Vitamin K

Antenatally, midwives should discuss the issue of Vitamin K with women. Whilst in labour, or immediately postnatally, it will also be discussed. Women, or the baby's father (if they are married - he then has parental rights and is able to consent) must give fully informed consent before it is given (however, in an emergency, such as admission to the Neonatal Unit/Special Care Baby Unit, it will be given without consent). Those with parental rights may also withhold consent to give Vitamin K.

Vitamin K is essential in order for blood to be able to clot. Low levels of Vitamin K increase the risk of bleeding. This is known as either Vitamin K Deficiency Bleeding or Haemorrhagic Disease of the Newborn. This bleeding can be fatal, and the most common site is within the brain. However, the incidence is low, affecting about 1 in 500 babies, with those who are pre-term at the greatest risk. It can occur up until twelve weeks of age, with the greatest incidence being between two and seven days of age.

Research in to Vitamin K is old and the women researched didn't have easy access to Vitamin K-rich food, such as dark green leafy veg, meaning that the research might not be relevant today.

It is believed that the baby is unable to produce Vitamin K until about six weeks of age, and that it doesn't cross the placenta well. The levels found in breast milk are low; however, colostrum and early hind milk contain the greatest quantities.

Parents who consent to Vitamin K must choose the route. If given by injection, only one dose is given. However, if given by mouth, multiple doses are required. However, this is not based on research. In fact, research concludes that oral Vitamin K is as effective as that given by injection, and that blood levels of Vitamin K were just as high after one dose of either route.

The final aspect for women to consider when consenting or not to Vitamin K is its production. Vitamin K is made using extracts from cow's gall bladders. This is often not discussed by midwives; in fact, it is often not known by health care professionals. There used to be an alternative; this was taken off the market a number of years ago.

Birth Plans - What to Consider

Labour is unpredictable. Women who have never had a vaginal delivery before may not to know what to expect. Women who have had previously had a vaginal delivery might expect a replica of their previous labour. The truth is; labour is unpredictable. Each woman experiences labour differently and each baby's birth is unique.

That being said, women are often quite keen to come up with a birth plan. In my NHS Trust, there is a space in the handheld records for women to write their thoughts on their labour. It is quite vague, but prompts women to consider some of the things that they will have some control over. Here is a look at some of the things in labour which women might like to think about beforehand.

Who will be there?
Women will no doubt have planned whom they will have as a birth partner. Quite often, this will be their partner who is generally the baby's father. But some times, this will not be the case, whether for cultural/religious reasons, or because there is no father or for any other list of reasons. It is important that the woman choose someone who is going to be there to support her, not just someone who wants to be there so they are the first to see the new baby.  Women should also consider who will go with her if she were to go to theatre. It will only normally be one of her birthing partners.

In addition to the birth partner, women may also wish to consider if they will have a student present. This will usually be a student midwife, but could be a student nurse or a medical student. And although I have never seen it, I presume it could also be a paramedic student, as paramedics sometimes end up delivering babies. Some women I have spoken to are under the impression that if they give consent for students to be present, there will be a long line of them at the end of the bed, just staring. This is not the case. There will only be one student present (although a medical student did come in for the actual delivery of one of the deliveries I did; she met the woman beforehand, and she was happy for this). Quite often, the student will only have one woman in labour, whereas the midwife may have more than one. This means that the woman will receive constant emotional support from the student whilst the midwife may have to pop in and out to look after more than one woman. The student may or may not be hands on with the delivery. A brand new student may just be there to observe and will do very little else other than chat to the woman and her birth partners, whereas a more senior student may provide most of the care, under supervision of the midwife. Regardless, though, the midwife and the student will seek consent before each procedure, such as vaginal examinations. Even if the woman consents to a student being present, she can decline for the student to also examine her.

Where will the birth take place?
There is no reason why a first time mother cannot give birth at home. A recent study (called the Birth Place Study) has found that low risk women who have babies at home are at a lower risk of a negative outcome, with the exception of first time mums, who have a slightly increased risk, although this is not statistically significant.

At home, women often feel more relaxed and as a consequence, there is better release of the hormone oxycontin - this is the hormone that causes the contractions. There is less risk of interventions and the woman can guarantee that the midwife will only have one woman to look after. There will also be a second midwife called for the actual delivery.

Women planning a home birth or a delivery in a birthing unit or midwife led unit, however, must be aware that there are certain times when transfer to hospital will be advised. Women should be prepared for this outcome, and should listen to t he advice of the midwife.

Will the baby be placed skin to skin?
Skin to skin, where the baby is placed, unwrapped, next to the woman's skin is great for bonding. It helps initiate breastfeeding for those women who are planning to do so, and helps the new born baby control their breathing, oxygen levels, temperature and heart rate. It is recommended that the mum and baby should be left like this, undisturbed, for up to an hour. However, some women do not like the idea of this, as the baby may be covered in some blood, vernix and liquor, and prefer for the baby to be dried down and wrapped up before being given to the woman.

How will the placenta be delivered?
Women can either chose to have an active or a physiological third stage of labour. The third stage of labour is the delivery of the placenta and control of any bleeding. There are two options; firstly, the woman may have an injection of syntometrine or syntocinon. This causes a large contraction and the placenta detaches from the uterus and is delivered with the help of the midwife. The other option is to allow it to happen naturally. The cord is left, attached to the baby an dis not touched by anyone. The woman's body will cause contractions to deliver the placenta. This may take as little as five minutes or as long as an hour. The midwife will observe for any bleeding, and may recommend the injection if there are signs of bleeding.

Will the baby have Vitamin K?
Vitamin K is essential for clotting. Research has shown that some new born babies are deficient in Vitamin K, putting them at risk of bleeding. This is known as Vitamin K Deficiency Bleeding, or Haemorrhagic Disease of the Newborn. Consequently, all parents are asked if they would like their baby to have Vitamin K. This can either be given as an injection shortly after delivery, or by mouth. The injection is given once. The medication by mouth has to be repeated on day 5 and, for breastfed babies, on day 28 also.

The research, however, is old, and was done with women having poor access to Vitamin K rich food. There are no recent research studies in to new borns and Vitamin K.

Waiting To Try

I am still patiently waiting to start trying to conceive. I have been waiting years. I was only about 23 when I first started considering it. And since then, things have got in the way constantly. Sometimes, they were things that I did, like going back to uni. There was no way I could have had a baby whilst still studying. It would have been difficult. Now, I'm looking for a proper, contracted post. But the problem is, I absolutely love being a bank nurse at the moment. I love the fact that I am able to plan when I choose to work. I can pick and choose the days I go in. It's great. I think I am going to have to find a job with regular, contracted hours in order that I can get maternity pay. And then, as soon as I can, I'll go back to just being on the bank.

I've really got to up my exercising and healthy eating, too. I want to lose a couple of stone before trying to conceive - I want my body to be in the best place possible for pregnancy, labour and parenthood.

Please share any tips you might have.

The Truth About Labour

Labour is a unique experience for every woman and for every one of her births. Some labours are fast, some are slow. Some labours are straight forward. Some labours have complications. It is not always easy to predict who will have a good labour and who will have complications. Indeed, labours seen by professionals as good labours may, to the woman, not seem to have gone well.

Some women should have continuous electronic fetal monitoring (CTG) during labour. This involves wearing a monitor to measure the contractions and a monitor to measure each of the fetal heartbeats. Some women feel that they are not allowed to move off the bed once the CTG is in place. With the exception of a few women, such as women who have a CTG due to having an epidural, providing both the fetal heart and the contractions can be picked up, women can choose whatever position they so wish, including being off the bed. Not all women need a CTG. Low risk birth settings - home and Midwife Led Units - will not have this as an option, and women who need CTG monitoring in labour will be transferred to a consultant unit. Women who do not need CTG monitoring will have the fetal heartbeat listened to by the midwife every fifteen minutes in the first stage and every five minutes in the second stage.

One common misconception about labour is the length. There is either an idea that labour goes on for days, when this is simply not the case. Women, particularly nulliparous (never given birth) women, may experience intermittent contractions for days before labour begins as the cervix prepares for labour. Whilst the woman may feel uncomfortable or in pain, and become tired during this stage of labour, this is not seen as active labour. This is the latent phase of labour where the woman's body has a lot to do, but the best place for her to do this, regardless of the intended place of delivery, is at home. As a consequence, women who present to hospital, or call out their midwife, will often be told they are not in labour and sent home with instructions to drink plenty of fluids, to rest and conserve energy and to have a light diet. Gentle mobilisation or the use of a birthing (gym) ball may help.

Conversely, woman may have opposite and unrealistic expectations for their labour. Television shows and films show babies being born as soon as the membranes (waters) have gone. The woman has a single contraction, and the baby is born. Whilst some women do have very quick labours, for the majority of women, it is somewhat longer than that. On average, primiparous women (those having their first baby) will be in labour for eight hours, with subsequent labours lasting an average of five hours Progress of 2cm in four hours is considered normal. UK national guidelines expect a primiparous women to be in the second stage of labour (cervix is fully dilated and there is a strong, involuntary urge to push) for no more than two hours. Whilst three hours is still normal, if delivery is not imminent after two hours, she should be referred to an obstetrician for delay in second stage. An instrumental delivery (such as a ventousse or forceps) may be performed. Multiparous women (those who have had a baby before) should be referred after one hour, but two hours is still within the normal time frame.

The midwife will see other signs as the woman approaches the second stage of labour. Her anus will also start to visibly dilate, she may develop a purple line running up from her anus, her sounds may change and the sacrum (lower back) may visible protrude more than it normally does. However, if no progress is seen, a vaginal examination (internal) may be recommended. Throughout labour, these will be offered four hourly, or more frequently if needed. Before each of these, the woman will be asked to use the toilet and her abdomen will be palpated. During the second stage of labour, the frequency increases to hourly. If the woman is unable to pass urine at least four hourly, she may be offered an intermittent catheter. The catheter is passed in to the bladder and the bladder is drained of urine. Whilst this may be an unpleasant thought, it is preferable to either a delay in labour or a damaged bladder from the pressure of the baby's head being forced on to it with each contraction.

While pushing, even once the head is visible, it can take a while to deliver the baby. The woman's pelvis has a bend in it; this is known as the curve of carus, so as the woman pushes the baby will move around this bend. As she relaxes, the baby will slip back slightly. With each contraction, more and more of the baby's head will become visible, and it will gradually remain visible for longer between contractions. Eventually, the head will remain visible between the contractions. A similar process occurs as the head is delivering - crowning. A small part of the head will deliver, and then retract slightly. This is when the genitalia will sting. The baby's head will sit there for a while, slowly distending the perineum (the tissue, including the skin, between the vagina and the anus), allowing it to stretch slowly. Eventually the head will be born. With the next contraction, the baby should be born.

To assist with pushing, the midwife may place her fingers in to the vagina and apply pressure to the vagina wall. This enables the woman to direct her pushing in the right direction. The midwife will be able to assess the pushing from there, as some women, who may appear to be pushing, are not pushing in the right direction.

Women often worry if their membranes haven't gone. These are designed to cushion baby during the contractions, and it is normal for them to break only when the woman is approaching the second stage of labour. Whilst it seems to be something which is offered frequently, or requested by the woman, it is not always necessary and may remove the cushioning the baby and placenta receive during contractions. This can increase the risk of fetal distress. However, there are times when breaking the waters (or preforming an ARM - Artifical Rupture of Membranes) is indicated, such as for induction, augmentation or to improve fetal assessment.

Labour is a messy business. Yes, some women do have their bowels open, particularly during the second stage of labour. This is normal, and is forced out as the baby's head passes through the pelvis. There will also be liquor (waters), blood (up to 500ml, about a pint, is the upper limit of normal) and the baby may have its bowels open as it is born, and a new born babies faeces is black and tarry. The baby may be covered in a white, waxy substance called vernix, and this may be present in the waters, too. A baby born slightly early may be covered in fine, downy hair (which it will soon lose). This is called laguna.

Once the baby is born, there is still the third stage to complete. This involves delivery of the placenta and control of the bleeding. The placenta may be delivered physiologically. This allows the placenta to deliver as nature intended it to, and may take up to an hour, usually much less, to deliver. The placenta is delivered by maternal effort: the woman has to push it out. It is easier to deliver than the baby. Activities such as sitting on a bed pan or toilet may help. Alternatively, the woman may be given an injection to deliver the placenta. This is called an active third stage. Some women will be advised to have an active third stage, such as those women who have had syntocinon (artificial hormones) in labour or women who have had a lot of babies before. Usually, the woman will have a drug called syntometrine, or, if there are any contra-indications to this, such as raised blood pressure, she will be given syntocinon. These drugs cause the uterus to have a contraction, which shears the placenta away from the uterine wall. The midwife will then apply pressure to the umbilical cord, called traction, and deliver the placenta. Sometimes, maternal effort is required to push out the placenta. Sometimes, the placenta doesn't deliver on its own and a manual removal is required.

Whilst there are a number of emergencies that may arise during labour, midwives and obstetricians are trained to deal with these. They are not that common, and they are often relieved by the initial, simpler and less invasive steps. However, despite all the unpleasant sides of labour, the end goal is a healthy baby and a new little family.

National Guidelines:
http://www.nice.org.uk/nicemedia/live/11837/36280/36280.pdf

Thoughts on a Miscarriage

When I was 19, I discovered I was pregnant. It was far from ideal. I was young and I was a penniless student. The father of the baby was someone I had fancied for a very long time, but he was not a good man. He was a liar and a cheat. He and his girlfriend were in an on/off relationship, and he frequently cheated on her. He cheated on her with me. Whilst I fancied him, at that time, I suddenly realised he could not be the father of my baby - he was nowhere near ready emotionally. In all honesty, I did not want to be a mum. Whilst I had always been against abortion, I did seriously consider it as an option. Fortunately, the decision was taken out of my hands.

One morning, about three days later whilst visiting a home for homeless young mothers, I started bleeding. I bled on to the chair I was sitting on and the manager of the home pointed it out to me. I was so embarrassed. I cleaned myself up, got in my car and drove home. I retreated to my bedroom for the next couple of days. I bled heavily, passed large clots and had the worst cramps I had ever experienced. I phoned my mentor and told her I wouldn't be in. I said I had come down with a terrible cold.

After about two days, I began to feel better. The bleeding, whilst still heavy, was settling down and the cramps were improving. I don't know what my mum thought: I had told her I had a terrible cold, but she could see I wasn't like I normally am with a cold. She has never asked me about it. I saw the man that evening when I went out. I just acted like normal around him. I felt only relief that I was not still carrying his baby.

I returned to placement that Monday, just five days after the bleeding started. I was a student nurse at the time and was out with the health visitor. I was surrounded by babies and young children, and yet this didn't bother me. In fact, the only thing which I was concerned about was bleeding and leaving a mark on someone's couch.

A year later, I had a placement on a gynaecological ward. I struggled to understand how people were so emotional when they miscarried. For me, at that time, the miscarriage was a blessing. And yet, there I was trying to support women who were going through a miscarriage or a threatened miscarriage. I struggled to understand their grief. The only thing which hit me was the fact that I never sought help of any kind when I was miscarrying; in fact, no one knew I was pregnant. And yet, there were a number of women who had been admitted for an evacuation of retained products of conception ( a D&C, as it is more commonly known) due to the risk of leaving the products within the uterus. I had even used tampons to control the blood loss! I realised how dangerous that was during this placement.

About a year after my placement, I thought I was pregnant again. Whilst that pregnancy would not have been planned, and again, I would have been single, I had almost finished university and was more emotionally ready to handle a pregnancy and becoming a mother. I felt guilty about the fact I never mourned the first pregnancy, and felt repulsed at my callousness regarding it. A pregnancy test, however, quickly ruled out that I was not pregnant.

To this day, no one knows of that pregnancy. But whenever I think about it, I felt guilt and sadness at the fact that the pregnancy, which was unwanted, turned out in such an awful way. Even now, that miscarriage brings tears to my eyes.

Shopaholic

I received an email from Amazon the other night, and am very excited to announce that the new book in the Shopaholic series by Sophie Kinsella is due to be released 25th September 2014. I can't wait to read the next instalment of Becky's life, this time set in LA. Shopaholic to the Stars follows Becky, Luke and their daughter Minnie to LA, where Luke is managing the career of a famous actress. Becky wants to become her personal stylist, but Becky ends up working for the actress's rival.

I cannot wait until 25th September to get my hands on this book!