TPM OCTOBER 2014

www.thepractisingmidwife.com The Practising MIDWIFE The best job in the world Volume 17 No 9 October 2014Nutrition PLUS NEW! Midwifery basics• Nutrition in pregnancy• Digestive health in pregnancy• Perspectives on tongue-tie• Magnesium - the relevance of research



All change! The Practising MIDWIFE The best job in the worldT his October is a momentous time as the Scottish electorate have voted to stay in In this issue the United Kingdom and midwives have voted for or against industrial action. What the former means to midwives throughout the UK will only become really 3 EDITORIALclear as time goes by, but we know that the latter will mean hard times ahead. In that 5 VIEWPOINT Fair pay for midwives! Cathy Warwickrespect, nothing has changed, as Cathy Warwick asserts in this month’s Viewpoint. But 6 NEWSchange is afoot with the promises made to Scotland in respect of the NHS – and a new 10 Nutrition in pregnancy: keeping in mind the prioritiesphase of midwives’ union activity, as members have taken the historic step of voting in a Michel Odent explains why pregnant women need brain selective nutrients, considers where these come fromballot – the first of its kind by the RCM. and what obstacles stand in the wayThe Practising Midwife this month has its own debate in the form of a presentation 14 Digestive health in pregnancy Charlotte Kenyon looks into some difficult conditions of pregnancy andof different perspectives on tongue-tie (by Rosemary Dodds and Debs Neiger) and its suggests how midwives can helpimpact on feeding, just one article of a number looking at the interplay of nutrition, 19 Magnesium: the relevance of research Rosemary Mander considers the evidence for magnesiumfeeding, pregnancy and the newborn: we have supplementation to relieve leg cramps in pregnancyarticles by Charlotte Kenyon (on digestive 23 Perspectives on tongue-tie Diagnoses of tongue-tie are not always sound and solutions are open to debate.health in pregnancy) and Michel Odent (on Rosemary Dodds and Deborah Neiger present two perspectivesnutrition in pregnancy) which offer advice to 26 DIARYwomen to keep their pregnancy as positive as 27 Brilliant breastfeeding! Sioned Hilton highlights threepossible and to enable optimum development areas of development in understanding from the 9th international lactation symposiumof the fetus. We also have Rosemary Mander 30 To ECV or not to ECV? The current evidence baseconsidering the qualities of magnesium and Laura Yeates, Managing Editor concerning external cephalic version In the second ofwhether supplementation can help women with our series on breech birth, Shawn Walker explains why turning a breech baby to be head down can helpleg cramps in pregnancy – or whether the 34 NEW! MIDWIFERY BASICS 1. The role andevidence shows this to be just a myth. responsibilities of a midwifery mentor Yvonne Jarvis and Joyce Marshall introduce the 14th series ofA very positive change for us is that we are delighted to welcome our new editor, Midwifery basics on MentorshipAnna Byrom BSc, PGCert, RM, Senior Midwifery Lecturer, University of Central Lancashire 39 THINKING OUTSIDE THE BOX Are emergency mnemonics help(err)ful? Sara Wickham looks at a [email protected]! about professionals’ knowledge of mnemonics and raises some questions for reflectionA note from the editor: 41 AROUND THE CONFERENCES Reflections fromIt is with great enthusiasm and excitement that I take up the Prague Dr Debbie Wisby reports from the ICM conference in Pragueposition of editor of the essential journal for all practising 42 COCHRANE CORNER Treatments for breastmidwives. My hopes are to use my midwifery experiences from Anna Byrom, engorgement during lactation Valerie Smith highlightspractice, education and research to create a vision for the journal Editor a review on treatments for breast engorgement duringthat reflects the needs of all midwives. I am looking forward to lactationsharing my expertise with you and celebrating, challenging and reviewing all aspects of 44 PROFESSIONAL DEVELOPMENTmidwifery practice. As we stand on the cusp of global shifts in midwifery, national 45 OVERSEAS OPPORTUNITIESpressures for maternity services and continued explosions of knowledge and information 46 LAST WORD Post caesarean section wound care Elaine Berry encourages midwives to ensure thatregarding childbearing, I'm thrilled to be in a position to reflect this in our journal. women receive the best care post-caesarean sectionI will end here, at my beginning, inviting you to stay passionate, informed andupdated - here's to our future and The Practising Midwife.Cover photo: Lea Paterson/Science Photo Library The Practising Midwife | October 2014 3

Editorial advisory board CONTACT: 020 8313 9617 [email protected] Caine BSc, Dip HE Midwifery, Joy James RGN, RM, ADM, Cert Correspondence: 66 Siward Road, Bromley BR2 9JZPGCert (HE and supervision of midwives), Counselling, Dip Counselling, PGCEM, RN,MSc, RM Midwife, Lecturer and PhD BA, MA Senior Lecturer, Midwifery, Editor: Anna Byromstudent, University of East Anglia and SoM University of Glamorgan [email protected] Crowther PhD, MSc, BSc (Hons.), Joyce Marshall PhD, MPH, BSc(Hons),RM, Managing Editor: Laura YeatesRM, Senior Lecturer (AUT University RN, FHEA, PGCAP Senior Lecturer in [email protected] NZ) and rural locum caseload Midwifery, University of Huddersfield (editorial/author submissions)midwife Rachel McKeon-Clark LLB(Hons) News Editor: Mandy GallowayDéirdre Daly MSc, PGDipEd, BSc (Hons), BSc(Hons) RM Nurse Advisor, NHS Direct [email protected], 020 8313 9617RM, DipMid, RGN Lecturer in Midwifery,Trinity College, Dublin Anne Marie Rennie MSc, RM, RGN, ADM, Advertising Manager: Margaret Floate BSc (Hons) Midwifery, PG Cert HELT [email protected], 01483 824094Ruth Deery PhD, BSc (Hons), ADM, RM, Lecturer in Midwifery, The Robert GordonFHEA Professor of Maternal Health, University Publisher: Ian Heslop [email protected] of the West of Scotland Mandy Renton RGN, RM, MSc Chief Facebook is a registeredJenny Fraser MSc, RN, RM, DPSM Nurse, Cambridgeshire Community trademark of Facebook, Inc.Independent Midwifery Consultant Services NHS Trust We are now on Twitter -Cathy Green MA, Bsc (Hons), BA (Hons), Verena Wallace MSc (HPPF), PGDip, MSc, follow us at @ThePractMidwifeDipHe, RM Midwife, Homebirth team, ADM, RM, RN Local Supervising AuthorityBirmingham Women’s Hospital Midwifery Officer for Northern Ireland © 2014 Medical Education Solutions Ltd. 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The views expressed in Viewpoint are those of the author and do not Cathy Warwicknecessarily reflect those of the editorial board of The Practising MidwifeViewpointFair pay for midwives!M idwives and maternity support prices since 2010, the typical midwife would working, and it is shameful that their reward workers (MSWs) are caring people. this year earn £4,000 more than they are for that superhuman effort is a metaphorical That’s what motivates them to do actually earning. That is enough to pay an slap in the face from their employers. I have nothe work they do. It's what motivates them to average household’s energy bills for three years. idea how they think midwives and MSWs arework long, often unpaid overtime, papering Crunch the numbers and you realise that it’s supposed to cope. Everything is getting moreover the cracks in our under-resourced, over £300 per month. This is a real loss of expensive, but pay just stands still, year afteroverstretched maternity services. earnings, and amounts to a deep cut in living year. No-one becomes a midwife or an MSW to I have no idea how they Ballotget rich, but that doesn’t mean they shouldn’t think midwives andbe fairly paid for the work they do. But fair pay I am typing these words as midwives andis not what midwives and MSWs are being MSWs are supposed to maternity support workers across England areoffered right now. Far from it. cope. Everything is still voting on whether or not to take industrial action in our pay dispute with NHS employers.Frozen again getting more expensive, But you are reading these words after all those but pay just stands still, votes have been cast and counted, and thePay was frozen in 2011, frozen again in 2012, result announced. So, you will know what I doand upped by 1 per cent in 2013. This year the year after year not, which is whether RCM members haveindependent NHS pay review body backed strike action and “action short of arecommended another 1 per cent rise for standards. Midwives and MSWs are being hit strike”.midwives, MSWs, nurses, paramedics, and very hard indeed.similar health professionals. This was rejected. Midwives worth their weight in goldWhat we have instead is a temporary 1 per Lack of appreciationcent pay rise for those at the top of their pay Either way, the fight for fair pay continues.scale, and no rise for anyone else. As the number of births in England has Employers are saying that midwives and MSWs skyrocketed, reaching its highest level since the are not worth a 1 per cent pay rise, despite all In two years’ time, in 2016, pay for NHS early 1970s, the pressure on those working in they do. You know and I know they are worthstaff will be back at the same level it was at in maternity services has been intense. For more their weight in gold. The Royal College of2013, which was only 1 per cent higher than it than a decade the NHS in England has been Midwives will continue to make the case thatwas in 2010. As bills go up and up and up, short of thousands of midwives. Maternity staff the recommendation of the independent NHScurrent plans are for pay to have risen by 1 per have had to work flat out to keep the service pay review body should be honoured, and the 1cent over the course of six years. Re-reading per cent pay rise for NHS staff implementedthat last sentence it seems almost unbelievable: without delay. tpmpay will have risen by just 1 per cent over thecourse of six years. That is scandalous. Cathy Warwick is chief executive of the Royal College of MidwivesCut in living standardsIf midwives’ pay had risen at the same rate as The Practising Midwife | October 2014 5

News analysisPublic ‘right behind’ midwivesover pay and industrial actionAs results of the ballot of are facing another pay freeze this year. The RCM is also expected to ballotmidwives over industrial action are Midwives cannot take another year of rising midwives in Wales after the devolvedabout to be announced, an household bills and frozen pay. A 1 per cent Government mirrored the “deeplyopinion poll shows overwhelming rise, as recommended by the independent pay disappointing” pay offer to staff employedpublic support for midwives’ pay review body, is affordable. It is the very least under Agenda for Change contracts indispute midwives deserve for all they do. England. There would be strong public backing for “This public backing fills me with hope for The Unite union has already balloted itsmidwives if the result of the ballot on our campaign and our ballot and I am sure it 6,000 members on the NHS pay deal in Wales,industrial action in their pay dispute with NHS will be welcomed by midwives. I do, however, which may include strike action in the autumnemployers is ‘Yes’, according to a poll want to reassure women and their families over the devolved Government’s “insufficient”commissioned by the Royal College of that they will continue to receive safe care offer, which it said was “intended to beMidwives (RCM). during any industrial action. The woman, her unilaterally imposed” in Wales and proposed baby and their safety are a midwife’s absolute cuts to terms and condition of employment. The opinion poll, conducted by pollsters priority and any action will not change that.”*ComRes, shows that almost two-thirds (63 per The Scottish Government agreed in Marchcent) of the British public would support The results of the opinion poll were to the 1 per cent across the board payindustrial action by midwives, provided that announced as the RCM began to ballot increase. Gillian Smith, director for Scotland atarrangements were made to ensure that any midwives in England on industrial action over the RCM, said at the time that this was apregnant woman in need of immediate care the rejection of the independent NHS Pay “sensible decision, and while it is only a modestduring the period of the industrial action Review Body (PRB) recommendation of a 1 per rise, the Scottish Government has honouredreceived care as usual. cent increase for all NHS staff. The ballot took the Pay Review Body’s recommendation, and place from 8th–29th September 2014, but that is to be welcomed. There is also overwhelming backing for a 1 although the result had not been announcedper cent increase to NHS staff pay, with four in as The Practising Midwife went to press, the “However, despite the increase we are stillfive (80 per cent) polled saying they would RCM had recommended that its members seeing the pay of midwives and other NHSsupport the pay rise. voted in favour of industrial action. staff in Scotland falling behind the cost of living. As the economy continues to recover we The public support for a pay increase has The Department of Health (DH) is calling on would hope that pay awards in the future willsignificant backing across the political midwives’ leaders to abandon the proposed reflect the real cost of living and allow NHSspectrum, and widespread support in every action and to “put patients first and return to staff pay to regain what has been lost over theregion of England and in every other UK the negotiating table. past few years,” Ms Smith said.country for both a pay rise and for industrialaction by midwives. “All staff should receive additional pay of at *ComRes interviewed 2,039 British adults least 1 per cent,” said a DH spokesperson. online between 29th and 31st August 2014. Cathy Warwick, chief executive of the RCM, Data were weighted to be representative of allsaid: “Midwives deciding whether to vote for “Paying staff a pay rise on top of their British adults aged 18+.industrial action [should be] reassured that increments, which are a minimum of 2 perthere is wide support for them across the cent for midwives, would risk frontline jobs.country, with the public backing industrial These are tough decisions but pay restraint hasaction. meant that we could afford 1,700 extra midwives since May 2010, as well as a further “Midwives’ pay was frozen in 2011 and 6,000 in training.”2012. After a 1 per cent rise last year, midwives6 The Practising Midwife | October 2014

News analysisNMC fee rise ill-timed and ill-judged say midwivesThe Nursing and Midwifery Council joining and remaining on the NMC register. proposed fee rise. As they see a real terms(NMC) is due to meet this month The RCM estimates that a midwife at the reduction in their earnings they are more[1st October] to decide whether or inclined than ever before to examine whethernot to impose an increase in the top of band 6 (the vast majority of those in the or not costs such as their registration fee areregistration fee in the face of fierce NHS) has had a real terms loss of income of value for money.opposition expressed during the £4,045 over the last four years; while the NMCconsultation period. is not responsible for a midwife’s earnings, this “They feel that they are paying for the past is another reason that the RCM feels a fee rise failures of the NMC and for a small number of The NMC wants to increase the fee to £120, is ill-timed and ill-judged. registrants who are coming before fitness to practise hearings. They want to see more worka hike of 20 per cent, and says the increase is For midwives who work the minimum coming out of the NMC which helps the hours in order to maintain their registration, majority of registrants who are doing their bestessential to perform its regulatory functions, the fee overall is an effective tax of £9.50 for to deliver high quality care to the public in each 12-hour shift worked. The RCM fears that difficult circumstances.”including maintaining the register, dealing with if midwives like these choose to stop practising they will be lost to the profession and the NMC If the registration fee increase goes ahead,fitness to practise cases and introducing will lose registration fees for future years. the NMC is looking into ways of enabling midwives to pay their registration fees inrevalidation. Cathy Warwick, chief executive of the RCM, instalments. said: “Our members are rightly angry at this The Royal College of Midwives (RCM) hasresponded to the consultation, saying theproposed fee rise is “ill-timed and ill-judged”,and would act as a disincentive to midwivesNew international standards provide reliablemeasures of fetal growthThe International Fetal and Researchers based their observations on more Janet Fyle, professional policy advisor at theNewborn Growth Consortium has than 20,000 women who met stringent Royal College of Midwives said the measures todeveloped and published inclusion criteria: most health and nutritional standardise the recording and reporting of fetalinternational standards to assess needs of the mothers were met; adequate growth were welcome. “They will provide afetal growth and newborn size for antenatal care was provided; and there were no consistent framework to compare newborn sizeuse in routine clinical practice. major environmental constraints on growth. In from 33 to 42 weeks gestation. These standards addition, the women were deemed to be at low will also help midwives to improve monitoring The Intergrowth-21st Project based the risk of impaired fetal growth and they had a pregnancies, especially in terms of identifyingstandards on sex-specific observed reliable ultrasound estimate of gestational age. fetal growth retardation early and recordingmeasurements for weight, length and head The authors claim the new international the movement of fetuses more accurately.”circumference for gestational age at birth. The standards are superior to local reference charts, Referencescharts, divided into centiles, correspond with of which there are a large number but which Villar J, Chiekh Ismail L, Victora CG et al.the World Health Organization child growth are inconsistent and, importantly, not sex- ‘International standards for newborn weight,charts, to enable midwives to compare the specific. This study showed that overall, boys length and head circumference by gestationalactual size of the fetus during pregnancy, and were heavier, longer and had larger head age and sex: the newborn cross-sectional studythe infant at birth against the standard, and circumferences than girls. of the Intergrowth-21st project’. The Lancet,for child growth to be monitored ‘seamlessly’ Commenting on the publication in The Lancet, 384(9946): 833-835.from early pregnancy to age five years. The Practising Midwife | October 2014 7

News highlightsLack of postnatal support is “false economy” says RCM Health reforms impact on patientFour out of 10 women are women in labour means that number of visits should be caredischarged from hospital after organisational needs are decided by the midwife ingiving birth before they feel preventing midwives giving care discussion with the woman. A survey of healthcareready to go home, according to a based on clinical need, and professionals and MPs has foundRoyal College of Midwives (RCM) women are not getting the best The RCM is calling for that for many NHS organisations,report. possible postnatal care. implementation of the NICE improving patient care came postnatal standards to ensure second to making efficiency The report, the latest in the \"We are seeing women being women get consistent and high savings.RCM’s Pressure Points postnatal discharged earlier without quality postnatal care and bettercare campaign, also says women adequate support. This leads to continuity of care. Only 5 per cent of healthcareare not getting the level of readmissions later on. This is a professionals who responded topostnatal care recommended by false economy. It is not good for Research by the RCM earlier the survey on the NHS reforms*the National Institute of Health women and babies and it is not this year found that two-thirds say they have improved patientand Care Excellence (NICE), good for the NHS.” (65 per cent) of midwives said care. Almost four in 10 (38 perincreasing the risk of readmission the number of postnatal visits cent) said that their impact hadand higher NHS costs. Among the report’s was determined by organisational been negative. recommendations to improve pressures and not the women’s RCM chief executive Cathy postnatal care are that there needs. This is completely contrary Only 2 per cent of respondentsWarwick said: “The continuing should be enough midwives to to the recommendations of NICE. said their organisation hadshortage of midwives, ensure all women receive the I To view a copy of the report adequate financial resources,particularly in postnatal care, and number of postnatal visits they visit www.rcm.org.uk/ according to the survey, by Dodsthe need to ensure cover for need, and that the appropriate pressurepoints. Parliamentary Communication.Better health and development in children of older mothers However, in some areas, efforts by Clinical CommissioningA new study has shown that • The risk of children having increasing in the UK. It has Groups are working well to drivechildren of older mothers have unintentional injuries requiring demonstrated that, while there are change and foster collaboration.better physical and emotional health medical attention or being many medical reasons why closethan those with younger mothers. admitted to hospital both declined attention should be given to the David Bowers, senior research with increasing maternal age physical well-being of older manager at Dods, said: “The survey Statistics from the Office for mothers and their infants, both shows a clear tension between theNational Statistics earlier this year • The number of infants who had during pregnancy and immediately need to make savings whileshowed that, in 2013, the average received all the standard after birth, an increase in older maintaining and improvingage of mothers was the highest immunisations by three years of motherhood should not necessarily standards of care. This is veryever, at 30 years. However, the age increased with maternal age be a cause for concern in relation much an issue [for] healthresults of the study by scientists at to subsequent parenting.” professionals whose commitmentBirkbeck, University of London and • Language development at ages to patient care remains steadfast.”University College London mean that three and four years was better for Barnes J et al (2014). ‘Theat a national level the increasing children with older mothers. Parenting of preschool children by *The Health Reforms - a checkage of mothers may lead to better older mothers in the United up: 3,628 NHS and otherchild health and development. Professor Jacqueline Barnes, Kingdom’. Eur Jour Developmental healthcare professionals were one of the study leaders, said: “This Psych, 11(4): 397-419. surveyed online between 11th- The study found: research was initiated in the 28th July 2014. knowledge that maternal age was8 The Practising Midwife | October 2014



Michel Odent explains Nutrition in pregnancy: keeping in mind the prioritieswhy pregnant women needbrain selective nutrients and SUMMARY: Since brain development is explosive during the second half of human fetalconsiders where these come life, the concept of ‘brain selective nutrients’ is a necessary point of departure to identifyfrom and what obstacles the basic nutritional needs of pregnant women. Two important brain selective nutrientsstand in the way are considered: iodine, essential in thyroid hormone production, and DHA, a very long chain polyunsaturated acid of the omega 3 family. Both of them are abundant in the seafood chain only. The particular case of pregnant women who do not have access to the seafood chain is considered. The focus is on the need to avoid blocking agents of the metabolic pathways of unsaturated fatty acids, particularly pure sugar, alcoholic beverages and trans fatty acids. Keywords Iodine, iodised salt, DHA, docosahaexenoic acid, polyunsaturated fatty acids, brain development, brain nutrients Author Michel Odent, surgeon, obstetrician, writer and expert on primal health During the second half I t may be counter-productive to advise presented as a member of the chimpanzee of pregnancy, the fetal pregnant women about nutrition. To be family with an enormous brain. During thebrain is developing at an happy and to live in peace, pregnant second half of pregnancy, the fetal brain is women need ideally to consume the kind of developing at an explosive speed. The specific explosive speed food they like. Their sense of taste has been nutritional needs of the developing brain conditioned by their cultural environment; have been recently clarified and are easily this includes what their mother ate when she summarised through the concept of ‘brain was pregnant and breastfeeding. These selective nutrients’. considerations are particularly relevant in cosmopolitan modern cities. Iodine Iodine is a typical ‘brain selective nutrient’ Brain selective nutrients because of its essential role in thyroid hormone production which, in turn, is needed However it is useful to constantly keep in for normal brain development. It is mind the specific nutritional needs of Homo significant that iodine is the only nutrient for sapiens during the early phases of which governments legislate development. Homo sapiens may be10 The Practising Midwife | October 2014

Nutrition in pregnancysupplementation, so that thyroid enlargement. Iodised salt al 1996). There was one highly concentrations of polyunsaturatediodination of table salt is became recently still more topical significant effect: the mean fatty acids in maternal blood.mandatory. In spite of such since it was revealed that the salt neonatal head circumference was However, whatever thewidespread legislations, iodine used for producing the brine for greater in the study group (34.65 circumstances, the levels of DHAdeficiency is the most common pickling food – and cm vs. 34.45 cm. 95 per cent CI remain stable (Wang et al 1991).nutritional deficiency at a commercialised ‘sea salt’ as well - 0.01-0.39). There was no The price of a stable DHA is anplanetary level. It is the leading have no iodine added. eclampsia and no recorded pre- imbalance inside the omega 3cause of preventable intellectual eclamptic toxaemia in the study family that is at the root of adisabilities. The inability to Fatty acids group; in the control group there series of further imbalances. Theseconserve iodine is a meaningful The brain, as a fatty organ, also was one eclampsia with facts suggest that when aaspect of human nature: in has specific needs in terms of convulsions and two severe pre- pregnant human mother hassituations of iodine deficiency, fatty acids, particularly long chain eclamptic toxaemia. Our Whipps difficulties in satisfying theurinary excretion of iodine polyunsaturated fatty acids. More Cross study was replicated and specific nutritional needs of thecontinues as usual (Cunnane precisely one molecule of fatty enlarged at Wolverhampton New fetal developing brain, a cascade2005). This inability suggests an acid represents 50 per cent of the Cross Hospital (Meeson 2007). of physiological imbalances isadaptation to diets rich in iodine - fatty acids that incorporate into Again the most significant induced.in practice, diets including the developing brain: this is the difference was related to headseafood. The needs are increased so-called DHA (docosahaexenoic circumference at birth. The need for seafood >>during pregnancy and lactation. acid), a molecule of fatty acid as After recalling that iodine isThe reinforced vulnerability to long as possible (22 carbons) and It is highly significant that the mostly provided by seafood andiodine deficiencies during as unsaturated as possible (six human pregnancy disease pre- that DHA is preformed andpregnancy makes it significant double bonds), which belongs to eclampsia is associated with lowthat the human disease pre- the omega 3 family. It iseclampsia is characterised by preformed in seafood.impaired thyroid functions. Ingeneral the level of free thyroxine I had wondered in the past if(T4) is low in pre-eclampsia, while discussing these issues withthe level of thyroid-stimulating pregnant women might havehormone (TSH) is high. The detectable effects in the perinatalalterations of the levels of thyroid period. In 1991, I started a studyhormones reflect the severity of in a London hospital (Whippsthe disease (Lao et al 1990). Cross), the objective of which wasFurthermore pre-eclampsia is to evaluate the possible effects ofassociated with fetal and neonatal simply encouraging pregnant women to consume fish (Odent et The human pregnancy diseasepre-eclampsia is associated with low concentrations of polyunsaturated fatty acids in maternal blood The Practising Midwife | October 2014 11

Nutrition in pregnancyabundant in seafood only, we can conclude Blocking agents learning that our health is to a great extentthat having access to the seafood chain during The important point, in practice, is to avoid the shaped during the ‘primal period’. We are alsopregnancy appears as a guarantee that the blocking agents (‘anticatalysts’) of the in the age of food industry and pollution byspecific nutritional needs of the developing metabolic pathways of polyunsaturated fatty man-made molecules and heavy metals. Manyfetal brain are met (Odent 2013). acids. It is worth talking about these perspectives can help to reintroduce and substances with all pregnant women, whatever deepen these topics. Let us take this opportunity to emphasise their cultural background. The main blockingthat, from a physiological perspective, Homo agents to mention are pure sugars (such as soft Understanding human priorities is a firstsapiens has all the characteristics of an ape drinks), all alcoholic beverages and also trans step.adapted to the coast. The daily needs in iodine fatty acids. Most molecules of trans fatty acidsare highly significant. Another characteristic is originate from the effects of oil processing and Meanwhile, when talking with pregnanteasily expressed with the language of conventional methods of making margarines. women, midwives must adapt to everybiochemists. It is once more about the specific They may be abundant in biscuits, cookies, particular case and avoid giving precisenutritional needs of the brain, particularly the certain cakes and so on. recommendations. tpmdeveloping brain. In simple terms, we can saythat the human body is not very effective at Harmful oxidative processes Michel Odent is a surgeon, obstetrician, writermaking a molecule of fatty acid which is We must add that very long chain molecules of and an expert on primal healthessential to feed the brain and that this polyunsaturated fatty acids – particularly DHAmolecule is preformed and abundant in the sea – are fragile and easily destroyed by oxidative Referencesfood chain only. Let us translate into the processes. This is one way to explain thelanguage of biochemists: one of the most importance of anti-oxidative substances: it Carlson SE, Rhodes PG, Rao VS et al (1987). ‘Effect ofsignificant characteristics of Homo sapiens is implies in practice, daily consumption of fruits fish oil supplementation on the n-3 fatty acid contentthe association of an enormous highly- and vegetables. This is also one way to explain of red blood cell membranes in preterm infants’.developed brain with a weak delta 4 enzymatic how cautious health professionals should be Pediatr Res, 21(5): 507-510.system of desaturation (Carlson et al 1987). before prescribing iron, which is a powerful Cunnane SC (2005). ‘Iodine: the primary brain selectiveThis fact suggests that Homo sapiens is oxidative substance. nutrient’. In: Cunnane S (ed). Survival of the fattest,adapted to an environment providing Singapore: World Scientific Publishing Company.preformed DHA. Nutrition in pregnancy and breastfeeding Lao TT, Chin RK, Swaminathan R et al (1990). ‘Maternal are vital questions at a time when we are thyroid hormones and outcome of pre-eclampticObstacles pregnancies’. Brit Jour Obs Gyn, 97(1): 71-74. This is facilitated by Meeson LF (2007). The effects on birth outcomes ofLack of seafood catalysts such as discussions in early pregnancy, emphasising theThese considerations about the specific importance of eating fish, PhD thesis. Wolverhampton:nutritional needs of the developing brain magnesium, calcium or University of Wolverhampton.inspire questions about the many pregnant zinc found in particular Odent M (2011). ‘Obstetrical implications of thewomen who never consume seafood. The land in vegetables, fruit and aquatic ape hypothesis’. In: Vaneechoutte M, Kuliukasfood chain, in practice, can only provide the A and Verhaegen M (eds). Was man more aquatic inparent molecule of the omega 3 family, with dairy products, for the past? eBook. Sharjah: Bentham Science.18 carbons and three double bonds (alpha example Odent M, McMillan L and Kimmel T (1996). ‘Prenatallinolenic acid). This implies that the enzymatic care and sea fish’. Eur Jour Obs Gyn, 68: 49-51.system of the mother must ‘desaturate’ and Wang Y, Kay HH and Killam AP (1991). ‘Decreased‘elongate’ the molecule. This is facilitated by levels of polyunsaturated fatty acids in pre-eclampsia’.catalysts such as magnesium, calcium or zinc Am Jour Obs Gyn, 164: 812-818.found in particular in vegetables, fruit anddairy products, for example.12 The Practising Midwife | October 2014



Charlotte Kenyon Digestive health in pregnancylooks into some SUMMARY: Women experience the physiological changes of pregnancy in a variety ofdifficult conditions of ways. Changes in pregnancy are associated with changing hormone levels. Thesepregnancy and hormonal changes have an impact on all body systems. Midwives need to have ansuggests how understanding of the changes so that they can enable women to manage their digestivemidwives can advise health effectively. The midwife needs to be vigilant in history taking to understand thewomen to help woman’s experiences and to be able to offer appropriate support and advice. There are aalleviate the symptoms number of conventional and alternative treatments that can help to prevent and alleviate symptoms. This article will consider the impact on the gastro-intestinal system and how changes can be managed. Keywords Pregnancy adaptation, hormones, digestion, comfort measures Author Charlotte Kenyon, senior lecturer in midwifery and supervisor of midwives at the University of Huddersfield Midwives need an Introduction Nausea and vomiting understanding of the changes that occur in During pregnancy, a number of physiological Nausea and vomiting (NV) affects between 50- adaptations associated with hormonal changes 90 per cent of pregnancies (Jarvis and Nelson- order to plan and occur and women experience physical changes Piercey 2011). It most commonly presents provide appropriate, as a result. Some women will be largely between weeks four and 16 of pregnancy.effective care and detect untroubled by them and may even embrace Although commonly referred to as ‘morning any abnormalities them as a positive sign that the pregnancy is sickness’, women can experience NV at any progressing well; however, for other women time of day (Locock and Alexander 2008). they can have a profound physical and Whilst it is multi-factoral, the most commonly psychological impact which affects their cited cause of NV in pregnancy is hormonal experience of pregnancy. This article focuses on influence. Human chorionic gonadotrophin changes to the gastro-intestinal system and (HCG) is found in large amounts during the first maintaining digestive health during pregnancy. trimester of pregnancy until the placenta takes Midwives need an understanding of the on its full function and levels fall. Increasing changes that occur in order to plan and provide levels of oestrogen and progesterone after this appropriate, effective care and detect any time are responsible for NV between 12 and 16 abnormalities. To enable women to manage weeks (Coad and Dunstall 2005). Women with digestive health in pregnancy, midwives must severe cases of vomiting which lead to be vigilant and undertake thorough history- dehydration and/or weight loss (hyperemesis taking to understand the woman’s experiences gravidarum) should be referred to the and rule out abnormalities. appropriate professional for further specialised14 The Practising Midwife | October 2014

Digestive health in pregnancy Figure 1 Location of Pericardium 6 Photo copyright: C Kenyon Despite the ‘normality’ The point used for alleviation of of the condition, women nausea is three of the woman’s own good quantity of sleep and relaxation to avoid fingerbreadths above the junction of stress or fatigue. This will be helpful due to can be profoundly the hand and wrist. Women should renewed physical and emotional energy to affected by the measure these themselves. At this manage their condition, and through reduction point a small indentation can be felt in stress hormones, which also have a negative experience of NV and between the two wrist tendons. It is impact (Jarvis and Nelson-Piercey 2011; Locock should therefore be often more tender to the touch. and Alexander 2008; Tiran 2004). offered advice and Pressure should be applied at this support in managing it point. Complementary/Alternative management Safety of pregnant women is paramount and it women who are prescribed pharmaceuticalmulti-disciplinary input. It is also important to is essential that midwives only give advice that anti-coagulants (Tiran 2004; 2012). Caution isremember that acute appendicitis can cause NV. they have been appropriately trained to give needed, whichever remedy women choose. For and that where needed, they refer women to greatest effect, either fresh ginger orConventional management an appropriate practitioner (Nursing and peppermint should be taken as an infusion andIt is important to recognise that, despite the Midwifery Council (NMC) 2012). There are a taken throughout the day to ease symptoms.‘normality’ of the condition, women can be number of complementary approaches which Sugary ginger or peppermint alternativesprofoundly affected by the experience of NV are useful for women with NV, including should be avoided.and should therefore be offered advice and acupuncture, homeopathy, chiropractic,support in managing it. Many women develop osteopathy and medical herbalism. There are Another popular alternative treatment isself-help methods before they see a midwife also some methods in common use, of which the use of ‘sea bands’. These are commonly(Locock and Alexander 2008; Tiran 2004). For midwives need understanding. For example, available for use in the case of travel sicknessexample, most women will find that avoiding the use of ginger as a method of managing NV (Steele et al 2001). Also from Chinese medicine,strong smelling, spicy foods and eating a diet comes from traditional Chinese medicine. It sea bands stimulate an acupressure pointwith a large quantity of fresh produce helps. will not be effective for all women and may associated with alleviation of nausea (seeMany women will be concerned, and may even exacerbate symptoms in some (Tiran 2012). For Figure 1). Accurate positioning is essential forcontribute to their condition, about adequate these women, the ‘cooling’ effect of efficacy (Gurkan and Arslan 2008). For suddennourishment of the fetus. Midwives should peppermint is a better alternative. It is also waves of nausea, 10-15 short intermittentreassure women and discuss the causes of NV important to note that ginger has an anti- presses on the point may help alleviatewith them. Increased understanding can, of coagulant effect and should be avoided in symptoms, but women should be advised thatitself, provide comfort. excessive stimulation can exacerbate nausea. Nausea and vomiting may be exacerbated Heartburnby low blood sugar. Women should be advisedto take regular, small meals to prevent Altered hormone levels of progesterone later inhypoglycaemia. Taking a small carbohydrate pregnancy have a further impact on thebased snack before bed and before rising in the digestive system. Progesterone is an essential >>morning is commonly advised and may help toease symptoms and help the woman tomanage her condition. More important inrelation to sleep routine is that women get a The Practising Midwife | October 2014 15





Digestive health in pregnancyhormone in maintaining pregnancy, but has a Prather 2004; Jewell and Young 2001). Meat through appropriate care planning and advice.relaxing effect on smooth muscle, including and dairy produce are known to be Women will often find their own self-helpthe gastro-intestinal sphincters and the gut constipating as are refined wheat and grains. methods, but midwives need to have anitself. Relaxation of the cardiac sphincter Whole grains such as rice and oats absorb awareness of both the changes and theirallows reflux of gastric contents and causes water in the gut, natural foods stay soft within management in order to enable women toheartburn. This is worse in the last trimester of the gut due to fibre content which absorbs maximise their health during pregnancy. tpmpregnancy due to raised intragastric pressure water and expands, therefore reducing theassociated with the growing uterus (Coad and impact of slowed peristalsis. Warm drinks may Charlotte Kenyon is senior lecturer in midwiferyDunstall 2005). Regular, small meals may stimulate the activity of the gut and an and supervisor of midwives at the University ofafford some relief and women should be increase in fluid intake to approximately two Huddersfieldadvised to avoid positions which reduce space litres per day is recommended. Regular gentlefor the stomach, such as frequent bending exercise such as walking helps maintain good Referencesover. Persistent heartburn can be treated with abdominal tone and aids peristalsis (Holfordantacids, but long-term use should be avoided 2009). Cautious use of pharmaceutical Coad J and Dunstall M (2005). Anatomy and physiologydue to their calcium leaching effect. Some preparations is needed. Where aperients are for midwives, Edingburgh: Elsevier.women may find relief from alternative needed, bulk-increasing agents should be used Gurkan OC and Arslan H (2008). ‘Effect of acupressuretherapies such as homeopathy and and it should be noted that some preparations on nausea and vomiting during pregnancy’. Compacupuncture. are contra-indicated in pregnancy (Jewell and Therapies in Clin Pract, 1(1): 46-52. Young 2001). Massage or reflex zone therapies Holford P (2009). The optimum nutrition bible, Kent:Constipation may also help women to manage their Platkus. constipation. Jarvis S and Nelson-Piercey C (2011). ‘Management ofThe relaxant effect of progesterone and nausea and vomiting in pregnancy’. Brit Med Jour, 342:reduction in other hormones leads to reduced Conclusion d3606.gastric tone and peristalsis and therefore slows Jewell D and Young G (2001). ‘Interventions for treatinggastric emptying. Slower passage of food Physiological changes in pregnancy affect constipation in pregnancy’. Coch Database Syst Rev, 2:through the gut means an increased quantity women in a variety of ways. Common CD001142. DOI: 10.1002/14651858.of fluid is absorbed in the colon (Coad and discomforts can be prevented and managed Locock L and Alexander J (2008). ‘Women’s responses toDunstall 2005; Prather 2004). This effect is nausea and vomiting in pregnancy’. Midwif, 24(2):further increased by raised levels of Midwives need to have 143-152.aldosterone and angiotensin. Physical an awareness of both NMC (2012). Midwives’ rules and standards, London:obstruction of the growing uterus causes the changes and their NMC.further mechanical obstruction (Coad and management in order to Prather CM (2004). ‘Pregnancy-related constipation’.Dunstall 2005). Oral iron supplements can Current Gastroenterology Reports, 6(5): 402-404.compound constipation and constipation in enable women to Steele NM, French J, Gatherer-Boyles J et al (2001).conjunction with increased pressure in the maximise their health ‘Effect of acupressure by sea-bands on nausea andveins below the enlarged uterus may vomiting of pregnancy’. Jour Obs, Gyn and Neonatexacerbate haemorrhoids. during pregnancy Nurs, 30(1): 61–70. Tiran D (2004). Nausea and vomiting in pregnancy: an Management of constipation in pregnancy integrated approach, London: Churchill Livingstone.is broadly similar to management within the Tiran D (2012). ‘Ginger to reduce nausea and vomitingnon-pregnant population. Dietary change and during pregnancy: evidence of effectiveness is not theregular exercise are advised for prevention and same as proof of safety’. Comp Therapies in Clin Pract,management. Reduction in meat and dairy 18(1): 22-25.intake and an increase in fresh produce andfibre intake will ease symptoms (Holford 2009;18 The Practising Midwife | October 2014

Rosemary Mander Magnesium: the relevance of researchconsiders theevidence for SUMMARY: The recent flurry of apparently conflicting research findings is likely to havemagnesium left practitioners, if not at a loss, at least bemused about this topic. How best should thesupplementation to midwife advise the childbearing woman on the subject of magnesium supplementationrelieve leg cramps in during pregnancy? It is possible that the recent welter of words may not have been ofpregnancy – and very much help to any of those who read them. In this paper I suggest that theconcludes that researchers may actually be missing the point as far as providing useful and usable dataresearchers should is concerned.listen to the voices of Keywords Research, magnesium, leg cramps, women’s voiceschildbearing women Author Rosemary Mander, Emeritus professor of midwifery at the University ofin setting the Edinburghresearch agenda Magnesium reduced risk of fetal growth retardation and Magnesium is a mineral which is important in pre-eclampsia (Conradt et al 1984). Alerted to the body because of its crucial role in the regulation of body temperature, the synthesis the possibilities of this observation, there of nucleic acid and proteins and the maintenance of electrical potentials between followed a cross-sectional study which nerve endings and muscle cells. The majority of women consume a diet with an adequate intake indicated that a greater intake of magnesium of magnesium in the form of dark green leafy Magnesium vegetables, legumes, nuts, seeds and unrefined was actually linked to an increase in birth supplementation was grains. During pregnancy, though, fetal demandassociated with a lower may render the usual intake insufficient, weight (Doyle et al 1989). These preliminary frequency of preterm especially if the childbearing woman is from abirth, low birth weight more disadvantaged background. findings constituted the opening salvos in the and babies who were small-for-gestational The research battle to find out whether magnesium age The flurry of interest which I have mentioned supplementation really does provide the answers originated with a retrospective records-based observation that magnesium supplementation to these fundamentally important challenges to during pregnancy was associated with a maternal, fetal and neonatal health. The Cochrane Database, widely regarded as the fount of all usable evidence-based knowledge, is of limited help in this matter; this is because of the variation in the findings which its systematic reviews report. Of particular interest are the publications of Maria Makrides and her colleagues, focusing on the benefits or otherwise of magnesium >> The Practising Midwife | October 2014 19

Magnesium supplementationsupplementation in pregnancy. This team’s (Ayres and Mihan 1969). Although regarded by abnormal postureoriginal 1998 systematic review was amended some as a minor disorder, the pain of these 3. the cramp may be relieved by stretching orand replaced by another review in 2001 episodes appears to be unusual in terms of(Makrides and Crowther 1998; 2001). The both its unpredictability and its severity. massage (Parisi et al 2003: 176).updated review indicated that magnesium Whereas most other painful conditions havesupplementation was associated with a lower attracted the attention of, if not researchers, at The seriously unpleasant nature of cramps isfrequency of preterm birth, low birth weight least clinicians, cramps are unusual in the better conveyed by Kunyan Zhou andand babies who were small-for-gestational age number of remedies which have been proposed colleagues, who recount the ‘sudden, intense,when compared with a placebo. It quickly on the basis of minimal knowledge (Young and painful and involuntary contractions of the legbecame apparent that, with such crucial Jewell 2004). These proposed remedies indicate muscles’ (Zhou et al 2013). While cramps arematernity problems in the ring, the stakes were the supposed pathological aetiology of leg ordinarily assumed to be nocturnal (Man-Son-being raised. cramps in pregnancy. An authoritative study of Hing and Wells 1995), this is not invariably the muscular cramps, though, concluded that ‘the case, as they do tend to occur at different An even more recent systematic review by causes and mechanisms are not clear’ (Parisi et times during labour and the early postnatalMakrides et al (2014) comes up with only al 2003: 178). period. The incidence of cramps increases asdisappointingly equivocal findings. Of the 10 the woman’s pregnancy progresses into thetrials which these researchers reviewed, only Nature of cramps third trimester, when cramps affect betweentwo were judged to be of sufficiently high The nature of leg cramps may be considered to 30-50 per cent of pregnant women, and thosequality to be included. The three main be too familiar to justify being described. Such affected are likely to experience them aboutoutcomes used in these two reasonable-quality a description, though, is necessary to twice per week (Sohrabvand and Karimi 2009).studies - perinatal mortality, small-for-dates differentiate these ‘paraphysiological cramps’and pre-eclampsia - indicate a lack of (Parisi et al 2003: 178) from those which are Cause of crampssignificant differences between the idiopathic or even pathological in origin. These Uncertainty about the cause of cramps is theintervention and the control groups. Thus, researchers define cramps in terms of: reason for the plethora of remedies. Thecontrary to the previous optimistic tones, the 1. the muscles affected are usually those of aetiology has been attributed toconclusion which was reached took the form excessive/insufficient exercise, metabolicof the old chestnut ‘more research is needed’. the foot and/or calf changes or vitamin E or D deficiency (Zhou et 2. the cramp is associated with a tense al 2013). Cramps may also be caused by lower In view of the uncertain significance of the motor neurones with hyperactive, high-outcomes mentioned already, it is necessary for contraction of the muscle, local pain and frequency, involuntary nerve spontaneousus to question the wisdom of funding agencies discharge (Allen and Kirby 2012). The imbalancepouring seriously scarce research funds into Contrary to the previous or deficiency of electrolytes (including calciumthe magnesium supplementation issue. Is it optimistic tones, the and sodium) has been blamed. Morereally necessary for such copious resources, in conclusion which was significantly in the present context, lack ofterms of staff, time, effort and cash, to be magnesium or hypomagnesaemia has also beenspent, or more likely wasted, when there are reached took the form of held responsible.other related areas greatly, not to say urgently, the old chestnut ‘morein need of answers? Treatment of cramps research is needed’ Obviously the treatment, if any, of cramp willA not-unrelated problem vary according to assumptions about the causative agent. Treatment options duringA topic which is thought to be closely related pregnancy will be restricted by considerationsto the magnesium problem is one of which of fetal welfare. For this reason the oft-many childbearing women are all too well- recommended quinine is not suitable and theaware. This is leg cramps, which I will refer toas ‘cramps’, sometimes known as ‘systremma’20 The Practising Midwife | October 2014

Magnesium supplementationsafety of L-carnitine during pregnancy has yet I next found the longstanding and familiar childbearing woman. The lack of relevantto be established. While leg-stretching review by Young and Jewell (2002) focusing on research cannot be justified on the groundsexercises have been shown to be of limited a range of medications to treat leg cramps that neither the woman’s nor the baby’s life orvalue, supplementation with magnesium during pregnancy. Their review is largely health is threatened. Neither is it appropriatebefore retiring to bed seems to be more helpful equivocal, concluding that the administration to argue that the experience of cramps is, bythan other interventions (Dahle et al 1995). of sodium (as recommended) may actually be virtue of being a characteristic of pregnancy,The research evidence, however, still remains iatrogenic and the faint praise for magnesium time-limited.far from strong. is that it is unlikely to cause harm (Young and Jewell 2002). It is possible that this admirable The impact of crampsResearch on leg cramps understatement by Young and Jewell will be The significance of nocturnal cramps wasPerhaps because cramps are not life- superseded by the forthcoming review by Zhou brought home to me by the male partner of athreatening and are time limited, the research et al (2013). In the meantime Cochrane leaves client who, in her middle trimester, was aevidence-base is not well developed. For this us to conclude that evidence is lacking to sufferer. Although she, like so many women,reason, I consulted first the Cochrane Database support any interventions to remedy the was reluctant to complain, he articulated allwhere the most authoritative and strongest excruciating leg cramps endured by the too clearly her difficulty in functioning in herevidence is supposed to be reported and childbearing woman. It remains to be seen demanding job due to a frequently-interruptedcritically and systematically reviewed. Here I whether the encouraging findings from the sleep pattern. He was also becomingfound the systematic review by Scott Garrison double-blind, randomised, placebo-controlled exasperated at having his own sleep disturbedet al (2012). These researchers aimed to review trial of oral magnesium by Supakatisant and on a regular basis by her leaping out of bed,the evidence for magnesium supplementation Phupong (2012) reach Cochrane’s exacting loudly verbalising her sudden and extreme legamong those of any age suffering from standards. pain. I was unable to offer any research-basedconditions featuring any form of skeletal remedy, having to resort to offering sympathy.muscle cramps. Garrison et al identified the Discussion – an outstanding questionpaucity of research as well as the poor quality The woman’s voice is disconcertinglyand inconclusive findings of the research that The question which is in urgent need of an lacking in the research on leg cramps. Ahad been undertaken. The reviewers highlight answer is whether cramps matter and, if so, Norwegian study with limited availabilitythe situation regarding the administration of why? In order to find the answers it will be identified the high frequency of cramps andmagnesium to treat cramps in pregnancy, necessary to listen to the experiences of the their pattern of occurrence (Valbø and Bøhmerdrawing attention to the small numbers of 1999). On the basis of their findings, thesesubjects and the inconsistency of the findings. The practitioner is left researchers concluded “leg cramps are still a with disturbingly limited common symptom in pregnancy and may Potentially relevant to childbearing women options when it comes compromize sleep and hence the ability tois the review by Fiona Blyton and her work” (Valbø and Bøhmer 1999: 1589). Thus,colleagues examining ‘non-drug’ interventions to the repertoire of the implications of cramps for the woman, herto treat leg muscle cramps (Blyton et al 2012). treatments available lifestyle and her family started to emerge.These researchers identified only one trial which are demonstrablywhich they considered eligible for inclusion. In the USA research into the effect ofPerhaps surprisingly, the eligible trial focused effective cramps on the childbearing woman’s sleep hason the administration of quinine. This resulted in a small number of publicationsmedication, whose side effects include (Hensley 2009; Mindell and Jacobsen 2000).teratogenesis, was used by a population ofpeople aged over 60, for whom it was found to What can be done?cause no significant improvement in Jennifer Hensley considers that offering thesymptoms. childbearing woman magnesium supplementation is the best treatment, while The Practising Midwife | October 2014 21

Magnesium supplementationshe acknowledges the weakness of the research limited options when it comes to the repertoire 10.1002/14651858.CD009402.pub2.evidence (Hensley 2009: 213). She goes on to of treatments available which are Hensley JG (2009). ‘Leg cramps and restless legssuggest that, after suitable trials, L-carnitine demonstrably effective. Research on the syndrome during pregnancy’. Jour Midwif Wom Health,may eventually prove helpful. woman’s experience of cramps remains 54(3): 211–221. seriously deficient. I would argue that the Lee KA and Gay CL (2004). ‘Sleep in late pregnancy Also writing in the USA, Mindell and research agenda needs to be reconsidered so predicts length of labor and type of delivery’. Am JourJacobson (2000) consider cramps only as a that it shows a greater responsiveness to the Obs Gyn, 191(6): 2041–2046.form of sleep disturbance, with no attention to immediate concerns of the childbearing Makrides M, Crosby DD, Bain E et al (2014). ‘Magnesiumthe underlying aetiology or the treatment or woman. supplementation in pregnancy’. Coch Data Syst Rev, 4:implications. These researchers, though, seem CD000937. DOI: 10.1002/14651858.CD000937.pub2.to regard personal accounts as too subjective The care of the woman (or perhaps her Makrides M and Crowther CA (1998). ‘Magnesiumto be of value, but then continue by justifying partner) complaining of leg cramps still supplementation in pregnancy’. Coch Data Syst Rev, 2:the use of such reports in research into sleep appears to come down to the meagre DOI: 10.1002/14651858.CD000937.disturbance (Mindell and Jacobson 2000: 596). recommendation by Jennifer Hensley that: Makrides M and Crowther CA (2001). ‘Magnesium supplementation in pregnancy’. Coch Data Syst Rev 4: As well as the effects on the partner, drawn “Listening to the concerns of the woman is DOI: 10.1002/14651858.CD000937.to my attention by a sleep-deprived husband, therapeutic in itself and should not be Man-Son-Hing M and Wells G (1995). ‘Meta-analysis ofand the Norwegian assertion of effects on the underestimated” (Hensley 2009: 217). tpm efficacy of quinine for treatment of nocturnal legwoman’s working life, a potentially even more cramps in elderly people’. Brit Med Jour, 310(6971): 13-17.sinister implication of disturbed sleep has been Rosemary Mander is Emeritus professor of Mindell JA and Jacobson BJ (2000). ‘Sleep disturbancesbrought to light. Lee and Gay in San Francisco midwifery at the University of Edinburgh during pregnancy’. Jour Obs, Gyn Neonat Nurs, 29(6):collected both physiological data and personal 590–597.sleep reports from 131 pregnant women in References Parisi L, Pierelli F, Amabile G et al (2003). ‘Musculartheir third trimester (Lee and Gay 2004). These cramps: proposals for a new classification’. Actaresearchers found that women who Allen RE and Kirby KA (2012). ‘Nocturnal leg cramps’. Neurologica Scandinavica, 107(3): 176-186.experienced more disturbed sleep were at Am Family Physician, 84(4): 30-35. Sohrabvand F and Karimi M (2009). ‘Frequency andincreased risk of longer labours and birth by Ayres S and Mihan R (1969). ‘Leg cramps (systremma) predisposing factors of leg cramps in pregnancy: acaesarean. On the basis of their findings these and restless legs syndrome response to Vitamin E prospective clinical trial’. Tehran Univ Med Jour, 67(9):authors are only able to advise life style (Tocopherol)’. California Med, 111(2): 87–91. 661-664.modifications. Thus, these worrying outcomes Blyton F, Chuter V, Walter KEL et al (2012). ‘Non-drug Supakatisant C and Phupong V (2012). ‘Oral magnesiumappear to be regarded with limited concern. therapies for lower limb muscle cramps’. Coch Data for relief in pregnancy-induced leg cramps: a Syst Rev, 1: CD008496. DOI: randomised controlled trial’. Mat Child Nutr, DOI:Conclusion 10.1002/14651858.CD008496.pub2. 10.1111/j.1740-8709.2012.00440. Conradt A, Weidinger H and Algayer (1984). ‘On the role Valbø A and Bøhmer T (1999). ‘Leg cramps in pregnancyThis brief overview of the links between of magnesium in fetal hypotrophy, pregnancy induced - how common are they?’ Tidsskrift for den Norskemagnesium, leg cramps and their perturbing hypertension and pre-eclampsia’. Magnes Bulletin, laegeforening: tidsskrift for praktisk medicin, nyeffects and associations has highlighted the 6(2): 68-76. raekke, 119(11): 1589-1590.possibility of personal and family disruption Dahle LO, Berg G, Hammar M et al (1995). ‘The effect of Young GL and Jewell D (2004). ‘Interventions for legresulting from cramps. The woman’s working oral magnesium substitution on pregnancy-induced cramps in pregnancy (Cochrane Review)’. The Cochranelife may also be affected, as may her labour leg cramps’. Am Jour Obs Gyn, 173(1): 175-180. Library 2, Chichester: John Wiley and Sons Ltd.and the mode of birth of her baby. In spite of Doyle W, Crawford MA, Wynn AH et al (1989). ‘Maternal Zhou K, Xu L, Li W et al (2013). ‘Interventions for legthese outcomes being unpleasant and magnesium intake and pregnancy outcome’. Magnes cramps in pregnancy (Protocol)’. Coch Data Syst Rev, 7:conceivably carrying health risks for the Res, 2(3): 205-210. CD010655. DOI: 10.1002/14651858.CD010655.woman and her baby, research attention to the Garrison SR, Allan GM, Sekhon RK et al (2012).problem of leg cramps remains paltry. ‘Magnesium for skeletal muscle cramps’. Coch Data Syst Rev, 9: CD009402. DOI: The practitioner is left with disturbingly22 The Practising Midwife | October 2014

Tongue-tie can cause Perspectives on tongue-tieproblems for both babies SUMMARY: In light of the recent NCT petition to Health Minister Dr Dan Poulter MP to update guidelines for the diagnosis and treatment of tongue-tied babies to avoid stressand their mothers – but and difficulties feeding for babies and their families, discussion has been sparked amongst mothers, midwives, health visitors and breastfeeding counsellors as to howthe diagnoses are not exactly services could be improved. Access to evidence-based, family-centred care is vital to address this potentially distressing condition. But are we too quick to jump inalways sound and the with a diagnosis that may ultimately be of no clinical significance? This article presents two professional perspectives on the issue and highlights thesolutions, open to pertinent research available. Keywords Ankyloglossia, tongue-tie, breastfeeding, frenotomydebate. Rosemary Authors Rosemary Dodds, senior policy adviser at NCT and Deborah Neiger, independentDodds and Deborah midwife in YorkshireNeiger present twoperspectives T ongue-tie - or ankyloglossia - is a lead to feelings of failure and high levels of condition where the membrane under the tongue (frenulum) is unusually thick, emotional distress (Amir et al 1996) and are the tight or short. It occurs in 2.8-10.7 per cent of all infants, partly due to differences in main reasons why mothers stop breastfeeding definition (Edmunds et al 2011). The impact of ankyloglossia varies between mother-baby in the first few weeks (McAndrew et al 2012). dyads, and function is more important than appearance in terms of assessment. More than Ankyloglossia problems certainly seem to be half of newborns with tongue-tie have no problems with breastfeeding and a smaller on the rise, with boys being affected more proportion with bottle feeding (Emond et al 2014; Hogan et al 2005). frequently than girls (Edmunds et al 2011),The lack of an accepted Problems arising from ankyloglossia include pointing towards a genetic cause; some classification of painful, bleeding nipples, frequent feeding with slow weight gain, and even hypernatraemic speculate it might be a midline defect caused ankyloglossia makes dehydration (Hall and Renfrew 2005). These can comparisons between by MTHFR (methylenetetrahydrofolate studies problematic reductase (NAD(P)H)) gene mutation. There are different approaches to dealing with ankyloglossia and we present two views here. Rosemary Dodds, from NCT, takes a broadly positive approach to dividing severe tongue-ties causing feeding problems. Deborah Neiger argues that tongue-tie is often >> The Practising Midwife | October 2014 23

Tongue-tiemisdiagnosed, resulting in unnecessary noted in maternal perception of frenotomy but not after the shamtreatment or premature cessation of breastfeeding (14 studies) and maternal procedure (p<0.001).breastfeeding. Both advocate careful pain scores (four studies). • Buryk et al (2011) found improved painassessment and doing what is best for babies: score compared to the sham grouphere they present their views on how this can Study limitations (p<0.001) and breastfeeding scorebest be achieved. Most studies suffered from small sample sizes (p<0.029). and lack of complete blinding. All RCTs offeredRosemary Dodds frenotomy to babies in the control group. In More recently a larger RCT in babies withSenior policy adviser at NCT two studies, this was immediately after mild to moderate tongue-tie who had assessment of pain and breastfeeding (Dollberg difficulty breastfeeding found frenotomy didEvidence on frenotomy et al 2006; Berry et al 2012); in one it was not result in an objective improvement in offered after 48 hours (Hogan et al 2005); and breastfeeding but was associated withA National Institute of Health and Care in one study it was offered within two weeks improved self-efficacy and fewer mothersExcellence (NICE) review in 2005 stated that (Buryk et al 2011). This prevented longer term changing to bottle feeding before five days.evidence suggests “there are no major safety comparisons being made between the Most women in the comparison arm opted forconcerns about division of ankyloglossia” and intervention and control groups. However, this the intervention after five days (Emond et al“limited evidence suggests that this procedure does not detract from the significant findings, 2014).can improve breastfeeding” (NICE 2005: 3). often immediately following frenotomy in blinded studies: Although a true, double-blind RCT Since then three systematic reviews and a comparing outcomes for longer than five daysmore recent randomised controlled trial (RCT) • In Hogan et al ’s (2005) study, 27 (96 per has not been attempted, we should nothave reported. However, the lack of an cent) mothers reported improved underestimate the importance of maternalaccepted classification of ankyloglossia makes breastfeeding within 48 hours of division, pain and the breastfeeding problemscomparisons between studies problematic. compared to only one mother in the non- experienced by up to 44 per cent of dyads with division group (p<0.001). tongue-tie (Emond et al 2014). The difficulty • Edmunds et al’s (2011) review found that of conducting such a trial when many mothers tongue-tie negatively affects breastfeeding • In Dollberg et al’s (2006) blinded, crossover and health professionals are not willing to dyads. In these cases, evidence indicates that study pain reduced significantly after frenotomy offers significant benefit and is a SCIENCE PHOTO LIBRARY simple, safe and effective procedure. Baby with what appears to be a tongue-tie • Finigan and Long (2013) included four RCTs and nine case studies and concluded that frenotomy is important in supporting continuation of breastfeeding, protecting mothers’ nipples from trauma, ensuring effective transfer of breast milk and improving satisfaction in feeding. • Webb et al (2013) found four RCTs and 12 observational studies considering breastfeeding problems in infants with tongue-tie. Frenotomy afforded significant objective improvements in pain (two RCTs), breastfeeding effectiveness (four studies), milk production and feeding characteristics (three studies) and infant weight gain (one study). Subjective improvements were also24 The Practising Midwife | October 2014

Tongue-tieconsent to a control arm is also underrated. Should we be more proactive in diagnosing prevalent a few years ago, gastro-oesophagealFor those with severe tongue-ties and problems tongue-tie in newborns? Or should we wait reflux was 'popular' in the years after that. Asbreastfeeding at least, we do not have until we have established that problems with awareness of those very real problems grew,equipoise (Buryk et al 2011; Emond et al 2014). breastfeeding (or bottle-feeding) are indeed diagnoses went up and then, after a while, due to a tongue-tie and issues with went back to normal, more realistic levels. IWhen frenotomy is best attachment and positioning have been imagine we might see the same happening excluded by a knowledgeable support person? with tongue-tie. Just surveying some socialClearly further research is required, including media breastfeeding help pages throws upon the degree of anklyoglossia that needs There are certainly many questions. many women asking questions about certainintervention. However, there is sufficient breastfeeding problems, often with easy, nonevidence that, for severe tongue-ties which The frenulum tongue-tie related answers, yet one of the veryhinder breastfeeding despite specialist first suggestions seems to be 'Has your babybreastfeeding support, pain is reduced and The spectrum of ankyloglossia causes been checked for tongue-tie?' Often, thebreastfeeding improved following frenotomy. confusion. Most of us have a frenulum; it is mother will check, see a frenulum and feelWithholding the procedure, causing distress not a problem in itself, just a normal feature of quite convinced that this is the root of theand leading to early cessation of breastfeeding our anatomy, helping with multifunctionality problem, even if she is seeing normal anatomy.would be more harmful. of the tongue in breastfeeding, moving food into and around the mouth and so on. In fact Interestingly this frequent diagnosis ofDeborah Neiger the absence of it can be indicative of Ehlers tongue-tie appears to only apply to womenIndependent midwife, Yorkshire Storks Danlos Syndrome, a connective tissue disorder who are well educated on breastfeeding issues, (de Felice et al 2001). Most frenulums are proactive in getting help and well connected.In my immediate circle of friends, clients and developed normally and cause no problems. Women who do not have good support oracquaintances, the incidences of tongue-tie Some are developed too short and thick, information have often never heard ofseem to exceed the 2.8-10.7 per cent mark therefore restricting normal movement of the ankyloglossia and are less likely to get aconsiderably, veering towards 50 per cent, if tongue. diagnosis, ending their breastfeeding journeynot more. Some have been able to get prematurely.treatment on the NHS easily; some have gone Diagnosing tongue-tiedown the private route and paid for their baby What to doto undergo a division of their tongue-tie, most However, appearance is not necessarilywith at least some improvement in their indicative of function and function does not What can we do to avoid this discrepancybreastfeeding problems. reflect in appearance. Some babies that appear tongue-tied certainly experience a normal between over-diagnosis and under-diagnosis? INew guidelines needed breastfeeding journey, and some babies display all the issues that tongue-tied babies personally don't believe that early screeningAs frenotomy can improve difficulties frequently have, yet appear to have normaldramatically (Buryk et al 2011; Hogan et al tongue anatomy (perhaps due to a posterior and preventative division is the solution.2005) with little risk to either the baby or the tongue-tie). This makes diagnosis difficult,mother (Hogan et al 2005) and at little cost inconsistent and at times problematic. Indeed, not all babies with mild to moderate(Klockars and Pitkaranta 2009), why are thereno concise, up-to-date treatment guidelines in Currently tongue-tie seems to be the tongue-tie encounter problems withplace? Are we due an overhaul of the NICE scapegoat for a disproportionate number ofguidelines on the issue (NICE 2005)? And why breastfeeding problems. In the last 15 years I breastfeeding and altering an anatomicalare some professionals still denying the have been intensively involved withexistence of tongue-tie induced difficulties breastfeeding, in my own parenting journey feature as a preventative measure seemswhen the evidence seems so clear? and as a midwife and I have seen a few 'fashionable diagnoses' in breastfeeding circles. problematic, particularly in areas with good For example, ductal thrush seemed very breastfeeding support structures. However, it would be helpful to have clear diagnostic criteria and a fast track pathway to access NHS resources for a swift tongue-tie division with evidence-based aftercare guidance, when frenotomy is required. Midwives should attempt to rectify >> The Practising Midwife | October 2014 25

Tongue-tieproblems with good old-fashioned attachment Breastfeed Med, 7: 189–193. review’. Evidence Based Midwifery, 11(2): 40-45.and positioning support before accessing swift Buryk M, Bloom D and Shope T (2011). ‘Efficacy of Hall DM and Renfrew MJ (2005). ‘Tongue tie’. Arch Disintervention to rectify a problematic tongue- neonatal release of ankyloglossia: a randomized trial’. Child, 90(12): 1211-1215.tie, should the issue arise. Pediatrics, 128: 280–288. Hogan M, Westcott C and Griffiths M (2005). de Felice C, Toti P, Di Maggio G et al (2001). ‘Absence of ‘Randomized, controlled trial of division of tongue tie Further studies on the long term outcomes the inferior labial and lingual frenula in Ehlers-Danlos in infants with feeding problems’. Jour Paediatr Childand timing of tongue-tie division are necessary syndrome’. The Lancet, 357(9267): 1500-1502. Health, 41: 246–250.and would certainly be very welcome indeed. Dollberg S, Botzer E, Grunis E et al (2006). ‘Immediate Klockars T and Pitkaranta A (2009). ‘Pediatric tongue-tie nipple pain relief after frenotomy in breastfed infants division: indications, techniques and patienttpm with ankyloglossia: a randomized, prospective study’. satisfaction’. Int Jour Ped Otorhinolaryngology, 73(10): Jour Pediatr Surg, 41: 1598–1600. 1399-1401.Rosemary Dodds is senior policy adviser at NCT Emond A, Ingram J, Johnson D et al (2014). McAndrew F, Thompson J, Fellows L et al (2012). Infantand Deborah Neiger is an independent midwife ‘Randomised controlled trial of early frenotomy in feeding survey 2010, Leeds: Health and Social Carein Yorkshire breastfed infants with mild-moderate tongue-tie’. Arch Information Centre. Dis Child Fetal Neonatal Ed, 99(3): F189-F195. NICE (2005). Division of ankyloglossia (tongue-tie) forReferences Edmunds J, Miles S and Fulbrook P (2011). ‘Tongue-tie breastfeeding, Manchester: NICE. and breastfeeding: a review of the literature’. Webb AN, Hao W and Hong P (2013). ‘The effect ofAmir LH, Dennerstein L, Garland SM et al (1996). Breastfeeding Review, 19(1): 19-26. tongue-tie division on breastfeeding and speech ‘Psychological aspects of nipple pain in lactating Finigan V and Long T (2013). ‘The effectiveness of articulation: a systematic review’. Int Jour Pediatr women’. Psychosom Obstet Gynaecol, 17(1): 53-58. frenulotomy on infant-feeding outcomes: a systematic Otorhinolaryngol, 77(5): 635-346.Berry J, Griffiths M and Westcott C (2012). ‘A double- blind, randomized, controlled trial of tongue-tie division and its immediate effect on breastfeeding’.DiaryOctober Mason: [email protected] / 18 October Supporting parents’ www.mkupdate.co.uk Contact:6 October Venepuncture and 020 8725 0228 decisions. London, £85. Info: [email protected] /cannulation. Dublin, £160. Info: www.arc-uk.org/ 017687 73030www.mkupdate.co.uk Contact: 14 October Decoding [email protected] / alcohol spectrum disorder. 20-22 October Clinical history 25 October Mothering Nature017687 73030 London, £25. Info: www.nofas- taking and physical examination. aspiring and student midwives uk.org [email protected] Nottingham, £450. Info: study day: Equality and diversity11 October Birth art café www.mkupdate.co.uk Contact: in maternity services. Manchester,training. Rochester, £337 (£315 16 October All Ireland annual [email protected] / £40. Info: www.motheringbefore 15/3/14). Info: midwifery conference. Dublin. 017687 73030 nature.co.uk. 07989 557512.http://www.eftforwomen.co.uk/bir Info: www.inmo.ie /thartcafetraining.html. Contact: www.rcm.org.uk 22 October Physiological birth: 29 October Social issues inTamara Donn at info@eftfor Promoting normality. London, maternity care. Birmingham £59women.co.uk / 01923 260050 16 October Developing the role £60/£40. Info: www.regonline. (£25 students) events@perinatal. of Healthcare support workers. com/pbpn2014 org.uk; www.perinatal.org.uk13 October Fetal monitoring in London, £329. Info: www.labour (CTG) study day. London. mkupdate.co.uk Contact: 23 October GynaecologyInfo: www.sgul.ac.uk/course/ [email protected] / assessment and examination.obstetrics Contact: Angela 01768 773030 Newcastle, £270. Info:26 The Practising Midwife | October 2014

BreastfeedingA report from the 9th Brilliant breastfeeding!InternationalBreastfeeding and SUMMARY: The 9th lactation and breastfeeding symposium was hosted in Madrid,Lactation Symposium by Spain in April 2014. This year the team also shared the information further afield, taking to Twitter to run live chats. This article reports on three discussions of interest to TheSioned Hilton, Practising Midwife readers: what is regarded as ‘normal’ in terms of breastfeeding; human milk lipids and health outcomes; and considering the research into the lactatinghighlighting three areas mammary gland.of development in Keywords Research, symposium, redefining breastfeeding, mammary gland, human milkunderstanding lipids Author Sioned Hilton, lactation consultant and education manager at a breastfeeding advisory company Kent’s new work can ‘Normal’ breastfeeding minute period). The majority used a combination, potentially eradicate with 57 per cent of babies including all three breastfeeding myths, The first day of this year’s symposium focused approaches in their breastfeeding journey.thus making it a truly on the latest recommendations for research-ground-breaking study based practice and, as part of this, we saw a A variety of patternsin the field of lactation presentation by Dr Jacqueline Kent on her She discussed that the individual experience for study concerning what is ‘normal’ in relation to both mother and baby is constantly adapting breastfeeding. during the breastfeeding period. Between one and six months of lactation, breastfed infants A variety of approaches become more efficient, taking fewer, faster, Kent pointed out that every breastfeeding larger feeds, but their total daily milk intake relationship between mother and baby is remains constant. Kent highlighted that there unique and that differences are not necessarily is a wide variety of breastfeeding patterns an indication of problems. Dr Kent explained among infants and that they do not need to that a breastfeeding session can involve one or conform to an average – there is not a both breasts, the majority of babies breastfeeding norm. experiencing a variety of approaches as either one breast only, a pair of breasts (starting on Dr Kent provided further detail explaining the second breast within 30 minutes of coming that 64 per cent of babies drink 20 per cent of off the first) or a cluster (first, then second, their daily milk intake at night, dispelling the then back to the first breast within a 30- myth that night feeding babies only feed for >> The Practising Midwife | October 2014 27

BreastfeedingPHOTOS: Medela AG Dr Lukas Christen, Prof Berthold Koletzko, Dr Danielle Prime Prof Peter Hartmann comfort. Some infants’ daily consumption of this to a breastfeeding mother who is The individual mother needs reassurance milk intake occurred with only four-six feeds, concerned by the regularity of her breastfeeds. that variations in breastfeeding behaviour are while others required 10-13 feeds. The duration If her baby is feeding often, she may feel normal - she can monitor effective feeding of each feed ranged from 12-67 minutes and concerned that she has insufficient milk with indices of healthy growth and the volume consumed was also wide ranging supply. However the reality may simply be that developments of weight, length, head from 54-234 ml each breastfeeding session. she has small storage capacity for breast milk, circumference, good tone and levels of so has to feed often. balanced alert and sleep states. Better Although the study uncovered varying knowledge of the variability and expected breastfeeding patterns it was key to learn that The lipids within human changes in breastfeeding patterns will also all of the infants who were monitored as part milk are dependent upon improve mothers’ confidence about their milk of the study were considered to be growing supply. normally according to the World Health the maternal diet and Organization (WHO) growth charts. Therefore more specifically the Changes are normal the variability was not a concern, but simply intake of LCPUFAs – it The breastfeeding community can take from an indication of perfectly normal cannot be matched by this study the understanding that changes in breastfeeding differences. Furthermore the an infant’s breastfeeding behaviours are frequency of feeding may be a result of the formula completely normal, as are differences between mother’s storage capacity as their overall milk babies. Using Kent’s new work to further volume over a 24-hour period is similar. educate health professionals - and in turn the mothers - on the expected breastfeeding Consistently healthy journey, can potentially eradicate The significant variability in frequency and breastfeeding myths, thus making it a truly volume intake of the healthy, exclusively ground-breaking study in the field of breastfed infant aged one-six months is lactation. remarkable. It is especially critical to explain 28 The Practising Midwife | October 2014

BreastfeedingHuman milk lipids and health in the maternal food chain: the higher the two portions of sea fish per week, includingoutcomes maternal DHA levels in pregnancy, the oily fish. For those women who do not eat fish greater the DHA transfer through the they are advised to take supplements withOn the second day, the theme was the unique placenta, and the same can be applied to the DHA. This talk was definitely food for thoughtcomponents of human milk and Prof Berthold DHA in mothers’ diet whilst breastfeeding, and an insight into the role of lipids, withinKoletzko’s exciting update regarding human milk regarding breast milk. breast milk, as the building blocks of thelipids fitted perfectly. He explained about the nervous, ophthalmic and immune systemssignificance of human milk lipids as he told the room Further developing his points, Koletzko within the human body.that they contribute around 45-55 per cent of the discussed the genetic make-up of humansenergy content provided to the fully breastfed baby (genotype) to synthesise lipids. Mothers and The lactating mammary gland: anduring the first six months of life. children in different parts of the world overview of research synthesise fatty acids differently, which mayImpact on development lead to differences in IQ, immune responses Professor Peter Hartmann has spent hisThese long-chain polyunsaturated fats and protective factors. Studies on maternal working life in researching breastfeeding, and(LCPUFAs) of the omega 3 and omega 6 series diet found that consumption of oily fish in has provided the breastfeeding world withdramatically affect infant health, growth and pregnancy or whilst breastfeeding related to a significant discoveries about human milk. Hisdevelopment. Never more so can we appreciate lower child allergy incidence. appearance on the podium was welcomed bythe importance of these fats than when we the delegates who gave him a standingrealise that by the age of two years, 80 per Food for thought ovation.cent of an infant’s adult brain growth has To conclude his talk, Professor Koletzkooccurred. With 50 per cent of the human brain recommended that pregnant and breastfeeding Vital organbeing made up of fat, we can really understand mothers need to receive a minimum level of Hartmann explained that he has been driventhe true value of human milk lipids. these essential fatty acids within the maternal by the question: How is it that we know so diet. Based upon the data presented, WHO now little about an organ that consumes more than Human milk is a unique and complex recommend that pregnant and breastfeeding 30 per cent of daily energy intake andproduct and completely different from formula women should consume preformed n-3 LC- contributes so much to the intellectual andmilk; the LCPUFAs – arachidonic acid (AA) and PUFA providing at least 200mg DHA per day. physical development and health of bothdocosahexaenoic acid (DHA) - not only support On average this can be attained by eating one- mother and baby? He asserted that thebrain growth but also visual, cognitive , motor lactating mammary gland should be accordedand immunological functions. These lipids are The lactating mammary the same medical and scientific status as othermore variable than other macronutrients gland should be equivalent organs in the body. Hartmannwithin breast milk and change with the time of believes that, once we have a volume of basicday and even within the feed itself. They are accorded the same research on human lactation that is equivalentvital to a baby’s development and have a key medical and scientific to that on other organs in the body, thenrole in breast milk. It is crucial, therefore, to breastfeeding mothers will be able to beunderstand that the lipids within human milk status as other supported by a medical specialty in humanare dependent upon the maternal diet and equivalent organs in the lactation – until that time it is vital wemore specifically the intake of LCPUFAs – it continue to research. Now that he has retired,cannot be matched by formula. body that is exactly what Professor Hartmann is able to do. tpm What is known is that human breast milkpromotes neural and white matter Sioned Hilton is lactation consultant andmaturation and is linked to enhanced education manager at a breastfeeding advisorymyelination, the longer the duration of companybreastfeeding. Professor Koletzko referred tothe importance of these essential fatty acids The Practising Midwife | October 2014 29

In the second of our To ECV or not to ECV?series on breech birth, The current evidence base concerning external cephalicShawn Walker versionexplains why turning a SUMMARY: External cephalic version (ECV) is the technique of attempting to turn abreech baby to be head baby in the womb from a head-up to a head-down position. The practice is grounded ondown will help reduce evidence that vaginal breech birth (VBB) presents greater short-term risks for babiesthe risks – and provide than caesarean section (CS) (Hofmeyr et al 2011), but that labour and vaginal birth alsobenefits - to both offer benefits to both mothers and babies. Therefore, if we can turn babies to a head-mother and baby down position, we can reduce the risks associated with both VBB and CS, and enable mother and baby to benefit from labour and birth. Keywords Pregnancy, external cephalic version, ECV, breech, shared decision making Author Shawn Walker, lecturer in midwifery at City University, London ECV reduces the What we know Obstetricians and Gynaecologists (RCOG) 2006).likelihood of both non- Additionally, CS increases risks for bothcephalic presentation at As a general rule, labour and vaginal birth are mothers and babies in future pregnancies good for babies and mothers (Vlemmix et al 2013). birth and CS In 2010, approximately 72 per cent of all elective caesarean sections (CS) were performed External cephalic version increases the because a baby was in a breech position, or normal birth rate in most cases because of a previous CS (Bragg et al 2010). The most recent Cochrane Review (Hofmeyr Evidence suggests that babies born by CS may and Kulier 2012) included seven randomised be at greater risk for various long-term health controlled trials (RCTs) and concluded that ECV problems such as diabetes, childhood obesity, reduces the likelihood of both non-cephalic asthma and eczema, and non-specific health presentation at birth and CS. This takes into problems at two years of age (Sinha and account the increased likelihood of a CS or Bewley 2012; Cho and Norman 2013). For operative birth after ECV as opposed to birth mothers, a CS carries a small increased risk of with no ECV, and the need to attempt serious adverse outcomes (Royal College of30 The Practising Midwife | October 2014

Thank you to Dr Helen Simpson and Midwife Emma Williams of South Tees Foundation Hospital for the photographs External cephalic version (ecv) ECV performed by Dr Helen Simpson, Consultant Obstetrician, South Tees Foundation Hospital 1) Disengaging the breech 2) Lifting the breech and gently rotating 3) Encouraging baby to somersault 4) Stabilising the cephalic presentation 1 approximately three ECVs to prevent one CS (de Hundt et al 2014). However, those seven RCTs showed considerable variation in the effect ECV had on the normal birth rate. In one trial, where ECV success rates were low and success of VBB high, ECV had no effect on the normal birth rate. Where VBB is less well supported and ECV success rates higher than 40 per cent, ECV makes a significant impact. 2 External cephalic version should be performed any time after 36 weeks Early ECV (prior to 36 weeks) is associated with a decrease in non- cephalic presentations at birth, but no decrease in the CS rate, and it may increase premature labour (Hofmyer and Kulier 2012). Also, ECV does not become less likely to succeed past 40 weeks; in some cases, for multiparous women, the opposite has been observed (Bogner et al 2012). A second (or first) ECV attempt with regional anaesthesia prior to a booked CS at term is a good option (Ben-Meir et al 2007). Multiple factors influence the success rate of ECV 3 ECV is more likely to be successful for multiparous women and babies who have flexed legs. It is least likely to be successful for nulliparous women, and women who have oligohydramnios, anterior placentas or frank breech (legs extended) babies. The use of tocolysis (uterine relaxant) and regional anaesthesia are associated with higher success rates (George et al 2014). However, perhaps the biggest influence on the success rate of ECV is the skill and experience of the obstetrician or midwife attempting it. Success rates of different providers vary greatly, even within the same institution (Bogner et al 2012). Women’s experiences of ECV vary greatly 4 Women’s perceptions of ECV are highly dependent on the success of the procedure. Women who have successful ECVs tend to experience the >> The Practising Midwife | October 2014 31

External cephalic version (ecv)procedure as less painful than those for whom published before the Term Breech trial Vignetteit is unsuccessful (Bogner et al 2014). The (Hannah et al 2000), and most of the womenexperience of pain is also worse in women with whose ECVs failed went on to attempt VBBs. Marie is a low-risk multip who has had twofear about the procedure, anxiety or More recent research has shown similar results previous straightforward cephalic births ofdepression, and this needs to be taken into (Reinhard et al 2013). babies weighing 4.0 kg and 3.7 kg. She is 37account when counselling women (Truijens et weeks pregnant with a frank breech baby, wellal 2014). Many providers admit to steering This corresponds to the Term Breech trial’s engaged, currently estimated to weigh 3.5 kg.women towards accepting an ECV, but this surprising data that, despite higher short-term After counselling and a thorough obstetricmay undermine a woman’s involvement in morbidity and mortality for those who planned review, she has a strong preference to plan adecision making and lead to decisional conflict VBB, long-term outcomes for infants at two VBB and is referred to the senior midwifery(Say et al 2013). years did not differ (Whyte et al 2004). Perhaps team who caseload women requesting a VBB. the common perception that breech Her breech-experienced team is comfortableECV is associated with a small risk of presentation itself is a problem should be supporting her until around 41 weeks, when itcomplications modified by the understanding that babies is likely her baby will weigh over 4.0 kg, soECV appears to be comparatively safe, meaning who spontaneously assume a head-down Marie chooses to book an ECV at this point.that the complications observed are no greater position are at less risk of an adverse outcomethan what we would expect in the population (Balayla et al 2014). Whilst ECV is not a What might happen?generally (Hofmeyr and Kulier 2012). panacea and cannot undo underlying problems • Straightforward vaginal breech birth atComplications directly attributed to the which may have contributed to breech 39+ weeks (45-75 per cent chance)procedure are rare but can include vaginal positioning (Mostello et al 2014), a successful • Baby turns spontaneously at 40 weeks andbleeding and severe bradycardia, initiating an ECV will increase the chances of a vaginal she has a water birth in the MLU (12-13emergency CS for about one in 200 women, birth; in areas where VBB is not supported, this per cent chance)almost always resulting in a good outcome for may be mothers’ and babies’ only chance to • Successful ECV at 41 weeks (90 per centthe baby. Recent research suggests that access the benefits of labour and normal birth. chance of success)adverse neonatal and obstetric outcomes may • Waters break at 40 weeks, but no labourbe greater following failed ECVs compared to To ECV or not to ECV? Women navigate ensues. Marie chooses a CS at this point, assuccessful ECVs or breech controls where no through a complex matrix of options, each of her team recommends not inducing breechECV has been attempted, and a successful VBB which is a reasonable choice. We do best by labours. She is happy her baby has chosenis less likely following a failed ECV compared women when both high quality ECV services his birthday.with no attempt (Balayla et al 2014). and a VBB are both easily accessible and well- supported. Marie’s hypothetical scenario illustrates aWhat we don’t know flexible, supportive approach to the choices we Perhaps the biggest offer women with breech-presenting babies,Ultimately, we don’t know whether ECV influence on the success which is most possible where providers areimproves outcomes for babies experienced and comfortable with all options,ECV lowers the non-cephalic birth rate, but rate of ECV is the skill and where women receive consistentthis in itself does not appear to change the risk and experience of the counselling within a continuity model. tpmlevel for these babies. After reviewing the obstetrician or midwifeevidence of the RCTs mentioned above, the Shawn Walker is a lecturer in midwifery at City2012 Cochrane Review concluded that ECV did attempting it University, Londonnot result in a difference in Apgar rates at oneor five minutes, low umbilical artery pH levels, Referencesneonatal admissions or perinatal deaths. This issignificant because most of these trials were Balayla J, Dahdouh EM, Villeneuve S et al (2014). ‘Obstetrical and neonatal outcomes following32 The Practising Midwife | October 2014

External cephalic version (ecv) unsuccessful external cephalic version: a stratified of delivery after successful external cephalic version: RCOG (2006). The management of breech analysis amongst failures, successes, and controls’. a systematic review and meta-analysis’. Obs Gyn, presentation. GTG 20b, London: RCOG. Jour Mat-Fetal Neon Med, June 25: 1-6: 123(6): 1327-1334. Say R, Thomson R, Robson S et al (2013). ‘A doi:10.3109/14767058.2014.927429. George RT, Singh N and Yentis SM (2014). ‘External qualitative interview study exploring pregnantBen-Meir A, Elram T, Tsafrir A et al (2007). ‘The cephalic version – the bad, the good and the what women’s and health professionals' attitudes to incidence of spontaneous version after failed now?’ Int Jour Obs Anesth, 23(1): 4-7. external cephalic version’. BMC Preg Childb,13(1): 4. external cephalic version’. Am Jour Obs Gyn, 196(2): Hannah ME, Hannah WJ, Hewson SA et al (2000). Sinha A and Bewley S (2012). ‘The harmful 157.e1–157.e3. ‘Planned caesarean section versus planned vaginal consequences of prelabour caesarean section on theBogner G, Hammer BE, Schausberger C et al (2014). birth for breech presentation at term: a randomised baby’. Obs Gyn Reprod Med, 22(2): 54–56. ‘Patient satisfaction with childbirth after external multicentre trial’. The Lancet, 356(9239): 1375-1383. Truijens SEM, van der Zalm M, Pop VJM et al (2014). cephalic version’. Arch Gyn Obs, 289(3): 523–531. Hofmeyr GJ, Hannah M, Lawrie TA (2011). ‘Planned ‘Determinants of pain perception after externalBogner G, Xu F, Simbrunner C et al (2012). ‘Single- caesarean section for term breech delivery’. Coch cephalic version in pregnant women’. Midwif, 30(3): institute experience, management, success rate and Datab Sys Rev, DOI: 10.1002/14651858.CD000166. e102-e107. outcome after external cephalic version at term’. Int Hofmeyr GJ and Kulier R (2012). ‘External cephalic Vlemmix F, Kazemier B, Rosman A et al (2013). ‘764: Jour Gyn Obs, 116(2): 134–137. version for breech presentation at term’. Coch Datab Effect of increased caesarean section rate due toBragg F, Cromwell DA, Edozien LC et al (2010). Sys Rev, DOI: 10.1002/14651858.CD000083.pub2. term breech presentation on maternal and fetal ‘Variation in rates of caesarean section among Mostello D, Chang JJ, Bal F et al (2014). ‘Breech outcome in subsequent pregnancies’. Am Jour Obs English NHS trusts after accounting for maternal presentation at delivery: a marker for congenital Gyn, 208(1): S321. and clinical risk: cross sectional study’. Brit Med Jour, anomaly?’ Perinatology, 34(1): 11-15. Whyte H, Hannah ME, Saigal S et al (2004). 341: c5065. Reinhard J, Sanger N, Hanker L et al (2013). ‘Delivery ‘Outcomes of children at 2 years after plannedCho CE and Norman M (2013). Cesarean section and mode and neonatal outcome after a trial of external cesarean birth versus planned vaginal birth for development of the immune system in the offspring. cephalic version (ECV): a prospective trial of vaginal breech presentation at term: the international Am Jour Obs Gyn, 208(4): 249–254. breech versus cephalic delivery’. Arch Gyn Obs, randomized term breech trial. Am Jour Obs Gyn.de Hundt M, Velzel J, de Groot CJ et al (2014). ‘Mode 287(4): 663-668. 191(3): 864–871. Are you - or could you be - a writer?We are always on the look-out for new writers in The Practising Midwife and welcome submissionsfrom midwives and others involved in pregnancy, birth and postnatal matters.If you feel you have something new to say, perhaps looking at a midwifery-related issue from adifferent angle - something which you feel midwives could take into their everyday practice to helpthem help women and babies - why not have a look at our guidelines for authors atwww,thepractisingmidwife.com and put it down in writing?We would love to read your thoughts and ideas, so do sendthem in.Please note that articles submitted to The PractisingMidwife are subject to peer review. The Practising Midwife | October 2014 33

Midwifery Basics: MentorshipYvonne Jarvis and 1. The role and responsibilitiesJoyce Marshall of a midwifery mentorMentorship is the 14th series of Introduction‘Midwifery basics’ targeted atpractising midwives. The aim of Mentorship of student midwives in clinical practice is an important part of the role of a qualifiedthese articles is to provide and experienced midwife (Steele 2009). All mentors for midwifery students are sign-off mentors.information to raise awareness The Nursing and Midwifery Council (NMC) (2008: 9) states: ‘The role of the sign-off mentor and/orof the impact of the work of link lecturer is to make judgements about whether a student has achieved the required standardsmidwives on women’s of proficiency for safe and effective practice for entry to the NMC register.’ However, mentorship isexperience, and encourage much more than this and can be considered as the process of giving support for personal andmidwives to seek further professional development. This can be provided in a range of ways, such as acting as a role model,information through a series of teaching, encouraging, offering feedback and formally assessing the student midwife. Less formalactivities relating to the topic. definitions suggest that the mentor is a guide, supporter and advisor (Casey and Clark 2012). TheIn this first article of the new mentoring process, the relationship between mentor and student midwife and the institutionalseries, Yvonne Jarvis and Joyce environment within which the mentoring occurs, can present a range of rewards and challengesMarshall consider some of the for both mentor and student.key issues related to the roleand responsibilities of the NMC requirements for supporting learners in practicemidwifery mentor in anoverview of the mentoring role. The NMC has set mandatory standards to support learning and assessment in practice (NMC 2008).These will be discussed in more In order to become a ‘sign-off mentor’, a qualified midwife must complete an approved anddetail in the series of articles accredited mentor programme to achieve the knowledge, skill and competence to meet stipulatedthat follows. outcomes. These outcomes specify the requirements for supporting students in practice under eight domains (See Box 1). Midwifery mentors Within approved pre-registration midwifery education programmes leading to midwifery support, teach and assess registration, students can only be supported and assessed by mentors who have met the criteria to become a sign-off mentor. students in clinical Scenario practice and need good Suzanne has been qualified as a midwife for almost two years; she is currently working on preparation and support the labour ward and has occasionally supported student midwives for a day at a time in the absence of their sign-off mentor. She remembers how important inspirational support from in order to do this mentors was to her when she was a student and is now keen to develop her skills to support students to learn, and improve her understanding of the role and responsibilities of a effectively mentor. She thinks to herself, ‘I will find out about the mentor preparation course at university as it would be rewarding to become a qualified mentor.’34 The Practising Midwife | October 2014

MentorshipBox 1 Domains of outcomes mentor must Box 2 Responsibilities of a mentorachieve to meet NMC standards to supportlearning and assessment in practice Organising and co-ordinating student learning activities in practice1. Establishing effective working Supervising students in learning situations and providing them with constructive feedback relationships on their achievements2. Facilitation of learning Setting and monitoring achievement of realistic learning objectives3. Assessment and accountability4. Evaluation of learning Assessing total performance – including skills, attitudes and behaviours5. Creating an environment for learning6. Context of practice Providing evidence as required by programme providers of student achievement or lack of7. Evidence-based practice achievement8.Leadership Liaising with others to provide feedback, identify any concerns about the student’s (From NMC 2008: 25) performance and agree action, as appropriate Providing evidence for, or acting as, sign-off mentors with regard to making decisions about proficiency at the end of a programme (From NMC 2008: 23)Aspects of the role and requires good interpersonal and these situations is the need to maintain aresponsibilities communication skills (Hayes 2012). The professional relationship. If the relationship relationship between mentor and student moves too much towards friendship, then itLearning in the clinical environment is should be based on trust and respect and this can become very difficult to remain objectivefundamental to pre-registration midwifery can be developed by actively listening to the in order to assess appropriately. The mentor-practice. Midwifery mentors support, teach and concerns and previous progress of the student. student relationship should be a professionalassess students in clinical practice and need As with any face-to-face interaction in clinical partnership with clear boundaries that balancegood preparation and support in order to do practice, maintenance of eye contact, giving supportive guidance with the ability to makethis effectively (Finnerty et al 2006). The NMC undivided attention and positive body objective, unbiased decisions about progresshas specified the activities that mentors are language is essential. Trying to minimise the (Casey and Clark 2012). Sign-off mentors needresponsible and accountable for (NMC 2008), power differential within the relationship and to make such judgements at the end of eachwhich are summarised in Box 2. A key aspect showing an active interest in the well-being of placement module as well as at the finalof all these activities is the relationship the student can also help to develop positive assessment of practice, to confirm thebetween the mentor and student which interactions (Hayes 2012). Students’ student’s achievement of competence for safe experiences of mentorship are diverse but a and effective practice conferring entry to the Activity 1 number of qualities have been highlighted as NMC register. being important, such as: being approachable, Find a learning styles quiz using the encouraging and willing to explain; being an Student learning in clinical practice Internet; do one and find out about advocate for women; and instilling confidence your own learning style. Consider as well as encouraging reflective evidence- People learn in different ways and differ in whether you feel this is the way you based practice (Hughes and Fraser 2011). learn best or not. Think about a peer their approach to learning (Shaw 2012). For or colleague whom you know well Sometimes there are tensions between and try to work out what learning different aspects of mentoring, such as example, some people are very active learners style they might have. Consider offering pastoral support and carrying out ways that you might help students assessment (Bray and Nettleton 2007), and this – they carry out the task and only afterwards with different learning styles to can lead to reluctance to fail students when learn best. the need arises (Duffy 2004). At the root of do they reflect on it - whereas others contemplate, weighing up aspects of the task before they do it. These differences are sometimes referred to as learning styles. As well as having differing approaches or >> The Practising Midwife | October 2014 35

Mentorship is not always easy, especially if a student is not making as much progress as expected; however, it is arguably the most important aspect of student learning and can be a positive experience for the student if done well. Feedback should be given using positive language, and should be specific, drawing directly on examples from practice situations to enable the student to understand exactly what they must do to make progress. There is a temptation to start with general observation about a student’s progress, especially if time is short, but it can be helpful to encourage the student to identify what they feel they do well and areas they feel could be improved – to provide a starting point for discussion. Using what is sometimes referred to as the ‘feedback sandwich’ can work well, initially drawing onpreferred ways of learning each student will This is the starting point for discussion about some areas of practice where the student ishave had varied experiences of life generally the learning opportunities within theand in clinical practice so far. It is therefore placement and provides a formal agreement doing well, followed by a discussion of areascrucial to find this out at the beginning of the for the learning that is expected. Careful jointplacement either by questioning and listening planning of learning opportunities has been for improvement then ending with positivecarefully to their answers or by watching as shown to be important to students (Finnertythey work clinically. The learning contract will and Collington 2013). encouragement.also help with this as students identify theirlearning needs by documenting what they Other aspects that are important to students Although most students achieve well in >>believe they have learned so far and what they are the ability of mentors to pass on their clinical practice, some struggle to reachwould like to achieve in the current placement. practical expertise or craft knowledge (Finnerty and Collington 2013) and a friendly, relaxed The mentor-student Activity 2 and supportive environment (Lewin 2007). relationship should be a professional partnership Consider your area of work and list Mentors are integral to the development of with clear boundaries the aspects of that environment student learning in practice, especially in that balance supportive that you think will support learning. relation to their influence on student guidance with the ability You might consider: physical confidence and self-esteem (Hughes and Fraser to make objective, aspects, how friendly it is, whether 2011). Miles (2008), writing from a student unbiased decisions you think students would feel part perspective, additionally suggests that positive about progress of the team, variety of learning mentorship promotes student autonomy and opportunities. Then consider any assertiveness, while providing woman-centred elements that might form barriers care. An important part of good mentorship is to learning and ways that these ensuring there is regular discussion between might be overcome. student and mentor to review the learning plan, involving open and honest reflection on achievements as the placement progresses. This36 The Practising Midwife | October 2014



Mentorshipcompetence at various points in the course. should be contained within the student record these areas will be discussed in more detail inMentors may be reluctant to fail students early (NMC 2008). There should be no surprises for future articles in this series. tpmin their training, believing that problems will the student.resolve over time. Yet if, following the early Yvonne Jarvis and Joyce Marshall are bothand regular support of the mentor by a link Conclusion senior lecturers in midwifery at University oflecturer, clear feedback and action plans do Huddersfieldnot mean the student achieves the required High quality mentorship is essential tostandard, then the student should not pass the maintain excellence in midwifery care and Referencesplacement. Mentors should be aware of their ultimately to protect the health and wellbeingrole in protecting the public and maintaining a of mothers and babies by ensuring that Bray L and Nettleton P (2007). 'Assessor or mentor?high quality of care by failing students if they student midwives develop essential knowledge Role confusion in professional education'. Nurse Eddo not reach the required standard at whatever and skills to become safe, competent and Today, 27: 848-855.stage of their training. This is an ongoing caring midwives. This article has outlined the Casey D and Clark L (2012). 'A collaborative approach toconcern for mentors and will be discussed in roles and responsibilities of a midwifery support trainee sign-off mentors'. Nurs Standard, 27:detail later in the series. mentor, including discussion of how the 44-47. student experience can be enhanced by Duffy K (2004). 'Mentors need more support to failAccountability and record keeping consideration of various aspects of the role of incompetent students'. Brit Jour nurs, 13, 582. the mentor, the NMC requirements and issues Finnerty G and Collington V (2013). 'Practical coachingPre-registration midwifery students should of responsibility and accountability. Each of by mentors: student midwives' perceptions'. Nurse Edhave supernumerary status and should work at in Pract, 13: 573-577.least 40 per cent of the total time in the An important part of Finnerty G, Graham L, Magnusson C et al (2006).placement with their allocated sign-off mentor good mentorship is 'Empowering midwife mentors with adequate trainingwhilst providing direct care for childbearing ensuring there is regular and support'. Brit Jour Midwif, 14: 187-190.women in the practice setting. Mentors are discussion between Hayes C (2012). 'Skills for mentorship'. In: Shaw MEresponsible for supervising midwifery students student and mentor to and Fulton J (eds). Mentorship in healthcare, London:either directly or indirectly and for grading review the learning plan M&K Publishing.their practice, which contributes to their final Hughes AJ and Fraser DM (2011). 'There are guidingdegree award. hands and there are controlling hands: student midwives' experience of mentorship in the UK'. Midwif, The ‘ongoing achievement record’ is part of 27: 477-483.the assessment-in-practice record and, like any Lewin D (2007). 'Clinical learning environments forclinical documentation, it should be a clear, student nurses: key indices from two studies comparedsuccinct and specific record of students’ over a 25 year period'. Nurse Ed in Pract, 7: 238-246.progress in clinical practice. Students should be Miles S (2008). 'Make or break: the importance of goodaware of all actions, and all documentation mentorship'. Brit Jour Midwif, 16: 704. NMC (2008). Standards to support learning andReflecting back on the scenario assessment in practice: NMC standards for mentors, practice teachers and teachers, London: NMC.In order to manage students’ learning and support them to develop into confident and Shaw ME (2012). 'Teaching and learning'. In: Shaw MEcompetent midwives, mentors draw on multiple skills and emotional resources. This is a and Fulton J (eds). Mentorship in healthcare, London:two-way process and both parties can gain much from the mentoring relationship. NMC- M&K Publishing.approved mentorship courses are run at most universities, and on successful completion of Steele R (2009). 'Gaining competence and confidencethe programme, the mentor’s name is added to the live mentor register that is held by the as a midwife'. Brit Jour Midwif, 17: 441-447.placement provider.38 The Practising Midwife | October 2014

Thinking outside the box Are emergency mnemonicsSara Wickham help(err)ful?looks at a studyabout professionals’knowledge ofmnemonics and A number of midwifery programmes that I have been involved withraises some questions offer an interesting session, early on in the course, in whichfor reflection students undertake one or more exercises designed to help them identify their individual learning style and/or preferred ways of knowing. In theory, this enables the future midwife to gain knowledge of their personal idiosyncrasies and learning preferences, which can be really helpful given the enormity of the educational journey on which they are embarking. In reality, the nature of teaching complex subjects to ever-larger cohorts of students with increasingly limited staff and resources means there may be little opportunity to accommodate different learning preferences throughout the three or four years that follow. However, many lecturers do their best to include a variety of different approaches and these sessions do at least afford the student the opportunity to gain self-knowledge.A recent study showed that midwives’ and doctors’theoretical knowledge of emergency mnemonics Recalling manoeuvreswas not as good as expected, and the researchersconcluded that teaching should focus on learning Both these sessions and the notion that there is a wide range of preferredwithout relying on mnemonics and eponyms. But learning and knowing styles have been in my mind since I read a paperthere are wide and varied issues to be considered which looked at the use of mnemonics for remembering how to deal withhere, including that different people have different shoulder dystocia. Jan et al (2014) used a questionnaire to evaluatelearning styles and ways of knowing, and that, for midwives’ and doctors’ knowledge of a number of emergency-relatedsome people, self-developed and/or alternative mnemonics including HELPERR, which is designed to aid recall of themnemonics may be more useful than those progression of manoeuvres to be attempted when caring for a woman whodeveloped for all. People may have different needs experiences shoulder dystocia.throughout their career and we need to ask howwe can balance the needs and learning preferences Of the 112 participants (including 61 midwives, 42 doctors and nineof the individual and honour the midwifery model who didn’t state their profession), 90 per cent were familiar with theapproach while also ensuring that all members of a HELPERR mnemonic, 79 per cent saying they used it in practice. However,team are able to act together when an emergency when those who said they used it were asked to write it out, only 32 per cent could do so. The same participants did better when asked to say whether descriptions of eponymous manoeuvres (like McRoberts) were correct, with an 84.6 per cent success rate. They fared less well again at matching the names and descriptions of manoeuvres, getting only a third of those relating to shoulder dystocia right.occurs. The value of mnemonics Mnemonics are taught for good reason; they serve as a helpful prompt for >> The Practising Midwife | October 2014 39

Thinking outside the boxthe individual, that is understood by the whole A midwifery model do when faced with this scenario.team, who can then quickly work together approach will not begin Some elements of Jan et al’s (2014)with a shared plan. HELPERR isn’t the onlyshoulder dystocia mnemonic; proposals by with the assumption findings are reassuring. Given a choice, Imidwives include Anderson’s (2007) version for that the woman is on imagine most women would probably prefer ause in home birth settings, Jones’ (2010) ‘Help! midwife or doctor who knew what to do whenMR SPARE’, which took into account the all- her back on a bed they encountered a shoulder dystocia over onefours position and Tully’s (2012) ‘FlipFLOP’. who could name the creators of theNone of these have achieved the same especially when working in the community, we manoeuvres but not apply them in practice.prominence as HELPERR, perhaps because of its would be more likely to get a woman into a Most of Jan et al’s (2014) participants were inassociation with the Advanced life support in deep squatting position, which is exactly the the former group, which may be why theyobstetrics (ALSO) course, but it is also same as the McRobert’s manoeuvre, but does concluded that teaching should focus onimportant to note that mnemonics aren’t not require two additional members of the learning without relying on mnemonics andnecessarily meant to be taught as a stand- team to apply it’ (Lewis 2014: 392). eponyms. But I think this would be a shamealone tool, rather as part of a wider learning for those who find these useful, and prematureexperience. Learning from within given the bigger picture. That said, I am all for a debate about how we can reconcile the As a learner and a teacher, I appreciate the Jan et al’s (2014) results made me wonder perceived need for universal and sharedvalue of mnemonics and am not about to whether people would be more likely to solutions with the fact that different people dosuggest that we ditch them. They have many remember their own mnemonics because they have such different learning styles. tpmadvantages and I am also mindful of Jenkins’ have been created from within rather than(2014) recent comment that midwifery imposed from outside. But would teamwork Sara Wickham is an independent midwiferystudents felt daunted by the updated RCOG suffer if we were all remembering different lecturer and consultant(2012) guideline and algorithm and found the mnemonics, or would it improve if we wereHELPERR mnemonic more useful. This able to follow our own learning styles and use Referencesobservation doesn’t totally contradict Jan et a numbered list, a picture or a re-worded popal’s (2014) findings; students may particularly song to help us recall the steps that might help Anderson T (2007). ‘A shoulder dystocia mnemonic forvalue tools such as the HELPERR mnemonic when facing shoulder dystocia? We could take homebirth’. The Practis Midwife, 10(5): 33-37.because it is really helpful to have frameworks the view that there is a fundamental disparity Jan H, Guimicheva B, Gosh S et al (2014). ‘Evaluation ofwhen you are learning a subject. between the notion that we need shared tools healthcare professionals' understanding of eponymous and the fact that we all favour different ways maneuvers and mnemonics in emergency obstetric Mnemonics can be highly valuable in other of thinking and knowing; and/or we could care provision’. Int Jour Gyn Obs, 125(3): 228-231.ways too. I often engage midwives in a dismiss this concern on the basis that such Jenkins L (2014). ‘Managing shoulder dystocia:mnemonic creation activity designed to help fundamentals are too important to experiment understanding and applying RCOG guidance’. Brit Jourthink through what is essential in an with. We could acknowledge that mnemonics, Midwif, 22(5): 318-324.emergency situation, and to highlight the fact like lots of other things, require a context in Jones L (2010). Help! MR SPARE: a new mnemonic forthat – as Anderson (2007), Jones (2010) and which to be truly effective; and/or we could shoulder dystocia? The Practis Midwife, 13(7):36-38.Tully (2012) all highlight – a midwifery-model see this as a debate which might further our Lewis P (2014). ‘Discourse on dystocia: a much neededmnemonic might look quite different from one thinking and increase the chances that professional dialogue’. Brit Jour Midwif, 22(6):390-392.rooted in a medical approach. One reason for midwives and others would remember what to Prusova K, Tyler A, Churcher L et al (2014). RCOGthis is that a midwifery model approach will guidelines: how evidence-based are they? 1-6.not begin with the assumption that the doi:10.3109/01443615.2014.920794.woman is on her back on a bed. Also, as Lewis RCOG (2012). Shoulder dystocia (GG 42), London: RCOG.points out, manoeuvres might be differently Tully G (2012). ‘FlipFLOP: four steps to remember’.interpreted by different groups: ‘As midwives, Midwif Today, (103): 9-11.40 The Practising Midwife | October 2014

Around the conferencesReflections from Prague Dr Debbie Wisby presents her personal reflections from the ICM 30thCongress Centre, Prague Triennial Congress – an inspiring and1-5 June 2014 uplifting global eventInternational Confederation of Midwives income countries (UN Population Fund (UNFPA) Evidence from the series suggests that if family et al 2014); more than 92 per cent of all the planning was included within the full packageThe International Confederation of Midwives world’s maternal and newborn deaths and of midwifery care, it would prevent 50-75 per(ICM) is the world’s largest alliance of midwifery stillbirths occur within these countries, with cent of maternal, fetal and neonatal deaths,associations, with 116 member associations led only 42 per cent availability of the world’s with a further 10-20 per cent reduction in allby midwives who determine their own governance midwifery and nursing personnel. deaths when linked to specialist care. Clearly,and activities. The ICM represents over three this features important evidence to reflectmillion midwives, working alongside United An extremely popular workshop was on upon, with regard to future global educationNations (UN) agencies and others to advocate, Midwifery education in clinical practice, the requirements for midwives aroundrepresent and strengthen professional midwifery aim of which was to explore the quality of contraceptive and sexual and reproductivebodies throughout the world (ICM 2014). learning and assessment in workplace and health care, as an important preventative placement settings of student midwives, within strategy in reducing mortality rates. The theme for the 2014 congress was the context of the ICM education standards‘Midwives: improving health globally’, which (ICM 2010). It was a really informative session This was my first time attending Congressreflects Millennium Development Goal (MDG) 5 and a great opportunity to discuss how we and it was uplifting to hear the work and(UN 2014). The conference was packed with a could develop forums for the sharing of experiences of midwives from across thewealth of interesting sessions and I was spoilt educational resources, as we listened to the world. tpmfor choice. experiences of midwifery educators who are more starved of resources than those in ‘the west’. Dr Debbie Wisby is senior lecturer and courseFemale genital mulitation leader in midwifery at UCLan Family planning to save livesOn day one, the symposium on Female Genital ReferencesMutilation (FGM) presented some alarming On my final day I attended a session on ‘Unmetstatistics from a joint report that was needs for family planning’. Whilst I am very ICM (2010). ICM global standards for midwiferydeveloped in collaboration with the Royal familiar with the range of contraceptive education, The Hague: ICM.Colege of Nursing (RCN), Royal College of methods and sexual and reproductive health ICM (2014). Triennial report 2011-2014, The Hague: ICM.Midwives (RCM), Royal College of Obstetricians services within the UK, I was particularly RCM, RCN, RCOG et al (2013). Tackling FGM in the UK:and Gynaecologists (RCOG), Equality Now and interested in the cost, use and access to intercollegiate recommendations for identifying,UNITE (RCM et al 2013). Evidence suggests that contraception from a global perspective, as I recording and reporting, London: RCM.66,000 women living in the UK have undergone am passionate about the need for enhancing Renfrew JM, Homer CSE, Downe S et al (2014).FGM, and over 23,000 girls under the age of 15 postpartum contraceptive care. The launch of Midwifery: an executive summary for the Lancet’sare now at risk, which illustrates the need for the Midwifery Lancet Series which was to be series, The Lancet, early online publication.effective multi-agency and multi-disciplinary published later in June 2014, highlighted the UN (2014). We can end poverty; Millennium Developmentwork to tackle this issue. importance of reproductive and sexual health, Goals and beyond 2015, Virginia: UN Publications. describing it as ‘fundamental to the health and UNFPA, ICM and WHO (2014). The state of the world’sAn unequal world wellbeing of individuals, families and midwifery 2014: a universal pathway. A woman’s right communities’ (Renfrew et al 2014: 131). to health, Virginia: UN Publications.Day two saw the launch of a key report whichpresents findings from 73 low and middle- The Practising Midwife | October 2014 41

Valerie Smith Cochrane cornerhighlights a review on Treatments for breasttreatments for breast engorgement during lactationengorgement duringlactation SUMMARY: The aim of this bi-monthly column is to highlight Cochrane Systematic 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 Infant feeding, breastfeeding, lactation, engorgement Author Dr Valerie Smith, lecturer in midwifery at Trinity College Dublin At around two-three Background birth a woman’s breasts produce colostrum, a days postpartum a highly nutritious substance rich in immunewoman’s milk ‘comes in’ There is ample evidence supporting factors that are thought to confer additional and her breasts may breastfeeding as the appropriate health choice protection to the new born baby (Edmonds etbecome heavy, swollen for both mothers and infants (Smith and Tully al 2006). At around two-three days postpartum 2001). Breastfeeding results in decreased a woman’s milk ‘comes in’ and her breasts may and tender problems such as infections (Cunningham et al become heavy, swollen and tender. This is 2005) and has been associated with known as primary engorgement and it is part enhancement of cognitive development, of a normal physiological process where less prevention of obesity, hypertension and insulin milk than is produced is removed from the dependent diabetes mellitus (Leung and Sauve breast as a woman’s body adjusts to making 2005). The World Health Organization (WHO) exactly the right amount for the baby (Mangesi recommends exclusive breastfeeding for six and Dowswell 2010). The majority of women months postpartum (WHO 2003) and in the UK manage this engorgement effectively and it and other countries, there is a growing usually self-resolves in the next few days. commitment to increasing breastfeeding rates, Engorgement that becomes problematic, especially among deprived groups. Following42 The Practising Midwife | October 2014

Cochrane corner Women in the swollen breasts (Arora et al 2008). It can result compression binders, fluid limitation, acupuncture group had in causing milk ducts to block and can cause information and advice and massage, and breast infection and non-infectious mastitis medical treatments such as analgesia, or a significantly fewer (Mangesi and Dowswell 2010). Importantly, it combination of both non-medical and medical symptoms at three, four can be extremely distressing for a woman, and treatments. Two review authors independently the associated pain during feeding can assessed each study for inclusion in the review, and five days after interfere with successful breastfeeding. This assessed the risk of bias (quality) of each study treatment can lead women to decide not to persevere and extracted the outcome data from each with or to abandon breastfeeding altogether included study. The primary outcomes ofhowever, occurs when the mother is not (Mass 2004). For this reason it is important interest to the review were temporary orfeeding her baby as frequently as she used to, that problematic engorgement is treated early permanent cessation of breastfeeding andthe baby is not latching on properly or the and effectively. mastitis. Secondary outcomes of interestbaby continues to remove less milk from the included maternal temperature (>38.0 Celsius),breast (Mass 2004). This engorgement is Methods maternal opinion and acceptance of treatment,associated with hard, painful, throbbing and analgesic requirement, hospital admission, Randomised and quasi-randomised trials were maternal confidence in continuing to eligible for inclusion in the review if they breastfeed and breast abscess. investigated a treatment for breast engorgement in women who were Findings >> breastfeeding. Treatments could include non- medical treatments such as support bra, Eight studies, involving 774 women were The Practising Midwife | October 2014 43

Cochrane cornerincluded in the review. Women in all of the numbers in this study, however, were small (n Where acupuncture andstudies had signs and symptoms of = 45). When breast-shaped cold packs worn in protease complex areengorgement such as swollen, hard, painful a halter were compared to routine care,breasts and sometimes pyrexia. In the main, women receiving the treatment experienced available to women, usewomen were recruited in the early postnatal reduced pain intensity post treatment of these should beperiod (two-five days postpartum). A broad (decreased mean pain intensity score from 1.84 recommendedrange of treatments was assessed in the to 1.23 in the treatment group compared withstudies. These were acupuncture versus usual an increase in the control group from 1.50 to positioning and attachment, knowing how tocare (two studies), cold versus room 1.79). However, these results should be assess a breastfeed and being sensitive andtemperature cabbage leaves (one study), considered with caution due to baseline supportive to women in encouraging themcabbage leaves versus cold gel packs (one differences between the groups. continue breastfeeding. tpmstudy), cold packs versus routine care (onestudy), protease complex tablets versus placebo Implications for practice Dr Valerie Smith is lecturer in midwifery at(one study), ultrasound versus sham ultrasound Trinity College Dublin(one study) and subcutaneous oxytocin versus A number of different types of interventionplacebo (one study). were evaluated in this review. Of these, References acupuncture for relieving the symptoms of There were no differences in antibiotic engorgement, protease complex for reducing Arora S, Vatsa M and Dadhwal V (2008). ‘A comparisonrequirements or in rates of breast abscess in pain and swelling and breast-shaped cold of cabbage leaves vs. hot and cold compresses in thewomen receiving acupuncture compared to packs were shown to be effective. Cabbage treatment of breast engorgement’. Indian Jourthose receiving usual care. Women in the leaves, alternatively, were shown to have no Community Med, 33(3): 160-162.acupuncture group, however, had significantly beneficial effect over other forms of treatment Cunningham FG, Leveno KJ, Bloom SL et al (2005).fewer symptoms at three, four and five days and sub-cutaneous oxytocin had a negative William’s obstetrics, 22nd edition. New York: McGrawafter treatment. The use of cabbage leaves effect on symptom relief compared to placebo. Hill.compared to gel and cold cabbage leaves Overall, the quality of the evidence from the Edmond KM, Zandoh C, Quigley MA et al (2006).compared to leaves at room temperature, studies in the review is low and most of the ‘Delayed breastfeeding initiation increases risk ofdemonstrated no difference in pain scores studies had small sample sizes. Furthermore, neonatal mortality’. Paediatrics, 117(3): e380-e386.between the groups. Women treated with an follow-up periods were short in the studies Leung AK and Sauve RS (2005). ‘Breast is best foractive protease complex (a plant enzyme) were resulting in a lack of information on longer babies’. Jour National Med Ass, 97(7): 1010–1019.more likely to have reduced pain and swelling term outcomes such as duration of Mangesi L and Dowswell T (2010). ‘Treatments forthan those receiving placebo. These women breastfeeding, or breastfeeding cessation. breast engorgement during lactation’. CDSR, 9 .:were also more likely to experience improved Based on the findings of this review, the use of CD006946. DOI: 10.1002/14651858.CD006946.pub2.symptoms. There was no difference in the cold packs for relieving the symptoms of Mass M (2004). ‘Breast pain: engorgement, nipple painduration of breastfeeding or in analgesia engorgement should be recommended to and mastitis’. Clin Obs Gyn, 47(3): 676–682.requirements in women treated with women. Where acupuncture and protease Smith JW and Tully MR (2001). ‘Midwifery managementultrasound compared to sham ultrasound, and complex are available to women, use of these of breastfeeding: using the evidence’. Jour Midwifboth treatments were equally associated with should be recommended also. Wom Health, 46(6): 347-351.reductions in ratings of pain, hardness and WHO (2003). Global strategy for infant and youngswelling. Sub-cutaneous oxytocin, used daily Comment child feeding, Geneva: WHO.until symptoms resolved, compared to placebo,demonstrated that, although more women in To help reduce the incidence of engorgementthe oxytocin group had symptoms after three in women, there are a number of importantdays (25 per cent versus 8 per cent), this actions that midwives can undertake. Thesedifference was not statistically significant. The include being knowledgeable about the physiology of lactation, being skilled in infant44 The Practising Midwife | October 2014

Overseas opportunitiesProfessional development The Practising Midwife | October 2014 45

Last wordPost caesarean section wound care Elaine BerryEvidence As women’s advocates, reducing and the health of pregnant women is midwives must take a increasingly variable, midwives need toThe caesarean section (CS) rate continues to role in generating the proactively generate and embed evidence torise, with a quarter of all pregnancies resulting evidence and starting promote safe and effective CS wound care. tpmin CS delivery in England (Health and social the debate to ensurecare information centre (HSCIC) 2014). As the women receive the best Elaine Berry is a midwife and infection controlmain provider of postnatal care, the midwife matron at Nottingham Univ Hospital NHS Trusthas a role in providing post CS wound care. Yet care post-CSthe evidence upon which to base this wound Referencescare is lacking. The majority of published women are now having children who wouldliterature on CS focuses on obstetric issues previously have been unable to due to certain Anderson V, Chaboyer W and Gillespie B (2013). ‘Thesuch as closure material and antibiotic health conditions. Obesity, acknowledged as relationship between obesity and surgical siteprophylaxis (for example MacKeen et al 2014) the main risk for SSI, is becoming ever more infections in women undergoing CS: an integrativeor on the rates and risk factors (Ward et al common in pregnant women (Anderson et al review’. Midwifery, 29: 1331-1338.2008; Johnson et al 2006). There are few papers 2013). The altering health status of the pregnant HSCIC (2013). Hospital episode statistics: NHS maternitywhich consider CS wound care from a population requires us to reconsider both the Statistics - England, 2012-2013, Leeds: HSCIC.midwifery perspective and all are theoretical risk of SSI in CS, how to reduce it, and treat it Johnson A, Young D and Reilly J (2006). ‘Caesareanpapers (for example Nobbs and Crozier 2011; effectively, should efforts in prevention fail. section surgical site infection surveillance’. Jour HospMurphy 2013). Women who undergo a CS Infect, 64: 30-35.should not be denied evidence-based practice The role of the midwife MacKeen K, Fleisher J, Vogell A et al (2014). ‘Suturein the midwifery elements of CS, such as compared with staple skin closure after cesareanwound care. As women’s advocates, midwives An obstetric perspective has dominated both delivery: a randomized controlled trial’. Obs Gyn,must take a role in generating the evidence CS wound and SSI debate but a 123(6): 1169-1175.and starting the debate to ensure women multidisciplinary approach to this topic, Murphy M (2013). ‘Caesarean wound care for midwives’.receive the best care post-CS. combining obstetric and midwifery skills and The Practis Midwife, 16(9): 27-30. goals will benefit women who have a CS. Nobbs S and Crozier K (2011). ‘Wound management inIncreasing risk and response Midwives should become more involved in CS obese women following CS’. Brit Jour Midwif, 19(3): wound management, both in identifying rates 150-156; 477-484.Surgical site infection (SSI) is a risk with any and risk factors and in providing an evidence Reilly J, Allardice G, Bruce J et al (2006). ‘Proceduresurgical procedure, although the risk is base for wound care. As the CS rate is not specific SSI rates and post discharge surveillance inacknowledged to be greater with certain Scotland’. Infect Control Hosp Epidem, 27(12): 1318-1323.procedures (Reilly et al 2006). Caesarean Ward V, Charlett A, Fagan J et al (2008). ‘Enhanced SSIsection has typically been viewed to be low-risk surveillance following CS: experience of a multicentrefor SSI due to the age and perceived good collaborative post-discharge system’. Jour Hosp Infect,health status of the pregnant population. 70: 166-173.However, due to healthcare advances, many46 The Practising Midwife | October 2014