Midwifery Caused My Vitamin B12 Deficiency.
Cognitive decline / Brain fog / Joint pain / Exhaustion / Vision loss / headaches.
Midwifery is a demanding job that bears a high level of responsibility. Working thirteen-hour shifts in a large obstetric maternity unit, juggling motherhood to three young children, and running a home was tiring.
The maternity unit was often short-staffed, and working without breaks meant going without food, sometimes for thirteen hours or more. The staff considered this a normal way of working, and it’s pretty extraordinary how quickly one can acclimatise to it.
Coming home late in the evening meant grabbing something to eat that was quick and filling. Quick meals are rarely nutritious. My children ate with their childminder, so I just had myself to feed. My regular quick meal was often a pizza thrown into the oven for ten minutes or a microwave-ready meal. I rarely ate meat; — I don’t like it. I’m a fussy eater. Pasta, pizza, and sandwiches became my regular quick fill-up meals.
After about ten years of maintaining an unhealthy lifestyle, I noticed changes in my health, cognitive balance, and character. I was thirty-eight, and some of my symptoms I passed off as normal age-related processes like a change in my eyesight; — I started to wear glasses to correct my vision, and the headaches I passed off as vision-related. The joint pain and lack of energy were typical for working long hours.
Thirty-eight years old isn’t old or even middle-aged, but it isn’t young either. I began to struggle to work the long shifts. I slept well every night, but I wasn’t getting enough sleep despite sleeping soundly. Sleeping eight hours straight did not restore my energy.
Tiredness became constant, even on my days off, and gradually over time, I began to recognise that it was more than tiredness; — It was exhaustion.
My symptoms had been building slowly for months and steadily worsening. I began to experience memory loss; it felt like a deep fog inside my brain that I couldn’t push through.
I began to struggle to concentrate. One day I forgot my pin number at the supermarket. Fortunately, my shopping hadn’t exceeded the chip and pin amount, and I could swipe my card instead. My neighbour called out to me over the garden fence on another occasion, but I couldn’t recall her name. We had been neighbours for ten years! I delegated the drug-round to others at work because I couldn’t concentrate fully.
Gradually, over time, my voice became slightly slurred. I needed to concentrate on speaking clearly. I was usually a fun and chatty person, but I stopped talking unnecessarily for fear that someone might notice my garbled speech or the awkward gaps when I spoke. At work, I would distance myself to avoid chatty situations.
It’s easy to avoid situations in a busy hospital environment. Looking busy at the staff hand-over was challenging. To avoid conversation, I would Keep a pen poised over a set of patient notes to give the impression that I was concentrating, therefore unable to interact; or disappearing to organise the drugs-cupboard or linen-cupboard was a good ploy for avoiding stressful situations.
The frustration of forgetting words was irritating enough, but then I began to lose concentration mid-sentence, and I would completely forget what I had been talking about. It is easy to laugh it off when it happens with friends or family; I would say, “oh, I’ve forgotten what I was going to say; I must be tired.” But, when it happens in a professional environment discussing professional issues with professional people, losing concentration becomes a serious problem.
I developed short term memory problems; — things like forgetting to follow up on a patient’s request for medication or failure to return to help a new mum with breastfeeding. It began to affect my confidence. I became anxious around people — not wanting to attract a situation that might highlight my inability to speak coherently or my failure to remember something important.
The realisation that I could potentially cause my patient’s harm began to dawn on me. My confidence dwindled. I began to withdraw, and I developed anxiety about going to work. My inability to function normally became evident and difficult to hide from friends, family and colleagues. I became scared because, deep down, I knew that I was entering into cognitive decline.
My recognition of how bad things had become happened one day working on the labour ward; my patient sustained a perineal tear and required suturing during a birth. I was asked to mentor a newly qualified midwife to suture my patient. We prepared the lady for suturing. We elevated her legs into stirrups, and together we perched between her legs on a low-level stool. I suggested that the patient continue to use the gas and air (nitrous oxide) for pain relief as she had done throughout her labour.
I began the usual conversation with the new mother, describing the procedure to repair her tear. It was a well-rehearsed speech that took place daily on the labour ward.
The conversation started okay — the repetitiveness of voicing the same conversation repeatedly makes these conversations easy. But when I began the usual spiel of informing and discussing the procedure, I struggled to find the words. I faltered, and there were long awkward gaps in my explanation.
Fortunately for me, the newly qualified midwife had been chatty and knowledgeable. She was one of those annoying people that liked to finish a sentence for you. So when I failed to recall the word ‘Apex’ used to describe where to place the first stitch, she was happy to say it for me. From that, I suggested that she take the lead, and I would remain quiet to allow her to demonstrate her ability. We agreed that I would intervene if required.
The new mother continued using gas and air throughout, allowing for a simple and straightforward procedure. The newly qualified midwife accomplished a perfect finish. I managed the process by silently utilising a pair of forceps as a pointer to direct each stitch.
I left the room at the earliest opportunity feeling distressed at the realisation that I was no longer fit to practice. The clarity of my situation screamed at me that day. Until that moment, I had been in denial, and I realised I could no longer ignore the fact that I had a cognitive impairment. I felt exhausted, overwhelmed and incompetent.
I visited my family doctor. He prescribed antidepressants and assured me I would feel better within a month. He handed me a ‘Sick Note’ for my employer, and I was advised to rest myself. “You are burnt out. You are suffering from occupational stress, and this has caused you to become depressed”. He said. It seemed like a reasonable diagnosis to me. All of my symptoms could be stress-related. Indeed, I had known colleagues to never return to work after a diagnosis of stress. Stress is known to be a serious and debilitating illness.
I wanted to believe that I could rest and return to my old self.
I took a month off work and returned to my doctor for another sick note. I felt no better. My doctor suggested I exercise more. I told him I could no longer manage the gym; I was exhausted all of the time. I had no energy to go out anywhere and no concentration to read a book. He sent me away with another sick note for my employer and more antidepressants.
My doctor carried out a simple memory test by the third month, requiring me to listen to a few sentences and then repeat the information. I failed.
I was referred to a neurologist for further tests. The neurologist sent me for a brain scan to determine any evidence of dementia. My results showed no evidence of dementia.
Meanwhile, my supervisor phoned me weekly to see how I was getting on. She sounded sympathetic, but I knew it was lip service; she was stressed. She didn’t have enough staff to cover the shifts, and having to phone a staff member that was putting her feet up under the guise of stress probably irked her.
Being off sick with ‘stress’ left me feeling guilty. An obvious visual reason like a broken leg would carry more clout to be off work. In my workplace, ‘Stress’ had become an umbrella term for skiving off work, especially if it went on for too long; that was considered ‘milking it’.
I was in a dark place — the guilt for not working caused my anxiety to increase. I withdrew further. I barely answered the phone anymore, and I avoided calls from my supervisor. She started emailing me instead. I explained that I couldn’t speak coherently, and emailing was easier. I explained that I kept forgetting words and struggled to string a sentence together;- email allowed me the opportunity to compose my words without awkward gaps. It made me feel like I wasn’t stupid; email meant I could still articulate a conversation without feeling under pressure.
Then, one day my supervisor emailed me to say that I must attend a ‘return-to-work’ meeting; I could not continue receiving full pay and that my options needed to be discussed face to face. By this time, I had been off work for four months.
In four months, there had been no improvement in my health. In reality, my health had deteriorated further.
I attended the meeting. I took a friend along for emotional support and to help me if I needed help to communicate coherently. Before the meeting, my supervisor informed me that it was simply a formality — an informal chat with herself and the head of midwifery. She had said they were looking forward to seeing me. In reality, the meeting felt hostile; I was questioned about my day-to-day life. It felt like an interrogation. I was reminded that I had a professional duty to my colleagues who were also feeling stressed. I left the meeting feeling inadequate, frustrated and utterly drained.
I knew that I could not perform at a safe or acceptable level as a midwife. I was in no fit state to manage any care to patients. My physical and mental ability had regressed to the point where I sounded like a babbling child. Almost unrecognisable to the person I had once been.
I agreed to attend the hospital’s Occupational Health team, but I knew that attending Occupational Health was simply a formality. It was a tick box exercise. Occupational health could not do any more than my doctor had already done. I was his patient, not theirs.
My next doctor’s appointment was the pivotal point of change. It was a week before Christmas. When I arrived at the surgery, I was informed that a locum Doctor was standing in for my usual doctor. I sighed and felt annoyed that I would have to embarrass myself, failing to speak clearly to a stranger about my symptoms and request more medication. But instead, he had already taken the time to read through my notes and was kind and sympathetic. He said, “You’ve not had any bloods taken, have you?” No, I replied. He tutted. He appeared annoyed that nobody had investigated my blood. He sent me to the nurse for a blood test.
It was 4.30 pm on Christmas Eve that the kind and sympathetic doctor telephoned me. “Your blood results have come back. Your Vitamin B12 levels are critically low. I’m sorry to inform you, but your levels are life-threatening low, and you are potentially bordering on brain damage. Please come to the surgery immediately, and I will start you on Vitamin B12 injections and folate.”
He explained that my red blood cells were enlarged, which indicates B12 deficiency, and my serum B12 level was severely low at 112 pg/ml. He also explained that my blood results revealed that I have no intrinsic factor, an enzyme inside the stomach essential for absorbing B12. “You have a condition called Pernicious Anaemia, and you will need Vitamin B12 injections for the rest of your life.” He told me that I had developed an autoimmune reaction inside my gut, probably due to prolonged malnutrition. It was not reversible. However, “it is easily treated with B12 injections.” He said.
My treatment started immediately with weekly B12 injections intramuscularly, initially for six weeks and then reduced to one shot every twelve weeks.
My symptoms disappeared within a matter of weeks. The recovery was incredible. My restored energy lifted my mood, and the aches and pains stopped. The headaches stopped, and gradually over time, my speech became clearer. I was able to structure a sentence within a few weeks of treatment coherently. I quickly began to feel like my old self again.
Five years on, I have an annual blood test to assess my B12 levels. My doctor is happy with my progress.
I researched my diagnosis in-depth and learned that B12 deficiency is easily treatable. However, it is often left undiagnosed and, for many, resulting in dementia and premature death. ( Pacholok & Stuart 2011) explain that misdiagnosis happens because B12 deficiency mimics so many other disorders;- stress, dementia, mental illness, Multiple Sclerosis, Parkinson’s disease, to name but a few. “An Epidemic of Misdiagnoses”. (Pacholok & Stuart 2011)
A slow depletion of B12 reserves can take up to five years before symptoms of B12 deficiency become apparent; this explained the initial slow, almost unnoticeable decline in my physical and mental health in the beginning. It had been my cognitive impairment that had eventually led me to seek help.
What is Vitamin B12 deficiency?
B12 deficiency results from one of three known factors; — The first one is a condition called pernicious anaemia, whereby the stomach is not producing an enzyme called Intrinsic factor, which is essential for B12 absorption. There can be several reasons for the lack of intrinsic factor; some medications, prolonged alcoholism, or drug abuse can cause Gastric atrophy, which is inflammation of the gastric lining. Pernicious anaemia can also be an autoimmune reaction whereby the immune system attacks the body’s own cells, or, Pernicious Anaemia can be genetic.
A second known factor that can cause B12 deficiency is Nitrous Oxide inhalation — an anaesthetic drug used as a method of pain relief for medical procedures and commonly used to relax a patient during childbirth and dentistry — often known as gas and air or laughing gas. Regular exposure to Nitrous Oxide can deplete B12 reserves to dangerously low levels. (Mills, 2021) explains that “Midwives frequently encounter chronic exposure to high levels of nitrous oxide.” Ordinarily, healthcare workers are not at risk from frequent exposure to Nitrous oxide, but when B12 reserves are low for whatever reason, the immune system is compromised. Inhalation of nitrous oxide could lead to B12 becoming inactivated and depleted, leading to ruinous health.
Working as a midwife with Pernicious Anemia and intimate close contact with labouring women meant the levels of Nitrous oxide that I was exposed to almost daily was detrimental to my health.
The third factor is — Malnutrition. B12 is an essential vitamin for humans and is found only in animal products. Vegetarians and Vegans need to supplement this vitamin.
Occupational exposure to nitrous oxide almost daily and malnutrition played a part in my declining health. My options were limited- my health demanded a lifestyle change.
Gas and air is considered a safe and effective method of pain relief during childbirth, and many women choose to use it. The decision to leave my career was devastating and life-changing. It wasn’t an easy decision, but realistically I had no choice.
Having Pernicious anaemia means having life-long injections to maintain my B12 levels. To expose myself to nitrous oxide would be self-destructive. But, sadly for me, it isn’t just about the nitrous oxide. The effects of B12 deficiency have left me with reduced intelligence. My doctor has told me I am fully recovered, but I can’t entirely agree. I still have slight brain fog and memory lapses — nowhere near to the extent of before, but I am aware that my intelligence is not what it once was. I have no way of proving that. An IQ test reveals that my intelligence is above average, and therefore from a doctor’s perspective, I am fully recovered. Unfortunately, I never did an IQ test before becoming B12 deficienct. I have no baseline with which to compare.
Often, busy healthcare professionals will neglect themselves whilst preaching the importance of a healthy lifestyle to others. As a midwife, I should have known better. I spent my professional life promoting a healthy diet to my pregnant ladies.
References
Pacholok, S. and Stuart, J., 2011. Could it be B12?. 2nd ed. Fresno, Calif.: Quill Driver Books.
Mills, G., 2021. International Journal of Obstetric Obstetric Anesthesia | Vol 5, Issue 3, Pages 145–220 (July 1996) | ScienceDirect.com by Elsevier. [online] Sciencedirect.com. Available at: https://www.sciencedirect.com/journal/international-journal-of-obstetrics-anesthesia/vol/5/issue/3> [Accessed 18 March 2021].
