TPM APRIL 2015

www.thepractisingmidwife.com The Practising MIDWIFE The best job in the world Volume 18 No 4 April 2015Childbirth controversies • In defence of bacteria • Fathers in theatre during caesarean with general anaesthetic • The place of Kielland’s forceps in childbirth • Hospital birth or home birth?

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Challenging The Practisingcontroversy MIDWIFE The best job in the worldP ersonal perspectives on childbirth vary. As a midwife, when I think of In this issue childbirth, I imagine a scene brimming with love and security: a mother and her family in a safe and supportive environment; a 3 EDITORIALcomforting space and place where respectful care is promoted to meet all the 5 VIEWPOINT Controversial controversy Rosemary Manderfamily’s needs, whatever the outcome. These peaceful images can reveal 6 NEWSthemselves in direct contrast to the torrent of controversies that sometimes 10 Being born is good for you Hannah Dahlen explains why thesurround childbearing and birth: controversies that cover global and local body’s natural bacteria are so important to our lifelong healthissues ranging from concern for consistently high maternal and infant 14 ADVANCING PRACTICE Decision making in midwifery: rationality and intuition Using a case study, Suyaimortality rates or ongoing human rights violations pertaining to maternal Steinhauer examines the need to involve women in decision making - and finds that intuition can play a significant partchoices, to our individual perspectives on birth, such as the personal position I 19 Fathers’ presence at caesarean section with generalpresent above. anaesthetic: evidence and debate Kevin Hugill, Ian Kemp and Carol Kingdon examine the arguments for and againstSome level of controversy can be important to ensure birth practices fathers being permitted in theatre during a caesarean section by general anaestheticimprove and childbearing women and their families’ voices are heard. 23 The place of Kielland’s forceps in reducing caesareanControversy can certainly section rates Pooja Balchandra, Fiona Marsh and Christine Landon examine the use of alternatives to caesarean birth, andaccelerate necessary change. It can explain why midwives need to be familiar with Kielland’s forcepsstimulate debate and lead to 26 Hospital birth: are we giving women the facts? Ayla Ozkan, who regularly witnesses the results of traumatic birth, refutescareful investigations to enhance the suggestion that home birth is inherently risky and explains why women are not necessarily safer giving birth in hospitalsafety and promote wellbeing for 29 Pictorial estimation of blood loss in a birthing pool - anall mothers and babies. Yet, by the aide memoire Using a simulation, Anushia Goodman provides a guide to help midwives more accurately tosame token, it can contribute to a estimate blood loss in waterculture of fear and blame; breeding 33 COCHRANE CORNER Interventions for treating painful nipples among breastfeeding women Valerie Smithuncertainty for childbearing highlights a Cochrane systematic review by Dennis et alwomen and maternity care Anna Byrom, Editor 36 THINKING OUTSIDE THE BOX Rethinking bugs Part 2 Sara Wickham continues her exploration of how re-thinking ourproviders alike. Unfortunately, all knowledge around bacteria may benefit women and midwivestoo often, birth controversies are sensationalised, especially via the media, 38 BABY FRIENDLY NEWS Taking neonatal care to the next level Francesca Entwistle highlights the place of breast milkigniting a sense of anxiety and concern for both the providers and users of in close, loving relationshipsmaternity services. 40 MIDWIFERY BASICS: MENTORSHIP 7. Mentor update and support: what do mentors need from an update? MariThis month The Practising Midwife explores some current controversies Phillips and Joyce Marshall consider what mentors need from their annual updateassociated with childbirth. We examine the concept while presenting some 43 REVIEWSkeys areas that can create disagreement within maternity care. Our hope is to 44 PROFESSIONAL DEVELOPMENTilluminate some important issues with a discussion focused on practice 46 LAST WORD A gathering of the like minded Molly O’Brienimprovement. For me, reading the contents of our April issue, I am reminded speaks out in defence of the NHSto manage the challenge of controversy through effective collaboration,continually striving to use the best available evidence but, most importantly,by listening to those in our care: childbearing mothers and their families. COVER PICTURE MARK CLARKE/SCIENCE PHOTO LIBRARY The Practising Midwife | April 2015 3

Editorial advisory board CONTACT: 020 8313 9617 [email protected] Caine BSc, Dip HE Midwifery, Joyce Marshall PhD, MPH, BSc(Hons),RM, Correspondence: 66 Siward Road, Bromley BR2 9JZPGCert (HE and supervision of midwives), RN, FHEA, PGCAP Senior Lecturer inMSc, RM Midwife, Lecturer and PhD Midwifery, University of Huddersfield Editor: Anna Byrom, BSc, PGCert, RM, Seniorstudent, University of East Anglia and SoM Midwifery Lecturer, University of Central Lancashire Rachel McKeon-Clark LLB (Hons) [email protected] Crowther PhD, MSc, BSc (Hons), BSc (Hons) RM Nurse Advisor, NHS DirectRM, Senior Lecturer (AUT University Managing Editor: Laura YeatesAuckland NZ) and rural locum caseload Anne Marie Rennie MSc, RM, RGN, ADM, [email protected] BSc (Hons) Midwifery, PG Cert HELT (editorial/author submissions) Lecturer in Midwifery, The Robert GordonDéirdre Daly MSc, PGDipEd, BSc (Hons), University News Editor: Mandy GallowayRM, DipMid, RGN Lecturer in Midwifery, [email protected], 020 8313 9617Trinity College, Dublin Mandy Renton RGN, RM, MSc Chief Nurse, Cambridgeshire Community Advertising Manager: Margaret FloateRuth Deery PhD, BSc (Hons), ADM, RM, Services NHS Trust [email protected], 01483 824094FHEA Professor of Maternal Health,University of the West of Scotland Katrina Rigby RM, MA, BA (Hons) Senior Publisher: Ian Heslop [email protected] Research Midwife and Team Leader,Cathy Green MA, Bsc (Hons), BA (Hons), Lancashire Teaching Hospitals NHS Facebook is a registeredDipHe, RM Midwife, Home birth team, Foundation Trust trademark of Facebook, Inc.Birmingham Women’s Hospital Verena Wallace MSc (HPPF), PGDip, MSc, We are now on Twitter -Joy James RGN, RM, ADM, Cert ADM, RM, RN Local Supervising Authority follow us at @ThePractMidwifeCounselling, Dip Counselling, PGCEM, RN, Midwifery Officer for Northern IrelandBA, MA Senior Lecturer, Midwifery, © 2015 Medical Education Solutions Ltd. 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The views expressed in Viewpoint are those of the author and do not Rosemary Mandernecessarily reflect those of the editorial board of The Practising MidwifeViewpointControversial controversyC ontroversies are problematic to any The value of controversy corresponds remarkably closely to the ‘post- occupational group. Disagreements and modern’ midwife, described by Robbie disputes may give the outsider and Clearly, tall poppies have a hard time if they Davis-Floyd (2005). Characteristically thispotential client the impression that these dare to raise their heads above the parapet of midwife is able to apply both traditional andprofessionals are not all singing from the same clinical practice or in other institutionalised more technological skills in her practice. Hersong sheet or that they may not even possess a settings. For this reason they may choose to unique skills lie in her knowing ‘the limitationssong sheet at all. When such conflicts arise, maintain a low profile and work hard at fitting and strengths of the biomedical system’ andthere is a risk of division or even schism that in with the prevailing regime. I regard such ‘how to subvert the medical system’ to ensuremay seriously weaken any united front which behaviour as entirely understandable. Why that care is woman centred (Davis-Floyd 2005:the group seeks to present and, thus, their should anybody seek unnecessary challenges? 33). Perhaps more disconcertingly in theattractiveness to both service users and In the midwifery context, though, such an all- present context, the post-modern midwife ispotential recruits. too-human response constitutes a loss to the sufficiently well educated to be able to service, to the profession and, most question not only her own practice but alsoRocking the boat importantly, to the childbearing woman. that of others.So how does midwifery address the difficulties Rather than cutting down the tall poppy Although some individual midwife leadersraised by those who are less than enthusiastic who advances controversial views or applying may be able to recognise and foster the skillsabout toeing the party line? These are the horizontal violence to the midwife who dares and attributes of the controversial tall poppy, Ioutsiders who may be seen by some as rocking to step out of the pre-ordained line, this would argue that the profession of midwiferythe boat which the insiders know all too well individual should be nurtured. The colleagues may be less welcoming, even accepting, of suchmay not be entirely seaworthy or may even be and management hierarchy should not feel individuals in its midst. This is a weakness inin danger of sinking. threatened, but adopt a policy of urgent need of being addressed. tpm encouragement. A healthy organisation would In midwifery, controversies may be regard the tall poppy like the grain of sand in Rosemary Mander is emeritus professor ofhighlighted by colleagues and others who the oyster, which will develop into a pearl, to midwifery at the University of Edinburghregard the status quo as less than ideal. Such the benefit of all concerned.opinions are likely to be based on personal or Referencesoccupational experience, or possibly on reading In advancing controversial ideas andor other research. Those who advance practices, the tall poppy is likely to focus on Feather NT (1989). ‘Attitudes towards the high achiever:controversial views may be met with the the need for the midwife to be ‘with woman’. the fall of the tall poppy’. Australian Jour Psych, 41(3):response which has been termed by antipodean This may be in contrast to an accepted policy 239-267.academics the ‘tall poppy syndrome’ (Feather which demotes the midwife to acting as an Hunter B (2004). ‘Conflicting ideologies as a source of1989). The organisational response to such obstetric nurse or being ‘with institution’ emotion work in midwifery’. Midwifery, 20(3): 261–272.individuals who draw attention to themselves (Hunter 2004: 266). Davis-Floyd R (2005). ‘Daughter of time: the post-and arouse envious notice, or even hostility, is modern midwife’. MIDIRS, Midwifery Digest, 15(1):to cut them down to size. Nurturing sound midwifery 32–39. The tall poppy to whom I have been referring The Practising Midwife | April 2015 5

News analysis THE KIRKUP REPORT NHS Furness General Morecambe Bay Hospital Hospitals NHS TrustInvestigation reveals serious failures of clinicalcare and avoidable harm to mothers and babiesA lethal mix of failures of care and event, and over four years after the competence, insufficient recognition of risk,inadequate investigation dysfunctional nature of the unit should have inappropriate pursuit of normal childbirth andcontributed to preventable deaths become obvious.” failures of team-working.in mothers and babies atMorecambe Bay The investigation found: Since 2008, there have been ten deaths in • Clinical competence was substandard, which there were major failures of care, six of The report of an independent investigation which could have been prevented withinto events at the maternity unit at Furness with deficient skills and knowledge; different clinical care.General Hospital (FGH) catalogues serious • Working relationships were extremelyfailures of clinical care, avoidable harm to The investigation in 2004 was rudimentary,mothers and babies and preventable deaths poor, particularly between different over-protective of staff and failed to identifyover a period of almost a decade. staff groups, such as obstetricians, underlying problems. Initial investigation into paediatricians and midwives; events in 2008 was again deficient and failed The Kirkup investigation found a • There was a growing move among to identify manifest problems. The 2008dysfunctional unit characterised by clinical midwives to pursue normal childbirth incidents were treated as individualincompetence, deficient skills and poor “at any cost”; unconnected events, and no link was madeworking relationships between staff groups. • There were failures of risk assessment with previous incidents. At least seven and care planning that resulted in significant opportunities to intervene over the Between 1 January 2004-30 June 2013, the inappropriate and unsafe care; and three years from 2008 were missed, includinginvestigation – headed by former deputy chief • The response to adverse incidents was during the Trust’s registration with the Caremedical officer Bill Kirkup – uncovered grossly deficient, with repeated failure Quality Commission (CQC) and at subsequentevidence of 20 instances of significant or to investigate properly and learn CQC assessments.major failures of care at Furness General lessons.Hospital, resulting in three maternal deaths Culture of denialand the deaths of 16 babies. Of these, at least The first sign of the problems at FGHone maternal death and 11 neonatal deaths occurred in 2004, when a baby died from the During this period, the Trust’s focus was oncould have been prevented. effects of shortage of oxygen, due to a operational objectives such as finance and mismanaged labour. waiting times rather than governance and The report catalogues a series of failures at quality of service, and a key managementalmost every level – from the maternity unit to Between 2006 and 2007, five more serious priority was pursuit of Foundation Trust status.those responsible for regulating and incidents occurred that showed evidence ofmonitoring the Trust, compounded by a problems similar in nature to the 2004 But the report also makes strong criticismpattern of failure to recognise the nature and incident. of the midwives at the Trust – not for theseverity of the problem, coupled with denial mistakes of individuals but because of thethat any problem existed, and a series of A cluster of five serious incidents occurred culture of denial that there was a problem,missed opportunities to intervene, that in 2008: a baby damaged by the effects of their rejection of criticism of them that theyinvolved almost every level of the NHS. shortage of oxygen in labour; a mother who felt was unjustified and which, on occasion, died following untreated high blood pressure; turned to hostility. Dr Kirkup states: “Had any of those a mother and baby who died from an amnioticopportunities been taken, the sequence of fluid embolism; a baby who died in labour due The report states: “We found clear evidencefailures of care and unnecessary deaths could to shortage of oxygen; and a baby who died of distortion of the truth in responses tohave been broken. As it is, they were still from unrecognised infection. All showed investigation, and events such as theoccurring eight years after the initial warning evidence of the same problems of poor clinical disappearance of records, although capable of6 The Practising Midwife | April 2015

THE KIRKUP REPORT News analysis NHS Furness GeneralMorecambe Bay HospitalHospitals NHS Trustinnocent explanation, concerned us. We also Freedom to speak up Bill Kirkup CBEfound evidence of inappropriate distortion ofthe process of preparation for an inquest, with The Kirkup report makes it clear that health A former deputy chief medicalcirculation of what we could only describe as professionals have a duty of candour to speak officer, Bill Kirkup was appointed‘model answers’. [And] where individuals up when issues arise that affect patient safety, chairman of the Morecambe Baycollude in concealing the truth of what has and that the national policy on whistleblowing Investigation in July 2013.happened, their behaviour is inexcusable, as should be implemented in a way that ensures a Previously he was a member ofwell as unprofessional. “systematic and proportionate” response is Hillsborough Independent Panel, made when concerns are raised. and led investigations into the “Serious incidents happen in every health Oxford paediatric cardiac surgerysystem because of the nature of healthcare, However, in Sir Robert Francis QC’s report unit and Jimmy Savile’sand no blame should be attached to staff who on whistleblowing, Freedom to speak up, it is involvement with Broadmoormake mistakes. It is, however, vital that clear that in many cases staff feel unable to Hospital. The investigationincidents are properly investigated, in order to speak up about patient safety concerns, or examined 15,280 documents fromidentify problems and prevent a recurrence,” were not listened to when they did. 22 organisations, and conductedthe report concludes. 118 interviews with staff and Francis says NHS staff must feel it is safe to victims’ family members. The Royal College of Midwives and Royal raise concerns, confident that they will be I The Report of the MorecambeCollege of Obstetricians and Gynaecologists listened to, and that their concerns will be Bay Investigation is available at:have expressed their deep concern at the acted upon. The report reinforces the ‘moral http://tinyurl.com/latnscrfailure of maternity services at Morecambe obligation’ of the NHS to support andBay, and fully support all the Kirkup Report’s encourage staff to speak out, but in contrast,recommendations. many organisations accuse whistleblowers of raising concerns for “dubious motives” such as These include the development of clear avoiding action to address their own poorstandards for incident reporting and performance.investigation; mandatory reporting of seriousincidents such as maternal or neonatal death; Francis concluded: “Speaking up is essentialan independent mechanism to scrutinise in any culture where safety is an issue.perinatal and maternal deaths, and stillbirths; Without a shared culture of openness andand a proper framework, statutory if necessary, honesty in which the raising of concerns isshould be established to conduct similar welcomed and the staff who raise them areindependent inquiries in future. valued, the barriers to speaking up will persist and flourish.” In a joint statement, the two Royal Collegessaid: “We will now take time in our respective RCM chief executive Cathy Warwick said:organisations to consider this report in detail “For too long midwives have faced opposition,and will identify actions that we need to take, harassment and bullying when they have triedboth together and separately. We are to raise legitimate concerns about patientcommitted to working together and to safety and standards of care. This must stop.”offering our support to ensure that therecommendations of this important report are The RCM has issued guidance onimplemented as soon as possible; this is crucial, whistleblowing, Standing up for highgiven the critical importance to high-quality standards, available at:maternity services of multi-professional http://tinyurl.com/po2xtu8working and collaboration.” And Health Education England has produced a film to help staff raise concerns, available at: http://tinyurl.com/ntjsbsc The Practising Midwife | April 2015 7

News analysis THE KIRKUP REPORTPerspectives on the Kirkup report NHS Furness GeneralAn extended version of these and other perspectives can be found at: http://tinyurl.com/p5npznv Morecambe Bay Hospital Hospitals NHS Trust Rineke Schram, consultant Sheena Byrom OBE, Milli Hill, writer and obstetrician and Chief independent midwifery founder of a movement to Medical Officer at East advisor and Chair of RCM’s improve the experience of Lancs Hospitals NHS Trust Campaign for normal birth birthDr Kirkup’s report on his investigation Reading this report instilled great This report shows a complex catalogueof serious incidents in the maternity sadness for the devastation of families of failings and the enormous tragedyservices of Morecambe Bay Foundation who lost their loved ones. The heartbreak of lives lost unnecessarily. But theTrust is grim reading for anyone is made more painful when explanations media attention on ‘musketeer midwives’involved in providing such services in and actions are flawed. My sadness was concerning, with headlines like,the NHS. We feel deeply for the families also extends to staff members of the “The cult of natural childbirth has goneaffected, but must avoid the temptation organisation, and their families, as most too far” (The Guardian, 5th March).to fix on easy targets (such as groups will have felt the unbearable pressure The idea that ‘natural childbirth’ is aof individuals and/or their supposed of working in a broken system, where fear kind of dangerous ideology that isobjectives). Let us focus, instead, on and uncertainty prevail. The report shows pursued to the detriment of safety isthe need to foster a culture where organisational malfunctions at every widely held, in spite of clear evidencetrust, respect and confidence between level. I hope the imminent maternity to the contrary. In the wake of Kirkup,midwives, obstetricians and mothers service review helps to support normal birth could become a soft yetlead to a situation where it simply is maternity services to understand that misguided target for people’snot possible for the sort of incidents safety includes promoting respectful justifiable outrage. While the reportdescribed to occur. In such a culture collaboration, kind and compassionate offers opportunities for positivewomen and their partners are treated care, and pursues opportunities to change, it is also potentially a setbackwith compassion and dignity, with fully understand and reduce the fear that for normal birth and ammunitioninformed shared decision making. inhibits the capacity to function. against all who advocate for it. Shawn Walker, lecturer in Rebecca Schiller, co-chair Alison Barrett, consultant midwifery at City of a charity protecting obstetrician and University, London human rights in childbirth gynaecologist, Waikato Hospital in Hamilton, NZLike many midwives, I welcome the Dr Kirkup's report makes for soberingKirkup report, though it made hard reading. It is clear from this, and the I’ve worked in lots of places, in differentreading at times. parallels with the conclusions of the parts of the world, and I know of noVery few of us wish to pursue an ethos Francis enquiry (and investigations into institution that is perfect. I’ve yet toof normal birth at all costs. But when similar tragedies elsewhere) that there work in a facility without some issues,an individual acquires unchallenged is widespread institutional disregard and I am sorry to report that I haven'tpower by assuming multiple roles in for the basic human dignity of women encountered a medical system wherethe risk management process, the system using our maternity services. When the patients escape harm. I’m mindful that,of checks becomes unbalanced. Safety system reaches breaking point the behind the Kirkup report, are bereavedrequires respectful, collaborative devastating consequences are clear. families facing unfathomable losses.communication among all professions, At Morecambe Bay, failures in the So I lamely offer them, and us, anand working environments where people system led to the deaths of women and acknowledgement of our collectiveare able to say, ‘I'm concerned,’ without babies. This is unacceptable. It is also failures. Doctors and midwives arebeing overridden or overriding someone unacceptable that many other women imperfect human beings, asked toelse's concern. Only by being rigorous, suffer the less extreme, but no less provide exemplary care, in a systemcompassionate and honest with each profound, effects of institutions that that sometimes conspires against us all;other can health professionals hope to process - rather than listen to - them. I a system that can bring out the worstprovide care that is all these things, for hope that the review panel deals with instead of the best. Despite this, mostpeople who trust them with their lives. these issues three-dimensionally. practitioners I know come to work each day wanting the best for every family.8 The Practising Midwife | April 2015

News analysisBreastfeeding boosts IQ and earnings in adulthoodBreastfeeding for 12 months or show a direct association with future adult breastfeeding are important.more can result in not only greater earnings. Commenting on the study, Janet Fyle,intelligence, and improvededucational attainment, but also a Previous studies have been criticised professional policy advisor at the Royal Collegehigher income in adulthood, because of the potential for the mothers’ of Midwives, said the research added to ouraccording to the findings of a socio-economic or educational status to knowledge of the benefits of breastfeedinglong-term prospective study. confound the assessment of intelligence or “lasting well into adulthood”. achievement, leading to overestimates of the The researchers in Brazil followed up nearly benefits of breastfeeding. She added: “It is one of the most important3,500 babies from all sectors of society, and markers of an individual’s future health andfound that those who had been breastfed for But this study was carefully set up to well-being and this is why health services needlonger scored higher in IQ tests as 30-year-old exclude factors such as the mother’s to make greater efforts to encourage newadults. Compared with those who were breastfed education, family income and the baby’s birth mothers to breastfeed and for longer throughfor less than one month, they also had more weight – and still found clear evidence of long better support, considerate maternity leaveyears of education and higher monthly incomes. term benefits. and strengthening policies and legislative framework that enable women to breastfeed The study confirms previous research that A possible biological explanation for the when out and about.has shown clear associations between findings is the presence of long-chainbreastfeeding and child intelligence, and long- saturated fatty acids in breast milk, which are “This also highlights the importance ofterm positive effects on adult intelligence and essential for brain development. The finding of good postnatal support and access to midwivesschool achievement, but this is the first to a dose-related effect suggests that both the to give women the help they need to establish quantity of breast milk and the duration of and continue breastfeeding.”M-320 The LightestBaby Scale AvailableWeighing only 2.4kg! NEWBRAND B£A1B9Y5S+CVAALTE• Ideal for Midwives and Health Visitors• Secure Hygienic Slide On/Off Weighing Pan Tel: 0845 130 7330 E-mail: [email protected] & PORTABLE www.marsden-weighing.co.uk Twitter: @MarsdenWeighing Designed and engineered in UK The Practising Midwife | April 2015 9

Hannah Dahlen Being born is good for youexplains why the body’s SUMMARY: The distrust in women’s ability to give birth and the pathologising of thisnatural bacteria, passed physiological process is a relatively recent historical phenomenon. While there ison from our mothers at increased recognition of the importance of normal birth for women, babies and societybirth, is so important to as a whole, the focus of researchers has, to date, been on relatively short-termour lifelong health outcomes; in particular perinatal mortality. As scientists develop the skills and gain knowledge in the area of epigenetics and the microbiome, we are glimpsing the potential long-term and even inter-generational implications of high rates of medical intervention during labour and birth. More research is urgently needed, and helping consumers to understand the potential ramifications is also important. Midwives need to be aware of these emerging areas of research and be able to communicate with women about them. Keywords Epigentics, microbiome, normal birth, medical intervention Author Hannah Dahlen, professor of midwifery at the University of Western SydneyAs medical men came Can women give birth? general anaesthesia (Simkin 1984). DeLee into the world of stated that, “labour has been called, and is Recent historical accounts demonstrate a believed by many to be, a normal function…childbirth there began surprising distrust of women’s bodies and their and yet it is a decidedly pathologic process to emerge a less ability to give birth, with very little recognition (DeLee 1904: 34). I wish I could say this was the positive view of of the importance of labour and birth to the distant past we are talking about but sadly the woman’s survival of the human race. Until the 17th these views of women’s bodies are still alive birthing body century, women were almost exclusively and well. In 2013 a urogynaecologist in attended by other women but, as medical men Australia made sensational headlines with his (originally barber surgeons) came into the claim that, “human childbirth is a fundamental world of childbirth there began to emerge a biomechanical mismatch, the opening is way less positive view of the woman’s birthing body. too small and the passenger is way too big” While Hugh Chamberlen describes the womb as (Corderoy 2013). I responded in an editorial “a dungeon, wherein he [the baby] hath been a that, “If health professionals truly believe this long time inclosed” (Mauriceau 1673: 353), this then what chance do women have to feel is in strong contrast to the description in confident in their bodies and capacity to give Trotula (11th century text book) of the fetus birth?” (Dahlen 2013). being “expelled from its bed by the force of nature” (Green 2002: 79). By the early 20th Much of the research on the effects of century we had Dr Joseph DeLee (father of intervention during birth has focused on the modern day obstetrics in America) promising short-term outcomes for mother and baby, and the elimination of the second stage by mainly on perinatal mortality. But what if, routinely using episiotomy and forceps under unknowingly, society is being reshaped on a10 The Practising Midwife | April 2015

Epigenetics and the microbiomePhotographs by kind permission of Holly Priddis a morbidity following birth and to be readmitted to hospital in the first 28 days forMeggan Brummer with Hannah Dahlen morbidities associated with interventions, such as forceps and vacuum birth (scalp trauma)microbiological and epigenetic level through without a medical intervention are becoming and being born early (breathing, feeding, sleepthe way women give birth and could this be increasingly rare, both in Australia and many and behavioural difficulties and jaundice)having long-term health effects? other developed nations. In 2012 we published (Dahlen et al 2014). However, we recognise this a paper showing only 15 per cent of low risk is still only giving us a short-term glimpse atThe value of bacteria first time mothers giving birth in private the potential impact of obstetric intervention. hospitals in my state of New South Wales didIn 1915, when caesarean section was rare, so without intervention, compared to 35 per Despite efforts nationally andKendall proposed that microbes, which colonise cent in public hospitals (Dahlen et al 2012). In internationally to reduce intervention ratesthe baby’s gastrointestinal tract following 2014 we published a follow up paper showing during childbirth, medical intervention isvaginal birth, ‘may be protective ’ (Kendall that babies born to low risk women in the becoming the norm. In Australia one in three1915). He said, “Very shortly after birth private sector, where the intervention rates women now give birth by caesarean sectionbacteria make their appearance in the mouth were so much higher, were more likely to have (nearly 1:2 in the private sector); more thanof the newborn, and organisms appear in the half are induced or have their labourmeconium from four to 20 hours post partum Loss of the usual labour augmented; and around 50 per cent are given(Kendall 1915: 209). Colleagues of Kendall had and breastfeeding route antibiotics to reduce the risk of infection. Inpreviously undertaken experiments sterilising of colonisation leaves a some countries, such as China, over 50 per centthe environments (including undertaking baby vulnerable to later of women now give birth by caesarean section.caesareans) and foods of newly born/hatched auto-immune disease The World Health Organization (WHO)animals, observing that development became estimated the cost of unnecessary caesareanaffected under these conditions. This led sections at US $2.34 billion globally in 2008,Kendall to conclude that these bacteria may be with 6.20 million unnecessary caesareans beingprotective under ‘ordinary conditions’. performed annually (Gibbons et al 2010). The WHO stated again in 2010 that caesareanThe impact of obstetric intervention section “rates >15 per cent may result in more harm than good” (Gibbons et al 2010). Of allIn the intervening 100 years, intervention in the developed nations in the world, Icelandchildbirth has climbed higher than ever before comes closest to meeting this target (17 perin the history of humankind. Vaginal births cent) and also has the lowest numbers of babies and mothers dying in the world. Never before in human history has there been such a dramatic uncontrolled and unevaluated experiment in progress for so long. Microbiologists are studying physiological processes beginning during pregnancy, birth and breastfeeding and neonatal gut flora. These gut flora have been inherited across generations from Neolithic times, and a co- dependency has built up between these organisms and the human immune system. Loss of the usual labour and breastfeeding >> The Practising Midwife | April 2015 11

Epigenetics and the microbiome “Intervening in childbirth is like throwing a pebble into a pond. The ripples keep on going and you don’t know where they will end up - but you can bet that on some distant shore there will be an effect. It is only relatively recently that we have been looking beyond the throw of the stone to the distant shore. What we see is very, very scary.” (Dahlen 2007)Mother Olivia feeds her new baby, Nathaniel environmentally triggered, epigenetic antibiotic use and caesarean sections - affect processes, such as DNA methylation, which the epigenetic remodelling processes and theroute of colonisation leaves a baby vulnerable involves silencing or switching off whole - or subsequent health of the mother and childto later auto-immune disease. A study parts of - individual genes so that they cannot (Dahlen et al 2013).published recently, using DNA sequencing, function, thus altering gene expression (Mosheshowed babies born by elective caesarean 2009). Genes and susceptibility to disease can In the EPIIC hypothesis, we propose thatsection lacked, or had, lower numbers of be activated or deactivated by lifestyle factors physiological labour and birth have evolved tocertain bacteria that are found in babies born and experiences such as diet, stress, exposure exert eustress (a healthy, positive form ofvaginally (Azad et al 2013). And we know to toxins – and childbirth. This relatively new stress) on the fetus, and that this process hasdisrupting gut microbes has been linked to a field of study is called epigenetics, which an epigenomic effect on particular genes,range of diseases, such as inflammatory bowel literally means above or on top of genetics. particularly those that programme immunedisease, allergies, asthma, cancer and so on responses. Reduced or elevated levels of the(Madan et al 2012; Penders et al 2006). EPIIC hypothesis hormones cortisol, adrenalin and oxytocin, which are produced during labour, may lead toEpigenetics In January 2012 Professors Soo Downe, Holly fetal epigenomic remodelling anomalies which Powell Kennedy and I brought together 11 exert influence on abnormal gene expression.An alternative explanation, or possibly a co- researchers (midwives, scientists, This reprogramming could manifest in a rangeoccurring mechanism, focuses on the stress epidemiologists, geneticists and epigeneticists) of diseases and behavioural problems in theresponse and the role of epigenetics in gene and developed the EPIIC hypothesis (Dahlen et neonate and later on in the adult. Thisexpression. Scientists are increasingly realising al 2013). We hypothesise that events during suggests that what goes on in labour and birththat the genetic legacy we pass on to our labour and birth – specifically the use of the may be crucial to epigenetic remodeling andoffspring is not fixed. While we are all born synthetic hormone oxytocin, along with the future health of society as a whole (Dahlenwith a unique gene profile, we now know that et al 2013).how our DNA is expressed depends on several Methylation In a recent comparative study, Swedish researchers found that certain cord blood cells of infants born by caesarean section had more global DNA methylation than those from infants born vaginally (Almgren et al 2014).12 The Practising Midwife | April 2015

Epigenetics and the microbiomeCommunicating with women about the mounting and it is very concerning. 2:e001723 doi:10.1136/bmjopen-2012-001723.emerging science Remarkably, 100 years after Kendall Dahlen HG, Kennedy HP, Anderson CM et al (2013). 'The • Like climate change we do not have all EPIIC hypothesis: intrapartum effects on the neonatalthe evidence yet, but we have enough to tell published his observations, vaginal swabs are epigenome and consequent health outcomes'. Medus something is going on. Like governments now being taken from some women giving Hypoth, 8(5): 656-662.faced with the science on climate change, birth by caesarean section and smeared on Dahlen H, Tracy S, Tracy MB et al (2014). 'Rates ofwhere not everyone agrees, we need to their nipples, or onto the baby’s face and lips, obstetric intervention and associated perinataldecide now: can we risk doing nothing, when to help seed the baby with important bacteria. mortality and morbidity among low-risk women givingdoing something will lead to other benefits As we continue to test this hypothesis, birth in private and public hospitals in NSW (2000–anyway? hopefully we’ll come closer to determining just 2008): a linked data population-based cohort study'. • Giving birth in environments where how being born is good for you. tpm BMJ Open, 4:e004551. doi:10.1136/bmjopen-2013-medical intervention is used cautiously and 004551.as a last option, not a first choice, gives us Hannah Dahlen is professor of midwifery at the DeLee J (1904). Obstetrics for nurses, Philadelphia: WBthe best outcomes for both mothers and University of Western Sydney Saunders.babies. Developed countries with the lowest Gibbons L, Belizán JM, Lauer JA et al (2010). The globalcaesarean section rates also have the best References numbers and costs of additionally needed andmaternal and perinatal outcomes in the unnecessary caesarean sections performed per year:world. Almgren M, Schlinzig T, Gomez-Cabrero D et al (2014). overuse as a barrier to universal coverage, Geneva: WHO. • The most effective way to reduce 'Cesarean delivery and hematopoietic stem cell Green MH (ed) (2002). The Trotula, Philadelphia:intervention in childbirth is by providing all epigenetics in the newborn infant: implications for University of Pennsylnania Press.women with midwifery continuity of care future health?' Am Jour Obs Gyn, 211(5): 502.e1- Kendall AI (1915). 'The bacteria of the intestinal tract ofand when they are low risk, encouraging 502.e8. man'. Science, XLll(1076): 209-212.them to give birth at home or in a midwife Azad MB, Konya T, Maughan H et al on behalf of the Madan JC, Farzan SF, Hibberd PL et al (2012). 'Normalled free standing birth centre. CHILD Study Investigators (2013). 'Gut microbiota of neonatal microbiome variation in relation to healthy Canadian infants: profiles by mode of delivery environmental factors, infection and allergy'. Curr OpinThere was also a relationship between the and infant diet at 4 months'. Can Med Ass, DOI:10.1503 Pediatr, 24: 753-759.length of labour and methylation in some /cmaj.121189. Mauriceau F (1673). The accomplisht midwife, treatinggenes. The researchers suggest that the Cardwell CR, Stene LC, Joner G et al (2008). 'Caesarean of the diseases of women with child and in child-bedpotential for adverse effects (such as disease) section is associated with an increased risk of translation by Hugh Chamberlen, London: Darby forcan lie dormant, unless or until a specific childhood-onset type 1 diabetes mellitus: a meta- Benjamin Billingsley.trigger acts on genes through these epigenetic analysis of observational studies'. Diabetologia, 51: Moshe E (2009). 'Early life, the epigenome, and humanprocesses. This would explain why labour and 726-735. health'. Acta Paediatr, 98: 1082-1084.birth events are associated with far-distant Corderoy A (2013). 'Push for natural delivery risks later- Penders J, Thijs C, Vink C et al (2006). 'Factorschronic (especially auto-immune) disease life problems'. Sydney Morning Herald, September 11th. influencing the composition of the intestinalstates such as asthma and diabetes (Cardwell Dahlen H (2007). The effect of a rising ceasrean section microbiota in early infancy'. Pediatrics, 118(2): 511-521.et al 2008; Thavagnanam et al 2008). rate on maternal and perinatal health, Paper presented Simkin P (1984). 'Active and physiological management at the NSW Health Department Caesarean section of second stage: a review and hypothesis'. In: Kitzinger Due to a dearth of research in this domain, Forum, Sydney. P (ed). Episiotomy and the second stage of labour. 2ndepigenetic changes which may occur due to Dahlen H (2013). 'Push for natural birth reduces risks Edition, Seattle: Penny Press Inc.medical interventions and environment later - an alternative opinion'. Sydney Morning Herald, Thavagnanam S, Fleming J, Bromley A et al (2008). 'Ainteractions remain unknown, as well as the September 12th. meta-analysis of the association between caesareanhealth implications for mother and child. The Dahlen HG, Tracy S, Tracy M et al (2012). 'Rates of section and childhood asthma'. Clin Exp Allergy, 38(4):evidence around the seeding of the neonatal obstetric intervention among low-risk women giving 629-633.gut with healthy bacteria, during and birth in private and public hospitals in NSW: afollowing birth, with breastfeeding is population-based descriptive study'. BMJ Open, The Practising Midwife | April 2015 13

Using a case study, Advancing PracticeSuyai Steinhauer Decision making in midwifery: rationality and intuitionexamines the need toinvolve women in decision SUMMARY: Decision making in midwifery is a complex process that shapes andmaking – and finds that underpins clinical practice and determines, to a large extent, the quality of care.intuition can play a Effective decision making and professional accountability are central to clinicalsignificant part governance, and being able to justify all decisions is a professional and legal requirement. At the same time, there is an emphasis in midwifery on shared decision making, and keeping women at the centre of their care, and research reveals that feelings of choice, control and autonomy are central to a positive birth experience. However the extent to which decisions are really shared and care truly woman-centred is debatable and affected by environment and culture. Using a case study of a decision made in clinical practice around amniotomy, this article explores the role of the intuitive thinking system in midwifery decision making, and highlights the importance of involving women in the decision making process. Keywords Midwifery, decision making, intuition, culture, amniotomy Author Suyai Steinhauer, home birth midwife at a practice serving an Amish community in the United StatesDecision making in Case study: *Janemidwifery is complex,often associated with risk This case study is taken from practice when I was a third year student midwife working withand uncertainty and my mentor at a stand-alone birth centre. We were caring for Jane, a low-risk primipara whodependent on good was labouring in the pool, supported by her husband.clinical judgement and At the first assessment, the baby was in an occipito-anterior position, with the head wellknowledge of the applied to her cervix, which was fully effaced, soft, stretchy and 5cm dilated. Jane’s uterus wasevidence base contracting regularly (3:10), with contractions strong to palpate and lasting for a minute. Four hours later, my mentor encouraged Jane to get out of the pool for a vaginal examination to assess her progress. Once out of the water, Jane appeared to be coping less well and was verbalising that she was struggling. My mentor performed the vaginal examination and found Jane’s cervix to be 8cm dilated with bulging membranes. She suggested artificially breaking Jane’s waters and left the room to speak with a senior midwife. I did not perceive that an amniotomy at this stage was clinically indicated in a woman who was progressing well and visual and verbal cues indicated was reaching the transitional phase of labour. Furthermore, my mentor had not discussed the intervention with Jane and therefore she would be unable to make an informed choice. * Name changed14 The Practising Midwife | April 2015

Decision making in midwifery‘Risky’ decision? Practice challenge exist, and the extent to which shared decision making and true informed choice can goI made the decision to discuss the risks of How much does authentic shared beyond rhetoric within the currentamniotomy with the client after my mentor decision making feature in your organisational culture of NHS has beenwho had suggested the intervention had left practice? Are you sure that the questioned (Kirkham 2004; 2010). However,the room. women you care for are aware of all balanced information provision, including the options, risks and benefits of the discussion of risks, benefits and alternatives, is This article explores the elements involved interventions offered to them? essential for an authentic consent process andin making this decision, and considers the What strategies can you put in place can also help woman-centred midwives tocomplexity of decision making in midwifery, to ensure that consent is truly support normal birth physiology and reducethe ethical implications and the imperative of informed? interventions.involving women in the decision makingprocess. Midwives are considered to be autonomous Decision making approaches practitioners, professionally and legally Decision making in midwifery is complex, accountable for all their interventions, actions Decision making is often dichotomised as aoften associated with risk and uncertainty and and omissions; any decisions made must be rational, logical approach on the one hand ordependent on good clinical judgement and clear and justifiable (Nursing and Midwifery an intuitive approach, based on experience, onknowledge of the evidence base. Decisions, Council (NMC) 2008). However the extent of the other. Models tend to sit on a continuumdefined by Dowie (1993) as the choice between that autonomy is debatable and affected by between these two camps, but in reality therealternatives, can be based on problems or various factors including the surrounding is often an overlap. While theories and modelsoptions, and seen from the perspective of clinical environment, local policy and culture are helpful, they rarely encompass theoutcomes or outcomes and process (Raynor (Marshall 2005; Hollins-Martin and Bull 2006). “messiness of reality” (Mok and Stevens 2005:and Bluff 2005). In maternity the focus tends Environment and culture can impact on 59), or the fact that midwifery decisions areto be the outcome: a healthy mother and baby. notions of risk, perceptions of autonomy and seldom made in isolation and involve factorsWhile safe and competent care is essential, the likelihood that a midwife will seek to such as resources, culture and client choice.experiences during the childbirth continuum intervene in the physiological birth processcan have long-term health and wellbeing (Mead and Kornbrot 2004). In this case, the While intuitive knowledge is perceived asimplications, and supporting women to make supervising midwife suggesting amniotomy less credible than the rational logical approachmeaningful decisions that are aligned with was accustomed to working in the busy labour and criticised for lacking scientific reasoningtheir individual cultural and social perspective ward environment, where there is a and rigour, it is also an “essential component ofis integral to holistic midwifery care. medicalised care culture and amniotomy is an, the art of midwifery” (Barnfather 2013: 131). “established normative practice” (Hollins- Greenhalgh (2002: 399) suggests there is aMidwifery decision making Martin and Bull 2006: 228). “false dichotomy between the science and art of clinical practice”, and that evidence-basedSince Changing childbirth (Department of Informed choice practice should be integrated with clinicalHealth (DH) 1993) there has been a focus in intuition. The intuitive experiential approachmaternity services on woman-centred care, Other than emergency situations where a with its holistic perspective is well suited to theand recent national drivers emphasise shared woman may be unable to give consent and midwifery paradigm, which encompassesdecision making and a policy of ‘No decision life-saving decisions must be acted on rapidly, different types of knowledge and knowing toabout me without me’ throughout the NHS decisions should involve the woman so that holistically deal with the complexity of(Coulter and Collins 2011). Surveys and her autonomy is respected (Birthrights 2013). childbirth as a life event (Siddiqui 2005). Thisqualitative research highlight the effect that This is the ideal, and explicit in the NMC Code approach focuses on tacit knowledge andchoice and external control have on the birth (2008), but in reality challenges and tensions emphasises intuition, pattern recognition andexperience (Green et al 1990; Cook and Loomis heuristics based on prior experience. Intuition2012), with psychological and bonding leads to rapid, unconscious judgements being >>implications into the postnatal period if this iscompromised. The Practising Midwife | April 2015 15

Decision making in midwiferyFigure 1 Modified Long and Cooper’s (2011) ‘How we make decisions’ model, incorporating decision making in Jane’s caseExperience Environment Cues/the woman• Amniotomy in a low-risk out-of-hospital Low-risk out of hospital setting • Jane just starting to verbalise environment - meconium stained liquor = that she can no longer cope - transfer to labour ward reaching transition? Why do• Women not explained risks and benefits of something that risks making amnioty can be seen as routine by contractions even more intense? midwives - lack of informed choice • Good progress/cervical dilation so farGut instinct INTUITION ANALYSIS Evidence baseJane will not want this Cochrane Systematic Reviewintervention - reflected in Rules of thumb/heuristics (Smyth et al 2013) amniotomybirth plan and desire to be • Most women in spontaneous labour with good does not speed up labour and canat birth centre make women feel they cannot cervical dilation will continue to progress normally cope with labourValues/beliefs without need for amniotomy• Normal birth agenda • Amniotomy can make experience more intense and Decision• Trust in physiology Jane may no longer be able to cope Inform Jane of risks and• Woman-centred care • Gestation - term + 5 days = increased odds of benefits of intervention• Why intervene if no meconium when supervising midwife has left room clinical indication?• Woman should be involved in her caremade based on a variety of verbal, non-verbal potentially making intuitive decisions hard to Analysis of the decision made by theand visual cues facilitating quick decisions. It is defend and justify, which can be challenging, student midwifethe domain of the expert who is able to use given the professional expectation forunconscious intuitive judgements combined justifiable decisions. Through reflection, Long and Cooper’s (2011) decision makingwith prior experience, no longer relying on practitioners can become more aware of their model developed for the farming contextanalytical processes to make sense of what is implicit knowledge and embodied and integrates intuition and rational analysis ashappening (Benner 2001). Whilst not an expert embedded knowing can be made visible, two parallel reciprocal systems of thinking andper se, a student midwife nearing qualification bringing to consciousness that which is knowing as opposed to separate systems atis expected to be an expert in supporting subconscious and supporting the development different ends of the spectrum. It was adaptednormal birth (NMC 2009), and uses pattern of expertise and clinical judgement. Siddiqui for this context and is presented in Figure 1.recognition and heuristics to make conscious (2005) highlights the importance of Rational analysis included the out-of-hospitalclinical judgements about low-risk labour care. articulating when intuitive and tacit setting, clinical assessments and the evidence knowledge informs practice so that its value around amniotomy, while the intuitive Since intuitive decision making is a may be recognised. thinking system considered past experience,subconscious process, accuracy can only be heuristics and values and beliefs including ajudged when reviewing the outcome, personal philosophy of facilitating normal birth16 The Practising Midwife | April 2015

Decision making in midwiferyand a commitment to woman-centred care. Practice challenge Having observed Jane’s changing behaviour, and in conjunction with verbal and non-verbalRational analysis Is the information that you give cues, I discerned that she was nearingAmniotomy is the deliberate rupture of the women around amniotomy transition, intuiting that any action that mightfetal membranes, resulting in drainage of the consistent with the latest evidence? increase the intensity of the experience wouldamniotic fluid (Howie and Rankin 2011). It is Do you still suggest amniotomy as a not be beneficial at this stage. A fastsuch a common intervention that it is almost a means of shortening labour? Are probability assessment of the situationroutine procedure, unquestioned by many, you aware that this is no longer informed me that, given that labour waseven in low-risk environments. It has recommended and that evidence progressing within normal parameters and thetraditionally been believed to accelerate labour from the latest Cochrane Review baby was in an occipito-anterior position,by increasing the rate and strength of (Smyth et al 2013) does not support there was a good chance that labour wouldcontractions but a Cochrane Review (Smyth et the intervention as a means of continue to unfold physiologically and noal 2013) found no difference in the length of shortening labour? intervention was indicated.labour and a possible increase in the caesareansection rate. It is not without risks, including meconium would be present, since Midwifery education is values-based andintra-uterine infection, umbilical cord prolapse, approximately 15-20 per cent of term babies emphasises the importance of accountability,fetal heart decelerations and ruptured fetal pass meconium in utero (Unsworth and Vause responsibility and advocacy, and I felt a duty ofblood vessels (Enkin et al 2000). This begs the 2010). Smyth et al (2013) conclude that care to inform the woman of the inherent risksquestion of whether it is an appropriate amniotomy should not be a routine part of of the intervention. Not to have done so couldintervention in an out-of-hospital setting. labour care and emphasise the importance of be construed as careless (Griffith 2012), givenFurthermore, it can increase the pain discussing the evidence with women. Given the the lack of evidence to support amniotomy inassociated with contractions, affecting risks and the potential for changing the that particular clinical context. In this way Iwomen’s coping ability in labour and may lead management plan, the Royal College of fulfilled my professional accountability byto the discovery of meconium-stained liquor, Midwives (RCM) is explicit that the decision giving accurate information and engaging thewhich, depending on the grade, may change “should only be taken in direct consultation woman in the decision making process (NMCthe management plan and could result in a with the woman” (2012: 2). 2008). Ethically, to perform an interventionrecommendation for continuous fetal that might cause iatrogenic harm with nomonitoring and/or transfer to hospital. Intuitive thinking system clinical indication would contravene the ethical The intuitive component of this decision was principal of non-maleficence (Jones 2005). >> Given that Jane’s gestation was 40 weeks influenced by past experiences of supportingplus five days, the odds were increased that women in labour who had not had the risks of Final practice challenge amniotomy explained prior to the intervention. Practice challenge In both cases the procedure had revealed After reading this article and meconium that changed the management plan reflecting on your own practice do How confident do you feel – one resulted in transfer to the hospital from you feel that the care you give is as supporting women when they a home birth, and the other led to continuous woman-centred as it could be? decline interventions that are fetal monitoring at the alongside birth centre. Think about the most common offered? Do you feel more able to do Jane’s birth plan and choice of birthplace were interventions that you offer in this in the birth centre or home reflective of a desire for a physiological birth practice…. Is the information you birth environment rather than with minimal intervention, which also played a give about these up to date, and delivery suite? What can you do to part in the ‘gut feeling’ to inform Jane of the does it provide enough information make your practice more woman- risks and implications of amniotomy. for women to make an informed centred in all settings? choice about accepting or declining what is on offer? The Practising Midwife | April 2015 17

Decision making in midwiferyConclusion It is almost a routine in midwifery practice, London: Churchill Livingstone. Kirkham M (2004). ‘Choice and bureaucracy’. In:This analysis has explored how decision making procedure, unquestioned Kirkham M (ed). Informed choice in maternity care.in midwifery can be complex and may be Basingstoke: Palgrave Macmillan.influenced by culture. In this case, the senior by many, even in low-risk Kirkham M (2010). ‘The maternity service context’. In:midwife advised the supervising midwife not Kirkham M (ed). The midwife-mother relationship, 2ndto perform an amniotomy, confirming my environments edition. Basingstoke: Palgrave Macmillan.clinical judgement and assessment of the Long B and Cooper I (2011). ‘Farmer decision making insituation. Exploration of the elements involved DH (1993). Changing childbirth. Report of the expert rainfed farming systems – the role of consultants,in making this decision has highlighted the maternity group, London: HMSO. farming systems groups and decision support systemscontribution that intuitive knowledge offers to Dowie J (1993). ‘Clinical decision analysis: background in Australia’. In: Tow P, Cooper I, Partridge I et al (eds).supporting physiological birth and providing and introduction’. In: Llewelyn H and Hopkins A (eds). Rainfed farming systems, Netherlands: Springer.responsive midwifery care, particularly when Analysing how we reach clinical decisions, London: Marshall JE (2005). ‘Autonomy and the midwife’. In:combined with the evidence base. While Royal College of Physicians. Raynor MD, Marshall JE and Sullivan A (eds). Decisionmidwives must be able to rationalise and Enkin M, Keirse MJNC, Neilson J et al (2000). A guide to making in midwifery practice, London: Churchilljustify decisions in terms of current evidence, effective care in pregnancy and childbirth, 3rd edition, Livingstone.the clinical situation and prevailing guidelines, Oxford: Oxford University Press. Mead MM and Kornbrot D (2004). ‘The influence ofthey must also ensure that care remains Green JM, Coupland VA and Kitzinger JV (1990). maternity units’ intrapartum intervention rates andwoman-centred and decisions are shared ‘Expectations, experiences, and psychological midwives’ risk perception for women suitable for(Jefford et al 2011). Intuition of both midwife outcomes of childbirth: a prospective study of 825 midwifery-led care’. Midwif, 20(1): 61-71.and woman has an important role to play and women’. Birth, 17(1): 15-24. Mok H and Stevens PA (2005). ‘Models of decisionacknowledging and reflecting on how it Greenhalgh T (2002). ‘Intuition and evidence – uneasy making’. In: Raynor MD, Marshall JE and Sullivan Asupports practice stands to enhance clinical bedfellows?’ Brit Jour Gen Pract, 52(478): 395-400. (eds). Decision making in midwifery practice, London:expertise, midwifery decision making and the Griffith R (2012). ‘Accountability in midwifery practice: Churchill Livingstone.normal birth agenda. tpm answerable to mother and baby’. Brit Jour Midwif, NMC (2008). The Code: standards of conduct, 20(8): 601-602. performance and ethics for nurses and midwives,Suyai Steinhauer is a home birth midwife at a Hollins-Martin CJ and Bull P (2006). ‘What features of London: NMC.practice serving an Amish community in the the maternity unit promote obedient behaviour from NMC (2009). Standards for pre-registration midwiferyUnited States midwives?’ Clin Effect Nurs, 9(2): e221-e231. education, London: NMC. Howie L and Rankin J (2011). ‘Labour – problems. Raynor MD and Bluff R (2005). ‘Introduction’. In: RaynorReferences Abnormalities of uterine action and onset of labour’. MD, Marshall JE and Sullivan A (eds). Decision making In: Stables D and Rankin J (eds). Physiology in in midwifery practice. London: Churchill Livingstone.Barnfather T (2013). ‘Can intuitive knowledge be taught Childbearing, 3rd edition. London: Balliere Tindall RCM (2012). Evidence based guidelines for midwifery- in midwifery practice?’ Brit Jour Midwif, 21(2): 131-136. Elsevier. led care in labour: rupturing membranes. London: RCM.Benner P (2001). From novice to expert: excellence and Jefford E, Fahy K and Dundin D (2011). ‘Decision- Siddiqui J (2005). ‘The role of knowledge in midwifery power in clinical nursing practice, New Jersey: Prentice making theories and their usefulness to the midwifery decision making’. In: Raynor MD, Marshall JE and Hall Health. profession both in terms of midwifery practice and the Sullivan A (eds). Decision making in midwiferyBirthrights (2013). Consenting to treatment, London: education of midwives’. Int Jour Nurs Pract, 17(3): practice, London: Churchill Livingstone. Birthrights. 246-253. Smyth RMD, Markham C and Dowswell T (2013).Cook K and Loomis C (2012). ‘The impact of choice and Jones SR (2005). ‘Making ethical decisions’. In: Raynor ‘Amniotomy for shortening spontaneous labour control on women’s childbirth experiences’. Jour Perin MD, Marshall JE and Sullivan A (eds). Decision making (review)’. Coch Data Syst Rev, 6: CD006167. Ed, 21(3): 158-168. Unsworth J and Vause S (2010). ‘Meconium in labour’.Coulter A and Collins A (2011). Making shared decision- Obs, Gyn Rep Med, 20(10): 289-294. making a reality. No decision about me, without me, London: The King’s Fund.18 The Practising Midwife | April 2015

Kevin Hugill, Ian Kemp Fathers’ presence at caesareanand Carol Kingdon section with general anaesthetic: evidence and debateexamine the arguments for andagainst fathers being permitted SUMMARY: In the UK, debate about fathers’ presence during the birth of their baby byin theatre during a caesarean normal birth is largely resolved. Fathers’ attendance during caesarean section, bothsection by general anaesthetic routine and emergency, remains controversial. This article draws upon research evidence,and conclude that the parents professional insights and the authors’ personal life experiences to contribute to theshould be allowed to decide debate about the presence of fathers during caesarean births with general anaesthetic. We argue that the widespread exclusion of fathers in these circumstances may be contrary to both parents’ wishes, and clinicians should consider offering women the choice of a nominated support person. Such a person can help the mother to fill in the missing pieces of the birth experience. Moreover, where this person is the baby’s father, there may be additional familial benefits for his transition to parenthood. Further research is warranted into the presence of fathers during births that are clinically problematic. Keywords Caesarean section, general anaesthetic, theatre, mother, father Authors Kevin Hugill, senior lecturer in the School of Health at University of Central Lancashire, Ian Kemp, consultant midwife in public health at Frimley Health NHS Foundation Trust and Carol Kingdon, senior research fellow in the School of Health at University of Central LancashireThere is little research Introduction and issues surrounding fathers’ presence ininto parents’ feelings maternity theatres during caesarean section about CSGA and, in In many cultures, fathers are present during (CS) under general anaesthetic (CSGA). childbirth, including some caesarean births. particular, their However fathers often find the experiences Time to change? thoughts about the around birth more emotionally challengingfather being present than expected (Johansson et al 2012). Despite policy, professional and patient groups’ Nevertheless, many fathers, given the right explicitly promoting normal birth, CS rates support, want to be present (Kululanga et al continue to rise. In the UK, one in every four 2012; Longworth and Kingdon 2011). In this births is by CS (Health and Social Care article, we draw upon data from a small Information Centre (HSCIC) 2013), with around qualitative study and reflective insights from 10 per cent of these operations performed the authors (all of whom are parents with under GA. There is little research into parents’ personal and professional experience of feelings about CSGA and, in particular, their theatre), to highlight some of the complexities thoughts about the father being present while >> The Practising Midwife | April 2015 19

Fathers present for caesarean section by general anaestheticFigure 1 Figure 2 Figure 3Kevin and his wife have had four children Ian pictured shortly after birth of his first Carol pictured ready to go to theatre afterall born by CSGA. At the first birth in 1987 child in 1989. It was this birth, and the birth of her daughter in 2010. Carolhe recalled that his presence in theatre feelings of being abandoned when his wife explicitly requested that the midwife whowas not mentioned nor discussed and he went into labour that prompted Ian to delivered her accompany her into theatre.was directed to leave the delivery suite and think about the experiences of fathers Her husband enjoyed precious time gettingonly returned some hours later after during birth in general and in his to know their daughter whilst Carol was inwalking around the hospital site alone. This midwifery practice during caesarean theatre. After two hours, he did activelychanged with later births and he and his section. In 2010 he wrote a reflective piece try to find out what was happening inwife were asked about him accompanying for this journal about his own experience theatre, and was subsequently allowed intoher into theatre – an invitation he that sought to sum up some of these recovery where Carol was awake and abledeclined, though with the last birth he was feelings: Kemp I (2010). ‘Exclusion zone: to once again hold her baby.encouraged to wait in the recovery area men and birth’. The Practising Midwife,and was given his daughter to hold within 13(11): 23-24.2 minutes of her birth and stayed with hiswife during her post anaesthetic recovery.the mother remains unconscious. received increasing research attention. Some of same time as that survey was conducted we Healthcare professionals have debated this research has focused on childbirth in less undertook a small qualitative study in the usual circumstances including CS (Hugill and north west of England.fathers’ presence at CS for over 25 years Harvey 2012). Studies show that fathers’(Sakala 1985; Smiley 2004): the same timespan presence can have short- and longer term Parental viewsas the authors’ own experiences of childbirth positive health effects for mother and baby(See Figures 1-3). Purported reasons for (Burgess 2007). Following ethical approval, eight parents withfathers’ continued exclusion include staff recent experience of CSGA were interviewedperceptions that men do not want to see their There is evidence that women are more (See Table 1, over page). Information was self-partner ‘like that’ and they might get upset or likely to experience greater psychological reported during interviews and cross-checkedannoyed and divert attention away from distress after CSGA. This is partly because most in hospital notes. All interviewees’ descriptionsmother and baby. All of the authors can relate are performed in obstetric emergency of their births by CSGA conveyed difficult andto this on personal and professional levels. situations, but is also attributable to women disempowering experiences for both mothersRegardless of this, there is now impetus for ‘missing’ the birth of their child (Clement and fathers. Parents’ frame of reference reflectedchange and current national CS guidance 2001). Yokote’s (2007) Japanese study (n= 6) concerns for their baby’s health, mothers’ (andrecommends that women’s preferences for identified the complexity of feelings and fathers’) continued need for a support personbirth should be accommodated whenever thoughts engendered when men’s partners and the familial significance of childbirth. Onlypossible (National Institute of Health and Care were about to have an emergency CS, but tell one CS was planned, all others were emergencyExcellence (NICE) 2011). us little about CSGA. One small survey of operations. For the fathers being unprepared parents in Scotland (n=109) reports that over for a CS, coupled with being uninformed aboutEvidence of benefits 80 per cent of women and 90 per cent of their partner gave rise to feelings of partners want fathers to be present during powerlessness, abandonment and anger.In recent years, fathers’ experiences during CSGA (McIlmoyle and Young 2012). Around thepregnancy, childbirth and parenthood have “I got told to stand outside; they’d come20 The Practising Midwife | April 2015

Fathers present for caesarean section by general anaestheticTable 1 Study participants Mother Father Baby Age Gestation Parity Indication for Time from Present Present Present Total Apgar Admission BF (years) CS decision at in on number score 1 to NICU to birth in hospital recovery return of births minPseudonym Interviewed minutes during to ward present birthAlice Mother 21 39 First Failure to 65 No No No 1 9 No No alone birth progressAmy and As couple 36 39+5 Second Pathological 12 Yes Yes No 1 10 No No John birth CTG traceAnna and As couple 26 39+6 First Pathological 15 Yes Yes Yes 1 9 No Yes Borys 38 birth CTG trace Yes Yes Yes 1 9 No Yes 40+5 Yes Yes No 1 1 No Yes Ben Father 39 Second Elective n/a alone 21 birthLouise and As couple First Fetal 22 Mark birth compromise and get me in a minute. Then a midwife “I felt like I didn’t have a bond with him not going to get in the way. To have a bit or a nurse came out and said ‘You can’t [the baby]; he was born by coming out of more involvement would be nice.” go in, we’re going to have to put her to my belly. I don’t know. I didn’t hold him “I think it should be behind a screen or sleep.’ Then the next thing, a load of straight away; it was a couple of hours something. A little screen you could be people came rushing past me into theatre after, so that made me feel like I didn’t watching and think I’ve seen that... You - and about half an hour-40 minutes have a connection. I was upset. I would want to be the first to see your child. The later, I was passed my son: ‘There you are,’ have preferred it if my sister had been bits you’ve missed, it’s the bits that were and told they had to resuscitate him. They there. I feel that if my sister had been really wanted”. went back in and I was left.” there, it would have been better. It’s more support: even if you get put to sleep, it Amy and John Mark feels more comfortable for that person who’s going through it if someone they Barriers to change Fathers attributed the strength of their love and are close to is there.”emotions to their concern for the safety of There is evidence of potential benefits oftheir partner and baby. At the same time, all of Alicethe mothers talked about the emotional fathers’ presence at CSGA: for the mothersignificance of no-one close to them or their In the absence of her baby’s father, Alicebaby being there in theatre. Contrary to many regretted that her sister was not there. The (filling in the missing pieces of events, creatinghealthcare professionals’ view this was more - familial significance of a family member ‘beingnot less - important because they were ‘asleep’. there’ was also apparent in the dialogue a storyline); for the father (presence easingUnconscious, the mothers had an ‘absent’ between couples, who shared a need topresence at the birth of their baby and the first visualise their child’s birth. transition to parenting); and for the babyfew hours of their life. “I think I would prefer you there. You’re (initiating skin-to-skin contact). This should act as an impetus for change. However this evidence is weak and professional opposition can be strong. One UK survey (Mcilmoyle et al 2010) highlighted that whilst one third of >> The Practising Midwife | April 2015 21

Fathers present for caesarean section by general anaesthetic Box 1 Key points for midwifery practice • We suggest the potential benefits of References fathers’ presence at CS with general • Controversy and debate concerning anaesthesia to include: for the mother Burgess (2007). The costs and benefits of active fathers’ presence at CS has been ongoing (filling in the missing pieces of events and fatherhood: evidence and insights to inform the for 25 years. Practice variations in creating a storyline); for the father development of policy and practice, London: maternity theatres remain common. (transition to parenting); and for the baby Fatherhood Institute. (initiating skin-to-skin contact). Clement S (2001). ‘Psychological aspects of caesarean • The current national CS guideline includes section’. Best Pract Res Clin Obs, 15(1): 109-126. the practice recommendation that • Routine debriefing following CSGA should HSCIC (2013). Hospital episode statistics: NHS women’s preferences for birth should be take into account both parents’ needs to maternity statistics 2012-13, London: HSCIC. accommodated where possible (NICE assimilate what they missed and to create Hugill K and Harvey ME (2012). Fatherhood in 2011). their own narrative of their child’s birth. midwifery and neonatal practice, London: Quay. Johansson M, Rubertsson C, Rådestad I et al (2012). • One small Scottish survey (n=109) reports • The choice should be available. Actual ‘Childbirth - an emotionally demanding experience for 80 per cent of women wanted their decision-making will require a balance of fathers’. Sex Reprod Health, 3(1): 11-20. partners present, compared to 90 per cent client preference and professional Kululanga LI, Malata A, Chirwa E et al (2012). ‘Malawian of fathers who wanted to be present judgement. fathers’ views and experiences of attending the birth during CS with general anaesthesia. of their children: a qualitative study’. BMC Preg Chb, • Further research is required. 12: 141.anaesthetists were in favour of fathers’ Longworth HL and Kingdon CK (2011). Fathers in thepresence during CSGA, midwives were less will be right for every mother or father as our birth room: what are they expecting and experiencing?supportive. In practice it is frequently said that own experiences testify. We had very different A phenomenological study. Midwif, 27(5): 588-894.an increased element of clinical risk is present experiences of birth and theatre, separated by McIlmoyle K, Bryden F and Armstong E (2010). ‘Labourand including non-health professionals would 25 years, during which time real progress has ward staff’s opinion of partners being present duringadd to the risk. This argument is based on been made in relation to family-centred care in caesarean section under regional and generalscant evidence of any direct causative general, but it would appear little has changed anaesthesia’. Int Jour Obs Anesth, 19(s40): 0959-289X.relationship in this or indeed in other areas of in relation to CSGA. In our study all participants McIlmoyle KR and Young S (2012). ‘A survey of patienthealth care, as we have experienced parents felt that having the option of the father/birth and partner views on the presence of the partner inroutinely accompanying their children to partner remaining in theatre during this time the operating theatre during caesarean sectiontheatre and being present during anaesthetic would be beneficial for the mother, father and performed under regional and general anaesthesia’. Intinduction. baby, but concern was raised by some of the Jour Obs Anesth, 21(s20): 0959-289X. mothers about how emotionally charged NICE (2011). Caesarean section. NICE clinical guideline Other arguments put forward include concern fathers can be. Our point is that the choice 132, London: NICE.about protecting the partner from witnessing should be made available. Actual decision- Sakala EP (1985). ‘Perinatal professionals' view ofdistressing events or a desire to ensure the making will require a balance of client fathers in the cesarean room’. Jour Psychosom Obswoman’s privacy and dignity. This claim is not preference and professional judgement. Gyn, 4(4): 285-293.supported by studies of parental views. Regardless, fathers should be prepared for and Smiley R (2004). ‘Opposer. Partners should be allowed supported through this time irrespective of to stay in the operating theatre during caesarean Finally, some have suggested that there is whether they are in theatre or not. tpm section under general anaesthesia’. Int Jour Obslittle to see during this time because of the Anesth, 13(4): 253-256.way procedures are carried out, so why go? Our Kevin Hugill is senior lecturer in the School of Yokote N (2007). ‘Fathers’ feelings and thoughts whenanswer would be because it is the birth of a Health at University of Central Lancashire, Ian their partners require an emergency caesarean section:child and this is a choice that should be open Kemp is consultant midwife in public health at impact of the need for surgery’. Japan Jour Nurs Sci,for the parents to make for themselves. Frimley Health NHS Foundation Trust and Carol 4(2): 103-110. Kingdon is senior research fellow in the SchoolPersonal reflections of Health at University of Central LancashireFathers’ presence at CSGA is not a choice that22 The Practising Midwife | April 2015

Kielland’s forcepsWith ever-rising rates of The place of Kielland’s forceps inbirth by caesarean section, reducing caesarean section ratesPooja Balchandra, SUMMARY: The rise in births by caesarean section (CS) is a global issue. A skilledFiona Marsh and obstetrician with a midwife knowledgeable in Kielland’s forceps (KF) is often able toChristine Landon achieve a successful rotational vaginal birth when safe. The KF, however, has risks - and outcomes must be audited.examine the use of In this article we present the results of a literature review and retrospective audit,alternatives, and explain evaluate maternal and neonatal morbidity associated with KF in our unit andwhy midwives need to be compliance with national standards.familiar with Kielland’s Our conclusion is that our unit complies with national standards and offers the womanforceps, to help women give an alternative to CS when it is safe to do so. Adverse outcomes with KF are not differentbirth without resorting to from other modes of operative birth.caeasarean Keywords Rotational forceps, Kielland’s forceps, complications, caesarean section Authors Pooja Balchandra, Fiona Marsh and Christine Landon, all doctors in the department of urogynaecology at St James’ University Hospital in Leeds There has been a Introduction about 80 per cent, even for women who have renewed interest in required more complex operative vaginal births alternatives to CS, Caesarean section (CS) rates are rising globally (Bahl et al 2004).such as the Kielland’s (Arulkumaran 2013). The association of forceps births with injury to the pelvic floor and A historical association of KF with maternal forceps trauma to the baby has led to a decline in the and neonatal morbidity has led to obstetricians use of forceps, further contributing to the preferring either manual rotation of the baby’s rising CS rates (Patel and Murphy 2004). head, vacuum extraction or CS (Gleeson et al Maternal morbidity due to a second stage CS 1992). However, recent studies have revealed can include major obstetric haemorrhage, risks that neonatal and maternal adverse outcomes of visceral injury and uterine tears (Spencer et with the use of KF by experienced operators are al 2006). Hence there has been a renewed no worse than using vacuum extraction or CS interest in alternatives to CS, such as the (Aiken et al 2014). Kielland’s forceps (KF). Obstetricians should be adequately skilled in Most women still aim for a spontaneous using KF to allow the woman to include this vaginal birth (SVB) (Sparks et al 2014). Women when making an informed choice. Midwives are more likely to have a successful SVB after a should be educated in the preparation, forceps birth than after a CS (Patel and Murphy procedure and risks of KF to enable them to 2004). The likelihood of achieving a SVB is provide relevant information. The quality of the >> The Practising Midwife | April 2015 23

Kielland’s forcepsrelationship between the midwife and woman, Table 1 Operator grade Table 2 Indication for Kielland’s forcepscontinuity of care and women’s awarenessregarding modes of birth all promote Operator grade Percentage (approx) Indication for Kielland’s Percentageempowerment for both the woman and and number (/59) forceps (approx) andbirthing partner, leading to a positive birth number (/59)experience (Dahlberg and Aune 2013). Consultant 15 (9)Aim of the review Malposition 7 (4)We conducted a review of the literature formaternal and neonatal morbidity following KF Senior registrar 10 (6) Malposition with prolonged 61 (36)and audited our obstetric unit’s performance second stage of labouragainst standards set by the Royal College of Registrar 73 (43)Obstetricians and Gynaecologists (RCOG). The Malposition with abnormal 3 (2)aim of this was to determine whether the use Senior house officer 2 (1) fetal scalp phof KF can be regarded as contributing towomen’s and babies’ safety when some All KF were undertaken in theatre under Malposition with 3 (2)intervention is needed in childbirth. Standards senior supervision. The majority of KF were bradycardia 24 (14)state that all KF must be undertaken in the undertaken for malposition. Table 1 detailsoperating theatre under senior supervision. indications. Fifty eight per cent (n=34/59) and Malposition with 42 per cent (n=25/59) of women required KF pathologicalMethodology due to occipitoposterior and occipitotransverse cardiotocograph position respectively.A literature review and a retrospective audit of birth positions and a reduced risk of perineal59 consecutive cases of KF in our obstetric unit Seventy three per cent (n=43/59) of KF trauma (Bodner-Adler et al 2004). Aover a 12-month period in 2012 were were performed by the speciality training percentage of women will, however, require anundertaken. Data regarding length of second registrar. All women had an episiotomy. Ten per operative vaginal birth. Inability tostage, indication for KF and location were cent (n=6/59) required blood transfusion and 8 competently manage a rotational instrumentalundertaken, grade of operator, presence of per cent (n=5/59) were diagnosed with an birth will lead to increased maternal andsenior supervision, position of the presenting obstetric anal sphincter injury. neonatal morbidity; renewed interest in KF inpart, birth weight, maternal and neonatal an attempt to reduce CS rates should not be atmorbidity were obtained. All women were Babies the cost of maternal and neonatal safety.provided with information by both the None of the babies had Apgar scores lowermidwife and obstetrician about the than seven at five minutes (See Table 2 for A KF in the hands of an experiencedcomparative risks of KF and an emergency CS. details). The average birth weight was 3643gm obstetrician supported by a knowledgeable (Range 2600-4670). Three per cent (n=2/59) of midwife may be a safer option than aResults babies had transient facial palsy and 3 per cent technically challenging caesarean section in (n=2/59) had a deep KF mark with local the second stage of labour.Women swelling. None of the babies needed neonatalThe average body mass index (BMI) of the unit admission. The KF has been shown to have a lower ratewomen was 25 (range 17-42); the average of adverse neonatal outcomes than all otherlength of the second stage was 159 minutes Discussion forms of instrumental birth in a retrospective(range 5-300 minutes). Fifty nine per cent review (Al-Suhel et al 2009). A study comparing(n=35/59) had an epidural prior to the second Our aim as healthcare professionals is to maternal and neonatal outcomes following astage of labour and 66 per cent (n=39/59) practise evidence based medicine whilst rotational vaginal birth versus CS revealed nowere augmented with oxytocin. promoting a positive safe birth experience. difference in outcome (Aiken et al 2014). A Continuous one-to-one support by the prospective cohort study found that maternal midwife is associated with a significant and perinatal outcomes were comparable with decrease in the use of oxytocin, use of more KF, vacuum extraction and manual rotation with few serious adverse outcomes (Bahl et al 2013). Another study confirmed the association between KF and low maternal and neonatal24 The Practising Midwife | April 2015

Kielland’s forcepsmorbidity (Burke et al 2012). Rates of short Due to small numbers, our findings cannot be management’. Wien Klin Wochenschr, 116(11-12): 379-term neonatal and maternal morbidity after extrapolated to the larger body of research 384.successful KF were found to be low via a evidence. Current evidence suggests that Burke N, Field K, Mujahid F et al (2012). ‘Use and safetyretrospective cohort study (Stock et al 2013). A adverse outcomes with KF are no different of Kielland's forceps in current obstetric practice’. Obslarge retrospective audit following different from other modes of operative birth. Gyn, 120(4): 766-770.methods of birth for malposition in the second Dahlberg U and Aune I (2013). ‘The woman's birthstage of labour showed that KF is a safe Midwives' resources should include experience - the effect of interpersonal relationshipsinstrument in experienced hands (Tempest et knowledge about KF, including its risks and and continuity of care’. Midwif, 29(4): 407-415.al 2013). complications; this will assist women in Gleeson NC, Gormally SM, Morrison JJ et al (1992). making an informed decision and consequently ‘Instrumental rotational delivery in primiparae’. Irish A forceps birth is associated with up to a 7 contribute towards a holistic positive birthing Med Jour, 85(4): 139-141.per cent risk of obstetric anal sphincter injury experience. Midwives have a significant central Jones LV (2015). ‘Non-pharmacological approaches for(OASI) (McLeod et al 2003). Our unit recorded role in promoting a successful SVB. tpm pain relief during labour can improve maternalan 8 per cent risk of OASI with KF. Local satisfaction with childbirth and reduce obstetricswelling and transient facial palsy were Pooja Balchandra, Fiona Marsh and Christine interventions’. Evid Bas Nurs, doi: 10.1136/eb-2014-recorded in 6 per cent of the neonates in our Landon are all doctors in the department of 101938.group. There were no admissions to the urogynaecology at St James’ University Hospital Larkin P, Begley CM and Devane D (2012). 'Not enoughneonatal unit. in Leeds people to look after you: an exploration of women's experiences of childbirth in the Republic of Ireland’. A Cochrane review revealed that gate References Midwif, 28(1): 98-105.control mechanisms of pain control, such as Mcleod NL, Gilmour DT, Joseph KS et al (2003). ‘Trendswater immersion and light massage, were Aiken AR, Aiken CE, Alberry MS et al (2014). in major risk factors for anal sphincter lacerations: aassociated with lower levels of pain during ‘Management of fetal malposition in the second stage 10-year study’. Jour Obs Gyn Can, 25(7): 586-593.labour and less oxytocin use. It also showed of labor: a propensity score analysis’. Am Jour Obs Gyn, Patel RR and Murphy DJ (2004). ‘Forceps delivery inthat continuous support in labour was 212(3): 355.e1-355.e7. modern obstetric practice’. Brit Med Jour, 328(7451):associated with lower rates of CS, instrumental Al-Suhel R, Gill S, Robson S et al (2009). ‘Kjelland's 1302-1305.birth, oxytocin use, neonatal resuscitation, forceps in the new millennium. Maternal and neonatal Sparks TN, Yeaton-Massey A, Granados et al (2014).shorter duration of labour and greater outcomes of attempted rotational forceps delivery’. ‘How do maternal views of delivery outcomes vary bysatisfaction with childbirth (Jones 2015). Aust NZ Jour Obs Gyn, 49(5): 510-514. demographics and preferred mode of delivery?’ Am Arulkumaran S (2013). ‘Caesarean section rates are Jour Perinatol, December 2014.The role of the midwife increasing worldwide. Preface’. Best Pract Res Clin Obs Spencer C, Murphy D and Bewley S (2006). ‘Caesarean Gyn, 27(2): 151-152. delivery in the second stage of labour’. Brit Med Jour,A midwife has the power to impact on all the Bahl R, Strachan B and Murphy DJ (2004). ‘Outcome of 333: 613-614.above-mentioned techniques and can subsequent pregnancy three years after previous Stock SJ, Josephs K, Farquharson S et al (2013).therefore play a fundamental role in reducing operative delivery in the second stage of labour: ‘Maternal and neonatal outcomes of successfulCS rates. The role of midwives in providing cohort study’. Brit Med Jour, 328: 311. Kielland's rotational forceps delivery’. Obs Gyn, 121(5):one-to-one care, encouraging mobilisation Bahl R, Van de Venne M, Macleod M et al (2013). 1032-1039.during labour and promoting the use of ‘Maternal and neonatal morbidity in relation to the Tempest N, Hart A, Walkinshaw S et al (2013). ‘A re-alternative birth positions is crucial to improve instrument used for mid-cavity rotational operative evaluation of the role of rotational forceps:chances for a SVB. The midwife plays a pivotal vaginal delivery: a prospective cohort study’. Brit Jour retrospective comparison of maternal and perinatalrole in helping women achieve a positive birth Obs Gyn, 120(12): 1526-1532. outcomes following different methods of birth forexperience (Larkin et al 2012). Bodner-Adler B, Bodner K, Kimberger O et al (2004). malposition in the second stage of labour’. Brit Jour ‘Influence of the birth attendant on maternal and Obs Gyn, 120(10): 1277-1284.Conclusion neonatal outcomes during normal vaginal delivery: a comparison between midwife and physicianThere was no major neonatal or maternalmorbidity with KF in our retrospective review. The Practising Midwife | April 2015 25

Ayla Ozkan, Hospital birth: are we giving women the facts?who regularly witnessesthe results of traumatic SUMMARY: An article published last year in the Journal of Medical Ethics comparesbirth, refutes the giving birth at home to being as reckless as driving without putting a seatbelt on yoursuggestion that home child (de Crespigny and Savulescu 2014). Planning to give birth at home is oftenbirth is inherently risky thought of as quite an ‘alternative’ decision, with just 2.4 per cent of women in Englandand, whilst she and Wales opting for this in 2011 (Office for National Statistics (ONS) 2013). The politicswelcomes the dedicated surrounding place of birth in contemporary maternity care are highly contentious andcare of her colleagues in not at all as clear cut as one may initially presume. As a midwife working in a busy UKhospital, explains why unit, I would liken the assumption that a low risk birth is inherently safer in a high riskwomen are not unit to investing in ill-fitting metaphorical seat belts, which may give the whole familynecessarily safer giving whiplash.birth in hospital Keywords Home birth, hospital, risk Author Ayla Ozkan, Brierley midwife at King's College Hospital, currently working with a voluntary organisation as clinical quality advisor in Cambodia Home births are Risk advises that, in the case of low-risk pregnantfrequently described as a women, it is safer to give birth at home or in arisky business or, at best, Giving birth has and will always pose a degree midwife-led unit. ‘relatively safe’, but do of risk. There will never be a way of doing it, or we prepare our women a place or person who can facilitate it and Hospital birthfor the risks they take by guarantee no complication. It is about minimising risk. In a society governed by fear, Home births are frequently described as a risky planning to have their risk and, increasingly, a culture of blame business or, at best, ‘relatively safe’ (Fraser babies in hospital? (Dahlen 2010), it is very easy to make sweeping 2013: 50), but do we prepare our women for statements like ‘Women should give birth in the risks they take by planning to have their hospital because something might go wrong’ or babies in hospital? Actively labouring alone for ‘It’s safer to have doctors nearby just in case’. hours and desperately trying not to push their However, such statements are fear-based and baby out in a triage bay or reception area not fact-based, remaining unsupported by the because there are no beds available; having a most contemporary research. This is particularly midwife who must divide her time between pertinent in the light of National Institute of two labouring women; receiving one-to-one Health and Care Excellence (NICE) guidance care from a midwife who is dizzy from not published late last year (NICE 2014), which eating or drinking for twelve hours: these are26 The Practising Midwife | April 2015

Home birth broader implications for the NHS, as these low risk service-users are propelled into a higher risk category, subsequently needing anaesthetic services, obstetric-led care, more midwives, a bed for at least one night, difficulties with breastfeeding and, occasionally, professional counselling afterwards (Wickham 2004; Bodner-Adler et al 2005; Kitzinger 2006)?Home birth is statistically safer for some women and their babies Traumaall risks. It is arguable that these occurrences – totally out of control, incapacitated by pain I work for a specialist service, to which manycommon to most busy maternity units – are relief and her bare legs held open by stirrups as women are referred following previousdue to staffing or logistical issues which can be people pour into the room. And what are the traumatic birth experience. Many others, onceresolved, but what of the statistical likelihood they start talking, begin to relay negativethat, just by planning to have a low-risk birth Many women require experiences about the way their first was born.in a high-risk unit, women are more likely to some form of Feelings of total disempowerment arehave a long labour subsequently requiring common; things were done to them that theyaugmentation, have an epidural, be more than counselling after a felt unnecessary, did not understand or feelthree times as likely to have their baby born by difficult birth, and the they properly consented to – sometimes evenforceps or ventouse, and almost four times as figures for how many the actual mode of birth. Others reportlikely to have an emergency caesarean struggle to bond with feelings of being extremely afraid that they or(Hollowell et al 2011)? Consequently, these their babies simply do their baby would die and, at the time, receivedwomen face a greater risk of severe perineal no reassurance to the contrary. Many womentrauma (Matsuo et al 2009), postpartum not exist require some form of counselling after ahaemorrhage (Hollowell et al 2011), and difficult birth, and the figures for how manyinfection (Bodner-Adler et al 2005). It is struggle to bond with their babies in their firstimpossible to quantify the psychological few weeks, months or even years simply do notimpact of these accumulative and arguably exist. Women are ashamed to speak up aboutunnecessary interventions as they hurtle this, often feeling as though they are failing attowards their peak, with a woman feeling the first steps of motherhood after the first ‘failure’ at giving birth the way they had hoped. Viable option It is not my place to ‘sell’ home births to the women I provide care for, and I would be devastated if I thought any felt coerced into one. Many who were originally set on a hospital birth change their minds in pregnancy simply because they hadn’t considered giving birth at home to be a viable option before and, despite being based in inner London, which some regard as devoid of social interaction, the >> The Practising Midwife | April 2015 27

Home birthwomen in our community talk. A lot. As one of from home if we have concerns and, in the or wrong answer for women and their families;the UK’s leading maternity units, we are event of something going awry, I am relieved it is a personal decision that should be madefortunate to work in an area with a very high to know there is a hardworking and dedicated while well informed and withouthome birth rate; any notions of home births as team to turn to in the hospital, whom I trust scaremongering. There are no seatbelts orcrude, reckless or a “return to the past” (de and am proud to be a part of. Our unit deals safety measures which can guarantee a risk-Crespigny and Savulescu 2014: 4) are totally with a variety of complex issues each day, free journey. That is, unless we considerunfounded, as we are at the forefront of arising as they would with any specialist or banning birth altogether. tpmskilled, modern maternity care. inner-city hospital, but also out of the sheer fact that it is a high risk unit. In the business Ayla Ozkan is a Brierley midwife at King's As emphasised in the recent article Home of birth, complications can and will spread like College Hospital, currently working with abirth and the future child, any risk of serious wildfire down the corridors of busy units, and voluntary organisation as clinical quality advisormorbidity is, of course, paramount for any there are nights when you wonder whether a in Cambodiawoman and her family in considering the postpartum haemorrhage could actually besafest way for their baby to be born (de some kind of airborne virus. ReferencesCrespigny and Savulescu 2014). It is importantfor first-time mothers to know that, Conclusion Bodner-Adler B, Bodner K, Patelsky N et al (2005).statistically, there is a small increase in risk of a ‘Influence on labor induction outcomes in patientspoor outcome to their babies by being born at It cannot be guaranteed that, by planning to with prolonged pregnancy: a comparison betweenhome (Hollowell et al 2011; de Crespigny and give birth at home, women will necessarily elective labor induction and spontaneous onset ofSavulescu 2014). For women expecting have the birth that they want, nor is it the labor beyond term’. Wien Klin Woch, 117(7-8): 287-292.subsequent babies, this increased risk does not case that, by planning a low risk birth in a high Dahlen H (2010). ‘Undone by fear? Deluded by trust?’exist; research suggests their babies are risk unit, women condemn themselves to Midwifery, 26: 156-162.actually slightly better off by being at home intervention and trauma; it is about statistical de Crespigny L and Savulescu J (2014). ‘Home birth and(Hollowell et al 2011; NICE 2014). Planning likelihood. Home birth is not the domain of the the future child’. Jour Med Ethics, doi:10.1136/how and where to give birth can be the first of unskilled or an inferior way to plan a birth by medethics-2012-101258.a lifetime of painstaking dilemmas as a parent any means. While it isn’t for everyone - nor Fraser J (2013). ‘A risky business’. Midwives, 6: 50-51.and any suggestion that planning a home birth ever will be - it is both sensationalist and Hollowell J, Puddicombe D, Rowe R et al (2011). ‘Theis reckless or selfish is severely misguided. In statistically inaccurate to say that giving birth birthplace national prospective cohort study: perinatalmy experience, the women who choose to in hospital is inherently safer. There is no right and maternal outcomes by planned place of birth.have their babies at home are those who have Birthplace in England research programme. Finaldone their research and carefully weighed up There are no seatbelts or report part 4’. NIHR Service Delivery and Organisationthe risks of home versus hospital. safety measures which programme, London: HMSO. can guarantee a risk- Kitzinger S (2006). Birth crisis, Abingdon: Routledge.Intervention is sometimes necessary ONS (2013). Births in England and Wales by free journey. That is, characteristics of birth 2, Newport: ONS.I am far from an anti-interventionist. I have a unless we consider Matsuo K, Shiki Y, Yamasaki M et al (2009). ‘Use ofprofound respect for modern medicine and a banning birth altogether uterine fundal pressure maneuver at vaginal deliverydeep admiration for my colleagues who work and risk of severe perineal laceration’. Arch Gyn Obs,tirelessly on high-risk units to safeguard the 280(5): 781-786.lives of those for whom giving birth presents NICE (2014). ‘Intrapartum care: care of healthy womenan intermediate or high risk to themselves or and their babies during childbirth’. Nice guidelinestheir unborn child. We always explain to CG190, London: NICE.women and their families that we err very Wickham S (2004). Induction: do I really need it?much on the side of caution with regards to London: AIMS.recommending a prompt and early transfer28 The Practising Midwife | April 2015

Using a simulation, Pictorial estimation of blood loss in a birthing poolAnushia Goodman - an aide memoireprovides a guide to help SUMMARY: The aim of this article is to share some photographic images to helpmidwives more midwives visually estimate blood loss at water births. PubMed, CINAHL and MEDLINEaccurately to estimate databases were searched for relevant research. There is little evidence to inform theblood loss in water practice of visually estimating blood loss in water, as discussed further on in the article. This article outlines a simulation where varying amounts of blood were poured into a birthing pool, captured by photo images. Photo images of key amounts like 150mls, 300mls and 450mls can be useful visual markers when estimating blood loss at water births. The speed of spread across the pool may be a significant factor in assessing blood loss. The author recommends that midwives and educators embark on similar simulations to inform their skill in estimating blood loss at water births. Keywords Visual estimation of blood loss in water, water birth, simulation Author Anushia Goodman, midwife at Cheltenham Aveta Birth Centre, Gloucestershire Hospitals NHS Foundation Trust Women should be Introduction difficult to comment on how the experimentinformed that there is was conducted. On conducting a search of a number of insufficient high databases, using the keywords 'visual According to the Cochrane review, there are quality evidence to estimation', 'blood loss' and 'water birth' and only three studies that include the second either support or going back 15 years, 12 publications were stage and none of the third stage of labour indiscourage water birth found, yet only one study was relevant to visual water (Cluett and Burns 2009). The National estimation of blood loss during water births, as Institute of Health and Care Excellence (NICE) opposed to ‘land’ births. This Masters level guidelines for intrapartum care state that study, comparing midwives' visual estimation of women should be informed that there is blood loss in water and out, found no insufficient high quality evidence to either significant differences in the accuracy of support or discourage water birth (NICE 2014). estimation between the two contexts (Lim The current Cochrane database review on the 1994). Although the study was a dissertation use of water for labour and birth is still focused cited in a few publications, it is impossible to on the benefits of water birth, disproving access by routine searches. Therefore it is perceived additional risks to women and their >> The Practising Midwife | April 2015 29

Blood loss in a birthing pool1.0 Blood being poured into the pool 1.1 150ml of blood poured in. Thin layer of 1.2 More blood being poured in. Blood blood, covering two thirds of the bottom of spreading towards the plughole the pool1.3 300ml of blood present. Blood has 1.4 More blood being poured in. Moving 1.5 450ml of blood present. Second layer ofreached plughole; thin layer of blood towards plughole and overlaps blood (overlap), covering three quarters of thecompletely covers bottom surface of pool bottom of pool1.6 Clots appearing under gloves 1.7 750ml of blood, bottom layer darker now 1.8 More clots under gloves1.9 1050 ml of blood 2.0 1050 ml with the water agitated 2.1 Blood was poured through a flexible tube30 The Practising Midwife | April 2015

Blood loss in a birthing poolbabies and a call for more research in this area make a contribution towards building a body diameter) flexible tubing was taped to the side(Cluett and Burns 2009). of knowledge in this aspect of water births: an of the pool down to the edge of the step (See aide-memoire rather than a prescriptive tool. 2.1). The pool was filled to approximately three There is evidence to suggest that The clinical implication of midwives improving quarters full. Warm water was used topractitioners are inaccurate in their visual their skills in estimating blood loss in water minimise the effect on clotting times. Expiredestimations of blood loss (Buckland and Homer would be to reduce the incidence of premature human blood was used for the simulation. This2007; Schorn 2010). These studies were based or delayed exit of a woman from the pool. included a mixture of old and recently expiredon 'land' births. It could be argued that Women who feel unwell, irrespective of blood blood. Blood was poured from a jug into theestimating blood loss in water can pose loss, would be advised to exit the pool. tube at the top of the pool, in pulses, to mimicadditional challenges (Garland 2011). There is blood loss from the woman into the pool.also evidence from a study conducted in 2012, The simulation Increasing amounts of blood were poured inthat simulated examples and blood loss and photographs taken at each stage.pictograms can help improve estimation This simulation was conducted at theaccuracy (Cheerranichanunth and Poolnoi Cheltenham Aveta free-standing birth centre, A pair of gloves was filled with water and2012). However, this was a small study with a utilising a permanent birthing pool (See taped to the bottom of the pool to mimic asample size of 49 multidisciplinary images). This was conducted in conjunction woman’s feet, to observe at what point theirprofessionals and relating to caesarean with the blood transfusion department and the visibility would be obscured. Whilst a humansections. Schorn (2010) concluded that visual medical photography department of the volunteer was preferred for this purpose, it wasestimation of blood loss by clinicians was so Gloucestershire Hospitals NHS Foundation Trust. not advised, due to the use of blood. This wasinaccurate that she questioned its continued done to test Diane Garland's guidance onuse in practice. Buckland and Homer (2007) The simulation was set up to mimic the end advising women to exit the water when eitherconducted an experiment assessing the of the second stage, as any significant blood the bottom of the pool or women's feet wereaccuracy of practitioners estimating various loss before then would be abnormal. It was not clearly visible. The water was not agitatedamounts of blood (land births). They concluded also set up to mimic a woman sitting on the until the end of the simulation. This again wasthat clinicians and educators should embark on step of the pool; clearly that is subject to the to mimic the stationary position that womensimilar exercises to help professionals improve type of pool used. Although women can be often adopt following the birth of their babies,their skill in this area. very mobile during labour, my experience is prior to exit from the pool. that women tend to be more stationary after Diane Garland suggests that the visibility of the baby is born, to receive and hold their Key observationsthe bottom of the pool or the mother’s feet is babies. To reflect this, wide-bore (4cm ina useful guide to detecting a postpartum The most useful images captured were of thehaemorrhage (PPH) at the exit of the woman It became difficult to following amounts : 150mls, 300mls andfrom the pool (Garland 2011). Whilst this visually differentiate 450mls. These key amounts were useful visualrecommendation comes from an expert between 450mls and markers. The intensity of colour, from a thinpractitioner and is invaluable, it is also good larger amounts of layer of blood, gradually became darker as thepractice to collate and underpin practice with blood, although more blood reached the plughole and overlapped,evidence, where possible (Nursing and moving back towards the source. It wasMidwifery Council (NMC) 2008). Currently, clots were seen difficult to differentiate between 450mls andthere is some anecdotal evidence that larger volumes of blood.midwives within the UK tend to use ‘less thanor more than 500mls’ rule in their blood loss It became difficult to visually differentiateestimation at water births. between 450mls and larger amounts of blood, although more clots were seen. This simulation was an attempt to providesome ‘evidence’ to the skill of blood loss The speed at which blood spread across theestimation at water births. The aim was to bottom of the pool may be a significant factor when assessing velocity of blood loss. This was >> The Practising Midwife | April 2015 31

Blood loss in a birthing poola coincidental observation noted when blood others do not. This should be taken into would support advising women to exit thewas poured into the tube at slightly varying consideration. water. Clearly, if the woman feels unwell,speeds. irrespective of how little blood she has lost, it The blood used was a mixture of old and is best for her to exit the pool. One interesting observation was made by recently expired blood, which would havethe midwifery team present at the simulation. affected clotting times. In my experience, clots The author would recommend that thisIn their experience, they had observed the pool often form quickly as blood enters the water. simulation be repeated, preferably with awater being fairly clear in a significant number human model to address some of theof water births, suggesting that some women The water filled gloves were too buoyant limitations previously mentioned. A simulationmay have lost less than the 150mls of blood. and not effective. Therefore the test of using real time imaging may be more useful.Interestingly, a nine-year observational study visibility was not adequately tried in thisof 9,518 spontaneous, singleton, cephalic simulation. tpmbirths (vacuum extractions excluded)comparing water births (3,617) with land births Conclusions and recommendations Anushia Goodman is a midwife at Cheltenham(5,901) found that women who birthed in Aveta Birth Centre, Gloucestershire Hospitalswater lost significantly less blood than those This simulation has provided some evidence NHS Foundation Truston land (Geissbuehler et al 2004). The midwives towards the skill of estimating blood loss inpresent felt that they may have been water for midwives working in settings that Referencesoverestimating blood loss and possibly advising use similar birthing pools. At best, the imageswomen to exit from the water prematurely, from this simulation can only be a guide or an Buckland SS and Homer CSE (2007). ‘Estimating bloodrather than just underestimating blood loss. 'aide memoire', but it could be useful to some loss after birth: using simulated clinical examples’. midwives in helping to reduce the incidence of Women Birth, 20(2): 85-88.Limitations delayed or premature advice for women to exit Cheerranichanunth P and Poolnoi P (2012). ‘Using the water. The visual marker in relation to the blood loss pictogram for visual blood loss estimation inThe pool size and colour of the pool can vary pool plughole and the intensity of the colour cesarean section’. Jour Med Assoc Thailand, 95(4): 550-in maternity centres, so the images may not be of the blood is a useful combination when 556.transferable, making these images a guide estimating blood loss in water. Difficulty in Cluett ER and Burns E (2009). ‘Immersion in water inrather than a tool. The size of the pool, the differentiating larger volumes past 450mls labour and birth’. Coch Datab Syst Rev, 15;(2):amount of water in the pool as well as the CD000111. DOI: 10.1002/14651858.CD000111.pub3.colour of the bottom of the pool will all affect The visual marker in Garland D (2011). Revisitng waterbirth - an attitude ofthe intensity of colour of the blood. The relation to the pool care, Basingstoke: Palgrave Macmillan.amount of water in the pool with a woman in plughole and the Geissbuehler V, Stein A and Eberhard J (2004).it will be different from the amount of water intensity of the colour ‘Waterbirths compared with landbirths: anused in the simulation. It is not possible to of the blood is a useful observational study of nine years’. Jour Perin Med,know the effect of this displacement . combination when 32(4): 308-314. estimating blood loss in Lim S K (1994). A study to compare midwives’ visual Lighting proved to be quite a challenge. To estimation of blood loss in 'water' and on 'land', MScenable good quality photographs, the room water Dissertation. Guildford: University of Surrey.was very well lit. During the day, where there is NICE (2014). Intrapartum care: care of the healthygood natural light, there will be similarities women and their babies during childbirth, London:with the captured images. However, often NICE.birthing rooms will have dim lighting to NMC (2008). The code - standards of conduct,promote a cosy environment. To address this, a performance and ethics for nurses and midwives,filter was added to the images to make them London: NMC.look darker and more realistic. In addition, Schorn MN (2010). ‘Measurement of blood loss: review ofsome pools have tiny lights built into the pool, the literature’. Jour Midwif Wom Health, 55(1): 20-27.32 The Practising Midwife | April 2015

This month Valerie Cochrane cornerSmith highlights a Interventions for treatingCochrane systematic painful nipples amongreview by Dennis et al breastfeeding womenwhich was published inIssue 12 of 2014 of the SUMMARY: The aim of this bi-monthly column is to highlight Cochrane SystematicCDSR Reviews of relevance to pregnancy and childbirth and to stimulate discussion on the relevance and implications of the review for practice. The Cochrane Collaboration is an international organisation that prepares and maintains high quality systematic reviews to help people make well-informed decisions about healthcare and health policy. A systematic review tries to search for, appraise and bring together existing research to answer a specific research question. The Cochrane Database of Systematic Reviews (CDSR) is published monthly online. Residents in countries with a national license to The Cochrane Library, including the UK and Ireland, can access the Cochrane Library online, free of charge, through www.thecochranelibrary.com Keywords Breastfeeding, painful nipples, nipple trauma, lanolin Author Dr Valerie Smith, lecturer in midwifery at Trinity College Dublin When breastfeeding Background per cent of women initiated breastfeeding practices are (Centers for Disease Control and Prevention Breastfeeding is associated with less infant (CDC) 2011); by three months postpartum onlysub-optimal, this may morbidity from gastrointestinal and respiratory 35 per cent of these were exclusively result in infants not infections (Marild et al 2004; Chantry et al breastfeeding. In Ireland, a national surveyreceiving the maximum 2006) and has been shown to reduce mortality found a 55 per cent breastfeeding initiation health benefits that among preterm infants (Vohr et al 2006). Other rate at birth (Begley et al 2008), but by 48breastfeeding provides studies have reported longer term protection hours, this had decreased to 42 per cent and from breastfeeding in relation to a reduction in had further declined to 19 per cent at three- type 2 diabetes (Owen et al 2006) and obesity four months postpartum. In the UK, while (Harder et al 2005). Despite these benefits, breastfeeding rates have increased, they are studies have shown that exclusive still not ideal. In 2010, initiation rates were breastfeeding declines considerably in the early cited as 83 per cent in England, 71 per cent in >> postpartum months. In the US for example, 75 The Practising Midwife | April 2015 33

Cochrane cornerWales and 74 per cent in Scotland (Health and excluded from the review. Three review authors nipple or areola. The interventions also variedSocial Care Information Centre (HSCIC) 2011). independently assessed each study for across the four studies and included glycerineWhen breastfeeding practices are sub-optimal, inclusion in the review, two assessed the risk of gel dressing, air drying the nipples afterthis may result in infants not receiving the bias (quality) of each study and three authors feeding then applying lanolin cream andmaximum health benefits that breastfeeding extracted the included studies’ data. The wearing breast shells until the next feed,provides. Although the reasons for primary outcome of interest to the review was breastfeeding assessment and correctivediscontinuing breastfeeding are varied and nipple pain (as defined by trial authors). education, application of lanolin three timescomplex, many women report discontinuing Secondary outcomes of interest included daily, application of EBM, no treatment anddue to difficulties encountered (McLeod et al nipple trauma-healing, nipple infection, all-purpose ointment.2002; Cooke et al 2003). One common mastitis, breastfeeding duration, breastfeedingdifficulty that many women experience is exclusivity and maternal satisfaction with For the primary outcome of nipple pain,painful nipples (Cooke et al 2003; HSCIC 2011), treatment and with breastfeeding. there were no differences in pain ratingswith rates among breastfeeding women between the groups in any of the followingvarying between 34 per cent and 96 per cent Findings comparisons:(Ziemer et al 1995; Duffy et al 1997; Tait2000). Poor infant positioning or latch has Four studies, involving 656 women were • Glycerine gel dressing compared withbeen identified as the most common cause of included in the review. Two studies were individualised breastfeeding educationpersistent nipple pain within the first 10 days conducted in Canada, one in Latvia and one inafter birth (Amir et al 1996). Others have Iran. All studies included postpartum women • Breast shells with lanolin compared withsuggested that nipple pain may be related to who had initiated breastfeeding and presented individualised breastfeeding educationthe use of nipple shields, lack of nipple with complaints of sore nipples, nipple traumaexposure to light and air, breast engorgement, or both. In three of the studies women were • Glycerine gel dressing compared withand the frequency and duration of feeding exclusively breastfeeding. Three studies breast shells with lanolin(Morland-Shultz and Hill 2004). specified a time frame of within 14 days postpartum for onset of nipple pain and • Lanolin applied three times a day Various treatments are available for nipple trauma; the remaining study did not specify a compared with treatmentpain. These include tailored education on time frame. Nipple pain and trauma wasfeeding technique, topical antibiotic/ described variably in the studies including the • EBM applied after feeding compared withantifungal creams, non-pharmacological presence of cracked, bleeding, blistered nipples, no treatmenttopical creams (such as lanolin), warm or a combination that may have fissures andcompresses, hydrogel dressings, nipple abrasions present, sore nipples and fissures on • EBM applied after feeding compared withprotection devices (for example breast shells), or around the nipple and painful nipples lanolinand expressed breast milk (EBM). It is unclear, having an open area of the skin on either thehowever, which, if any, treatments are most • Lanolin compared with an all-purposeeffective in resolving or reducing nipple pain. It is unclear which, if ointment any, treatments are mostMethods effective in resolving or For the outcome of nipple trauma, there were no differences between the groups in anyRandomised trials or quasi-randomised trials reducing nipple pain of the treatments except for improved nipplewere eligible for inclusion if they evaluated healing at six to seven days’ post-treatment inany intervention used to treat nipple pain women with no treatment compared toamong breastfeeding women. Women with women who used lanolin and, at four to fivenipple pain due to manual expression of milk days post-treatment in women who used EBMusing a breast pump and women with infants compared to women who used lanolin. Thewho had ankyloglossia (tongue-tie) were only reported differences in maternal satisfaction, across treatments, were increased satisfaction with treatment in women using lanolin compared to no treatment and increased satisfaction with breastfeeding in women using lanolin compared to all-purpose ointment. There were no differences between34 The Practising Midwife | April 2015

Cochrane cornerthe groups in two studies that measured pain. For example, explaining this finding to tract infection in US children’. Pediat, 117(2): 425-431.breastfeeding duration and exclusivity (lanolin women may help them cope better with the Cooke M, Sheehan A and Schmied V (2003). ‘Acompared to no treatment and lanolin pain, knowing it may soon self-resolve. description of the relationship between breastfeedingcompared to all-purpose ointment) and no Anticipatory guidance is a known strategy for experiences, breastfeeding satisfaction and weaning indifference in mastitis in one study (lanolin reducing stress and for promoting coping the first 3 months after birth’. Jour Hum Lact, 19(2):compared to all-purpose ointment). (Dennis et al 2014). Further, it may help sustain 145–156. breastfeeding during a difficult time when Dennis CL, Jackson K and Watson J (2014).Implications for practice women are feeling vulnerable and are more ‘Interventions for treating painful nipples among likely to discontinue. A final consideration for breastfeeding women’. CDSR, 12.The findings of this review do not support practice, in the absence of evidence of Duffy EP, Percival P and Kershaw F (1997). ‘Positiverecommending any one treatment over effectiveness for treatments, is a renewed effects of an antenatal group teaching session on postanother treatment or no treatment for focus on preventing nipple pain and trauma in natal nipple pain, nipple trauma and breastfeedingresolving or reducing nipple pain or trauma the first instance, especially that resulting from rates’. Midwif, 13: 189–196.among breastfeeding women. Although improper latching or positioning. It is of vital Harder T, Bergmann R, Kallischnigg G et al (2005).women using lanolin reported increased importance, as midwives, that we attentively ‘Duration of breastfeeding and risk of overweight’. Amsatisfaction, this did not transfer to a and immediately assist new breastfeeding Jour Epidem, 162(5): 397-403.reduction in pain or an increase in nipple women after birth, with the aim of preventing HSCIC (2011). Infant feeding survey 2010: early results,healing. Women should be informed of this in nipple pain or trauma all together. tpm Leeds: HSCIC.practice so that any decisions made around Marild S, Hansson S, Jodal U et al (2004). ‘Protectiveusing lanolin are based on them fully knowing Valerie Smith is a lecturer in midwifery at effect of breastfeeding against urinary tract infection’.that it will not confer a healing benefit. Trinity College Dublin Acta Paediat, 95(5): 164-168.Irrespective of treatment used, this review McLeod D, Pullon S and Cookson T (2002). ‘Factorsfound that, for most women, nipple pain Note influencing continuation of breastfeeding in a cohortappeared to reduce around seven to 10 days Two related Cochrane reviews that might be of of women’. Jour Hum Lact, 18(4): 335–343.after birth. This has important clinical interest to readers are: Morland-Schultz K and Hill P (2004). ‘Prevention of andimplications for women in managing their therapies for nipple pain: a systematic review’. Jour 1. Dyson L, McCormick FM and Renfrew MJ Obs Gyn Neon Nurs, 34(4): 428–437. It is of vital importance, (2005). ‘Interventions for promoting the Owen CG, Martin RM, Whincup PH et al (2006). ‘Does as midwives, that we initiation of breastfeeding’. CDSR, 2. breastfeeding influence risk of type 2 diabetes in later attentively and life? A quantitative analysis of published evidence’. Am immediately assist new 2. Renfrew MJ, McCormick FM, Wade A et Jour Clin Nutr, 84(5): 1043-1054. breastfeeding women al (2012). ‘Support for healthy breastfeeding Tait P (2000). ‘Nipple pain in breastfeeding women: mothers with healthy term babies’. CDSR, 5. causes, treatment and prevention strategies’. Jour after birth, with the aim Midwif Wom Health, 45: 197–201.of preventing nipple pain References Vohr BR, Poindexter BB, Dusick AM et al (2006). ‘Beneficial effects of breast milk in the neonatal or trauma all together Amir LH, Dennerstein L, Garland SM et al (1996). intensive care unit on the developmental outcome of ‘Psychological aspects of nipple pain in lactating extremely low birth weight infants at 18 months of women’. Jour Psychosom Obs Gyn, 17: 53-58. age’. Pediat, 118(1): 115-123. Begley C, Gallagher L, Clarke M et al (2008). The Ziemer MM, Cooper DM and Pigeon JG (1995). national infant feeding survey 2008, Dublin: The ‘Evaluation of a dressing to reduce nipple pain and Health Service Executive. improve nipple skin condition in breastfeeding CDC (2011). Data and statistics: breastfeeding report women’. Nurs Res, 44: 347–351. card, Atlanta: CDC. Chantry C J, Howard C R and Auinger P (2006). ‘Full breastfeeding and associated decrease in respiratory The Practising Midwife | April 2015 35

Thinking outside the boxSara Wickham Rethinking bugs Part 2continues her explorationof how re-thinking ourknowledge aroundbacteria may benefitwomen and midwivesBacteria seem to be getting mentioned everywhere L ast month, I wrote about my observation that bacteria seem to beat the moment, and could even be said to be ‘trending’ at the moment, and explained my hope that their current‘trending’. In this second instalment of a two-part popularity might have a part to play in improving care for women andarticle, I argue that we need to re-think the care babies. In that article, I questioned how bacteria are portrayed, both inand treatment we offer to women for a number of everyday life and in theories of health and disease, and asked whether therereasons. Using the example of group B strep may be potential benefit in understanding that our relationship with bacteriadisease, I argue that avenues other than the is not simple or easily summed up. In this article, I am going to look at somecurrent treatment pathway are worthy of specific examples of how, if we were open to rethinking and embracing ourexploration, and with antibiotic resistance an complex relationship with bacteria, we might be able to move our knowledgeincreasing problem, this may be the best way forward.forward. I conclude that, because the need forreconsideration of some elements of maternity Why do we need to re-think?care is so great, the current focus on bacteria andthe potential that this has to throw new light onto I am certainly not suggesting that we throw the proverbial baby out with theold areas may be very helpful. bathwater (not least because bathing our babies is another area that we need to reconsider), and I want to acknowledge the importance of appropriately detecting and responding to sepsis, as highlighted in the latest MBRRACE-UK report (Knight et al 2014). Pasteur’s achievements were incredible, and we should be grateful to him every time we sip a glass of wine, let alone when we use an antibiotic that is truly warranted. But we don’t have to throw out or devalue his work in order to reconsider elements of it or think about the issues in a more nuanced way. We will soon need a different approach to the current trend of giving incredible volumes of antibiotics to large numbers of people, which is unsustainable in the long term because of antibiotic resistance. There are many reasons for re-thinking, including that it may help us to get back on track as far as giving effective care is concerned. In Reed and Johnson-Cash’s (2014) overview of emerging knowledge about the human36 The Practising Midwife | April 2015

Thinking outside the boxmicrobiome and the way in which this relates almost everything bar make a cup of tea from certain type of GBS bacteria. Why not look atto pregnancy, birth and early mothering, they the comfort of our smartphones (and I expect that, and ask deeper questions about thepoint to the theory that stress can affect our an app for that will be available soon), can we terrain, or the way in which our bodies relategut microbiota and ask whether antenatal care really not find a way to determine which to the bacteria that live within us? As Ishould focus on reassurance and relaxation individual women and babies are at risk - and recently wrote, “as long as there is arather than clinical testing and discussion of why - rather than only being able to offer possibility that GBS disease has multiplerisk. How many other areas of care could we sledgehammer-level treatments to the entire causes, or is caused by something else in theimprove if we could go back to the drawing population? presence of GBS bacteria then the best thingboard? that we can do for our current and future The clues in the question babies is to keep our minds open to otherThe GBS example possibilities” (Wickham 2014: 108). There are a couple of really tantalising cluesThe prevention of group B strep (GBS) disease which may serve as starting points. One is that, I don’t know what these other possibilitiesis one example of an area in which I believe although the currently available research are. I accept that the roads I’ve described maythat a re-think might help us drastically studies are not of premium quality (Wickham not be the exact ones that we need and thatimprove the care we offer. Here, we have a 2014), there is a bit of a trend in the studies we may have to go down lots of cul de sacssituation where a particular kind of bacteria is looking at the various possible treatments for before we find a better pathway than weknown to live within about a fifth of people GBS, which include chlorhexidine douching currently have, but I think we owe it to women(although testing is not especially accurate, so and water birth as well as antibiotics. They and babies to keep exploring. And it’s preciselythis figure may not be either) and it causes no show that it is relatively easy to reduce because I think that we should keep exploringharm in the vast majority of situations. It gets colonisation with GBS bacteria but that this that I am so delighted about the focus onpassed to about half of the babies born to doesn’t necessarily lead to a reduction in GBS bacteria. Because, in my book, anything thatwomen who carry it, and most of them disease. This might not be the case if we did helps us re-evaluate and re-think what weexperience no ill consequences, but now and better research studies, but even the possibility think we know is a jolly good thing indeed. tpmagain it causes huge and potentially fatal that the presence of GBS is only one of theproblems for a baby (Wickham 2014). Often, factors needed for GBS disease to occur may Sara Wickham is an independent midwiferythese babies are already compromised, for be worth exploring. It might come to nothing, lecturer and consultantinstance because they have been born preterm, but we’ll never know if we don’t try.but this is not always the case, so there is no Referencesstraightforward linear explanation here. Another avenue for exploration is that we know from the experiences of women whose Knight M, Kenyon S, Brocklehurst P et al (2014). Saving As current methods of screening and babies have had GBS disease that some of lives, improving mothers’ care. Lessons learned totreatment require lots of healthy women and these women have low levels of antibodies to a inform future maternity care from the UK and Irelandbabies to be exposed to antibiotics, there is confidential enquiries into maternal deaths andongoing discussion about whether we could How many other areas morbidity 2009-2012, Oxford: NPEU.come up with a better response to this of care could we improve Reed R and Johnson-Cash J (2014). The humanproblem, with one proposed solution being a microbiome: considerations for pregnancy, birth andvaccine (Schrag and Verani 2013). Yet if we could go back to early mothering. Available at: http://tinyurl.com/oo6usbh.vaccination also has limitations and side the drawing board? Schrag SJ and Verani JR (2013). ‘Intrapartum antibioticeffects, including that it may negatively prophylaxis for the prevention of perinatal group Bimpact on a woman and baby’s microbiome. To streptococcal disease: experience in the United Statesmy mind, one of the main reasons that we and implications for a potential group B streptococcalshould also be considering other options is vaccine’. Vaccine, 31(Suppl 4): D20-26.that a vaccine would have to be offered to Wickham S (2014). Group B strep explained, London:every woman, too. In an age where we can do AIMS. The Practising Midwife | April 2015 37

Baby friendly newsFrancesca Entwistle Taking neonatal care to the next levelhighlights the placeof breast milk inclose, lovingrelationshipsBreastfeeding or breast I n 2010, the National Institute of Health and enable babies to receive breast milk, andmilk feeding premature and Care Excellence (NICE) produced breastfeed where possible.and sick babies improves specialist neonatal quality standards their short- and long- presenting specific, concise quality statements Early and sick babies term health and well providing parents and health- and social-care professionals with definitions of what high Breastfeeding or breast milk feeding premature being outcomes, quality neonatal care should look like and how and sick babies improves their short- and long-reducing both mortality these could be used as a benchmark for term health and well being outcomes, reducing improvement (NICE 2010). both mortality and morbidity (Renfrew et al and morbidity 2009). Involving parents in their baby’s care is At the heart of care essential to achieving the best outcomes. Routine practices within the system may Currently, one in 10 babies born alive receives discourage a mother from initiating or specialist neonatal care of some sort and this continuing to breastfeed (McInnes et al 2010). number is increasing, due to recent Midwives are in a position to act as a conduit improvements in survival rates of very between the postnatal ward, transitional care premature babies and those with complex and neonatal unit in the early days to ensure needs. Lack of feeding with breast milk for that good foundations are laid. Good practice these infants is an important and costly will ensure that the mother is enabled to be problem that, if addressed successfully, has the with her baby, build a close and loving potential to contribute to addressing relationship and express, store and transport inequalities in health (Renfrew et al 2009). The her breast milk as required. NICE quality standard requires that the physical, psychological and social needs of Achieving successful preterm breastfeeding babies and their families are at the heart of all can be challenging and requires an care given (NICE 2010). understanding of the physiological development of the baby. The midwife and The Unicef UK Baby Friendly Initiative neonatal nurse, working together, require the standards (Unicef 2012) for neonatal units knowledge and skills to be able to offer require that facilities value parents as partners culturally sensitive care practices, practical in their babies' care, support parents to build guidance and the physical environment to close and loving relationships with their babies, facilitate parent-infant closeness (physical and38 The Practising Midwife | April 2015

Baby friendly newsemotional) and family-centred care (Flacking strategies to optimise the neonatal space andet al 2012). Optimising care will help promotebreastfeeding, relationship building and organisational culture are required to welcome Supporting andpositive infant brain development. parents as ‘empowered players’ in the care ofBreast milk for all babies their infants, providing family rooms, chairs, educating staff to beds, privacy and culturally sensitive care implement practices thatThe evidence for the use of human milk in the practices, such as prolonged skin-to-skinneonatal unit is compelling, but the translationof this evidence into best practices, toolkits, contact and family-centred care (Unicef 2012). help parents to have apolicies and procedures, talking points and Supporting and educating staff toparent information is limited (Meier et al2013). The use of human milk needs to be implement practices that help parents to have close and lovingprioritised, and midwifery and neonatal staff a close and loving relationship with their baby relationship with theirprovide consistent practical support and help and that encourage breastfeeding is essentialto optimise the use of human milk for allbabies. to changing a unit culture to fully value and baby and that encourage support the parent’s feeding choices. NeonatalSkin-to-skin culture within the UK requires a ‘sea-change’ breastfeeding is essentialSkin-to-skin/kangaroo mother care is also to implement a cultural shift in the waybeneficial for all babies, as it promotes cardio-respiratory and temperature stability, sleep parents are valued as partners in care. Only byorganisation and duration of quiet sleep andneurodevelopmental outcomes. Kangeroo setting high expectations will mothers andmother care is also associated with improvedbreastfeeding outcomes, reduced stress, babies be placed at the centre of care and neonatal unit’. Maternal Child Nutri, 6: 306-317.enhancement of mother-infant bonding andpositive effects on the family environment and parents valued as partners. tpm Meier PP, Bigger HR, Rossman B et al (2013).the infant’s cognitive development (Charpak etal 2005). Bergman et al (2004) found that ‘Supporting breastfeeding in the neonatal intensivepreterm babies who had kangaroo care hadbetter physiological outcomes and stability Francesca Entwistle is professional advisor at care unit: Rush mother’s milk club as a case study ofcompared to incubator care alone. Now thisknowledge must be translated into everyday the Baby Friendly Initiative and midwifery evidence-based care’. Pediatr Clin N Am, 60: 209–226.practice in UK neonatal care. lecturer at the University of Hretfordshire NICE (2010). Specialist neonatal care quality standardClose and loving relationships References (QS4), London: NICE.Preterm, sick or very preterm infants who may Renfrew MJ, Dyson L, McCormick F et al (2009).be separated from their parents for longperiods require special consideration to support Bergman NJ, Linley LL, Fawcus SR (2004). ‘Randomised ‘Breastfeeding promotion for infants in neonatal units:the development of an emotional and physicalcloseness that may be important for the controlled trial of skin-to-skin contact from birth a systematic review’. Child care, health and dev, 36(2):formation of secure, long-term, attachmentrelationships. Flacking et al (2012) argue that versus conventional incubator for physiological 165-178. stabilization in 1200 to 2199 gram newborns’. Acta Unicef (2012). The evidence and rationale for the Paed, 93(6): 779-785. UNICEF UK Baby Friendly Initiative standards, London: Charpak N, Ruiz JG, Zupan J et al (2005). ‘Kangaroo Unicef UK Baby Friendly Initiative. mother care: 25 years after’. Acta Paed, 94(5): 514-522. Flacking R, Lehtonen L, Thomson G et al (2012). ‘Closeness and separation in neonatal “These comprehensive teaching resources intensive care’. Acta are great. The power of the breath and Paed, 101: 1032-1037. McInnes RJ, Shepherd AJ, self-hypnosis cannot be underestimated!” Cheyne H et al (2010). www.relaxandbreathebirthing.com ‘Infant feeding in the [email protected] 07717 783 230 The Practising Midwife | April 2015 39

Midwifery Basics: MentorshipMari Phillips and Joyce 7. Mentor update and support:Marshall what do mentors need from an update?Mentorship is the 14th series of Introduction‘Midwifery basics’ targeted atpractising midwives. The aim of The Nursing and Midwifery Council (NMC) is very clear that all mentors should maintain andthese articles is to provide develop their knowledge, skills and competence related to mentorship through regular updating.information to raise awareness This normally takes place annually and ensures that mentors have current knowledge of NMCof the impact of the work of approved programmes, are able to discuss the implications of changes to NMC requirements, havemidwives on women’s an opportunity to discuss issues related to mentoring and are able to review and reflect on theexperience, and encourage assessment of student competence and fitness for safe and effective practice (NMC 2008a).midwives to seek further Mentors may be required to demonstrate to their managers that they have done this as part ofinformation through a series of their triennial review or appraisal and to NMC quality assurance agents when monitoring visits areactivities relating to the topic. undertaken.In this seventh article MariPhillips and Joyce Marshall Value of annual updatingconsider some of the key issuesrelated to mentor update and Pre-registration midwifery students spend 50 per cent of their programme in practice placementssupport and consider what and must be supervised by a sign-off mentor for a minimum of 40 per cent of that time so thementors need from their annual role and responsibility of the sign-off mentor is a vital part in the education of healthcareupdate. professionals (Bray and Nettleton 2007). Mentors continue to learn and become even more effective mentors through attending update events and participating in discussion with colleagues All mentors should (Gopee 2011). The provision of an annual update is an integral part of the support for sign-off maintain and develop mentors and provides an opportunity to reflect on both the successes and challenges of their knowledge, skills and mentorship. competence related to mentorship through Attendance not only means that the sign-off mentor is compliant with the Standard for regular updating supporting learning in practice (NMC 2008a), but also that they are fulfilling the requirements of the Code (NMC 2008b) which requires nurses and midwives to keep their knowledge and skills up Scenario Suzanne recently mentored Annabel and during the final discussion realised that there were some changes to the midwifery curriculum. She is not due to mentor another student immediately but she is keen to find out what the changes are and if there will be any impact on the practice placement. She is due to attend a mentor update session next week.40 The Practising Midwife | April 2015

Mentorshipto date throughout their working lives and to Updating sessions are normally provided by these fit with the university processes, intake part in appropriate learning and practice and located within the employing trust and particular the assurance of inter-markeractivities that maintain and develop sessions may vary in duration. They may be reliability, are common topics. Preparation forcompetence and performance. offered as part of generic mentor updating to grading practice increases inter-rater reliability all healthcare practitioners or more commonly and reduces grade inflation (Scanlon and Care The challenge for mentors is to prioritise planned within the schedule of annual 2008) but ongoing education offers thethis activity when they are already feeling mandatory sessions provided to midwives as opportunity for further dialogue (Passmore andpressurised by service demands as well as part of Clinical Negligence Scheme for Trusts Chenery-Morris 2014). It is always valuable tomeeting the needs of their mentees. This is (CNST) requirements. Some trusts may offer draw on the range of experiences thatfurther complicated by the changing patterns updates that are facilitated by dedicated colleagues bring to the discussion and toof working, such as 12-hour shifts, practice learning staff, but more often these highlight the importance of the consistentreconfiguration of services, rotation of are undertaken by academics (link lecturers) application of the grading criteria.midwives and also the increase in part-time from the local university. Updating mentorshipworking which has affected the nature of is the second commonest activity for The challenge for the lecturers facilitatingmentoring. It is therefore important that midwifery lecturers in practice placements the session is to offer the opportunity formentorship updates “take account of the (Collington et al 2012). This offers further meaningful discussion, often within a veryfeelings, experiences and pressures on mentors” opportunity for partnership working, between limited time frame, and also to avoid repetition(Jervis and Tilki 2011: 587). the university and the service, in relation to of material. They may ask at the beginning of pre-registration education, and provides the session if anyone has specific questions orTypes of update specific time for mentors to engage directly issues that they wish to discuss. One useful with lecturers. format for updating sessions is the use ofWhen time is short, practitioners have to scenarios. These provide a helpful focus forensure that they choose the most appropriate A typical update session discussion of challenging situations ortype of learning for their continuing potential problems; see, for example, theprofessional development (CPD) (Steele 2009), A typical session will start with a welcome and situations discussed by Kenyon et al (2015).and the provision of online updating activities introductions and provides a good opportunity Mentors are usually very clear about whatmay be extremely useful. However the nature to meet and network with mentors working in constitutes ‘safe’ clinical practice, but guidanceof the Standards (NMC 2008a) means that other areas; this simple activity is sometimes may be required when dealing with studentsthere has to be some type of face-to-face difficult to achieve in very busy areas. The who may be upset, manipulative or aggressiveactivity. session will certainly include an outline and when being referred or failed in a practice explanation of any changes, actual or planned, setting (Jervis and Tilki 2011). Other mentors’ Activity 1 to the organisation or content of the views of helpful strategies and possible curriculum or placements. Any changes to the solutions or experiences of less helpful If you are a mentor consider any curriculum will be subject to a university and approaches can provide further insights into issues that arose when you NMC approval process but it is important to the complexities of mentorship and assessment mentored your most recent student. consider how these may impact on the and help develop confidence and competence Identify and write down potential individual placement areas and the nature of in mentorship practice. It is important that the questions that you might ask at experience that student midwives will need to anonymity of individual students is maintained your next mentor update to help obtain. It is essential that mentors are familiar and confidentiality of any personal you mentor more effectively. with the learning opportunities that students information assured. If you are a student think about may be required to access and any changes to your experience on your last the practice documentation. Getting the most from sessions placement and list all the skills you think a mentor needs, to effectively Refreshing mentors’ knowledge of Attendance at a mentor update session can help students learn. assessment requirements, and the way in which sometimes be viewed as rather a ‘chore’, >> The Practising Midwife | April 2015 41

Mentorshipespecially when there are so many competing Table 1 Explanation of SMART objectivesdemands on time. It may be helpful to thinkabout the session as an opportunity to Specific A specific goal is more likely to be achieved. Try answering the‘sharpen the saw’ (Covey 1989) and part of the questions: Who? What? Why? Where? When?habit of continuous improvement that S Identify the criteria for the goals you set. How much? How many?contributes to an enhanced level ofunderstanding of mentorship and makes a M Measurable Ensure it is possible to achieve the goals you set.contribution to post-registration ongoing A Achievableeducation and practice (PREP) requirements R Realistic Given the resources – can it be done?(NMC 2011). T Time bounded Set a time frame to complete your goal. As with any other continuous professional (Adapted from Doran 1981)development activity, preparation is essentialto get the most out of an update session. recorded and the local register updated. This speed of change in health care has increasedReflection on recent mentoring experience can evidence will be helpful for meeting triennial the need for strong partnerships, andgenerate questions or issues for discussion. It review requirements (Gopee 2011) and is part managers and supervisors of midwives maymay be helpful to formulate these as personal of the personal accountability of each also provide useful points of advice andlearning objectives, which should be SMART healthcare professional to maintain and support (Finnerty et al 2006) especially in(specific, measurable, achievable, realistic and improve their professional knowledge and relation to practice issues. Many trusts employtime-bounded) (See Table 1). Guidance competence (NMC 2008b). practice learning facilitators (or equivalent)provided for PREP (NMC 2011) suggests that a who are able to provide advice on specificdetailed account of each learning activity Other sources of support problems and are usually knowledgeable aboutundertaken is documented, as part of the trust policies and the interface with theprofessional portfolio, together with the The annual update is just one aspect of the university.outcome, including a record of the effect it support for mentors. If a mentor has ahas on subsequent work or practice. Each particular concern about a student’s progress Conclusionmentor should ensure that their attendance is or achievement then contacting the appropriate link lecturer will certainly be the It is essential that mentors are up to date with Activity 2 first step. However, it is also useful to discuss mentoring challenges with another Activity 3 Identify the date for your next experienced mentor, though being very aware update and ensure that you have that students do not perceive that they are If you are a mentor, following your booked your place. Revisit the being discussed behind their back (See earlier annual update session, make a list questions you identified and try to article in this series: Kenyon et al 2015). The of your own CPD in the mentor role. formulate some SMART objectives Consider how you can keep yourself for the session. Find some journal Reflection on the scenario up to date and what you might articles on mentorship that relate to include in your professional your objectives and read these Attending the mentor update can assist portfolio. Discuss this with your before attending the session. Suzanne in clarifying the requirements supervisor of midwives. If you are a student consider your of the midwifery curriculum that the If you are a student imagine you are next placement and set some students are studying and help Suzanne mentoring a student who is less SMART objectives to focus your to better plan the learning opportunities experienced than yourself (there are learning and to discuss with your for her next student. often peer mentoring schemes in mentor. place for students). Consider how you might prepare for a meeting with that student to offer helpful support.42 The Practising Midwife | April 2015

Mentorshipcurrent midwifery and mentorship practice and Today, 27(8): 848-855. Kenyon C, Hogarth S and Marshall J (2015). 'Challengesare required to demonstrate how they Collington V, Mallik M, Doris F et al (2012). 'Supporting of mentorship'. The Pract Midw, 18(3): 36-40.maintain their professional development as the midwifery practice-based curriculum: the role of NMC (2008a). NMC standards for mentors, practicepart of their commitment to lifelong learning. the link lecturer'. Nurse Ed Today, 32(8): 924-929. teachers and teachers, London: NMC.Mentor update sessions are one part of the Covey SR (1989). The 7 habits of highly effective NMC (2008b). The Code: standards of conduct,ongoing support for mentors and provide the people, London: Simon and Schuster. performance and ethics for nurses and midwives,opportunity to share the successes and Doran GT (1981). 'There’s a SMART way to write London: NMC.challenges of preparing the next generation of management goals and objectives'. Management Rev, NMC (2011). The PREP handbook, London: NMC.midwives. tpm 70(11): 35-36. Passmore H and Chenery-Morris S (2014). 'Exploring the Finnerty G, Graham L, Magnusson C et al (2006). value of the tripartite assessment of students in pre-Mari Phillips and Joyce Marshall are both 'Empowering midwife mentors with adequate training registration midwifery education: a review of thesenior lecturers in midwifery at the University of and support'. Brit Jour Midwif, 14(4): 187-190. evidence'. Nurse Ed Pract, 14: 92-97.Huddersfield Gopee N (2011). Mentoring and supervision in Scanlon JM and Care WD (2008). 'Issues with grading healthcare, London: Sage. and grade inflation in nursing education'. Annual RevReferences Jervis A and Tilki M (2011). 'Why are nurse mentors Nurs Ed, 6: 173-188. failing to fail student nurses who do not meet clinical Steele R (2009). 'Gaining competence and confidenceBray L and Nettleton P (2007). ‘Assessor or mentor? performance standards?' Brit Jour Nurs, 20: 582-587. as a midwife'. Brit Jour Midwif, 17: 441-447. Role confusion in professional education’. Nurse EdReviews also on page 45Abortion in Asia: local dilemmas, global politics are shown to increase women’s need to resort to abortion, relate to poverty, early childbearing and interpersonal violence. The briberyAndrea Whittaker and corruption which are endemic in many settings only serve to2012, Berghahn Books, 253pp, £21.00, pbk, ISBN: 978 0 85745 795 0 aggravate women’s difficulties. Although this edited book focuses on research undertaken in Asian Although the complications of unsafe abortion are often countries, the material is remarkably relevant mentioned, the ever-present spectre of maternal death tends not to to many western countries, not least the be directly addressed. Technology emerges as a mixed blessing, with United Kingdom. The reasons for this prenatal diagnosis being regarded as a precursor to abortion; sex- relevance may surprise some; they are found selection, though, tends to be portrayed as no longer a problem. in the many women’s health issues raised by the abortion debate, which are shared Thus, although there is a wealth of commonalities, these papers internationally, if not universally. The present the context as crucial. The contributors make good use of countries profiled are variably westernised, women’s personal stories to invigorate the discussion of the many wealthy and patriarchal; all show massive dilemmas. The women’s stories also demonstrate the extent to which local initiatives may be compromised by global influences, asimbalance between the experiences of women in rural and urban exemplified by short-sighted religious campaigns and the resultingsettings. Thus the health issues following both internal and donor/aid restrictions. The contributors’ focus on Asia actually makesinternational migration emerge loud and clear. Some of the this book more applicable, even germane, to women’s health careimbalance of experiences is associated with urbanisation and internationally.industrialisation, which are linked with changes in attitudes, and Rosemary Mandercreate distrust and conflict within families. Particular problems, which Emeritus professor of midwifery at the University of Edinburgh The Practising Midwife | April 2015 43

Professional development www.cusultrasound.co.uk CENTRE FOR ULTR ASOUND STUDIESCASE accredited part-time Ultrasound Education andTraining in BournemouthApplications are now being accepted for the PgCert/PgDip/MSc.PgCert, PgDip or MSc Medical UltrasoundThis part-time innovative programme has been designed by a team of ultrasound experts. AECC is an Associate College of Bournemouth UniversityA exible programme with opportunities to study:• Gynaecology Ultrasound• First Trimester Obstetrics Ultrasound• Second and Third Trimester Obstetrics Ultrasound• Negotiated Ultrasound Skills – exibility to suit your learning needs including NT Screening and Gynaecology Contrast Studies &ŽƌŵŽƌĞŝŶĨŽƌŵĂƟŽŶ Centre for Ultrasound Studies +44 (0) 1202 436 200 13-15 Parkwood Road [email protected] Bournemouth, Dorset BH5 2DF NEONATAL CONFERENCE TAKING NEONATAL CARE TO THE NEXT LEVEL Speakers include: Nils Bergman, Paula Meier, Shoo Lee unicef.org.uk/neonatalconference …7PKEGH7-,GʘU 19 May 2015 Royal Institution, London W1S 4BS Ticket price: £9544 The Practising Midwife | April 2015

Guernsey Reviews also on page 43Midwives How to conceive healthy babies – the natural way. Second edition.Salary: Band 6 up to £39,378 with an additional £3,000bonus (pro rata) paid on completion of two year’s Belinda (Nim) Barnesservice and an £1,075 (pro rata) annual bonus. 2014, Author Essentials Ltd, 405pp, £9.99, pbk,We are seeking to recruit a number of Midwives to join our ISBN 13 978 1 78003 698 4innovative and progressive maternity unit. We offer midwiferyled and maternity team care, providing midwifery care for all This book aims to inform and educatenormal and high-risk pregnancies, actively encouraging and those couples who wish to embark on asupporting women. The unit has 17-beds with a delivery rate healthy pregnancy resulting in a healthyof approximately 650 - 700 babies per annum. As a smaller baby. It addresses issues of infertility andunit it offers great continuity of care. The posts offer a variety miscarriage and details how diet andof experience, both in the hospital and community settings environment can negatively influenceand will involve rotation through all clinical areas. these. The book then further suggestsWe are looking for flexible and enthusiastic Registered how, through (amongst otherMidwives who are committed to providing a high quality approaches) hair analysis, dietarystandard of care and are currently registered with the NMC. supplements and a cleansing programme prior to conception, aYou must possess post qualification midwifery experience successful healthy pregnancy can be achieved resulting in aand have the ability to lead and motivate staff whilst healthy baby.delegating and prioritisting your workload. For those couples who have experienced the tragedy of infertilityWe cover the costs for shortlisted candidates to be or pregnancy loss this book provides information and advice notinterviewed in Guernsey and successful applicants will also widely available in main-stream medical care. Although containingbenefit from a 15 year housing licence, competitive salary, a large amount of in-depth information, it is written in angenerous relocation package, subsidised accommodation / informal style interspersed with ‘real life’ testimonies, making it anrent assistance and bonus scheme (terms and conditions easy read, and is concluded with an extensive supportive appendix.apply). All this information is gained not only from the author’s own 30For further information please contact Tracy Fearis, years of knowledge and experience but also those of contributingHR Advisor on 01481 725241 ext. 4714, email: clinicians, researchers, experts and [email protected] or our recruitment team on Due to Foresight’s ethical standing, they will never be involved in01481 747394, email: [email protected] for a full job research with a control population. Their programme cannot bedescription and application pack. measured for efficacy using standard methods; however there areClosing date: 30 April 2015 numerous references to relevant research throughout the book and a detailed survey of Foresight results in relation to fertility over aWe will be attending the RCN Job Fair in Glasgow seven-year period, giving weight to the success of their methods.on the 9 & 10 April 2015. Speak to the above This book encourages couples to be in the best possible healthcontacts for more information. prior to achieving a pregnancy which, as midwives, is also the advice we actively promote in our daily care of women. For those www.facebook.com/HealthcareJobsGuernsey couples who struggle to achieve a pregnancy or experience the heartache of recurrent miscarriages, the science portion of this @HealthJobsGsy #loveguernsey book is interesting; from a midwifery perspective, however, formal evaluation would be valuable. Amanda Gotch Midwife at Aberdeen Maternity Hospital and midwifery lecturer, Robert Gordon University The Practising Midwife | April 2015 45

Last word A gathering of the like mindedMolly O’BrienO n an August weekend in Norfolk, an weekend, including feminism, guidelines, risk the overwhelming magnitude of the difficulties array of tents sprang up to create culture, evidence, management and bullying. ahead and the even more frightening scenario ‘home’ to a group of 70 midwives, of ‘business as usual’.student midwives, doulas, mothers and others Denis Walsh started the weekend with ainterested in birth. This event was the Birth presentation on feminism and how important Mavis’ presentation helped us understandGathering! the movement is to midwifery. how and why midwives behave as they do when they feel powerless and when the system is The sun shone, mostly, and in the Next, Soo Downe led an interactive session bedevilled by negative management styles andneighbouring field, sheep were unperturbed by on the importance of perinatal education. horizontal violence. She described the behaviourlate night chatting, singing and mulling over of of midwives working in the NHS as coping withthe days’ sessions. We were grateful that the Participant-led workshops were brief but loss and grief. Feelings of anger, blame and guiltweather was kind, making the post prandial informative. Physiology, biomechanics, - common manifestations of the grief process -storytelling round the camp fire comfortable, rhythms of labour and third stage were are now everyday emotions for midwives.as passionate and heartfelt exchanges stirred amongst the topics discussed, instigating anfire in our bellies. addition to next year’s programme: ‘Sharing Midwives under pressure tricks of the trade’!Supportive network Midwives are exhausted and frustrated, If we want a caring NHS working within an industrial medical model ofThe Birth Gathering, which offers a unique that is ‘free at the point care that has risk and fear at its core, while ouropportunity to share information and of delivery’, there is no midwife hearts are rooted firmly in a social,experiences, is now in its fourth year. Organised option but to become public health model. Midwives are torn apartby a group of midwives, it developed out of a by the contradictions of this dichotomy.shared passionate belief in the awesome political.physiology of pregnancy and birth, and a desire The discussions and ideas continued right toto address the injustices that occur in Midwives are coping the end, inspired by an eagerness to makematernity care against women, babies, families changes. There was a will to reclaim midwiferyand birth workers through the over- Mavis Kirkham was the ideal closing speaker. and our identity as midwives; both for themedicalisation and institutionalisation of birth. Her presentation ‘Midwives coping in the NHS’ women we care for and ourselves. WeThe event encourages the growth of a came after days of pouring our hearts out. expressed our deep concerns regarding thesupportive network, sharing experiences and We’d shared tears of sadness, anger and privatisation of the NHS. Ultimately, theinformation. frustration but we were also full of passion and consensus was that if we want a caring NHS determination to make things better. We had that is ‘free at the point of delivery’, there is no Many of the participants were recently identified areas where we felt we could make option but to become political.qualified or students eager to learn but readily changes, but there was a palpable feeling ofsharing fresh eyed opinions about an NHS “If you can’t see the light shining at thebattling under huge pressure. end of the tunnel then get down there and bloody well light it yourself”.Themes Watch this space… Midwives rise up! tpmRecurring themes emerged throughout the Molly O’Brien is a midwife in Norwich46 The Practising Midwife | April 2015

Don’t miss an issue Subscribe today www.thepractisingmidwife.com The Practising MIDWIFE The best job in the world Volume 18 No 4 April 2015 MIDWIFEThe Practising The Practising MTheIDPraWctisIinFg E Now also Childbirth controversies The best job in the world The best job in the world available Volume 18 No 2 February 2015 MIDWIFE Volume 18 No 4 April 2015 • In defence of bacteria The best job in the world online • Fathers in theatre during caesarean with general anaesthetic Volume 18 No 3 March 2015 • The place of Kielland’s forceps in childbirth • Hospital birth or home birth? www.thepractisingmidwife.com www.thepractisingmidwife.compractisingmidwife.com Effective interventions Psychology, midwifery and birth Childbirth ocf boacntertiaroversies To find out more visit • Midwives managing emotion www.practisingmidwife.co.uk •••AIEnnftfteeercnvtaeivtnaetlinoinontnse-trpovhebanortmioosantcsborleoagsitcfaeleidnitnegrventions • Trauma in childbirth • In defence and click on • Use of the Internet • Early pregnancy loss “find out more about online” • Domestic violence in pregnancy •••HTFaohtsehppeitrlaaslcienbiotrhftheKaoiterrlelhadonumdr’esinfbgoirrctcahee?pssarienacnhwilditbhirgtehneral anaesthetic Name Instruction to your bank or building society to pay Direct Debits Please complete parts 1 to 6 to instruct your bank or building society to Address make payments directly from your account (UK ONLY). Postcode Country 1 Enter full name and postal address of bank or building society To: The Manager Job title (if applicable) Name of bank/building society Institution (if applicable) Address Telephone Email Postcode Rates Please tick the rate appropriate to you For printed version only save £5 if you pay by Direct Debit (UK personal rate only) – lower rates in 2 Name of account holder 3 Bank/building society sort code brackets 4 Bank/building society account no 5 Reference (office use) Personal rates Originator’s identification no 2 5 8 7 7 2 6 Instructions to your bank/building society: I Fully qualified UK £65 (£60) I Europe/Eire £75 I Online only £50 Please pay FastPay Ltd re Medical Education Solutions Ltd from the account I Student UK £50 (£45) I Europe/Eire £65 I Online only £40 detailed in the Instruction subject to the safeguards assured by the Direct I Rest of world (surface) £100 I Rest of world (airmail) £130 I Online only £50 Debit guarantee. Student’s course ends: Institutional rates I Online only £123 I UK £134 I Online only £123 I Europe/Eire (airmail) £144 I Rest of world (airmail) £190 I Online only £123 Back copies - p & p extra (Please call number below) Signature Date I UK £7 I Europe/Eire £9.50 I Rest of world £12.50 PAYMENT OPTIONS – Four ways to pay! Some banks and building societies may not accept Direct Debit instructions Please return this form to: TPM Subscriptions, 66 Siward Road, 1 Direct Debit (UK only) I Please complete the Direct Debit instruction opposite. Bromley BR2 9JZ. 2 By credit card/debit card (circle required option) Credit card hotline 01752 312140 The Direct Debit guarantee This guarantee is offered by all banks and building societies that take part in the Card number: Direct Debit Scheme. The efficiency and security of the Scheme is monitored and protected by your own bank or Start date: Expiry: 3 digit security code: Issue no (switch only): building society. If the amounts to be paid or the payment dates change, Medical Education Solutions Ltd will notify you 10 working days in advance 3 BACS I 40-22-26 / 42634317 / HSBC Medical Education Solutions Ltd. of your account being debited or otherwise agreed. If an error is made by Medical Education Solutions Ltd or your bank or building society, you are Please put your NAME as reference guaranteed a full and immediate refund from your branch of the amount paid. You can cancel a direct debit at any time by writing to your bank or 4 Cheque I I enclose a cheque payable to Medical Education Solutions Ltd building society. Please also send a copy of your letter to us. You can also call our credit card hotline 01752 312140 Please return this form to: TPM Subscriptions, 66 Siward Road, Bromley BR2 9JZ.

THE IRON SHE NEEDS.Not everyone finds conventional iron food supplements easyto take. Spatone® is different.• 100% natural iron rich water that has been scientifically proven to help top up iron levels during pregnancy1• The iron in Spatone® has an average absorption of 40%2, compared to 5-10% from conventional iron food supplements• This means fewer of the unpleasant side effects associated with conventional iron food supplements3Food Supplement Feel the difference Iron contributes to the reduction of tiredness and fatigue.Food Supplements should not be used as a substitute for a balanced diet and healthy lifestyle.If pregnant or breast feeding always consult a healthcare professional before taking any food supplement.1 Halksworth et al. (2003). Clin. Lab. Haem, 25, 227-231. 2 Nelsons Nutritional Study - The Significant Impact of Spatone on Iron Levels, 2009 3 Worwood, M et al (1996). Clin Lab Haem, 18, 23-27.