Reflecting on midwifery practice

Matilda is on the ball!  (it's never too early to prepare for good birthing)

In preparing for my recent professional practice review, I was able to identify several incidents in which I believed it was important for me as the midwife to act within my professional skill to ensure the safety and wellbeing of the mother and/or baby. In other incidents I engaged collaboratively with specialist maternity care providers, also with the goal of ensuring safety and wellbeing.

'hands-off'?

I don't know who first came up with the idea of the 'hands-off' midwife: the midwife who has a good set of hands and knows how to sit on them.

Midwives are not universally 'hands-off' when we should be, nor are we always 'hands-on' when we ought to be. That latter point is what I am attempting to write about today.

Reviewing the past couple of years

To Daddy

A couple of years ago the federal Health Minister announced a Maternity Services Review, declaring that the government intended to provide “More Choice in Maternity Care – Access to Medicare [funding] and PBS [prescribing] for Midwives”. The monopoly of government funding for maternity care being available only for services provided by doctors and hospitals was to be broken.

Midwifery exam, 1973

click to enlarge

I found this exam paper when going through an old file.
I read through the questions, and this is what I noticed:

• Questions on breech presentation: diagnosis, ECV, indications for Caesarean section, and foetal risks associated with [vaginal] breech delivery.
• A question on [vaginal] delivery of the second twin.
• Questions on anaemia, fundus not equal to dates, varicose veins, onset of second stage, increasing parity, indications for forceps, polyhydramnios, placenta succenturiata, inversion of the uterus, and infants with sticky eyes, thrush, physiological jaundice, and cephalhaematoma.

Global Forum, Day 6

Spring roses in our garden

For the online discussion, click here.
Optimizing the roles of health workers to improve MDGs 4 and 5 discussion forum.

Today's question: Over the weekend we would like you to continue to discuss the question:

“If Traditional Birth Attendants are available, what practices or tasks should they undertake to reduce maternal and neonatal mortality and morbidity?”

Global Forum, Day 5

For the online discussion, click here.
Optimizing the roles of health workers to improve MDGs 4 and 5 discussion forum.

Today's question:

“If Traditional Birth Attendants are available, what practices or tasks should they undertake to reduce maternal and neonatal mortality and morbidity?”

Global Forum, Day 4

For the online discussion, click here. The forum community is continuing to grow with 624 members from 86 countries!
Optimizing the roles of health workers to improve MDGs 4 and 5 discussion forum.

Today's question:
Today we will continue to discuss the role of the lay health workers. However, we would like you to elaborate more on the specific issues below:
- What wider social roles, such as promoting female empowerment, should lay health workers take on in communities?
- What approaches that have been used in different settings to motivate and retain lay health workers, to improve the quality of the services they deliver and to promote the delivery of high priority services for maternal and newborn health?

Global Forum, Day 3

Optimizing the roles of health workers to improve MDGs 4 and 5 discussion forum

Today's question:

Community or lay health workers are health care providers who have no formal professional or paraprofessional tertiary education but are usually provided with job-related training.They can be involved in either paid or voluntary care. The term 'lay health worker' is therefore very broad in scope and includes, for example, village health workers, promotoras, treatment supporters and lay counsellors. Lay health workers may take on a wide range of different health-related tasks including giving help and advice about child health, child illnesses, pregnancy and medicine taking. In some studies, lay health workers also treat or refer people for particular health problems.

Global forum, Day 2

The forum leaders have written:

Today we continue to discuss Day 1's question on:

"What practices or tasks should be undertaken by health care providers other than medical doctors at the primary health care level to accelerate the reduction of maternal and newborn mortality and morbidity?"

Reducing maternal and newborn mortality and morbidity at the primary health care level

Today's discussion topic in the Global Forum is:
What practices or tasks can be undertaken by health care providers other than medical doctors at the primary health care level to accelerate the reduction of maternal and newborn mortality and morbidity?

My quick response is to ask the same question differently, placing the focus on the woman-baby unit, rather than the tasks:

What needs do mothers and babies have that can be addressed at the primary health care level by health care providers other than medical doctors, and how will the addressing of these needs accellerate the reduction of maternal and newborn mortality and morbidity?

Global forum: optimising the effectiveness of Health Workers to achieve MDG's 4 and 5

The WHO Guidance Global Network invites you to join a NEW online discussion forum.
8-16 November 2010
The World Health Organisation and partners are developing global guidance on enhancing the effectiveness of different cadres of health workers through evidence-based practice to improve maternal and newborn health care.

Theme: Crossing professional boundaries to define what safe and effective practices can be delivered by different cadres of health workers at the primary and community level to improve maternal and newborn health.

Register: to participate and receive a daily discussion digest, click here.

Reminder
MDG 4: Child health
MDG 5: Maternal health
To review the eight UN Millennium Development Goals, click here.

Spring roses in the front garden

“Of all tyrannies, a tyranny sincerely exercised for the good of its victims may be the most oppressive. It would be better to live under robber barons than under omnipotent moral busybodies. The robber baron's cruelty may sometimes sleep, his cupidity may at some point be satiated; but those who torment us for our own good will torment us without end for they do so with the approval of their own conscience."

~ C.S. Lewis

Women may 'go it alone' on home births Ireland

[Posted: Fri 15/10/2010 by Niall Hunter, Editor - www.irishhealth.com]

A campaign group has warned that some women may opt for home births without professional care as a result of problems with indemnity insurance for qualified home-birth midwives.

The Association for Improvements in the Maternity Services-Ireland (AIMS) says proposed new midwifery legislation will in effect make it illegal for a home birth midwife to provide antenatal and birth care if the pregnant woman's circumstances do not meet criteria set in a current memorandum of understanding which midwives have to sign with the HSE.

Krysia Lynch of AIMS told irishhealth.com said the memorandum, which will be used in the legislation, outlines the criteria for State indemnity insurance cover for midwives in home births but these criteria were too restrictive.

She claims they are based on a misinterpretation by the HSE of evidence-based guidelines for home births and claims the HSE is attempting to restrict home birth and midwife-led services.

AIMS says the restrictive criteria could lead to midwives becoming uninsured in the middle of a home birth should the mother's clinical circumstances change.

Midwives attending women having home births could face could face fines or imprisonment or both if they are found in breach of the new legislation, which is expected to be passed by the Oireachtas before the end of the year, AIMS says.

It adds that a growing number of women who do not want to attend maternity hospitals are saying that if professional midwife-led home birth services are not available to them, they will "go it alone" with their home birth without professional care providers.

Ms Lynch said this type of "underground home birth movement" has already taken root in other countries where home birth services are restricted.

AIMS says it understands a group of lay midwives without medical training are now offering their services to women who have difficulty in finding professionally-registered midwives.

The organisation is calling for revisions to be made to the Nurses and Midwives Bill in order to change the professional indemnity criteria for home births.

It is organising a petition calling for a changes in the proposed legislation.

Further details on this issue, and a petition to sign, are available here

I have signed the petition - signer #873:

Ireland's Home Birth Services: MOU and Nurses and Midwives Bill 2010.

The Australian Government's current effort to reform maternity services is also likely to have this negative effect of directing women with known 'risks' into the underground home birth movement.  Midwives are faced with real and imagined restrictions when providing care for women who have had previous caesareans, or whose pregnancies continue beyond Term, or who are over weight, or ...  These women would likely benefit greatly from a known midwife primary carer.

Understanding statistics

Those who want homebirth to be, if not outlawed, at least so marginalised and dirty that noone with any sense would go near it, are able to use statistics to coerce their listeners into compliance, and to assure authorities that they are acting 'in the public interest'. There have been a couple of outstanding examples of this phenomenon in the past year.

Firstly, remember the Australian Medical Journal's publication of Planned home and hospital births in South Australia, 1991-2006: differences in outcomes (Kennare et al 2010), using shameless distortion of facts gathered in the research. I wrote about it and set up links to the paper at the MiPP blog in January this year. Alarm bells sounded, and media picked up the story from the abstract: X7 higher risk of intrapartum death and X27-fold higher risk of death from intrapartum asphyxia in the planned home births group.


The second doozie [for readers who are unfamiliar with this word, it's Australian slang - not sure what it really means, but it seems to fit here] is the Wax et al 2010 paper on maternal and newborn outcomes for homebirths in North America.

Various reliable midwifery organisations have critiqued this paper for its methodology and conclusions. The Medscape "Attention-Grabbing No Doubt, But Uninformative" comment by Andrew Vickers, copied in full (below) is worth reading.

Midwives can also understand statistics.

"Home Birth Triples the Neonatal Death Rate": Attention-Grabbing No Doubt, But Uninformative
Andrew J. Vickers, PhD

Posted: 09/27/2010

Home birth, according to a position statement from the American College of Obstetricians and Gynecologists, is "trendy" and "fashionable." Moreover, women who choose to deliver a baby at home "place the process of giving birth over the goal of having a healthy baby."[1] Interesting thoughts, I guess, but hardly evidence-based. Has anyone actually interviewed home-birthing parents to determine, for example, that they rate having a healthy baby at, say, 5 out of 10, whereas being allowed to listen to druid chanting during the second stage of labor is rated an 8? And with respect to being fashionable, have researchers really evaluated the wardrobes of home-birthers compared with those choosing to labor in the hospital, finding in the former a higher proportion of Marc Jacobs and Manolo Blahnik?

So it is nice to finally see some data that quantify the relative benefits and harms of home birth. Joseph R. Wax and colleagues conducted a meta-analysis, combining data from 12 studies including more than a half million deliveries, in order to report on a wide variety of outcomes, including process (eg, use of epidural), maternal morbidity (eg, vaginal laceration), neonatal morbidity (eg, prematurity), and mortality (of both mother and child).[2] What isn't so nice is the spin. The study authors themselves, who are from a department of obstetrics, report a highly alarming statistic -- that home birth is associated with a triple the risk for neonatal death. The American College of Nurse-Midwives, predictably enough, finds fault with the methodology of the study and cautions against overinterpretation of the findings.[3]

I am sympathetic toward the critiques. A meta-analysis is only as good as the studies that are entered, and it is somewhat disconcerting to see a mixture of prospective and retrospective observational studies all mixed in with a single randomized trial. (On which point, it is even more disconcerting to find that the paper referenced for the randomized trial was a discussion piece, not a trial report.) But for the sake of argument, let's assume that the paper is perfect and accurately represents the true outcomes of home and hospital delivery.

First off, how should we interpret a "tripling of death rates"? This is what statisticians call a relative risk, and it is widely known to be problematic for decision-making. As a simple example,[4] would you buy a pair of slippers if I told you that they were 90% off? Well, no, you would want to know how much they cost. It is the same with risk; it is the absolute amount that matters. The classic example is the contraceptive pill and breast cancer. One estimate is that the pill raises the risk for early breast cancer by 50%. This sounds pretty scary until you realize that most women's risk is so low that this translates to about 1 woman with breast cancer for every 10,000 on the pill. Most women would feel that is a risk worth taking, given the benefits of the pill and the possible harms of the alternative: pregnancy, which after all, has dangers of its own.

In place of a "tripling in death rate," the more informative statistic is the absolute increase in neonatal death associated with home birth. On the basis of the results tables, it is possible to calculate that this turns out to be 1 neonatal death per 1000 women who choose home birth. However, the results tables show that those women would also experience some benefits, including 40 fewer premature labors, 45 fewer cesarean sections, 140 fewer vaginal lacerations, and 140 fewer epidurals. This type of cost-benefit analysis -- trading off neonatal mortality against maternal morbidity -- can seem sort of cold-blooded. But if the only thing we cared about was a healthy baby, then we'd do cesareans on all pregnant women at 38 weeks (as well as insist that all women conceive once they turned 21). We implicitly trade off risks and benefits anytime we consider a medical procedure. Let's do it explicitly rather than implicitly, on the basis of decision-analytic statistics such as absolute risk, rather than headline-grabbing statistics such as a "tripling of the death rate."

References
1. American College of Obstetrics and Gynecologists. ACOG statement on home births. Medscape OB/GYN and Women's Health. 2010.Available at: http://ww.medscape.com/viewarticle/725383 Accessed September 9, 2010.
2. Wax JR, Lucas FL, Lamont M, Pinette MG, Carlin A, Blackstone J. Maternal and newborn outcomes in planned home birth vs. planned hospital births: a metaanalysis. Am J Obstet Gynecol. 2010;203:e1-e8.
3. American College of Nurse Midwives. The American College of Nurse Midwives expresses concerns with recent ACOG statement on home births. Medscape OB/GYN and Women's Health. 2010. Available at: http://ww.medscape.com/viewarticle/725382 Accessed September 9, 2010.
4. Vickers AJ. Top scientific papers vs. furry green slippers: which should you trust? Medscape Business of Medicine, 2010. Available at: http://ww.medscape.com/viewarticle/722723 Accessed September 9, 2010.

The current state of private midwifery practice

This is a brief summary - more detailed information can be sourced, of course.

Private midwifery practice for planned homebirth
Midwives continue to practise as we have for many years, providing the full scope of pre-, intra- and postnatal services for women who want to give birth at home, working without medical interference, without drugs to stimulate labour or relieve pain, and in harmony with natural physiological processes.

Midwives continue to provide statistical data to the government data collection agencies, as we have done for many years.

Midwives inform our clients that we are not able to purchase professional indemnity insurance for homebirth, and that the government has provided a 2-year exemption from this requirement, until June 2012. We don't know what will happen after that date.

The Nursing and Midwifery Board (NMBA) is preparing a Safety and Quality Framework document which (according to the most recent draft) is:

• "consistent with the principles underpinning provision of primary maternity care (Attachment 1) and
• "recognises the full scope of midwifery practice.
• "recognises that women will make the final choice about their care and birthing choices in most circumstances [MOST circumstances ???]

"It is incumbent upon privately practising midwives (PPMs) to provide balanced and contemporary clinical advice to ensure that informed decisions are able to be made."

The Framework also relies heavily on the ACM National Midwifery Guidelines for Consultation and Referral (2008). A further 'guidance' document on collaboration is being prepared under the auspices of the National Health and Medical Research Council (NHMRC) - we have not seen drafts of that yet.

Private Midwifery practice for planned hospital birth
Many women who intend to give birth in hospital employ a midwife to attend them for birth, and provide continuity of care through the pregnancy to the postnatal period. Although private midwives do not have visiting access arrangements with hospitals, the partnership between the labouring woman and her known and trusted midwife is able to transcend most situations in which a hospital protocol might derail normal birth. The woman and her private midwife make decisions about when to travel to hospital, as the midwife uses her knowledge and skill to protect the natural processes in birth and early parenting.

This aspect of private midwifery practice goes unrecognised in Australian birth reports. The woman who plans homebirth, then transfers her care to hospital can be tracked statistically, but not the woman whose plans include a private midwife for planned hospital birth. The position of the private midwife in hospital has not been mentioned in all the so-called 'reform' that we are engaged in at present.

Private midwifery practice and Medicare-eligible midwives
This is the aspect of private midwifery practice that is set to emerge from 1 November, less than one month away. There are more questions at present than answers.

The Medicare-eligible midwife who I will refer to as the 'MEDI-WIFE' will be a very different person from the ordinary privately practising midwife. The MEDI-WIFE will:

• have a close working relationship with a group of obstetricians (no doctors work 24/7 these days
• provide prenatal checks in the community, possibly in 'rooms' shared with obstetricians or other doctors
• attend births in private hospitals where she has visiting access, and where the 'senior' member of the professional team is always the obstetrician
• be able to order basic tests and prescribe basic drugs, such as oxytocics
• provide postnatal services for mothers and babies in hospital, and possibly at home.

The Australian Medical Association has published Collaborative arrangements: what you need to know, in preparation for the birth of the MEDI-WIFE.

A great deal of discussion is taking place in the world of midwifery about the signed collaborative agreements that have been required, under law, for a midwife to be eligible for Medicare &c. Go to the MiPP blog for more information.

Midwives are now being asked to record examples of our efforts to comply with the requirements of the Determination, so that the implementation of the government's maternity 'reform' can be reviewed over time.

What is the position and/or importance of independent midwives as an option for pregnant women?

This is a question put to me by a lawyer representing a midwife who is answering charges of unprofessional conduct with the regulatory board. I will express my opinion on the position and/or importance of independent midwives as an option for pregnant women, and provide statistical information as to the current status of independent midwifery practice in Victoria.

My report is based on my midwifery qualification and more than 30 years’ experience in midwifery, including teaching, writing, professional and regulatory work.

It is my opinion that midwives are capable of practising privately and independently as primary maternity care providers, ensuring safety and wellbeing for the mother and child, and effectiveness of the service provided. Some current statistical information will be provided below.

The Definition of the midwife (ICM 2005) (the Definition), which is accepted in Australian midwifery education and professional codes of practice, states that “The midwife is recognised as a responsible and accountable professional ... to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant.”

The Definition does not comment on issues of employment by an agency, or self-employment. Although most Australian midwives work as employees of maternity hospitals, the option of being self employed has existed historically. The midwife who practises privately enters an agreement with the individual woman (client) who pays the midwife’s fee. There is no government funding for privately employed midwives, which compares with free hospital based maternity services.

The Definition states that “A midwife may practise in any setting including the home, community, hospitals, clinics or health units.” The independent midwife is the only provider of home birth services in most communities. The current exceptions in Victoria are publicly funded home birth programs based at Sunshine and Casey hospitals.

The question of the importance of independent midwives as an option for pregnant women is a personal one. Childbirth is not a medical condition, and many women who choose home birth object to what they perceive to be excessive and unnecessary use of medical intervention in hospital births.

A woman planning to give birth at home understands that the midwife does not use drugs to stimulate labour or to take away pain, as is commonly available in hospital.

The Definition addresses situations in which transfer from home to hospital may be advised: “This care includes … the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures.”

The ACM (2008) National Midwifery Guidelines for Consultation and Referral (Guidelines) are also used by midwives in the provision of primary maternity care. These guidelines are not designed to be prescriptive, and are to be used within the context of informed decision making by the individual woman.

When a complication such as non-cephalic presentation is detected, the midwife will usually seek to arrange consultation with a specialist medical practitioner (obstetrician). The woman is able to make decisions based on the advice she receives. Transfer of care from planned home birth to a hospital or private obstetrician will only occur if the woman chooses that option.

When transfer of care occurs, the independent midwife usually continues to provide private midwifery care within the context of the new care plan.

There are occasions when, after a midwife has advised and referred a woman for specialist medical consultation, the woman chooses to continue with a plan for spontaneous labour and birth. This may be against medical advice. The woman makes an informed decision as a competent person.

The number of women who give birth at home is small, approximately 0.2% of all births in Australia (Laws and Sullivan 2009, p21).

There is controversy about the safety of planned homebirth in Australia, particularly since the publication in the Medical Journal of Australia of Planned home and hospital births in South Australia, 1991-2006: differences in outcomes (Kennare et al 2010), in which all births recorded as planned homebirths over a 16-year period were reviewed retrospectively. Many questions have been asked about statistical method and conclusions drawn. There are probably only two women in the study whose babies died who started labour at home planning a homebirth. The others whose babies died had all transferred before the onset of labour, which means that the management of the labour was in the hands of the hospital, not the independent midwife.

Annual reports on perinatal data are published in Victoria by the Consultative Council on Obstetric and Paediatric Mortality and Morbidity, within the Department of Human Services. The most recent published report refers to births in 2007 (CCOPMM 2009). Of the 253 women whose births were coded as planned home births, seven babies were admitted to hospital nurseries. This is a similar rate of admission to the group of babies born at small hospitals with less than 100 births annually. (CCOPMM 2009, page 30). I am not able to draw conclusions about these births.

There is a degree of uncertainty in all births.

[If you would like the references quoted above, please contact me joy@aitex.com.au to request them, or leave a comment with your email address)

RCM Campaign for normal birth

The Royal College of Midwives (RCM), the professional body for midwives in the United Kingdom, has a Campaign for normal birth.

The protection of normal birth will, without doubt, save lives of mothers and babies and reduce morbidity in both developed and developing countries.

The promotion of normal birth is a message that must be a top priority for all midwives and other maternity care providers in an age that embraces gadgets, quick fixes and technology, and ignores the sensitive intuitive processes that are essential to human life.

The support of normal birth is contingent on the undeniable fact that the safest and most wonderous way for a baby to be brought into this world is, in most cases, in harmony with natural physiological processes.

The midwife holds the key to protecting, promoting, and supporting normal birth. The midwife has the skill and duty to be 'with woman' as the first level (primary) care provider, and to engage and work with other specialist providers when and if the individual woman or her baby need specialist intervention.

It seems to me that 'normal birth' is perceived to be the default position in midwifery care: if there are no complications, 'normal birth' will ensue. In fact, nothing could be further from the truth.

Having practised independently for the last 15+ years, I have learnt, mainly through refelctive learning, that the practice of promoting, protecting and supporting normal birth is in fact the most demanding, engaging professional challenge that I have ever known.


Here is an example of the very useful links featured at the Campaign for normal birth site:
Latest news
* Cathy Warwick comments on the Lancet editorial which criticises homebirth and midwife-led care
* Promoting normal birth key to cost savings
* Midwifery Care and Normal Birth - Recent Policy statement by Canadian Association of Midwives
* Specialist preparation pre-pregnancy produces no measurable outcome benefits
* Giving birth at home is as safe as doing so in hospital with a midwife



Readers of this and related blogs will be aware of the enormous threats that are at present being experienced by midwives who practise privately in Australia.  Government 'reform' of maternity services threatens to restrict midwifery with excessive bureaucracy and rules that ignore women's basic human rights and autonomy in choosing their care provider and place of birth.  Rather than focusing on the dog's breakfast of 'guidelines', 'frameworks' and regulations, I call on all midwives to shift our focus to a campaign for normal birth.

Breastfeeding babies exclusively

These two mothers breastfed their babies at a rally outside the Health Minister's office.  Well done!

Exclusive breastfeeding for the first six months of life, followed by continued breastfeeding as well as a diet made up of nutritious family foods to the age of two years and beyond is the gold standard in infant nutrition.

Far too few babies in our world get past the first week exclusively breastfed, which sets them up for subesquent feeding difficulties.

I won't try to explain why exclusive breastfeeding is so important to both mother and baby. Sufficient to say that the principle "In normal birth there should be a valid reason to interfere with the natural process" applies as much to the establishment of breastfeeding as it does to progress in labour. Interferences will likely interrupt natural physiological processes, including mother-baby attachment, bonding, onset of lactogenesis 2, baby's ability to suckle, baby's gut flora, jaundice, and a mother's acceptance of the maternal role, just to mention a few.

A baby who is born at home, whose mother takes the baby to her breasts and who is able to initiate breastfeeding without interruption in the next hour or so is very unlikely to ingest anything other than his own mother's milk in the first week of life. It's a busy week, with baby eagerly taking the breast frequently through the day and night, and often with both parents facing endurance challenges. Some mothers and babies face some of the not uncommon difficulties with flat nipples or very large breasts or whatever. But by about day 4 or 5 there is an abundance of wonderful milk, a baby who sleeps blissfully after spending time at the breast, and there's light at the end of the tunnel.

The over-medicalisation of birth has led to many babies experiencing non-physiological challenges at birth, and this leads on to wasting of the baby's energy resources, painful surgical wounds in the mother, and separation of mother and baby. The end result is that babies are given artificial formula feeds to 'supplement', 'top up', or 'complement' what the baby is able to get from the breast.

Where the natural provision for a baby is ideally suited to the baby's physiological needs, of small volumes of colostrum that coats the digestive tract and supports cell proliferation and colonisation of the gut with the normal bacterial flora, the baby who is given, at 2 hours of age, 30ml of the white chemical concoction that is called infant formula has the whole process interrupted and interfered with. While that baby's energy needs may be met a whole lot of other needs are being denied.

A midwife recently told me that she was concerned about her client giving birth in a particular hospital because any baby born over 4 kilos was immediately treated as if at high risk of hypoglycaemia. The baby would be taken to the nursery, separated from the mother soon after birth, and blood glucose levels tested. With interruption to the first breastfeed, and separation, it's likely that a 'negative' result - blood sugar level lower than the required amount - would be obtained. That baby would then be given a formula feed, and the whole process repeated in a couple of hours. A mother who objects to the infant formula will be given information about the horror of hypoglycaemic brain damage, and only someone who is well informed knows that she has another option - to breastfeed effectively.

With approximately one in three babies in hospitals being born by caesarean surgery. The usual post operative pain management regime in hospitals in Melbourne maternity hospitals is Endone (a narcotic, dangerous drug that comes with the warning, "Do not take ENDONE during pregnancy or during breastfeeding as it may cause difficulty in breathing in an unborn or newborn child."), Panadol and Voltaren. I have written about Endone at my villagemidwife blog



Anyone who takes exclusive breastfeeding seriously knows it's an uphill battle in most hospitals. Even the Baby Friendly hospitals. It has been 15 years since the Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding was produced and adopted. The Declaration, adopted by all WHO and UNICEF Member States, has been a key strategy on improving health of infants and young children through optimal nutrition. [for more information go to Innocenti + 15]

Maternity care today is so wedded to infant formula use that it will take a major reformation to change the trend. The community must demand protection of the infant's right of access to the breast. We must also demand that human infants are given only human milk: that milk banks should be available for any additional requirements of breastfed babies.

VBAC - assessing safety and success

This Reference will be of interest to readers who seek to understand vbac.

Vaginal birth after caesarean for women with three or more prior caesareans: assessing safety and success.

Cahill AG, Tuuli M, Odibo AO, Stamilio DM, Macones GA.

Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Washington University School of Medicine, 660 South Euclid, St Louis, MO 63110, USA. cahilla@wustl.edu

Comment in:

* BJOG. 2010 Jul;117(8):1034; author reply 1034-5.

Abstract

OBJECTIVE: To estimate the rate of success and risk of maternal morbidities in women with three or more prior caesareans who attempt vaginal birth after caesarean (VBAC).

DESIGN: Retrospective cohort design.

SETTING: Multicentre, from 1996 to 2000, including 17 tertiary and community delivery centres in north-eastern USA.

POPULATION: A total of 25 005 women who had had at least one prior caesarean delivery.

METHODS: Women who attempted VBAC with three or more prior caesareans were compared with those who attempted after one and two prior caesareans. Univariable and stratified analyses were used to select factors for multivariable analyses for maternal morbidity. Maternal characteristics were compared using a Student's t test, Mann-Whitney U test, chi-square test or Fisher's exact test, as appropriate.

MAIN OUTCOME MEASURES: The primary outcome was composite maternal morbidity, defined as at least one of the following: uterine rupture, bladder or bowel injury, or uterine artery laceration. Secondary outcomes were VBAC success, blood transfusion and fever.

RESULTS: Of 25 005 women, 860 had three or more prior caesarean deliveries: 89 attempted VBAC and 771 elected for repeat caesarean. Of the 89 who attempted VBAC, there were no cases of composite maternal morbidity. They were also as likely to have a successful VBAC as women with one prior caesarean (79.8% versus 75.5%, adjusted OR 1.4, 95% CI 0.81-2.41, P = 0.22).

CONCLUSION: Women with three or more prior caesareans who attempt VBAC have similar rates of success and risk for maternal morbidity as those with one prior caesarean, and as those delivered by elective repeat caesarean.

more on risk management

In a previous post I explored the presentation of 'risk' by a doctor to a woman who was planning for vaginal birth of her second child after a caesarean birth of her first.

We live in an information era. Our challenge, as midwives, is to understand reliable information and to present it in a way that enables our clients to make good decisions. A good decision is, literally, a decision that leads to good outcomes for that mother and her baby.

Managing risk is a difficult topic to write about, and can be even more difficult if you are confronted with decisions needing to be made. The pendulum of risk-managed maternity care has swung a long way from the centre, to the point where any identified increase in risk is immediately considered a valid reason to interfere with the natural process.

When research has been carried out on a group of 'patients' in a way that quantifies a particular risk, the practitioner has a duty to inform the client about the research. This is obvious. Yet, in my mind, the prevailing risk-averse culture in maternity care today robs women of any semblance of informed decision making. Instead, by even mentioning risk of death (known as 'shroud waving'), maternity services ensure a high level of compliance with the prevailing culture of intervention, and devaluing the spontaneous physiological birth process.


Recently I was with a woman who was advised to have an induction of labour a couple of days after 41 weeks' gestation. The reason given was that the volume of amniotic fluid (AFI) around her baby was less than the normal range (AFI 5-25) - a feature that was identified coincidentally when untrasound examination was carried out for another reason. The fetus was active, and there were no other unreassuring features identified.

The doctor who presented induction of labour as the planned course of action explained that there was an increased and unacceptable risk of death of the baby. In quantifying 'risk' he stated that at 41 weeks there was a risk of 1 in 1000; while if the AFI was reduced the risk was 3 in 1000, or 1 in 333. Furthermore, the doctor stated, induction of labour at 41 weeks does not increase the 'risk' or likelihood that a baby will need to be born by caesarean.

The numerator in the equation is death of a baby at or around the time of birth. The denominator is all births with that particular set of features.

Most women who hear words such as "we need to induce labour because there is an unacceptable risk to the baby if we don't induce labour" will be frightened, and immediately agree to whatever plan is presented to them. They cannot contemplate the thought of losing this precious baby. They cannot ask questions that enable careful consideration, because that makes them feel as though they are willing to place their baby's life at risk.

Words such as 'unacceptable risk' are used deliberately. The argument by the doctor is that he or she would be taking an 'unacceptable risk', from an indemnity point of view, if he or she did not recommend action to get the baby born without unreasonable delay.


The pathway to healthy, normal, physiological birth begins long before labour, including:
* a healthy mother, who cares for her body and the child she carries
* a fetus who has grown normally
* a fetal head whose position inside the maternal pelvis, in relation to the internal os of the cervix is able to bring about normal onset of labour

We don't know what gets human labour started in nature. Not 'knowing' makes waiting for spontaneous onset of labour an 'unacceptable' delay in many situations where an increased risk has been identified.

Logically an increase of 2 in 1000 births is not a big risk. As I have discussed previously, there is a background risk for death of a baby of about 1 in 100 for all births. Many of the babies who die have increased risk because of abnormality, prematurity, or illness of the mother. That means that the real risk to a healthy woman with a healthy baby is greatly reduced.


The question I am placing to myself, and to other midwives who may face this dilemma, is:
at what point does it become unreasonable to wait for spontaneous onset of labour,
or,
at what point does it become important to move out of Plan A?


A midwife's decision-making is a constant process, and it continues throughout the episode of care. The woman whose baby has not been born by 41 weeks, and who has been told by a doctor that she needs induction of labour, may look to her midwife to help her unpack the issues so that she can understand the situation well enough to make a wise decision. The informed woman who accepts induction of labour, or any other departure from 'Plan A', does so because she believes it is the best course of action for her and her baby at that time.

A midwife in the situation described here would be unwise to insist in a blinkered way that 'natural is best' - yet she could also be challenged if she supported the plan for immediate induction of labour.

The midwife has to see beyond the risk of a perinatal death, and evaluate all the other reasons for promoting, protecting and supporting physiological processes in the childbearing continuum. The birth of a baby, although hugely significant, is not the 'end point'. It's only a beginning. The ability of a mother to accept her baby, to form lifelong bonds, to nurture the child, to feel well physically and emotionally in herself: to get along in life, cannot be trivialised. Similarly, the ability of the baby to make those huge natural transitions from the womb to the outside world, to search for and take life-giving milk from the mother's breast, and to become resillient and grow strong: these are all matters of immense value to the mother and her child, and the midwife.


I have written enough for today. I have a big pot of soup on the stove, and am looking forward to enjoying a bowl with my family. I hope that today's discussion supports other midwives and women who have to confront risk management in their daily lives.