everyone else is reading about these topics.

3. Add a statistics tool to the blog so you can see who's coming to the blog - something like http://www.statcounter.com

4. Get a feedburner account and add a widget that allows people to subscribe by email - if you want a hand with that, let me know.

I'm off to spread the word to my network about this exciting new blog.

cheers Sarah

Delivery suite reflection

2008-11-15T12:47:00.000-08:00

Back in Delivery suite again, as part as maintaining my competencies to practice as a midwife. Its taken some organisation due to shortage of staff but finally have managed to spend a two week placement there. I am a ‘born community worker’ so do admit to feeling uncomfortable at being back into the structure of the hospital situation, not to mention the feelings of mild anxiety I experienced wondering whether or not I would cope with what comes through the door; at the same time not wanting to make a fool of myself in front of colleagues .

The first week was fairly quite. I felt very privileged to care for a second time Mum and Dad. The baby girl was delivered after a lot of hard work from Mum, following a quick four hour labour. Quick, but intense and hard work according to Mum. All in the room expected a rapid second stage but as baby was in a posterior position at the start of the second stage heaps of energy was required by Mum to push baby out. The joy on the couples faces dispelled all my doubts of my ability to enjoy my experience in Delivery Suite. It was awesome! The good thing is that I get to visit Mum and Dad at home after my two week experience.

Week two was busy and unpredictable as only Delivery Suite could be. Opportunities presented themselves for me to regain my skills and confidence. I was involved in providing care for women undergoing epidurals, prem labours, and women with various degrees of PET. After one exceptionally busy day, where it seemed as though women were literary pouring through the door, I ended up transferring a woman expecting twins, who on U/S had a shorten cervix by helicopter to Hastings . Providing care for this woman was very special, as between the both of us a bond developed in the space of a very short interaction. Her care had been transferred to Secondary Care, and from attending a routine clinic appointment in the morning she was shocked to be told that she had to be flown out of PN, due to NNU being full that day. I was glad that I was able to provide her comfort and support, and on reflection I learnt that when establishing a supportive relationship between clients and yourself, time is not always available or necessary.

I survived and enjoyed my two weeks, and ended up feeling more confident than at the start. I learnt that its like riding a bike, some things you never forget, you just have to refresh you memory to keep confident. I am going to try and arrange more time in D/S next year, with less length between stints.

Welcome

2008-11-13T15:49:00.001-08:00

Hi and welcome,

This blog has started in response for those of us who have just completed the Reflection on Practice paper with Otago Polytechnic. We have all enjoyed the course, learning about reflection for our professional portfolios and the new forms of communication that we have all been introduced to.

The course has enabled me as a practitioner, rather than emotionally reacting to situations reflectively but to think about my method of reflection and to look at how it fits in with the Midwifery Competencies and what sort of learning plan I can put in place. This enables me to react in a more logical way to the situations that may arise.

I was wondering if anyone else had thought of how this process could be transferred into the work place. I`m not keen on the audit process, I believe it makes professionals uncomfortable feeling like you are being judged by a pack mentality and the process can leave you feeling professionally `mauled`. I don`t believe anything worthwhile is learned from this environment and all it seems to to is promote the `blame and shame culture`.