Pizzas are delivered……… by Karen King

As a Consultant Midwife my job description tasks me with promoting and supporting normal birth. Well how hard can that be? Women have been giving birth since time began and the size of the global population suggests very successfully. Women have been supporting each other through childbirth for centuries. The first known usage of the word midwife was in the 14^th Century and originates from old English for mid (with) and wif (woman).                

The World Health Organisation (WHO), International Confederation of Midwives (ICM), International Federation of Gynaecology and Obstetrics (FIGO), Royal College of Midwives (RCM) and the Nursing and Midwifery Council (NMC) all agree that pregnancy and childbirth is a normal physiological process and life event and that midwives have a unique role to play in promoting and supporting normal birth.

 So I find myself asking why is it in the 21^st Century we require a specific midwifery role to promote and support normal birth – is that not what a midwife does?

It is complex and multi-factorial and relates to changes in culture and society, the medicalisation of childbirth and the emergence of litigation.

Women have always been anxiousand/or fearful of labour and childbirth which is normal and healthy. However, in 2000 Hofberg and Brockington first identified a condition known as tokophobia (a morbid fear of pregnancy and/or childbirth). This condition has led to an increase in the number of women requesting elective caesarean section. Women no longer support each other in childbirth and are not directly experiencing the process. Women now get information from TV and social media sites which tend to focus on the dramatic and emergency situations. In addition sadly some women are so traumatised by their first birth that they simply cannot face the process again.

The medicalisation of childbirth saw doctors take over from the traditional female birth attendant and women were no longer “with woman” whilst they gave birth but doctors (generally male) were “delivering” women. Control was taken away from women and how a woman was to be delivered was quite prescriptive – generally on her back with legs in lithotomy. Some medical advances were extremely positive with the advent of antibiotics seeing a reduction in deaths from puerperal fever and oxytocic drugs preventing deaths from post partum haemorrhage. However despite the many advances we still cannot find a better way to give birth than nature in that any of the interventions we use all have potentially harmful side effects.

It seems it is best to let nature take its course and as far as possible use natural sources of pain management such as water immersion which has robust evidence of efficacy with no side effects.

With medicalisation comes litigation and the perceived risk that someone will sue can lead to fear amongst health professionals and defensive practice which generally means more intervention.

 It is therefore my job to work with midwives and our obstetric colleagues to have confidence and trust in the women we care for to achieve a normal birth and crucially to identify when that is not going to be the safest option and advise and support her accordingly. The emphasis is on achieving the best birth experience and not necessarily about the type of birth.

We need to work together to reduce the fear. It has been demonstrated in many ways that fear can be toxic – from its ability to alter the labour process and outcome to the culmination of fear across a whole organisation resulting in harm to patients.

Midwives do have a unique role in that they are with women through hours of labour and are privileged to be present at the birth. If we are hard to negotiate with it is because we are advocating for and protecting women against unnecessary interventions. I aim to ensure that midwives are truly person centred in their approach to labour and birth and women tell us what their hopes and aspirations are for their baby’s birth. It is the midwives job to do everything she can to help achieve those aspirations.

I was sad about the nature of the announcement of Prince George’s birth. “Her Royal Highness The Duchess of Cambridge was safely delivered of a son at 4.24pm today”. So who gets the credit for “delivering” the Prince– the Queen’s Gynaecologist! This young woman gave birth – it was she who laboured for hours and felt all the pain, followed by the joy of greeting her new son.

So any women reading this and considering having a baby I would urge you to take back control of your birth – the midwives are ready to support you. You will give birth to your baby (however that may be) and we can leave deliveries to the pizza guy.

The midwives in Dumfries and Galloway are mounting a campaign to encourage women to take back control and have the best birth they can. Look out for the MPower event on 24^th May 2014.

Karen King is a Consultant Midwife in NHS Dumfries and Galloway

Whisky with Water by Nigel Calvert

A man dies and goes to Heaven. When he arrives he sees that there is a long line to the Pearly Gates. After some time he hears a commotion behind him and turns to see a man in a long white coat with a stethoscope in the pocket cutting past everone. He strides right through the gates without a pause and past everyone who had been waiting forever. When the man gets to St. Peter he says, “Say, who was that guy who cut past everybody and walked right through?” St. Peter replied, “Oh. That’s God. Sometimes he likes to think he’s a doctor.”⁽¹⁾.

There was a time when only doctors and nurses had access to the medical information necessary to make a diagnosis and decide on the treatment that was needed. The World Wide Web has changed all of this and now anyone can have access to an almost inconceivable amount of information, both accurate and poor quality. According to the Office for National Statistics, eight out of ten Brits use the web regularly ⁽²⁾. It is interesting to consider the ways that this can impact on health. That, together with a shameless plug for our new Health Protection and Screening website ⁽³⁾ is the subject of today’s blog.

It’s very easy to “Google” a few search terms and come up with a wide range of material, some legitimate and peer-reviewed, some of dubious provenance and quality. With unfettered access to all kinds of health information, we need to help people to make sense of it all. I’m reminded of “J.” the narrator in Jerome K Jerome’s Three Men in a Boat who went to the British Museum one day to read up the treatment for hay fever. In an unthinking moment, he idly turned the pages of the book and discovered that (apart from Housemaid’s Knee) he suffered from every complaint listed ⁽⁴⁾. The scare stories erroneously linking MMR to autism happened in the early days of the web and certainly before today’s almost universal access, yet various anti-vaccine websites still managed to stir up public opposition to the vaccine despite any credible evidence. How much worse might this be now?

But what about the positive ways in which the web can affect health? Using the web as a means of interacting, and even as a tool for delivering healthcare has exciting possibilities. Peer support forums, often run as self help groups – with or without the support of charities – are common. These are perhaps most beneficial for stigmatising or embarrassing conditions where the relative anonymity of the internet can be an advantage. People with rare conditions can also benefit from the global reach of the web. Online consultations with GPs now take place using email, and increasingly with Skype/FaceTime etc. In a rural area, telemedicine can help an isolated GP to get a quick dermatological opinion about an unusual rash. In Scotland we have many national Managed Clinical Networks and teleconferencing over the web can sometimes save hours of travelling for some more productive use of the time.

The web has enabled a shift in the balance of power between health professionals and the public. More than a decade ago, there were reports ⁽⁵⁾ of patients bringing printouts of websites into their consultations with health professionals and today this is commonplace. Interestingly in that survey, the patients reported far more benefit in bringing in material from the web than did the health professionals.

The wider public health can also be affected by the web. An internet-enabled society means that more of us can “home work”. Whilst this may reduce traffic pollution, congestion and potentially accidents, it can also lead to isolation and perhaps a reduction in physical exercise. When whole communities come together on the web it can build social capital. Inevitably when talking about public health, we must consider inequity. The term “digital divide” has been coined to describe the gap in web access that exists between the “have nets and the have nots”. As we grapple with ever decreasing budgets and more printed health information is replaced with web pages (with all the benefits that this brings) we may, paradoxically, be making it much harder for the very people we are trying to reach to actually get access to information about breast screening, immunisation and how to stop smoking.

As healthcare professionals we have to adapt our practice to embrace the world wide web. It provides exciting opportunities to improve quality of care and access to services, particularly in a rural area such as ours. It is true that not everyone has access to a computer, and that in some remote areas internet speeds are still very slow, but in time that will improve.

By its nature, the health related material on the web can’t be controlled so we have to provide easy access to high quality health information. Many charities such Marie Curie, Meningitis UK and Diabetes UK do a great job. The NHS too has some websites of which it can be justifiably proud – NHS Inform is a good example. Now for my shameless plug. Just before Christmas we launched our new Health Protection and Screening website. It provides some original content, such as our policies and newsletters, but much of it consists of links to other material on the web – there’s some great stuff out there if you know where to find it. So far, we’ve had about two and a half thousand hits – a reasonable start. Please have a look – just remember Gavin and Stacey’s Uncle Bryn’s ⁽⁶⁾ sage advice to put w-w-w (whisky with water) in front of absolutely everything – www.dghps.org.

References

1. http://jokes.cc.com/funny-god-jokes/fg98b0/heal-the-world
2. http://www.ons.gov.uk/ons/rel/rdit2/internet-access-quarterly-update/q3-2013/stb-ia-q3-2013.html
3. http://www.dghps.org
4. http://www.gutenberg.org/ebooks/308
5. http://www.ncbi.nlm.nih.gov/pubmed/11956037/
6. http://www.imdb.com/character/ch0122304/quotes

Nigel Calvert is a Consultant in Public Health Medicine at NHS Dumfries and Galloway

 

World Voice Day (April 16th) by Becky Davy

The 16th of April commences WORLD VOICE DAY (dun dun duunn… cue the music) I thought I would take the opportunity to spread awareness of voice and celebrate! Feel free to pop a cork when you get home…

Before I studied to become a speech and language therapist I had little idea about what makes the voice work and what the voice box looks like. I vaguely remember picturing a little harp with lots of little strings… I’ve since found out that’s not the case.

Here’s what I learned in 4 years at uni in a nut shell: Essentially, the voice box (or larynx) is made up of two tiny flaps of tissue (vocal cords) which vibrate together to create voice. The muscles which make this process work are very intricate and small. When air comes up from the lungs it accelerates through the small space and creates a suction, which brings the vocal cords together. This process is called Bernoulli’s principle. A wee fact for your next dinner party: Bernoulli’s principle also makes planes fly!

Not all speech therapists work with ‘voice’. It’s something that I’ve always been interested in and I’ve been lucky enough to have the opportunity to exercise my enthusiasm since working in Dumfries and Galloway. I’m the newest member of the team and have been working for just over 6 months. I’ve always had aspirations to move to the countryside, so I threw the cat, the boyfriend, and all my worldly possessions in the car, drove down from Glasgow to the middle of nowhere and bought a puppy… I’m living the dream!

As a speech and language therapist I work with swallowing, language, speech, and communication.  Voice is only a small part of what I do. Essentially ‘voice’ is the quality of the sound of your speech. Is your voice husky? Breathy? Loud? Rough? Do you sound more like a Joanna Lumley or Lisa Simpson? A Rod Gilbert or a Paul O’grady?

People use their voice for different purposes. Are you a singer? The next xfactor wannabie? A shouter? A parent?! A quiet listener? The quality of your voice can depend on how you use it… and if you abuse it! Some voices are sturdier than others and can withstand more abuse, others run off at the slightest hint of a football match, or Karaoke night! Losing your voice can be a sign that you are hurting it in some way. Similarly, having a gruff or rough voice for a number of weeks without having a cold or other cause can be a sign of vocal misuse.

A lot of emotion can be held in the voice. How often have you picked up the phone to call a friend, and as they’ve answered ‘hello’ you’ve immediately said ‘what’s wrong?’ The moment you hear their voice you can tell that there’s something up. This emotional holding pen can get strained at times and begin to affect the physiology of the voice, causing tightness or soreness. Psychology and voice are interrelated and the relationship can be complex.

Not using the correct techniques when pushing the voice can sometimes cause problems. I often have to remind people that the ‘power’ of the voice comes from the breath, not the throat. If your shoulders move when you take a big breath in…. you’re doing it wrong! Breath control can produce lovely strong voice without putting any strain on the voice box. Breathing and relaxation exercises can help to keep the voice healthy. (That’s why when you pop in to the speech therapy department, you’ll find us all practising our relaxation techniques with a big slice of cake… its therapy… honest!)

There are lifestyle changes we can make to help look after our voice. I find myself giving the same advice to most of my patients having voice therapy. One of the most important is to increase our water consumption. “Gallons and gallons” I cry! “Think of how beautiful your skin will be!” I cry! No one ever listens…! Maybe it seems too easy? Too straightforward? When I recommend complex vocal exercises, people are ardent. I’d be interested to know why people find this one such a stickler to put into practice? Is it the taste? The inconvenience? Thinking it’ll make you run to the loo every 5 minutes? Please feel free to leave some comments! It’s recommended that we drink up to two litres a day, very few of us do. How much do you manage?

Some more advice that I often nag on about is throat clearing…  it’s the little seemly insignificant things that can affect the voice. “Throat clearing? HURUMGH No I never do HURUMGH that. What’s that? HURUMGH I’m doing it right now? I never HURUMGH noticed….” Don’t ask yourself if you throat clear, ask your exasperated colleague across the desk…. As well as being an annoying habit, throat clearing is bad for your voice box. Essentially creating a vicious circle; a wee tickle makes you feel like you want to clear your throat, which bangs your vocal folds together violently, which creates mucus, which causes a wee tickle… and round and round we go. Instead of clearing your throat, try sucking a sweetie, taking a sip of water or gently humming to get rid of the tickle (although that might also annoy your colleagues, there’s just no pleasing some people!)

I also find myself advising people that their voice problem could have links to the environment that they spend their time in. Air conditioning and central heating can be very drying. Sometimes it is necessary to get humidifying equipment to help to moisten the air. The vocal folds are happiest in a botanical gardens glass house. Perhaps the hospital board will consider this when planning for the new hospital? Get your pot plants at the ready people.

I’m hoping that you are reading this, first thing, with a cup of steaming beverage (followed by a glass of water, caffeine is so drying darling, don’t you know?!) and contemplating starting your working day. Before you do, before the tension, the throat clearing and the air con kicks in and throttles your little vocal folds… take 2 minutes to do a quick vocal warm up. We are all professional voice users to some degree or other, some professions use their voice as their main working tool for the whole of the day.

Be nice to your voice.

Read this in your most soothing, inner head voice (the one that says “it’s okay, have some chocolate, you deserve it”… ):

Sitting in your chair, both feet on the floor. Rotate your head all the way around, stretching the neck. Slowly and gently, both directions. Tuck your chin in, and then raise your head and look at the ceiling do this once or twice. Pull your shoulders up to your ears and let them drop again, do this a few times. Gently hum a few notes, feeling the vibration in your throat and enjoying the wide open feeling in the throat. Lastly do some soft vowels… aaaahhhh eeeeeee   ooooooohhhh.

We will have some info out in the foyer and a stall on the 16th so please pop along and say hello.

All the best, Becky.

Becky Davy is a Speech and Language Therapist at Dumfries and Galloway Royal Infirmary.

IDEAS – A Project in Dementia Service Improvement by The IDEAS Team

The three members of the IDEAS team writing today are Fionnuala Edgar, Alison Groat and Lorraine Haining.

At the recent Mental Health Nursing Forum Scotland Awards, the IDEAS team were delighted to lift not only a practice excellence award in the dementia category but received ‘Practice of the Year’ as the overall winner This multidisciplinary team (Nursing, Psychology and Occupational Therapy) was formed in 2012 following a successful bid to the Putting You First fund to address non-pharmacological management of stress and distress in dementia, in line with Scotland’s National Dementia Strategy.

 

(L-R; F.Edgar, L.Haining, M.Born, W.Chambers, R.Warwick, missing from pic A Groat)

 Three members of the team write about their experience of the project to date:

 Lorraine Haining, Advanced Nurse Practitioner writes:

 As the nurse in the team I was extremely pleased to receive this accolade as it acknowledges and celebrates the work and efforts not only of the team but of the Care Homes and supporting services that have made it possible. In my career I have been lucky enough to have had several opportunities to make a positive contribution to changing the way we value and provide care for people with dementia and the IDEAS Project has been another of those vehicles for change.

This multidisciplinary approach lends itself well to holistic care, with each profession providing education and support from their clinical perspective. In terms of Nursing my aim is to promote the prevention of stress and distress symptoms by ensure screening for treatable physical or mental health conditions, ensuring regular reviews of antipsychotics and other psychoactive medications, addressing polypharmacy issues and ensuring effective care planning incorporating all health and medical needs.

A major personal driver for me is that my father has dementia. His experience on the journey has so far been positive and he is coping well with the diagnosis. We have had that difficult conversation about the future and not wanting to be a burden on his family he has opted that we should consider a care home if he is not coping at home so therefore I need to make sure that his positive journey continues if this turns out to be the case and there is no better driver for the best possible outcomes than your love for your family.

Quotes from Staff attending Nursing session:

 

 

 

 

Fionnuala Edgar Clinical Psychologist writes:

In Dumfries and Galloway Mental Health services have been at the forefront of reducing reliance on anti-psychotic medications for stress and distress/challenging behaviour in dementia since 2008. Through the IDEAS team we have been able to be more fully committed to the delivery of support and education to carers working in care homes across the region. This has allowed us to deliver a holistic, person-centred approach that has received overwhelmingly positive results across the region. Training has been based on current guidelines developed by the British Psychological Society (BPS) ‘Alternatives to antipsychotic medications: Psychological approaches in managing psychological and behavioural distress in people with dementia’ (BPS)

From a psychological perspective I have seen a positive shift in carer’s understanding and beliefs about dementia and this will, in no doubt, lead to better quality of life for residents. Staff morale has reportedly increased significantly as carers feel more valued and confident in their role and in their ability to successfully manage stress and distress without the need for psyco-active medication.            

Quotes from Staff attending the Psychology session:

 

 

 

 

Alison Groat, Mental Health Occupational Therapist writes:

As one of three Occupational Therapists involved in the IDEAS project (along with Wendy Chambers and Michelle Born) we feel this Team approach has worked very well. From an OT perspective, we wanted to focus on the Environment and creating opportunities for Meaningful Activity within it.

All Care Homes have been offered the opportunity to undergo a dementia design consultation with OT following completion of The Kings Fund Care Home Environmental Checklist (www.kingsfund.org.uk). Working in partnership with Care Home Staff, immediate environmental changes were identified such as improved signage, improved lighting, and contrast. Some areas have also able to include dementia friendly principles within longer term plans for refurbsihment.

Before and after photos                                                                                          

Change achieved by visually removing door by blending it into the wall has resulted in a marked reduction and on some days a complete removal of this stress for residents.

Staff were also provided with further information and tools on the implementation of meaningful activity tailored to the individual person. SMART Goals were developed with Staff around activities they planned to implement and follow up was offered. A main focus has been on creating the opportunity for normal everyday activity within the environment. We have been delighted to see Care Homes updating Interest Checklists, carrying out more Life Story work and adding everyday activities in to the environment e.g. dusters and sweepers.  We have witnessed excellent examples of meaningful activity already being implemented, which we have been able to share.      

Quotes from Staff attending the OT session: 

 

 

 

 

To date, the Foundation Level Training has been attended by over 600 care home staff and the Intermediate Level Training has been attended by 99 care home staff. We are in the planning stages for the Advanced Level training which will include a Train the Trainers element (for Foundation Level training) thus ensuring the long term sustainability of gains made as the project draws to a close in September.                           

For further information contact:

 Fedgar1@nhs.net; alison.groat@nhs.net; or lorrainehaining@nhs.net