Category Archives: Perinatal Mental Health

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. 

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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. 

Sleep Deprivation: Why the postnatal period should not be an endurance test. 

  

I was involved in a discussion on Twitter the other day, reminiscing about the old days when babies were taken into the nursery at night and cared for by the staff on the maternity unit whilst mum was able to take advantage of the opportunity to catch up on some much needed sleep. Within seconds I was questioned (rather accusingly) as to whether I supported the concept of ‘separating mums and babies’! 

Actually nothing could be further from the truth. I think the mother-baby dyad should be supported and nurtured whenever possible when that is what the mother wants but establishing a secure attachment goes much deeper than just rooming in and promoting skin to skin.

Sleep deprivation is known to exacerbate mental health issues, occasionally with very severe consequences. Fit, healthy males have been known to suffer from hallucinations whilst undertaking the Royal Marine Commando Course whilst undergoing enforced periods of sleep deprivation to test endurance, and many fail. The very fact that we would treat something which is just generally expected of new mothers as an endurance test should speak volumes yet this is rarely acknowledged by health care professionals.

The subject of sleep needs to be discussed with women antenatally, especially those who may have pre-existing mental health conditions or identified as being at high risk of developing PND. Sleep is not a dirty word. It is a fundamental human need and is essential to promote mental well being.

Dads or birth partners should be a welcome addition to the postnatal ward. There is no golden rule that states all parenting duties should fall to the mother. Allowing partners to remain on the postnatal ward overnight ensures a mother is able to rest properly whilst her baby is cared for in the same environment, dads can enjoy skin to skin too!

Women should be encouraged to think about how they will protect their sleep, especially during the early days when establishing breast feeding (or not) or simply adjusting to new motherhood. It would be incredibly unrealistic to expect to be able to sleep through the night, but a plan to enable the new mother to have a few hours uninterrupted sleep during a 24 hour period can literally be a life saver. Friends and/or relatives can be instrumental in achieving this.

Midwives and health visitors are notoriously good at knocking on the door to perform a postnatal visit just after a mother has finally fallen asleep after a wakeful night then reminding her to ‘sleep whilst the baby sleeps’ as we leave. Co-ordinating these visits with a mother and her support network can ensure that precious ‘sleep time’ can be protected and she is able to sleep whilst friends or family take over with baby for a few hours.

24 hours of sleep deprivation can lead to symptoms of psychosis in healthy adults, similar to those observed in schizophrenia. Sleep deprivation also triggers a key biomarker in psychosis important in the research of anti-psychotic drugs and has been proven to lead to a re-wiring of the brains emotional circuitry. Is it any wonder women can begin to experience a significant deterioration in their mental well being when this goes on for much lengthier periods of time?

As health care professionals we must not be afraid to address the fact that, for some women, sleep must be prioritised. We are not interfering in the parent-infant bond by suggesting a woman think about a sleep plan in the same way we would encourage her to make a birth plan. Psychiatric disorders are a leading cause of maternal death according to the most recent MBRRACE-UK report (2014) and sleep deprivation has been identified as a contributory factor in many of these cases. Sleep should be considered equally as important as any other intervention necessary to maintain good physical or emotional health. If we want to be truly baby friendly we need to first achieve ‘mum friendly’.

Why I stay in the job I love…

I read an article recently, actually I’ve seen it several times, popping up on my social media feed as friends and colleagues have shared it with their followers etc. 

The article is by a midwife with 8 years of experience who has been forced to resign because of what she feels is a culture of stress and bullying and has begun a new career in risk management. 

I wish her well but I’d like to share a few thoughts with you now, on why I choose to stay in this profession. 

I qualified in 2000 having been a haematology nurse before that. I hadn’t had children when I started my midwifery career, believe me becoming a mother changes your perspective on pregnancy, childbirth and (especially) breastfeeding. I felt so safe as a student midwife in Norwich. Part of a team, surrounded by wonderful midwives who’s practice I wanted to emulate and who really wanted to teach me how to become an expert in normal birth. I’ve stayed in touch with many of them over the years and hope they feel that I’ve lived up to their high standards and professionalism as well as compassion and caring. 

The role is not always easy, shifts can be horrendously busy, there are times when it seems like there will never be enough staff. It’s tiring, challenging, emotionally draining and very demanding but here’s the thing.

I work with an INCREDIBLE group of women. 

Wives, mothers, daughters, sisters, all here for a common goal. To support women, mostly strangers before they encounter them on this journey, as they embark on motherhood. 

They care, boy do they care. 

They want that woman to achieve the birth she hopes for, they will fight anyone who enters the room in order to protect the birth environment if they need to and they will watch over her whilst she drifts in and out of sleep in between contractions thinking of their own experiences of childbirth in the spirit of sisterhood.

These women supported me as I gave birth to my own three children, they watched me transition into motherhood in front of their eyes and I would still trust each and every one of them with my life and that of my children.  I love the fact that I have the pleasure of seeing the women who brought my children into the world every day and they see my children growing up. 

Don’t get me wrong, we’ve had some dreadful shifts. Times when all we want to do is just put our coats on and go home because our shift has ended and so what if it’s short staffed?? But we don’t, we stay and make sure everyone is safe because that’s what you do when you care. 

I’ve seen midwives break down and cry after delivering the “born asleep” baby of the woman who they stayed after their shift to care for because they’d made a connection. I can tell you that we still hold our breath, in the faint hope that there may be some mistake, that this beautiful, precious child will take a breath and cry at birth because if wishing could make it happen it surely would. 

I’ve watched the expressions on the faces of my colleagues as we’ve heard women in the second stage of labour, the sounds turning to that first cry of a newborn baby, smiling to themselves in secret relief that another baby has safely made their way into the world but always ready to rush to the side of the midwife who has requested help. Calmly co-ordinating themselves without the need for instruction to ensure everything and everyone that is needed is on hand. 

And the women, and partners, who I truly feel honoured to be able to support during the most life changing event they will ever encounter. The wonderful conversations we have during the course of our meeting. Some of the women I meet have overcome the most horrendous personal circumstances to get where they are, some have been gifted with the most amazing lives but each of them have a story and they fascinate me. There can surely be few people on earth who are lucky enough to witness a couple become a family in front of their eyes. That beautiful moment when a mother first sets eyes on the child that has emerged from her body and the look that is exchanged between her and her partner. Those who have seen it will know exactly what I mean. 

I’m not trying to paint the picture that everything is perfect. There are many reasons why midwives are leaving the profession in droves, but, for me, there are many more reasons to stay. 

A Time To Act

This is my first blog.

I’ve been toying with the idea for some time but life (and work) seems to get in the way, however today is different, today I woke up to the news that I imagine has affected all of you reading this in the same way. The news that yet another new mum, instead of starting out her journey into motherhood with the same apprehension, excitement and hope that we remember all too vividly, has seemingly ended her life in a tragic and senseless manner. At the time of writing this we have no news of baby, this in itself leaves me feeling so desperately sad yet still there remains a tiny glimmer of hope.

It seems Charlotte Bevan had struggled with mental health issues for some time, as yet we do not know what, if any, help and support was open to her. What we do know is that mental health on the whole seems to be an issue so far removed from any public agenda that today, in the light of such a tragic story, SKY news itself has chosen to debate whether or not “James Bond Has Had its Day” rather than tackle this taboo.

Is it really still, in 2014, such a stigma to be afflicted by mental health issues? We live in an age where information is freely available, we are taught at school from an early age how to access it, yet still so many people suffer in silence, feeling they are alone and isolated. We know that isolation only serves to exacerbate mental illness yet still we chose to ignore it, judge people and assume the worst. Its small wonder people chose not to access care, fearing prejudice and the impact admitting having a mental health issue may have on their lives.

People will be quick to point the finger. I have already heard today “how could she walk through a hospital with a baby in her arms unchallenged?”.

Those of you reading this who work in hospitals will know how it is not unusual to see patients walking through a hospital in clothing unsuitable for outside. People are generally free to mobilise around the site as an in patient and it is not unusual to see parents carrying their children to and from out-patients appointments. Hospitals are not prisons.

I question the security of a ward where exit is granted merely through pressing a door release button but that is not the fault of the staff, who are no doubt devastated. I send my thoughts and prayers to them today, this is not something they could have prevented or predicted whilst caring for women and babies on a busy postnatal ward.

I question a government who chose to consistently cut funding to mental health services, who refuse to prioritise mental health equally with physical health and who choose to continue to put women and babies at risk by not investing in maternity services.

Its not expensive or difficult to invest in perinatal mental health.

The unit I work in identified a gap in service provision for women with mental health issues requiring support in pregnancy and the postnatal period two years ago and we are fortunate that external agencies got on board to create a multi-agency pathway to help the women and professionals co-ordinate care.

Mental illness is not a stigma and people should not die simply through lack of care.

Over to you Mr Cameron…