That Was The Week That Was: Some Thoughts of Mine…

The 11th of August was a day to remember if you work in maternity services. The news story of the day was about how the RCM had “dropped their normal birth campaign” and almost immediately a storm erupted on social media.

The context behind the story was, in essence, that a change in language was required as the word “normal” could impose feelings of failure in women who required intervention during their labour and could imply that midwives are only interested in supporting women who have a vaginal birth with no intervention.

As midwives we of course know nothing could be further from the truth but, personally speaking as someone who has an interest in parent-infant mental health, I welcomed the change in language as “normal” has never been a word I am particularly fond of simply because one persons definition of normal will vary hugely from another and feelings of failure and inadequacy often feature heavily in women with post natal depression. That said, the role of the midwife is, and always has been to be an expert in “normal” childbirth. Now the term has been replaced with the word “physiological” I do not see the role of the midwife changing with the introduction of this new terminology and nor should it.

The debate on social media, in particular on Twitter, became increasingly heated as various interested parties expressed their views and was both interesting and difficult to observe because, aside from the inevitable sensationalistic input from some journalists and other elements not necessarily with insight into maternity services in the U.K., those entering the debate although polar opposites in their position on the surface of things, actually all demonstrated such passion and commitment to safe maternity services and ensuring women are supported and cared for throughout pregnancy and birth I felt strangely reassured that whilst these fantastic people continued to hold each other to account for their views, maternity services will always feature highly on the health agenda. This can only ever be seen as a positive.

My only concern throughout the debate was over the link made between the normal birth campaign and the findings of the Kirkup Report on the enquiry into the deaths of 16 babies and 3 mothers at Furness General Hospital between 2004 and 2013. Undoubtedly a toxic culture had evolved where relationships between midwives and doctors were described as “dysfunctional” and where midwives had failed to escalate concerns about complications with devastating consequences however as a practising midwife myself I find it hard to link these behaviours to our role as the expert in “physiological” birth when the NMC code is explicit in ensuring we remain within our scope of practice and escalate when necessary.

These behaviours are endemic in a culture where good relationships between the multi-disciplinary team are not nurtured and mutual respect is not fostered. I have been very fortunate in the fact that every maternity unit I have worked in has a culture where the MDT has a shared priority of communication, respect and working in partnership to ensure the families we are caring for have the best possible outcome and experience, I feel this is the case in most units across the UK.

Training together as a multi-disciplinary team, for example PROMPT training, affords staff the opportunity to drill themselves in emergency scenarios to gain a mutual understanding of the importance of each other’s roles in managing complications and most importantly empowers staff to escalate when situations deviate from the straightforward. It enables the multi-disciplinary team to come together in a safe, non-threatening space and for me, epitomises everything the word team encompasses.

I personally feel that merely changing a word will have no impact on outcomes because I do not feel it is the word “normal” that is the problem.

Breaking down the barriers which exist within some units and changing cultures to ensure that the multi-disciplinary team is indeed a team is the answer and the way forward in ensuring families get the care and support they need during pregnancy and birth and that staff are equally supported in delivering high quality care.

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Why compassionate care should begin with each other.

I haven’t posted in a while. Work and home life have been equally demanding and I think it’s good for us to take a step back every now and then and gather ourselves. 

Over the past few weeks I’ve been questioning why as midwives we are able to demonstrate such kindness and compassion to the families we work with yet when it comes to our colleagues we don’t always find it so easy.

I think we can all be guilty of focussing on our own clinical areas with the belief that we have the greatest challenges within a unit but in truth that is rarely the case. Every area has its pressures, some just manifest in different ways but it is all relative and a lack of understanding of a persons role should not lead to an assumption that they are somehow less important or hard working than you. 

It can be difficult,  on the days when the workload is intense, to remain civil to the person who has just asked you to accept another admission into the ward, or the agency who have just contacted you for information at the very moment you have logged out of the system you need to access, but try we must because who knows what sort of a day that person too is having?

Throwaway comments, especially when overheard, can be incredibly wounding and leave the person on the recieving end feeling sad, disheartened and distrustful of the perpetrator. What is said cannot be unsaid, even in the heat of the moment.

My grandma always used to say to me “taste your words before you spit them out”, in other words think before you speak. I can’t say I have always practiced this and there have been times when I have been just as surprised as everyone else by what has come out of my mouth! As I have got older though I have gradually learned to just pause before responding to something I may find as unreasonable. 

The other premise my grandma used was to ask 3 questions before responding.

1) is it true?

2) is it necessary?

3) is it kind?

If the answer to any of those questions is “no” it is best left unsaid.

The NHS I work in now has changed so much since I started back in 1991 as a student nurse at The Royal Free. More is being asked with less resources and fewer staff which is why now, more than ever, we need to take the time to care for each other. Kindness goes a long way, as does respect and courtesy, and that shouldn’t be dependant on banding or any other hierarchical notions. 

The ward housekeeper is every bit as important as the chief executive of the hospital. Without either the organisation would grind to a halt and I wholeheartedly agree with Sir Richard Branson when he says that if you take care of your employees they will take care of your clients. 

Nurturing a culture of kindness has to be a priority in today’s NHS and can have a huge impact on the lives of those around us. Our days are happier when we give people a bit of our heart rather than a piece of our mind. 

MAMA: No Alcohol = No Risk 

  

It’s been 18 months of hard work and back to the drawing board moments but this week, in collaboration with the Hospital Alcohol Liaison Service, and Public Health we are proud to be launching our MAMA (Maternal Alcohol Management Algorithm) Pathway in our maternity unit.

Women have been receiving mixed messages from various sources regarding alcohol consumption in pregnancy and gaining a true reflection of drinking habits has historically been a challenge as women risk being judged for being honest or indeed are unable to give a true account in view of a lack of awareness into what even constitutes a unit of alcohol.

When devising the pathway we knew we had to change our approach. Asking how many units women were drinking prior to and during pregnancy did not give a true insight into their habits and potential risks and women who had reported to ‘binge drinking’ prior to pregnancy were not offered any support or signposting into services for the duration of their pregnancy and beyond. 

TWEAK is a 5 item scale for harmful drinking in pregnancy and is an acronym for the questions below:

  • Tolerance – How many drinks does it take to make you feel high?
  • Worry        – Have close friends or relatives complained about your           drinking in the past year? 
  • Eye Opener – Do you sometimes take a drink in the morning when you wake up?
  • Amnesia      – Has a friend or family member ever told you about things you said or did whilst drinking that you could not remember?
  • Kut Down    – Do you sometimes feel the need to cut down on your drinking?

All women are now screened at their first appointment with the midwife using this tool. The screening is then repeated in the 16th week of pregnancy. Screening for harmful drinking will potentially improve pregnancy outcomes by targeting women for interventions to help reduce their alcohol intake during pregnancy. Postnatal follow up will help prevent women resuming harmful habits, enhancing their ability to care for their newborn and prevent future alcohol related damage to the unborn baby in subsequent pregnancies. 

Women attending their appointment with the midwife will be given information around the potential risks of alcohol consumption during pregnancy as a standard. This on its own can motivate women to change their habits as an awareness is raised of the potential long term effects of alcohol in pregnancy. Those identified as being at higher risk will, with consent, be referred to the Enhanced Midwifery Service for more specialist support during pregnancy and onward referral into specialist alcohol services for support and treatment as appropriate.

One of the further benefits of the MAMA pathway is that for the first time the results of maternal alcohol screening in pregnancy will be recorded in neonatal notes to enable any potential long-term impact of maternal alcohol consumption during pregnancy to be tracked and considered when seeking diagnosis of FASD in the child in the future. The information will also be shared with the Health Visitor to ensure ongoing support once the woman is discharged from maternity services.

We feel this is groundbreaking work and has the potential to reduce the incidence of FASD in an area of the country which already has a higher than average incidence of hospital admission through alcohol harm. In the run up to the launch of this pathway there have also been 200 members of staff trained in the recognition and management of patients at risk of harmful drinking. 

If women are given a clear, consistent message about the risks of alcohol during pregnancy we enable them to make an informed decision about their own health and that of their unborn baby. In view of a lack of evidence around what actually IS a safe amount of alcohol to drink whilst pregnant that message must be No Alcohol = No Risk. 

Tackling a Four Letter Word

  

I’ve been reading a lot of interesting posts on Twitter lately discussing a four letter word which is rapidly becoming the elephant in the room as far as providing maternity care goes so I thought I would have a go at trying to give my perspective via a forum which isn’t limiting me to 140 characters.

The concept of RISK is emotive. Being ‘risk averse’ seems to be something which is considered negative, a form of defensive practice and, from some of the posts I’ve been reading, not something that midwives should be supportive of if we want to be considered truly supportive of the birth process. However, The Cambridge English Dictionary defines the term as being ‘”unwilling to take ​risks or ​wanting to ​avoid ​risks as much as ​possible” which I have to admit I feel comfortable with and, should anyone wish to evaluate my practice, would be happy with that description.

Alongside the subject of risk is the statement I see repeated with almost the same frequency that ‘a healthy baby isn’t all that matters’. To contextualise, the point being made is that outcomes should also be measured by the mothers experience of birth and not the condition of baby alone but there is the risk that this could read, to some, that the experience is more important than the outcome and that is wrong.

Being risk averse does not mean the primary focus is on the baby, there are many variables involved in a good outcome. A healthy baby does not mean that the mothers wishes have been ignored, to suggest that the two are mutually exclusive is irresponsible and does nothing to promote trust and respect between families and professionals.

I liken the concept of risk management in pregnancy and birth to crossing the road. In both scenarios there is an identified risk: that statistically despite this being an everyday process, there will be occasions where there will be an adverse outcome. That is a fact, not a scaremongering tactic, and we do women, their partners and their babies a great dis-service if we choose not to acknowledge this in case it prejudices the decision making process.

To minimise the chance of an adverse outcome when we cross the road we would need to identify potential hazards, for example the obstruction to the drivers vision which may prevent him from seeing us cross, or the 60mph speed limit which gives us less time to cross, and look for a solution which enables us to still cross the road, but in a safer place where the desired outcome of reaching the other side of the road in one piece has a greater chance of being achieved. The same can be said when discussing and planning maternity care, and in particular, place of birth.

Some women live on that quiet country lane which is quiet, calm and traffic is infrequent. She will have had a healthy, uneventful pregnancy and, after discussing the options of where to cross the road (or give birth) will have many options open to her where the outcome will still be the same, however she must still be aware of the fact that she cannot predict the rogue driver who may decide to make an appearance at the time she chooses to cross. Caution should still be applied, even on an empty road.

For the woman who lives near the motorway (or has a slightly more complicated pregnancy) the traffic may not be so calm, but she still wants to cross the road safely. The potential hazards need to be identified so that she can decide where to cross and it may be that the traffic is so heavy she may need to seek an alternative way of getting to the other side, however, there will be times when the traffic slows and even stops so that, if she is ready, she can make her way safely across without the help that is available.

To manage risk it has to be identified. Acknowledging it exists and looking at how to minimise it is good practice. Risk taking rarely saves lives except in disaster movies and patient safety should not be considered as the antithesis to patient choice. Good communication skills, knowledge sharing and respect all contribute to ensuring the two can work together in providing a positive and safe outcome for all. 

Good enough IS good enough.

  
I read a post this morning from a friend who was feeling guilty because she lost patience with her toddler and wondering how to manage her frustrations. Following this I have just returned from what can only be described as the shopping trip from hell with three children who managed to fight and complain their way around the entire store. Loudly. 

It got me thinking on how, as mothers, we see the fact that we have become annoyed or frustrated as a ‘parenting fail’ which only serves to increase our feelings of guilt, and how in doing so we are probably doing our children a great dis-service.

I have to confess, I don’t feel I’m any different to any of my friends if the conversations we have about our children are anything to go by, but there must be some out there who manage to remain emotionless upon discovering their entire Clarins skin care collection has been emptied down the toilet, or their beloved progeny has taken a marker pen to their newly decorated bedroom otherwise we surely wouldn’t compare ourselves unfavourably against them. 

Surely if we suppress our own emotions in front of our children we are encouraging them to suppress their own which is not helpful when trying to teach them how to process their own thoughts and feelings and deal with them effectively.

There is a line of course, witnessing aggressive and intimidating behaviour is incredibly damaging for a child emotionally, but for a child to see that mummy is feeling angry at the moment so is taking some time out to calm down teaches them that a) anger is an emotion everyone experiences and b) there is a non-destructive way to deal with it. 

Sensible parents don’t expect perfection from their child but by expecting perfection from themselves they are enforcing an ideology that just ‘trying your best’ simply isn’t enough.

It’s perfectly OK for mummy and daddy to have a disagreement in front of the children. You are teaching them that people may experience conflict but there will be a way to resolve a situation through talking and listening. You are also teaching a very valuable lesson in how it is important to hold on to your own thoughts and opinions and that everyone has a right to be heard.

I see parenting as a huge privilege and acknowledge that there are many people who are unable to embark on this journey for many reasons but I don’t think this should in any way detract from the fact that it is incredibly hard work.

We are helping new humans join this society and we should try to be as open as possibly in encouraging them to embrace their humanity in all its glory. In other words it’s ok to tell your child when their behaviour is having an impact on you. Good or bad! 

I don’t want to be perfect. I have no desire for my sons or daughter to grow up thinking that a good mother resembles a Stepford wife with low expectations and infinite tolerance to intolerable behaviour because I know that they deserve better in their future lives and I don’t want them to spend their their lives feeling let down when they discover that perfect doesn’t exist.

Humans are, by definition, flawed. We get emotional because we are emotional beings, not robots. Seeing emotions used in context will teach our children far more than suppressing them until they jump out shouting ‘SURPRISE!!’ at the onset of puberty.

Perfection is one heck of a target to set. I prefer ‘good enough’ because you know what? It really is. 

Baby Whisperers Please Pipe Down

  
People who know me well know my feelings on so-called ‘parenting experts’. I have been known to ‘relocate’ a certain publication which we midwives know and loathe to the ‘Facism and Nazism’ section in Waterstones (other book retailers are available) and would actively encourage any of you reading this to do the same. 

It’s not that I have an issue with people offering advice, it’s a fact of life, especially when you are a new parent, and some of it you might even take! The issue I have is people who prey on the fears and insecurities of these new parents by offering them a solution to their perceived lack of knowledge, or a becon of light to guide them through the fumbling darkness in the form of….a book!

The idea of these books/baby bibles or whatever you wish to call them is that they tell you exactly what you should do, at what time and for how long etc and eventually you will end up with what television presenter Eamonn Holmes and his partner Ruth Langford described, after following a particular regime, as a ‘clockwork baby’ (which was, to them, a good thing).

Gina Ford published a strict regime in her “Contented Little Baby Book” encouraging parents to break their day down into five minute slots in order to get the newborn baby into a routine as soon as possible. Of course once you have actually had a baby you realise pretty quickly that achieving anything in five minutes is nigh on impossible (unless it’s a shower!). 

The baby should be woken and fed at 7am, parents fed by 8am then the baby fed (in the nursery!) every 4 hours until the last feed at 6:15 whereby parents must not, under any circumstances, make eye contact with their child in case it gets excited! Seriously?

We, as a family when our first born child made his entrance into the world, failed miserably at the first hurdle. Rather inconveniently our son was not born with the ability to read so had absolutely no idea what he was supposed to be doing in regard to this regime. What he did seem to know, rather instinctively, was that he needed to feed more frequently than 4 hourly and certainly had no intention of fasting after 6:15 no matter what Gina Ford said! 

Eye contact was unavoidable. Gazing into his eyes became a favourite pastime in our household and it soon became apparent that he was in charge and we, as his parents, were simply put on this earth to to cater to his every whim. Resistance was futile. Once we accepted and embraced that everything fell into place.

Babies are not born with the ability to manipulate. They only know what they need and when they need it. They are actually very accomplished communicators, you just need to tune in to what they are telling you and trust me, they have so much to say.

Watch your baby, talk to him and watch him mimic your facial expressions even from an early age. He is constantly learning from you and the early stimulation he receives from you will set the stage for how he learns and interacts with others in later life. Loving interactions with caring adults strongly stimulate the brain causing synapses to grow and existing connections to get stronger. Connections that are used become permanent, those which are not used ‘die’ and are irreplaceable. 

Gina Ford also advises parents to leave their child to cry for up to an hour so it will learn not to always expect to be picked up.  Why would we want our child to not expect to be comforted if he is upset or needing reassurance? The child that is left to cry doesn’t stop because he has suddenly acknowledged the error of his ways. He has stopped because he has become exhausted and realised that crying is futile because nobody will come anyway. 

Parenting is one of the hardest ventures any of us will ever embark on. The pressure to be perfect is immense, after all if we get this wrong we risk our child’s future happiness/life chances/mental health…etc but do we need perfection and if so, who gets to decide what perfect actually is?

I have encountered so many parents who have been reduced to tears and left with huge feelings of inadequacy because they have been unable to get their two week old infant into a routine which includes sleeping through the night, and are having nightmares about their child becoming a future delinquent because they ‘overslept’ and gave the 7am feed at 7:30. 

Enough! 

Parenting means to prioritise your baby’s needs above your own. It’s tiring and demanding but nobody said this parenting malarkey was easy. Feed your baby when he is hungry, cuddle him close, sing and talk to him and enjoy these interactions. These days pass so quickly and you will never get them back. Trust your instincts, and his. You know what you need and so does he. You know your baby better than anyone else and YOU are the expert on your child. Babies do not need routines, they need loving, responsive parents who nurture confidence in their child by providing the assurance that they are there to catch them when they fall. 

Baby Whisperers have too much to say and they need to pipe down. 

When The Facebook Motherhood Challenge Became The Friendship Challenge

  

I’m not a fan of Facebook crazes, but you can always rely on them to expose the kind of people you really should cross the street to avoid.

I remember the first time I called BS on it all and lost a couple of ‘friends’ for my trouble (I survived).

It was when the ‘No Make Up Selfie’ did the rounds. The idea being that women post selfies wearing no make up to raise awareness and to raise money by donating to cancer research. It started well, people were posting their selfie beside a screenshot of their donation with the number other people could text to do the same. Only by the time it got to my timeline nobody seemed to be posting the number to donate, or the screenshot of their donation. Instead my timeline was taken over by selfies of people who I hadn’t ever met who seemed to be under the impression that a photo of them with no mascara on would somehow make the world aware of this awful disease that they obviously had never heard of previously whilst people I did know told them how gorgeous they looked.

What had no doubt started as a genuine attempt to raise awareness and some much needed funds had turned into a narcissistic exercise in posting a pic where the obligatory ‘I look terrible/awful/OMG’ type comment was made before sittingback and waiting for the ‘you look amazing hun’ comments to roll in. 

I questioned the relevance, a) because I really hate selfies, seriously I know what my friends look like and they are far prettier without the duck face pose and b) because I felt it was incredibly distasteful to hijack a genuine attempt at doing something good simply in order for people to have their ego stroked. Some took offence and unfriended me (I think, it took several months before I noticed they’d actually gone!) but most agreed or didn’t say anything at all, which brings me to the latest fad. The Facebook Motherhood Challenge.

I have no strong feelings either way about this one. I love seeing pics of my friends and their lovely children (that is the point of Facebook for me) but I’m acutely aware that several of my friends have experienced loss either through miscarriage or stillbirth or are experiencing infertility and were finding these unsolicited posts difficult to deal with although they would never have approached any of the mums who were posting the pics with those thoughts. 

In the spirit of solidarity with them, when I was tagged I posted a link to SANDS instead and soon I noticed that a couple of friends of mine had blogged about how The Facebook Motherhood Challenge had made them feel. Never in a million years would I have expected them to receive a backlash for it but I’d clearly forgotten about how the internet can be a haven for people who have a desire to lash out at complete strangers who have the audacity to be capable of independent thought.

I read the blogs and thought they were reasoned, sensitive and non-confrontational accounts of the feelings they are entitled to have and to express. They didn’t criticise or belittle the mums who had chosen to post their selfies with their children, more that they invited people to consider the people on their timelines, their actual friends, who may be finding things equally as difficult. The responses truly shocked me, and I’m not easy to shock.

I saw people actually laughing at the thought of someone finding the constant stream of motherhood challenge selfies upsetting. I saw them calling them horrible, unkind names and even posting links to a satirical story referencing ‘childless infertile women who should be banished to live with wolves’. It should be noted that these were professional women who I had once respected. It stunned me to think that we could live in a society where people could actually demonstrate such a lack of compassion or empathy, or sisterhood simply because the view these brave women had shared by baring their souls had made other women feel uncomfortable. 

What have we become? 

Voltaire had it right by saying ‘I may not agree with what you have to say, but I’ll defend to the death your right to say it’. But then again they didn’t have Facebook in those days.