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So my plans for tomorrow involve going through the evidence on epidurals and pain relief in labour and writing a decent piece on it.

That article in Evidence Based Midwifery, still doesn't exist. Only piece Walsh did in the latest volume (never mind issue) is a literature review which has nothing to do with what he's been quoted on. I'm also going to be hunting people for their sources on this one.

This has annoyed me. I am not letting go. And his sex still has nothing to do with it.

EDIT: Denis Walsh's paper has not yet been published in EBM. Ha! So anywhere claiming it was in a journal that was published recently (I'm looking at you, BBC, and you, Daily Mail) is fibbing! Linkie
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There seems to have been a bit of an uproar about Denis Walsh and lot of the anti-Walsh comments I've been hearing are because of his sex. Because he is, shockingly, a man. Even the BBC have called him a male midwife. Riiiight. So, let's start referring to female doctors again, shall we? Because obviously your sex is in any way relevant to how you perform professionally.

Denis Walsh is an amazing midwife, and his evidence based practise series of articles and entire oeuvre is pretty much required reading for us. With good reason. "Evidence based", two words that I'm a bit used to at this stage. Blindly accepting anything as gospel without evidence is what gets us into a situation where active management of labour is so bloody common! Gah, rant rant.

I am no less of a midwife because I haven't given birth. Denis Walsh is no less of a midwife because he hasn't, either. That's the thing about evidence based care, it's based on more than one set of information. There's a reason why midwifery degrees are 3 or 4 years long depending on where you train. The support I give to women in labour is no less because I've never given birth. Every labour is different, every woman is different, everyone's experiences of pain are different.

As regards what he has actually said on the matter of increased use of epidurals, well, one to one support in labour. Big fan of that. Big fan of choices and information. Especially, big fan of midwifery care. But that's a bit obvious.
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Grr. Started flicking through BJOG for fun after someone completely mis-referenced an article I was looking for for long essay and I got distracted. Pre-eclampsia, one of the risk factors is first pregnancy With A New Partner. Yet I'm seeing a ton of "research" about pre-eclampsia in subsequent pregnancies that neglects to mention if the partner was the same as in the first, be that a pregnancy carried to term or a miscarriage. Grr. Without that bloody vital bit of information these are useless to me.

Telling me that women who've had a miscarriage are more likely to have pre-eclampsia on subsequent pregnancies* is not all that much use if you don't tell me that the partner is the same. *sigh* A simple "same partner? y/n" question mentioned would have sorted that. Which is really, really annoying, because we still don't know what causes PET. I'm going with boy germs. Hell, it's as valid a conclusion as the ones I'm readin'.

Hey, I've missed the staying up all night reading journals Sarah. Got quite ranty a few times today as well. Summer's here! I'm baaaack! HA!

Edit: Innnnnteresting, about to do some reading about whether or not oral intake of semen reduces risk of pre-eclampsia. Heh. Seriously, I love my job :)

Further edit: Oh my.

(Why, yes, I have a personal interest in the matter, too.)
*Vol. 115 Iss. 13 p1623-1629.
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So, the Canadian Obs/Gynae society has started to think that, ya know, maybe breech babies don't have to all be planned c-sections. That maybe we could start building up skills of vaginal breech birth again. That the Term Breech Trial (that made me wince when I first read it last year) might not have been the most sound piece of research ever.

In the space of 18 years, section rates for breech babies has rocketed thanks in part to the TBT. Obstetricians have long lost the skills of vaginal breech birth, most are leaving their training never having seen one at all, same with midwives. I've never seen a breech birth that wasn't a section, have become far too used to hearing at report on postnatal "elective section for breech."

I've never been afraid of vaginal breech, but then I was one of those awkward ones, determined to cause as much hassle as possible by entering the world arse first. I've read enough descriptions of breech births (and know the mechanisms of labour enough) to know that it's gotta be dammed scary to see for the first time. But then, so was the first cephalic birth I saw!

Thinking is good, learning is good, not blindly accepting a single trial as gospel, now that's the sort of thinking we need to encourage. And this makes me very very happy indeed.
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Two things from yesterday's Irish Times:
Ireland to participate in CEMACH, woo! We've needed a CEMACH equivalent for donkey's, but being such a small country and with very low maternal mortality it's very difficult for it to stay confidential. There have been something like three maternal deaths in Ireland since I started my training, it's no secret who they were. This is certainly not me complaining about a low maternal mortality rate!

Drogheda midwife led unit passes the 1000 birth mark! More woo! This, this is why I do what I do. And an awful lot of my continued passion for what I do is down to Cecily Begley and her organisational skills. Thanks to her, my course exists in the form is does and I have a lot of contact with a wonderful kooky sociology lecturer who keeps us passionate about protecting the normality of pregnancy. Because it is a normal physiological event.

I love my job.
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Well, I didn't make it to the march thanks to a slightly dicky tummy. But I reckon at 70-100,000 one of me wouldn't have made a huge difference. I'm just going to have to exclude all the possible triggers and then slowly re-introduce them one by one to see what happens. How terribly methodical. Tummy, not union related.

Got a bottle of tasty enough merlot from someone for looking after her kid for a while. I do like barter, always did prefer it for this sort of thing. Babysitting is far more fun when there's a tasty carrot at the end. Now I know where I've been hiding my sharkey lever corkscrew, life is even better. (In my toiletries basket, for some reason.)

Contemplating some summer stuff, not so much where to go as what to do. Care assistant work is nice and lucrative and hasn't been hit too badly with cutbacks so far. Also need to focus on actual school work, that dissertation isn't going anywhere, even if the length is decreasing with every draft of the guidelines. Currently down to 8,000 words. That's going to be a challenge to keep to. I know who I want as my supervisor, but will be finding out in the next couple of weeks who it actually is. I hope I made it obvious enough from my submission who it should be. All my talk of woman-midwife relationship is very in keeping with a certain sociologist's interest.

Late shift Monday, finishing 8-9ish, then back on to earlies for the rest of the week. Just about starting to know my way round the department and while there are many things I want to change about it they're the sort of things that can't be changed without significant expense. (Staffing levels, buildings...)

Oooh, I did my first booking history by myself, on my own, alone on Weds! Hope I didn't flamingo it up, but once I'd convinced the incredibly slow 'puter to co-operate (the lag is atrocious) it went well. There was quite a lot of "are you alright in there, you're taking a long time" because I took more than 10 minutes in total with her. Sod it, supernumerary, I'm going to enjoy my time there. And because I haven't bounced enough, 91% on pharmacology. Go me!

I've a 300 word thing due Friday about refusal of consent. Pretend case we've been allocated is a woman whose cervix has dilated to 3cm, foetal heart slows to 90bpm (normal 110-160) and doesn't recover, section proposed by obs, woman refuses. That pesky Constitution keeps getting in my way. Article 43.3.3, how I hate you right now. Pesky equal right to life, pesky diminished capacity for consent (in law) of woman due to pregnancy and pain! Pesky Irish law. Pesky high standards that I set myself!
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I should be heading out the door to college now, but I can afford to be a few minutes late. This is pretty much for my own amusement and rantage, you've been warned.

Until April or so 2008, independent midwives in Ireland were insured by the Irish Nurses Organisation. Now, I quite like the INO as a union despite having some issues with it not keeping up and not mentioning midwifery in its title. The midwives who did the pilot programme of what I'm doing are not nurses, and there are still a few working who qualified before the 1957 change to midwifery training where it was decreed that you needed to be a nurse before you could be a midwife. That's leaving aside the non-Irish-trained midwives working in the country who are not nurses and there are many of them.

For reasons uncertain, the INO decided to discontinue insurance coverage of IMWs. Then changed their mind again and brought it up to September last year when someone pointed out that the insurance is only about a grand a year. That's less than some people's car insurance. Yes, insurance companies realise that's how low risk home birth is for the majority of those who choose it. Compare that to medical insurance where in the 90's most maternity hospitals were paying 20% of their annual budget in medical insurance. There are a whole host of reasons, not least those related to the carer-woman relationship, for that.

So last year, the INO finally went "no no no no no la la la la la can't heeeeear youuuuu!" and the IMWs entered talks with the HSE to get insured under the same scheme as GPs are insured under. Again, nice n low risky stuff. And after a while a document emerged. The Memorandum of Understanding. So IMWs can now be insured by the HSE (and paid by the HSE to care for women under the Maternity and Infant Care Act as they bloody well should have been before but weren't which meant that only those who could afford it could engage an IMW - more rantage about power of medics) Cark and Kerry women could get an IMW through the HSE before that, which was nice but not so helpful if you live elsewhere. Yay insurance! Yay being paid! Yay women not having to pay! (I'm including private health insurance as women paying cos that ain't free.)

Only thing is, the HSE noticed that there are about 100 midwives about to finish their training in September 2010. Oh noes! Untested in the field because they get at most a month of community midwifery training in that 4 years! But until now, coming straight out of training and going independent wasn't an issue. Not many did it, we've 15 IMWs in the entire country (nice clustering around Cark/Kerry) but there was no reason why they couldn't. But now, a midwife needs three years post-registration midwifery experience before they can get insured and paid by the HSE. But! There is no mention of if that's full-time experience, or where that experience had to be gained. Brilliant. So someone like myself, contemplating further education after graduation/registration with An Bord Altranais and working occasionally as an agency midwife to keep food on the table while studying is deemed to have the same post-reg experience as someone who goes straight into a hospital to work full-time? Yes! Brilliant.

While I love that I'm living in a country that listens to the WHO and FIGO about how bloody brilliant midwifery is and doesn't make my profession illegal or alegal, it does rather annoy that there's not enough trust being put in the education system to get me out as a safe midwife and that for many the only way to get the three year's post-reg experience will be in a hospital. Three years is more than enough time to get ground down and lose faith in midwifery and women's ability to birth.

And now I'm going to be late for my bus. Oopsie.
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Hmm, Holles Street conference on community midwifery soon. Dunno if it's worth going to or not. It's Holles Street. The home of O'Driscoll and his ideas that we've exported cos damnit, we're good at obstetrics in this country. *twitch*

But it's community midwifery. And it might be nice to get a slightly different slant than the one I've been exposed to, in the name of being properly edumacated n all. The community midwives in my hobbidal are luvverly and the three (four? five?) independent midwives I know really have shaped me. I'm trying not to let the words "wine reception" sway my decision. Especially when I can get Vocal after boozery when I disagree with people. Decisions, decisions. Mildly miffed at lack of stoodent rate, mind, seeing as there are NMHSarahs too. Will speak to classmates, could be interesting as a group. Heh.
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Monday week I'm back on the wards. In gynae. Pre- and post- surgical cases so I'm going to go over some stuff that came up during my theatre placement last year. Though I have to admit that I don't remember an awful lot of theatre, simply because I was off my face on drugs of the prescription painkiller variety. I should be reading about hysterectomies or D+Cs or lap+dyes or myomectomies or tubal ligatures or any of the millions of things that I need to know about. Like intrauterine deaths. The universe's sense of humour is not something I'm appreciating right now. Only 6 shifts though, and I can do anything for 6 shifts. Two long and one short day per week. Don't dare say I have it easy, a long day is 0730 - 2030 and a short day is still 8 hours.

So instead I'm watching birth videos. Cos that's always fun. Not least cos it reminds me that occiput anterior is the most common cephalic presentation. I seem to only get occiput posterior - where the baby's spine is against the woman's, so a lot more painful and generally longer labours. Particularly in first births there's a high instance of needing assistance in the form of vacuum or forceps with this presentation. This is why I have only three catches.

Hmm, might change my international baby trade tag to something else. Something that doesn't suggest I sell babies.

Random thought - I don't like the phrase "birth canal" and I don't know why. There's something too... mechanical or something about calling it a canal. Or implies barges and horses and tow-paths and I'm fairly certain I've never found any of them in there. Aha! That's it! It's bloody O'Driscoll again and his bloody talk of "passengers" and "passages." That book has scarred me. It's an incredibly simplistic read as well.
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Right, time to start thinking about the dissertation. Halp? I have four topics that I might work on, I'm only allowed do one. I have until December 2009 to do this, so plenty of time to conduct the research and hopefully find willing women to participate. Which of these is most likely to keep my attention for the next 16 months? (These are just general ideas, actual proposal to be worked on once I decide what area I want to concentrate on.) Or possibly also, which would bother you least about reading about for the next 16 months :)

Domestic violence in pregnancy and access to supports.
Non-heterosexual women's experiences of maternity care in Ireland.
Women's experiences of having a child with trisomy 21 or trisomy 18 that was not diagnosed antenatally. (Down's and Edwards' Syndromes respectively.)
The difficulties faced by non-English speaking women when trying to access maternity services in Ireland.

Uhh... there's nothing in my curriculum document about the weighting of my dissertation. In fact, it's not mentioned at all. Hmm. I know I have to do one, so it'd be nice to know what it's worth in terms of my degree.

And here's me panicking: I can't find my little blue book of competencies. This is a book that I need to submit at the end of my four years with all my midwifery skills signed off on. It's the record of my antenatal and postnatal exams, my catches (3! Please, let me lose my OP curse! I need another 37! Please let me get some night shifts in delivery in 4th year!), all the little skills that go to proving that I can do what I do. It's not where it should be.

Birth tech

Jul. 22nd, 2008 01:32 pm
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Pregnancy is not an illness.
Birth is not a disease.

Now I've got that out of the way... Recently I was linked to something that made me goggle more than usual. So much so I had to check that I wasn't hallucinating. It's the BirthTrack. A device designed to save women from those nasty midwives and their horrid hands.

At the minute we're completely backward here - we've to use fingers, ewwww!, to see how a cervix is dilating. Wouldn't it be so much better to have a machine tell us instead? Because machines are great at deciding if a woman's insides are stretchy, or well-effaced, or if the cervix is still posterior. And you get to watch a monitor the whole time! So no more of this uncertainty of 4-5cm of a dilated cervix, you'll know if it's 4 or if it's 5! Wow! And so will your partner! Instead of helping with your needs, look, another shiny med monitor to look at and become obsessed with.

And as for deciding if the baby's head is dropping (it has to be a head, all babies who don't turn are booked for sections, right? No-one could ever manage pushing a breech babby out!) well we'll just stick a probe in its head so we can tell! And it'll mean we can tell exactly what the heartbeat's like because we've screwed a probe into the baby's head. Very nicely giving baby his first ever scar! Who doesn't love a good scar story? "I'm so tough, I've got scars from when I was born!"

While we're at it, let's give 4 nice routes of ascending infection! Membranes have to be ruptured (one! ha ha ha!) so we can stick a probe into the baby (two! ha ha ha!) and attach clips onto the cervix (three and four, ha ha ha!) Of course, it's only to be expected that some reduction in mobility will happen, but at least you don't have those pesky midwives at you with their fingers!
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Er, is it just me or is it absolutely ridiculous that not every hospital in Ireland has a website? I know damn well from working in enough of them that things like visiting hours are not standard. That they can be bloody sprawled out things, and so a map of the buildings might also be useful to someone who is not there every day. That transport information just might be handy. Hell, information on where the hospital actually is, that's also a huge help.

This post was brought to you at this hour by me trying to organise a week/fortnight placement for next year. Maybe for October, maybe December. Maybe even August/September if I can get things organised really quickly. If I'm extra quick and get it sorted for Aug/Sept then I don't have to worry about public liability insurance running out on me halfway through.

Options I'm looking into are either the midwife led unit in the Lourdes (20 minutes saunter from my house!) or one of the independent midwives, er, somewhere. A lot more poking is required of the latter, though chance to be at a homebirth! Even if it is _strictly observation_ this time round. Poop. Wanna catch a baby! No opportunities for that next year, unless one of my women in outpatients gets a bit too excited. And yes, I know I used the p word there, but that's what the department's called.

Once the leg's working I'll pop up to the MLU, see if I can have a chat with someone up there. Know a couple of the midwives up there anyway so with any luck... Was contemplating Cark, cos there's some interesting stuff out there and it'd be nice to get some more DOMINO under my belt (domiciliary in and out - most of the antenatal and postnatal care is done in the home, coming in to hospital just to birth.)

There's very little in the works as regards training/conferences at the minute which saddens me. Still very very annoyed at missing the ICM but it would have been a very spendy few days. There is a day course on the new Sands guidelines in September, but I don't think that would be a particularly good use of my time, energy and money. Not right now. Maybe next time. The internet says I'm not on placement when the TCD one is on (1st week in November.) I do hope it stays like that.
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Facing my third all-nighter of the week to get my competency documents up to scratch. [1] One more week. One more. Then a week off, or "study leave" as I believe it's officially known, then exams, then mental health. Been looking after my own a bit more lately by actually seeing real people in real life and talking about real things. Today I found myself out in Blanch, in Wendy's kitchen drinking coffee and beer and eating toast and catching up and totally not caring about failing film course.

Study leave. My Christmas holidays are "annual leave." Er, no, holidays, thank you very much. See, student, not employee. And even then they're holidays. Harrumph!

NEHB, or HSE NE as it's now called, things aren't happy there. The next few weeks and months are going to be interesting. As long as you're not sick or think you might have been. At the same time, I like that RTE pronounce the S in Lourdes when referring to Drawwda hospital.

Giving up on doing elective placement abroad, too spendy. Instead I'll focus my efforts on securing a two week placement in the midwifery led unit in the Lourdes. For two reasons: it's the only sort of unit that will keep me in hospitals after I'm registered and it's 20 minutes stroll from my house.

Plan for the summer:
- work ass off earning monies.
- take a real holiday. Abroad. Proper abroad.
- work ass off going over 2nd year stuff and start on 3rd year stuff, like figuring out what the hell I want to do my dissertation on. Erk.
- take another holiday. Cork/Galway would be nice. Both relax me. If Cork, see more of the city than just the English Market. Ahem.
- work ass off in general. Making it be smaller would be good. Am back up to where I was before I lost the weight three years ago. Buggrit. Must get that off, soon. Not least cos I chucked out all my super fat clothes.
- see more of friends. I've missed ye. Sorry for being crap about keeping up with people in real life.
- have picnics. I like picnics.
- camping! I'm going camping! No idea where or with whom, but I'm doing it.

And that's me. Still hiding in my room for fear of Drama but otherwise good.

[1] Edit at 01:48: sod that, going to sleep. Shall just have to hand them in on Monday, not in the mood for three all-nighters in a week. Though the weekend is rather full. Hmmm.

Further edit, 04:17: Buggrit. No sleep. Can't. Bashed head when getting into car this morning, head now lumpy, sore, and refusing to admit that pillows feel nice. So no sleep for me again. *whinge*
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It really is the small things that make a massive difference. I know this from my placements, have bounced about it in the past when people have thanked me for a small thing I did that made a difference.

Today, someone did one small thing that made a huge difference to me. One of mum's nuns (who was pretty big in obstetric circles and had the Masters of the Dublin maternity hospitals oohing and aahing when they visited her a few months back) sent home a few articles about midwifery "for your daughter." They're not your bog standard information articles, but stories of people who've done work with MSF, the MMMs and the like. Reading them reminded me how much I want to do what I do, why I want to do it, how challenging it is and yet how ultimately rewarding.

I've been having a bit of a crisis of faith of sorts in the last few weeks. Not to the extent of considering withdrawing from the course, just a horrible feeling of facing a constant battle. Even my own meagre experiences to date show just how much we're expected to slot into a hospital system that deals with pregnancy as an illness. Episiotomies without consent, drugs given without informed consent, talking down to women and their families, no input from women about whether or not they understand and consent to different procedures. I don't put up with that. I don't have much time for people who assault others. But it can wear one down after a while. Being on the other end recently with J made it even harder.

Small things make a difference. I'd forgotten what it's like to be on the receiving end. A doc who worked mostly in obstetrics, reminded me of everything I've been talking about for years.

Skewl stuff

Aug. 1st, 2007 02:09 pm
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Next year's timetables and the umpteenth change to the 4 year planner arrived this morning.
No psychology! Modules look interesting: pharmacology, adaptation in pregnancy, pre-existing pathophysiology, unexpected outcomes of pregnancy and childbirth. Yeah, lots of "sick people" stuff that I need to know but that doesn't change the fact that it's a normal experience. Otherwise, as I keep saying, species wouldn't have survived. The nonsense that is the obligatory Broad Curriculum module (hopefully film, I need at least one thing I can coast through) hasn't been finalised yet.

2 weeks off round Christmas and another two round Paddy's Day. This is looking a lot more surviveable than last year. Plus! Woo! We must have really annoyingly vocal yet well spoken class reps [1] cos cos cos, the option to work our placement hours as it suits us (assuming it suits on a ward level and the like) INCLUDING! Woo! Possibility of doing nights! Woo! [2]

Surgical and medical placements will not have weekends in them. At all. Wheee! Makes up for having to go to Naas. Somewhat.


[1] Ahem. But also, muahahaha! I has influence! Silly people, letting me at course and school board meetings.
[2] We get assigned a preceptor to follow around and learn from and then be sent off to do stuff by. We also have to work with them for a certain number of hours to ensure continuity. When they move to nights (night duty is week of nights as in 7x13 hour shifts in a row, week off) we're kinda screwed for 2 weeks. Moving to nights may get up An Bord Altranais's nose, but nah nah ne nah nah. I argued, obviously successfully, that as long as we get the hours in it shouldn't matter when we do them, what with midwifery never being a 9-5 M-F job. So option of doing long days or short or nights depending on what suits. I like getting what I want. Plus nights suit better for commuting, weirdly.

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