From MIDWIFERY MATTERS, Issue No.106, Autumn 2005
I went to my first ARM meeting a couple of months ago at the end of my third
year. Previously I have subscribed to the journal and used articles in essays
whenever possible. I walked into Alison's home and found many of the midwives
I've enjoyed working with. It seemed more like a group of friends getting together
with a theme of midwifery for starters and dessert and a lovely potluck lunch
in between. We talked about articles for this issue, watched a home waterbirth
video and Bridget presented her Masters, which looked into communication with
women about induction of labour. I was so taken by the day I volunteered to
have the next gathering at my place and offered to teach some yoga for pregnancy,
which was willingly accepted.
Yoga and midwifery
My background training in physical education eventually led me to yoga, which
is the first recorded system of techniques for optimising health and wellbeing.
I've been practising yoga for more than 10 years now and consider it an essential
part of my everyday life, like sleeping and eating. I taught yoga full time
for two years before starting my midwifery training and have continued teaching
classes whenever possible over the past three years. I'm teaching a weekly yoga
for pregnancy class at the moment and am currently on placement with the Llandeilo
midwives. They work as an integrated team (connected to Carmarthen hospital)
providing continuity of care for women by offering antenatal, intrapartum and
postnatal care. Some of the women they care for are coming to the yoga classes
so I have the wonderful opportunity to deepen my connection with these women
throughout their childbirth journey. For me yoga and midwifery go together,
they both have their roots in the origins of life, which in yoga is known as
OM, the sound of the source of creation. There are so many ways in which yoga
techniques can contribute to midwifery practice and I looked into this for my
final year dissertation and research proposal.
Elective placement
I have also been able to witness yoga midwifery first hand when I spent two
weeks at Hvidovre hospital in Copenhagen with Ambika in August 2004. When I
first heard about the elective placement I knew I had to find a yoga midwife
to spend time with and I wanted to be with someone who had studied the same
teachings I follow, as there are many different schools of yoga. Ambika has
been a yoga teacher for 16 years and a midwife for five years. Recently she
was appointed to run a maternity unit in Copenhagen.
With the support of Billie Hunter I was awarded a student bursary from the Iolanthe
Trust and the Dame Paget Award, which enabled me to pay for my trip. During
my placement I stayed at the Scandinavian School of Yoga and Meditation (now
established for 30 years) in the centre of Copenhagen, which enabled me to attend
pregnancy and post natal yoga classes. The centre is impressive, with seven
teaching rooms and 3,000 students attending classes each year. The pregnancy
classes are the most popular with five classes a week and at least 20 women
in each class. Yoga is very well established and accepted in Denmark, so it
is natural for women to want to do yoga during pregnancy and it is viewed as
an ideal way to prepare for childbirth and widely recommended by doctors and
midwives.
I observed midwifery practice with Ambika at antenatal clinics and on the labour
ward and gained insight into how yoga can be applied to support women at all
stages of pregnancy.
Statistics and staffing
I observed differences in midwifery practice on my visit, some of which I would
like to include in my practice here. Everyone at Hvidovre was very friendly,
they seemed happy whilst at work. There were good facilities, a large staff
room and kitchen for meal breaks, individual lockers, changing room and a good
sized midwifery station for discussing and writing up case notes. In summer
the midwives wear sandals at work and most do not wear make-up. There is a choice
of clothing for the uniform including trousers, tracksuit pants, tunic top,
tee shirt, dress, long sleeved cotton cardigan and bolero style jacket. Staff
uniforms are named and washed by the hospital laundry. The hospital is mostly
on one floor, so with considerable distance between wards doctors use push scooters
to get around when they are on call.
Five midwives work each shift to provide 1:1 care in six birthing rooms, two
others are at home on call. This part of the labour ward deals with high-risk
women and there are 3,400 births each year. Low risk labours are allocated to
four rooms in the postnatal wards, known as clinics 1 and 2, with a combined
total of 2,000 births. In Copenhagen the homebirth rate is similar to UK (1-2%)
and this shows regional variation as it does here, with higher rates in rural
areas. A team of nine experienced midwives rotate on-call shifts to provide
cover for women requesting homebirth.
Handover is a process of negotiation and throughout the shift an experienced
midwife acts as an advisor if required. Midwives are not expected to report
to her or the doctors, instead it is recognised that they will ask for help
if required.
Hospital facilities
On the labour ward there is a sizeable waiting room with fridge and tea making
facilities for the family. This room is also used by women waiting to receive
specialist antenatal care, (monitoring FHR, scan, planned section briefing etc)
in rooms adjacent to the labouring rooms. Each room has a beanbag, birthing
ball, birthing stool, mat, walking frame, fan and radio. The beds have an arm
pulley to reduce lifting loads for the midwives and the warmer for the baby
is on a long swinging arm so it can be used over both the baby table and the
bed. Although all the birthing rooms have baths these are mostly used for first
stage in labour; water-birth is not common.
Record keeping
Pregnant women see their GP between 5-9 weeks. The medical history is reviewed
in a 20-30 minute appointment to assess all relevant risk factors. Routine bloods
are collected for blood type only and screening for rubella, parvovirus, hep
B, toxoplasmosis, syphilis, HIV and chlamydia is not routine. Women then see
the midwife as indicated averaging about eight appointments (13-16, 22, 29,
33, 38, 40, 41 weeks). The GP is seen at 25 weeks for an antibody screen.
Each woman carries her own antenatal summary sheet in an envelope. It is a self-carbonating
sheet, so that the midwife puts it on top of her copy, which is kept with the
loose-leaf hospital file in her records and this makes for easy duplication
with a minimum of writing.
During labour every time a new action is taken the midwife writes a mini care-plan
in the notes in table form outlining indication and action, which is very clear
to read. Gaps are left in between entries in the notes and the birth summary
and baby notes are a series of checklists. There is only one copy of notes as
the hospital record is available on the computer system once it had been typed.
Care during labour
During labour women are encouraged to vocalise if it helps to cope with the
pain. I did not observe the attitude of 'give her some pethidine to keep her
quiet' which I have observed in other units. A wet towel placed in a plastic
bag and heated in the microwave for three minutes, then wrapped in a soft cloth,
provided good pain relief for the mother's back. The CTG monitor is used only
on indication and can be plugged in to make the trace visible on a computer
screen in the midwives' station so doctors or the supervising midwife can check
it. Disposable soft foam straps with velcro ends are used to hold the transducers
in place and these could easily be adjusted so as to be comfortable for the
women. Long Pinards are used routinely and the FHR is monitored every 15 minutes
in first stage and 5 minutes in second stage. This is done three times over
5-sec intervals to measure variability, this is recorded as 10 (x 12 = 120)
- 11 (x 12 = 121) - 10.
Fetal scalp electrodes (with a long cable) are used so the woman can stand and
move around during labour whilst monitoring the FHR. VEs are performed only
on indication, rather than following a four hourly pattern and foam pads are
used to clean the vagina before and after inspection. These were easy to use
and appeared more practical than gauze swabs. Bloods are not taken routinely
at cannulation, which midwives perform and a soft stretchy net bandage is used
to keep the line in place, which means little or no tape is needed on the skin.
Cord blood samples are taken routinely for statistical purposes.
Birth and third stage
Women usually give birth in a semi reclining position although women who have
attended yoga classes and have become more familiar with other positions (for
example being on all fours or squatting) are supported in using what feels best
for them.
The placenta is removed by cord traction although time is given to wait for
signs of separation, (e.g. cord lengthening) so generally guarding the uterus
is considered unnecessary. The placenta may be examined on the bed where parents
are shown it and often take a photo, before it is weighed in the sluice room
by one of the labour ward assistants.
Following birth, the baby is wrapped in towels from the constantly stocked warming
cupboard and doesn't routinely wear a hat. Skin to skin is given, and although
Hvidovre does not have baby friendly status it has a 95% breastfeeding rate
for women leaving hospital and 77% at three months. A rubber band has replaced
the plastic cord clamp and there has been no increase in haemorrhage or sepsis
over the past two years. Vitamin K is given by injection with the parents' consent.
The baby check performed by the midwife includes head and abdominal circumference,
length, congenital hip malformation, and feeling for the pulse in the groin
(to check for stenosis). Hospital clothes are provided for the baby and a washable
cotton nappy is put on to show clearly when urine is first passed.
Prescription drugs during labour
Misoprostol is used for induction (it is thirty times cheaper than prostin),
and lignocaine is used for local anaesthetic. The syntocinon rate is 10, 20,
40, 60, 80, 100 ml/hr with a maximum of 200 during second stage. Bupivicaine/fentanyl
is given for a walking epidural (the rate is about 20% and 50-60% of these women
need help to walk). An assistant arrives with the anaesthetist to set up the
epidural, so the midwife is able to support the mother.
Some analgesia choices varied compared with practice I have seen in Wales. There
is an adjustable setting on the wall to alter the mix of oxygen and nitrogen,
and this seems to result in less nausea and dizziness.
Oxygen is given through the face mask to mothers after breath holding during
contractions and this seemed to result in faster recovery of FHR. Syntocinon
is given for managed third stage and the injection is given after the baby is
born. There is a very low rate of vomiting following this injection compared
to what I have observed with syntometrine and there is no increase in PPH.
Many of the midwives are trained in basic acupuncture and one of the midwives
is a fully trained acupuncturist so this is readily available to women as a
form of pain control.
Postnatal Care
Women are moved into the postnatal area about two hours after the birth. These
clinics are staffed by three midwives and two assistants and have 16 beds in
total. All women have a private room with a fold out settee so that fathers
can stay the night. The father is also given the job of placing a coloured pin
in the wall-board recording the birth of the baby, which makes a good visual
overview of birth statistics for the year in progress.
There is a toilet, bathroom and changing area for the baby shared between every
two postnatal rooms. There is a large kitchen area for family where tea, coffee,
fruit and toast are provided free of charge and fathers can also order hospital
meals so they can eat with the mother and baby. Following natural childbirth
most women stay one or two nights. Physiotherapy classes are offered in a good
sized and well-equipped room in the postnatal area between 11.30 - 12 noon daily.
Once women leave the hospital a nursery nurse provides advice on baby care including
breastfeeding. If women have any other symptoms they see their GP or perhaps
phone the midwife who has cared for them antenatally, but midwives do not make
home visits.
In summary I had a very beneficial time away on my elective placement and am
immensely grateful to everyone who supported me in making this visit possible.
Special thanks to Ambika for giving me a grounded and realistic vision to follow.
Christine Kalimurti is a final three year midwifery student. She currently
teaches yoga for pregnancy in Llandeilo, Carmarthenshire.
Updated LW December 1, 2006