 There we go. We're recording now. So the idea behind an affording is it's based on a birth that happened to me and you just run through it and talk about what you would do and what decisions you would make and we'll just go through it from there. And so first of all I'll just talk about us. So this is my practice. We work in rural New Zealand and we cover sort of semi-rural, rural and remote rural just outside Christchurch. We have in our area two primary units. So these are midwifery primary units. One of them is in is part of a little hospital. So there's no midwives there at all. There's a nurse there and when we birth there we have to have two midwives to go and the second primary unit has one midwife there as our backup and six beds. So they're very small units and about 30 minutes away we have a tertiary hospital. So it's the main hospital for the South Island of New Zealand. We work in pairs so we back each other up and I personally take a small case load of women every month. We all live and work locally. We offer 24-hour midwifery care and we provide antenatal, labour and birth and postnatal care and we're quite happy to birth where the woman wants to birth. Oh we've had someone else join us. Hello Melissa would you like to microphone to talk? Okay so this is my lovely lady. Her name was Claire. She was a healthy woman, she's 27. This was her first baby. She booked with me early and so she was put on folic acid and iodine in New Zealand. She had a negative blood group and a BMI of 34 and I think this was quite linked a little bit to her polycystic ovary syndrome. She was on metformin but she was under the GP for the metformin and she stopped that early in pregnancy. We do MSS1 in New Zealand so that's maternal serum screening. That was normal for Down syndrome, trisomy 13 and trisomy 18 and all her scans were normal. Her GTT was normal and her booking blood pressure was 108 over 68. So her pregnancy was unremarkable. She was really healthy throughout. She planned to birth in the hospital as her first baby. She wanted a normal birth with no pain relief and physiological third stage. So the idea for her was and in our tertiary hospital we have a primary room which I did which is another story but we were planning on providing her with planning a primary birth in a tertiary setting and then in our local unit if you have a normal birth you can't stay there postnatally because the hospital beds are for people who require tertiary care so they transfer back to the local primary units for primary postnatal care. At 36 weeks she was screened for preeclampsia because she did have a high blood pressure of 140 over 90 with some swelling but all the blood tests came back negative so likelihood was she was still working full-time at this point. She was a teacher. She spent a lot of her days on her feet. She had her last appointment with me at 38 weeks and everything was normal. A little bit of swelling but she was well. So the first decision point for Claire's care was she phoned me at 9 a.m. reporting mild period-like cramping. Her waters are broken at 8 30 so half an hour earlier and she was 38 plus 5. If this happened to you what would you do? Oh we've lost Melissa. Okay. So do you want me to talk? Yes I'd love you to talk. I talked to her about how long she's been having cramping pains and how she's coping with them. I'd ask her about the colour of the water and how much water there was. Had she been feeling the baby's movements? Had she tried any pain relief options if she felt she needed to even if that was something like a bath? How she was feeling? What she felt she needed at this point? Yep and that is pretty much what me and her did. So her waters were still clear and they were still trickling so she popped a pad in. She felt baby movements and she wanted to stay at home until the contractions increased. I was actually working at the unit that morning so I said well if you want to come in for an assessment later on you can. Obviously to call me if the labour began in Ernest. She felt well and she was just sitting on her Swiss ball watching movies with her partner. I know she was wonderful. And then I received a call from her partner James and the contractions had begun at 11.45. Now the story behind it is quite funny. He actually left to pop to go to McDonald's to pick them up some food and apparently as soon as he walked out the door she established into full blown labour and she was frantically trying to phone him to get him to come home while he was ordering Big Macs which was quite funny. So when he did get home and gave me a call the contractions were very strong. They were every two minutes and Claire couldn't walk and she felt like pushing. So what would you do? It depends how far she is from you or how like who can get there quicker. If you were close by you could say look I'll just come round or if they were you know you could meet them because I know she was planning to go to the hospital. It depends I guess on what they felt they could do and how close you were to each other or how close they were to the unit. She lived 10 minutes from the unit and 30 minutes from the hospital. So it sounds like it might be best for her say to come to the unit and assess her there and to see is she feeling like pushing because she is in the second stage or is it just you know she's got really a lot of pressure and there's more time. I think that's what I would suggest. See her anyway. Yeah and that is exactly what we did do. I told James to bring Claire to the unit and I was banking on her being a first-time mum basically and not having the baby in the car. Claire and James arrived at the unit and she was fully pushing on arrival. I did she had lots of clear liquid draining normal fetal heart rate and I did a very quick vaginal examination. There was no cervix but I did feel a bag of forewaters but I wasn't very happy with that vaginal examination and so 10 minutes later I asked her if I could do a proper one and it wasn't four waters I was feeling. It was testicles. I called in the one core member of staff at the unit to get her to confirm this presentation and so what would do you have a primary unit where you work? What do you do? It's a very different set up there by the time spent. It is isn't it? That's right well I thought it would be interesting if you had a few people here because then we could talk about what everybody would do in their areas. So there was just one other midwife there? Yep. Well with just one other midwife I guess if that baby is coming then you're gonna need to facilitate the breath there with both of you but I guess you could contact other backup. I don't know if you'd have like some sort of ambulance transfer available to the main unit in case of needing it, say if the baby was born needing resuscitation and needing that support and you obviously talk to Claire and James and discuss with them what this means. Yes we do have an ambulance transfer system but it is only for women when if we have one for a baby it's got to come as a special ambulance that comes from the hospital with a retrieval team so and that can take up to three hours for them to arrive because they've got to get the special ambulance, the transfer unit for the baby and they come with a NICU reg and a NICU nurse. So luckily yeah luckily we do yeah. I was just asking you you've got all the setup at your unit your app for a birth so you've got resuscitation equipment and that. Yes we do yes we do and so that's exactly what we did. We set up the resus and we prepped for PPH because obviously this is a rather rapid neighbour. We called an ambulance because at this point we were still hoping to possibly transfer her in and we also have telephones in the birth room so we called birthing suite we called NICU and we called in two extra midwives so we had two midwives for the women and two midwives prepped and ready for the baby. The baby was a trooper. Her fetal heart rate remained normal. He did pass the meconium but Claire she continued to push beautifully. We did hands and knees and James was just with her all the time. We told her exactly what was going on and we documented carefully. So then the ambulance arrived at 110 and would you transfer in or would you stay? It's a really tough decision because I guess it depends where the baby's at and like you know what stage is the baby at as she's pushing. At this point we were hips on view. Then I'd stay. Yeah you don't want to get an ambulance because the baby's just going to be born. I know and the other thing is in New Zealand the ambulances they don't have anything. Oh wow. They don't at this point when this happened they didn't I don't think they even carried oxytocin on them or PPHs. Yeah yeah they've just been brought in. Where are you with them? Yes yeah. So we stayed at the primary unit. We did keep the ambulance on hold though and they're brilliant. They stayed. Not just that as well as sometimes when there is an emergency it's all about people. So the fact that we had two extra people there who could give us a hand if it was required was you know really important for us. We had hips on view. Claire continued to push. She was beautiful. The two extra midwives arrived so they were brilliant. We had one on the phone to Nicu ordering the retrieval team and one on the phone to birthing suite to let them know what happened. All this time Claire was wonderful. We stayed hands off and the ramp was born at 124 and then we had the first leg, second leg almost immediately afterwards and she birthed the baby in one push essentially from umbilicus to head in one push which was wonderful. Very quick. We did have one minute of delay called clamping. I was extremely lucky the core member of staff that was with me. She was an extremely experienced home birth midwife so it was great to have her advice. Baby did have a fetal heart rate of 100 and he did grimace. So we did give him a heart and with apgas of two but after one minute we clamped and cut and got baby to the resuscitare. He had basically he just had a few inflation breaths and just a little bit of support breathing and he was breathing independently by 145 within 15 minutes of being born. He had pinked up beautifully and was doing really well. He had a normal newborn check with vitamine K because the parents had consented and by 215 he was skin to skin with mum. The Nicu transfer team arrived shortly afterwards and he did have lactates of 13.45. So do you do lactates? I think if we do then we call it something different. I'm trying to translate that in my head. So you have um fetal blood sampling? Yeah and we do the PHs and we do do lactates. Yeah we do. I haven't worked in a hospital in a little while so I'm not, it's not in my head. Yeah we do do PHs but we don't use them too much for clinical decisions but in the hospital they do a lot of decisions on lactates but basically if a baby's got a lactate I think it's above seven they usually go to a section because the baby's getting distressed. So the fact that this baby had lactates of 13.45 is really rather serious and then lactates can mean all sorts of things. So they transferred baby into Nicu for observation. Anyway with Claire she had a physiological third stage with an estimated blood loss of a hundred mils. She had a tiny tiny little first degree tear that didn't require suturing. After the baby had left for Nicu she was up, dressed, showered, all her observations were normal and her and her partner jumped into the car and drove to the hospital and a little side note is when she walked into the hospital the midwives couldn't believe that she was the woman that just done a breech birth at a primary unit because she looked so well. There you go and the baby was in Nicu just for one day only for observation. I don't think they even gave him fluids or antibiotics which is quite surprising and he did have an extra day because he had extremely swollen testicles so they gave him some paracetamol and he also required a hip check at six weeks for breech and he apparently had a little bit of physio on his neck most likely because he was breech. Claire was absolutely fine. She had some anti-dein in the hospital because the baby had a positive blood group and her blood pressure did creep up after arrival in the hospital so she did end up staying in the hospital for four days. She struggled hugely with the breastfeeding and she soldiered on but she eventually went to formula and she just had normal postnatal cares afterwards. I know and there he is. I know but I quite like that first photo because you can really see the breech head. Very very flat. So this was him up in Nicu I think on his first day and the second photo is on his second day and that was him at I think it's about four months by the looks of it. There we go. Have you got any questions? No, it's such a good way of using a story and asking questions along the way is such a good tool for everyone. I think it's really good for students when you're learning. It's really helpful for those decision-making moments. I think so and it would have been lovely if we'd had some people from other countries here discussed because we've all got access to different services and like although we have an ambulance service here it really is just St John's. If we want a paramedic we have to stop and pick one up. I just think I wonder how that would be different to say in the UK. Yeah the ambulance service is quite different. There's usually a paramedic on board and you can let them know that's what you need and they'll send one. Yeah I think in our area I think we have one paramedic and we have to stop and pick him up. So it was lovely talking to you. So what are you presenting? I'm presenting session 20 and it's about caring for LGBT families. Oh lovely! That looks like a really good presentation. Yeah we'll see hopefully it'll go well. Oh I'll come to yours and I'll ask some questions on my microphone. Thank you. Awesome. Linda is there anything else that we would like to add? No I think Linda's gone. Awesome. Oh well thanks Sarah. That's okay there's a link at the top so you can take you straight back to the conference. Cool and I'll stop the recording now.