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Cambodia Blog (2)  Reading around the subject

So here we are nearly a month on from the induction day and I am no less excited about the prospect of heading for Cambodia than I was.

I have just worked out that there are actually only five more pay days to put enough by, to survive the month in Cambodia.  Not that I will not be given some subsistence funds, but I will have to survive a couple of weeks with no salary and I need to cover my commitments at home. My month is two weeks annual leave and two weeks unpaid from the NHS.  I do not know how people survive on longer volunteering trips. This really has focussed my attention on how little time there is left.

Only Four more blogs before I go. The most mind blowing quote I have come across so far is:-

“Cambodia is not just like every other developing country. A quarter of the population died. You can’t sweep that under the rug.” (2014 Globalpost.com)

I had been aware of the Khmer Rouge and the tragedy that was inflicted upon the Cambodian people. I was a teenager. The Killing Fields movie has been seen and absorbed since.  But when I read the above, it really made me realise that this beautiful country is literally rising from the ashes.  But they are very old ashes, of a country with thousands of years of history before the Khmer Rouge. My lonely planet guide is proving a godsend.

I again am feeling that feeling I had, when I first learned of the RCM project. I really do want to help in any way to enable maternity services in Cambodia to move forward.  The emphasis has to be on making the care of women and babies a priority. Healthy babies lead to healthy adults, for a future healthy nation. It’s about building.

 

Malaria, floods and a dam

I have also found out a great deal about malaria and will go armed with mosquito nets, repellent, Vitamin B1 etc.  These insects love me wherever I encounter them and I was not aware, till reading around the topic, that they are alive and well and breeding so well in this part of the world.

There are parts of Cambodia that flood each year usually in September. In 2013 the Tonle Sap Lake burst its banks and the Battambang region was underwater. Even areas of Phnom Penh were affected.  I am pleased that my visit is planned for January hopefully the water will have receded, but it does pose a question as to how to plan maternity services for this annual event.  Rural populations are difficult to reach at the best of times, in flood it can be impossible. I remember seeing pictures of a woman in the Indian floods who had literally given birth up a tree.  When the baby wants to come, it comes.

The thoughts on stagnant water and flood water led me on to reading about work on a new controversial dam. This would be the first large hydropower dam to be built in the Mekong River Basin in Cambodia.  Massive undertakings like this will have advantages and disadvantages and there is a lot of press out there on both sides.  Providing a form of power for the nation is of course of paramount importance in a world where energy is so scarce. But alas this means the permanent flooding of vast areas of the country, the loss of people’s homes, farmland and ancient landscapes.

There have been several villages  put under water in the UK, to create massive reservoirs for local water needs. Beneath the waters of Ladybower Reservoir in Derbyshire lies an area which was once the villages of Derwent and Ashopton.  In Wales Tryweryn was flooded to hold water for Liverpool. The future is never easy when people and the ownership of land are involved.

Midwives oversees

            I have been digesting the The State of the Worlds Midwifery Report 2014 and the International Global Midwifery Competencies.  It makes me think about how one side of the world is on a different rung of the ladder than the other.  It makes me proud of the care we have in the modern western world, however I am aware of the need not to share aspects of that care that in hindsight may have done more harm than good.  Why do most women in America give birth on their backs in lithotomy delivered by a doctor? Please let that not be imported into developing countries.  All the evidence supports midwives and their ability to care for the majority of women and save lives.

There will be a projected 0.6 million Pregnancies per annum by 2030 in Cambodia where the majority of the population (83%) still live in rural areas. No legislation exists for Midwifery as an autonomous profession. There is a recognised body to regulate the profession, but no licence is required to practice midwifery. But there is a live register of midwives.(p 72 SoWMy 2014). 

Building links with the Cambodian Midwifery Association is the goal for the Global Twinning Project I think it would be great to connect early in order that the month can be as fruitful as possible for all sides.  Networking is the key and I understand Cambodian Midwives are on Twitter. Yey.

Chumree up sooh  –  Hello

Chumree vleer – Goodbye.

Interestingly can’t find the word for “push”  in the phrase book.

References

http://www.globalpost.com/dispatch/news/regions/asia-pacific/cambodia/140616/cambodia-suffers-appalling-mental-health-crisis

Phnom Penh Post Looking beyond the reservoir. Aug 2014  Dam

Flood warnings

Dam

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Dahlen HG, Caplice S. What do midwives fear? Women Birth (2014), http://dx.doi.org/10.1016/j.wombi.2014.06.008

My response

I have always been interested in the Psychology of Childbirth.  I just know that whoever is in the room at births, and how they are with the woman and themselves, effects what goes on. I did some research many years ago (sadly never published), where I just sat and watched what went on in the birth room.  This enabled me to witness at first hand the roles of all that were in the room; including the carers, the partners and other family members and of course the woman.

It has become clear over many years through the work of Dick-Read (2004 Orig.1959) Gaskin (2002 Orig. 1975) Ranor and England (2010) Hodnett et al (2012) and others;  that there is something about this hugely psychological episode, that needs to be acknowledged and explored further.

Midwives have mentioned to me often in my career, that they feel they may be having an effect as “all their ladies end with Caesarean”.  What they need to understand is it is not only them.  The family, the woman herself and the Obstetrician if necessary, all effect the psychological balance in the room  Therefore we must all try to ensure that the atmosphere during pregnancy and at births is as positive as it can be.  I have counselled women in my care to only take in those who will help them during the process.  Sadly currently in the UK often they are not in a position to choose their carer. This is an important relationship which is the firm basis for the events that will take place.

This article by Hannah Dahlen(2014) describes a study whereby professionals were given an opportunity of sharing their fears about pregnancy and childbirth. The following list appeared.

Midwives top fears.

    • Death of a baby 177
    • Missing something that causes harm 176
    • Not knowing enough and making a mistake 80
    • Doing something wrong/damage/harm 43
    • Not recognising something is wrong 31
    • Causing poor outcome for mother and baby 13
    • Causing serious perineal damage/episiotomy 9
    • Obstetric emergencies 114
    • Shoulder dystocia 23
    • Postpartum haemorrhage 21
    • Obstetric emergency (not defined) 14
    • Foetal distress 14
    • Neonatal resuscitation 11
    • Cord prolapse 6
    • Other (APH, ruptured uterus, eclampsia, etc.) 25
    • Maternal death 83
    • Being watched and criticised 68
    • No support from doctors/organisation 19
    • Litigation 16
    • Being criticised/persecuted/judged 9
    • Workplace stress (bullying/surveillance) 9
    • Doctors criticising/pressuring/questioning 7
    • Support people/relatives 4
    • Professional standards/tribunals 4
    • Being the cause of a negative birth experience 52
    • Saying the wrong thing 21
    • That I will disturb the process 8
    • Woman’s satisfaction 7
    • Negative experience for the woman 6
    • Women being exposed/disturbed/no privacy 5
    • Intervention/trauma during birth 5
    • Dealing with the unknown and not being prepared 36
    • Not knowing what to do/say 18
    • The unknown 10
    • No time to think/feeling out of control 8
    • Losing my passion and confidence in normal birth 32
    • Not having a relationship with women 9
    • Losing passion/confidence in normal birth 8
    • ‘Going to the dark side’ 6
    • Loss of trust in women/birth/midwifery 9
    • No fear 1

I make no apology for repeating the whole 739 item list here, even though it was later reduced to 32 sub-categories. Some commentators in the media clearly think that professional staff involved in maternity care, do not think about the implications of their work as they practice. It is apparent they may be very scared indeed.

I am also in no doubt that if the study (Conducted in Australia and New Zealand) were repeated in the UK, it would obtain similar results. Mmm…. maybe we should ask.

Alas, in my current role I am sure I have become one of the fears. It is my role as an Audit Midwife, to ensure midwives are documenting what they say they have done during pregnancy, birth and the puerperium.  I monitor maternity practice and its effects on women and their babies. It is my bread and butter.

But sadly my role seems to be focussed on the negative findings rather than highlighting the good. I do personally try hard to give feedback when I find really good practice with the midwife or Obstetrician concerned, but the professionals themselves only feel and hear the bad comments.

The role is absolutely “risk” based. But that ‘risk’ seems to be “fear of litigation” in essence. Identifying an issue in retrospect, rather than ensuring good practice is out there to reduce the “risk” of an occurrence in the first place. After reading and reflecting this may soon change.

I totally agree with Dahlen and Caplice (2014) that if professionals are scared to practice, scared of poor outcomes, scared of the retribution of their organisation or the families they care for, it will have an effect on their care that is provided.

There is now growing evidence that women who are in spontaneous physiological birth (those without medical complications), should be supported to do it as naturally as possible.  There will be, I am sure , more evidence in the future that women even with problems should be encouraged along a more physiological route.

When the “allowance” for the second stage of normal labour was extended to three hours in the National Institute of Clinical Excellence (NICE) recommendations (2007) I have to admit, I personally cheered.  I have also been pleased to witness medical staff not going in as ‘gung ho’ after one hour of pushing, as they used to in my early career.

I truly believe Obstetric staff, are as keen as midwives, to work towards the support of physiological birth and the best outcomes for mother and baby. I believe we are changing, challenging and changing together.

Dahlen and Caplice(2014)  go on to offer tips on helping midwives deal with fear: They are all useful to help staff continue with their important roles.

  • Share your fear/s with someone you trust
  • Take responsibility for them-most are a creation in your mind
  • Breathe and slow everything down so you can think
  • Watch the self talk and practice stopping negative thoughts
  • Use positive visualisation
  • Do an obstetric emergency skills course like ALSO
  • Write about your fear and reflect
  • Centre yourself with affirmations such as ‘‘trust in the process’’
  • Be sceptical when others fuel fear; gather information, think carefully
  • Beware the language of fear as it has many forms
  • Remember the loudest voice in the room usually indicates the most frightened
  • Balance your fear with faith in human female physiology
  • Reassure each other that we can reassure women that birth is normal
  • Facilitate women to trust in their ability to handle the outcome, whatever it may be
  • Retell the positive stories about birth to each other and to women
  • Most importantly shed the fear and do not carry it to the next birth

There was also “have a cup of tea”, which sometimes is a very rare occurrence on a busy Obstetric led unit. This is especially true when compelled by the senior midwife on into the next birth. Granted, rest breaks in places of birth should be mandatory.

And there was also one item that did make me laugh out loud.  Not because it is not true and valid in itself, but its place, again on a busy Obstetric Unit, might be questioned i.e. “Knit or crochet at births – it reduces adrenaline.”  Especially with the amount of paperwork required to record all events and this being the aspect that is teased apart in a court of law.  I can see it now “But my midwife was in the corner knitting”…..    One of the biggest complaints now is “my midwife was in the corner writing”, Hmmm.

But that aside. Dahlen and Caplice(2014) have brought to the fore the elephant in the room. It is my opinion that we have to assist the carers with their “fear”  to be able to be; calm, quiet, positive, and encouraging, sometimes assertive, but to have a strong belief in basic physiological childbirth, which might actually make it more likely to occur.

 

References:

Gaskin IM  (2002 Orig. 1975) Spiritual Midwifery 4th Edition Book Publishing Company

Dick-Read G Odent  M (2004 Orig 1959) Childbirth without Fear: The Principles and Practice of Natural Childbirth

Hodnett ED, Gates S, Hofmeyr GJ, et al. (2011) Continuous support for women during childbirth. Cochrane Database of Systematic Reviews Issue 2. Chichester: John Wiley and Sons Ltd.

NICE (2007) Clinical Guideline 55 Intrapartum care. Care of healthy women and their babies during Childbirth Section 1.71. Guidance. www. nice.org.uk/cg5

Raynor M D England C 2010 Psychology for Midwives: Pregnancy, Childbirth and Puerperium  Open University Press

RCM 2012 Evidence Based Guidelines for  Midwifery-Led Care in Labour Supporting Women in labour