The art of preserving

Some of the plum and apricot crop are preserved as jam

We had a hot day yesterday, and there was a couple of kilos of ripe plums needing to be made into jam.   While I went out to visit a postnatal mother and her baby, Noel worked on the jam.  Now we have newly filled jars to add to our stock for the year, or to give away.

This happens each year.  Sometimes a big crop, sometimes hardly any.  We use simple methods - blanching and freezing, drying, and making jam - and we know that our fruit is preserved free of chemical additives. 



My thoughts now turn to bigger issues.  As I am thinking about retirement from midwifery practice, I look for fruit, and wonder what from my professional journey is worth preserving.

I think the need to preserve knowledge and to pass on skill has always been a professional duty of midwives.  When I have read historical books written by or about midwives, I have enjoyed linking my knowledge to the knowledge of the woman who lived and worked in a different century, attending the women of her community as they gave birth to their babies.  Many women have written journals, and some who are skilled writers have published stories that have endured.  Twenty years ago, when I launched my career in private midwifery practice, the internet (wonderful worldwide web) was new and exciting.  I sensed new possibilities that the www offered.  A book in a shelf is accessible only by those who are physically able to take the book and read it.  The www is a virtual library, and everyone who can access it can benefit from it. An ordinary midwife, like me, could write her stories and present them in a way that anyone could access them.


Recently I had a conversation with a young woman who is expecting her third child.  As her second pregnancy progressed it became apparent from ultrasounds and electronic monitoring that her baby's heart was not functioning well.  This mother experienced weeks of investigations, and visits to specialists, and medication, before her baby was born.  This mother knows the anxiety and stress of a complicated, high risk pregnancy.  We agreed that, in pregnancy and birth, 'uneventful' is good. 

Midwives working in primary maternity care (private and mainstream) in places like Melbourne today usually see healthy mothers and healthy babies - whether the births occur at home or in the hospital.  But a midwife can not forget the possibility of damage or death in any birth, no matter how 'low risk' or uncomplicated it appears.  We know that healthy mothers are most likely to have healthy babies, yet it would be foolish to make some sort of guarantee, that if a mother follows a particular process of preparation, and diet, and physical activity, or state of mind, she will give birth naturally and without incident. 

Every woman is an individual, and her birthing experience is uniquely related to herself, her baby, her family and community situation at the time.   A woman who asks me to be her midwife has usually made very clear choices about her maternity care: that she intends to give birth naturally, avoiding drugs to stimulate labour or to control pain, because she believes that to be the safest way to proceed.  I agree. 

Some women have no concept of carefully informed decision-making; they seem to believe it's their right to choose a birth journey.  The feminist movement has taught them that by controlling their bodies in all areas, including reproduction, they are taking charge of their lives.  It has become common for women to claim that they have been violated in the obstetric interventions used to get their babies born.  Idealistic notions of birth, that a midwife can somehow coach a woman's breathing, or put pressure on some magical point, or manipulate the woman's pelvis, and make it all work well - these ideas may be attractive, but lack substance.  There would be no need for professional attendance if the outcomes could somehow be pre-determined.  There is a journey for each mother and baby, and the interests and wellbeing of both will either open or close doors to options as time passes.  While mainstream obstetric care might proceed quickly to surgery, the authentic midwife will guide a mother in a way that promotes normal birth if that is a reasonable option.


When looking at the epidemiological data of births in Australia, we notice trends: older mothers, more caesarean births, fewer unassisted, spontaneous births.  This is the terrain in which midwives practise for planned home birth, as well as mainstream maternity care.  Women who are giving birth at home aged at least 35 years (30%) are likely to have physical and emotional factors that relate to their age and impact on their ability to give birth in a natural physiological way. Women who have had previous caesarean birth(s) cannot pretend that the uterine scar means nothing.  Women who have been smokers for a number of years; or who are obese; or whose sugar metabolism is compromised, cannot ignore the impact of these conditions on their birthing potential.

If I could preserve one midwifery lesson today, it would be that the woman and her baby are unique, and the midwife's role includes understanding how the related sciences translate into useful knowledge for that individual mother-baby pair.


Thankyou for your comments

Seasons

plums begin to ripen

December brings us to summer.

We have some lovely fruit trees in our back yard, and we look forward to the crops each year.  Apricots are the first of the stone fruit.  They are on an old tree, and there may be enough for a couple of batches of jam, as well as the nicest ones to eat fresh.

Plums are next.  They have begun to develop colour, which will intensify over the next couple of weeks.  Once we have eaten what we need, and shared fruit with the family, there may be some plum sauce this year, as well as excellent jam.  Apricot and plum jam make very acceptable gifts.

The fig tree is heavy with green fruit, which will ripen over the next few months.  The young pear trees are looking good, and I counted 50 green pears on them.  Peaches are the last to ripen, at the end of the summer and into autumn, and we are usually able to lightly stew and freeze a large number of plastic containers of peaches. 

We don't get them all.  Brightly coloured parrots visit and take a noisy meal; possums work through the night; and there are a few insect pests that claim their own sustenance.  The little brown hens do their best to clean up the understory.

Noel and I enjoy working together on the fruit.  Noel's job started months ago, in the early spring, when he got the soft hair brush to dust pollen from one flower to the next.  Living in the suburbs we don't see many honey bees or other natural pollinators.

Now that the first fruit is ready it's important to get it prepared for preserves, and some for dehydration.  We don't use chemical sprays, so molds and pests will quickly damage the ripe fruit.   We have old recipes that our mothers used, from the PWMU Cookbooks.  We have sparkling clean jam jars put away in the cupboard, waiting to be filled.

Recently we bought some stewed peaches and pears, as our frozen supply had come to an end.  What a disappointment!  The commercial ones lack taste, texture, and body.  I won't be rushing to purchase more of them.

That's all very nice, you might say, but what does it have to do with the new theme of this blog, ageing and retirement from paid work?  The fruit trees have been an important part of our lives, marking the seasons, and encouraging us to enjoy the produce of the garden.  We look forward to continuing in this theme as each year comes and goes - tending a few trees, watching the flowers, the little green fruit, the ripe heavy fruit, and enjoying eating and sharing it through the year.

Life is often referred to in terms of seasons: the early spring time; the mature summer; the autumn when the harvest is completed and brought in; and the winter time of rest.  In that sense, the years of retirement are the winter.  In this life there is only one cycle, in which we engage and learn and invest and produce whatever we can.  There is a harvest, but it is in other lives: the lives of our children and grandchildren, and others whose lives we have nurtured or influenced in some way.  They each have their one cycle, and so it goes on.

I do not yet have a vision of the next life, which I look forward to.  Perhaps the winter time of rest will be a time of preparation for eternity: the new heaven, and new earth, and the new body.   







Thankyou for your comments

The passage of time

It seems to me that time has become more of a currency - a commodity of value - as I have got older.  Today I am going to take (approximately) big 10 to 15-year steps back in my memory, to illustrate how I have learnt to value time.  I hope this is more than a self-obsessed reflection (navel-gazing) - I hope it encourages readers to plan to use your own strengths over your expected life journey.

Yesterday I sat next to a friend who is 96 years old.  "How are you, Joyce?" I asked.  "I'm well," she said, "just old."

It is good to belong to a community - to have friends from age groups across the span of time.  It amazes me that a person like Joyce has been 'old' for the time it has taken me to develop and practise as a midwife.  Another friend, a woman in her early 90s named Margaret, was a registered nurse.  In her 80s she was still working in a nursing home, looking after many people who were years younger than her.  These grand ladies set a high standard for 'young ones' like me to follow.  I wonder if I will be able to say, with dry humor, "I'm well - just old" in 15, 20, or 30 years from now!

Most of the time I don't feel old now, even though the government has given me a seniors card.  Most of the time I am able to enjoy work, family, garden, friends - a pretty full life.  But when I miss out on a night's sleep I am reminded that there are lots of younger midwives, all fired up with a strong professional commitment, and keen to practise.  Also, they don't mind staying up all night.


About 20 years ago I took a redundancy package from St George's hospital in Kew, where I had been working as an associate charge midwife.  I joined Midwives in Private Practice (MiPP), and asked a few of the independent midwives (Annie Sprague, Chris Shanahan, and Robyn Thompson) if I could learn from them.  With their support, and the support of women in their care, I attended births in the home for the first time, and decided I was ready to take my own bookings.  I remember noticing little things - that the front door remained closed, and noone who was not invited came anywhere near the labouring woman; that the baby didn't have a plastic name tag on its arm and leg.

I told myself, "I have at least 15 years ahead of me, before I will need to think about retiring.  I am a midwife: I understand midwifery.  I am a mother: I gave birth to and nurtured my four children.  I can guide women, make clinical decisions, and write, teach, and guide other midwives.  I want to practise midwifery in a one-to-one relationship with each woman in my care."  

About 10 years before that, in the early 1980s, I was working night shifts at the Women's Hospital in Carlton.  In a quiet moment I mused to a colleague "One day I would like to work with just a few women, and work with them through the pregnancy, the birth, and postnatally."  (Back then we didn't have words like 'continuity of care', or even the definition of the midwife, and we didn't have the research upon which to base such aspirations.  It was my 'gut feeling'.)

About 10 years before that, in the early 1970s, I went through an amazingly fast journey, of leaving my home in Brisbane, coming to Melbourne to study midwifery, meeting the love of my life (the day after arriving in Melbourne), then (in quick succession): engaged, married, pregnant, graduate, move to USA, and give birth.  No time to consolidate my midwifery learning in a formal sense, but plenty of  maternity-related 'prac' as our babies came into our lives.  (a side note: Noel's graduate studies added to my maternity-related learning, as his research demonstrated the protective effect of colostrum on the newborn calf.  That was new knowledge in the 1970s!)

My mother was a wonderful support to me when our second daughter, Bec, was born.

I would like to conclude this post by telling you, dear reader, that I did not know when I studied midwifery that I would become a good midwife.  In journeying along life's path, I discovered the wonder of love, and of new life.  I have been surprised at how blessed I have been.   God, the Creator and giver of life, has been good to me.

I expect that the 'midwife' in me will continue for as long as mind and body function.  The midwife who is guardian of the mothers and babies; who has skill and knowledge that can be shared in a way that makes sense.  Even when I have ceased receiving calls in the wee hours, to attend the labouring woman, my heart will follow them in their journeys of discovery about the meaning of life.



Thankyou for your comments

Looking forward

with Poppy and baby Lucinda

This blog is taking a new direction.

The time has come for me to prepare for retirement from my full professional role as a midwife, and it seems fitting that I commit this part of my life experience to writing in the way that I have been following for most of the past 20 years.

I have been writing midwifery blogs since 2007, and recording my journey as a midwife since a decade before that (The Midwife's Journal)- before we had blogs.  I have always sought to write with openness, while realising that my topic is often about private and personal matters.  In recording my own thoughts I have attempted to explore issues that will be relevant for midwives and women, as long as midwives attend women.  And although midwifery is the constant theme that gives me a reason to write, giving colour and texture to everyday events, the over-arching theme which offers limitless opportunities for reflection and comment, is life.

My life is being lived within my family and community.  The challenge I face in writing about preparation for retirement from being with woman  is that I do not want to be retiring (yet) from making an active contribution to life.  As I look forward, I hope that in relinquishing the most physically demanding aspects of midwifery practice, I will be able to find new ways of using my skill and passion.

I would like to identify themes that are important in this part of my life journey, and return to them from time to time.  Themes such as

• the passage of time
• ageing
• relationships
• health
• ...

I would like to be able to answer questions that arise.

I would like to be able to comment on changes as I see them in the midwifery profession, and in childbearing.



Recently I was visiting a mother after the birth of her baby, as she reflected on the births of each of her children.  I have been privileged to attend her, in her home, for four of her five children. 

Even as the addition of each child to their family is a time for joy and thanks, there is also a sense of recognition of the great claim each child makes on the mother's energy and life.  This energy is claimed by the little one in early pregnancy, when nausea and retching can leave a mother dehydrated and unable to function normally.  It's claimed in the late pregnancy, when the weight of the child within, together with the relaxation of ligaments, lead to physical pain and exhaustion.  It's claimed in labour, as the mother approaches the time of giving birth, and relinquishes control to the massive natural physiological events that are about to take place.  It's claimed each time the baby takes the breast: self-sacrifice for the sake of the offspring.  It's claimed each time the mother puts aside her own interests for the needs of her child, over and over again, to a certain degree for many years to come.

The work of a midwife is parallel to motherhood.  Each episode - from early pregnancy; through nesting and preparation; through labour and birth; and through the establishment of a nurturing relationship that meets the needs of both mother and child - claims that special caring energy from the midwife.

And just as women reach a time when our bodies cease to bear children, or when we, as managers of all the resources given to us by God choose to cease bringing babies into the world, the midwife is aware of her own time limitations and physical boundaries.

For me, the awareness of a boundary has become evident in my ability - or willingness - to accept the unknowable, unpredictable nature of each birth.  In order to be a midwife I need to be ready to get out of bed in the night, or miss a night's sleep completely - to attend a woman in labour.  Sleep is interrupted by a loud telephone ringing sound, and I spring out of bed, fumble with the phone, and eventually say hello.  The voice at the other end of the line may be familiar, or I may take a moment to work out who is calling.  Then I must get dressed, gather my equipment, supplies, and anything else that may be needed (such as the knitting bag), take an apple for the home journey, and possibly some roasted almonds to nibble on, and head out.  Once on the road I need to be sure of directions - the home visit at 36 weeks usually sets up a plan in my mind. 

When I return home, 6 hours, or 16 hours later, or more, the physical challenge continues.  Exhaustion leaves cold feet, poor circulation, and often sleep is evasive.



The work of midwifery - supporting and working with the mother, and checking the baby's progress and wellbeing - does not challenge me as much as the physical and emotional demands of the job. 

As I think about the time when I will have no more bookings for births, I know there are a good number of younger midwives who are keen to provide the service. 

As I look forward, I think the midwifery profession is in a better place today than it was in 1973, when I graduated, or in 1993, when I commenced private practice.  I also know that there is a great deal of work needing to be done, in protecting, promoting and supporting women's and babies' natural processes in birth and nurture.


Thankyou for your comments

Graduate Certificate in Midwifery

My graduation certificate has arrived, and I have posted the application for endorsement of my registration.

It has been a long journey that I probably would not have taken of my own volition.

Once the paperwork has been processed, I will be a midwife prescriber, and will have my own prescription pads.  The number of scheduled medicines that I will want to use is likely to be very small: syntocinon, syntometrine, maxalon, benzyl penicillin.

post script 16/10/13
I sent the paperwork off last Friday, and got a phone call today telling me that the notation as a prescriber is now on the register.  So fast!

I have set up a new facebook group for midwife prescribers and others who are interested. 

conversation on cord clamping

This week an article Are we cutting umbilical cords too soon? by Sydney midwife, Professor Hannah Dahlen, appeared in The Conversation.

I posted the following comment:

...
I would like to make a point here that the normal physiology of the third stage relies on spontaneous unmedicated progress through the preceding stages of labour. The processes of separation and expulsion of the placenta and cessation of bleeding are finely orchestrated when relying on the mother's hormonal activity.
In the world of spontaneous unmedicated birth, the midwife acts to support the natural physiological processes, and one of the key points is to maintain an intact umbilical cord as the baby is being born. If immediate resuscitation is required, the midwife may instruct the mother to kneel and place her baby on a clean towel on the floor in front of her. The midwife kneels next to the baby, and proceeds with whatever is needed - tactile stimulation, and blowing on the baby's face is often sufficient while assessing heart rate and respiratory effort, but the process may include suction of airways, bag and mask respiratory support, and external cardiac stimulation. As such a baby recovers, the pulsing of the cord is an early sign of resuscitation, ensuring an immediate surge of oxygenated placental blood (with a dash of adrenaline) is delivered with the aid of gravity, to the baby. Then the mother can take her baby to her breast, and wait for the natural completion of the third stage.

My submission attracted a strongly worded response from a person who is identified as a 'public hospital clinician' (presumably a doctor), who considered that I was incorrect in the statement that "the pulsing of the cord is an early sign of resuscitation, ...".  She stated that:

If the midwife conducting resuscitation does not understand newborn physiology, including placental circulation, the baby may well be in better hands in hospital.

I have not tried to defend myself in The Conversation, but will make some comments here here.

I consider the criticism of my statement to indicate a mis-reading of what I have written. In stating that the baby receives oxygenated placental blood, I did not differentiate between arterial and venous blood.

Pulsation of the umbilical cord is in response to the baby's heart action.  The umbilical veins bring blood from the placenta to the baby.  

I can only assume that this criticism came from someone who objects strongly to the very idea of homebirth, and has used criticism of what she understands to be the midwife's knowledge to justify her objection.   She provides further objection to homebirth with the claim that homebirth results "in three times excess mortality for the babies of low risk mothers (compared with birth in hospital)."  This is an unsupportable statistic that has been quoted from time to time, which I think is based on a retrospective report of homebirths in South Australia, published in 2010.  Click here for more discussion and links.

The safety of homebirth is difficult to explain using logic or science.  It makes sense that quick access to all the machines and highly skilled people, if something 'goes wrong', should result in overall better outcomes than being in the woman's home.  Although a midwife is ready and skilled to intervene, and provide neonatal resuscitation, or other life-protecting measures for the baby or mother, the safety of homebirth is not in the interventions: it's in the woman's and baby's own abilities to proceed through the amazing transitions in birth, and the midwife's skill to work with, and not against, those natural physiological processes.

The umbilical cord does not pulse by accident after birth.  It pulses because the link from the newborn baby's heart is open.  This opening will quickly close as breathing becomes established, and the baby's body becomes independent of the mother. 

A recently published (2013) Cochrane Review of 'Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes' states that:

There were, however, some potentially important advantages of delayed cord clamping in healthy term infants, such as higher birthweight, early haemoglobin concentration, and increased iron reserves up to six months after birth.

Those who have seen births in hospitals will know that there is often a great flurry of activity by the accoucheur immediately after the birth of the baby, and that the cutting of the cord and passing the baby to a second person (doctor/midwife) who proceeds with the rituals of drying, and 'resuscitating' the baby, happens very quickly.  These practices need to change. 

I am often the only midwife present at home births.  There is noone to pass the baby to, other than the baby's own mother - cord intact. The woman in her own home is free to choose the place where she gives birth, and the body position she adopts to give birth.  She may be kneeling, lunging, sitting, standing, squatting, or lying.  The baby may be born in water or into air.  My response as the moment of birth approaches is to be ready to take action if required, or to simply be there and witness the wonder of creation in the birth of a child.



Thankyou for your comments

GBS screening

INFORMATION SHEET

Making a decision about prenatal GBS testing

Your midwife or doctor may recommend that you have a test in late pregnancy to determine whether or not you have a particular bacteria, known as group B Streptococcus, or GBS, in your vagina and anus.  This Q&A is designed to give you factual information about GBS screening, to assist you in making an informed decision.

Q.        What will happen if my baby develops GBS infection?

A.        The purpose of both ‘screen and treat’ and ‘risk factor’ protocols (see below) is to prevent early onset GBS in the newborn baby.  A baby who develops a GBS infection may quickly become very ill, and requires expert neonatal services that include assessment, treatment, and observation from a skilled team of doctors, nurses and other services such as pathology and X ray.

Q.        Is there any risk to my baby if I have antibiotic treatment in labour?

A.        Antibiotics should not be used without a good reason.  The potential side effects of antibiotic treatment include altered colonization of the baby’s skin and digestive tract.  Discuss the potential risk and benefits of the treatment protocol that is recommended to you with well informed professional care providers.

Q.        I don’t feel unwell, so why would I need to be tested for this bacteria?

A.        It is estimated that one in four pregnant women will return positive GBS swabs.  The presence of GBS in the genital tract usually produces no symptoms, and is not harmful, except during labour. 

Q.        How is the test performed?

A.        The test requires a small sterile swab to be placed into your vagina, then in your anus.  Your privacy is ensured, and a midwife will offer you the choice to swab yourself, or to do it for you.  The swab is then placed in a special medium in a test tube; labeled carefully, and sent to the laboratory.

Q.        When is the test performed?

A.        Between 35 and 37 weeks’ gestation.  Screening cultures take 24-48 hours to become positive, so this test is not useful once labour has started.

Q.        Is there any way that I can eradicate GBS from my genital region?

A.        There is no evidence that treatments to eradicate GBS lead to improved outcomes, such as reduced rates of GBS infection in the mother or baby.

Q.        What will happen if I have a positive GBS test?

A.        The purpose of this screening test is to identify any pregnant woman who has GBS, so that antibiotic treatment can be started in early labour, at least four hours before the baby is born, or when the waters break, and continued until the baby has been born.  This plan is called ‘screen and treat’.  The antibiotics are usually given intravenously, via a cannula in your arm. 

Q.        What will happen if I decide not to have the GBS test?

A.        When the GBS status is unknown, your midwife will observe for risk factors that would indicate the likelihood of GBS infection, and advise you to have antibiotic treatment if any one of these factors presented.  This is called the ‘clinical risk factor’ in labour approach.  The risk factors are: labour starting at or before 37 weeks’ gestation; rupture of membranes for 18 hours or more; maternal fever of 38C or more (usually accompanied by fetal tachycardia); previous GBS infected baby; or a positive GBS urine test during this pregnancy.

Q.        What will happen if my GBS test is negative?

A.        You will not receive antibiotics in labour, unless you develop one or more clinical risk factors.

Comment:

Midwifery imperatives of working in partnership with each woman, and the promotion of normal birth, as well as preventative measures, the detection of complications in mother and child, and the accessing of medical care when indicated (ICM 2011) are principles that guide my thinking as I engage in clinical assessment, discussion, and ongoing planning of care for each woman.  At all times the wellbeing and safety of mother and fetus/child are paramount.   

There is no clear, ‘black and white’ answer to the question of screening well women for GBS that will ensure safety and wellbeing.  In my practice I do not ask women to undergo screening. 

 
Thankyou for your comments

Coming to the end of the course

This week I will be submitting the final two assignments for the course.  Once the results have been finalised I will be able to apply for a prescriber number.  Here's the process (I like to record the links here so that I can refer back to it when I need to, or if anyone asks me about the course):

Applications forms are available from the AHPRA website:

http://www.nursingmidwiferyboard.gov.au/Registration-and-Endorsement/Endorsements-Notations.aspx.

Once I have been endorsed with APHRA as a midwife able to prescribe scheduled medicines, I need to apply for a prescriber number. Information regarding this process, application forms and order forms for prescription pads with my name on them are available from the Medicare Australia website: http://www.medicareaustralia.gov.au/provider/other-healthcare/nurse-midwives.jsp.

Once I have a prescriber number I can register to receive the Australian Prescriber journal, which is free to all Australian prescribers. Details are available from their website: www.australianprescriber.com.

 
One of the areas of  'extension' to my knowledge that I have experienced in completing this course is a better understanding of the relatively simple and routine investigations that are done for healthy women in their pregnancies.  For example, blood tests that detect anaemia, (FBE and Iron studies), and understanding when anaemia is best treated with iron supplements. 

The wonderful web has given me access to good sites that I might not have accessed otherwise.  For example, from the UK GP Notebook site:

The mean minimum value for haemoglobin accepted by the World Health Organisation is 11.0 g/dl (at sea level). A woman with haemoglobin levels below this value that occur during pregnancy has, by definition, anaemia in pregnancy.

Anaemia in pregnancy is more common in patients who are already anaemic at conception e.g. patients with haemoglobinopathies, poor diet, with a history of menorrhagia. Women with a multiple pregnancy are more prone to the development of anaemia.

During the antenatal period Hb estimation are routinely taken at booking, 28, 32 and 36 weeks. An iron deficiency anaemia will exhibit a low serum iron and raised total iron binding capacity, with a hypochromic microcytic film and low serum ferritin.

(GP Notebook: Anaemia in pregnancy http://www.gpnotebook.co.uk/simplepage.cfm?ID=1516961871 )

Comments on ferritin, from Melbourne Haematology

Small amount of circulating serum ferritin reflects body iron stores.  Is now well established in assessment of iron stores

Normal range 15 – 300 ug/l  (reference ranges vary depending on the method used)

Levels < 15 ug/l reflect absent / reduced iron stores 

Elevated levels may reflect iron overload but will be increased in liver disease, inflammation or malignant disease. In the presence of inflammation, a level of > 100 ug/l generally excludes iron deficiency (Melbourne Haematology http://www.melbournehaematology.com.au/pdfs/guidelines/melbourne-haematology-guidelines-iron-studies.pdf

Note on Haemoglobin: NICE (2008) advises that Hb below 11g/dL in early pregnancy (at first contact) and 10.5 g/dl at 28 weeks should be investigated and Fe supplementation considered.

The fall in Hb during pregnancy, indicating a healthy plasma volume expansion, does not indicate the need for Fe supplementation. (Little et al 2005)

There is a considerable variation in the Reference values for low (100-115) and high (137-165)



From the South Australia Health Department's site

Anaemia with a low MCV that does not respond to iron supplementation should be investigated with iron studies. True iron deficiency is characterised by the following taking all parameters into account:

>  Low ferritin (< 15 mg / L) 

>  High transferrin (> 5.56 mmol / L) concentration (transferrin levels are higher in than outside pregnancy)

>  Low serum iron (< 8 mmol / L) 

>  Low transferrin saturation (< 10 %)

SA Health Dept, Maternity Care in SA: Anaemia in pregnancy (http://www.health.sa.gov.au/PPG/Default.aspx?PageContentID=2479&tabid=95 )
Thankyou for your comments