messages about breech births

 A couple of days ago I wrote about 'informed or mistaken'.

Although there are no guarantees in any life event, the truth is that when we make plans and decisions about giving birth to our children we want to avoid anything that could be harmful or lead to poor outcomes.

And although there are many mistakes occurring every day in health care, the first rule of medical ethics is 'First, do no harm': Primum non nocere.

The other 'rule' that applies in this matter is the basic principle of midwifery: "In normal birth there should be a valid reason to interfere with the natural process." (WHO 1996. Care in Normal Birth: a practical guide)

Today I would like to collect a few messages about breech birth that are available in professional circles, and look at each of the messages from this high standard.  Just to be clear, my starting point for 'do'-ing, in the statement 'First, do no harm' is any form of intrusion, interruption, intervention, or altering of the natural process.  This can be something as obvious as induction of labour for social reasons, to more subtle matters, such as requiring a woman to be prone for the convenience of the accoucheur. 

1 Safety of vaginal breech birth

1.1 "The current practice of caesarean section for all breech presentations is not supported by the medical evidence.  Many breech babies can be born safely vaginally."  [BBANZ]

1.2 "a caesarean section is lower risk than a vaginal breech birth"  Dr  

1.3 "Although it is common for obstetricians to advise that it has been proven that the outcomes of planned caesarean section (PCS) are better than the outcomes of vaginal breech birth (VBB), this is an oversimplification of the evidence and is misleading." [BBANZ] 

1.4 "... with the application of strict criteria before and during labour, planned vaginal delivery of the singleton breech at term remains a reasonable option to offer to selected women" [RANZCOG]

 2 Increased risk of complications for the baby

2.1 "Babies born in the breech position (bottom first) are at increased risk of complications at birth because of a delay in the birth of the head.  "  [Cochrane Summaries]

2.2 "OVERALL breech babies have lower Apgars than cephalic babies-REGARDLESS of how they are born"  [FB]

3 External cephalic version

3.1 "Turning a breech baby to head first in late pregnancy may reduce these complications. A procedure called external cephalic version (ECV) describes when practitioners use their hands on the woman's abdomen to gently try to turn the baby from the breech position to head first." [Cochrane Summaries]

3.2 "My preferred option is to turn the baby to head-first position in order to avoid a caesarean section." Dr

4 Moxibustion

4.1 "... moxibustion can be used for turning babies from breech presentation to cephalic presentation ... There is some evidence to suggest that moxibustion may be useful for turning babies from breech presentation (bottom first) to cephalic presentation (head first) for labour when used with either acupuncture or postural techniques of knee to chest or lifting buttocks while lying on the side.  [Source: Cochrane Summaries]

Comment: "First, do no harm"
These statements, taken from reliable sources, demonstrate a little of the current conflict in messages and advice about breech births.  

The principle of 'first, do no harm' is probably the driving force in the medical quest to follow what is called evidence based practice - all in the interests of safety and wellbeing for the 'patient'.  The rise and rise of the randomised controlled trial in the past couple of decades has reshaped and redefined the boundaries of many professional practices.  Perhaps none more so than breech births.  The Term Breech Trial (Hannah et al 2000) has led to the standardisation of elective caesarean for women with babies presenting breech, and the loss of skill and knowledge in the obstetric and midwifery communities, as to critical thinking about the safety of proceeding within physiological processes in particular situations.

Elective caesarean surgery can never be considered benign.  The potential for harm exists for both mother and baby.  Mothers who undergo major abdominal surgery face the physical risks of infection, haemorrhage, and iatrogenic causes such as retained surgical material.  Subsequent pregnancies face increased risk of placental abnormalities, which may lead to severe haemorrhage. The psychological impact of elective surgery cannot be ignored.  Babies delivered this way do not have the normal hormonal preparation that comes with labour, and may need hours or days of specialised care, which involves separation from their mothers, and frequently interferes with the establishment of bonding and breastfeeding.

First, do no harm?  Unnecessary surgery may result in maternal and newborn morbidity, with the potential for mortality.  Unnecessary surgery for any reason should be avoided.  The emergence of maternal deaths at the time of the primary caesarean, or subsequent births, is an infrequent, but serious aspect of potential harm.


When the need for caesarean surgery arises in pregnancy, or in labour, the potential to 'first, do no harm' is changed.  In the case of failure to progress, the likelihood of harm is greatly increased by not intervening.

In the past couple of decades the practice of external cephalic version (ECV) has been fine-tuned by obstetricians in teaching hospitals.  This has been promoted as a way to avoid elective caesarean - for the successful ones - while the default position for breech presentation is caesarean.  ECV does not, per se, prevent the need for caesarean.  Babies who would experience a failure to progress due to cephalo-pelvic disproportion will make this clear in labour, regardless of the presenting part.

In applying the 'first, do no harm' principle, every midwife and obstetric doctor needs to be ready and able to attend vaginal breech birth without fear.  The midwife or obstetric doctor who hides behind the 'de-skilling' banner of the Term Breech Trial (2000) may be delinquent in clinical situations that can arise without warning, when a mother presents in advanced labour, about to give birth to a breech baby, or when a mother intentionally proceeds with a spontaneous vaginal breech birth.
  
 
Thankyou for your comments

Breech vaginal birth: Turn the picture up the other way

Today I am focusing on the subtle but significant difference between spontaneous breech birth, and managed breech delivery.

Recently I was in a major public hospital with a woman in labour, who was intending to give birth to her breech baby vaginally.  This was her first baby.  The fact that her baby was presenting as a complete breech (tailor sitting - legs crossed) had been discovered by a midwife during a routine antenatal check a couple of days earlier.  She was labouring well, and was probably close to fully dilated at around 06:00 hours, when the medical team entered the room to have a chat with her.

Dr #1 was accompanied by Dr #2.  They were both very new to their respective jobs - teaching hospitals have times, like this, when the new Registrars and Residents take up their positions.  Dr #1 did the talking; the younger #2 watched and listened.  They had been told that this woman wanted to give birth vaginally.  Dr #1 was very friendly, using old-fashioned familiar language such as 'dearie' and 'sweetie' that is not really acceptable in such circumstances, in today's world.

Dr #1 informed the woman that the hospital's advice at this point in time was a caesarean birth; that the hospital considered the risk of vaginal breech birth to the baby to be too great, and quickly listed off a bunch of horrible things that could happen to the baby if she did not have that caesarean.  There was no mention of risk to mother or baby from caesarean.  There was no scope for an informed decision or questions - the decision had been made.

I wish I had made a note of the items on that list.  I was surprised at the speed of delivery, and the inherent threat.  Babies being rushed to the nursery with cerebral palsy from hypoxia; with broken bones; with other brain damage ... and that the mother herself had a greater risk of a fourth degree tear!  That if she refused a caesarean she would be required to have an IV line in situ, and continuous electronic fetal monitoring, and be placed in lithotomy position with her legs in stirrups.  I don't think the mother heard or understood much of what was said to her in that brief exchange.

I stayed at the woman's side, and was not able to question or debate the doctor's pronouncements.  She finished her shift in the morning, before the baby was born.

The point that was clear to me was that this doctor was performing what she considered her 'duty of care', in the interests of wellbeing and safety of mother and baby.   She took the high moral ground, referring to the evidence (the 'Term Breech Trial' - Hannah et al, 2000) which was like the Pied Piper of Hamlin, leading all the breech mothers directly to the operating theatre.


I began this post saying that I wanted to explore the subtle but significant difference between spontaneous breech birth, and managed breech delivery.

The hospital in this little story, and probably all the other hospitals in Melbourne, would not acknowledge spontaneous breech birth as a realistic option; as indeed women who want spontaneous natural cephalic births, and spontaneous natural third stages can find themselves arguing against the experts.  The only way that most obstetricians know for vaginal breech birth is a managed breech delivery.   I have witnessed doctors performing the moves with great skill, and have seen babies come through managed breech deliveries well.

There is an excellent set of drawings, accompanied by brief comment and instruction, available online at the Women's Hospital Policy, Guideline and Procedure Manual: Breech - Management of (Publication date (08/10/2012)

This guideline describes vaginal breech delivery.  The drawings are all done with the woman's sacrum below the action.  Even Picture 1, which describes the position of the fetus at the beginning of labour, shows the woman's pelvis in a recumbent position.

Turn Picture 1 and Picture 2 a quarter turn to the Right, and the mother's spine will be upright, as indeed a woman in active first stage labour would usually be.

Pictures 3-8 need to be turned a full 180degrees.  The woman needs to be on all fours - hands or elbows, and knees, as the breech progresses and the baby's body becomes visible.  The body needs to hang, using gravity and the weight of the baby to bring the head into the pelvis and through the birth canal.  Picture 9a becomes irrelevant, and picture 9b is reversed.  Maneuvers to release the arms, and to flex the head, if needed, can be performed by the accoucheur. 

Here is a YouTube video of spontaneous breech birth demonstrating the 'all fours' position for the birth of the baby. 

Thankyou for your comments

decision-making for breech births

In recent months I have been very impressed by the work of a consumer-led group, Breech Birth Australia and New Zealand (BBANZ).  This site has a great deal of useful information and birth stories.  Readers who are interested in being part of the social media discussion on breech births can apply to join the facebook group.


In this context, I have been drafting an information sheet on the decision-points for a woman who has a baby in a breech presentation:

Decision Point #1:      DIAGNOSIS of breech presentation at or near Term

Your midwife or doctor may diagnose breech presentation by palpation, and recommend further investigations such as ultrasound.  Your decision—yes or no—will lead to the next Decision Point.

 Decision Point #2:      ATTEMPT ECV

IF your baby’s breech presentation is confirmed, then you may consider attempt(s) at external cephalic version (ECV). 

After ECV, your baby may be presenting cephalic (head first), or the breech presentation may persist.  In either case, if there is no valid reason to interfere with the natural process, await spontaneous onset of labour.

 Decision Point #3:      PLAN for VBB

Consider the capacity for vaginal breech birth (VBB) at your intended place of birth; the skill and willingness of your primary maternity care team to proceed with VBB; and access to emergency obstetric and neonatal care if required.  Consider the possibility of changing to another maternity service that is more able to support VBB.

Decision Point #4:    Onset of labour

Your midwife or doctor will advise you of recommended ‘boundaries’, such as gestational age of your baby, spontaneous pre-labour rupture of membranes, and changes in your own and your baby's condition. 

Decision Point #5:    Progress in labour

Your midwife or doctor will monitor your progress, and your baby’s wellbeing, as labour becomes established.

NOTE: The wellbeing and safety of mother and baby guide all maternity care.

This list makes it all sound very straight forward, and it should be. 

UK midwife Mary Cronk MBE wrote in 1998: 

These are the points which midwives should bear in mind when facilitating a vaginal breech birth:

• Don't push a breech through a pelvis with oxytocic drugs
• No inductions, no augmentations
• If the labour does not progress - caesarean operation
• Don't pull a breech down through the pelvis - no breech extractions
• Breech by propulsion, not traction
• If it isn't coming down - caesarean operation
• Keep your hands off - sit on them if necessary
• Be ready to bag and mask. (AIMS Journal)

In that article, Mary Cronk outlined the features of a breech birth (as distinct from a breech delivery):

Breech birth

• Spontaneous onset anytime after about the 37th week.
• No augmentation if labour is slow or there is poor progress - caesarean section.
• Mother encouraged to assume positions of choice during the first stage.
• Fetal heart listened to frequently with a Pinard stethoscope or a hand held Doppler Sonic aid using ultrasound.
• Food and drink encouraged, but remembering that women in strong progressing labour rarely want to eat.
• Membranes not ruptured artificially.
• Vaginal examinations restricted to avoid accidental rupturing of the membranes.
• If, and when spontaneous rupture occurs conduct a vaginal examination as soon as possible.
• Second stage by maternal propulsion and spontaneous expulsive efforts guided by the attendant if judged appropriate.
• Mother encouraged to be in an all-fours position.
• No routine episiotomy.
• Third stage without chemical or mechanical assistance, usually managed according to woman's wishes.

It's clear to me, from a midwife's perspective, that in the journey of decision-making for spontaneous breech births, there are several points at which caesarean surgery would be the next step.  Many colleagues would say, what's the point? 

We will never know if a vaginal breech birth (VBB) is possible unless we proceed down this mystery pathway.  We will never know if labour is able to progress normally if an elective caesarean is performed at 39 weeks.  The avoidance of unnecessary caesarean surgery is of great benefit to the mother and baby, and subsequent children.

A breech birth requires skill, patience, and courage on the part of the woman, the midwife, and the support team.  A breech birth also requires the willingness of the woman to engage in decision-making over time, as the process unfolds, rather than being attached to an inflexible plan for vaginal birth.

A breech birth relies heavily on the ability of the woman's body to intuitively progress through spontaneous onset of labour, and progress in the first and second stages of labour.  There is no room for induction or augmentation of labour, which might mask the natural reluctance of the woman's body to proceed with the birth of a disproportionately large or poorly positioned baby.  There is no room for mind-numbing narcotics which distance the woman from her ability to make a natural response to her labour, and which inhibit the baby's ability to breathe in the moments after birth.  The maneuvers that a midwife may undertake in the moments before the birth, such as gentle turning to release a nuchal arm, or support to flex the head, require confidence in the mechanisms of breech birth and the midwife's skill.

DIFFICULTIES in achieving VBB
A dilemma we face today when approached by a woman who plans to give birth vaginally to a breech baby is the lack of understanding and skill in spontaneous breech birth in most hospitals.  It's almost a lost art.  Even hospitals where the obstetrics team have indicated 'support' for VBB (more accurately, breech delivery or extraction), the requirement is usually that the woman is in lithotomy position once the presenting part is on view, and that the obstetrician manages the birth.  The baby's cord is clamped and cut soon after birth, and the baby is passed to the paediatric team for resuscitation. 

This scenario contrasts with spontaneous VBB birth: in second stage the woman adopts an upright position (such as 'all fours', kneeling, or supported squat) and her baby is born with minimal touch and without any pulling by the midwife.  The integrity of the cord is maintained, and if initial resuscitation is needed baby is placed on a flat surface, continuing to receive the oxygen-rich placental transfusion from the mother, while the baby's independent breathing is being established.

A second dilemma that midwives face is the discussion on place of birth.  Midwives who understand the advantages to mother in baby in spontaneous breech births are often strongly in favour of home birth.  Yet the implications for the baby particularly, if urgent caesarean birth becomes the birth of choice, mean that there is a real advantage to being in hospital for the latter part of first stage, and second stage labour.  The other matter for midwives to consider is the 'unprofessional conduct' notification that would almost certainly follow a transfer of a breech baby or mother to hospital.  Never mind the woman's choices: midwives are expected to refer women with breech babies to a higher power (Category C in ACM National Midwifery Guidelines, 2008.

In conclusion:
I believe that the process of decision-making in breech births is all about getting the best possible birth for that mother and that baby.  It's not about vaginal birth or caesarean, no matter how much the spontaneous physiologic birth is the preferred option.  If a caesarean is required, then it would be tragic if a caesarean was not available.  



Thankyou for your comments

taking a break

I don't expect to be updating this blog until I return to study next year.

For readers who are interested in an update on our family, please go here.

Journal: exam finished

Yesterday morning, between 9am and 12.30pm local time, I and around 90 other midwives (I think) sat the exam.

The discussion at the university online forum and the fb site Graduate Diploma of Midwifery has been focused on relief.  The analogy to a difficult labour has, understandably, been made. 

The exam consisted of 18 questions, randomly allocated by computer for each student from a bank of questions.  There were multiple choice; true/false; short answer; and 'discuss the statement' questions.  I would have liked more time to complete the work - I spent more time than I should have on the early questions.  There were questions on pharmacokinetics, the absorption, distribution, metabolism and excretion of a drug; the therapeutic range for a drug; the changes in pregnancy when a drug is used, and what happens to the developing fetus.  There were questions that brought up polypharmacy, drug-drug interactions, genetic variances in enzyme activity, and social attitudes towards medication use in pregnancy.
 
I have nothing to compare this exam with, as it's the first of its kind, but I felt it was a reasonable test of the knowledge that should have been acquired over the past 5 months. 

As I have journalled my student experience since July 18 I have sought to look at the course, and my personal response to the challenges that it presented me with, objectively.  I put these things into writing as much for my own record as anyone else's. 

On the positive side of the ledger I have enjoyed learning the basics of pharmacology, and the application of pharmacology to midwifery practice.  I have appreciated the challenge to work on concepts that did not come easily to my ageing brain.  Visualising the microscopic processes which project molecules of drugs through the blood stream, across cell walls, and to target tissue is fascinating.  Remembering and revising basic science that I studied more than 40 years ago, understanding the constant movement of ionic charge from particle to particle, considering the anatomic function of the various body organs - this has all been good.  I have enjoyed it.  My friend Julie who I play tennis with most Thursdays is a high school science teacher, and she helped me revise the science of water solubility.

The less than positive side of what I want to record here is the lack of teaching by the university.  One tutor responded to calls for help, and presented helpful tutorials using the online webinar facility of the university.  With the wisdom of hindsight, I would encourage the faculty to offer a revision course for any students who are not up to date with current undergraduate midwifery knowledge in basic pharmacology - this applies to most of those for whom the course has been offered.  I think a series of lectures in the first month or so, using the webinar, would assist those students who have not studied at university in the past decade.  I have spoken in person about this to the head of the faculty for this course.

The ability to prescribe is still a little way off.  There is a further topic in the Graduate Diploma of Midwifery, Diagnostics and Investigations, which I will undertake in the first semester of 2013.  After that I will be able to apply for endorsement as a midwife prescriber.

I am thankful to the Commonwealth of Australia for the scholarship assistance that I have received. 


Thankyou for your comments

Journal: Preparation for exam

This week I am trying to spend some good time in revision of the core concepts that I will need, not just to achieve a pass mark in the pharmacology topic, but to consolidate the learning.

One of the main criticisms that I and other students have had as we approach the end of the course is that there has been a lack of teaching of the basics of pharmacology.  We are reading text books and academic papers, and for me the words and concepts of the science are often a confused jumble.

To address this deficit I have been watching a set of  lectures on Youtube

One of the faculty tutors hosted a webinar on Tuesday evening, and went through the practice exam that had been provided.  I found this very helpful.  A couple of points that were identified, at which I might improve my performance in the exam are:

• understanding how points are awarded: a question that is worth 2 marks towards the total score requires the student to make 4 statements (ie .5 each) that are relevant to the question.
• In multiple choice or true/false questions, a student will be awarded marks for each correct statement, whether it applies to the correct answer, or making the argument as to why a statement is incorrect or false.
• Clinical questions, such as discuss a pregnant woman who has a headache and wonders if she can take paracetamol, require discussion of the pharmacology of the drug in pregnancy, as well as the basic midwifery investigations, such as check the blood pressure, and question the cause of the headache.
• Polypharmacy is defined as the concurrent use of 5 or more medicines, which can include prescriptions, over the counter, and complementary.  For example, a woman who is receiving one prescribed medicine, such as oral antibiotics (1) for a chest infection in late pregnancy, may also take an antacid (2) for heartburn, raspberry leaf herbal tea (3) to achieve good uterine tone, an iron supplement (4) for anaemia, and pyridoxine (5) to treat mild fluid retention.  These substances will likely pass easily across the placenta to the fetal compartment.  What are the possible drug interactions with this group of apparently innocuous medicines?

Your comments are welcome.

Journal: Prescribing portfolio ready for submission

Today I am finalising the prescribing portfolio, which is worth 10% of the marks for the topic.  
The finished document contains dated responses to questions posed by the writer of the course, and summaries of my learning and reflections through the course.

September and October were very busy months for me, with a full caseload.  I have not been able to devote all the time I would have liked to, to the course.  Babies have been born, and I have been privileged to accompany a small number of women in their birthing journeys.  In this brief time I have shared great joy, and great sorrow.

I started this course without much idea of how to navigate an online learning situation.  As I now prepare for the exam in a month's time, worth 50% of the mark, I am seeking to consolidate the new knowledge that I have accessed in the past few months.  I expect to do well in the exam, and I am satisfied that I will have met my personal learning objectives at the conclusion of the course.

Personal Learning objectives:

30 July 2012

• To critically review my knowledge of the medicines which I currently use as a midwife
• To develop a useful body of knowledge about the prescription of medicines which will become part of a midwife’s formulary
• To explore and reflect on published scientific work that is relevant to pregnancy, birth, and breastfeeding.
• To undertake the course of study that will meet my undertaking to the NMBA, to successfully complete "an accredited and approved program of study determined by the Board to develop midwives' skills and knowledge in prescribing"

These objectives are within the topic’s stated learning objectives

Some of the issues I have reflected upon and explored have already been mentioned in this blog.  In summary, here are a few highlights: 

Journal of a new student: I have learned a lot about working within an online learning site, and I can now work my way through MIMS online.  This is a big achievement.  I do not yet feel 'fluent' in a virtual library - I just get lost!

Writing prescriptions: I will need to continue to work on the knowledge and skill of prescribing.  The small number of medicines is OK.  I think there are many aspects of the various formularies that still need to be ironed out.  The Victorian law is in the process of being amended to allow midwives to prescribe.

The two Case Studies in which we explored the prescribing of Metoclopramide for nausea in pregnancy, and Benzylpenicillin for Group B Streptococcus (GBS) colonisation of the genital tract, provided good opportunities for learning and critical thinking.  Where I exceeded the word limit, and needed to remove some of what I wrote, I brought it across to this blog, such as in Case Study 2.  Blogs have no word limit!  

A significant piece of work that this study brought me to is the pharmacology of uterotonics.  I am not surprised that the study of pharmacology has confirmed my desire to work in harmony with wonderful natural processes in pregnancy, birth, and nurture of the infant. 

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.  

A question on collaboration has given students the opportunity to engage in the maternity reform process that requires a collaborative arrangement as the starting point for women to receive Medicare rebate for a midwife's services.  It looks like this:
$$=carrot; collaboration=stick 

Collaboration is actually not onerous; it's basic to midwifery practice.  The problem with collaboration as the Australian government requires is that it's one-way collaboration, which is an oxymoron.  'co' + 'labor' requires at least 2 parties to participate.


As I look back on (most of) the pharmacology course, it's worth stepping into the assessor role, asking questions about how the course met my learning needs, and how it could be improved.

I am conscious of a great deal of new knowledge that is foundational to an understanding of pharmacology.  The course lacked systematic teaching of that basic body of knowledge.  I believe this could be corrected by offering weekly lectures for the first month or so, using the webinar function of the interactive online learning site.  Although the course is post graduate, most students have not studied undergraduate contemporary pharmacology courses, and even those who have would do well to refresh their minds. 

A further step is the application of that knowledge to effective midwifery practice.  This is a challenging topic, and could be used for debate between midwives working in various settings.  

Are midwives who have achieved the endorsement as 'prescribers' likely to take a liberal attitude towards medicines, and prescribe excessively, like a kid with a new toy? 



Thankyou for your comments

Formularies

I went to the First national health professional prescribing  summit, which was held in Melbourne, Monday and Tuesday of this week.

I plan to record a few observations here, for my own future reference, and for anyone else who is interested.  The presentations are to be available at the conference site (with a password) after about 5 days.

It became clear to me as the summit progressed that formularies are likely to become bogs in which we get stuck.  This opinion was shared by well-informed people.  Already midwives have a formulary put out by the NMBA, another put out by PBS, and a third put out by each state or territory health department.   Someone has been employed to develop each list, and committees have reviewed and approved them. 

In practice an individual midwife, or other practitioner, has a group of medicines which we are able to work with.  This is the case with my practice now, even before I am authorised to 'prescribe'.  The problem with formularies is that the items listed are effectively taken out of professional scrutiny, and are used because they are available.  An example is the synthetic narcotic, Pethidine.  Pethidine has been used in hospitals for labour pain as long as I have been a midwife.  Without doing a literature review here, I have been aware for many years that there are good reasons for avoiding the use of Pethidine, and many maternity services have moved away from it.  Yet the formularies for midwives, developed by both the NMBA and the Victorian Health Department, include Pethidine. The formularies fail to ask critical questions, and it is quite possible that some midwives will interpret presence of a scheduled medicine on a formulary as a direction for its liberal use.

Don't get me wrong: I know very few doctors who have the same scruples as I do, restricting the use of 'dangerous drugs' to situations of clear need.  I know of very few instances where a doctor counsels people who have symptoms of upper respiratory infection that it is probably caused by a virus, and therefore won't be helped by antibiotics.  Yet almost every practitioner you talk to will easily mention 'evidence based' practice, as if the word equates to the deed.


Listening to the various presentations, I was aware that this is uncharted territory.  I made a list of words that kept coming up:

team, teamwork
collaborate, collaboration
partnership
credentialling
evidence, evidence based
protection of the public
scope of practice
competence, competency
standards
framework

Each of these words was brought into the discussion with, I am sure, the best of intention.  But each can be twisted into unintended meanings, and at times I have to shake my head and ask myself how does this particular theory fit my practice, or anyone else's for that matter. 

The government's reforms that are behind the expansion of non-medical prescribing have led to a flurry of activity, making up rules.  Midwives find ourselves with various formularies being developed in an attempt to 'protect the public'.  "What am I being protected from?" you may ask.  A midwife who is intentional about protecting, promoting and supporting natural physiological processes in childbearing and nurture will move into the world of prescribing medicines with a high level of caution, regardless of what the notation as a prescriber allows her/him to do.




Thankyou for your comments

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