Fear

Becoming a parent can, for some, be the most frightening experience in the world. You can ask about others experiences, you can read all the books, you can look on the internet but nothing can really tell you what it's going to be like. It is quite normal for first time mums to focus on the labour that is ahead of them and read all you can on the subject or alternatively, completely stick their heads in the sand and not think about it at all. I was someone who had to read everything I could. For me, as a future midwife, as someone who has been through labour twice, as a mum who wonders what parenthood will bring that day, I wonder if I can help alleviate some fear? I certainly hope that I can, for women that I work with and with friends who are to become parents in the future.

Labour is certainly something that holds a lot of fear and it's understandable that it does because anything that involves pain, is something to worry about. Instinctively, as humans, if there is pain then there is something wrong. However labour is unique in that, it is the only time that pain is actually a good thing. If you are someone that has had a tough pregnancy, or you go overdue, or you've just had enough of waiting, you may even find yourself wishing for the pains to start. The one time in your life, you will wish for pain?

Television doesn't help of course...it gives the impression that when you go into labour your waters will break and you are instantly in agony. I'd hope that most people realise that labour generally takes longer than how it is usually portrayed on the tele. For most women, labour begins with mild, irregular pains. Many women liken them to period pains. You can breathe through them, you can walk through them, you can easily talk through them...not like they'd have you believe in Albert Square. They can be 10-15 minutes apart, they can stop for a few hours and then start up again. This is the main reason women are recommended to wait before rushing up to the hospital. Yes they hurt, some are stronger than others but as it's not a constant pain it's something women can cope easily with. The fear that can accompany those pains however, is what some women find difficult to handle. The not knowing how long it will last for, can be difficult to handle. And sometimes whilst the pain isn't that strong yet, it can still prevent women from sleeping or getting comfortable, and this can have an impact on how well women cope.

I believe that fear surrounding labour and birth should be handled at the antenatal stage, or perhaps pre-conception would ideal. I wholeheartedly believe, that in the delivery suite is not the place though. It's much more difficult to maintain normality when someone is terrified. It's not impossible and I have witnessed some amazing midwives who can calm the most frightened of women, and ground them, manage their fear, soothe them and make them feel safe. I hope to be this kind of midwife. I believe that the overwhelming fear that some women experience does sometimes lead them to choosing an epidural for pain relief. They don't know what to expect and how long it might take. Providing women with accurate information, and helping them to make an informed decision is vital. Being able to alleviate their fear is also vital. I have witnessed frightened women "choosing" an epidural and as someone pointed out to me, how can it be an informed choice when it is a fear based decision. Women should not reach this level of fear.

When I was pregnant with my second daughter, I attended an antenatal group, as previously mentioned in my Inspirational Midwives post last year, where I was given all the information I could possibly need to make an informed choice about where I wanted to give birth, my pain relief options and what to expect if things didn't go to plan. I always wished I'd attended the group when I was pregnant for the first time. What I find incredibly sad, is that group had to stop running due to a lack of funding. Those midwives inspired a number of women to have a home birth, who in turn inspired others to also have home births, and that cycle is still continuing, their inspiration still continues on. They gave women a voice, because they provided the information, they probably saved the NHS a lot of money because a women who knows what to expect, needs far less interventions, would decline unnecessary interventions. In an ideal world, the community midwife would be able to handle all fears about labour and birth during an antenatal appointment. Sadly there just isn't time - too many women and not enough midwives. Midwives constantly thinking about the next woman they have to see....it's not that they don't want to, it's more that it's just not possible.

Fear is the biggest barrier for a woman facing labour and birth. Time is one the biggest barriers facing the midwife. My biggest fear about becoming a midwife, is not having the time to be able to give women the care that they need, that they deserve and becoming frustrated with time constraints. I hope to remember the midwives who managed to give the time without neglecting others, somehow found a way to manage it. 

And so begins 2nd Year

We are no longer shiny and new. We've all had different experiences on placement, good and not so good. We've all already started to think about the kind of midwife we want to be - learning from those we've been working with. We've even already become a little cynical about the changes we thought we could make because we've seen how restrictive working for the NHS can be.

I've been back in Uni for two days and already I feel revitalised and hopeful about my future. During one of courses we will be looking at hypnobirthing and complementary therapies and I am so excited...this is exactly the kind of midwife I want to be. I want to embrace normality and encourage women to believe in their bodies to give them the best possible chance of a normal birth. Did you know that it is a well known phenomenon that women's labours halt or slow down when they enter a hospital? Did you know that it was only once the doctors got involved that babies began to be born in hospitals instead of at home?

Don't get me wrong, I 100% believe that hospitals have their place and women and babies lives have been saved as a result. However I do believe that for the majority of women, home would be a perfectly safe place to give birth. I may well be biased having had personal experience of a home birth and loved it but it is something I am passionate about. Sadly I also believe that we are a long way off turning things around again. Women have different expectations now - they expect pain relief, they expect doctors or midwives to tell them what will happen and when, and so on. It's not that women are wrong but perhaps we are wrong in how we guide women's expectations if that makes sense?

It's not often that I hear people say that they loved their antenatal classes...at least not once they've had the baby. The most common statement I hear is that the classes didn't prepare them in any way? So is this where we are going wrong? Is this where we can make a huge difference to how birth and labour is viewed? I do believe that no-one can be fully prepared for just how much parenthood changes your life but I also believe we could prepare women better for birth, and increase the chances of a normal delivery. I've been on the receiving end of wonderful, inspirational antenatal discussion that led me to my home birth. However I was also fully prepared for if things hadn't gone to plan, and I still had plans in place to maintain control of MY birth. Shouldn't all women be given that opportunity?

I would also like to make the disclaimer that I am not saying that anyone who hasn't had a normal delivery, had unrealistic expectations. There is many factors to consider and I am certainly not in a position to judge whether or not someone was given the opportunity to have a normal delivery. Do you think you were well prepared for the birth of your baby?

Nightmares

One more week on placement, one more assignment result to come in and almost one year's training completed. The last year certainly seems to have flown by all of a sudden, although it didn't feel that fast whilst it was happening.....definitely felt slow when I was writing assignments.

This past week I have been spending my time with a Health Visitor and some of the other staff that work in the Children's Centre. The staff are lovely and have tried hard to fill my week with a number of different activities so that I get to see plenty. However it has been an unusually quiet week and I haven't seen much at all. It's also quite unusual for me to have nothing to do, as it's an observational placement. I've found it really difficult to sit back and not do anything and well I'm not very good at keeping my mouth shut.

Over my time at various groups with my own children, and time spent on parenting forums, I had heard a variety of stories, both good and bad, about Health Visitors. Stories of poor advice, outdated advice, fantastic support, reassurance, pushiness, unrealistic advice amongst other things. I could probably write a book of stories I have heard about health visitors. Personally I have only had the misfortune of one poor experience with a Health Visitor, all the rest have been fantastic. So whilst this doesn't really relate to my Midwifery training, I thought I'd share my experience. I'd been to see her about my daughter's nightmares, desperate for any advice I could get and she told me it was a bad habit. My jaw literally dropped and I was almost speechless. My husband "encouraged" me out of the room fairly quickly as he could sense my temper was rising. My daughter is now 5 and still suffers from nightmares, although she is far better than she was. At the time I approached the Health Visitor, she was having 3-4 nightmares a night and it would take 30-50 minutes to calm her down each time. She'd wake shaking with fear, sweating and her eyes would dart around the room looking for whatever horror it was that had scared her. Yet this was a "habit"? A year later, some educational psychologists happened to visit the school and I took the opportunity to ask their opinion on nightmares. They were very reassuring and calm, and explained how it was quite normal at her age, and that I should expect it to pass within a couple of months. They then asked me how long she'd suffered with them? My reply was "at least 2 years" and it was their turn to have their jaws drop.

I've always been fairly confident of the reason behind her nightmares - she has a very active imagination. She could make up stories and worlds of her own from a very young age. She would carry around her imaginary friends of spiders and monsters....and it was my feeling that in actual fact, it was spiders and monsters that she was afraid of.  At 5, she still has one nightmare a night most nights....very occasionally she'll sleep through the whole night. We've tried keeping a diary, reducing her cheese intake, giving her a nightlight and a variety of other things suggested to us. She's always had a good bedtime routine of bath or quiet time, story and then bed. Nothing has really made any difference to whether or not she has a nightmare. These days I may not be able to completely stop the nightmares but when she does wake from the one that she has, I "give" to her a good dream, which somehow seems to work. I live in hope that one day she will outgrow them but for now I will just be there for her to comfort her, and never will I consider it a habit she has to break.

I guess my experience with this particular Health Visitor has taught me,  to always think about what I am saying, that if I don't know the answer to something, that it is ok to say so and that making assumptions is bad enough without voicing them as well.

Life in clinic

Since last week I have been working in antenatal clinic. It's a completely different experience in so many ways to what I have already done. Every day there are clinics run by the consultants, who may or may not be in attendance. I am well aware that it doesn't sound right that someone can be booked for a consultants appointment and for the consultant to not actually be there....so let me explain.

I had heard of the terms SHO, Registrar and Consultant but had absolutely no idea how it related to seniority....although I assumed that the Consultant was the most senior position. I assume that I am not the only person to have found it a little confusing as to who is who.

So an SHO is a Senior House Officer. This is a junior doctor who is undergoing training within a specialised area, supervised by the consultants and the registrars.

A Registrar is commonly called the Reg for short, and is a doctor who is undergoing advanced training in a specialised area in order to become a Consultant.

And finally the Consultant is the senior doctor who has completed all training in a specialist field and is deemed to be an expert in their area.

So if you are booked into the antenatal clinic for a Consultant appointment, it may very well be that it's not the consultant you will see. However rest assured, for if the SHO or Reg decide that the Consultant needs to be involved in any decision making, then they will not hesitate to bring him into the room.

So anyway being in clinic is very different from my community placement where we'd run clinics. The midwife there is autonomous and makes decisions regarding care herself, though of course, if she has any concerns, she would send the woman in to the hospital - whether it would be to see a consultant, or fetal assessment unit, or maternity assessment unit, or triage - it is the midwife that makes the decision. In antenatal clinic, it is very much the doctor that makes the decisions. Mostly I have been taking blood pressures and testing urine, and on some days I have also been palpating to check the position of the baby, and measuring the fundal height (the height of the uterus which gives an indication to the growth of the baby when compared with previous measurements) and listening in to the baby's heartbeat.  This has given me the opportunity to practise my basic skills and improve on them.

However I have also had the opportunity to listen and learn about care of more high risk women. The women coming into clinic are all coming for very different reasons - previous Caesarean Sections, bleeding in pregnancy, thyroid problems, sickle cell trait in the family, previous stillbirth, high blood pressure, recurrent urine infections and the list could go on and on. As you can imagine there are varying degrees of severity, which is why for some women, seeing the SHO is perfectly suitable and for others, seeing the Consultant is essential. It's not a case of special treatment, it's merely a case of medical requirement. You have to remember that in order to become a doctor, the SHO has already undertaken years of training. So if it turns out that when you thought you were seeing a Consultant, and you actually saw a Junior Doctor, it doesn't mean you are any less special, it just means that your care for the moment, is not as high risk as it may be for some others. And just to flip the coin, if you did see the Consultant, it may not be that you are extremely high risk, merely that he had already seen his highest risk patients and was now seeing anyone else waiting for their appointment. Confused? Yep I was too......after nearly two weeks there, I think I am just about getting to grips with it all.

What do women want?

I've talked quite a lot about the kind of midwife that I want to be but the other day I was considering the kind of midwife that women want? I am in the unique position of knowing a variety of women, who have all had very different labours and experiences, positive and negative, so I took the opportunity to ask them just how they felt about their births and how they felt about the midwives involved in their care. The response was very mixed, as you'd expect but there were some common answers that seemed to run through their replies. The responses made for very interesting reading, and sometimes very emotional reading.

It came as no surprise that the women wanted to feel listened to; that they were more than just a number and treated as an individual. It's a well researched fact that women in labour have better outcomes when they receive one to one care and yet this doesn't appear to be happening for all women. Their are midwifery shortages throughout the UK which places a huge impact on the services that midwives are able to provide and the subsequent experience that women will get. Although it cannot be denied that staff shortages are not the sole reason that some women do not receive one to one care and despite listening skills being highlighted as an essential requirement for any midwifery student candidate, it appears that some midwives have lost the ability.

The vast majority of positive experiences were during labour and planned caesarean births and the women spoke of calm, reassuring midwives who kept them informed. There was disappointment spoken of, if a midwife who had been present for their care, had come to the end of her shift and a different midwife had taken over. Again I was reminded of the importance of one to one care and how much of a difference it made to women.

I was particularly sad to read that for most women the postnatal care, and in particular the breastfeeding support was declared to be awful. This is where there was frequent mention of a lack of staff, the staff that were there being in a rush because of the number of women they were caring for, coming across as uncaring and uninterested. It also seemed that whilst midwives had the knowledge about breastfeeding and support, they didn't have the time to spend with women supporting them.

Another factor in whether or not women had a positive birth experience, appeared to be their expectations of how things would be. I have heard it said many times that for the woman with the explicit birth plan, strict dos and don'ts of what they want, is a straight to theatre kind of woman. Whilst this is said very tongue in cheek, there can be a bit of truth in that statement - in particular for the first time mother. If you've not experienced it before, then how can you truly know what you'll need? If you aren't expecting labour to be hard work, then it's unlikely that a choice of no pain relief is going to work out. If you are expecting to jump straight back to normal following a Caesarean section, then you will get a bit of a shock.

There are no gold medals given out for childbirth and whether or not you use pain relief, whether you "manage" without an epidural, whether or not you give birth vaginally or your baby takes the sun roof! Yet I have heard many women speaking of feeling like a failure because things didn't go to plan.

My advice to women would be to be as open minded as you can be about pain relief, and positions and what you might need. It's good to know roughly what to expect but don't get fixed on a plan.

My advice to myself and any other aspiring midwives would be to always listen to women; to always remember the value of time and try wherever possible to provide one to one care, to keep women informed, be honest with them and let them know what is happening. When you can't spend time with someone, explain why not but try to organise something so that they do get some time with someone who can help. I know this won't solve the problems of staff shortages but we can all do our best.

And finally I just want to say a huge thank you to all of you that contributed answers to my questions about your experiences. I think I have learnt far more than I have put into this post, and I value each and every reply.

Formula free hospitals

I've just completed my time on the postnatal ward and now have a study week before I return to the Midwife Led Unit for four weeks. So far on placement, if the mother has been formula feeding her baby, she merely requested a bottle and a teat and it was provided for her - as of today this is no longer happening and I can't deny that I'm pleased not to be there this week as the changeover happens. What will happen now is that mothers who plan to formula feed, will need to bring with them a tin of stage one formula and two bottles. A milk kitchen is provided where new mums will be shown how to sterilise and prepare the bottles safely, according to guidelines. 

One of the most common issues I have seen with supporting new mums to breastfeed is time. Midwives are already stretched by busy wards and a less than optimum number of staff; that I can only be concerned by how much more time the milk kitchen will require from them. Prior to beginning my training I would have been 100% percent behind the plan to remove formula from hospitals but whilst I am still in support of this happening, I have a more realistic view of the challenge it will pose to the staff. 

I am in support because I think it provides a more accurate view of how bottles are prepared and the time that it takes. I also hope that a midwife may be less inclined to encourage "trying" a bottle when it's not as easy to just grab one from the cupboard. Of course, this all falls in line with all midwives being trained in breastfeeding support and how best to support women, which I certainly know is happening in both my placement hospital and my local hospital. I hope with the growth of accurate information being provided, more women will feel supported rather than pushed. 

I am however concerned about the women who are post caesarean section, unable yet to get out of bed, possibly even finding it difficult to sit up for themselves. These are the women that already need a lot of support - how does the milk kitchen work for them? I can only assume that there will always be some formula milk in the hospital for the women who go into labour prematurely, or come in without their bags. Will there be milk provided for the women who need a high level of support? Or the women who plan to breastfeed but perhaps change their mind, maybe it just doesn't work out for one reason or another? What will happen then? I guess there are a lot of unanswered questions at the moment. 

Is this a cost-saving exercise for the NHS or a move towards a society where breastfeeding is the norm? Can it be both? I am certain that there will be teething problems but I am optimistic that it will work out. I am ever hopeful that the breastfeeding support will increase, the breastfeeding knowledge will increase and women will feel more confident in their abilities. 

Breast is Best?

The WHO (World Health Organisation) guidelines state:

"Breastfeeding is an unequalled way of providing ideal food for the healthy growth and development of infants; it is also an integral part of the reproduction process with important implications for the health of mothers. As a global health recommendation, infants should be exclusively breastfed for the first six months of life to achieve optimal growth, development and health. Thereafter, to meet their evolving nutritional requirements, infants should receive nutritionally adequate and safe complementary foods while breastfeeding continues for up to 2 years or beyond. Exclusive breastfeeding from birth is possible except for a few medical conditions, and unrestricted exclusive breastfeeding results in ample milk production."

So there you have it - the official guidelines from those in the know....so why is there so much debate over breastfeeding? Why are people surprised to see babies older than 6 months breastfeeding? Obviously I am only talking about in the UK here, as I can't speak for anywhere else. I think the answers are quite simple really:

1) Breastfeeding can be hard work to get established. It can be painful and sore.

2) Breastfeeding is often hidden away as something private, particularly with older children. Therefore unless you know someone who breastfeeds, your experience with it may be very limited or even non-existent. 

3) It's an emotional topic and when breastfeeding doesn't work out for someone, it can affect how they feel about it. 

Apparently only 2% of women cannot physically breastfeed either due to medical conditions or for an unknown reason. A common misconception, particularly in the 1960's and 1970's, was an inability to feed due to a lack of milk. It is unlikely that this would truly have been the case for the majority of women who switched to formula milk. This was a time when women were advised to put their babies into 4 hourly routines and not feed them in the night time which is has since been evidenced as being detrimental to milk supply. However it is something that is still said today, and many mothers are still worrying about routines and length of time between feeds, and consequently questioning their ability to produce enough milk. There is also little known about growth spurts, so when the baby is suddenly feeding all day and all night to increase milk supply,  again mother's can question their milk production - sometimes leading to early weaning onto solids; but that's another debate! 

So anyway that's the guidelines and official figures - still doesn't tell you my opinion does it? 98% of women can breastfeed....does that mean that 98% should? No I don't believe it does. Nor do I believe that repeatedly telling people the health benefits is the way to increase the number of breastfeeding mothers. I believe that some antenatal class teachers, some of whom are midwives, are almost frightened to talk about the difficulties that women may have with breastfeeding, worried that it will stop women from even trying. Some midwives don't discuss breastfeeding at appointments for a variety of reasons, such as not having enough time, thinking it's too early to consider, that it will be covered by antenatal classes, that anything that is said won't be remembered anyway etc. 

Some women don't want to breastfeed. They don't want to try and it doesn't matter what anyone says to them, they simply don't want to do it. Is that wrong? Well it might be an alien feeling to my own, but it doesn't make it wrong. We are lucky to live in a country of choice, where formula can be made up safely with clean water and for some women the choice is clear, and they choose formula. 

A lack of support is probably the most common reason for women to stop breastfeeding - whether it is a lack of support from health professionals or family and friends. This can be combined with pain, or a lack of knowledge about how breastfed babies feed. I have alluded to routines and growth spurts already but this aggravated by comments such as "are you feeding that baby again?" or "why don't you give that baby a bottle?". There is no benefit to comments such as this and for a mother who has pain and is unsure what she is doing, it can't help. 

Some women try to breastfeed but stop because of pain and soreness. There can be a number of reasons that there is pain during breastfeeding, most of which can be corrected. If the baby is positioned incorrectly, then the nipple can become very sore, cracked, even bleeding. If the mother is given support and advice before too much damage is caused, then the mother can go on to breastfeed as long as she likes. Poor positioning can sometimes also lead to mastitis as the milk ducts aren't emptied properly but again with the correct support and advice this is easily remedied. Nipple thrush can be another cause of pain to the mother, but also to the baby. Once identified, both the mother and baby must be treated simultaneously or it will continue to be passed from one to the other. Thrush can be a nuisance to get rid of, and it can be a nuisance to get the correct treatment for, but with the correct support and advice, it is easily dealt with. Engorgement is also a common cause of pain for the mother, especially when the milk first comes in. The easiest way to deal with it is feeding the baby although it can make it harder to get the baby latched on, in which case, it can be easier to express a little milk off just to make the breast softer. There are other causes of pain of course, but these tend to be the most common so I have focused on these for now.

However before anyone thinks this is a pro-formula post, it isn't. For me, it is like choosing to buy powdered dried milk in the supermarket instead of the bottles of milk in the chiller. It is a perfectly good substitute but it's not what I would choose - give me fresh every time! Wouldn't you say that's what most people do? Isn't that how breastfeeding should be? The norm? In cultures where breastfeeding is the norm, problems with positioning are practically non-existent. Women are used to seeing breastfeeding, and learn from childhood how to position their babies. They automatically support each other, and after giving birth, the family rallies around so that the mother can get used to her baby and get feeding established, without worrying about visitors and the housework. 

I am proud that I have breastfed my children. Whilst the health benefits didn't matter to me before, they do now. I am glad that I have given them the best start in life but at the same time I am incredibly grateful that I had the right support in order for that to happen. I hope I don't come across as smug about it, but actually help to further the view that breastfeeding can be easy, pain free and enjoyable and that it might just be worth a go?

Breastfeeding - my experience

Those that know me know that I am still feeding my almost three year old daughter and those that don't know this about me, may be surprised to know this. I feel passionate about breastfeeding and I know a lot about breastfeeding, positive and negative. Anyway I felt it was time to talk a little bit about my experiences, my opinions and my expectations; and I will say now that some of what I say may surprise you.

My Experience

When I fell pregnant with my first daughter and thought about how I planned to feed her, I merely thought "well I'll give breastfeeding a go but if it doesn't work out then I'm not going to beat myself up over it"....and I don't think that's a rare way to feel at all. I went to my antenatal class about feeding and noticed that there was a distinct drop in numbers attending. I listened dutifully to all the benefits to me and the baby and felt no real difference, and certainly no more prepared. I don't recall them discussing problems at all, though it is possible they did.

When my daughter was born, we did have skin-to-skin but in the immediate time following the birth there was no mention of feeding her. I certainly didn't have a clue what to do, or whether I should be trying to feed her or not. Anyway eventually someone did come to try and help me to breastfeed, I have no idea whether or not she was a midwife or maternity support worker. She certainly did her best, but my boobs would challenge most I think, as they are on the large side. Anyway she did manage to get her latched on but she didn't feed for long, and just wanted to sleep. Overnight she was very unsettled and I did my best to feed her but had no idea whether or not I was doing it right and come the morning I asked the midwives for some support. They did their best but she just didn't want to feed at the time they were able to help me, and when she did feed it was only for about 5 minutes. The midwives in the morning wanted me to stay a bit longer and get some more support with feeding, the afternoon midwives discharged me home. Did I feel confident? No, but having said that, I wanted to go home because I didn't feel that I was getting the support I needed whilst I was there anyway.

Over the next few days I gradually got sorer and my nipples cracked and were bleeding. I dreaded every single feed. However if someone suggested I switch to formula, I was like a stubborn child, I dug my heels in and was determined that it wasn't going to beat me. It was at this time, I actually discovered how much being able to breastfeed, mattered to me. I couldn't tell you why it mattered all I know is that it did. At that moment I certainly didn't give a monkey's about the health benefits, and I certainly wasn't thinking that formula was evil; I just knew that I wanted to breastfeed. Even now I can remember how determined I was whilst at the same time, I sobbed through every feed, and curled my toes.

Before I scare anyone who hasn't had children off breastfeeding for life....I would like to add that it changed very quickly - once I got the right support. I've actually already mentioned the inspirational midwife Annie who corrected my positioning and helped me on the road to pain free feeding. I saw Annie at home on day 5, and attended the breastfeeding group the same day. By the time I returned to the group a week later, the pain was gone. With my eldest daughter I went on to be pain free for the remainder of our breastfeeding journey which was ended by her when she was 13 months 1 week old. I attended the breastfeeding support group every week.....ok I wasn't experiencing pain but I did feel like I needed support. I made a lot of friends at that group, some of whom I consider amongst my closest friends now, one of which is in fact my second daughter's godmother. Having friends that had experienced the growth spurts, the distracted nursing child, the sleepless nights was essential.  Of course some of things are nothing to do with breastfeeding, but neither were the conversations about our husbands or families! The point was, someone had always had the same or similar experience and it meant you didn't feel quite as alone. At the time I was grieving the loss of my brother, who had died when my eldest was 10 weeks old; and whilst many of them may not have known that, they helped me more than they could ever know.


With my second daughter, I didn't anticipate any problems - after all, I had attended the group for well over a year, I'd already breastfed one child, I knew about all the problems to look out for...what could go wrong? Well...my daughter hadn't done all those things and she needed to learn how to feed, even if I didn't. There were no major problems, but boy did she have a strong suck on her and I experienced a couple of days of soreness as a result. When she was weighed on day 5, she'd already gained 13 ounces, so there was nothing wrong with her latch.

Over the coming months we experienced reflux , breast refusal, biting, mastitis and even a fairly long period of time where she would only feed from one side. I still have no idea why she only fed from one side; there seemed to be no real reason to it. She'd refuse to feed completely when she was teething but we invested in an amber teething necklace which seemed to do the trick. I was once a sceptic when it came to these alternative methods but the one and only other time she refused to feed, my husband had forgotten to put her necklace back on after her bath. The group helped support me, in that I knew it was quite common for babies to refuse to feed when they were teething, and that it was normal for different babies to react in different ways. With my first daughter, we'd never known she was teething, we'd just suddenly realise she had a new tooth.

When people found out that I had breastfed babies with teeth, they would always ask me about biting and doesn't it hurt. I have been bitten, and in all honesty, my second daughter once bit me so hard it drew blood. Not once did it occur to me, to stop breastfeeding because of it. I dealt with it in the same way I dealt with it any time she did something naughty. I told her very firmly no, and put her on the floor. She'd yell and cry, and I'd pick her up, tell her firmly not to bite and we'd continue. I'd like to say I only had to tell her once but it wouldn't be true. However I also learnt the signals for when she was considering biting, and the continued consistent reaction from me, ensured that it was soon a thing of the past; and she certainly never once bit me as hard again.


The couple of times I had mastitis, I was lucky in that I knew the signals and I was able to beat it becoming a more serious issue by feeding, feeding and feeding some more. I'd use a variety of positions to ensure that all the ducts were emptied properly. Again I am grateful to my attendance at the group, for knowing just how to handle it.

If you've learnt anything from this blog post, you should have worked out just how much I value the breastfeeding support group; it should therefore come as no surprise that I went on to become a breastfeeding mother helper and along with a friend, facilitated the group. I was awaiting training to become a peer supporter but I actually got my place at University before that happened. I did however attend the monthly training meetings with other mother helpers and peer supporters so I gained a wealth of knowledge about how to support women.

You might think from this blog post that I believe every woman should breastfeed...well you'd be wrong but I shall save telling you all about my opinion for my next blog post......

Inspirational Midwives

I have heard it said that along the way in my training it is likely I will see some bad practice, some ways of practising that I won't want to use and hopefully a lot of good practise. So it got me to thinking about putting down in writing what it was about the two midwives that I know, that inspired me so much, so that when I am suffering from a lack of confidence I can look back and read it. Of course it will be hard to convey exactly why they are so inspiring in writing but I shall do my very best. Those that know me and are local to me will know exactly who I am talking about but obviously I need to keep this confidential so I shan't be mentioning their names - I shall call them Jo and Annie for the purpose of this post.

I first met Annie when my eldest daughter was about 5 days old. She visited me at home to perform her heel prick test and she unfortunately had to come back and repeat it when she was 9 days old as she just hadn't bled well enough. I opened the door to her and cried with relief at seeing her. Now I shall talk in more detail about breastfeeding later but on day 9, I was at the end of my tether with breastfeeding. I was sore, my nipples were cracked and bleeding, I was incredibly engorged and I had a baby that wanted to be constantly feeding. Annie helped me to get her latched properly, and encouraged me to attend the breastfeeding support group later on that day. So later on that day I managed, somehow, to get myself out the door and down to the group. I shan't bang on about the group now, as I will cover it in more detail when I talk about breastfeeding, but Annie ran this group so amazingly well. She'd manage to balance supporting women, without ever judging them or pressuring them. She knew when it would help for someone to have a peer supporter provide one on one support and when someone needed more. When Annie ran the group we had a thriving membership, sometimes there weren't enough chairs; yet when government funding was pulled back, it meant she was only able to drop in on the group when she could, and the running of the group fell to the peer supporters themselves. Whilst the peer supporters did a fantastic job, the membership dwindled considerably. It was down to Annie and that group that led me to breastfeed as long as I did, as well as myself of course.

I can't remember when exactly I first met Jo as she'd sometimes come along to the breastfeeding group, though that was more Annie's domain, or whether or not it was at the  Baby Massage class that she ran. Jo has a wealth of knowledge on many many subjects not just midwifery related and I believe she has recently completed her Masters.

Together Jo and Annie ran the antenatal group/drop in. They were much like the antenatal classes run by the hospitals in some ways but far far better. They would cover all the usual topics you'd expect at, such as pain relief, positions in labour, instrumental deliveries, episiotomies etc. However what made this group so fantastic is that there was no limit on how often you attended. When I fell pregnant with my second daughter, I attended early on following some bleeding I had and then more regularly from around 28 weeks. It meant that you got to know the others that attended, some would be further along than you, and some would be earlier in pregnancy. When I attended the hospital classes when I was pregnant with my first daughter, we had one of those awkward get to know each other games and everyone was uncomfortable. At drop-in, as I shall call it, we did always introduce ourselves and although it was always a little bit uncomfortable, it got it over and done with, not to mention once you'd been a few times you found it easy. It also gave you a chance to say what had been going on with you that week, to raise something that might be worrying you, to moan about work or relatives. And it always felt like someone else had been through the same or was currently experiencing the same and that made for a very reassuring environment. So Annie and Jo provided this opportunity to access the information we needed, time to speak to a midwife but also time to speak with our peers. Separately they are both brilliant but together they are the best!

When I fell pregnant with my second daughter it was only natural to me to book with Annie. I saw her every week at the breastfeeding group and I felt so comfortable with her. Throughout my pregnancy I saw either Annie or Jo and got to know them both so much more. They gave me the confidence and the information to choose a home water birth. It was the ultimate joy when it was Annie and Jo that were present for the birth of my 2nd born. My first daughter was delivered by the midwives, my second daughter was delivered by me. Annie and Jo helped that to happen and in the case of a normal birth, this is how it should happen. The best part of this is, it's not only me they have this effect on. Amongst my friends, I can see how many they have empowered in their births....whether they were home births, Cesarean sections, instrumental deliveries or inductions....Annie and Jo inspired them all.

If I can be half as good a midwife as either of them, I shall be proud. I feel honoured to have known them, and words can't describe how I lucky I feel to have had them at the birth of my second daughter.

Assessment, Assignments and Exams

I have now had half of my results for the year, thankfully all passed, and it's got me thinking about the different ways in which we are tested. Before even getting into University we all had to pass a Maths and English test and it has felt a bit like we've been constantly tested since then. So I thought I'd tell you all a bit more about the tests that we've had to do and how I have "survived" them.

Academic Skills - 2000 word assignment.
I enjoyed this assignment in some ways and in other ways it frustrated me. The assignment was, depending on our prior experience, teaching/reminding us how to write an essay and how to source references. We also had sessions on how to do Harvard Referencing  and four activities designed to help us so that by the time we came to actually write our assignment we'd done most of the work already. For the assignment itself we had to summarise our chosen article and then write about how we it links to our future role. Finally we had to talk about the academic skills we had learnt in the process. I enjoyed it from the perspective that I actually enjoy writing essays and I enjoy doing further reading. I felt frustrated because I was limited by it in so many ways. I would have enjoyed exploring the focal point of my article some more but it wasn't what the assignment was for. That said I am thoroughly enjoying researching my psycho-social assignment which is my next one due in.

Practice Assessment Document (PAD)
I have made reference to this book before. This is the book we carry everywhere with us on placement. For each placement that we do we have key areas that we have to achieve e.g. supporting women to breastfeed in challenging circumstances, recognise the onset of labour, be the initial port of contact for pregnant women, competently provide information regarding screening etc... You'll have to excuse me a little here as my book is currently with my personal tutor so I have had to rely on my memory and I couldn't recall exactly how they were written. When I first got my book and I looked through everything that we had to get signed off, it felt so overwhelming. Once on placement it almost felt even more overwhelming. The opportunity to get anything looked at let alone signed off, felt very remote. However I soon learnt you had to find the right balance of forceful, respectful and keen. However it is important to note that the balance can be different for everyone that you work with. I certainly found it far easier to get my book signed once I was into the Community part of my placement. Anyway for each section of our PAD we have to have at least one formative assessment before the summative assessment is done and a mark awarded. The mark given definitely depends on who you are working with, not just your ability and it seems that our mentors were every bit as confused as us; however in their defence it is a fairly new way of doing it so they are still learning too.

Exam - Biological Basis of Health.
A 2 hour exam consisting of 25 multiple choice questions, a midwifery specific diagram and 4 midwifery specific short answer questions. Now I am the first to admit that Biology is not my strong point. When I was at school and was choosing my options (is that showing my age or do they still call it that?) I could choose whatever I wanted. I wanted to do a science but knew it wasn't my strong point so I went to my teachers in turn to ask their advice. They each advised me not to take their subject......and this was a grammar school. looking back I think that says more about the teachers than it does me but hey that was then and this is now. So having said that I do sometimes wonder whether I was really that bad or more that I wasn't good enough. Either way it has left me with this feeling that I am no good at science. Having said that I think I have a good enough understanding of where things are in my body, and how the reproductive system works, and there are certain parts of our lectures I have found easier than others. Anyway to cut a long story short, I studied hard for my exam. Of all my assessments, exams are what I dread the most.

Other students have often asked how I revise and I can only tell you what I do and say that it works for me. During lectures I take extensive notes even if they tell me it's going to be put up on our portal system. Following the lectures, I head to the library and type up my notes (not always immediately before anyone thinks I am a complete geek, I actually tend to do big chunks at a time) and when I reach a part that I've written that I don't understand I can reach for a book and read up some more so that I do understand it. I may include flow charts so that I can see that x leads to y and so on and so forth. I won't say it leads to me remembering it all but it does help and it does mean I understand it better.

Drugs Calculation Test
We had two weeks in which we had to log in and answer 20 drugs calculation questions. We were allowed to use a calculator and perform the test wherever we liked, although they did request that we did it on our own. In the two weeks preceding we could access practice tests so that we could get used to the format and the kinds of questions we'd be asked. We did have to get 100% to pass but in all honesty, would you want me to be correct with drugs calculations anything less than 100%? I wasn't nervous about the test; I hadn't had any problems with the practice questions after all. I guess the only thing I was worried about was making a silly mistake or misreading the question. It would be too difficult to misread mg as mcg or similar. Thankfully I passed first time but I was surprised by how nervous I was when I was doing it.

So what's left for this year? My next task is my Psycho-Social assignment, then my Values assignment and then my PAD for my second placement this year. Oh and I almost forgot, we have a poster presentation as part of our Psycho-Social this Friday; although it's not graded.

My advice to current students and future students is plan early! For us, we were given all our assignment details early, so I started to think about them early. I have had to plan my study time around my children and family commitments. When we had only one lecture in a day, I didn't go home, I went to the library. This gave me time to rewrite parts I wasn't happy with. It also gave me time to look through the assessment criteria and see if I had covered all I needed to. With my revision notes for the Biology exam, starting early meant I was re-covering things rather than learning things for the first time.

An unexpected pain

Anyone who has lost someone they love will know what I mean when I talk about the occasions where it hits you smack in the chest with a reminder of who you have lost, completely unexpectedly. There are of course the days that you know will be more difficult; the anniversaries, the birthdays, special occasions. You also know sometimes from the moment you wake up, that today is going to be a bad day, where the ache of missing them is as bad as the day you lost them. People tell you it gets better with time and that is both true and a lie. It's true that the fog lifts, and you are more able to function with every day that passes. However it's a lie that the pain lessens....at least that is the case for me.

I feel like I've started this post a little back to front as I am sure I have readers that don't know my history. My brother died in May 2006. He had a brain tumour that he just couldn't beat, despite his very best efforts. In spite of the fact that he'd been ill for some time, and we'd been told there was no more they could do, it still hit like a sledge hammer when he died. His wife had given birth to their son just two days previously, whom he sadly never met and it felt incredibly unfair. At the time, my eldest daughter was just 10 weeks old, and my sister's youngest son was just 8 months old so I don't know whether or not that made it feel worse to us, that he never got to meet his son. I have a very treasured photo of my brother holding my daughter but at the same time I almost feel guilty about having it at all. I could talk on and on about my brother - about his qualities and his faults but suffice to say I miss him just as much today as I did on the day he died.

Today at Uni I had one of those sledgehammer moments where the pain hit me hard in the chest completely unexpectedly. We were sat in our Ethics seminar talking about ethical decisions and one of the topics under debate was the case of Diane Blood who went to court to fight for the right to use her deceased husband's frozen sperm in order to conceive. The issue of consent was discussed and the fact that her late husband had not given consent for his sperm to be used if he should die but he also hasn't specified that he wouldn't want it to be used. When my brother was first diagnosed with a brain tumour and he and his wife knew that he was going to have chemotherapy, they made the decision to freeze some of his sperm knowing that they were planning to have a family. It is now an automatic part of the "service" to ask whether or not consent is given for the sperm to be used in the event that they pass away. My brother has given permission for it to be used so my sister-in-law will never have to fight for her rights there. However there are still a number of issues surrounding her actually using it so I know that it will never be an easy nor straightforward decision for her.

Anyway sitting in class today and listening to these debates going on around me on this topic; the rights of the deceased husband's parents, the rights of the children, the rights of Diane Blood. It hit me bang in the chest, that it could easily have been a conversation about my brother and his wife. Due to the fact that I didn't know my fellow students before beginning the course, they of course had no idea about my brother. Actually come to think of it, I don't think many people know about his frozen sperm....and why would they? Is it anything to do with anyone else?

It's made me think about my brother obviously but it's also made me think about the fact that we all bring our own histories and it isn't always obvious what someone has experienced. I believe that no-one should be taken at face value and that our experiences shape us and our opinions on things. Sometimes it is good to challenge yourself and think about why you think what you do? Where has it come from? If you explore it more deeply, is it what you truly think? Just to put this into perspective; I grew up believing that all terminations were wrong. I had never really thought about why I felt like this - was it my upbringing, my religion, how I really felt? Ultimately of course, I can only make a decision about what is right for me, and as a midwife, I need to be able to support women in their decisions without judgement. Therefore how I feel is somewhat irrelevant, providing it doesn't affect the care that I give. And that goes for anything not just terminations.

I feel a little like I have rambled my way through this post but I would like to share this very precious photo of my brother David, holding my daughter.

Towards the end of placement now

I shall soon be going back into Uni, sitting my first exam, submitting my first assignment and doing a drugs calculation test. It already feels like I've come a long way since May and whilst I still have a long way to go, I am pleased with what I have already learnt. I've really enjoyed being able to apply some of the things we learnt in University to placement and I can definitely say some things were a lot easier to understand when we applied them to real women.

So what have I learnt so far? I've learnt about the importance of using the correct professional terminology in the notes....apparently writing "sore boobs" is not professional and yes I did do that. When pointed out to me, I was actually quite embarrassed but hey I'm here to learn after all. The other errors I made were a lot less embarrassing - thrombocytopaenia instead of low platelets is not obvious after all.

I have learnt that feeling for the top of the uterus is harder than it seems and that muscle can confuse me. Also it's important not to assume that just because the measurement doesn't appear to fit with gestation length, doesn't mean I have measured wrong. You can also move the uterus to fit what you want it to and it's obviously important not to do this. Holding the measuring tape quite tight can also affect the measurement and it seemed that I did that frequently. Women's pubic bones are at different heights and it's important to make sure you do measure from it and some women's are harder to feel than others. It's also quite surprising how many women go commando.

I feel I have also learnt how to manage my time better when talking to women. My first booking appointments I'd  let women and their partners talk away but my more recent booking appointments I have been more confident to take control and move the appointment along when needed. It's important to recognised when women need to talk but it's also important to recognise when it's not necessary so to speak. Goodness knows I have the gift of the gab and can talk all day long....just ask anyone who knows me; but a community midwife has to manage her time effectively in order to fit all the appointments in.

That some days I feel quite confident and that I know what I am doing and other days I feel like my brain fell out overnight and I haven't got a clue. So on the Thursday, I "ran" the clinic. I was confidently palpating, writing notes, checking urine and blood pressures and then on Monday at clinic, I felt like I fumbled my way through, guessing rather than knowing and being very grateful that my mentor was there to confirm or correct my findings. I was assured it is quite normal to have days like this though.

I have found that many women are interested in me as a student and are very happy to be a part of their care. Before I started I wondered whether I would have anyone who would object to me being there but so far that hasn't been the case. The feedback I have been given from women and their partners has been very positive and  I have been wished luck for my future from many of them. As part of my Placement Assessment Document I have to get feedback from two women and I found it quite hard to ask but both were really happy to do it for me, and gave me lovely feedback.

I have learnt the value of continuity and how much of a difference it can make to my learning and my confidence. I always knew that I'd work with a lot people when I came out on placement, I planned to make myself as useful and as amenable as possible but I completely underestimated how much it would affect me. I never thought I would get upset so early on in my training. In some ways, I think it's been an important learning curve for me and I hope that with my future placements I will know how to manage whilst working with a variety of mentors. On the other hand, I do believe that it's a common issue for student midwives and can make it harder to learn how to do things. It's certainly feedback I will take back to university but I am sure it's something they have heard time and time before.

I have also learnt how much pressure I put on myself and that my own high standards can serve to upset me if I don't reach them. When I think how embarrassed I was about writing "sore boobs" instead of breast tenderness, I also need to remember how much I have learnt. After all if my mentor is happy to come and go from the room whilst I do bookings, then she must be happy with how I am doing and confident in my abilities and therefore I shouldn't beat myself  up quite so much when I make a mistake. Certainly none of the mistakes I've made have been life threatening after all.

And alongside all of this I have improved upon my clinical skills. I am now confident at taking women's blood pressures. I am no longer at a complete loss when I palpate a woman and am currently working out the baby's position correctly. I have even begun to feel for level of engagement and starting to feel that I can tell the difference. I am able to read the urine dipsticks confidently now, whereas initially I was sometimes unsure whether there was a green tinge on some of the squares or not. I am much more confident on how to locate the heartbeat and tell the difference to maternal heartbeat, and whether or not it is through the cord I can hear it.

So I have just one more week in placement and as I will be working with a different community midwife this week, my mentor completed my summative assessments and as a result gave me my final grade for the placement. I am thrilled to have passed my first placement and to now be able to enjoy my final week, seeing how another midwife works, without the pressure of getting my book signed.

Running the clinic

On Thursday of last week we had a bit of time before the clinic began so my mentor and I sat and went through my book that I have to get signed off during my time on placement. We sat and talked about what we'd already covered and what I already knew and looked at what I didn't know. It really made me think about what we do and why and made me feel good about the things I had learnt along the way.

So my mentor then told me she was going to let me "run" the clinic. Of course she wasn't going anywhere but whereas previously she'd do the writing and most of the talking, whilst I did the urinalysis, blood pressure and we both did the palpation, this time I was going to do the lot and she'd check my palpations intermittently...particularly those that were worried about the size of their baby or had babies in awkward positions previously.

We saw around 20 women and had barely a break in between. I find I work better when it is like this - it seems to solidify my learning so much more. I think I got almost every palpation correct and I felt like I was getting to grips with measuring the height of the bump too. It really made a difference as to how I came across to the women as well I think as I am sure they can pick up when I am more uncertain about things.
For more information about what happens at antenatal clinic, you might find it useful to look at my previous post Antenatal Clinic.

Another part of being a Community Midwife is the postnatal visits to new Mums in their homes. There are three guaranteed visits that all women get. The first visit is the day after the woman and baby get home from the hospital. Around day five we visit to perform the heel prick test on the newborn and if the baby is breastfed we also weigh the baby. The final visit is usually on day ten where we discharge the woman to the Health Visitors care. Women are covered by maternity care until day twenty eight but most women won't require this. It may also be that women get more than the three visits during those first ten days but it does depend on what their needs are. For example, a lady who has just had a third baby and is comfortable with all she is doing, recovering well may well not need anymore visits. Whereas a first time Mum who is getting to grips with breastfeeding and recovering from a section would benefit from more visits. And it's not as simple as saying well she's a third time Mum she won't need us, because she might, so it's looked at from an individual basis.

We ask the woman about her bleeding and how she is feeling in general. The reason for this is because sometimes after giving birth there can be retained products - parts of placenta or membranes. The uterus may expel them naturally but the last thing we want is for the woman to get an infection. If the Mum has increased bleeding combined with a temperature then we'd be palpating the uterus to check it's contracting down as expected. If the uterus is "spongy" then it's an indication that something could be going on and we'd send the Mum and baby back into the hospital to be checked over. Sometimes women have heavier bleeding if they've been more active, or just after they have been breastfeeding or also when she gets up after a long period of lying still so heavier bleeding on it's own is not an indication of anything to worry about. Similarly it's quite normal to have a temperature when the milk comes in so it's vital to look at the whole picture.

We also ask the women about their toilet habits....yes Midwives are obsessed with wee and poo! The reason for asking is quite simple. The bladder, uterus and bowel are all very close together and the bladder can be damaged and lead to urine retention. It is common for many women not to have a bowel movement until day 4 or 5 but we ask about it because women can be very nervous about it, particularly if they have stitches. So it provides the opportunity to reassure them. Also we want to avoid women becoming constipated and so we can talk about ways to avoid this.

We also ask whether or not their breasts are comfortable whether or not they are breastfeeding. This is because almost every woman will have milk come in regardless of whether they choose to breastfeed or not. This gives breastfeeding mothers to talk about any concerns they may have about position and latch, frequency of feeding and so on. We can also talk to bottle feeding mothers about how to cope with the pain and the engorgement as quickly as possible. We also like to ensure that women are eating, drinking and sleeping  - well sleeping as well as they can considering they have a newborn. The body needs food, water and rest in order to produce milk but also the women need the opportunity to recover from the birth.

We ask about how the women are feeling emotionally. We can reassure women that it's normal for emotions to be all over the place after giving birth but we also want to be aware of any women who might be at risk of postnatal depression. Postnatal women are at risk of deep vein thrombosis so we ask if they have any pains in their legs and this is particularly important with women who have had a Cesarean section. We also make sure that women are aware of their postnatal exercises.

Of course we also check the baby over. We look at their temperature, frequency of feeding, whether or not the cord has come off yet, how their nappies are and how frequently they are needing changing, and we also look at their skin. Newborn babies often have very dry skin which is normal but we can advise women on what to do to prevent it becoming sore, cracked and potentially infected. We recommend olive oil as it's a natural substance and won't harm a baby's delicate skin. The other thing we have to look out for is any bruising or fingertip marks. I am thankful that this is not something I have seen.

So what does it all mean?

You get back from your appointment and glance through your notes and there are all these abbreviations that you have no idea what they mean. I'm going to now do my best to explain some of the most commonly used abbreviations or terms but if there is one that you've had that you want to know..just leave me a message and I'll do my best!

 
ANC - antenatal clinic - may be used to let you know where you next appointment is.
ARM - artificial rupture of membranes which is when they break your waters for you. Generally done to encourage/speed along progress in labour.
BBA - born before arrival. Those babies that don't want to wait for the midwife to arrive or the labour takes Mum completely off guard and end up being born in a car park (mentioning no names here). Anyway it means that no midwife was in attendance for the birth.
BMI - body mass index. Something that most of us don't like but it is your weight in kgs divided by height in metres squared. A healthy BMI is 20-25.
BP - blood pressure. We all know it's recorded but do you know what it actually tells us? The top figure, the larger number is the systolic measurement. This tells us the maximum amount of pressure during contraction of the ventricles. The lower figure is the diastolic measurement and this tells us the pressure in the ventricle at rest.
BPD - seen this on your scan reports? This is the biparietal diameter which is essentially a measurement of your baby's head. The parietal eminences are the two "points" (it may help to feel your own skull lol)  on the top of your head - one on the left and one on the right. The sonographer can use this measurement to estimate within about a week, the gestational age of the baby.
CRL - again seen on scan reports. This is the crown rump length....exactly as it sounds it is the measurement of the baby from the top of the baby's skull down to the bottom of the spine. Also used to asses the gestational age of the baby.
CTG - cardiotocograph. The machine that is used to monitor your baby. Either in the fetal assessment unit or during labour.
ECV - external cephalic version. This is the manoeuvre they use to try and turn a breech or transverse baby into the head down position.
Engagement - this can be very confusing as it depends on the midwife writing it as to which way they mean. Some will write 2/5ths and this will mean that they can feel 2/5ths of the baby's head, meaning the baby is 3/5ths engaged. Others will mean that they can feel 3/5ths and so is 2/5ths engaged. One thing I would say is, 2/5ths or 3/5ths it doesn't really matter. What matters is there is a degree of engagement. The baby's head may well not engage any further anyway if there is some of the waters in front of their head, blocking them from dropping further into the pelvis. 
FHHR - I am sure most of you have worked out that this means the baby's heart has been heard but can you work out exactly what it stands for? It means fetal heart (heard and regular).
FMF - fetal movements felt.
Gravida - either a primigravida or a multigravida. A primigravida is a woman who is pregnant for the first time and a multigravida is a woman who is pregnant for the second or more time.
GBS - group B streptococcus. This is a bacteria found in either the rectum or the vagina of approximately a quarter of all pregnant women. It can cause an infection in the baby, and in rare cases death of a baby so it is commonly treated with antibiotics during labour to reduce those risks.
GTT - glucose tolerance test. The test that checks for gestational diabetes. It is more commonly found in women who have a high BMI and/or a family history of diabetes.
IOL - induction of labour. 
IUGR - intrauterine growth restriction. This basically means that the baby is anticipated to be a small baby...where perhaps the baby has stopped growing, or is growing more slowly which can indicate that the placenta isn't working as well as it should be.
LMA (RMA) - left (right) mentoanterior . This would be in reference to the position your baby is in. So the mento refers to the baby's chin; so in this case the chin is to the left of the pelvis and facing towards the front of the woman's pelvis and the baby is going to be born face first. This would only be detected by a vaginal examination, as externally you cannot feel which position the baby's head is in.
LMP (RMP) - left (right) mentoposterior. As above but the chin is facing to the back of the woman's pelvis. Again would still be a case of the baby being born face first.
LOA (ROA) - left (right) occipitoanterior. This, whether left or right, is the more ideal position for the baby to be in. It means that the occiput, which is the bone on the very back of the baby's skull, is facing towards the front of the woman's pelvis. The baby has tucked it's head right down onto it's body and is therefore presenting the smallest diameter to be born. (Imagine you are putting on a jumper with a tight neck, you wouldn't try and push your face through, you tuck your head down onto your chest)
LOP (ROP)- left (right) occipitoposterior. As above but the baby's occiput
LSP (RSP)- left (right) sacroposterior. This means that the baby is in a breech position and facing to the back of the woman.
MSU - midstream specimen of urine
NAD - nothing abnormal detected....always good to see
NT - nuchal translucency. This is the part of the scan when they are screening for Downs Syndrome and other disorders. They measure the skin at the fold at the back of the neck. This is most commonly used alongside a blood test to give a more accurate risk factor.
PG - prostaglandin. The hormone that is used in induction of labour.
PPH - postpartum haemorrhage. Bleeding to excess following the delivery of the baby.
SFD - small for dates.
SOB - shortness of breath.
SPD - symphisis pubis diastasis.Causes moderate to severe pelvic pain during pregnancy due to the relaxin hormone.
SRM - spontaneous rupture of membranes.
SVD - spontaneous vaginal delivery.
Transverse - the baby instead of being head down or even breech, is instead lying across the abdomen. This can result in a more unusual shaped bump. Fairly obviously if the baby is in this position at term, and any attempts to turn the baby have failed, this would mean a Cesarean section as the baby simply won't fit into the pelvis. This can often happen in women who have an unusual shape to their uterus e.g some women have a heart shaped uterus.
UTI - urinary tract infection.

I have no doubt missed plenty out but please do shout and I will try and clear them up for you!

Antenatal Clinic

Every week the midwife I am working with runs an antenatal clinic. This is not a drop in clinic like you have with the Health Visitors but appointments made in advance. At the booking appointment, it is decided whether or not the woman will have consultant led care or midwife led care. It may well be that she only actually sees the consultant once during her pregnancy but the next appointment after the booking appointment is at the hospital so that she can see a consultant as well; this appointment is at approximately 16 weeks of pregnancy. If the woman is under midwife led care then the next appointment will be at the antenatal clinic run by the midwife at the children's centre.

So what is it that happens at these appointments and why? Well in part it's an opportunity for the woman to ask any questions she has - whether they are about labour, or something she has been experiencing in pregnancy. It's also a vital appointment for the midwife to make some important checks. So at each appointment the woman's urine is tested for glucose and protein; and depending on the dipsticks being used it may also be tested for leukocytes, blood and ketones. Glucose may show up in the urine if the woman has eaten a lot of sugar prior to providing the specimen but it can also be an indicator for gestational diabetes. Protein can be a side effect of discharge but can also be an early indication of pre-eclampsia. Leukocytes and blood can indicate a urine infection. Ketones in your urine indicate that you are burning fat which could just mean you're hungry and need to eat something; they are often present in women who are suffering from morning sickness or hyperemesis. The main thing to be careful of is dehydration in this case. However if the woman is diabetic then the presence of Ketones is an indication that glucose levels are too high and there is not enough insulin.

Blood pressure is also monitored - it is taken at the booking appointment and at every appointment thereafter. High blood pressure can be an indication of pre-eclampsia but it can also be a side effect of hot weather. In the 2nd trimester it is quite common for blood pressure to drop and for women to suffer low blood pressure. It's always important not to just look at blood pressure results on their own but to look at the whole picture - one high result with no other symptoms is not necessarily a concern. Whereas a result that may be within normal guidelines but is high for that woman who is also showing protein in her urine is a concern. In this
circumstance, the woman would be sent to the hospital for monitoring or a blood test or both.

The other part of the antenatal appointment is measuring the woman's bump, checking the baby's position and listening in to the heartbeat. The bump is measured after 16 weeks of pregnancy to ensure that the baby is growing and that the baby is, to the best you can tell, growing accordingly to gestation. The position can generally be ascertained from around 28 weeks. This can sometimes provide an answer for women experiencing a lot of back pain and confirm whether they can feel feet or a bottom. At around 34 weeks it is hoped that the baby will be in the ideal position for birth but prior to that the baby can be in any position it likes. Identifying the position of the baby also helps to find the best place to find the heartbeat. Hearing the heartbeat gives reassurance to the mother but also provides the midwife with an indication of how the baby is doing.

So this gives you just a glimpse into what may seem so routine but is actually so very important. For most pregnant women, all the checks are normal and are reassurance but a midwife is there for them too as well as those for whom it is most definitely not routine. Something that women often find after their appointment is that when they read through their notes they don't always understand what has been written so next time I'll cover those abbreviations and what they really mean.

The first meeting with a midwife

I think most people have an idea of what a midwife is but how many understand what a midwife actually does?

As I am working so closely with a community midwife at the moment, I thought it would be interesting to give you a glimpse of what they actually do day to day and why. I was going to show you a typical weeks work but felt that certain parts needed more description and therefore understanding, so I am going to start with the booking appointment for now.

Booking Appointments: This is the first time the midwife meets with the pregnant woman, usually when she is 8-10 weeks pregnant although there are still a number of women who book later in their pregnancy. But what exactly does a booking appointment involve? Most women are excited about going to their first midwife appointment but don't really know what it entails. Well essentially it's form filling...fun eh! There is a lot of information to gather - contact details, next of kin, medical history, family conditions that could be hereditary, details of any previous pregnancies which includes terminations and miscarriages, information about previous labours and births, information about any children they currently have, allergies, any social concerns, any previous serious accidents, any operations, nationality of both the woman and the baby's father, date of their last period, whether they usually have regular periods and how long they normally last, whether they were using any contraception or if it was planned, have they taken any medication, have they taken folic acid, how tall are they, what they currently weigh, what shoe size they are, and what ailments they've suffered in this pregnancy. Some questions give way to other questions whereas some the answer is one word and we can move on. From this long list I am sure you can begin to understand why the booking appointment needs to be a long one - it generally takes 30-45minutes.

But the important question is this - why do we need all this information? Some of it is obvious - we need to identify risk factors that could impact on the pregnancy. For example, if the woman had a serious car accident in the past and had to have surgery on her pelvis, we need to know about it, as it could be a factor in her ability to birth vaginally - of course it may not affect her at all. Or if there is a family history of high blood pressure during pregnancy then it's something we would be watching for as it often does run in the family. Something may not seem very important but it can have a huge impact on the care required. Something that might seem unimportant is asking whether or not they are rubella immune or if they have ever had chicken pox. Chicken pox can be quite dangerous in early pregnancy or in the last weeks of pregnancy but if you have had it as a child then your immunity will protect the baby unless you are one of those rare people who didn't maintain immunity. Rubella or German Measles is also very dangerous in pregnancy and this is why all teenage girls are offered the innoculation in school. It is advised that before anyone starts trying for a baby, they make sure that they are rubella immune.

History about previous pregnancies and labours is very significant. If a woman has come to us on her second pregnancy and had a previous Cesarean section then we need to know why that happened. It is not true that because she has had one c-section that she would automatically need or want another one. However in some circumstances it would be the recommendation as the safest way to have the baby. You can also get some information about pain relief used and what worked for them and from this you might get an idea as to the kind of labour they hope for this time. We also need to know whether they had any problems recovering from the birth - did they have a post-partum haemmorhage? If the answer to that is yes, then it impacts on the type of birth we'd recommend to them; a home birth would not be the safest option.

Just asking who the next of kin is, can open the door to details about the father of the baby and whether or not he is in contact or if they are still together. It also offers the opportunity to ask about racial background and nationality. In some cases this has an impact on risk factors - for example Sickle Cell Disease is generally only found in people of sub-Saharan African descent. It can also raise any social issues - are there any other children? Do they live with them or are they refused access to them? I am sure it is obvious why we need to know these things.

Knowing the date of their last period obviously helps us to work out the estimated due date of the baby but also information about the usual length of cycle can help too. It also is essential for working out what scans are needed and when as for things like the nuchal scan, there is a window of opportunity for the most accurate results.

Probably the thing that is asked that is less clear as to why we ask it is shoe size and height. Why on earth do we need to know them? Well give me your best suggestions and I'll tell you if you are right lol

If I have raised something and not fully answered why we ask it then please do ask and I will do my very best to answer you!