African women

Five shifts, five labouring black African women, five cesarean sections. I've taken to carrying a scalpel around with me in case I see a poor pregnant black woman - might as well whip it out of her asap.

The problem, of course, is that all our "research knowledge" about normal physiological labour has been done on white women. We don't understand the way women from other races labour, and why it differs (and it does differ sometimes, in some women). We often get told at Uni - "many black African women have pevises shaped like x, as opposed to many Caucasian women, who have pelvises shaped like y", yet get no indication as to what these differences may actually mean in practice.

And when we get a black woman in the room in labour, we insist on treating her "non progressing" labour as we would a white woman's. Then, when she gets a section for failure to progress, we talk about obstructed labour and how, if she were "at home", her and her baby would have died. And by home, they mean Senegal or Ethiopia. Is it wrong that I bite my tongue and don't say that she is at home? That she lives right here?

We're in a sticky mess. Basically, the NHS is at pains to treat everyone the same - which means treating everyone based on the progress guidelines developed after observing white women. That is not equality. We can respect that many black women will labour differently - that's not racism. What is racism is the insidious notion creeping through my consultant unit that black women can't birth their babies. The smirk in handover when we hear a surname we think is African - the pointed comment of "I'll ring theatre, tell them to get ready!" and the snigger.

We are supposed to individualise care. To greet a black woman walking on to the ward and assuming they will labour in a certain way becasue they are black is as useless as assuming anythig in obstetrics. But, knowing that black women often make slow progress at the beginning of their labours, can we not make allowances for that before deeming them obstructed? Could we not integrate this into an overall clinical picture with confidence?

In the next post, I'll outlione what happened to the five African women I looked after on my last week on delivery suite. You can decide whether these women got sectioned for failure to be patient or failure to progress.

Soldiering On

Well, I am blummin exhausted. Does anyone else get that thing where you are laying there idly thinking about something, and then you suddenly realise it's 4am and you've been lying awake thinking about said thing (which is usually something rubbish and nonsensical - this morning it was whether Tiffany lamps are good or crap) for hours? Well, I do. But then it makes me think - was I really lying there awake for two hours thinking about Tiffany lamps? Or was it only a few minutes and because I was half asleep and time does weird bendy things when you're asleep and I just think it was hours? How does one find out for sure?

Anywaaaaaaay, was lying there minding my own business thinking weird stuff when my alarm. Went. Off. What the fuck? It was dark. I was tired. I am a student - student's alarms do NOT go off at 5.45am, do they? I thought I read they'd amended the Human Rights Act to include this, or something.

So I struggled out of bed, fumbled around in the pitch black, knackered because I'd spent the night perusing Tiffany lamps that exist only in the mind, managed to get out of the house and arrived on Labour Ward.

Was assigned to a primip (first time Mum) contracting well, had had some pethidine a couple of hours before and had been found to be 3cm on VE (vaginal examination) four hours earlier. in the hospital it's "protocol" to VE every four hours to assess progress, and if the woman has not progressed at a rate of 1cm of cervical dilatation per hour, she has deviated from The Line (really, we draw a graph of dilatation and if she strays from the "ideal" line, we take action. What's that at the back? Women are individuals, you say? How can we expect every woman's cervix to do exactly the same thing in labour, you say? Shut up! Heresy! Take her to the stake, she must be a WITCH!!!!)

Ahem, sorry. So yes, if she deviates from the Line, action is taken. Action that involves painful and invasivie procedures, usually. So examination time is always a time when your stomach goes a bit lurchy and horrible, because if it's slow progress (whatever that is), what has been up to then a lovely empowering labour can degenerate preeeeeety quickly into something sucky. And this particular girl had been laying flat on her back for ages - not the best position to labour in, and certainly the one that's most likely to get you off The Line in terms of progress, but she just felt too woozy from the pethidine to do much else, despite my encouragement. Just before the examination she puked a lot, and had a little cry, so I thought the signs were good that she was progressing well (women often become sick and emotional during transition, a stage of labour that occurs when they are getting to full (10cm) dilatation).

Perfomed the VE, a "routine" procedure that can be extremely painful and degrading for the woman involved, but since when did that stop us? Found a tiny lip of cervix left at the front, and could clearly feel all the sutures and fontanelles (soft spots on the babes head) which let me know which way round the baby was facing. Discussed rupturing her membranes with her (again, a more or less routine intervention with no real proven benefit and lots of proven drawbacks), but she declined (may be something to do with the fact I talked up the drawbacks!). So she was basically almost completely dilated - hooray! She had progressed brilliantly despite not moving around at all.

About an hour later she started telling us she needed a poo, which basically means she can feel the head. A short while later she was having an uncontrollable urge to push. Had a little peek and voila! Her bag of membranes was just visible when I parted her labia. Told her to push as and when she felt like she wanted to and soon her bag of waters (which looks like a grey balloon) was completely bulging out of the vagina. Could see the baby's hair floating inside! Tried to break them with an amnihook (the usual tool for breaking waters) but the bloody membranes were made out of rubber! They were so tough! Explains why they didn't go on their own at the beginning of second stage. Eventually did it with a pair of artery forceps, and five minutes later a 7lb baby boy was born. It was weird acutally - his head came and then very quickly his arm, looked like he was clambering his way out of a hole - which I suppose he was. Reminded me of a soldier crawling through a combat zone on his belly.

A trainee paramedic was observing, and after the placenta was delivered I went to the sluice with him and went through the placenta (what it is, what we look for etc). The poor guy was as green as his uniform. HAAAAAA!

Lovely delivery, lovely shift - she needed some stitches but there you go. Now, Tiffany Lamps - vile or divine?

Home birth

I'm on community at the moment. Had a call from my mentor at 8am this morning - she was on call the night before and had just been called out to a homebirth. She had VEd and the woman, Sam (not real name) was 6cm dilated. Set off on my way.

Arrived about 100 years later having missed the turning and not realising I'd missed the turning until I hit the coast and having to turn back and wander about desperately trying to find this house! Got there at 10 and assumed as I was pulling in that I would have missed the birth, as I had assumed the woman was a multip (had already had a baby).

Arrived and could hear Sam as I was coming up the drive - definitely hadn't missed the birth! She actually turned out to be a primip and had only started having pains at 5am. She was working really hard with contractions which were coming every three minutes and lasting a good forty five seconds, puffing and panting her way through the and the way she was moving was amazing! It really was absolutely textbook stuff - she was on hands and knees rocking back and forth, standing up, kneeling on the bed hanging on to her very valiant mum, who was supporting her!

She was being supported by her mum and her auntie - her partner and brother were around but not in the room. Also there was the second midwife and her student, my lovely friend. So there were plenty of us in the teeny bedroom and the other student, second midwife and I were feeling a bit spectatory, as the only place for us all to stand was at the end of the bed in a line! So we trooped out and kind of spied on all the happenings from outside the door - had a great view but were not being intrusive.

Really I was completely superfluous as any kind of support, emotionally or otherwise for Sam and clinically wasn't allowed to do much, as my mentor had not had a birth for a while and wanted this one. No problem for me, as it meant I could completely immerse myself in watching and observing and just drinking the whole thing in without doing stuff. I LOVE doing stuff, but this was a good experience too. Watching her was just brilliant - I really saw and understood the term birth dance. She was moving so fluidly, off the bed, around the bed, hands and knees, standing, kneeling, rocking, keening and moaning. She was totally in her world but kept her hands tightly clasped with her mum the whole time. What struck me was the way she just did stuff - just got off the bed, just got on hands and knees, just grabbed a glass and drank some water- without asking permission for everything like they do in hospital. It was so wonderful!

About an hour after I got there things went a bit horrible for a while - my mentor decided to re-examine, even though it had only been 3 hours since last exam, because she wanted to know what was happening, and possibly break her waters. The door was shut and she was examined, and it sounded pretty traumatic for Sam, who was shouting "Get off! It hurts!" etc etc. SRMed on VE, waters clear. Cx 9cm dilated. But it seemed to change the atmosphere - Sam had lost control. She stopped moving (which she may have done anyway, I know) and just hung on to her Mum for dear life and screamed. And screamed. Then we got her back moving again, put her knickers back on (again, wouldn't happen in hospital), my mentor started giving her a massage and things chilled out again for a bit.

Then she said she needed to push. This happened a few contractions in a row, and then contractions stopped, textbook latent phase of second stage. About twenty mins later, she was sort of pushing and not pushing, on all fours. My mentor kept putting her fingers in and could feel babies head right there and then unfortunately the second midwife started coaching the pushing - "deep breath, chin on your chest" bollocks. Why? It's like it's ingrained. This went on for a bit and they got her on left lateral, then on her back doing classic Valsalva, then my mentor seemed to come to her senses and realise that this was denormalising things. "Right!" she said "get back on all fours". Sam did. She then out her fingers in and pulled down on perineum (! - she kept doing this!), focussed very squintily on the perineum and barked "Get me some jam!" I did and asked her "why are you going to put jam on her perineum?” Cue hilarious laughter and me realising I was a twat!! It was funny though. Sam had a few spoonfuls of jam and then my mentor said "right, let's walk" This was noon.

So we trailed around the (very small) house, from bedroom to living room and back, all of us in a line! Very silly. She kept sinking to her knees with contractions and then getting up and carrying on. Eventually she came to a rest in a supported kneel over the sofa, the other student and her mum supporting. I grabbed everything from the bedroom and bought it to where we were, then sat down on floor near business end. Everything felt very "female" - does that make sense? We were eight women, together in this - when she rocked, we did, when she held her breath, we did. We spontaneously formed a kind of circle with her labouring at the centre. It was pretty cool and powerful actually (if my mentor was reading this she would laugh at me! But it was!). Then, after an hour of saying she couldn't or wouldn't push this baby out, she looked up and said quietly, but so clearly "OK. I'm going to push him out now". That moment was electrifying - made the hair on my neck stand up. The air was filled with solidarity and anticipation but there was no stress or anxiety.

And she did. So so slowly the head crowned and looked at us. My mentor didn’t guard the perineum but did keep the head really well flexed. It extended across the perineum verrrrry slowly. Didn't really restitute. Shoulders slipped out and we had a screaming baby boy, over 7lb, at 13.00. Intact perineum. Placenta was a battledore insertion and there was a bloody great vessel in the membranes - good job she wasn't ARMed!

Babe was cleaned and wrapped and given to mum, mess cleared up (by me! i do have some uses). Left mum snuggled on sofa with tea and toast whilst grandmum bottlefed the baby. Brilliant experience.

Filosofofofy

Midwifery isn't what you think. It isn't shouting "PUSH!" at the top of your voice and watching with satisfaction as the woman turns purple. It's not wandering in, smiling in a vague yet caring way, catching a baby and wandering out again. It's more than this. Sometimes, it's less than this. But through the profession runs the philosophy of woman-centred care, and that informs and influences everything we do.

We advocate for her. The doctors banging on the door because labour has gone on too long and they want to get in with their forceps and drag the baby out? "NO!" we say, as long as mum and baby are doing fine. Drugs to augment her contractions being prescribed when what she really needs is a sandwich and a walk up and down the corridoors to get things going? "NO!", we say, and get her up and moving. We try to ensure that any intervention is justified and needed, not simply being done because that's what's always been done. We keep up to date on research so we can be ready to support the decisions our women make. We don't tell the woman what to do - we give her all the information she needs so she can CHOOSE what to do. We sit with her through labour, not doing much, but being vigilant for signs that things aren't OK. If we're good, we make her feel like she can do anything - if we're bad we can start off a cycle of resentment and fear that leads to a c-section, or postnatal depression, or simply the uncomfortable feeling of a job badly done. Midwife means "with woman" and that's what we should be, all the time.

Obviously, it doesn't always happen. Our efforts may be obstructed by "old-school" midwives, who still think of women as patients, who think of birth as dangerous, who think that they know best and that the womans own intimate knowledge of her body and her life mean nothing. We may be obstructed by doctors, who are only called to complicated births and so begin to think of birth as complicated. We may be obstructed by the fact we that we are short-staffed and overworked and we just don't have the time to spend with each woman, to encourage and coax them, to talk through their fears and their hopes and their choices. Sometimes it's easier just to strap them to a monitor and pop them on a bed.

A couple of weeks on labour ward have shown me how birthng can be. What a beautiful, transforming joy it is. But I've also seen how it shouldn't be - a textbook "cascade of intervention", where the midwife starts doing things and sends the woman irretrievably down a path of more and more interference with her labour. I've seen women pushing on all fours, and being made to lie down because it's what the midwives feel more comfortable with. I've seen an unnecessray section, I've seen a cheerful first time mum who wants to do everything naturally be gradually worn down by people who just want to get her off the labour ward conveyor belt. Next time, I'll tell you all about it. But right now, I need to think. I need to firm up my own philosdophy and my own convictions. I need to remind myself that one day, I'll be making the decisions.

I'll be with woman.

The worst blogger...

No, I didn't get sucked into that strangers vagina, in case you're wondering. I'm just rubbish. Begin stuff with the best of intentions, then wander off to catch the last ten minutes of Corrie and realise with a start I haven't moved for four hours, that's me. Only in the case of this blog, it was four months.

Whatevs, people. Bygones and all that. Let's start again. Give me another chance.

In Midwifettes little world, things weren't going brilliantly. I spent seven weeks all told on the community. Did I see a birth? No I did not. I almost did (the only births you'd get to see on community would be home births), but I only got there in time for the emergence of the placenta. The placenta looks an awful lot like a pigs liver that has come alive, mated with some cellophane and cauliflower, gone on a gap year round the world trip where it took too many drugs, decided to go sky diving and forgot to open its parachute. I mean, it's interesting and all, but it's not quite the joyful miracle of a babys birth.

So, I faffed around at Uni for a bit, learning and crap, and now I'm back on placement - on labour ward. If I can't see a birth on labour ward... well, you get the idea. I'll be wrathful. And when I'm wrathful I don't look completely unlike a placenta.

I'm looking forward to it in more ways that I can number. I've done six months theory, I've poked and prodded pregnant women until my hands felt sore, I've helped women breastfeed, I've helped them bottlefeed, I've examined their stitches, I've weighed their babies. I just haven't seen a bloody birth (and it will be bloody). I'm psyched, I'm ready... bring it on!!

Grey hessian, anyone?

Today was my first day shadowing my community midwife. She turned up, all mad hair and cackly laugh and immediately pretend-shrieked at a huge spot pretending to be My Third Eye, smack bang in the middle of my forehead. I fell for her immediately. We trundled off in her ancient Ford and started our rounds.

I should stop here and reveal a secret: I'm not mad keen on babies. That may sound like heresy of the most heinous and evil kind, but really, being a midwife is about supporting the mother and her family and helping them achieve the most positive birth experience possible. Babies are the equivalent of Sean Connery in Robin Hood here: a cameo role, right at the end, that makes the whole thing just that bit better (but without the take-me-now sexiness). I mean, I like babies - I'm just not obsessed with them. And boy, they fucking hate me. Kids love me, as I am more than prepared to get into a serious conversation about Batman or whether there are fish under the sofa (and I don't use a stupid high pitched voice when I talk to them). But babies - they scream as soon as I come within a five mile radius. If I attempt to touch them, they try to throw themselves off the changing mat. They skip ten years of development and spontaneously start dialling ChildLine if I do any stupid cooing thing.

Until today. I don't know what it is about that chafey ex-Siberian prison camp inmate grey hessian sack the bods at How-Can-We-Make-Our-Student-Midwives-Look-Their-Ugliest University decided we have to wear, but it worked wonders. I held babies. They didn't cry. They didn't screw their faces up into walnuts. Two went to sleep. One farted loud and long and then did a grin (a farty grin, not a real grin). It was great. I felt warm and funny and...shit!

I think I just started loving babies.




In other news: I saw a strangers vagina today. Just like mine. Not as odd a feeling as I expected.

Pop my cherry

I am a blog virgin.

Correction: I was a blog virgin. I've just set up a blog and written a description. I'm writing my first post. That's got to be the blogging equivalent of fellatio, surely? When I actually press post on this, I'm going to count myself a put-it-about blog ho. I hope it's good. Does the earth move?

Anyway, enough babbling. This blog is going to serve as my reflective diary whilst I'm training to be a midwife. What I do, how I do it, why I do it, what I should have done better, what went fantastically, and above all, how I feel about it all. They're big on feelings, my lecturers. It can get a little touchy-feely-vegan-hippy-commune-karma-yoghurt-weaving in my lectures occasionally. But anyway, we're supposed to keep a reflective diary as a learning tool. And today seems as good a day as any to start, as it was my first day in clinical practice placement. Mostly paperwork etc, but I have the blog ready to go when I actually do something. Hopefully that will be tomorrow.