taking a break

I don't expect to be updating this blog until I return to study next year.

For readers who are interested in an update on our family, please go here.

Journal: exam finished

Yesterday morning, between 9am and 12.30pm local time, I and around 90 other midwives (I think) sat the exam.

The discussion at the university online forum and the fb site Graduate Diploma of Midwifery has been focused on relief.  The analogy to a difficult labour has, understandably, been made. 

The exam consisted of 18 questions, randomly allocated by computer for each student from a bank of questions.  There were multiple choice; true/false; short answer; and 'discuss the statement' questions.  I would have liked more time to complete the work - I spent more time than I should have on the early questions.  There were questions on pharmacokinetics, the absorption, distribution, metabolism and excretion of a drug; the therapeutic range for a drug; the changes in pregnancy when a drug is used, and what happens to the developing fetus.  There were questions that brought up polypharmacy, drug-drug interactions, genetic variances in enzyme activity, and social attitudes towards medication use in pregnancy.
 
I have nothing to compare this exam with, as it's the first of its kind, but I felt it was a reasonable test of the knowledge that should have been acquired over the past 5 months. 

As I have journalled my student experience since July 18 I have sought to look at the course, and my personal response to the challenges that it presented me with, objectively.  I put these things into writing as much for my own record as anyone else's. 

On the positive side of the ledger I have enjoyed learning the basics of pharmacology, and the application of pharmacology to midwifery practice.  I have appreciated the challenge to work on concepts that did not come easily to my ageing brain.  Visualising the microscopic processes which project molecules of drugs through the blood stream, across cell walls, and to target tissue is fascinating.  Remembering and revising basic science that I studied more than 40 years ago, understanding the constant movement of ionic charge from particle to particle, considering the anatomic function of the various body organs - this has all been good.  I have enjoyed it.  My friend Julie who I play tennis with most Thursdays is a high school science teacher, and she helped me revise the science of water solubility.

The less than positive side of what I want to record here is the lack of teaching by the university.  One tutor responded to calls for help, and presented helpful tutorials using the online webinar facility of the university.  With the wisdom of hindsight, I would encourage the faculty to offer a revision course for any students who are not up to date with current undergraduate midwifery knowledge in basic pharmacology - this applies to most of those for whom the course has been offered.  I think a series of lectures in the first month or so, using the webinar, would assist those students who have not studied at university in the past decade.  I have spoken in person about this to the head of the faculty for this course.

The ability to prescribe is still a little way off.  There is a further topic in the Graduate Diploma of Midwifery, Diagnostics and Investigations, which I will undertake in the first semester of 2013.  After that I will be able to apply for endorsement as a midwife prescriber.

I am thankful to the Commonwealth of Australia for the scholarship assistance that I have received. 


Thankyou for your comments

Journal: Preparation for exam

This week I am trying to spend some good time in revision of the core concepts that I will need, not just to achieve a pass mark in the pharmacology topic, but to consolidate the learning.

One of the main criticisms that I and other students have had as we approach the end of the course is that there has been a lack of teaching of the basics of pharmacology.  We are reading text books and academic papers, and for me the words and concepts of the science are often a confused jumble.

To address this deficit I have been watching a set of  lectures on Youtube

One of the faculty tutors hosted a webinar on Tuesday evening, and went through the practice exam that had been provided.  I found this very helpful.  A couple of points that were identified, at which I might improve my performance in the exam are:

• understanding how points are awarded: a question that is worth 2 marks towards the total score requires the student to make 4 statements (ie .5 each) that are relevant to the question.
• In multiple choice or true/false questions, a student will be awarded marks for each correct statement, whether it applies to the correct answer, or making the argument as to why a statement is incorrect or false.
• Clinical questions, such as discuss a pregnant woman who has a headache and wonders if she can take paracetamol, require discussion of the pharmacology of the drug in pregnancy, as well as the basic midwifery investigations, such as check the blood pressure, and question the cause of the headache.
• Polypharmacy is defined as the concurrent use of 5 or more medicines, which can include prescriptions, over the counter, and complementary.  For example, a woman who is receiving one prescribed medicine, such as oral antibiotics (1) for a chest infection in late pregnancy, may also take an antacid (2) for heartburn, raspberry leaf herbal tea (3) to achieve good uterine tone, an iron supplement (4) for anaemia, and pyridoxine (5) to treat mild fluid retention.  These substances will likely pass easily across the placenta to the fetal compartment.  What are the possible drug interactions with this group of apparently innocuous medicines?

Your comments are welcome.

Journal: Prescribing portfolio ready for submission

Today I am finalising the prescribing portfolio, which is worth 10% of the marks for the topic.  
The finished document contains dated responses to questions posed by the writer of the course, and summaries of my learning and reflections through the course.

September and October were very busy months for me, with a full caseload.  I have not been able to devote all the time I would have liked to, to the course.  Babies have been born, and I have been privileged to accompany a small number of women in their birthing journeys.  In this brief time I have shared great joy, and great sorrow.

I started this course without much idea of how to navigate an online learning situation.  As I now prepare for the exam in a month's time, worth 50% of the mark, I am seeking to consolidate the new knowledge that I have accessed in the past few months.  I expect to do well in the exam, and I am satisfied that I will have met my personal learning objectives at the conclusion of the course.

Personal Learning objectives:

30 July 2012

• To critically review my knowledge of the medicines which I currently use as a midwife
• To develop a useful body of knowledge about the prescription of medicines which will become part of a midwife’s formulary
• To explore and reflect on published scientific work that is relevant to pregnancy, birth, and breastfeeding.
• To undertake the course of study that will meet my undertaking to the NMBA, to successfully complete "an accredited and approved program of study determined by the Board to develop midwives' skills and knowledge in prescribing"

These objectives are within the topic’s stated learning objectives

Some of the issues I have reflected upon and explored have already been mentioned in this blog.  In summary, here are a few highlights: 

Journal of a new student: I have learned a lot about working within an online learning site, and I can now work my way through MIMS online.  This is a big achievement.  I do not yet feel 'fluent' in a virtual library - I just get lost!

Writing prescriptions: I will need to continue to work on the knowledge and skill of prescribing.  The small number of medicines is OK.  I think there are many aspects of the various formularies that still need to be ironed out.  The Victorian law is in the process of being amended to allow midwives to prescribe.

The two Case Studies in which we explored the prescribing of Metoclopramide for nausea in pregnancy, and Benzylpenicillin for Group B Streptococcus (GBS) colonisation of the genital tract, provided good opportunities for learning and critical thinking.  Where I exceeded the word limit, and needed to remove some of what I wrote, I brought it across to this blog, such as in Case Study 2.  Blogs have no word limit!  

A significant piece of work that this study brought me to is the pharmacology of uterotonics.  I am not surprised that the study of pharmacology has confirmed my desire to work in harmony with wonderful natural processes in pregnancy, birth, and nurture of the infant. 

This study has given me information which confirms my commitment to protecting, promoting and supporting unmedicated, physiological birth, except in clinical situations where there is a valid reason to intervene.  The benefit of synthetic oxytocic treatment in preventing excessive blood loss after birth is undeniable.  My reluctance to use these drugs routinely rather than as indicated is related to the majority of women for whom the treatment is not required, and who are thereby exposed to unnecessary medication with attendant risks.

I am also concerned about the extent of possible adverse effects in newborn babies, particularly any sick babies who may need to receive drug treatments, and who may experience adverse drug reactions to syntometrine in mother's milk.  

A question on collaboration has given students the opportunity to engage in the maternity reform process that requires a collaborative arrangement as the starting point for women to receive Medicare rebate for a midwife's services.  It looks like this:
$$=carrot; collaboration=stick 

Collaboration is actually not onerous; it's basic to midwifery practice.  The problem with collaboration as the Australian government requires is that it's one-way collaboration, which is an oxymoron.  'co' + 'labor' requires at least 2 parties to participate.


As I look back on (most of) the pharmacology course, it's worth stepping into the assessor role, asking questions about how the course met my learning needs, and how it could be improved.

I am conscious of a great deal of new knowledge that is foundational to an understanding of pharmacology.  The course lacked systematic teaching of that basic body of knowledge.  I believe this could be corrected by offering weekly lectures for the first month or so, using the webinar function of the interactive online learning site.  Although the course is post graduate, most students have not studied undergraduate contemporary pharmacology courses, and even those who have would do well to refresh their minds. 

A further step is the application of that knowledge to effective midwifery practice.  This is a challenging topic, and could be used for debate between midwives working in various settings.  

Are midwives who have achieved the endorsement as 'prescribers' likely to take a liberal attitude towards medicines, and prescribe excessively, like a kid with a new toy? 



Thankyou for your comments

Formularies

I went to the First national health professional prescribing  summit, which was held in Melbourne, Monday and Tuesday of this week.

I plan to record a few observations here, for my own future reference, and for anyone else who is interested.  The presentations are to be available at the conference site (with a password) after about 5 days.

It became clear to me as the summit progressed that formularies are likely to become bogs in which we get stuck.  This opinion was shared by well-informed people.  Already midwives have a formulary put out by the NMBA, another put out by PBS, and a third put out by each state or territory health department.   Someone has been employed to develop each list, and committees have reviewed and approved them. 

In practice an individual midwife, or other practitioner, has a group of medicines which we are able to work with.  This is the case with my practice now, even before I am authorised to 'prescribe'.  The problem with formularies is that the items listed are effectively taken out of professional scrutiny, and are used because they are available.  An example is the synthetic narcotic, Pethidine.  Pethidine has been used in hospitals for labour pain as long as I have been a midwife.  Without doing a literature review here, I have been aware for many years that there are good reasons for avoiding the use of Pethidine, and many maternity services have moved away from it.  Yet the formularies for midwives, developed by both the NMBA and the Victorian Health Department, include Pethidine. The formularies fail to ask critical questions, and it is quite possible that some midwives will interpret presence of a scheduled medicine on a formulary as a direction for its liberal use.

Don't get me wrong: I know very few doctors who have the same scruples as I do, restricting the use of 'dangerous drugs' to situations of clear need.  I know of very few instances where a doctor counsels people who have symptoms of upper respiratory infection that it is probably caused by a virus, and therefore won't be helped by antibiotics.  Yet almost every practitioner you talk to will easily mention 'evidence based' practice, as if the word equates to the deed.


Listening to the various presentations, I was aware that this is uncharted territory.  I made a list of words that kept coming up:

team, teamwork
collaborate, collaboration
partnership
credentialling
evidence, evidence based
protection of the public
scope of practice
competence, competency
standards
framework

Each of these words was brought into the discussion with, I am sure, the best of intention.  But each can be twisted into unintended meanings, and at times I have to shake my head and ask myself how does this particular theory fit my practice, or anyone else's for that matter. 

The government's reforms that are behind the expansion of non-medical prescribing have led to a flurry of activity, making up rules.  Midwives find ourselves with various formularies being developed in an attempt to 'protect the public'.  "What am I being protected from?" you may ask.  A midwife who is intentional about protecting, promoting and supporting natural physiological processes in childbearing and nurture will move into the world of prescribing medicines with a high level of caution, regardless of what the notation as a prescriber allows her/him to do.




Thankyou for your comments

Journal: Case Study 2 completed

I have had a busy week, with births, postnatal work, and the deadline for the second Case Study, which accounts for 20% of the total mark in the course.  I had some concern when I checked the word count of my draft, and found that I had written about 6,000 words.  The word limit was 3,000.  So I did some radical editing, and posted the finished document on Thursday morning, then went out and enjoyed a game of tennis with my friends.

The Case Study question was about Group B Streptococcus (GBS) colonisation, and treatments.  I chose to focus on the use of prophylactic antibiotics in labour. 

In my 20 years of primary care midwifery practice, attending women who are planning homebirth, I have experienced a couple of examples of GBS infection that, without timely consultation and referral and antibiotic treatment, would have likely led to severe infant and maternal morbidity or mortality.  A case that I would like to record here is that of Katy, a primigravida, aged 28.  Katy had been well through her pregnancy, and at Term experienced spontaneous rupture of membranes, with a gush of clear amniotic fluid at 06:00 hours.  

Katy felt well, and was active through the day.  Her labour became established, and within 12 hours, she asked me to attend.  When I arrived at the home, Katy was in good labour, and appeared to be progressing quickly.  Initial observations were within normal limits.

Over a period of 1-2 hours, I observed Katy’s condition deteriorating slightly, in that she could not keep herself warm.  Katy then went under the shower.  Her temperature was not elevated, but the fetal heart rate was high >170.  Although Katy’s membranes had ruptured spontaneously, and she had had quick progress in labour, and no vaginal examinations, I suspected infection.  I arranged immediate transfer of care to the local hospital, where Katy gave birth spontaneously soon after arrival.  Blood and swabs were taken from mother and baby, confirming GBS infection, and both were treated with antibiotics, and did not experience further morbidity. 


Here are a few excerpts from my assignment. I have not included all the references, as I do not try to present an academic paper in this blog.

Antibiotic regimes in labour, and strategies in neonatal care to prevent GBS colonisation of the fetus and newborn have been implemented since the 1970s, leading to a dramatic decrease in case-fatality ratio from as high as 50% to 4-6% currently.    

In the absence of screening for GBS, specific risk factors for GBS infection in labour and birth are:

• previous infant with GBS sepsis
• GBS bacteriuria in this pregnancy
• Onset of labour <37 weeks
• Membranes ruptured >18 hours
• Fever > 38.0C 

 Any one or more of these risk factors indicate the need for antibiotic treatment in labour.

In settings implementing universal screening, it has been estimated that “2000 women will need to be screened and 500 treated to prevent one neonate developing EOGBS.  Assuming intrapartum antibiotic prophylaxis is 80 % effective in preventing EOGBS disease, 20,000 women would need to be screened for GBS to prevent one neonatal death from EOGBS.” (3Centres 2006, p1).  If a woman makes an informed decision to decline the recommended antibiotic prophylaxis, I am confident that ongoing observation of mother and fetus in labour would indicate the onset of sepsis, and the need to revisit the decision.

My usual practice is not to screen; to be vigilant about risk factors; to avoid internal examinations; and to advise treatment if there are any signs of developing infection.
 
Thankyou for your comments

Journal: the pharmacology of uterotonics

Today I have reflected on bleeding after birth.


In preparation for this study I accessed MIMS online, to revise the pharmacology of the uterotonics that midwives and doctors use in the third stage of labour.  These drugs are Syntocinon, Syntometrine, and Misoprostol. A site linked to MIMS, with consumer information about medicines, is myDr.com.au . Readers may search for other information online, but I have linked each of these drugs to the myDr site to allow easy access to consumer information.

My study method when reading copious pages of information is to look for flashing red lights, which are anything that I didn't know, didn't expect, or am surprised about.  Today's study has provided me with a few flashing red lights.



Before revising the pharmacology of these drugs, I have reviewed the evidence around bleeding and the management of the third stage.  The unavoidable issue that arises for me is that I do not agree with national and international experts who recommend routine active management of third stage for all women.  My disagreement relates to women in my world: women who are well, and who intend to give birth within unmedicated normal physiological processes, and for whom there is a very low risk of morbidity as a result of post partum haemorrhage.  This is an informed position, which I have been studying since I began private midwifery practice in 1993, and realised that there is something unique and protective about protecting, promoting and supporting natural processes in birth and the nurture of the infant.  The principle I follow was set down by World Health Organisation:

"In normal birth there should be a valid reason to interfere with the natural process."

WHO (1996) Care in Normal Birth: A practical guide. 

When I attend a birth at home I carry an ampoule of Syntocinon®10 units, and an ampoule of Syntometrine®.  I use an intramuscular injection of one or both of these drugs if indicated.  A more recent development in preventing obstetric haemorrhage, developed for use particularly in resource-poor countries, is Misoprostol.  I have used this drug in hospital births, but do not carry it.

A few selected facts:

Syntocinon® is a synthetic oxytocin.  Oxytocin is that wonderful love hormone that causes the uterus to contract, and the breast to yield its milk in abundance. 

Pharmacodynamics:

... stimulates the smooth muscle of the uterus, producing rhythmic contractions, particularly towards the end of pregnancy, during labour, after delivery and in the puerperium, i.e. at times when the number of specific oxytocin receptors in the myometrium is increased.... being a polypeptide, is largely inactivated in the alimentary tract and therefore virtually ineffective when ingested. (MIMS)

Pharmacokinetics: 
Plasma levels and onset/ duration of effect. Intravenous injection and intramuscular injection. When administered by intravenous or intramuscular injection for prevention or treatment of postpartum haemorrhage, Syntocinon acts rapidly, with a latency period of less than one minute by intravenous injection and of two to four minutes by intramuscular injection. The oxytocic response lasts for 30 to 60 minutes after intramuscular administration and possibly less after intravenous injection. Distribution. Oxytocin distributes throughout the extracellular fluid, with minimal amounts reaching the fetus. ... Plasma protein binding is very low. Oxytocin may be found in small quantities in mothers' breast milk.
Biotransformation. A glycoprotein aminopeptidase, oxytocinase, is produced during pregnancy and appears in the plasma. It is capable of degrading oxytocin. Enzyme activity increases gradually until term approaches, at which time it rises steeply to high levels. Enzyme activity then declines after delivery. Enzyme activity in the placenta and in the uterine tissue is also high during this period. There is little or no degradation of oxytocin by plasma in men, nonpregnant women or cord blood.
Excretion. The relative ease with which the rate and force of uterine contractions can be regulated by the intravenous infusion of Syntocinon is due to the short half-life of oxytocin. Values reported by various investigators range from 3 to 20 minutes. Removal of oxytocin from plasma is accomplished mainly by the liver and the kidneys. The metabolic clearance rate amounts to about 20 mL/kg/minute in men as well as in pregnant women. Less than 1% of a given dose is excreted unchanged in the urine.(MIMS)

Precautions: ...
Third stage of labour and puerperium. When Syntocinon is used for prevention or treatment of uterine haemorrhage, rapid intravenous bolus injection of oxytocin at high doses should be avoided, as it may cause acute short lasting hypotension accompanied by flushing and reflex tachycardia. These rapid haemodynamic changes may result in myocardial ischemia, particularly in patients with pre-existing cardiovascular disease. Rapid i.v. bolus injection of oxytocin at doses amounting to several IU may also lead to QTc prolongation. When Syntocinon is used for the management of the third stage of labour, multiple pregnancy must be excluded before the drug is injected.(MIMS)

Use in pregnancy. (Category A) Use of oxytocin has contributed significantly to the safety of parturition. However, there have been instances of idiosyncratic sensitivity of the uterus resulting in fetal anoxia.(MIMS)

NOTE: I have asked a question in a tutorial about Syntocinon's inability to cross the blood-brain barrier, while endogenous oxytocin, from the posterior lobe of the pituitary, does.  This topic is not addressed in the MIMS information.  The tutor said she would check the specific pharmacokinetics of synthetic oxytocin.


Syntometrine® synthetic oxytocin/ergometrine maleate

... Syntometrine combines the rapid uterine action of oxytocin, a nonapeptide hormone released by the posterior lobe of the pituitary, with the sustained uterotonic effect of ergometrine [an ergot alkaloid].

Following intramuscular administration, the latent period for the occurrence of the uterine response is considerably shorter with Syntometrine (about 2 1/2 minutes) than with ergometrine given alone (about 7 minutes), whereas the uterotonic effect of Syntometrine lasts for several hours, compared with only 1/2 to 1 hour when oxytocin is given alone. These properties make Syntometrine intramuscular suitable for the active management of the third stage of labour (see Dosage and Administration) and for the prevention or treatment of postpartum haemorrhage, particularly in situations where for any reason the intravenous administration of a uterotonic agent is impracticable. ...

Indications: Active management of the third stage of labour. Prevention and treatment of postpartum haemorrhage associated with uterine atony.

Contraindications: Hypersensitivity to oxytocin, ergometrine or to any of the components in the formulation. Pregnancy, ... Severe hypertension, pre-eclampsia or eclampsia. Severe cardiac disorders. Severe hepatic or renal impairment. Occlusive vascular disease. Sepsis.

Syntometrine has the potential to cause serious adverse drug reactions in breastfed newborns/ infants. Postpartum women receiving Syntometrine should avoid breastfeeding for at least 12 hours after the administration. Milk secreted during this period should be expressed and discarded. (MIMS)

NOTE: I have highlighted this paragraph in red, because I need to follow up on it.  I have never heard this information before, despite many years of working and using it in hospitals, as well as private practice.

Misoprostol is a synthetic prostaglandin E₁ analogue.is used in tablet form, given either orally, PR or PV.  Its use has been promoted for use in resource-poor settings - see FIGO initiative. 
I will not go into the pharmacology of this drug here, as I do not use it.  As with Syntometrine above, it comes with a warning about breast feeding:

Use in lactation. Misoprostol is rapidly metabolised in the mother to misoprostol acid, which is biologically active and is excreted in breast milk. Misoprostol should not be administered to breastfeeding mothers because the excretion of misoprostol acid could cause undesirable effects such as diarrhoea in breastfeeding infants.  (MIMS)

COMMENT:
This study has given me information which confirms my commitment to protecting, promoting and supporting unmedicated, physiological birth, except in clinical situations where there is a valid reason to intervene.  The benefit of synthetic oxytocic treatment in preventing excessive blood loss after birth is undeniable.  My reluctance to use these drugs routinely rather than as indicated is related to the majority of women for whom the treatment is not required, and who are thereby exposed to unnecessary medication with attendant risks.

I am also concerned about the extent of possible adverse effects in newborn babies, particularly any sick babies who may need to receive drug treatments, and who may experience adverse drug reactions to syntometrine in mother's milk.  

Thankyou for your comments