Wednesday, October 29, 2008

Cyber Talk and Midwives

Tonight I presented a lecture about Cyber talk: The presentation was a brief introduction to the Internet, focusing mainly on blogging. The aim of the presentation was to raise the awareness of midwives about the internet, who blogs and why, also to highlight the legal and professional responsibility of cyber mediums such as Facebook, MySpace, Skype, YouTube, Twitter and blogging. Currently there are approximately 22million blogs online. Blogs are becoming one of the fastest growing mediums for discussions relating to marketing, legal issues, health, political activism and social change.1

So, what is a blog? It’s a journal, reflection, diary, newsreel or a newsletter. However you describe it, it is something you write that is personal and informal for the world to read. Blogs are designed for the public forum – they can be updated daily, weekly, monthly or whenever the writer chooses. Blogs are very easy to set up – any of the major search engines will direct you to a site of your choice and you simply follow the instructions. 2

Major legal issues surrounding publishing on the Internet relate to: defamation, copyright, trademarks, moral rights and confidentiality. I am sure there are more but for now I will concentrate on these relating to midwifery.

All Midwives be they; community, independant, hospital based are bound by legislation such as the Nurses and Midwives Act. Within this framework we are regulated by the ANMC Code of Conduct (2008),
Code of Ethics(2008) &
The Competency Standards for the Registered Midwife (2006). If midwives fail to meet the required standards of these Codes, then they can face disciplinary action as stated within the legislation. Therefore midwives need to know and understand what the Codes mean and how they work. It is important to remember when you are blogging to be professional at all times, being mindful not to bring our profession into disrepute. Once something is published on the web it is very hard to delete, it is passed around the cyber world like lightening creating lots of threads and being saved in different places.

There are many health professionals blogging, sharing stories, practices, education and reflecting care given. This increases the risk of breaking patient/client confidentiality due to the blogger or authors sharing too much information, such as subspecialties, names, places and content.

The Journal of General Internal Medicine published an article titled “STUDY HIGHLIGHTS RISK OF BREAKING CONFIDENTIALITY IN BLOGS” this was a study that examined 271 medical blogs and found that 56% of the blogs contained enough information to reveal the author’s identity. 3 The study found that blogging was a great way to reach both patients and health professionals so long as people were responsible about it. However “blogging does pose serious concerns about confidentiality and bringing the profession into disrepute. 3”

Defamation occurs when one person communicates material that damages the reputation of another. This can be verbal, written or pictures and the publication must reach someone else other than the person being defamed. However there are several defences to defamation such as: is it a ‘fair comment’ on a matter of public interest or was it simply an opinion, was it an honest opinion of the author 3.

ANMC Professional conduct refers to the manner in which a person behaves while acting in a professional capacity. It is generally accepted that when performing their duties and conducting their affairs professionals will uphold exemplary standards of conduct, commonly taken to mean standards not generally expected of lay people or the ‘ordinary person in the street’.

The moral from this evening's presentation is to know your ANMC Codes inside out, they provide you with a tremendous framework. As for my presentation, I must remember to have my cheat sheet with me, because once I start talking lots of new ideas come through and I forget the ones I was going to focus on. This is such a massive topic that I really just tipped the iceberg.

Happy Blogging - 'have blog will travel'

1. Sylvia Mercado-Kierkegaard, Blogs, lies and the doocing: The next hotbed of litigation? Science Direct.
3. BMJ 2008;337:a1043; Study highlights risk of breaking patient confidentiality in blogs.

Monday, October 27, 2008

A vaginal Birth with an epidural. It is all about informed choice!

Birth of Logan Mark

This birth story has been written with the permission of Nikki & Scott. Thank you.

Firstly I will congratulate my son Scott and his fiancĂ© Nikki on the birth of their son on the 19th October at 0115, weighing in at 3420gm. Nikki has always wanted an epidural, with the birth of Jessica (8hr labour) their first child, she also had an epidural which was not very effective and Nikki ended up with an episiotomy and Neville Barnes forceps – not very nice. Why do some women want an epidural? – Well that is simple, as Nikki would say “I don’t do pain” and “I am the biggest sook”. Now I don’t agree with Nikki’s choice of terminology, because pain is whatever the woman/client says it is and epidurals have a place in childbirth, because it is all about informed choice. The aim is to achieve a safe spontaneous vaginal delivery (SVD) or birth. As midwives our role is to inform women of their options and assist them to achieve the birth they choose. Nikki wanted a normal birth without an episiotomy and that was pain free. The only way to have a pain free birth is by having an epidural, all other forms of pain relief do not take the pain away completely they just knock the top off the mountain. In saying all this, epidurals are not completely foolproof; sometimes they do not work or only partially work as Nikki found out. Full credit to the excellent midwife who was looking after Nikki, who did everything possible to make sure that Nikki’s epidural was working effectively, finally after all possible top-ups etc Nikki was comfortable, now we could concentrate on getting more effective contractions.

Nikki called me at about 3pm not sure if her waters had broken, I was on my way to see my friend and decided to call in a see how Nikki was going – sure enough there was a wet patch on the bed, and most women hate the thought that they may have wet the bed, heaven knows why, you have a baby constantly pushing on your bladder, it would not be surprising at 38+5 days. Anyway after resting on the bed with a pad on for 20 minutes the pad was wet, had a sweet odour and was clear. The baby was moving nicely, the head was engaged, and there was a good fetal heart. There were no apparent contractions and Nikki described having a cramping feeling, so we decided to keep her walking around the house. I decided to go home, which is only 10 minutes away, and finish cooking my dinner and we would share it. Scott’s sister Faye and Brendon & their children would come over and we would pass some time – Nikki reminded me that she still wanted an epidural and not to leave it too late, I also said to Nikki that it would be beneficial if she was in established labour before she had the epidural to ensure an vaginal birth and she was agreeable.

About 6:30 Nikki’s pad changed colour, it was meconium stained (the baby has done a poo in-utero), lightly stained meconium. Nikki was still not contracting regularly or strongly, we rang the hospital, and were advised to make our way in. There was mild disappointment in the air, meconium stained liquor, and this changes things now.

We arrived at the Labour and Birth suite at about 1945hrs – Scott was dropping off Jess and would meet us there shortly. Nikki was great, we had a good talk in the car about expectations, epidurals and how to push effectively when you have an epidural in place so as to avoid having an episiotomy. Nikki laughed at my analogy – as you can’t feel anything, close your eyes and imagine that you are totally constipated and you have to push the biggest shit out – that’s what you have to do.
No sooner were we there when Nikki was assessed, hooked up to the CTG, examined – it was good to see that she was 4cm dilated, however the head was -3. IV inserted and bloods taken. Nikki was happy to stand next to the bed whilst being monitored; it was now meconium 2, which meant continuous fetal monitoring. Her contractions were still not strong, getting more uncomfortable for Nikki, so the epidural was arranged. The CTG had good variability however a couple of late decelerations – the decision about using an oxytocics was made, to increase the strength and frequency of the contractions, due to the meconium and late decelerations. Nikki was happy to get things going, anything to make it work rather than having a caesarean section. Nikki was coping really well, now comfortable with her epidural almost working effectively – it was denser block on one side, her left leg was numb and difficult to move.

Scott was like a cat on a hot tin roof – he had his own expectations, and did not share them. He is 6’+ and seems like a gentle giant and he felt out of place in the delivery suite, although he very much wanted to be there. Like most men he was busy comparing the CTG machine to the equipment he used when working out in the bush with the geologist comparing it to the seismograph. This did make me smile; he was constantly eating, lollies, biscuits, fruit and pacing the floor.

The baby was difficult to monitor, and I really could not understand why, as Nikki is tall and fairly slim – certainly not obese – therefore theoretically should be easy to monitor, however the “little fella” was playing possum with us. The CTG baseline rate was about 145bpm, variability was good however we were getting complicated variable decelerations. The pressure was on; “I don’t want a caesarean section” was Nikki’s lament. It was time to reassess due to the complicated variables, at approximately 1130pm Nikki was still 4cm, head 2-, so the head had come down, it was really no surprise that the cervix was still 4cm as the contractions really were not yet effective or strong enough. The decision was made to continue and reassess in 30 minutes. We changed positions, left lateral, right lateral, then upright to try and improve the trace. Another top-up as well as self administered top-ups were given, Nikki still has an uneven block, however she was more comfortable now. The syntocinon was titrated upwards as per the protocol and Nikki’s contractions finally kicked in, 4:10 strongly, however with this came more complicated variable decelerations, the registrar decided to tickle the baby’s head, to ascertain if the baby’s heart rate would accelerate which would be equivalent to a 7.25 pH and therefore the baby is not hypoxic. Hooray! The little fella’s heart rate went up to 165bpm, which bought us some more time.

At 0100hrs the midwife decided to put a scalp electrode on the baby’s head, so it would be easier to monitor him – and to her/our surprise Nikki was fully dilated – fantastic – that is an efficient uterus - she did a test push, Nikki was fantastic, she visualised and pushed well. It was time to birth, Nikki, Scott and the midwife were happy for me to catch – as was discussed earlier.

It was a wonderful vaginal birth, intacted perineum – little Logan Mark was born at 0115hrs weighting 3420gms.

On reflection talking to Nikki and Scott a few days later – Nikki found the birth easier than Jessica’s birth and was grateful to have the midwife and myself present, “everything was easy, casual and relaxed – it was awesome!” Nikki said that she had back pain for at 5 days post the epidural.
Scott reflected that he thought that there would be more blood and gore! He cut the cord which gave him a sense of fatherhood. However, Scott did say that he felt superfluous through the whole process. I wonder when women have an epidural does it change the focus for men, as the level of support may change due to the level of pain being different. I did notice that both Nikki and Scott watched TV and debated which movies to watch.

As for me...............This was as always a memorable experience. It is a privilege to help birth your grandchildren, to support the women of your family and share your knowledge, expertise, love, warmth, caring, just being there. It is truly a magnificent moment – a true reminder of the miracle of birth and the power of a woman’s body, truly spectacular.

It’s all about what the woman wants!

Interesting comments by Louise Sliverton

I was browsing the net, as you do on a Sunday night after a very busy weekend (withdraws from the Internet) I came across this story from the 'Fear of pain' causes big rise in cesareans, written by Denise Cambell.
I thought what a "surprise" there's nothing new! the difference is that a Midwife has made the comments - and who is the midwife - Louise Silverton.

Now one of Britain's leading midwives has reignited the debate about cesareans. In an interview with The Observer, Louise Silverton, deputy general-secretary of the Royal College of Midwives, has controversially claimed that an increasing number of women under 40 are less prepared to undergo the physical trauma of childbirth than their predecessors, a trend that is pushing up the rate of surgical deliveries.

I have had the pleasure of meeting Louise on several occasions. It is always nice to meet the author of books you have read. I also think it is time that midwives became more vocal, it does raise our profile.
The article goes on to talk about current trends in the perception of pain in today's society, which is very interesting. I do tend to agree with Louise when she argues that people today do not want to deal with any sort of pain, the answer is take a pill, however I am not sure that is is contributing to the increase in the cesarean section rate. These comments have created debate from all angles, to the point of blaming the shortage of midwives to the raising cesarean rate. I also found it interesting that the cesarean section rate is lower in the UK than in WA which is currently at 30%. I think that people forget that a cesarean is major abdominal surgery, as it is never portrayed in this way.
'Currently, the Cesarean rate [in England] is 24.3 per cent. Therefore one has to question whether the women of this country are physiologically incapable of having normal births, and I don't think they are,' said Silverton, a midwife for 30 years. She wants Britain's rate brought closer to the 15 per cent recommended by the World Health Organisation and fears cesareans 'have been normalised in the minds not just of women but also midwives and obstetricians'.

If you have time click on the link and read the comments by women relating to their experiences of birth.

We all know that 'fear' plays a big part in the birth experience, so if you feel as if this is stopping you or you want to debrief seek some counselling, talk it through.
The best way to deal with 'fear' as Susan Jeffery's would say is "feel the fear and do it anyway"

Friday, October 17, 2008

Best poem nominated by United Nations in 2006

I have to share this poem that was passed to me at work today:

This poem was nominated by UN as the best poem of 2006, Written by an African.

The poem is called


When I born, I black
When I grow up, I black
When I go in Sun, I black
When I scared, I black
When I sick, I black
And when I die, I still black
And you white fellow
When you born, you pink
When you grow up, you white
When you go in sun, you red
When you cold, you blue
When you scared, you yellow
When you sick, you green
And when you die, you gray
And you calling me colored?

Sunday, October 12, 2008

Writing a joint article using the internet - Perth WA - Dunedin NZ

I have been wanting to publish an article about the growing trend and use of the Internet. It always astonishes me how much information is out there and how many women seek out this information or use the Internet to spread information about pregnancy, childbirth, freebirth, unattended birth, medicalised care, good & poor care received from midwives. I am also perplexed or surprised at how many midwives still do not utilise this resource or are afraid of it - 'the Internet' or cyber world as I like to call it.

It seemed a logical step to take when I asked Sarah Stewart to co-publish with me, Sarah has been a great support to me since I began blogging in January of 2008. Today I contacted Sarah via Skype to discuss the next step, which has been to create a document using google docs,(you do need to have a current google account) by which we can both write and edit our article, it is so great, I can't believe it is so easy, off course once you know how! It was so amazing to talk to Sarah after blogging for 10 months we have finally spoken. I find it unbelievable that technology takes us this far, here I am in Perth WA and Sarah is in Dunedin NZ, five hours of time between us and we spoke and saw each other as if we were face to face - it is really amazing.

My first task is to brainstorm all the things I'm interested in, as I have already mentioned some of them, Sarah did point out to me that we could write several papers and culling will be very important.
This is a familiar problem for me - too many ideas, that's where Sarah will keep me focused.

Watch this space to see how we go ..............

Joint Media Statement From NZCOM And RANZCOG

This is a Joint Media Statement from New Zealand College of Midwives and the Royal Australian New Zealand College of Obstetricians and Gynaecologists.

see full statement: Joint Media Statement From NZCOM And RANZOG

"The NZCOM and RANZCOG have recently signed a memorandum of understanding between their respective organisations and are already committed to enhancing the relationship between obstetricians and midwives so that our combined workforce provides a seamless and responsive maternity service," say Ian Page, spokesperson for RANZCOG, and Karen Guilliland, spokesperson for NZCOM

congratulations, we are watching you lead the way............

Prenatal Company: Midwife goes to top executives office for antenatal care

What a tremendous story this is, check it out in the Evening Standard
Midwives are providing highflying City women with pregnancy care at their desks, it was revealed today.

The 24-hour working culture means many female executives find it impossible to juggle hospital check-ups with meetings.

But a London midwife has now launched the first ante-natal service tailored for women who want to combine motherhood with a high-profile career.

Lexie Minter, 29, set up The Prenatal Company after identifying a gap in the market for a service for women in the workplace.

A typical consultation lasts from half an hour to an hour and is arranged to fit round the client's work schedule.

The cost of the service, which provides support throughout pregnancy, is £5,000.

This includes blood tests, work check-ups and advice on the best place to give birth and exercise tips during pregnancy.

What a fantastic idea, I can see how it would work in London, shame in Australia midwives do not have the same impact on care. I think this is two fold, one is, our health care system is funded differently for pregnancy and secondly, we have a higher uptake of private insurance, which means, more women opt for private health care (specialist obstetricians) thinking they are getting the best care, which is always not the case.

Very interesting!

Saturday, October 11, 2008

Midwives are shown to have best outcomes for women.

It is really great to see a positive story about midwives in the press: I came across this story in the Sydney morning Herald. It is nothing any midwife does not already know, but it is good to see in print and raises our profile.
The story talks about midwives being the best option in terms of midwifery led care for women during pregnancy.
Kate Benson writes
Women who are cared for by midwives rather than GPs or obstetricians are less likely to lose their babies within the first six months of their pregnancies, an international review of maternity services has found. Researchers gave no reasons for the shock finding, taken from an analysis of 11 trials involving more than 12,200 women in four countries, but a spokeswoman for the Australian College of Midwives, Hannah Dahlen, said women who were seen by the same midwife during pregnancy, labour and birth usually felt more supported and less anxious, leading to reduced risk of miscarriage.

What a surprise to see that the Australian and New Zealand College of Obstetricians and Gynaecologists, are not happy with these findings. It is a shame that collaboration is not the focus.
The analysis, which is the largest undertaken in the world, also found that women in midwife-led models of care were less likely to be admitted to hospital during pregnancy, have instrumental deliveries, episiotomies or require analgesia and were more likely to have spontaneous vaginal births, feel in control during labour and better able to initiate breastfeeding.

The Australian college of Midwives spokes person Dr Dahlen said
the analysis, published by the Cochrane collaboration, considered the gold standard of assessing medical evidence, proved that midwife-led models of care had no adverse outcomes and many benefits.
"If this was a tablet, it would be mandatory that all women have it, but instead we have to deal with all this shroud waving by obstetricians. Now we know the evidence for their claims just isn't there,"

What a good analogy from Hannah Dahlen. Off course this is nothing new for midwives, we have always argued that midwifery-led care offers more for women and would reduce the Cesarean rate which is currently at 31%.
Our government needs to work towards more midwifery-led models of care and obstetricians need to start collaborating with midwives rather than always opposing us, after all we all want the same thing, informed choice for women and safe birthing options.

We need to listen to what women want, and stop being paternalistic.

Reference: Sydney Herald:

Thursday, October 9, 2008

All Australian legislation makes reference to Indemnity Insurance for (independent) midwives:

South Australia currently has the Nurses and Midwives Bill 2008 going through parliament (As laid on the table and read a first time, 23 September 2008) – what is good about this legislation is that the definition of
midwifery means any treatment, care or advice provided by a person to — (a) a woman in relation to her pregnancy; woman or child in relation to the birth of the child, (whether such treatment, care or advice is provided)
‘midwifery’ ( is much more defined in the SA Bill than the Nurses & Midwives Act 2006 WA ('midwifery' means the practice of assisting a woman in childbirth) our definition of 'midwifery' is very broad– however definitions aside, both legislations puts restrictions on midwives when it comes to indemnity insurance.

This is the South Australia Nurses & Midwives Bill 2008 section 41 page 27 states:
“41—Services providers to be indemnified against loss
1) A services provider must not, unless exempted by the Board, provide nursing or midwifery care through the instrumentality of a nurse or midwife unless insured or
15 indemnified in a manner and to an extent approved by the Board against civil
liabilities that might be incurred by the nurse or midwife or services provider in
connection with the provision of such care.
Maximum penalty: $10 000.
(2) The Board may, subject to such conditions as it thinks fit, exempt a services provider,
20 or a class of services provider, from the requirements of this section and may, whenever it thinks fit, revoke an exemption or revoke or vary the conditions under which an exemption operates.”

(This is very similar to the West Australian Nurses & Midwives Act 2006: Section 32 Professional indemnity insurance page 24 states.....2 “(a) that – (i) the nurse or midwife must hold professional indemnity insurance: (ii) the professional care provided by the nurse or midwife must be covered by professional indemnity insurance. (iii) the nurse or midwife must be specified or referred to in professional indemnity insurance......(b) that the professional indemnity insurance must meet the minimum terms and conditions approved by the Board.” 4. The Board may, on its own motion or on the application of a person the subject of a condition imposed under this section, on reasonable grounds, revoke or vary the condition.”

What does this all mean: the bottom line is the word “MAY” it is very open and powerful. This is the word that is detrimental for independent midwives. It means that The Board can insist that before you can register as a midwife you have to have indemnity insurance.

I know the Australian College of Midwives is actively trying to find and insurer before National Registration comes in, we have to work together to resolve this issue. This is a worldwide problem, not just synonamous to Australia.


Tuesday, October 7, 2008

National Registration for Nurses and Midwives in Australia: - Have your say!

At the end of September I went to a meeting to discuss the National Registration and Accreditation Scheme, being proposed for Australia. I must say it is long overdue that we as health professionals should be able to work in any State or Territory in Australia without having to pay different fees and register in within each State or Territory we choose to work in. At some point of my career I have registered and worked within four of our States, it will be nice to know that by July 2010 I will be able to register nationally and be able to work anywhere in Australia, this seems to make more sense. Consequently this will change the way our current Nurses & Midwives Boards will be governed.

The council of Australian Governments (COAG) in March this year signed an agreement on the health workforce. This agreement was the first step in creating a single national registration and accreditation system for nine health professions: nurses & midwives, medical practitioners; pharmacists; physiotherapists; psychologists; osteopaths; chiropractors; optometrists and dentists. This means less red tape and a more flexible workforce, greater safe guards for the public and will stop banned practitioners from registering in another State.

However with such a system comes consultation and changes; so, what are the changes and how does it affect us as nurses and midwives: I suspect for nurses there will not be a great deal of change however for midwives it will mean that all independent midwives will need indemnity insurance to be able to register. This is a huge problem for us. I know that the Australian College of Midwives is working to secure indemnity insurance for our midwives; however this is proving to be a mammoth task. The other issue that will prove to be difficult will be the complaints and review process, there are current discussions happening to resolve some of these issues.

I urge all of you to read the consultation document as submissions close on the 29 October, so have your say.


Sunday, October 5, 2008

Stealing a long weekend away

We have been back from our overseas holiday just over 2 months and our feet have not touched the ground with work, family & new grandchildren. We are waiting for our latest grandchild to be born, due in about 3 weeks or so, that will be the last one for this year. Currently this little one is still breech, here’s hoping he will turn in the next few weeks. So Ian thought this would be an opportune time to steal a long weekend away, or so he thought. Ian did not count on me having approximately 50 analytical essays to finish marking, so he booked a romantic weekend away, also forgetting he was on call. Great stuff, typically male, don’t you just love them. I will say in his defence, I would always have a reason not to go away due to work commitments, he did well.

So away we go to Basildene Manor in Margaret River, a beautiful spot set in our wine making district, with my papers, laptop in toe and Ian with his mobile phone and his laptop. Wow I can see this is going to go well. I did not take much notice of the scenery on the way down to Margaret River; I took this time to continue marking papers. I get great satisfaction from marking a paper that has everything you anticipated it would have in it, one that follows the marking guide and the student endeavours to get it all right, and then I feel I got the message across. Conversely, it is the opposite when the student gets it all wrong, and then there is the student that is right on the line, 50%. I am not sure if that equally means I have not done my job well? I have yet to make a decision on this.

Margaret River is one of our favourite places and we try to stay somewhere different each time we come to this region, we also endeavour to try several different vineyards, of course. Basildene Manor is an old manor which was built around 1902 and owned by the Willmott family. This is a grand venue, set on 14 acres and has enchanting gardens, luxurious rooms, our room has a king size bed and a spar, sheer bliss for us, mixed with elegance and a taste of old world charm. Breakfast was set in the conservatory overlooking the 14 acres of enchanting gardens watching the exotic birds playing in the trees; it really was peaceful and relaxing. We would stroll around the grounds each morning enjoying the surroundings and thankful we live in such a beautiful country.

Cape Lavender holds a special place for us; we just adore the spot and love the wine, hence why we bought two cases– we indulged in afternoon tea – that is lavender tea, lavender scones & cream, sheer decadence and see it was tea we enjoyed, it goes to prove we do drink tea.

Dinner Saturday night was at Leeuwin Estate – what can I say except to say “exquisite” we went back the next day to see the grounds in the daytime to also enjoy the gardens. It is my aim to get to a Leeuwin concert...........

Redgate – wine tasting, you just have to try the white port it is very special, especially with lots of ice and a slice of lemon – it is to die for!

The Knights Inn –was one of the local pubs where we had dinner Sunday night – nothing beats a pub dinner watching the English football - Portsmouth vs Tottenham was playing so my hubby was in his element and I did not mind either, we had a table in front of the wood fire and the big screen what more could you ask for?
Only 20 papers left, the students are doing to badly, it does make a change to sit out in the gardens marking it gives you a different perspective.

Our last day – we visited the Voyager winery, this place has to be seen to be believed, it is just an unbelievable spot. We had lunch there and it was “outstanding”

Now it is time to go home, we feel refreshed the battery is recharged and ready to start again, until the next time, ciao from Margaret River.

Save Homebirth

Home Birth Australia