Delivery Suite, and a tour of A+E
So this week I have been in delivery suite, although I only managed a shift and a half!
My mentor was a lovely midwife of 15 years who'd worked up and down England before settling back home. Our first shift we were at 'the back', where inductions of labour are started, compromised of small bays with usually 8 women a day coming, it was 'Q' and we had 3. The women were being induced for various reasons, one was a previous caesarian. Usually prostin is used here generally up to 3 times, only once if the woman is planning a VBAC.
One really interesting thing is, they occasionally use osmotic dilators for their cervical priming. I'd never actually heard of this, the midwives refer to them as 'seaweed sticks', and the idea is a few of the sticks are inserted (depending on parity, comfort levels etc) into the cervix and the vaginal/cervical mucus and moisture is absorbed into the sticks which dilates them sort of like a sponge does. There is reportedly no risk of fetal heart anomalies as with prostaglandins, and are reportedly more effective at dilating the cervix to allow for artificial rupture of membranes AND are not contraindicated for previous caesarians. It's not used often but is usually in cases where the prostin has not opened the cervix enough to rupture membranes, mostly in previous caesarians.
A really strange thing (to me) is presentation scans are performed before the start of the induction process, I haven't had the chance to properly dig out (if there is any) research, but from my brief search I found nothing. The midwives perform the scan, apparently it was implemented after some women were induced with breech presentations, possibly a knee jerk reaction that stuck? I personally feel a bit strange about it, although ultrasound is generally thought of as safe, the studies done looked at mortality and childhood cancer, not morbidity, and guidelines for use suggest it is only used for short periods of time for diagnostic purposes, decent summary here. No intervention is absolutely safe, even as midwives we are an intervention of sorts to a physiological pregnancy and birth, as much as we try to safeguard it, we (as caregivers, with the person) always have to question is this absolutely necessary? Will the information we get change what we do? Can we do something else?
I think what makes me slightly uncomfortable about this, is I feel palpation is a key midwifery skill, its part of your bread and butter. As humans we make mistakes, and don't always get it right, but is further ultrasound exposure necessary if a midwife feels confident its a cephalic presentation? Which can be further confirmed by asking the woman where she feels most fetal movements, and again confirmed by where the fetal heart is auscultated. Plus if there is any uncertainty, i've never observed a midwife hesitate for a second opinion, and then a presentation scan offered. I'm more than happy to be proven wrong that this is wholly necessary when inducing labour, but these are just my initial thoughts. I'm interested to look into the research of the accuracy of abdominal palpation for fetal presentation, too.
On the topic of things that give me a weird feeling about the policies, fresh ears is another one. Fresh ears is similar to fresh eyes for a CTG during labour, where once an hour another midwife will come into the room while you auscultate, and count to see if you get the same rate, listen for accelerations, decelerations and variability. I was part of a twitter debate not so long about this, which started with this tweet. I sort of feel its the same principle as I've said before, intermittent auscultation is a bread and butter midwifery skill that we should be able to do? As far as I gather, it came about from an RCOG suggestion, which I have confirmed there is no evidence for! The problem with 'logical' suggestions is that they aren't always so, I fully respect the stance that logically, having someone else 'confirm' findings, may reduce interpretation errors because surely the more people who hear it, the more chance of picking up a problem. We thought the same with CTGs, we *thought* by continuously listening to the fetal heart we could spot problems with babies in labour, because thats logical. The problem we have is that actually all we've done is increase the caesarian and instrumental birth rate, because of inappropriate use. Once you start implementing widespread CTGs its so difficult to take that back, because of issues with litigation, wanting to appear to be doing 'something' to help, even if we know its not helpful. It's quite irresponsible to make suggestions like these, without fully evaluating the clinical benefits and possible harms. How can we counsel and gain informed consent for something we have no evidence for? 👀
Perhaps its more political than that, fresh ears as a policy is another chip off midwives' professional autonomy and undermines the profession as more and more of what we do, we are being told we cannot do alone. Not to mention the fear of litigation, if someone else has 'confirmed' the fetal heart as fine, it will 'hold up better in court', but is practising defensively a good enough reason for non evidence based practice? I'm not convinced it is, but when your whole livelihood relies on one income, and the fear of litigation is palpable around you, it makes it a hard thing to deal with.
On a happier note, well actually its not, I also had a tour of A+E. In a rather anticlimactic fashion I banged my hand off the door, dislocated and breaking my little finger *sympathy pause*. I did have a nice patient experience downstairs though, but it has meant i've had to cut my placement short due to the strapping being a hand hygiene issue. Not to panic, only missed a shift and a half and the strapping will be off by next week in time to go back to Yorkshire Storks!
My mentor was a lovely midwife of 15 years who'd worked up and down England before settling back home. Our first shift we were at 'the back', where inductions of labour are started, compromised of small bays with usually 8 women a day coming, it was 'Q' and we had 3. The women were being induced for various reasons, one was a previous caesarian. Usually prostin is used here generally up to 3 times, only once if the woman is planning a VBAC.
One really interesting thing is, they occasionally use osmotic dilators for their cervical priming. I'd never actually heard of this, the midwives refer to them as 'seaweed sticks', and the idea is a few of the sticks are inserted (depending on parity, comfort levels etc) into the cervix and the vaginal/cervical mucus and moisture is absorbed into the sticks which dilates them sort of like a sponge does. There is reportedly no risk of fetal heart anomalies as with prostaglandins, and are reportedly more effective at dilating the cervix to allow for artificial rupture of membranes AND are not contraindicated for previous caesarians. It's not used often but is usually in cases where the prostin has not opened the cervix enough to rupture membranes, mostly in previous caesarians.
A really strange thing (to me) is presentation scans are performed before the start of the induction process, I haven't had the chance to properly dig out (if there is any) research, but from my brief search I found nothing. The midwives perform the scan, apparently it was implemented after some women were induced with breech presentations, possibly a knee jerk reaction that stuck? I personally feel a bit strange about it, although ultrasound is generally thought of as safe, the studies done looked at mortality and childhood cancer, not morbidity, and guidelines for use suggest it is only used for short periods of time for diagnostic purposes, decent summary here. No intervention is absolutely safe, even as midwives we are an intervention of sorts to a physiological pregnancy and birth, as much as we try to safeguard it, we (as caregivers, with the person) always have to question is this absolutely necessary? Will the information we get change what we do? Can we do something else?
I think what makes me slightly uncomfortable about this, is I feel palpation is a key midwifery skill, its part of your bread and butter. As humans we make mistakes, and don't always get it right, but is further ultrasound exposure necessary if a midwife feels confident its a cephalic presentation? Which can be further confirmed by asking the woman where she feels most fetal movements, and again confirmed by where the fetal heart is auscultated. Plus if there is any uncertainty, i've never observed a midwife hesitate for a second opinion, and then a presentation scan offered. I'm more than happy to be proven wrong that this is wholly necessary when inducing labour, but these are just my initial thoughts. I'm interested to look into the research of the accuracy of abdominal palpation for fetal presentation, too.
On the topic of things that give me a weird feeling about the policies, fresh ears is another one. Fresh ears is similar to fresh eyes for a CTG during labour, where once an hour another midwife will come into the room while you auscultate, and count to see if you get the same rate, listen for accelerations, decelerations and variability. I was part of a twitter debate not so long about this, which started with this tweet. I sort of feel its the same principle as I've said before, intermittent auscultation is a bread and butter midwifery skill that we should be able to do? As far as I gather, it came about from an RCOG suggestion, which I have confirmed there is no evidence for! The problem with 'logical' suggestions is that they aren't always so, I fully respect the stance that logically, having someone else 'confirm' findings, may reduce interpretation errors because surely the more people who hear it, the more chance of picking up a problem. We thought the same with CTGs, we *thought* by continuously listening to the fetal heart we could spot problems with babies in labour, because thats logical. The problem we have is that actually all we've done is increase the caesarian and instrumental birth rate, because of inappropriate use. Once you start implementing widespread CTGs its so difficult to take that back, because of issues with litigation, wanting to appear to be doing 'something' to help, even if we know its not helpful. It's quite irresponsible to make suggestions like these, without fully evaluating the clinical benefits and possible harms. How can we counsel and gain informed consent for something we have no evidence for? 👀
Perhaps its more political than that, fresh ears as a policy is another chip off midwives' professional autonomy and undermines the profession as more and more of what we do, we are being told we cannot do alone. Not to mention the fear of litigation, if someone else has 'confirmed' the fetal heart as fine, it will 'hold up better in court', but is practising defensively a good enough reason for non evidence based practice? I'm not convinced it is, but when your whole livelihood relies on one income, and the fear of litigation is palpable around you, it makes it a hard thing to deal with.
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| Walking wounded, with Hinny keeping me company! |
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