What clinical experiences makes a good student midwife?

Midwifery education in Australia is about to undergo a review as the Nursing and Midwifery Board look at the standards underpinning midwifery education. One of the potential controversies that is likely to be debated during the consultation process, is the clinical requirements that students are expected to achieve.

Follow-through (continuity of care) experiences
At the moment, student midwives are required to obtain 20 follow-through, or continuity of care experiences during their education. During the continuity experience, the student follows a woman through her pregnancy, birth, and up to six weeks after the baby is born.  Students feel that this experience is an incomparable learning experience, and gives the student a sense of the whole context that a woman comes from, which is invaluable, whatever model of practice the student goes on to work in as a midwife.Students also find it easier to obtain experiences and skills such as perineal repair and vaginal examination when they are working with women they know well, as opposed to complete strangers. 

Workload
The problem that students are finding is that these experiences are very time-consuming, expensive and being on call means they are not free to work during their time off.  These requirements, along with all the other clinical requirements, are creating huge workloads for student midwives.

Contraversey
There are some midwifery educators who want to drop the number of continuity requirements because of workload issues, whilst others see the continuity experience as a non-negotiable elements of midwifery education, especially as the Australian maternity system is so fragmented.

Need to focus on normal midwifery
Having spent 11 years as an educator in New Zealand, as well as one year teaching in Australia, I whole heartedly support the continuity experience as one that not only provides clinical skills, but also re-enforces an understanding of childbirth as a holistic process, and not a fragmented one which is encouraged by the other clinical requirements such as 100 antenatal visits, 100 post natal visits,  and so on. I believe the continuity experience should not be a luxury or add-on, but the essential core of midiwfery education. However, my personal feeling (and not necessarily that of the Australian College of Midwives) is that student midwives in Australia have too big a clinical workload.

If any requirements are reduced, it should be those that focus on the technical, medical skills that are quickly picked up in hospital, such as working with women with epidural, or providing care for women who have had cesarean section - midwives pick up those skills quick enough once they are registered  because of the high epidural and cesarean rates in Australian hospitals.

Holistic midwifery
During their education program,  students must be given the opportunity to learn about supporting normal birth, and develop a full understanding the role of midwife. They may not go on to work in a continuity scheme as a midwife, but they will understand how midwifery is provided in that context so they can support their sisters who do work in these models of care. But more important, they have a framework on which they can base their understanding of childbirth, and guide their interactions with women and families, especially when they work in fragmented hospital systems.

If you are interested in reading more, here are some references that the Australian College of Midwives is currently collating:  http://www.midwives.org.au/scripts/cgiip.exe/WService=MIDW/ccms.r?PageId=10175

Are you a student midwife - what do you think about your clinical experience? How does it prepare you for practice as a midwife? What would you change, if anything?  Are you a pregnant woman? Have you had experience of working with a student midwife? What did you enjoy about having a student midwife?


Image: 'Soheyl'
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Found on flickrcc.net

5 top tips for pregnant women about to have their baby

I was asked the other day by some pregnant women to write a post about labour and birth. So here's my top 5 tips for women who are about to have a baby.

My default position is that every pregnant woman should have a known midwife who provides care throughout pregnancy and birth, and home birth for low-risk women. However, not every woman can have, or chooses, either. These tips are for women who have chosen to have a hospital birth, and in particular do not have their own midwife. 

1. Do not agree to have your labour induced the minute you reach 40 weeks pregnancy
There's no doubt that every day over 40 weeks of pregnancy seems like the longest day of your life. This problem is accentuated by all the modern tests we have that emphasize pregnancy dates. Gone are the days when women think about having their babies in terms of.... the phase of the moon.... month... or even season. These days we talk about giving birth down to the last day, hour, minute...

The reality is pregnancy varies considerably from woman to woman, and term pregnancy is defined up to 42 weeks gestation. There is evidence to show that mortality increases after 42 weeks pregnancy, however, the number of deaths are few, and each mother and baby's risks should be reviewed individually. My experience has been that when you try to induce labour before the mother's body is ready, the induction process is much longer and painful for the mother, with increased risks of medical intervention at a later stage.  This is what we call the "cascade of intervention", which is so often started by unnecessary induction of labour,

It goes without saying that if you have risk factors such as high blood pressure or your baby is showing signs of ill health, then you must follow the advice of your doctor. However, if you are fit and healthy, and have a low risk pregnancy, then resist pressure to have your labour induced. Focus on keeping active, yet relaxed, and spend your time preparing your body and mind for life as a new mum.

2. Stay at home as long as you can before you go into labour
The longer you stay in an environment where you feel relaxed and in control of what's happening to you, the better the outcome for you.  The longer you are in hospital, the greater risk you run of being submitted to unnecessary medical interventions. This can be a little tricky, especially when you are expecting your first baby because you don't know what to expect. I find it is often the dads/partners that get nervous and want to take their wife into hospital as soon as they can, so it is helpful to have someone with you at home who can support you. The best thing, if you can arrange it, is to get a midwife to come and check your progress at home, and make sure you do not go into hospital until you are in established labour.


3.  Have an advocate with you when you are in labour
By this, I mean, have someone with you who will ensure you have your wishes adhered to, that you are treated with respect, and that your right to informed choice is maintained at all times.  I don't think that husbands/partners can always do this because they can become very emotionally involved. So I think you should take a third person who is not so closely related to you. This person may be a friend or family member, or even an employed doula. This person must recognise that there are times when the best laid plans can turn to custard and medical intervention is required, but at the same time, be able to stand up for you against pressure for treatment, or attitudes that are inappropriate, and that everything is fully explained to you at all times.


4. Wait as long as you can before you have an epidural, if that is your choice of pain relief
I have mixed feelings about epidurals. On the one hand, when epidurals are well managed they can relieve severe pain, and assist mum to have a quiet, controlled birth which is a joy to behold. But in my experience, these births are few and far between.

Epidural interfere with the physiology of labour and birth, make labour longer, increase the risk of needing powerful drugs to increase contractions, prevent women from being able to push and increase the risk of a forceps delivery - with the accompanying risk of damage to mum and baby. Epidural also increase the risk of cesarean section for baby distress, which is thought to be caused because epidural increase maternal body temperature.

Bottem line: if you can manage your pain without an epidural, then do so. However, if you decide to have an epidural, leave it as long as you can before you have it because you will increase your chances of having a normal birth. 


5. Do not agree to continuous baby heart monitoring with a CTG machine unless your doctor or midwife can provide strong evidence that your baby is at risk
Many hospitals insist that women have a CTG baby heart monitoring trace when they first go into hospital, and even that they have continuous monitoring throughout labour. However, for low risk women, this medical intervention has been shown to have no impact on birth outcomes, and indeed, increases a woman's risk of procedures such as cesarean section.

If you are not sure what goes on in your hospital, check out their policies and guidelines for labour and birth while you are still pregnant. The more homework you do before you go into labour, the better prepared you will be.


What are your top tips for a pregnant women to think about before she has her baby?

If you want to read more details with links to research evidence, have a look at this article: What to reject when you're expecting. 10 procedures to think twice about during your pregnancy. The other blog that presents excellent evidence-based information about birth is: Science and Sensibility. And if you're a dad, may I recommend this blog: Beer and Bubs. As a midwife, some of the places I go for evidence-based information about labour and birth are:

• Cochrane database;
• NICE guidelines;
• The Royal College of Midwives' Normal Birth campaign
• Australian College of Midwives Position Statements
• Google Scholar - has some academic articles freely available, although they can be a bit tough to read and understand some times.

Image: 'untitled'
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Found on flickrcc.net

Needing help to develop smartphone apps for the Australian College of Midwives

One of the things that really stands out to me, working with midwives in Australia, is how "mobile" they are. They do not have the time to sit around for ages glued to a computer, but they do like to access information, resources and services via their smart phones. Consequently, I have been thinking about what services and resources the Australian College of Midwives (ACM) can provide to midwives via smart phone apps.

What could be turned into apps?
Needless to say, there are any number of resources that could be turned into apps for midwives from straight forward pieces of information, such as the Midwifery Guidelines for Consultation & Referral, to more interactive activities such as the recording of CPD straight into the midwife's MPR portfolio system.

Making your own apps?
I know there is software available on the Internet that allows you to make your own apps, such as TheAppBuilder, but to be honest, I do not have the time these days to investigate or "play" with development. But at the same time, the ACM  are getting an increasing number of requests from midwives for  "mobilize" itself.

Student project
What I was thinking was that developing some apps for the Australian College of Midwives would be a nice project for IT students. So, if you know of any lecturers in the university or tafe sector who might be interested in working with us, please let me know.

Have you ever made your own apps? What software did you use, and what tips would you pass on? Have you come across any apps that would be relevant and useful for midwives?

Image: 'Make the Call'
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Found on flickrcc.net

A response (of sorts) from The Warriors about their sponsorship deal with a formula feed company

At the end of last year I wrote to The Warriors and CEO of the NRL, in my role of Professional Development Officer, about the concerns the Australian College of Midwives has about The Warriors new sponsorship deal with the formula feed company,  Fernbaby. Needless to say, the response has been less than reassuring!

Sponsorship deal
Toward the end of last year I blogged about my concern that the rugby league team, The Warriors, had signed a sponsorship deal with a formula feed company. This includes wearing the company's logo on their shorts. The concern is that the World Health Organisation marketing of formula product has been contravened, with the implication of giving mixed messages to families about breastfeeding. The Warriors is giving the message that they support formula feeding, which we know is detrimental to health. This is particularly concerning considering the population that supports The Warriors are at especial risk of exactly the health conditions that formula milk increases.

Australian College of Midwives
In December I supported the posting of letters to The Warriors and the CEO of the NRL, in conjunction with UNICEF, voicing our concerns. Interestingly, there are constraints around rugby companies signing up for sponsorship from cigarette companies, yet no such consideration with this equally importnat public health issue.

Newspaper
As yet, we have not had an official reply. However, both the NRL and Warriors have spoken to a sports reporter, Daniel Lane, and confirmed that The Warriors will be going ahead with the deal, and that it has not contravened the NRL sponsorship guidelines.

In thinking about what we can do next, I am considering that we need to write a paper giving guidance about marketing, sponsorship and issues about engaging with formula companies, for the NRL and similar bodies. What do you think? What do you think should be our next move, or do you think we're getting our knickers in a twist about a non-issue?

The pros and cons of Kobo

I have been reading books via a Kindle app on my smartphone for some months, but because my phone is quite small, the reading experience has not been a particularly comfortable one - I have found it to be great when I'm doing short journeys, on the bus to work, for example. However, for serious reading sessions, the print has been too small, and I have to be forever turning the pages. When I decided at long last that I would succumb and buy an eReader, my daughter beat me to it and gave me a Kobo eReader for Christmas.

What I like about my Kobo
I am really enjoying my Kobo Glo. It's light to carry and easy to use. The pages turn with a light tap. There are a number of functions such as spell check and annotation, if you want to little more interactivity.

There is a back light which is meant to facilitate reading at night, but I have it on all the time. I am not sure how this will impact on battery time, but I am happy to accept a shorter battery life. The battery is supposed to last for a month, but I am not too sure about this. I haven't had it long enough to assess, but it looks to me that this is a little optimistic.

It did take me a little while to work out how to sync the reader with my Kobo desktop. Unfortunately, the instructions on the website were not as clear as they could be, but I got there in the end.

I have read various complaints on the internet about Kobo, saying that it crashes a lot, but I haven't found that to be a problem - the reader itself works like a dream. But.....

What drives me mad about Kobo
The thing that has put me right off Kobo is the website and experience of buying a book. I have lost count of the number of computers I have used, and Internet browsers, but I seem to come up across the same problems and issues.

• Getting messages that say - "Sorry, we do not have any items at the time"

I don't know if the web site crashes at times of extreme use, or what happens. Sometimes, the message clears when I clear my browsing history. The problem is...in one session on the website, I might have to clear my browsing history at least half a dozen times, which is really annoying.

• Having the currency appear in New Zealand dollars, and not Australian dollars.

This has come about because I originally set up my account when I was in New Zealand at Christmas. But now I am back in Australia, the currency has not changed in response to my change in IP. To be fair, the Kobo team are trying to fix this, but it is taking forever to come right, and is irritating to say the least.

The other things about the web site that are irritating are:

• Having to sign into my account every time I buy a book , even in the same browsing session.
• Having to buy each book individually instead of being able to put it in a shopping basket and buy all in one go.
• Having no way to save to a wish list.

Comparing Kobo to Amazon

The book prices do not appear to be much different, and whilst Amazon probably has a greater range of books than Kobo, I have always been able to find the books I want on Kobo.

I do not have a Kindle eReader, but as I have said before, I do use a Kindle app on my smartphone. Whilst I love my Kobo eReader, the experience of the Kobo website is very poor compared to Amazon. I have never had any problems shopping, buying or  downloading books from Amazon.

The other thing that gives Kindle the edge over Kobo is I am able to download hundreds of free books in the genre I read....historical romance. I even belong to an Amazon email group that constantly updates readers when new freebies are released. Kobo does have some free books that you can download, but no where to the extent that Amazon does.

My recommendation
I don't think I can recommond one reader over another because I haven't used a Kindle. I am certainly loving my Kobo. But my very frustrating experiences of the Kobo website has put Amazon and Kindle way ahead of Kobo. So if you're thinking of buying an eReader, it is worth taking these things into account.

Do you have a Kobo eReader? What experiences have you had? What would you recommend?

I never thought I'd say this but....

...I have an eReader!

Yes...I have been given a Kobo eReader for Christmas and love it.

I have always been skeptical about eBooks, until recently.

I love reading and I love paper books. I love the whole experience of books....browsing around book shops...ordering them from Amazon...waiting for them to arrive in the post (and let's face it...I don't get anything else through the post these days...even bills and bank statements arrive by email these days!)...settling into the bath with my latest trashy bodice ripper.....collecting flashy hard backs that I never read, but look intellectual on the book shelf...

I have always been of the opinion that you can never replicate that experience with eBooks. 

But the trouble with paper books is they take up a lot of room, and I have been forced to give many away over the years every time we have moved house.

Books are also difficult to travel with. They take up a lot of room in a suitcase. I always travel with...what I call..disposable books....books that I leave in hotel rooms or airport when I have finished reading them.

So to address the problem of traveling with books (especially on the bus, back and forth to work), I have recently discovered the joys of reading with a Kindle app, which I have downloaded onto my smartphone. I download free books from Amazon, which are fun but are easily deleted when I have finished. The only problem with the smartphone is the pages are very small, and fiddly to read.

My eReader is bigger and easier to read....I don't need my glasses! It also has back lighting, which means I can read it in bed without disturbing my hubby, or requiring a big torch. I have even had it in the bath, although I am terrified of dropping it!

I am sure that eBooks will never totally replace paper books for me. I still like to buy paper books in book shops...collect them...smell them, feel and look at them...all experiences that you cannot replicate electronically. However, where my eReader will come into its own is when I am traveling. It will be so much easier to travel with a device that weighs a couple of pounds, compared to 10 books that take up half my suitcase.

What do you think about eBooks? Have you ever read one? Do you have an eReader? Do you think paper books will eventually become extinct?