Conference

Back to remembering what independent midwifery is about while out with B*. This business doesn't have to be complicated. We choose to make it complicated.
One set of terminology I have taken on from conference is the labelling of high-risk pregnancy as complex instead.

The issue of trust is important in the midwifery partnership. B* is currently with a woman who B* believes has marijuana smoking in the house and the woman is wary of strangers. How many things does a midwife have to not see? Where do I stand?

This makes me think of the situation of the Northland porn actress who wants her birth filmed for inclusion in a prn movie. Her midwife has withdrawn her services and she has the support of the New Zealand College of Midwives. There is obvious concern as a midwife about the videotaping of a birth if something was to go wrong. And the midwife will have her own set of morals and ethics about the situation. What I would like to understand is what the position of the New Zealand College of Midwives. Is every woman in New Zealand entitled to the care of a midwife during her pregnancy and birth?

Conference Photos

Photos from the NZCOM 2002 Conference. Not many, but you can see where it was held and a few photos around Dunedin.

Midwifery Outside Normal

I have moments of assurance and moments when I have crises of confidence. It is all about knowing what I am doing and what direction I should choose for next year. I feel that I am equipped for normal births which I will get plenty of next semester, but I am unsure about the realm of abnormal. Admittedly what I am seeing that is abnormal does not always fall under the care of the independent midwife, but there are many instances where care is not transferred and the independent midwife has to manage the abnormal process in consultation. I feel that I would benefit from the relationships I would build and the experience I would get by going through the postgraduate programme. My feelings about this fluctuate depending on my experiences during the day.

Yesterday I went with one of the hospital midwives to take a full-term stillborm baby to morphology for post-mortem. The baby looked very peaceful. I felt sad at the circumstances for the family and that this peaceful baby never experienced life. I was shocked at the way the doctor handled the baby. She let the head flop. I guess this broke the illusion of a peaceful sleep. It wasn't that she didn't treat the baby with respect, but that the illusion was broken and the baby didn't need to be handled in the same way as a live baby. I don't think I could handle a dead baby like that.

Delivery Suite

It was really wonderful to be called in as second midwife for a birth with N*. I checked the suction and oxygen and really felt that if I had to, I would be confident to use them. One thing I didn't check which I am kicking myself for is syntocinon. I even got a little time to quickly check F*'s blood group and booking sheet.

I was not extremely organised or quick, but I got everything done that I needed to do. I hope I got everything in the right order in the notes.

Diagnosis of Stridor in Children

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Antenatal Ward

I have investigated a few areas and put them into my online journal. This is invaluable and I should continue to do this.

I thoroughly enjoyed the time I spent on the antenatal ward. The variety was confusing, but posed a good challenge. I achieved some consistency in working with the same women. Of particular note was my learning curve in applying the CTG to a woman pregnant with twins at 25-26 weeks gestation. I was also able to follow the mother through with her ultrasound and her caesarean section. The caesarean section was for IUGR of one twin who had absent end diastolic flow on doppler which was then changed to reversed end diastolic flow.

The experience that day was invaluable. To see a woman through an antenatal complication who then delivered, and knowing that in about two weeks the babies will still be in the neonatal unit, I will have the opportunity for real continuity of care in some respects.

Areas I need to investigate further are pre-eclampsia, blood results, infections, haemorrhage, and embolisms.

I managed to accomplish care according to my objectives in blood glucose monitoring, CTG monitoring, blood results, infections, pre-eclampsia, and ultrasound.

One thing that is glaringly obvious to me from working in a high-risk area is how much I don't know. I've never doubted whether midwifery is the right thing for me to be doing, but sometimes I wonder if I really know enough to be competent. I guess I am really relating that to a hospital setting. However, knowing the type of person I am, I like to be competent in all areas of a field I am working in to the best of my ability.

One thing I dislike is the conflict between the hospital and the independent midwives. Working through the post-graduate programme at the hospital would certainly prepare me better in those relationships as long as I don't lose track of normal.

Primary Facility

L*'s birth yesterday was great for wetting my feet again and getting used to the Birthing Unit.
L* was in labour with her second baby. On visiting her at home she was found by B* to be 3 cm dilated with a very soft cervix and contractions were regular and lasting for more than 60 seconds. I hadn't met L* previously, but she was happy for me to be there.

We drove into the hospital and set things up for when L* arrived. I have quite a learning curve ahead in getting oriented to the processes of a different unit to where I am used to working.

On a subsequent examination baby was still high, and B* did an artificial rupture of membranes. When she said the head was still high I offered to apply fundal pressure. A small amount of clear fluid leaked.

The intensity of contractions slightly increased and L* was wanting to try entonox. This provided some relief. L* was upright and walking throughout first stage.

B* determined second stage commencing from L*'s uncontrollable urge to push. Her pushing was not as effective as it could have been. L* was standing, leaning into the raised bed. So a change of location to the toilet was suggested. Pushing in this position was very effective and after about 4 contractions the baby's head started to stretch the perineum.

It was certainly awkward having the birth in the confined space of the toilet, but cleaning up afterwards was much easier.

Itching

ITCHING

Pruritus - the symptom of itching

Anderson, K.N. & Anderson, L.E. (1998). Mosby's pocket dictionary of medicine, nursing, and allied health. Missouri, USA: Mosby.

Pruritis gravidarum - unique to pregnancy as the result of elevated oestrogen and progesterone levels. Onset in the third trimester. No lesions on the skin.

Candida - fungal skin infection in skin folds, under the arms and breeasts.Round, blotchy areas of redness

Toxemic rash of pregnancy - Red, elevated itching hives on the skin of the abdomen, but unrelated to pre-eclampsia.

Papular dermatitis of pregnancy - eruption of highly itchy hives over the entire skin surface. Lesions 3 - 5mm in diameter and do not occur in clusters.

Pruritic urticarial papules - Late in the first pregnancy, itchy pimply skin eruption presenting with oedema and redness on the abdomen and in stretch marks. Not harmful and will disappear postpartum.

Herpes gestationis - Onset signalled by fever, hot and cold sensations, malaise, nausea, headache and itching. Lesions start as a red rash on the abdomen and usually disappear by 6 months after birth.

Pruigo gestationis - Benign lesions which appear as raw, itchy, non-blistering papules on the arms and legs during the second half of pregnancy.

Frye, A. (1998). Holistic Midwifery: Care during pregnancy. Oregon: Labrys Press.

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Biblioscape - Reference Management Software

Biblioscape - Reference Management Software, and the Express version is free and fits on a floppy.

Stress

Stress, stress, stress! Do I have enough hours? I feel as though I am in a safer position than other class members. As well as assignments and exams it is yet another thing to worry about. The class needs to form a strong united front.

Balance

I have commented in my portfolio that one of my current issues for focus is to balance relationships, especially my family and midwifery. This is an ongoing struggle.

Something I need to have clarified is whether we are legally safe if the lead midwife does not call another midwife in to attend at a hospital birth. Am I at risk?

I have lost a little bit of focus this semester. I'm not really sure why. I seem to be most motivated when I am out with the midwife.

Time to Journal

My reflective journal writing this year has been erratic. I guess I have been scared off by I*'s cautionary words. Other than getting an experience off my mind, I don't see much benefit from not using first names because as time passes it will be even more difficult to recall the people and the event.

Where I was once confortable and enjoying journalling, I now put it off because the purpose is clouded.

However, I feel more relaxed relating learning events at university. Today was the assessment. The woman who assessed me was difficult to read and I don't even know if I've passed. I know I checked everything, but did I articulate these sufficiently?

Safe Journalling?

It has been far too long since I have written in my journal. It is interesting the caution with which journals are used because of the potential for them to be used against a midwife. It all comes down to communication. I consider a journal to be a conversation with myself that I can read later and learn from and chart progress. However, a lawyer would probably read it differently.

I am not sure whether I will use a reflective journal as an independent midwife. A comment in my conversation to myself could be misconstrued by a third party. I enjoy and appreciate the value of journalling but only if I feel safe.

I am a little bit frustrated at doing so few births this year but can appreciate the benefits for my family. I* put it really will when she said some of us are getting quality instead of quantity. However, one good thing about quantity is that you remember and build habits from repetition.

A great experience for me has been L*'s use of accupuncture. The most incredible evidence of its effectiveness was during F*'s labour where she was contrcting 1:10 and immediately following.during needling contractions jumped to 4:10. Then unfortunately following removal of the needles, contractions became incoordinate and irregular again. I was so amazed that I asked the couple if I could photocopy the relevant section of the CTG tracing.

Lots of other things about that labour were difficult, but at least I have a high point to recall. One try with the prostin, accupuncture, two days, and ARM, more accupuncture, two tries at cannulation, syntocinon, entonox, three tries at an epidural, a dural tap, and finally a forceps delivery. No wonder midwives practise defensively and don't write reflective journals. Mustn't forget the resuscitation because baby stopped breathing and the blood patches required for the spinal tap headaches.

I know I still feel the anger at the outcome of my stitches with my first birth and that the scars and damage is permanent. For something relatively minor I still felt cheated . So how does a woman with a traumatic birth deal with it? Interestingly there is a group dealing with birth related post-traumatic stress. Maybe F* might be interested.

I got great feedback from L* on my evaluation form. I got two passes so far so I am getting through. The only cloud on the horizon are the exams.

Different Expectations

I didn't get much written last night because I had kids climbing all over me. It's not much easier now, but best to get it done.

I'm not meant to use full names, or even any form of recognisable identifier, in my journal for privacy reasons. I find this difficult in some ways because at the least a first name aids recollection. I think I will continue using a first initial and careful editing for my online journal.

S*'s birth was arduous. We first saw S* at 8:30 am on Thursday and she was contracting regularly but was still comfortable with them.

Later on in the day L* attended J*'s home birth. A lovely home birth that I didn't attend because J* had plenty of support, a lack of space, and I hadn't met J* earlier.

L* phoned at about 8:30 pm and let me know that S* was anxious and in pain with regular contractions and we were meeting her in the hospital at 9:45 pm. S* was 1 cm dilated.

S*'s anxiety and pain perception dictates a slow process. On arriving, contractions slowed, and were further slowed by a bath. However, S* was in pain to the extent that she requested and was given pethidine.

On vaginal examination she was still 1 cm. Further on through the night it was decided that syntocinon would be required to augment labour. S* was not coping well because she would not consider returning home, has a needle phobia, and was objecting to the need for vaginal exams and absolutely refused an artificial rupture of membranes.

It was a slow process to talk S* through the importance and need for these interventions in consideration of her dilatation and pain tolerance. We almost had a meltdown when L* suggested that S* was heading towards a caesarean section.

J* was consulted about S*'s labour.

S* surprised all of us when she dilated from 3cm to 6cm as it was unexpected. So a vaginal birth was back within reach. The trickiest part was managing the epidural as even with a full block S* was not receiving relief for right hip pain.

L* left at midday because she was exhausted. I stayed for two reasons. I wanted to be there as a familiar face and for some form of continuity for S* and L*. The second reason irritated me because I considered that if I left before the birth I couldn't actually count it in my numbers even though I had been in attendance for 15 hours.

It was such a relief that in the end S* had a vaginal delivery of baby assisted by J* using forceps. It looked like S* was bleeding heavily and L* confirmed that S* had a PPH.

A* commented to L* that I wasn't acting in a strictly observing capacity and something I did was inappropriate. I'm not clear what it was, so will try and gt the information from A*.

I was quite upset and tried to take it on board as something to consider and learn from, but without specifics it's a bit difficult. Some factors I have since rationalised about include the fact that I was tired, I had established a relationship with S* and L*, and that for S* and L* my communication was acceptable. What I need to think about is the colleague and professional relationships where two-way support and respect is crucial. Further to this is that I feel that L* is satisfied with my level os interaction, otherwise I feel that she would have said something further in respect to her perspective of the birth.

Our relationship is developing and I am really enjoying watching and learning from L*. Life is crazy busy but I really love what I'm doing.

Looking Ahead

Back at school...hooray! I forgot how tiring it is to be back and how hungry expending brain energy can be. I love being at university doing what I'm passionate about. I feel revitalised and focused.

We're going to have a busy year and I'm dreading pharmacology. I've got a wonderful midwife who does a lot of home births. Once again it's a challenge getting to know a new person. That comes with the territory.

Different Needs

On 2 October I met C* who is over the age of 40 and is a 38 weeks expecting her first baby. She was confident and self assured but very anxious about her pregnancy and her birth. I used the term "precious cargo" when N* first discussed C*, and this was reinforced by her communication during the visit.

When we visited S* it was fantastic being able to palpate her twins. As there is less room I found it quite tricky identifying the lise of the babies. N* did a palpation and guided me through. After N* showed me, everything seemed obvious.

I'm enjoying visiting M*. Her husband was home and he didn't seem to be very happy. Their son is getting really used to me visiting. I'm really hoping that I am able to attend the birth. I guess I'll just have to wait and see.

S* let me know that while she was quite happy for me to be able to be at her birth, her husband wasn't so keen and wanted it to be a private affair. When I first heard it I was quite disappointed, but now I'm quite philosophical about it. I think of it this way that I've done more births than the minimum and at the moment I have 1 definite birth to attend and 3 maybes. I'm still ahead and any little bit I do gets me ahead.

The next day I met T* and her husband at delivery suite. We soon figured out what his reluctance was in attending the birth. He was fine with the new birthing rooms and the standard delivery rooms but when we took them into one of the delivery theatres he loked very uncomfortable. It was partly the clinical apearance of the place as well as the smell.

Monday the 9th was a really busy day. We had to quickly stop in and visit N* who had a severe nosebleed on her way to work. We checked her blood pressure and did a general check and N* recommended the N* visit her GP as everything was alright in relation to her pregnancy.

N* had 3 appointments at the rooms she uses at the Karori Village Medical Centre. I didn't see one of the couples as we were short of time so I went through booking paperwork with another couple. One thing I realised about booking visits for multiparous women is that one of the most important things for discussion is the previous birth.

We visited one woman postnatally and I had an opportunity to hold her baby. On feeling his head I was amazed how moulded his skull bones were. It was easy to identify the posterior fontanelle.

N* warned me about S*'s house before we arrived and her concerns that the state of the house posed a health risk to the whole family, and especially a newborn. S* is an uncompromising woman and continues to smoke during her pregnancies and after the births of her babies.

I felt composed until I passed their dog and it decided to growl at me. I took a quick breath to reassert myself and told the dog firmly to be quiet. This worked but it certainly put me off balance.

When we entered the house I was shocked. It probably isn't the worst I'll ever see but I hadn't really expected it to be as bad as it was. This is where N*'s years of experience as a community nurse and her previous work with S* provided me with a model for interaction. N* treated the whole situation as normal.

S* is expecting her fourth baby and they currently have six people living in a three bedroom house. I know what that's like, but our home was definitely not in that state. S*'s partner arrived and I felt like he was looking down my top. I'm not necessarily worth looking at, but that made me really uncomfortable.

After we left N* said that she intentionally chose the lounge for the discussion as the kitchen was appalling. She suggested that S*'s would be a good birth to attend. I think I'm a little wary because N* has stated that S* can be really blunt. If she was directing her frustrations at me, how would I react? Tears, a joke, or just brush it off, or return the comments. I don't know, but I think I would follow the patterned response set by N*. It could be quite helpful being there if S*'s husband is away when she goes into labour.

I'd already checked with Adrian and was able to go in with N* to commence an induction for one of W*'s clients N*. They hadn't met S*, so I didn't feel as though I was stepping on her toes. They were happy for me to attend the birth and I went home excited with anticipation.

Adrian and I are both learning as we go along about the nature and timing of midwifery. I'm learning to work out estimates and Adrian's happy if I respect his needs and keep him informed.

I was up bright and early for the induction and got to the hospital in time, but it looks as though it might pay to be a little bit early as N* gets started as soon as she arrives and I might miss things.

It was a really cold day. I felt as though I had two left thumbs. One comment another midwife made is that she finds students tiring because she is directing traffic and they aren't as quick as she is. And these comments she was applying to a third year! I felt as though I fulfilled these comments. After enough births a lot of the processes become automatic. I'm looking forward to then, but right now evrything seems painfully slow.

N* provided us with a tricky induction process. Frequent monitoring was required because baby didn't like having the syntocinon rate too high. N* and her husband had a few questions which I felt I answered accurately. Possibly questions they weren't wanting to ask N*.

Once again the privacy and confidentiality issue arose. I am super aware of it after querying N* about a first year being disciplined and she stated that it was over a breach of privacy. One question I need and answer to: Can our reflective journals be used against us in relation to breach of privacy and malpractice? If we meet a family in public who we cared for during pregnancy and labour, are we able to introduce them to our family or friends, and how should that introduction be worded?

During the labour there wasn't quite the feeling of being connected with N*. She was tired and sore and was in a fast/slow time warp dealing with pain.

Conference

Another fantastic day. Heard an awesome inspiring speaker, Rangimarie Rose Pere. She gave us all plenty of food for thought.

I won a prize draw. It's rather exciting, but I haven't seen it yet and it's not the Sonicaid.

At the hangi dinner the atmosphere was much more relaxed then the dinner the previous evening. I enjoyed it, but couldn't get into the dancing after the Pacific Island group and the Maori culture group. I missed Adrian, and felt lonely and shy.

Conference

I love today. So much to see and do and participate in.

I found it completely confounding that we had men speaking on behalf of the women for the powhiri.

It was fantastic meeting Sarah and Sheryl from the midwives list.

I was really disappointed in the dinner as the quality and quantity of the food was not satisfactory value for the price paid for the meals.

It's amazing to see midwives let their hair down and have fun. I can imagine I'll be like that in a few years. As Sandy and I have discussed, there is a definite culture of midwifery, and as students we feel as though we have a taste of it, but are on the outside looking in.

Pre-Conference

We made it here without too many problems. I'm disappointed that none of the other first-year students are staying at the school dorms, but I'm definitely pleased to be here because it's the more economical option.

It is obvious that there are sub-cultures in this culture of midwifery. N* suggested that to get peer support as a practitioner the student and midwife needs to be aware of, and absorb, all aspects of midwifery culture.

I need to work on my literature review and tonight looks like the best night to get some good work done.

The material presented today has been fascinating. The workshops are really more of a lecture, but in smaller groups.

I purchased Spiritual Midwifery and hope I can get Ina May Gaskin to sign it. We'll just have to wait and see.

Like the Optimal Foetal Positioning workshop, the information we are getting makes me question practices that are considered normal and check my experiences.

I often feel in this midwifery student role as though I am a passive observer watching and learning by standing back and absrobing interactions and culture.

Continuity of Care

What a glorious day! I truly experienced the joy a midwife must have at being able to provide continuity of care with final postnatal visits for two of the women whose births I attended.

Our first visit was to L* who is due in February. She has already finished work and is happily homemaking and preparing and making beautiful items for baby. Her house is absolutely gorgeous. Perfect design and decor. If L* had a hand in it I thought she should go into business, but they bouight it that way.

S* had a look around the hospital to figure out what the plan was for her birth. It looked and felt to N* as though both babies were head down, with one baby firmly descended. This looks good for S*. While N* thought it would be good for me to be at the birth, I fielded the idea with S* so that she could think about it.

V* is doing really well. We me B*'s parents. B* and V* gave me the disk back with the photos which is fantastic. I will have to wait for a copy of the other photos fom the camera so I can show other students the birth chair. N* and I don't think they realise how close that V* was to a serious haemhorrage.

J* is a character. Once again we caught her in the shower. She is being pampered by her mother in classic Indian tradition. Even though baby was premature, he is really thriving.

It was wonderful seeing D* again. As I told her in a slightly humorous way that I'll never forget the first birth I attended, and what a privilege it was. I would love to be able to keep in touch by email. The final visit offers closure for the midwife and the woman to move on to their next endeavours.

I was really stunned that L* and G* had given me a card and a box of chocolates because they had already given me a gift by allowing me to attend J*'s birth. I guess it's more to recognise the special connection I will always have with them and their baby.

I gleaned lots of practical information from N* today about midwifery practicalities to how a new practitioner might build up their practice.