 I would like to welcome Nicky, who is a lovely midwife working in Royal Lumsden in New Zealand, and she's going to talk about some of the challenges in the joys of that in the next location. Thank you for coming, Nicky. I think it's a particularly relevant topic at the moment in New Zealand. We've lost many of our rural community health services, and I'm sure many people can relate. I'm looking forward to your presentation and the discussion after. OK, this is me. Welcome, everybody. I'm actually working in a little, um, beautiful place in the southern part of New Zealand, in UC Oldland. This first address is actually just taken from my window at home. And that over there that you can see is like a piano. Um, yeah, rural medrithwy, goodness me. For me, rural medrithwy really means and it just sort of upholds the whole philosophy of what the medrithwy's profession is about. And it just reflects that whole principle that we all work with under who, you know, primary healthcare for the vast majority of women who are fit and healthy. Um, yeah, if they start their journey towards their country. You know, for me, primary care just means that looking at other women who are sharing with them their pregnancy about, you know, what is a normal, healthy process of life. OK, so if you're people who don't know where we are, go right down the bottom of the road here, this is New Zealand. Um, this little red square down here, that displays you in South Ireland. We've got two islands in New Zealand. This is a map that I've opened at the top there, Wellington. A little old Dunedin down there there, the main centres. They carry big tissue units. The little mark down the bottom there that's in the chagall, that's a secondary unit, so we can leave the area in there. And then we're just going into this next part, showing the area that little London sits here, that little primary unit there, and we have women in that area. And when we added up, we were quite shocked that it covered 8,200 units. So you need a good car, and you need a starter. However, a block there is that don't get covered by the starter. The little unit that I work at is at London, and I actually live in Tiana, so the women that live in Tiana, Tiana is about 2,500 population. And the women that live in Tiana, then drive to London to have their babies. So I live in Tiana, so I can run regular clinics here and draw the postulatory care here about huge mileage. And then, yeah, when we go into labour women from Tiana, I'm myself drive to London, which is about 78 kilometres. And then the other midwife, Michelle Scott, is my teammate. She is based in London, she actually has a little slap at the unit, and we back it so that up beats the... She has her own case load and I have my own case load. OK, my secondary services in New Zealand. Well, basically how it's funded by the government, every single woman in New Zealand who becomes pregnant attracts a funding to herself that covers primary care and secondary care. So primary care being anything that normal healthy women are in a pregnancy. And secondary care is a touch to her also in case she needs to access secondary services that would be any referral made to her who has come from an obstetrician or a pediatrician, or any reason that her pregnancy isn't going well or has complications. That funding is then paid for by hospital. There's some issues, but you know we all face about that at that time. LMC here has gone from leading to secondary care, that's anybody who can provide full service to these women who are pregnant. And that can be either a midwife or a GP if he's got his primary obstetric or a consultant. And we're playing to each trimester, so the first button and third trimester. Then the labour and birth have a big pay-out and then up to six weeks of primary care. So the running get to know is really well if you're following the mark on booking, which we do at about 8 and 10 weeks most of the time. And then that takes you through right to six weeks after the baby. And this is our little unit, LMC, on the front gate. It's been there for a long, long time as an maternity hospital, about 15 years ago when lots of changes were going on. The community around the area decided that they really wanted to keep a midwifery and maternity centres and maternity centres at the unit in the LMC. So a tax to this client unit is a little medical centre by one GP there. But he doesn't have anything to do with a midwifery and he's not connected to us at all. So just to go over that primary care again. Primary care we all know is recognised as a mongeon of the woman and her baby through the pregnancy, saying information to encourage good decision making regarding how a lifestyle is, where she wants to be. And preparation is kind of a matter. And you know, preparation and believing that women are here to do this job of having babies. And you know it's a good job we have such a good plan with them. Because I think a lot of women now feel that they can hand over that care or somebody must take control of it for them. You know, you do have to build a good relationship with them, give that power back to them, that control back to them. Nobody's going to make them live it anywhere so women have to choose birth at London. They are often, you know, if they don't want to go to a hospital to do it, they can travel to Invercargill. They put some of the piano up about a two hour journey. So London itself is about an hour from Invercargill, so we can look at it as a half hour journey. And then secondary care is recognised as a referral of women to a specialist care in the hospital with complications, treatment complications through either for the mother or the baby. I'll just go and put this in the slide and show you that difference between primary and secondary units in the region. As you can see the little red dots, Levenson is sitting there as a little primary unit. We have a little unit in two separate groups, another unit in Winton and Gore. And Franklin is, which is in Queenstown, a lot of people might have heard of it, it's a big tourist place. And they've got a small unit there. The Invercargill's got a blue dot that's a secondary unit, so they can do daily infections and problems with it. And then the Levenson is the tertiary unit where no conversations take place anywhere in the region. So a scope of practice really from me is including the promotion and the solicitation of a specific logical process of pregnancy and starter. In other words, Levenson women recognise that there is a normal process to do. And I need to have the knowledge and the ability to identify anything that goes out to happen. And that's my job, that's what I do. I share that with women, I see them regularly, they get to trust what I tell them. And then we assess at an appropriate level of specific resistance. We couldn't do our job, add in the rules that are used without, you know, what the decisions, you see the decisions you need to sit in, waiting first to come in any time you take them. Yeah, big areas to cover. I'm living in work and you've put this huge air in me and we are absolutely blessed for the women who live here to understand that we're distant. They are very, very good to us. And we're very clear with our boundaries too, you know. We can't be running out to see that everybody all the time, they understand that our priorities have to be women who are presenting in labour at our time in the unit. And they understand that it's safer to have two mid-last sessions of that. You know, the boundaries that we've had are very, very clear. They have access to us by itself though. But they also understand that if they are out of coverage, which happens in and out all the time, that we will get back to them in the time they can, not just win us, but it's clear. So they see us regularly enough that they know that they can talk to us then. And yeah, they understand that, you know, I'll be there in an hour. We deal off our continuity of care and that's one-to-one midwifordnment relationship. And because how we organise the care, so Michelle, who's based at London, sees the women that are living in that area regularly, we start booking from between eight and ten weeks. And then we see them every four weeks at the 28th week, at the moment, please. After that, we see them every two weeks, up to 36 weeks, and then we get up to every week. And amongst that time, we do try and arrange that the women from Tiana will come over to London at some times in pregnancy, at later pregnancy and meet with themselves. And we also have another midwife, Kate Bentley, who listened to me then and travelled saying, Every fort might depend on a fair spot, and it's just a way to handle it. So the women, we try and get them to come on a fair spot. Informating sharing is what it is all about. You have to talk to women, and they have to be comfortable with you to share information. Each visit we have with them, we build on the relationship that they've had with us. We have a women's health note, they trade their own notes, rewrite them there, they can write them in anything that happens, at any time when we have to see them. And if they need to be seen by consultants, or a key decision, they have those notes with them, and the information they've been shared from me is available to them to take with them. And we do. We tailor the needs of each woman to the appropriate level of care that they require. Some women are very motivated, they come back to me with all sorts of wonderful, great things, but I keep going, well, that will be good. And we talk about... We just discuss the level where they want to go. Some women, you know, absolutely, once they don't be taken to hospital. It's all in big detail, really. It's a beautiful process, taken from the TEPRA planner. Yeah, back to basics. That's what being a role model is all about. You have to know the basics. We need to know that women are healthy and fit. We use our hands, our eyes, our ears, and our tongue. We build on those regular visits. We do the previous... That's the mechanism that's shared with us. We make the process of mother's physical well-being. And we make the background nutritious to make sure that everyone's doing well. You offer basic care for the anti-natal blood well-being that you do, especially the eye-leveling schools. We do run some anti-natal classes that we promise a year at London, so a lot of women find it for that. I have to say, in midwifes, I don't dwell too much on whether craft or anti-natal educators, and I also spend a lot of time reassuring women. Actually, when you have the baby, that has to tend to be much, much easier when you have the baby. You can call it routine sex. I like to say that I'm really full of the mother. It's like a blood pressure regularly. There's a urine sample. Maybe a new picture. It's just a little heart. It's just a little movement. It's just a little issue that arises again. It's just all those things that we do with all the time. Diet, medicine, et cetera. Here's a lovely good picture of our little birthing women at London. The bed looks like it dominates the place, but it doesn't. It doesn't use it very often. That's why it's got to get pushed around a little bit. There's grass in the background. We call it the lemon-co-lipidule. Just to the side though, where that's blue joy. That's a little ensuite basket. You can see it. There's a little alcove here that you can't see. That's because the cupboard's a mirror. It's basic. Click my button, that'll require a little bit of time to move it through. We do have a receptive pair that we've put into it 30 years. Let's get that put somewhere back. I'm starting to take that back. It's mostly shared as a woman. I think we've talked a little bit about that, but it is about sharing and building knowledge that's gentle and each relationship. I don't ever put up... I do believe that discussion has to happen. They have to understand why we're doing them and how those tests are going to... and what results we'll get from them. What will it take? All the women have all the copies of their results and I make sure that they understand them when they arrive. It just makes sure that both the midwives and the mother get to make sounds coming through the business. We talk a lot about in New Zealand about informed consent. That means everything. We discuss everything. We discuss whether we're going to use a necropolic for the third stage. We discuss everything. Everything that's going to happen around that baby. The little baby. At the unit at Lund Cymru. I've got lovely big double bags that I can unseat. I'm in the bathroom for everybody. I move to all the little tops. So we must have a full head, but if we don't... I move to the shoulder. So any of our beautiful women there? OK, so looking at the women. I move to everything is well and healthy. But that's basic. You have to recognise the plight of when something's not right. The rule of midwife, I think, that's one of the things I've learnt very quickly, is that, you know, in fact, just pop out the door and try to come to come with it. There's a guy identifying women. I'm not identifying, but he's made a name. He's got a lot of acting on him. It is a cute awareness of availability of any specific medical aid. We do work on the strict guidelines of what it's called section 80A. It's very detailed and comprehensive, and it pays to make the return. Sometimes you do have to be a bit pussy, because you know you can't listen to. And there's no space you can expect to do this. And also we do have this constant awareness of available weather conditions. Just for instance, tonight Michelle was going to join me to listen to his words. Yesterday we had 15 degrees down here in Tiana. Today it's 3 degrees, and we've got snow on the top. So as a private practice, it wasn't a good time to come over and chat on my computer. You'd have to get back to the other side. So it's being very rare to live together. One good thing in our failure is that there is only one road in Tiana that's a bit of a dead-end care. Most people go on to music bands, and then that's been run from there. Local road people want to keep it open. Lots and lots of people come. People sing songs, poppies, and stories. It is very well maintained. I think in all the years I've been here, it's just five years altogether. I've had one day, and then if I needed to go, I would have got to sing band on the group, because I need to manage my channel. We also have to do a bit of availability of emergency services, access to medical backup. We sell on our budget services. Kate Winsley is coming on the week and makes sure that she has our nurses that cover the unit. Don't you have women's phone calls, thank you? A lot of them have been around a long, long time. They're very happy people. We do like to have two people there at the same time. Sometimes we get calls out. The emergency services availability, you think that, yeah, just an ambulance, but even at lunch from there, you have a local ambulance sitting there, rostered, and getting those calls of volunteers and sometimes they just cannot provide us with an ambulance right away. So sometimes when we're in for one, you may have to wait for one to follow some group, or even some in the car which can take up to 45 minutes to get there. We are very lucky in Tiana that we have a fantastic helicopter emergency service and we do have a big medical centre here that's got at least five doctors and we do have quite a big ambulance service here for the tourists a lot of the time. So it really doesn't get really, really stuck to do the helicopter will come. So we do have to talk to the hospital to request a helicopter. In all the times I'm touching this here, in all the time that I've been here at London, we've only been in a helicopter for quite a long time. That was very, very serious. I was talking to a lady, she had a simple speaker, and I was happy about it. I was pleased about it myself. I was pleased about it, and I had to go in the helicopter that arrived from Tiana with a BT on board in my mum's hospital. The lady left over two and a half hours ago and she was very compromised. She came back and had another baby with her for two years later. It was a normal birth. It was a terrible night. That was one of those nights. In the middle of winter, the police had closed the main road, to draw the ice, the black ice, and when we ran, they were in desperate fate. They didn't want the ambulance to come up the road. It was just one of those hideous nights, but we did get the helicopter, and we got them. I came back to that for me. Midwild, we do it in the first, and the final step in that has to mean that women are young, and have an uncomplicated picture and understand the meaning of the process of labour. We spend quite some time going through. What is going to happen in labour? We talk about the message, and I've done it to go to the middle. We talk to the husband too. We have a labour and through discussion. We come to the unit and look at the person. They know that we don't have any girls or what does really happen. The panadol and the movement. Most transfers that we get out of Lumsden are for women who usually are first-time labourers who are very excited about first contraction and tend to work hard or nice and help me a lot. It's a bit more now, and then it's time to go on a thing slow down and open through the transfer. It's time to transfer the second services. I've just talked about it in terms of disability about getting an ambulance. But it all goes well. It's called the ambulance, it's local, it comes and it's in the down and in the car. It's quite intense with the women, especially in the later stages of labour. We always have on-the-graph travel in the ambulance, and we have on-the-graph music channels to try. I've just gone back to that previous slide. I'm just showing you this one here, because this was my unexpected birth out of Lumsden. This is a wonderful woman called Tiffany, with her daughter Selina there and with Jim Young and her husband, Bruce. We're coming at the back there and we're going to sail with the blood cell and we just have to do this. We're trying this pregnancy from the start to birth at the end of the cycle. It's up there. I've just had babies a bit of things. On the day that she went to labour, it was early in the hours of the morning to run the ambulance. I went on to the hospital, the ambulance. Everybody knew I'd spoken to the ambulance people. I knew they were at the hospital. I didn't think very smoothly until we got about 30 minutes into the journey. The day in mind we were heading to the hospital. We were on top of the gold hill and we were hanging onto the bars above her to be in the ambulance, her husband was following the child. That was a nice big breath I took. I quickly ran the cell. He was involved in another birth at Lumsden. He was just pumped during that lady's end to see the child with ventilation. I hadn't been doing that. I quickly cleaned up the living room and we drove over to Lumsden. Our biggest scare was that Bruce came in behind and we couldn't get him on his cell phone because he'd gone out of trouble. We did get him on his cell phone. We arrived at the unit and we had 801. I'm looking forward to see the light of it. I'm very happy that we could take that. Michelle was just wrapped it for the first time. She didn't want to bring up her face. Mae, I'm looking at Bruce. I'll go there, but I have to say, I really like Bruce pumped. I've finally transferred to this field and practising your emergency skills. The music and military camps are constantly for practice. You have to attend every three or four years to see all the technical skills that part of that technical skills always is to do with the unexpected things there. I'm a little bit social. I have to say the rule, because you never know what's going on. But if you know how to deal with it, it's good for you. This lady here, beautiful Roy, she looks like she's practically from Oxford. This is Paula and Eric. Paula's one of our local CTs. She's her third baby. She went 10 days over to the field and was good to go down from the car door and was very disgusted about because she's had a beautiful picture. So it was her second child, Roy was her third child. She's getting a little bit disgruntled. For the night before she was good to go down to the car door, I said to her, go to the Lumsen. There was nobody in. So her and her husband spent one mile at the hotel Lumsen. She managed to get a dozen labour. So at 8 o'clock that morning, it was a lovely regular contract. She sent that for a big walk. While she was going round the block, she had to have a tomb because she'd spotted in the bushes and had a tomb. So that baby's head went down onto her car as she came back up. The water broke and within a minute we had Roy's head popping out and then we realised that Roy's shoulders didn't come. She was in the bath. She just popped her out onto the bed, lego, by moving her back three times. So she's a very happy baby. This is Kate. This is our third wedlock who comes to the leather. We couldn't do our job with that case. Being a royal wedlock, you have to have regular climate. It's absolutely fabulous. When we didn't have anybody to come and cover us, it's very hard to be just one midwife on, one midwife off all the time. It's just lovely to know that Kate comes and Kate's been a midwife as long as I have. She's also changed in the UK. She's been a midwife for 30 years and has nothing to say with Kate. It's a great character. It's a great one. She's gone in there with our lovely old list of the pair. We have just gone from fundraising and have got some great new equipment to install, but this is what gets built in and it gets put in at the end. Documentation, my goodness me, I sound like a teacher now. Document is absolutely about you. You have to write down what you've discussed with them. They hold their own notes, all discussions and the decisions made with the woman you're talking to. We retain as midwives, we retain a copy of exactly what's in their book, all the test results, all the scans, all the histories. We are at a risk of birth society and have the need to control of things that we're encountering. And that's hard. We can't control things. Not one of those things we can control. So we need business, we need investment and monitoring and that meditates many of it. And when the problems do arise, there's a lot of energy, a lot of resources, a lot of resources, they happen and you do with it. And what you do need to do, that regular, meaningful assessments with those discussions with those women, is all of these things again, they came back and at least once after their birth, so they're present in our garden. Second boundaries, I'll just set up on a little bit of extra in here. It's a bit close to the end of this lesson, but we'll just talk about this. Second boundaries is absolutely vital to ensuring our personal safety. Most of the fellow and I have been to experiences that we've been over-tried and have been doing that. So we have to be quite strong in how we give that information to women and not only to women, but to other people who use our unit. They know that they're there and they're on call for those days sometimes. It's a little bit of a focus. Somebody's texting you, texting you a little bit about anything there. Some of the younger generation are texting you, you know. Can I say, I can't look the next Friday, but it's kind of happened to me and the best way to respond to that is just not to answer until you get to normal hours the next Friday. I think that's a good message. The priority for us, obviously, is to help in the recovery to your birth at London and that I create for our families. Any complications that require a birth at the hospital that suffocates women being connected to a midwife who lives locally to that and in the car good for us or in the room. If they require a second repair, and I have to include indications, I think a lot on midwives now are getting a bit below say about providing care and we get this switch around in the hospital. So, just between, oh, this is actually no, it's back to chronic care and I'm actually not a believer in that. Nobody knows what's going to happen when we're in that scene and we interfere with the normal process. An experience doesn't just mean you're drug-free in a situation. It actually means being in the woman's case and making that a case for her to be comfortable with it. It's easy to be monitoring. All that is into this. All that is into being with a low-key pattern to the woman. So, it's a partner to be into it today. So, it's very good. Many, very good. This is one case I've sent a lot of my time off to the beautiful Lake Nesbora. This is Andrew Naskin. It's one morning we wrote off and it was costly. I don't know if I can. It's close enough to do that. I'm going education. We do have a three-year rotating program in New Zealand that requires maintenance. I've come to the group that are under practice to do it. We do that by trying to change the other midwives and health professionals. We have government-funded medicine covenirs available for rural midwives in training courses, but we're not in our local area. I'm inspired by the in-house education that we run monthly at London. We have a regular staff meeting with all the nurses and all the midwives and then following that, we need to have a little education that's done as well as we're very lucky that our neonatal association that we applied to the other years that women and those educators did a lovely day in our unit using our equipment. We have a lovely lady called Chris who is a private midwife that still does our CPR for people who sell them out. He's just the only one on the floor. One of our lovely nurses lives in the background is in the lab at London. A good profession. We all get on now. We all have a bit of a laugh. We all have great communication and that's our unit run really well. We have great good nurses here. Along with Roste, when we have some of the community unit we have a lot to take them and maybe we'll build in the resources that we've done. We all talk about Somalia, but it's difficult. We have a booth, cleaners are involved, healthcare staff has got to be paid, ambulance staff involved, and then, of course, we have our relations with the hospital. Carriers, they have to be brought down all the time, maintenance, that kind of thing. We are, we talk to everybody, we talk to all the people. These are little beautiful twins. They slept like this for over four months. They slept down where they would sleep with that. I've had a lot of space to go in with all my life, take a work. Where there's nothing now, the facility maintenance and compliance now, we have audits coming out of our ears. We've got a campaign. An audit by one person should be listed. We've also started an audit now for breastfeeding assembly. I absolutely understand the necessity for using chaff of what's going on. That's a small unit like us who's paid $6,000 at the BSHRK. This can be better. I'll doubt that one. It is getting more and more difficult to maintain. Teamwork, this is the list slide up here. This is Michelle and me swimming in Lake Tiana. We did a sponsored sprint to raise money for our infrastructure. Unfortunately, our cover for the weekend is called three. Michelle did the full distance. It's two kilometres across the lake. I've done it in the last week. I've got a hundred myself going to my son. For anybody who wants to know yet, it's 12 degrees on a good sunny day. We're going to do it again next week. My son noted that I had the goggles on. These are just some lovely pictures that I'm going to share with you now. Some of our lovely families. This is about the outside of our unit. This is a little comeback. This is saying one of our lovely nurses. The nurses are awesome. All of our breastfeeding education and plastic women. They're all rural women. They can all cook. That's what they do for our women. That's going to be something new. I've got the back of my car. It came along to the blessings on these days. There's the twins to centre. That's just in the roof. It's big in the hole. It's kind of a profile tree that comes there. All I had I had a second baby. That was four of the two. He just delivered that day and we were doing it. There you go to centre. We do have a lot of pictures again. How beautiful. This is going to tell you about CPI. Helen is coming behind her. Obviously she's coming with something very important. She's part of that. There's piles on the news. She's been there. A lot of people on the floor have just announced that she's not. They've fucked up the babies. I'm going to involve those. There's no such thing as a father's day. Children usually come and visit their grandma. That's how they do it. There's one of that person over here. Very good. Not every day. It's just a garden. It's beautiful. You're back home. I'm going to be back. I'm going to be in the kitchen. Is there any questions now? Thank you. You're welcome. Is there any questions? Hi. I know you had worked in an urban centre before in a tertiary centre. Now you've got the experience of this remote area. What's been the biggest challenge that you've had to meet in making that transition? I think that it was amazing telling that what it's made very clear is that there's a difference between timely and secondary care. The women here have to travel a long way to secondary care so that option of oh well I'll just go and have a message if I don't make it, it kind of isn't there for them. That makes it very clear for us. It makes a very clear difference between the timely and secondary care. I don't think it really was a challenge in my life, but I have to say that having not done some of the classes it was crumbling back to I'd be a student midwife. I thought it was a popular textbook, just to refresh yourself on that. Most of it really is that lovely healthy woman that can be in that area. Sometimes midwives and tertiary centres look down on rural areas, but I'm always so impressed by the strength of the skills that you need and you highlighted that really well, Nicky. Talking about being able to identify the flags and then you need really strong skills to work in a rural area. Thank you very much. You're welcome then. Nicky, you've got a couple of questions in the chat box. Someone was asking, what's the criteria kind of start and what's the rate of transfer? What's the rate of transfer? The rate of transfer. The numbers last year for London, for instance, between the cell and myself 100 women came through London. Some of those obviously were not booked with us and some of them just came to Post-Maker Care but we were involved in 100 of the other women. We had 48 births at London last year out of a total booking I think our numbers got to just over 60, 80. Actual women booked with us and then 48 births at London, so yeah, 50 per cent. Okay, and then someone's asked, do you notice more women are breastfeeding when you finish with them at six weeks? Do we notice more women are breastfeeding? Hmm, not from POM, but from London. Well, I have to say that our breastfeeding rates are nearly 100 per cent. It's just how it is. I don't know why we're so successful. I think it comes down to the the number of people they come in contact with giving them the same information, like the nurses are so committed to it. Some women do choose to bottle feed and we don't make them feel bad about that. Yeah, so yeah, women who choose to bottle feed even then often will give a costume and then we save them, we help them to make sure that they know what they're doing with the bottle feed. Yeah, our breastfeeding, it's not a big issue here and I think the cost of formula puts a lot of people off, so I'm looking there to use all of them. Awesome. I'm going to actually have to call it clicks here because we are newly up to 10 o'clock but I just want to say thank you to you. I know. And there's hoots of questions so if you'd like to have a quick look at the chat box and answer some of them there. Okay, I'll be happy to do that. Yeah. That would be better. Thank you for your stunning presentation. Love the photos. I've got my I've got my little placement coming up so I'm going to look forward to it now. Go, yeah, you will enjoy it. It is so, it is pure magnificent. It is. Thank you everybody. I really enjoyed myself.