Tuesday, 28 September 2010

So what does it all mean?

You get back from your appointment and glance through your notes and there are all these abbreviations that you have no idea what they mean. I'm going to now do my best to explain some of the most commonly used abbreviations or terms but if there is one that you've had that you want to know..just leave me a message and I'll do my best!

ANC - antenatal clinic - may be used to let you know where you next appointment is.
ARM - artificial rupture of membranes which is when they break your waters for you. Generally done to encourage/speed along progress in labour.
BBA - born before arrival. Those babies that don't want to wait for the midwife to arrive or the labour takes Mum completely off guard and end up being born in a car park (mentioning no names here). Anyway it means that no midwife was in attendance for the birth.
BMI - body mass index. Something that most of us don't like but it is your weight in kgs divided by height in metres squared. A healthy BMI is 20-25.
BP - blood pressure. We all know it's recorded but do you know what it actually tells us? The top figure, the larger number is the systolic measurement. This tells us the maximum amount of pressure during contraction of the ventricles. The lower figure is the diastolic measurement and this tells us the pressure in the ventricle at rest.
BPD - seen this on your scan reports? This is the biparietal diameter which is essentially a measurement of your baby's head. The parietal eminences are the two "points" (it may help to feel your own skull lol)  on the top of your head - one on the left and one on the right. The sonographer can use this measurement to estimate within about a week, the gestational age of the baby.
CRL - again seen on scan reports. This is the crown rump length....exactly as it sounds it is the measurement of the baby from the top of the baby's skull down to the bottom of the spine. Also used to asses the gestational age of the baby.
CTG - cardiotocograph. The machine that is used to monitor your baby. Either in the fetal assessment unit or during labour.
ECV - external cephalic version. This is the manoeuvre they use to try and turn a breech or transverse baby into the head down position.
Engagement - this can be very confusing as it depends on the midwife writing it as to which way they mean. Some will write 2/5ths and this will mean that they can feel 2/5ths of the baby's head, meaning the baby is 3/5ths engaged. Others will mean that they can feel 3/5ths and so is 2/5ths engaged. One thing I would say is, 2/5ths or 3/5ths it doesn't really matter. What matters is there is a degree of engagement. The baby's head may well not engage any further anyway if there is some of the waters in front of their head, blocking them from dropping further into the pelvis. 
FHHR - I am sure most of you have worked out that this means the baby's heart has been heard but can you work out exactly what it stands for? It means fetal heart (heard and regular).
FMF - fetal movements felt.
Gravida - either a primigravida or a multigravida. A primigravida is a woman who is pregnant for the first time and a multigravida is a woman who is pregnant for the second or more time.
GBS - group B streptococcus. This is a bacteria found in either the rectum or the vagina of approximately a quarter of all pregnant women. It can cause an infection in the baby, and in rare cases death of a baby so it is commonly treated with antibiotics during labour to reduce those risks.
GTT - glucose tolerance test. The test that checks for gestational diabetes. It is more commonly found in women who have a high BMI and/or a family history of diabetes.
IOL - induction of labour. 
IUGR - intrauterine growth restriction. This basically means that the baby is anticipated to be a small baby...where perhaps the baby has stopped growing, or is growing more slowly which can indicate that the placenta isn't working as well as it should be.
LMA (RMA) - left (right) mentoanterior . This would be in reference to the position your baby is in. So the mento refers to the baby's chin; so in this case the chin is to the left of the pelvis and facing towards the front of the woman's pelvis and the baby is going to be born face first. This would only be detected by a vaginal examination, as externally you cannot feel which position the baby's head is in.
LMP (RMP) - left (right) mentoposterior. As above but the chin is facing to the back of the woman's pelvis. Again would still be a case of the baby being born face first.
LOA (ROA) - left (right) occipitoanterior. This, whether left or right, is the more ideal position for the baby to be in. It means that the occiput, which is the bone on the very back of the baby's skull, is facing towards the front of the woman's pelvis. The baby has tucked it's head right down onto it's body and is therefore presenting the smallest diameter to be born. (Imagine you are putting on a jumper with a tight neck, you wouldn't try and push your face through, you tuck your head down onto your chest)
LOP (ROP)- left (right) occipitoposterior. As above but the baby's occiput
LSP (RSP)- left (right) sacroposterior. This means that the baby is in a breech position and facing to the back of the woman.
MSU - midstream specimen of urine
NAD - nothing abnormal detected....always good to see
NT - nuchal translucency. This is the part of the scan when they are screening for Downs Syndrome and other disorders. They measure the skin at the fold at the back of the neck. This is most commonly used alongside a blood test to give a more accurate risk factor.
PG - prostaglandin. The hormone that is used in induction of labour.
PPH - postpartum haemorrhage. Bleeding to excess following the delivery of the baby.
SFD - small for dates.
SOB - shortness of breath.
SPD - symphisis pubis diastasis.Causes moderate to severe pelvic pain during pregnancy due to the relaxin hormone.
SRM - spontaneous rupture of membranes.
SVD - spontaneous vaginal delivery.
Transverse - the baby instead of being head down or even breech, is instead lying across the abdomen. This can result in a more unusual shaped bump. Fairly obviously if the baby is in this position at term, and any attempts to turn the baby have failed, this would mean a Cesarean section as the baby simply won't fit into the pelvis. This can often happen in women who have an unusual shape to their uterus e.g some women have a heart shaped uterus.
UTI - urinary tract infection.

I have no doubt missed plenty out but please do shout and I will try and clear them up for you!

Wednesday, 22 September 2010

Antenatal Clinic

Every week the midwife I am working with runs an antenatal clinic. This is not a drop in clinic like you have with the Health Visitors but appointments made in advance. At the booking appointment, it is decided whether or not the woman will have consultant led care or midwife led care. It may well be that she only actually sees the consultant once during her pregnancy but the next appointment after the booking appointment is at the hospital so that she can see a consultant as well; this appointment is at approximately 16 weeks of pregnancy. If the woman is under midwife led care then the next appointment will be at the antenatal clinic run by the midwife at the children's centre.

So what is it that happens at these appointments and why? Well in part it's an opportunity for the woman to ask any questions she has - whether they are about labour, or something she has been experiencing in pregnancy. It's also a vital appointment for the midwife to make some important checks. So at each appointment the woman's urine is tested for glucose and protein; and depending on the dipsticks being used it may also be tested for leukocytes, blood and ketones. Glucose may show up in the urine if the woman has eaten a lot of sugar prior to providing the specimen but it can also be an indicator for gestational diabetes. Protein can be a side effect of discharge but can also be an early indication of pre-eclampsia. Leukocytes and blood can indicate a urine infection. Ketones in your urine indicate that you are burning fat which could just mean you're hungry and need to eat something; they are often present in women who are suffering from morning sickness or hyperemesis. The main thing to be careful of is dehydration in this case. However if the woman is diabetic then the presence of Ketones is an indication that glucose levels are too high and there is not enough insulin.

Blood pressure is also monitored - it is taken at the booking appointment and at every appointment thereafter. High blood pressure can be an indication of pre-eclampsia but it can also be a side effect of hot weather. In the 2nd trimester it is quite common for blood pressure to drop and for women to suffer low blood pressure. It's always important not to just look at blood pressure results on their own but to look at the whole picture - one high result with no other symptoms is not necessarily a concern. Whereas a result that may be within normal guidelines but is high for that woman who is also showing protein in her urine is a concern. In this
circumstance, the woman would be sent to the hospital for monitoring or a blood test or both.

The other part of the antenatal appointment is measuring the woman's bump, checking the baby's position and listening in to the heartbeat. The bump is measured after 16 weeks of pregnancy to ensure that the baby is growing and that the baby is, to the best you can tell, growing accordingly to gestation. The position can generally be ascertained from around 28 weeks. This can sometimes provide an answer for women experiencing a lot of back pain and confirm whether they can feel feet or a bottom. At around 34 weeks it is hoped that the baby will be in the ideal position for birth but prior to that the baby can be in any position it likes. Identifying the position of the baby also helps to find the best place to find the heartbeat. Hearing the heartbeat gives reassurance to the mother but also provides the midwife with an indication of how the baby is doing.

So this gives you just a glimpse into what may seem so routine but is actually so very important. For most pregnant women, all the checks are normal and are reassurance but a midwife is there for them too as well as those for whom it is most definitely not routine. Something that women often find after their appointment is that when they read through their notes they don't always understand what has been written so next time I'll cover those abbreviations and what they really mean.

Wednesday, 8 September 2010

The first meeting with a midwife

I think most people have an idea of what a midwife is but how many understand what a midwife actually does?

As I am working so closely with a community midwife at the moment, I thought it would be interesting to give you a glimpse of what they actually do day to day and why. I was going to show you a typical weeks work but felt that certain parts needed more description and therefore understanding, so I am going to start with the booking appointment for now.

Booking Appointments: This is the first time the midwife meets with the pregnant woman, usually when she is 8-10 weeks pregnant although there are still a number of women who book later in their pregnancy. But what exactly does a booking appointment involve? Most women are excited about going to their first midwife appointment but don't really know what it entails. Well essentially it's form filling...fun eh! There is a lot of information to gather - contact details, next of kin, medical history, family conditions that could be hereditary, details of any previous pregnancies which includes terminations and miscarriages, information about previous labours and births, information about any children they currently have, allergies, any social concerns, any previous serious accidents, any operations, nationality of both the woman and the baby's father, date of their last period, whether they usually have regular periods and how long they normally last, whether they were using any contraception or if it was planned, have they taken any medication, have they taken folic acid, how tall are they, what they currently weigh, what shoe size they are, and what ailments they've suffered in this pregnancy. Some questions give way to other questions whereas some the answer is one word and we can move on. From this long list I am sure you can begin to understand why the booking appointment needs to be a long one - it generally takes 30-45minutes.

But the important question is this - why do we need all this information? Some of it is obvious - we need to identify risk factors that could impact on the pregnancy. For example, if the woman had a serious car accident in the past and had to have surgery on her pelvis, we need to know about it, as it could be a factor in her ability to birth vaginally - of course it may not affect her at all. Or if there is a family history of high blood pressure during pregnancy then it's something we would be watching for as it often does run in the family. Something may not seem very important but it can have a huge impact on the care required. Something that might seem unimportant is asking whether or not they are rubella immune or if they have ever had chicken pox. Chicken pox can be quite dangerous in early pregnancy or in the last weeks of pregnancy but if you have had it as a child then your immunity will protect the baby unless you are one of those rare people who didn't maintain immunity. Rubella or German Measles is also very dangerous in pregnancy and this is why all teenage girls are offered the innoculation in school. It is advised that before anyone starts trying for a baby, they make sure that they are rubella immune.

History about previous pregnancies and labours is very significant. If a woman has come to us on her second pregnancy and had a previous Cesarean section then we need to know why that happened. It is not true that because she has had one c-section that she would automatically need or want another one. However in some circumstances it would be the recommendation as the safest way to have the baby. You can also get some information about pain relief used and what worked for them and from this you might get an idea as to the kind of labour they hope for this time. We also need to know whether they had any problems recovering from the birth - did they have a post-partum haemmorhage? If the answer to that is yes, then it impacts on the type of birth we'd recommend to them; a home birth would not be the safest option.

Just asking who the next of kin is, can open the door to details about the father of the baby and whether or not he is in contact or if they are still together. It also offers the opportunity to ask about racial background and nationality. In some cases this has an impact on risk factors - for example Sickle Cell Disease is generally only found in people of sub-Saharan African descent. It can also raise any social issues - are there any other children? Do they live with them or are they refused access to them? I am sure it is obvious why we need to know these things.

Knowing the date of their last period obviously helps us to work out the estimated due date of the baby but also information about the usual length of cycle can help too. It also is essential for working out what scans are needed and when as for things like the nuchal scan, there is a window of opportunity for the most accurate results.

Probably the thing that is asked that is less clear as to why we ask it is shoe size and height. Why on earth do we need to know them? Well give me your best suggestions and I'll tell you if you are right lol

If I have raised something and not fully answered why we ask it then please do ask and I will do my very best to answer you!

Thursday, 2 September 2010

So what is that makes a good mentor?

And why is it that you hear so many horror stories? This is something that is not unique to Midwifery but also occurs in Teaching, Nursing and no doubt many other careers.

Before beginning my training I had read on forums about students being bullied by mentors, being left to do things that they shouldn't be doing alone, not being allowed to do things, struggling to get things signed off in their books, and the list goes on. I had also read a lot about fantastic mentors and how supportive they could be. So going into placement I was apprehensive about who I would be working with and especially when I thought about Community as I would be with one Midwife all the time - can you imagine how hard that would be if you didn't get on? So now I am well into placement and really enjoying working with my Community Mentor, I have been thinking about what it is that makes a good mentor.

1. Consistency. Both in who you are working with and also in how they work. When you work with someone different each time, you soon discover that everyone has their own way of doing things. It can be really good experience of course to see the different methods but it certainly doesn't help when you try to do something, and the person you are working with says "oh no that's wrong, don't do it like that" or something similar. It is also nigh on impossible to learn, if the person you are working with does it differently each time with no apparent reason, and no explanation. Also if you consistently work with the same mentor, they can see how much you improve and learn along the way which just isn't possible when you only work one shift with each person.

2. Time. It is important as a student to have the opportunity to discuss things with your mentor. So you can understand why things happened the way they did, why certain decisions were made etc. Labour is generally quite a slow process, and the actual delivery of the baby can also be slow but once the baby is born, then things are generally a little busier - decisions can be made very quickly and there isn't always the opportunity to ask questions, and of course sometimes it isn't appropriate. So in an ideal world, there would be time later on to sit down and "debrief". For the student, it is also imperative to have a chance to look at the placement books and the essential learning outcomes that need to be signed off on. Left too late and this can be a real problem. I also believe it helps the mentors as well, as then they know where to focus the students learning.

3. Friendly, approachable and supportive. Yes I know this should go without saying, particularly in a caring profession such as Midwifery but unfortunately this isn't always the case. I mean to me it's common sense, if the mentor is approachable and friendly, then the student is far more willing to try, far more confident at having a go, knowing that the midwife is there to support as needed, and therefore much more likely to say when they don't know something. It's much easier as a student, to build confidence, with someone who is supporting you, letting you try, letting you make mistakes but at the same time ensuring you aren't putting anyone at risk. It's well proven that you learn better by doing something yourself than by simply watching.

4. Recognises the student as an adult learner. Again this seems obvious but I do think some people forget this. And I am not restricting this issue to the mentors, I believe that some students forget that they are responsible for their own learning too. The mentor should treat the student as an adult, not as a pupil. And the student should not act like a child but as an adult who wants to learn - I'd also like to see this in University but I'd take a guess that you'll always get those that thing it's funny to sit in lectures looking at magazines and laughing. A bit of mutual respect goes a long way I find. The student should speak up about the things that need doing - like the placement book. It's their responsibility to ensure it is done, not the mentors, and to not leave things till the last minute. On the other hand, it is the mentor's responsibility to give the student the time when reasonably able. (and yes I know this really belongs in my time section)

5. Showing an interest. Not all mentors choose to be mentors and in many ways I don't think it's fair on either the student or the mentor for this. But it most definitely helps if the mentor is interested in being a mentor as then they are far more likely to offer the time and support to the student. It also helps the mentor and the student if the mentor knows what kind of experience the student already has - can save on a lot of repetition.

All of this is what I believe makes a good mentor and at the moment I have a fantastic mentor. I hope I get to work with her again in the future but I am going to enjoy the coming weeks with her. On the flip side I'd like to think I am a good student and that I am fulfilling my side of the relationship by acting professionally, showing willingness to learn, asking when I don't know something, being honest when I'm not sure of something so she can be confident I'm not about to do something unsafe, being on time and being friendly. A good working relationship depends on both parties playing their part after all.