SHIFT CHANGE SYNDROME

I've kept myself rather out of the doula world this year. Too many worries at home mean I've cut right back on this, my favourite work, because the emotional burden is just too much; I know how to put boundaries between work and home life, sure, but as a doula one is shouldering the emotional life of another family besides one's own and right now, without going into details, my own is quite enough to be getting on with.
But when an antenatal teacher colleague rang me yesterday morning asking to have a quick chat with her brother, whose wife was in labour, I could not resist the opportunity for a bit of long-distance doula-ing.
After several dud attempts to call the father to be, who was having trouble finding a phone signal, I got through to him and from his slightly disjointed, utterly worn-out account this was the picture:
First time mum R. had been in labour about 36 hours on and off. She had gone to the nice local midwife-led birthing centre in the evening and was found to be 4 cm dilated; got in and out of the pool overnight; by 7am was up to 9cm dilated. So far so good. But by 10am the midwife was now suggesting she "go to hospital for help" (synto? epidural? ventouse? she didn't specify) because mum was exhausted and had been "stuck" at 9cm for about  3 hours and her contractions were slowing down.

His voice breaking with tiredness, the dad asked me - "Shouldn't we go to hospital? R is completely exhausted, and they keep checking the hearbeat which makes it hard for her to rest, and who are we to ignore the advice of a midwife of 30 years experience?"

Any doulas out there recognise this narrative? It's what I am tempted to name "shift change syndrome". My first question was: "How's the baby's heartbeat?"

"Oh, fine," he said. So no problem there. No medical reason, as far as the baby's concerned, to get doctors in as yet.
R was kneeling up on the bed leaning over the raised end of the bed, sucking on Entonox.

I considered the facts: simply it looks as though a first time mum has laboured well through the hours of darkness, and contractions are getting a bit further apart when three things happen at once:

1. Daylight comes, which often brings with it a slowing down of labour, whatever stage things are at.
2. Mum's cervix gets to a point of dilation where the head is no longer pressing so vigorously as before on it to stimulate oxytocin production.
3. There is a change of personnel just as she was reaching 9/10 centimetres dilation. The by now trusted night shift midwife says a reluctant good-bye at a critical moment, and a new face appears, someone who hasn't been present through the whole labour story but enters the room and puts her own interpretation on the scene. It doesn't help that it happens to be the sort of midwife who boasts that she has 30 years' experience (which means she was trained at a time when, let's face it, mothers were still expected to labour on their backs and do what the doctor told them). Even if, though, R's care had been taken over by a more subtle personality, the change in carer would have had a powerful effect on her labour, inducing the fear of the new -  which causes an adrenalin bounce and, again, depresses oxytocin production. But to be taken charge of by someone whose words suggest powerfully to R that she is not coping, that she "can't do it on her own"...catastrophic.

So I said: "OK, suppose you do go to the hospital (a 30 minute drive). It's now 10.15am. Believe me, if she wants an epidural it's going to be nearly lunchtime before she actually gets it. The drive will slow down labour. The epidural will probably slow it down too though it would let her rest. The journey might slow her labour down even more. And if it doesn't, suppose she is starting to want to push while she's in transit? That's going to be really unpleasant for her and she might as well have stayed in the birth centre."

"But she's exhausted!"
"Exhaustion goes with the territory at the end of labour," I said, and wondered if I'd been too cruel, but pressed on.

 "The truth is that it's all nearly over; and the truth is that she can do it - her body will give her an adrenalin shot when she needs the extra effort to push. What she needs now is someone there who believes she can do it -  and she needs an oxytocin boost. Why not go back in, close the curtains, give her lots of physical contact, yes, give her a big cuddle, try nipple stimulation, and tell her she can do it and that you believe in her. Oh, and see if you can get her to cut back on the Entonox - just a few puffs at a time, any more isn't helping."

He staggered off. I didn't hear anything for a while; I assumed as I usually do that I had been too cruel, that she had gone to hospital, the baby had been malpositioned and wasn't going to come down in a month of Sundays, she had required epidural, synto, ventouse, forceps, the whole dog's breakfast...

Then a text from my friend: R had decided to take my suggestion and stay put in the midwife-led birth centre - and gave birth beautifully and naturally to her baby daughter just two hours after I'd spoken to her husband. 

Hooray! If only doula-ing was always this easy! But, remember: this was a mum who WANTED a natural birth. If she had been in a consultant-led unit from the word go, I wonder if she would have been able to resist the "30 years experience" midwife's negative suggestions?

This episode has got me thinking a lot not just about how much I miss being a birth doula...but also about what happens when the midwives change shift at a hospital or birth centre birth (home birth midwives generally stick around for the duration) and I feel I should warn my clients and classes of how this will affect them.

Firstly, labour may slow down and you will need to get to know this new person FAST so that mum can feel comfortable with her. Once mum has relaxed, and "forgotten" about the new person, things will hot up again.
Increased tension may cause mum to feel pain more. Again, once she's got accustomed to the new person and relaxed again, her endorphins will kick back in.
The second shift midwife hasn't seen the mum labouring before. She doesn't know her. She needs to be filled in on what's happened. She has her colleague's notes to look at - but I believe she also needs to listen to the partner and the mum (if mum feels like talking).
So here are my tips for avoiding SHIFT CHANGE SYNDROME:

• You have hopefully built up a good relationship with the previous midwife; make the most of this by telling her exactly what you want conveyed to her successor. A job for the partner.
• Have another copy of the birth preferences handy; if you've written this document out in the way I advise my clients and classes to, then it will give an instant snapshot of what kind of woman you are and what your aspirations are.
• Try and have the partner field all the questions, not the mum, so that mum's focus is not broken.
• Ask the midwife a few questions back - you need to get to know her very fast indeed so be nosy!
• The change in personnel, with questions and conversation, may break the mood and bring mum out of her "zone" and that's not good for the labour. HypnoBirthing couples may find it a good time to do the Birth Companion's Deepener script - or to do any other deepening script that they think will help mum to zone in. (It might impresse the new midwife, too. )
• See the shift change positively, as a chance for a change in scene or mood that YOU are comfortable with. For example, if you are free of moorings, lines and tubes, take a walk down the corridor, visit the loo, change the music.

Don't assume from what I have written here that shift change is always a danger point. I've seen a brilliant, inspirational "second shift" midwife work absolute wonders with a tired mum who was beginning to lose heart and being intimidated by a knife-wielding consultant. She was just one of those people who had the experience and confidence to know that this was not a time for "poor old you" but a time for "OK, Kathy, you gotta get this baby out now - the doctors are talking about caesareans. I want you up and pushing. Put the gas down and get to work, kiddo." (An approach which can go disastrously wrong, by the way.)

And there have been "first shift" midwives that I was heartily glad to see the back of, as well as some who simply stay over past the end of their shift because they want to see the job through.

The NHS midwife is one of the most incredible health professionals in the universe; but she is not a mind-reader. Make her understand what YOU want and she will then be best placed to help you.

www.birthhypnosis.net

Is it reflux? Is it colic?

I've been finding out some fascinating stuff about reflux and colic and I'd like to share it with you.

Every other baby I meet these days seems to have something called reflux but an awful lot of these babies seem to have what in my day we just called colic. It's really confusing - are they the same thing?

So here's what I've found so far.

Gastric Oesophageal Reflux (GOR) is the normal phenomenon of stomach contents washing back past the oesophageal sphincter into the oesophagus. 70% of all healthy, happy, thriving babies do it several times a day. The peak period is 3-7 months and normally babies have stopped by 12-15 months old.

Gastric Oesophageal Reflux DISEASE (GORD) is when the reflux causes the baby pain and/or not to thrive because it is affecting digestion, feeding and causing damage to the oesophagus

My take on this: GOR is when the spitting up is mainly a problem for your laundry basket. GORD is when it is distressing the baby persistently and causing poor health.

“Silent reflux” – no outward signs (i.e. no regurgitation) but baby is unhappy because stomach contents are washing up a short way into the oesophagus àoesophagitis.

NB: JUST BECAUSE IT LOOKS LIKE REFLUX DOESN’T MEAN REFLUX IS CAUSING THE PROBLEM – THERE MAY BE UNDERLYING REASONS! Such as excessive gassiness, constipation, a food intolerance (especially to cow’s milk/soy milk), INFECTION, sensitivity to tobacco smoke, “colic” (baby is too little “switch off” crying) – MUM SHOULD ALWAYS CONSULT DOCTOR IF IN DOUBT (see “red flag” list)

An easy way of remembering the various solutions for GOR and GORD is:

·         Gravity – anything that helps the food go down and the air go up

·         O (= a boob!) – improve the breastfeeding technique or pattern

·         Reassurance/relaxing – anything to soothe baby (and mum)

·         Diet,  Doctors and other health professionals – medical and alternative therapy solutions

Gravity:

Baby as upright as possible during feed – eg in a wrap sling

Keep upright after feed 30 to 40 mins – a sling/carrier can help a lot

Baby upright as when over your shoulder rather than slumped in a chair (American Journal of Paediatrics, Orenstein and Whitington, October 1983)

Frequent burping BEFORE, during and after feed

Avoid car seat immediately after feed

Avoid nappies or clothing tight round tummy

Baby at 30 degrees – not flat –  in cot or on babygym

When changing nappy, put a cushion under baby’s head

Sleepcurve and special wedges

O   = a boob (Better breastfeeding)

Check the latch – getting air in?

One breast at a time, allow baby to continue until stops.  Sucking à continuous muscle movement through digestive tract àkeeps it all going down; baby emptying breast ensures baby ends with calorie-rich hind milk which stays in stomach longer; at end of feed flow is slow àless coming in at top while muscle movement still keeping things moving down.

In some cases with overactive letdown even two feeds in a row on one breast. Consider whether using a breast pump in between feeds is really helping.

Feed baby when not over-hungry so not gulping in air.

Feed baby more often to encourage smaller, more manageable feeds and more downward action.

Reassuring, relaxing and soothing

A pacifier helps baby carry on the helpful sucking action

Atmosphere calm and cosy –You are not a failure if you can’t “stop the baby crying”, you are a hero for giving baby the kind of environment that helps baby to calm self eventually

Mum relaxed with a glass of wine? (recommended by  Dr Jack Newman!)

Lying down;

Massaging Baby tummy and back, upright

Movement that is rhythmical and swaying - rocking, buggy, swing-seat, your lap, your arms

Support from others: Take turns, Find another mum with a colicky/reflux baby

Diet, Doctors (and other health professionals)

Write down everything mum eats for 3 days and log fussy episodes – is there a pattern?

Try cutting out one suspect eg dairy products for 3 days

All these foods and substances have been implicated in GOR and GORD:

cow’s milk protein, chocolate, spices, citrus, cauliflower, onions, broccoli, mustard, aspirin, decongestants, peanuts, wheat, tomatoes, cucumber, soy, apples, bananas...

 A probe or endoscopy can check for acidity and/or damage to the oesophagus.

·         Antacids  - infant Gaviscon

·         Acid blockers eg Pepcid

·         Motility improvers (muscle tone) eg Domperidone

Also many parents find relief after treatment by a cranial osteopath, herbalist.

new breastfeeding helpline

A breastfeeding helpline to support new mothers has been officially launched by the Government. Public health minister Dawn Primarolo announced a £150,000 year package for the advice line to give women practical support and information. Studies have shown that babies who are breastfed are less likely to be obese in later life and gain protection against conditions like asthma, eczema and chest infections. Mothers benefit too, with studies showing a protective effect against ovarian and breast cancer. The Department of Health recommends exclusive breastfeeding up to six months, with continued breastfeeding alongside solid foods afterwards. A new report published by the Scientific Advisory Committee on Nutrition (SACN), suggests a need for more support for new mothers. It looks at the Infant Feeding Survey of 2005, which showed breast feeding rates went up from 69% in 2000 to 76% in 2005 across the UK. However, only half of women in England were still breastfeeding after six weeks. The Government cash will help support the new helpline, which will be run by two existing networks. The Breastfeeding Network and the Association of Breastfeeding Mothers, which receive around 28,000 combined calls each year on breastfeeding, will merge and run the advice line. The Government hopes the newly-created National Breastfeeding Helpline will be able to handle a far higher number of calls than either organisation on their won. The new helpline number is 0844 20 909 20. Copyright © 2008 The Press Association.