Journal: Case Study 2 completed

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

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

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

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

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


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

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

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

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

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

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

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

Journal: the pharmacology of uterotonics

Today I have reflected on bleeding after birth.


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

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



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

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

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

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

A few selected facts:

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

Pharmacodynamics:

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

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

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

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

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


Syntometrine® synthetic oxytocin/ergometrine maleate

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

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

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

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

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

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

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

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

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

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

Thankyou for your comments

Journal: collaboration

Activity: Establish a working relationship with a doctor 
There is currently much grief and anger surrounding the term “collaboration” when used in the maternity care setting in Australia at present. ... discuss the following issues –
• What actually is collaboration?
• What would the best model of how women and their babies can have their needs met in pregnancy, birth and the postnatal period, including midwives AND doctors, look like?
• Discuss your own individual situations where you presently work, or intend to work.
• What ways are you currently able to work with local doctors?
• What works well?
• What doesn’t work well? Why? Is there scope to change this? ...

I have reflected a great deal on collaboration, especially in the past few years, with the rules demanding a formal and pedantic process that is called a collaborative arrangement, for each woman in my care, in order for that woman to access Medicare rebate.

Collaboration is, in my mind, simply working together 'co'+'labor'.  One person can't collaborate.  It takes two.  In maternity care, the woman+baby unit is at the centre of the care, and a midwife+/- others work together to provide the maternity care. 

+/-?

This is the point at which disagreement arises.

For maternity care at its most basic level, the midwife is able to provide the entire episode of care, on her/his own responsibility, provided the woman and her baby are well and progress through pregnancy, labour, birth and the puerperium without complication.

Collaboration is added to the care mix if the woman or her baby need care that is outside the scope of the midwife's practice: whether it's collaboration with a dentist, obstetrician, physiotherapist, or paediatrician.


When I read the heading for this activity, "Establish a working relationship with a doctor", I asked myself, "which doctor?"

I have initiated collaborative arrangements with about 30 doctors in the past 18 months.  Most are GPs; a couple are obstetricians.  On a couple of occasions the same doctor has provided collaboration for more than one woman.  Most of these doctors I have never met or spoken to.  One of these doctors has given birth at home in my care.  Another doctor knows a woman for whom I have been midwife.

My understanding of good collaboration in maternity care is summarised in the letter that I send to a doctor when a woman asks me to be her midwife. (If the doctor is an obstetrician, and the woman is planning birth in a private hospital, the wording is slightly different.  Most of my work is with women planning birth at home, or in a public hospital)

"The plan is basically to proceed under normal physiological conditions, working in harmony with the natural processes, unless complications arise. We plan to go to the [X] hospital without delay for urgent obstetric concerns, or [the woman] would be referred to you for non-urgent medical indications."

Collaboration for midwives who are participating in Medicare has been set out in the National heath (collaborative arrangements for midwives) determination 2010
In the real world these rules present midwives with a difficult, though not impossible, situation.  I don't have energy to waste on resisting.  I hope that when my turn comes to be audited, my processes and records will be acceptable.
Thankyou for your comments

Journal: back to pharmacology

The last two weeks were the mid-term break for the university, and I was happy to take a break from study.  However, it wasn't a restful time for me, as several babies needed to make their entry into this world of ours, and they all needed me to be on the job through the night.  The early postnatal days are very demanding for the new mother, even after an uncomplicated birth, and the midwife needs to stay focused as we watch and support and at times guide.

We are now in Week 9 of the pharmacology course.  The focus is on writing prescriptions, and working on the second case study.

Today I have listened to the recording of an online tutorial of a session that one of the tutors has put up for students to access.  This is the first 'live' opportunity that any of the students have had to interact with the faculty.  Unfortunately it was attended by only 3 students, who were able to put questions and discussion.

The tutor gave information about the course expectations for the assignments.  I found the tutor's comments useful - would have preferred having this prior to submission of the first case study. The tutor stressed the importance of referencing scholarly articles, and going into depth about the pharmacology of the medications that are being discussed. This is the field that I would like more teaching on. I have read the articles, but find there is a lot of new knowledge to acquire, and I think it's a good learning strategy to hear and discuss a topic as well as to read about it.

For example, when considering the pharmacology of metoclopramide, used to treat nausea, we need to discuss the general pharmacokinetic and pharmacodynamic actions of the drug, together with the changes that occur as a result of pregnancy.  In addition to the physiological changes in a pregnant woman's digestive system, metoclopramide has an effect on the dopamine receptors in the GI tract, inhibiting some receptors, and activating cholinergic effects leading to increased motility of the GI tract, in addition to the effect of metoclopramide on the central nervous system.  Reference to scholarly papers is needed for each point made.

Much of this language is new to me, and to the midwifery profession as I know it.  I recognise the importance of a strong foundation when establishing a new body of knowledge.  I have written to the tutor requesting more opportunities for live teaching as well as discussion, so that I can hear as well as read and discuss these aspects of the course. 


Thankyou for your comments