TPM APRIL 2016

The Practising April 2016MIDWIFE Volume 19 No 4 The best job in the worldwww.practisingmidwife.co.ukVULNERABILITIES IN THIS ISSUE: Supporting younger mothers to breastfeed: linking to CPD module online Midwives coping with FGM How can we make a difference in substance misuse? Midwives are vulnerable, too: the impact of rapeCOMING SOON - Visit your new online community and learning zone to develop, prepare and share your practice www.practisingmidwife.co.uk

* * World’s first of its kind Pregnacare® trial published in British Journal of Nutrition Pregnacare® tablets shown to benefit the health of pregnant mums and their babies in major UK trial As widely reported in the national press, Vitabiotics Pregnacare® tablets have been shown to benefit pregnant women and their babies in a major UK trial1, carried out by the Institute of Brain Chemistry and Human Nutrition at London Metropolitan University and the Homerton University Hospital. “TO THE BEST OF OUR KNOWLEDGE, THIS IS THE FIRST REPORTING OF SUCH FINDINGS OF ANY STUDY PERFORMED IN THE UK OR THE DEVELOPING WORLD.” The lead researcher, Dr Louise Brough, commented: “This research highlights the concerning fact that a number of women even  in the developed world, are lacking in important nutrients during pregnancy.  It  also  demonstrates  the  benefit  of  taking  a  multiple  micronutrient  supplement  such  as  Pregnacare®.  It  is  especially  important  to  have  good  nutrient  levels  during  early  pregnancy  as  this  is  a  critical  time  for  development of the foetus. Pregnacare®, as used in the study, was shown to  improve nutrient status relative to placebo.” By the third trimester, mothers who took Pregnacare® Original tablets were also found to have, relative to placebo, increased levels of iron, vitamin B1 and vitamin D3. Specially formulated by experts, Pregnacare® tablets replace a usual multivitamin and provide a careful balance of 19 essential vitamins and minerals. It includes the recommended 10mcg vitamin D and also 400mcg folic acid which contributes to maternal tissue growth during pregnancy. Plus iron which contributes to normal red blood cell formation and normal function of the immune system. The pregnancy multivitamin brand MIDWIVES RECOMMEND MOST† Before Conception Original Plus Omega 3 Breast-feeding *ADPRGPROFP15-02-16E Pregnacare® is the pregnancy multivitamin brand midwives recommend most†, so you can recommend it with confidence. 1 L Brough, GA Rees, MA Crawford, RH Morton, EK Dorman (2010) Br J Nutr. 2010 Aug;104(3):437-45 † Based on a survey of 1000 midwives. For more information on this research, please visit www.pregnacare.com/mostrecommended * Nielsen GB ScanTrack Total Coverage Value and Unit Sales 52 w/e 25th April 2015. www.pregnacare.com

CONTENTS5 EDITORIAL THIS MONTH’S FEATURED ARTICLES 33 GUIDELINE COMMENTARY6 VIEWPOINT 8 Supporting young mothers MBRRACE - Confidential enquiries into maternal deaths Zika: an opportunity for change who want to breastfeed Hannah Rogers reviews the new report in Latin America? Phoebe Pallotti addresses the question of Anna Maria Speciale argues that advising what young mothers may need and want 37 THINKING OUTSIDE THE BOX women not to get pregnant in affected from breastfeeding support countries is not enough The importance of everyday 18 Substance misuse: birth wisdom13 ADVANCING PRACTICE Sara Wickham shares details of a study can midwives really make a difference? which identified rituals undertaken by FGM and midwifery practice Zoe Hughes examines the role of the midwives looking after women in labour Marianne Mitchell promotes the education midwife in relation to substance misuse of midwives in providing optimum care for 40 LETTERS women with FGM 21 The trafficking of women 40 REVIEWS29 MIDWIFERY BASICS and the role of the midwife Hannah Tizard helps midwives to 41 DIARY 7. Perineal suturing understand the impact of trafficking Megan Blease and Kerry Taylor provide 42 LAST WORD learning hints and tips for the newly 24 The emotional impact of maternal death qualified midwife learning and practising Filing empty spaces with sadness this skill Samantha Whelan addresses the effect Amanda Chinery explains how important of maternal death on midwives it is for midwives to be non-judgemental 26 We are vulnerable, too A student midwife confronts feelings that lay buried for yearsCOMING SOON ONLINE @ www.practisingmidwife.co.uk CURRICULUM ARTICLES COMMUNITYOur website features a series of eLearn LINK ARTICLE THIS MONTH: Areas for prospective students, studentmodules and assessments focused around SUPPORTING YOUNG MOTHERS midwives and registered midwives. Mutuallythe following practice themes: WHO WANT TO BREASTFEED supportive arena for you to chat, discuss and1 Midwifery becoming and being including Read the article by Phoebe Pallotti in this give and seek advice month’s journal. Complete the eLearn module Also - Refectory You can look up events taking Organisation, caring and roles and assessment to gain a certificate for your place in coming months, read and comment on Midwifery care portfolio, ready for revalidation and proof of CPD the latest news stories and access midwifery- Midwifery core skills Access to current and past TPM journal articles related information2 With woman and family including Woman and childbearing Lead article each month, taking you from the CLINICAL GLOSSARY Baby and family journal to the website for a module on the3 Personal and professional development subject. This month Nutrition and nurture: A-Z list of common clinical conditions andWithin these areas you will find modules breastfeeding by Phoebe Pallotti, soon midwifery topics to help inform your practicecovering a range of topics essential to linking to www.practisingmidwife.co.ukmidwives and associated roles TPM, April 2016, vol.19, issue 4 3

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VIEWPOINTWhat makes us vulnerable?Human beings are vulnerable to our physical, psycho-social and cultural environment. Anna Byrom Our vulnerabilities are represented in a regular and alarming myriad of colours Editor through daily news feeds, via the media. Whether it's the effects of war, famine, natural disasters or criminal activity, human beings’ shared vulnerability is universal Follow me on Twitter:and constant. Yet how our common vulnerability manifests itself is frequently individual and @acb-midwifeuneven. Such inequalities arise in response to current social structures and systems, favouringthe wealthy and powerful. Individual midwives and mothers can find themselves vulnerable, particularly as systems andpolicies, resources and investment are inconsistent with variable priority in national agendas.Exploration of key maternity reports, guidelines and statistics highlight public health concernsfor childbearing women and their babies: maternal and perinatal mortality and morbidity,persistent gender and health inequalities continue globally. Simultaneously, ongoing reviews ofmaternity services identify areas of constraint and strain upon maternity units and ourprofession, with consequences for childbearing women, babies and families. In this month's issue of TPM we explore some of the vulnerabilities women and midwives canface. Our hope is to offer an insight into issues that can create conflict and challenges forchildbearing women and mothers, with practical suggestions for addressing these specificaspects of vulnerability. Alongside the negative consequences, human vulnerability can offer windows of opportunity,generating creativity and innovation as we search to find new ways of achieving, adapting andresponding to the challenges we face. As midwives, exploring our own vulnerabilities and sharingthem could allow our experiences to soften – rather than harden – us. Exposing our ownvulnerability to others can ignite new channels of communication, forging stronger relationshipswith those we serve. Reflecting and learning from our own experience and how we manage andsurvive despite adversity, could help to build future resilience. Alone we are vulnerable; together we can be strong. Standing together as midwives andwomen for the future of maternity services, our profession and our childbearing experiences canmake a difference. Exposing our resilience and power, reinforcing our capacity, abilities andneeds can change things for the better and ensure services are developed to address our sharedvulnerabilities. As we look forward it is worth remembering the African Proverb: \"If you want togo fast go alone; if you want to go far, go together\".TPM, April 2016, vol.19, issue 4 5

VIEWPOINT Zika: an opportunity for change in Latin America?Anna Maria In recent months, stories of the Zika virus and its Zika, global health leaders are calling on countriesSpeciale rapid spread have become a constant in the news. to make abortion more readily available and legal (Watts 2016).Technical adviser, COMPLEX PROBLEM ELIMINATING HARMFUL PRACTICESDepartment of Global In response to the crisis, ministries of health in several Latin American countries have advised The newly released sustainable development goalsOutreach, American College women to avoid pregnancy in the near future. call for “achieving universal access to sexual and Unfortunately, such guidance ignores the current reproductive health care…” (Goal 3), and ” theof Nurse Midwives reality of these countries and in most of Latin elimination of all forms of violence against women America. This problem cannot be resolved by and girls, the end of all forms of gender-based placing responsibility on the individual woman, but discrimination, and the elimination of harmful requires a larger health system and policy approach. practices... ensuring universal access to sexual and reproductive health and reproductive rights” (Goal In Latin America and the Caribbean, over 50 per 5) (UNFPA 2016). The Zika crisis is an urgent and cent of pregnancies are unplanned (Guttmacher practical case study in the necessity of these goals. Institute Media Center (GIMC) 2014). In Brazil, the rate of unmet need for family planning is estimated Zika is pushing women’s rights and women’s to be 6 per cent (Maki 2007). In neighbouring health to the forefront, not only in Latin America, countries, unmet need is much higher: Bolivia 22.7 but globally. Strategies to resolve the Zika crisis per cent, Haiti nearly 40 per cent (World Health must recognise women’s reproductive health and Organization (WHO) 2009). The second greatest women’s reproductive safety as a human rights cause of unmet need is unavailability or limited issue that requires health system support and choices of contraception (Maki 2007). Globally, political action. tpm women who are rural, poor, less educated or adolescent are less likely to access family planning REFERENCES (United Nations Population Fund (UNFPA) 2016). This is also true in Latin America and presents a GIMC (2014). New Study finds that Worldwide 40 challenge in countries like El Salvador, where one in per cent of pregnancies are unintended, New York: 12 girls is pregnant before the age of 15 (Santiso- Guttmacher Institute. http://tinyurl.com/htdes97 Glavez et al 2015). GIMC (2015). Facts on abortion in Latin America and REAL CHALLENGES the Caribbean, New York: Guttmacher Institute. http://tinyurl.com/zc6ydq9 However, this is not just a story of contraceptive availability. It is about the need for women’s health Maki S (2007). Unmet need for family planning and access to reproductive health services to play a persists in developing countries, Washington DC: larger role in national policy agendas and health Population Reference Bureau. http://tinyurl.com/ systems planning. Current warnings to avoid zjcnstk pregnancy ignore the realities of a woman’s ability or inability to choose when she has sex, access and Santiso-Gálvez R, Ward V and Bertrand J (2015). choice to use contraception and the realities of Family planning in El Salvador. The achievement of 50 physical and sexual violence. And this is before years, Chapel Hill: Carolina Population Center. adding abortion to the discussion. Currently, http://tinyurl.com/hu9p9p2 abortion is illegal in the majority of Latin America, with only Uruguay, Guyana and Cuba allowing UNFPA (2015). Sustainable development goals, New women to abort for any reason, up to a determined York: UNFPA. http://tinyurl.com/q4ddfbf gestational age (GIMC 2015). In El Salvador and Haiti, laws governing abortion prohibit abortion UNFPA (2016). Universal access to reproductive under all conditions, even as a life-saving measure. health. Progress and challenges, New York: UNFPA. Abortion is legal in Brazil only as a life-saving http://tinyurl.com/hvzjqx6 measure for the woman (GIMC 2015). In the light of Watts J (2016).‘UN tells Latin American countries hit by Zika to allow women access to abortion’. The Guardian, 5th February. http://tinyurl.com/hpftqy4 WHO (2009). Monitoring unmet need for family planning, Geneva: WHO. http://tinyurl.com/jmjft3a6 Speciale, TPM, April 2016, vol.19, issue 4

Vitamins & nutrients in pregnancy The power of maternal nutritionHelping mums put governmentguidance into practice Folic acidMaking it simple for mums            Vitamin D Omega 3 (DHA)          IodineDespite Department of Health recommendations of 400µg folic acidand 10µg vitamin D, mums are not supplementing daily•••Why don’t mums take supplements?THEY ARE CONFUSED. THEY FORGET. THEY MAKE THEM SICK.         One nutrimum bar a day: Iron a convenient way for mums to get the additional nutrients they and their baby need nutrimum cereal bars replace mums’ daily tablet supplement making it easy for them to fortify their diet in pregnancy and breastfeeding everyday. One nutrimum bar (40g) per day meets Department of Health supplementation recommendations, providing 100% RNI of folic acid and vitamin D during pregnancy and 100% RNI of vitamin D during breastfeeding, as well as other key nutrients such as omega 3 (DHA), iodine and iron.11 The nutriNVNQSFHOBODZSBOHFIBTCFFOTQFDJĂDBMMZEFWFMPQFEUP provide 5 important nutrients women need during pregnancy, each cereal bar contains: 400µg folic acid, 10µg vitamin D, omega 3 (DHA), iron and iodine. eln.nutricia.co.uk/midwife *N nutritional needs; the importanc SHRSOHoVHDWLQJEHKDY      ˀNICE quality standard on improving maternal and child nutrition includes the r women attending antenatal and health visitor appointments arReferences:2QH3ROO(DUO\QXWULWLRQVXUYH\VRIPRWKHUVPRWKHUVWREHDQGKHDOWKFDUHSURIHVVLRQDOV$XJXVW'DWDRQƬOH(DUO\1XWULWLRQIRU/DWHU+HDOW            SUHJQDQWDQGEUHDVWIHHGLQJZRPHQ-XO\'DWDRQƬOH1+6&KRLFHV1DXVHDDQGPRUQLQJVLFNQHVV>2QOLQH@$FFHVVHG$XJXVW1+6&KRLFHV9LWDPLQVD        )UDQH\&HWDO5HFHQWWUHQGVDQGFOLQLFDOIHDWXUHVRIFKLOGKRRGYLWDPLQ'GHƬFLHQF\SUHVHQWLQJWRDFKLOGUHQoVKRVSLWDOLQ*ODVJRZ$UFK'LV&KLOG*UH        JSUHJQDQF\5HY2EVWHW*\QHFROs6NHDƪ6$,RGLQH'HƬFLHQF\LQ3UHJQDQF\7KH(ƪHFWRQ1HXURGHYHORSPHQWLQWKH&KLOG1XWULHQWV1XWULHQWVs         $OOHUJLHV6FLHQWLƬF2SLQLRQRQWKHVXEVWDQWLDWLRQRIKHDOWKFODLPVUHODWHGWRLURQ()6$-RXUQDO()6$3DQHORQ'LHWHWLF3URGXFWV1XWULWLRQDQG$OOHUJLHV6FLHQWLƬF2SLQLRQRQWK      DLPUHODWHGWRLURQ()6$-RXUQDOQXWULPXP3URGXFWV>2QOLQH@$FFHVVHG$XJXVW1,&($QWHQDWDOFDUH>2QOLQH@$FFHVVHG$XJXVW1,&(1XWULWLRQLPSURYLQJPDWHUQDODQGFKLOGQXWULWLRQ>2QOLQH@$FFHVVHG$XJXVW

BREASTFEEDING SUPPORTLINK ARTICLE Phoebe PallottiLead article each month,taking you from the Lecturer in maternal care at University of Leedsjournal to the websitefor a module on the Supporting young motherssubject. who want to breastfeedThis month: This article is a discussion of some of the current knowledge on how to best support young mothers whoSupporting young wish to breastfeed. It includes practice points taken from Phoebe’s own qualitative research on youngmothers who want to mothers and infant feeding and also a discussion of the valuable work of other midwives and researchersbreastfeed by Phoebe on the subject.Pallotti.Go to the module, soon We know that breastfeeding can have significant benefits for mothers and their babies; we also knowcoming to that young mothers, as a group, are less likely to breastfeed than other mothers. Breastfeeding is anwww.practising emotional subject: it can be empowering and satisfying, but it can also be a time of emotional strain andmidwife.co.uk negative feelings of guilt and failure. This article aims to increase the understanding of what young mothers may want and need from breastfeeding support. RESEARCH EDUCATION, AGE AND BREASTFEEDING Ethnographic interviews and participant There is a social gradient in the initiation and observation were used to explore the lived duration of breastfeeding in the UK. The Infant experiences of 10 young mothers aged 16-18 and Feeding Survey (IFS) in 2010 (McAndrew et al 2012) their babies, from pregnancy to weaning onto solid showed that 91 per cent of women who completed food. I also performed a metasynthesis on the extant further education initiated breastfeeding, compared literature and used this to inform the study. I present with 63 per cent of women who left school at 16.This elements of both the primary research and inequality is more apparent in mothers under 20, of metasynthesis here to give here an overall picture of whom only 46 per cent initiated breastfeeding. the challenges young mothers face when wanting to Women who live in families with the lowest incomes breastfeed, and to propose some novel solutions for also suffer more ill health during pregnancy and practice. throughout their lives (Wilkinson 1997). Therefore, the benefits that breastfeeding can offer are of great INTRODUCTION importance to these mothers and their babies. Further, whilst recent interventions, such as peer We know that breastfeeding has many benefits for support, have increased the rate of breastfeeding in mothers and their babies. Horta et al (2007) review more deprived areas, they have not had the same the evidence of the benefits and show that effect on the rates in younger mothers (McAndrew breastfeeding provides optimal nutrition for babies. et al 2012). It can reduce the risk of many diseases, such as eczema and asthma in childhood and heart disease SUPPORT WHERE IT IS NEEDED >>>> and diabetes in adulthood. Mothers can also benefit, with reductions in ovarian- and some breast cancers This is the research behind the public health aim to and healthier body mass. Renfrew et al (2012) also increase breastfeeding, but it is important for demonstrate that breastfeeding is a cost effective midwifery practice that we see this scientific way of improving infant health, including by evidence in its social and cultural context. reducing infant hospital admissions. Breastfeeding does not just deliver an optimum8 Pallotti, TPM, April 2016, vol.19, issue 4

Reference: 1. nutrimum. Products [Online]. Accessed: August 2015. One nutrimum bar a day AS9285 / Feb 2016 ensures pregnant mums get the additional nutrients they and their baby need without the need to take tablets. ONE A DAY An alternative to mums’ pregnancy supplement One nutrimum bar (40g) per day helps mum meet Department of Health recommendations, providing 100% RNI of both folic acid and vitamin D during pregnancy, as well as other key nutrients such as iron, omega 3 (DHA) and iodine1 A range of breastfeeding bars is also available. 7RƬQGRXWPRUHYLVLWeln.nutricia.co.uk/nutrimum RUFDOORQHRIRXUH[SHUWVKRXUVDGD\ GD\VDZHHNRQ0800 093 4400

BREASTFEEDING SUPPORTPractice sugggestions• Discuss including the fathers and family in breastfeeding support• Collaboratively produce support plans that can include mixed feeding and with a focus on milk expression• Discuss infant behaviour and feeding cues. Be particularly sensitive when discussing normal infant weight loss after birth• Support young mothers to engage with local support groups• Discuss strategies for feeding in public in a way that feels safe for a young mother food; it is a social, moral and emotional act, which is milk expression to enable their partners and done by women who are part of families and wider mothers to feed the baby. As Ash, a 16-year-old, said social networks. Until we take into account the when she was pregnant: \"That's another reason why I holistic meanings of breastfeeding, as a profession wanted to express as well, so my mum can get to feed him we won't be able to adequately help those who need and my sister and my nan.\" our support the most. However, most of them struggled with “Breastfeeding support must go beyond information expression, finding that they could not reliably and encouragement to include…action that values pump off what they regarded as a sufficient volume. women’s productive and reproductive work, women’s bodies, and their choices, and ultimately promotes and One practical solution is to include the family at supports the value of children and families of all kinds” key points of breastfeeding education as Smith et al (McCarter-Spaulding 2008: 212). (2012), Dykes et al (2003) and Ineichen et al (1997) suggest. However this may be increasingly difficult DISCUSSION as we face cuts and staff shortages, meaning we can Supporting the family deliver less one-to-one care at home. Another suggestion is, given the importance of letting other Supporting and including the family around the family members feed the baby, to work on milk young mother may be an important element in expression techniques and education in a more offering effective breastfeeding support.The fathers focused way with the young mothers. Collaborative of the babies in my research play a part in feeding production of individualised plans to support decisions; as Tom, an 18-year-old father, says: \"I breastfeeding whilst still including bottle feeding didn't find it (breastfeeding) too bad, but when it came to (with either expressed breast milk or formula) may the bottle I found it a lot easier, because then I could take be important for young mothers. Further research over and help out a bit more!\" into this potential strategy is needed. The maternal grandmothers also helped a lot, Fears of inadequacy and their own experiences of child rearing were part of their advice to their daughters. As they had their The Baby Friendly Initiative (BFI) guidelines (Unicef children in the 1980s and 1990s, when health 2012) place emphasis on supporting the mother and professionals often encouraged formula feeding, it infant bond and the communication of feeding cues, was understandable that they were comfortable with which is important for all mothers, but perhaps feeding their grandchildren by bottle. Most of the especially so for young mothers. Currently, BFI is young mothers in my study initially wanted to use focusing on further development of attachment10 Pallotti, TPM, April 2016, vol.19, issue 4

BREASTFEEDING SUPPORT NEW PRODUCTbased feeding guidelines. A common theme in much of my The NEW SONICAID Digitalresearch was young mothers’ worry that, because their babies Doppler offers a newwanted to breastfeed frequently, that meant that they were hungry dimension in sound and visionand that, as mothers, they were not 'doing a good job' (Hunter andMagill-Cuerden 2014; Spear 2006). Medical equipment suppliers Huntleigh have announced the \"I know that the first part of the breast milk is like the most important release of the Sonicaid Digitalpart, so I tried to keep it going for a week. But I thought, I don't want to Doppler range, combining beststarve her!\" (Marley, 17) performance in probe sensitivity, audio clarity and a new visual A lack of exposure to other breastfeeding mothers and representation of the fetal heartsometimes confusing or contradictory advice from different rate. The colour screen displayhealthcare professionals can also make young mothers doubt that provides a BIG NUMBERS view and,breastfeeding is adequate for their babies (Brown et al 2011). when required, an innovative TRACEFurther, because many young mothers do not know many other CAPTURE view, enabling intermittentmothers who breastfed, it can seem like a strange, a 'not normal' auscultation examinations to be(Condon et al 2013) thing to do that is not appropriate for them. electronically documented onSignposting to 'young mother friendly' breastfeeding cafés and Huntleigh’s software packagegroups may be useful if they are locally available. Sonicaid FetalCare 3. Further, the routine weighing of babies in the early days also IMPROVEMENTS HELP MIDWIVESled some of the young mothers in my study to worry that breastmilk wasn't sufficient, as the baby had lost weight. The BIG NUMBERS mode displays the heart rate in a high contrast colour for optimum visibility, making it easy to see at arm’s length Kiara, aged 18, here shares her concerns about her son's weight or in water birth environments. The clear backlit display reducesat day five: \"It was just…3 per cent [of birth weight lost]… doesn't sound the risk of misreading the fetal heart rate, especially in dimly-lita lot does it? But I can't risk him going into hospital if he's not feeding, environments.so I’d just better put him on bottles.\" Its new 2MHz and 3MHz probes provide enhanced fetal heart Whether this concern is shared by the wider population of detection and audio clarity. Using our revolutionary Dynamicyoung mothers is a matter that requires more research. However, Digital Noise Reduction (DDNR) system, hiss and crackle whileKiara's words do highlight the importance of our clear searching for the fetal heart are eliminated but, more importantly,communication about babies’ weight and normal behaviour. In it reduces FHR noise and so provides optimum heart rateaddition, as Dykes et al (2003) find, supportive and encouraging detection.care for young mothers is crucial in the early days. REDUCED RUNNING COSTSSupport for breastfeeding in public Supplied with a medical grade charger, convenient batteryThe stigma of breastfeeding in public is still a problem for many charging through the integral USB port and improved powermothers, and especially young mothers, despite recent legislative consumption per use, the Sonicaid Digital Doppler has lowerchanges. Hunter and Magill-Cuerden (2014), Dyson et al (2010) and operating costs.Condon et al (2013) all find that the fear of public breastfeedingwas an issue for the young mothers in their studies. In my own NEED TO DOCUMENT ACTIVITY?breastfeeding experiences, I have been asked to leave a theatre, afamily pub and – once – a doctor's waiting room in order to Healthcare organisations are driving the move towards electroniccontinue breastfeeding. I made the appropriate complaints, recording systems as evidence of activity. The new Sonicaid Digitalalthough it made me feel awful at the time. Doppler series provides a future-proof investment as it has the capability to record and download short FHR traces for transfer to For young mothers, who are not always so convinced about the our Sonicaid FetalCare 3 software package. This can provideinherent 'goodness' or acceptability of breastfeeding, such documented evidence of the examination and will become anencounters can be the 'pivotal point' (Hoddinott et al 2012) at integral part of the electronic patient record.which they judge it as too difficult, or 'not for them'. Further, as myresearch makes clear, the family home is also often a public space SATISFACTION GUARANTEEDand therefore young mothers’ choices of places to feed are severelylimited. As with all Huntleigh products, performance, reliability and durability are things our customers have come to expect. The Deedee, 17, discusses the problems with feeding in her family exceptional build standard of the new Digital Doppler is nohome, which is a 'public space', as she cannot control who visits exception. Designed to provide value for money to theand when. \"I fed him here when my little brother was here and professional, it offers optimum combination of whole-life cost andeverything, and I've had to do the blanket thing and stuff like that.” quality to meet the user's requirements. Kiara, 18, reiterates this: \"It were…a bit harder, because I've got a For further information, please contact Huntleighbig family, and everyone were here; it was embarrassing! [Laughs]. My >>>> +44(0)29 2048 5885 [email protected], TPM, April 2016, vol.19, issue 4 11

BREASTFEEDING SUPPORT experience is key to offering individualised breastfeeding support. The young mothers in my study all wanted to do their best for their babies; it is our role to support young mothers like them to enable them to achieve their breastfeeding goals. tpmbrother, and my brother's friends were here!\" REFERENCES Offering support to negotiate breastfeeding Brown A, Raynor P and Lee M (2011). ‘Young mothersspace in the family home may be a useful option for who choose to breastfeed: the importance of being part of asome young mothers. supportive breastfeeding community’. Midwifery, 27(1): 53-59. Social marketing campaigns, like the Be a star Condon L, Rhodes C, Warren S et al (2013). ‘“But is it acampaign, have tried to make breastfeeding in normal thing?” Teenage mothers’ experiences ofpublic more socially acceptable and 'normal' for breastfeeding promotion and support’. Health Educationyoung mothers. From a practice point of view, Journal, 72(2): 156-162.producing regularly updated lists of 'safe' places tofeed, may help young mothers to feel more Dykes F, Hall Moran V, Burt S et al (2003). ‘Adolescentconfident in going out and still being able to mothers and breastfeeding: experiences and support needs.breastfeed. For example, a regularly updated list of An exploratory study’. Jour of Human Lactation, 19(4): 391–401.the following local information may be useful: Dyson L, Green J, Renfrew M et al (2010). ‘Factors • Cafés and shops that have signed up to some influencing the infant feeding decision for councils’ 'breastfeeding friendly' sign schemes socioeconomically deprived pregnant teenagers: the moral dimension’. Birth, 37(2): 141–149. • Chain stores with comfortable feeding rooms • Local council mother-and-baby provision. Hoddinott P, Craig LCA, Britten J et al (2012). ‘A serial qualitative interview study of infant feeding experiences:LIMITATIONS AND FURTHER RESEARCH idealism meets realism’. BMJ Open, 2(2): e000504.Current literature looking at young mothers and Horta BL, Bahl R, Martinés JC et al (2007). Evidence on thebreastfeeding has gone some way to explaining the long-term effects of breastfeeding: systematic reviews and meta-slower rates of increase in breastfeeding in mothers analyses, Geneva: World Health Organization.under 20 and to illuminate the complex physical andpsychosocial barriers to breastfeeding that young Hunter L and Magill-Cuerden J (2014). ‘Young mothers'mothers may experience. However, we do not know decisions to initiate and continue breastfeeding in the UK:what interventions may be effective to support tensions inherent in the paradox between being, but notyoung mothers to both initiate and continue being able to be seen to be, a good mother’. Evidence Basedbreastfeeding and much more work needs to be Midwifery, 12(2): 46-51.done in this area. Ineichen B, Pierce M and Lawrenson R (1997). ‘TeenageCONCLUSION mothers as breastfeeders: attitudes and behaviour’. Journal of Adolescence., 20: 505-509.The discussion above gives some ideas to creativelyand collaboratively support young mothers who McAndrew F, Thompson J, Fellows L et al (2012). Thewish to breastfeed. Most importantly, as with all Infant Feeding Survey 2010, Leeds: Health and Social Caremothers but especially with this group, we must see Information Centre.breastfeeding as an embedded and deeply social act.Understanding the context of a young mother’s McCarter-Spaulding D (2008). ‘Is breastfeeding fair? Tensions in feminist perspectives on breastfeeding and the family’. Journal of Human Lactation, 24(2): 206-212. Renfrew MJ, Pokhrel S, Quigley M et al (2012). Preventing disease and saving resources: the potential contribution of increasing breastfeeding rates in the UK, London: Unicef UK. Smith P, Coley S, Labbok M et al (2012). ‘Early breastfeeding experiences of adolescent mothers: a qualitative prospective study’. International Breastfeeding Journal, 7(13): DOI: 10.1186/1746-4358-7-13. Spear H (2006). ‘Breastfeeding behaviors and experiences of adolescent mothers’. American Journal of Maternal/Child Nursing, 31(2): 106-113. Unicef (2012). Guide to the Baby Friendly Initiative standards, London: Unicef. Wilkinson R (1997). ‘Socioeconomic determinants of health: health inequalities: relative or absolute material standards?’ British Medical Journal, 314(7080): 591-595.12 Pallotti, TPM, April 2016, vol.19, issue 4

ADVANCING PRACTICE Marianne Mitchell Senior lecturer in midwifery at University of HertfordshireFGM and midwifery practiceMidwives in the UK should have appropriate education in order to provide optimum care for womenwith female genital mutilation (FGM) and know how to safeguard any children who could be at risk. Inaddition to this, women with FGM have a right to progress though their pregnancy and beyond, safelyand confidently, in a supportive environment, and must be empowered to do so. Efforts are beingstrengthened by the government to tackle the issue of FGM and prevent further cases; therefore all thoseworking in maternity care need to ensure they are equipped to deal with this issue. This article focuseson some of the factors that should be considered in the identification and referral of women with FGM,the planning of their maternity care and related safeguarding issues.INTRODUCTION It is imperative that clear guidance on FGM is developed and implemented within the clinical area,Female genital mutilation (FGM) results in damage so that health professionals are aware of the careto the health and wellbeing of both girls and women required and responsibilities they hold. This shouldand is a practice that clearly violates human rights include a care pathway for pregnant women with(Royal College of Midwives (RCM) et al 2013). With FGM, with relevant safeguarding aspects, as well asthe recognition that FGM should be categorised as an FGM maternity guideline. An example of ana form of child abuse (HM Government 2014; RCM FGM maternity care pathway (MCP) is detailed inet al 2013), come enormous implications for the role Figure 1; this is an adaptation of previous work by theof the midwife in addressing this issue sensitively author and colleague (Flynn and Ablett 2005). Theand effectively. A midwife should not only be FGM MCP reflects recommendations by theexpected to support a woman with FGM safely government and professional bodies and considersthrough childbirth and address any current health the safeguarding measures that should be in place.issues, but also consider the safeguarding aspects It should be used in conjunction with the recentlyfor any girl or woman thought to be at risk. implemented FGM mandatory reporting duty and related resources (Home Office (HO) 2015; DepartmentIDENTIFICATION OF FGM AND of Health (DH) and National Health Service (NHS)MATERNITY CARE England 2015a; 2015b; NHS 2015) and key guidance that has supported its development.The exact number of women who have experiencedFGM has always been difficult to determine (HM Discussion about FGM must always be managedGovernment 2014), but recent statistics are in a sensitive way, but to avoid any confusion whenconcerning, in that approximately 103,000 women of screening for this, direct questions may be usedpotential childbearing age (15-49 years old) affected within the conversation, such as “Have you beenby FGM were residing in England and Wales in 2011 closed? Were you circumcised? Have you been cut(Macfarlane and Dorkenoo 2014). This figure down there?” (HM Government 2014: 21). However,reinforces the need to effectively screen for FGM at the midwife should still be aware that these simplebooking, and refer to a lead FGM midwife and questions can be misinterpreted. For example, aconsultant, so that a plan of care may be initiated woman may think when you are talking about ‘a cut’(Royal College of Obstetricians and Gynaecologists that you are referring to a right mediolateral >>>>(RCOG) 2015). Mitchell, TPM, April 2016, vol.19, issue 4 13

ADVANCING PRACTICEFigure 1 Female Genital Mutilation (FGM) maternity care pathway Key History of FGM • Record history of FGM in maternity An tenatal identified/Family known notes.Intrapartum Postnatal to support FGM. • Assess individual risk. If under 18 yearsSafeguarding of age, refer to FGM mandatory Refer to consultant obstetrician and/or lead reporting duty for action required. midwife for FGM preferably by 16/40. Liaise with local safeguarding Book Interpreter if necessary. Inform team/children and young people’s woman about the appointment. services/multi-agency safeguarding Husband/partner invited to attend. hub (MASH). Woman attends appointment to make a plan for her care.To include: assessment of FGM • Assess risk- find outand current health, options for deinfibulation (necessity, procedure and after care), support thoughts on FGM: would couple perform FGM on required (physical, psychological, social) with referral for psychosexual counselling their own child? Any (if wanted), education about FGM, contact details for FGM specialist services. family members Health and Social Care Information Centre FGM Enhanced Dataset explained. supporting the practice? Any sibling with FGM? Inadequate introitus for a Adequate introitus for a vaginal birth. vaginal birth. No • Discuss health implications of FGM and Deinfibulation offered deinfibulation required. UK legislation. antenatally. May follow normal • Liaise with local Woman declines Woman consents for labour pathway. safeguarding team.deinfibulation procedure. deinfibulation procedure. Report to children and young people’s services Birth plan made and Preparation for procedure. if unborn child/familyrecorded clearly in notes. Deinfibulation performed member at risk. at approximately 20 weeks • Inform key professionals gestation/ at a time involved in care, suitable for woman. outcome of discussions. Refer to birth plan. If deinfibulation Midwife/doctor conducting the birth to be aware of any required: offer choice of vaginal/perineal scarring that could impede the birth.If caesarean section, offerdeinfibulation after this. performing early in Post deinfibulation ensure woman/couple aware that it is labour; if declined, offer against the law to be reinfibulated (ideally discussed antenatally). in the second stage of labour. Lead midwife for FGM to Male child. No further action. follow up all FGM cases/ midwife caring for woman • Inform key health • Liaise with lead midwife for FGM, local safeguarding to note sex of baby. Child not considered to be professionals teams and FGM specialists. at risk - continue to involved in care. Refer to children and young Female child. observe. • Liaise with lead people’s services/MASH midwife for FGM, Refer case to MASH. • Immediate risk - report toRecord history of FGM in local safeguarding police. mother/child records. Observe for teams and MASH. • Inform key health professionals involved in any care. indication • Counsel woman/family members on health that child is implications of FGM and UK legislation. at risk of Child at risk- action FGM. required.Adaptation of previous work by author and colleague (Flynn and Ablett 2005), with reference to key guidance (Home Office 2015; RoyalCollege of Nursing (RCN) 2015; HM Government 2014; RCM et al 2013; RCOG 2015).14 Mitchell, TPM, April 2016, vol.19, issue 4

ADVANCING PRACTICEepisiotomy she has had with a previous birth. inspection. If so, the woman can follow a normal PRACTICE CHALLENGETherefore, it can also be helpful to use terms specific labour pathway. Alternatively, if the woman has type You are a midwife workingto a particular country, as listed by HM Government 3 FGM, known as infibulation, she will require in the community and a(2014), who also outline further questions that could deinfibulation, also sometimes known as a ‘reversal’, young woman attends yourhelp if confusion occurs. Additionally, whilst the which is where the tissue concealing the vaginal antenatal clinic. Sheterm FGM is used among health professionals, less opening and urethral meatus is opened (Royal informs you she has beenoffensive terms (such as female circumcision) College of Nursing (RCN) 2015). It is important to circumcised, but hasshould be considered for a woman’s handheld notes discuss and offer this in the antenatal period so that already been referred (by aor when speaking with her, so as not to cause any it has time to heal and she can potentially be treated previous midwife) to theoffence or distress to the woman and her family. as ‘normal’ in labour. This has huge implications for consultant clinic to discussAdverse reactions from staff have been noted (HM the normalising of childbirth for these women, so this.You notice she is 17Government 2014), which is inappropriate, not only that they may be empowered to make decisions years old, but the policefor the fact that a woman may have already suffered freely and not be subjected to the high risk agenda have not been informed asextensively from the FGM, but this could also impact they would if they remained with a type 3 FGM.This per the new FGMon the overall experience of her pregnancy and would support the RCM evidence-based guidance mandatory reporting duty.birth. In their survey on maternity care, Redshaw to promote midwifery-led care (RCM 2012) and Speak to your localand Heikkila (2010) demonstrated that women want address the woman’s emotional needs more safeguarding midwife/teamindividualised care that is provided in a respectful effectively. The midwife should still be aware of any about what to do in thisand kind manner. They emphasised that if women vaginal and perineal scarring from the FGM and scenario. Explore thefeel able to trust the staff involved, this is a crucial intervene accordingly if progress is impeded in the responsibilities of thefactor as it could affect any decision-making, as well second stage of labour (RCN 2015). Alternatively, the health professional,as their own personal feelings about the care being woman may choose to be ‘opened up’ during labourprovided. So while it is important to address the as this is the custom within her community (RCNissue of FGM, we must not forget the needs of a 2015) and this should be respected. However, thispregnant mother, so that a better relationship is built could place her at risk if a midwife or doctor iswith the woman and her family. unsure of how to perform a deinfibulation in labour, which highlights the requirement for national FGMDEINFIBULATION PROCEDURE education, to promote the safety and wellbeing of both mother and child.The World Health Organization (WHO) classifiesFGM into four types (as detailed in Table 1), but SAFEGUARDING AND adherence to the NMC Coderecognising FGM can sometimes be difficult (DH INTERPROFESSIONAL WORKING and the new FGMand NHS England 2015a). In maternity care, when a mandatory reporting duty.woman is being assessed for FGM, one of the main Efforts are being strengthened by the government Find out what action youfactors to consider is whether the woman has an to tackle the issue of FGM and prevent further cases. would need to take.adequate introitus for the birth of her baby, which is The recent introduction of mandatory reporting toevident if the urethra is easily visualised on the police of girls with FGM under the age of 18 (HO >>>> 2015), emphasises the need to urgently improveTable 1 Classification of FGM (WHO 2008: 4) national services provided for women with FGM and ensure that all midwives feel fully skilled to face Type 1 Partial or total removal of the clitoris this issue. However what needs to be explored and/or the prepuce (clitoroidectomy). further is the scenario where a midwife could potentially miss or fail to report a case of FGM under Type 2 Partial or total removal of the clitoris and his/her care, as this could now be referred as a the labia minora, with or without excision of the fitness to practise issue (HO 2015), in line with the labia majora (excision). Nursing and Midwifery Council (NMC) Code (2015). Until all midwives feel fully competent to screen Type 3 Narrowing of the vaginal orifice with effectively for FGM, this could be a real issue. So if a creation of a covering seal by cutting and case is missed initially, hopefully the situation will appositioning the labia minora and/or the labia be assessed appropriately by the NMC and a majora, with or without excision of the clitoris midwife supported in the right manner. Accurate (infibulation). contemporaneous record keeping by a midwife is going to be crucial, for example in cases where a Type 4 All other harmful procedures to the young woman informs a midwife she does not have female genitalia for non-medical purposes, for FGM, but then later reveals she has, or where it is example: pricking, piercing, incising, scraping difficult to assess if FGM has occurred (as and cauterisation WHO (2008: 4). sometimes a woman does not even know). Guidance has been provided in relation to what comes under Mitchell, TPM, April 2016, vol.19, issue 4 15

ADVANCING PRACTICEPRACTICE CHALLENGE the duty to report to the police and what can be dealt considered. It is by building a supportive andA pregnant woman is 16 with through local safeguarding procedures (DH trusting relationship between midwife and parents,weeks gestation and on and NHS England 2015a; 2015b; HO 2015) and this that key factors such as FGM can be addressedassessment, it is noted she should be followed. effectively. tpmhas type 3 FGM. Thewoman is keen on having Mandatory education on FGM for all health and REFERENCESeverything as normal as social care professionals should be high on thepossible for her labour and agenda, with the introduction of a learning package DH and NHS England (2015a). FGM mandatory reportingbirth, with thoughts about for NHS staff (DH and NHS England 2015b).having a water birth. She Confronting the issue of FGM is a multi- duty: guidance for health professionals, London: DH and NHSwould like to discuss professional issue (RCM et al 2013), so educationoptions that may facilitate that involves the multi-disciplinary team is key, as England. http://tinyurl.com/ zrbzhddher to achieve this. well as the involvement of women fromAs a midwife, consider communities practising FGM (Norman et al 2009) DH and NHS England (2015b). Mandatory reporting of FGM:what options are available and known FGM specialists. Communication skillsfor her, so that she can be should be honed and, to help with this, Health a new professional duty. Training package for NHS organisations,empowered to have the Education England (HEE) (2015) provide an onlinebirth she wants. Look at FGM module which includes videos on how to London: DH and NHS England. http://tinyurl.com/jgfbf8yyour local policy and communicate when discussing FGM.identify whether any Flynn M and Ablett J (2005). FGM care pathway (PILOT).change could be made to Due to the safeguarding aspects, any womanpromote normality. with FGM (regardless of type) should be referred Version 1.2, Reading: Royal Berkshire and Battle Hospitals NHS antenatally to an FGM lead, not only to discuss herPRACTICE CHALLENGE health status, but to find out her thoughts on Trust.Within the next month, whether she would have FGM performed on acomplete the FGM e- female child. The woman should be made aware of HEE (2015). e-FGM educational programme, London: HEE.learning package by HEE current UK legislation on FGM (House of Commons(2015). Read the resources 2003; Her Majesty’s Stationery Office (HMSO) 2015) http://tinyurl.com/ll373j4on the mandatory reporting and as long as it is in the woman’s best interests, itof FGM (HO 2015; DH and is important for her husband/partner to participate HM Government (2014). Multi-agency practice guidelines:NHS England 2015a; 2015b; in these discussions, as it has been noted thatNHS 2015). pressure from other family members can place a female genital mutilation, London: Crown copyright.Share the knowledge you female child at risk of FGM (RCN 2015).The midwifehave gained with your can then ensure that he is also aware, not only of the HMSO (2015). Serious Crime Act: Chapter 9, part 5: Protectioncolleagues and discuss how legislation, but of the health risks associated withyour own practice may be FGM. This opportunity enables a couple to think of children and others: female genital mutilation, London: Crown.improved. about the future of their child’s health and make the right decisions together. Other family members http://tinyurl.com/ zk3s3ev supportive of the practice may also be identified, so the midwife can assess what actions are required at HO (2015). Mandatory reporting of female genital mutilation- this stage, alongside how to support the family. It must be remembered that not every individual or procedural information, London: Crown. family who have experienced FGM will be supportive of the practice themselves and offence http://tinyurl.com/jfgho4m has been caused when this has not been recognised (Norman et al 2009), hence the need for a sensitive House of Commons (2003). Female genital mutilation Bill: a and respectful approach by the midwife. Bill to restate and amend the law relating to female genital CONCLUSION mutilation; and for connected purposes, London: The Stationery There is no doubt that an effective system of care needs to be in place for pregnant women with FGM, Office. and it is critical that all midwives should have the appropriate education to care for these women and Macfarlane A and Dorkenoo E (2014). Female genital safeguard girls who could be at risk. All women have a right to progress through their pregnancy and mutilation in England and Wales: updated statistical estimates of the beyond, safely and confidently, in a supportive environment. It is important that FGM is not the numbers of affected women living in England and Wales and girls only focus of their experience, but, like all women, their needs in becoming mothers should also be at risk. Interim report on provisional estimates, London: City University. NHS (2015). FGM: supporting girls (leaflet for patients), London: NHS. http://tinyurl.com/hppq7yg Norman K, Hemmings J, Hussein E et al (2009). FGM is always with us: experiences, perceptions and beliefs of women affected by female genital mutilation in London. Results from a PEER study, London: Options Consultancy Services and FORWARD. NMC (2015). The Code, London: NMC. Redshaw M and Heikkila K (2010). Delivered with care: a national survey of women’s experience of maternity care 2010, Oxford: National Perinatal Epidemiology Unit, University of Oxford. RCM (2012). Evidence based guidelines for midwifery-led care in labour, London: RCM. RCM, RCN, RCOG et al (2013). Tackling FGM in the UK: intercollegiate recommendations for identifying, recording and reporting, London: RCM. RCN (2015). Female genital mutilation: an RCN resource for nursing and midwifery practice, 2nd edition. London: RCN. RCOG (2015). Female genital mutilation and its management. Green-top Guideline No.53, London: RCOG. WHO (2008). Eliminating female genital mutilation: an interagency statement, Geneva: WHO16 Mitchell, TPM, April 2016, vol.19, issue 4

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SUBSTANCE MISUSE Zoe Hughes Student midwife at Swansea UniversitySubstance misuse: canmidwives really make adifference?Substance misuse makes a woman vulnerable. During pregnancy, in particular, the issues surroundingsubstance misuse and its treatment are very emotive. Pregnancy often prompts women who substancemisuse to seek help for their addiction for the first time, but for some it is part of a cycle of failure andloss: failure at rehabilitation and facing the loss of yet another child, be it through child protection issuesor from the medical complications of addiction. As a midwife only engages with a woman for a relativelyshort period of time, can their actions have a lifelong impact on the woman and her unborn child? Thisarticle aims to examine the stigma of substance misuse and the role a midwife plays, not just as a maternitycare provider but also in the continued journey of the woman and her child. INTRODUCTION This article analyses addiction and its treatment in order to determine the impact a midwife can have Midwives have a duty to meet the psychological and on the care of women and babies affected by SM. social needs of their clients. It is important to consider the psychosocial issues encountered by BACKGROUND each client in order to understand the effect on the health and social well being of mother and child. The World Health Organization (WHO) (2015: 1) One issue encountered in midwifery practice is defines SM as the “…harmful or hazardous use of substance misuse (SM). With some substance psychoactive substances, including alcohol and illicit drugs.” However, SM and addiction are closelyResearch suggests that marginalisation can linked. impact on perinatal care quality O’ Leary et al (2011) define addiction as the uncontrollable urge to carry out a behaviour. As misusing mothers reporting feelings of vulnerability some women report having an uncontrollable urge and judgement from health professionals and to take substances, this suggests that they are society, it is important to understand their needs in addicts. It is important to understand why a woman order to better inform practice for individualised may continue to take substances, despite midwifery care. Research suggests that recognising the potential harm to her baby. marginalisation can impact on perinatal care quality. COMMON PERCEPTIONS Statistics for illicit drug use report a fall in numbers over recent years; it is most popular amongst males from 24-59 years old, with the most common drug18 Hughes, TPM, April 2016, vol.19, issue 4

SUBSTANCE MISUSEreportedly being cannabis (Home Office (HO) 2015).However, when relating to SM, statistics can beunreliable, as they depend on individuals reportingtheir use of substances. As SM is often hidden, it isfeasible that more women are using illicit drugs thanshow in the statistics. Women encountered in midwifery services donot always fit the stereotypical profile of a substancemisuser.THEORIES FOR ADDICTION drug users; they were also more likely than other substances, to link heroin use to criminal offences.Abadinsky (2010) argues that certain people are An interesting explanation for this is the labellingpredisposed to addiction, because of an endorphin theory: this suggests that, once labelled, thisdeficiency, reducing their ability to cope with stress. becomes the individual’s defining quality. TheseHeroin, for example, binds to opioid receptors in the labels lend themselves to assumptions being madebrain and blocks pain messages, making stress by health professionals about substance misuserseasier to manage. This theory may be applied tomaternity service users, as women in today’s society That a woman would choose to takeare facing increasing levels of stress fromexpectations of perfection in work, relationships, drugs despite the risk caused to her childhome life and motherhood. Emotional abuse ofwomen has also been more publicly recognised, goes against society’s belief that a motherevidenced by recent changes in the law, now citingemotional abuse as a criminal offence (Her Majesty’s should protect her childGovernment (HMG) 2015). This is important, asSinha (2008) cites emotional abuse as a key risk and their ability to parent, with Room (2005) >>>>factor for stress-induced addiction and relapse. suggesting that social and health professionals commonly make decisions on behalf of substance Whilst many support the arguments offered by misusers without consideration of their wishes.the neurobiology of drug addiction, others arguethat addiction is a choice. The transactional analysis Although research serves to support the negativetheory of addiction qualifies this by viewing attitudes of society towards SM, women can also besubstance misuse as a conscious decision. The subjected to stigma and prejudice from healthcaresuggestion that a woman would choose to take drugs professionals. Campion (1995) suggests thatdespite the risk caused to her child goes against neonatal intensive care unit nurses sometimes feelsociety’s belief that a mother should protect her anger towards mothers with drug addiction and,child.This in turn may affect how society and health although research by Jenkins (2013) reported thatprofessionals alike view pregnant substancemisusers.STIGMA AND RELAPSEDrug use generates strong views in society. A studyby Barry et al (2014) highlighted that public opinionis often less sympathetic to drug users than to othermarginalised groups within society. Ahern et al(2007) surveyed drug users regarding how they feltthey were perceived by society. Results reported that78 per cent experienced stigma and discriminationassociated with their SM. Based on these findingsand accompanied by some substance-misusingmothers failing to attend antenatal appointments, itcould be argued that women are concerned aboutpublic opinion of them. The media play a role in influencing publicopinion. An evidence review carried out by UnitedKingdom Drug Policy Commission (UKDPC) (2010)showed that tabloid newspapers were twice as likelyto use condemnatory language when talking about Hughes, TPM, April 2016, vol.19, issue 4 19

SUBSTANCE MISUSEmidwives generally have a supporting attitude to have a detrimental effect on the maternity servicewomen using illicit drugs during pregnancy, the experience and the health of both mother and child.findings are not a definitive representation of The role of the midwife as advocate is vital in carewomen’s experiences in general. The consequences planning for women with SM issues. The encounterof such judgements have serious implications, as it women have with a supportive and non-is suggested that prejudice from health judgemental midwife may be considered as a keyprofessionals, in particular, can induce a stress component in the continued health and well beingresponse in an addict, which may lead to relapse. of mother and child. tpmUNDERSTANDING TREATMENT REFERENCESTreatment for drug addiction is often via drug Abadinsky H (2010). Drug use and abuse: areplacement therapy. However, it is important to comprehensive introduction, 7th edition. California:understand how pregnancy affects the metabolism Centage Learning.of drugs such as methadone. Failure to considersuch factors could impact the woman’s ability to Ahern J, Struber J and Galea S (2007). ‘Stigma,successfully manage her addiction. discrimination and the health of illicit drug users’. Drug and Alcohol Dependence, 88: 188-196. Drug therapy treatments should not be used inisolation. Support groups are regarded as vital in the Barry CL, McGinty EE, Pescosolido BA et alcognitive rehabilitation of addiction. It is suggested (2014). ‘Stigma, discrimination, treatmentthat addressing physical and psychological needs is effectiveness and policy: public views about drugthe most successful strategy in the long-term addiction and mental illness’. Psychiatric Services, 65:rehabilitation of SM (Harden et al 2006). 1269.IMPLICATIONS FOR PRACTICE Campion MJ (1995). Who is fit to be a parent? London: Routlege.A midwife plays a vital role in identifying andproviding holistic care. As an advocate, a midwife Downe S, Finlayson K, Walsh D et al (2009).should respect all women, seeking to individualise ‘Weighing up and balancing out: a meta-synthesisher care when other health professionals may make of barriers to antenatal care for marginalised womendecisions based purely on her label as an addict. in high-income countries’. BJOG, 116: 518-529.Midwifery care should be non-discriminatory. This Doi:10.1111/j.14710528.2008.02067.xis important, as Downe et al (2009) reported thatmarginalised groups were more likely to attend for Harden A, Brunton G, Fletcher A et al (2006).antenatal care with non-judgemental health Young people, pregnancy and social exclusion: aprofessionals. Midwives should inform their systematic synthesis of research evidence to identifypractice with an understanding of drug therapy effective, appropriate and promising approaches fortreatment of SM, and with the knowledge of the prevention and support. London: EPPI-Centre.importance of engaging with support groups. Indoing so, women are able to demonstrate that their Hart S (2008). A mother apart, Carmarthen: Crownability to parent is not always impaired by their House Publishing.addiction, thus enhancing the case for women andtheir children to remain together following birth. By HMG (2015). Serious Crime Act 2015 c9, London:supporting women to maintain guardianship of Crown. http://tinyurl.com/jgdekkftheir infants, a midwife is potentially aidingcontinued rehabilitation from their addiction. HO (2015). Drug misuse: findings from the 2014/2015 crime survey for England and Wales, 2nd edition. Hart (2008) supports this by suggesting that the London: Office for National Statistics.shame and guilt associated with having your childremoved from your care can lead to further social Jenkins L (2013). ‘A survey of midwives’ attitudesexclusion and isolation. Isolation is a contributing towards illicit drug use in pregnancy’. Evidence Basedfactor to relapse in drug addicts (Campion 1995). Midwifery, 11: 10-15.This demonstrates that a midwife has a huge impacton the holistic health of marginalised clients and O'Leary J, Warland J and Parker L (2011).their families, not just for the period of time that they ‘Prenatal parenthood’. Journal of Perinatal Education,are within their care, but much longer term. 20: 218-220.CONCLUSION Room R (2005). ‘Stigma, social inequality and alcohol and drug misuse’. Drug and Alcohol Review,Evidence has served to suggest that stress and 22: 143-155.prejudice experienced by substance misusers can Sinha R (2008). ‘Chronic stress, drug use and vulnerability to addiction’. Annals of the New York Academy of Sciences, 114: 105-130. UKDPC (2010). Representations of drug use and drug users in the British press: a content analysis of newspaper coverage, London: Loughborough University. WHO (2015). Substance misuse, Geneva: WHO. http://tinyurl.com/78v6ght20 Hughes, TPM, April 2016, vol.19, issue 4

WOMEN TRAFFICKING Hannah Tizard Second year student midwife and research assistant at University of Central LancashireThe trafficking of womenand the role of the midwife Health can be contextualised in relation to globalisation. Economic and societal influences, increasing gaps between middle income and impoverished groups, mass media, culture sexualisation, consumerism, psychological control and criminal activities, such as the drugs and sex trades, amplify challenges to maintaining the health and wellbeing of populations (Lee 2004). UK policy makers develop tools to determine care pathways, in theory allowing those working in public health roles to support individuals to better long-term health.The health needs of trafficked women and the role of the midwife require particular consideration so that this group is not further exposed and unprotected. It requires partnership with a great number of agencies within healthcare itself, but also with charities, government bodies, external organisations and the police. This article explores the health problems associated with the trafficking of women and the clinical implications in the identification and treatment of these victims for the midwife in a public health capacity.BACKGROUND AND THE LAW including midwives, is limited. The UK’s national referral mechanism (NRM) isGlobal reports suggest 600,000-800,000 men, womenand children are trafficked across international the protocol for the assessment of trafficked victims.borders yearly; around 80 per cent are women and In 2015 the NRM received 3,266 referrals – a 40 pergirls trafficked into commercial sexual exploitation. cent increase on 2014, 53 per cent of which wereNot only does trafficking have a devastating impact female (National Crime Agency (NCA) 2016). It ison individuals who suffer physical and emotional important to highlight that this number onlyabuse and threats against their person and family, it represents those who have had a ‘conclusivedeprives those involved of their human rights and grounds decision’ made and are now recognised asfreedom, fuels the growth of organised crime and victims in the UK. No part of the UK is protectedundermines global health, safety and security. from the activities of highly organised criminal gangs in their exploitation of people and there are The Modern Slavery Act (Her Majesty’s many more who have not been identified.Government (HMG) 2015) focuses on combatingtrafficking, law enforcement and immigration RECOGNISING THE PRESENTINGissues. Hossain et al (2010) argue that a healthcare WOMANstrategy has been largely excluded from politicaldialogue and, as a consequence, current assessment Midwives are unusual in being one of the fewtools and education for healthcare workers, professionals who may interact with women who >>>> Tizard, TPM, April 2016, vol.19, issue 4 21

WOMEN TRAFFICKING have been trafficked and could be still in captivity. for the Adult human trafficking victim care and Trafficked women using maternity services usually coordination contract) it is suggested that it falls present late, antenatal attendance is chaotic and short of requirements. The standard of expert requests for abortions are high; although unknown knowledge necessary to ensure the adequate, to the midwife, the victim may not consent (Baldwin effective care provision of these individuals is so et al 2011). Usually victims are accompanied by a crucial that mistakes are likely to be made during trafficker. Macy and Graham (2012) discuss the role delivery of the service, with inadequate of female sex traffickers, who come across as understanding of the issues (Baldwin et al 2011; trustworthy and are highly effective at gaining the Zimmerman et al 2003). confidence of their victims. Some of these traffickers have grown up in servitude and are still being exploited The Code (Nursing and Midwifery Council in criminal activity.Those accompanying the woman (NMC) 2015) sets out midwifery standards in may appear overbearing and try to control the relation to ethics of confidentiality and consent. The conversation, often interpreting/speaking on behalf leaflet, however, assumes adult consent be given for of the woman. Trafficked women suffer from the referral and does not suggest a course of action multifaceted health problems and often appear in a if the woman does not consent to the referral being state of physical neglect, characterised by low body made. There are unfortunately no figures on how mass indices (BMIs) due to inadequate food and many midwives have seen the leaflet or e-learning water, dental problems due to lack of access to module linked to it, only that dispersal of this health services, symptoms of psychological distress information was facilitated at a local level by due to poor treatment, sexual trauma or self-harm, consultant midwives. Fyle (2013) suggests the best forced or consensual substance misuse and physical course of action a midwife could take in the scenario abuse and, as a consequence, have the potential for of suspected trafficking would be to admit the poor maternal and infant outcomes during and woman for further assessment until further following childbirth (Fyle 2013). Hossain et al (2010) investigation of her circumstances could be made, discuss increased risk of psychological morbidity for thus prioritising the woman’s immediate safety. sex trafficked women, due to these victims having higher levels of post-traumatic stress disorder than CLINICAL BARRIERS even those involved with intimate partner violence and those fleeing war and mass violence. Due to the lack of specific tools, the clinical implications for pregnant victims of trafficking, Midwives making their first assessment of a whether disclosed or not, is that they could be trafficked woman may pick up on subtle clues: body defined under all four categories of the National language, inability to describe their social Institute of Health and Care Excellence (NICE) circumstances, inconsistent and vague medical Pregnancy with complex social factors pathway (2010), history and/or assessment of many of the issues which details guidelines for substance misuse, discussed previously. recent migrants, asylum seekers or refugees, young women aged under 20 and women who experienceMany of these women had the self- domestic abuse. A multi-agency needs assessment coordinated by all agencies helps overcome thebelief and confidence to move away barriers to effective care and develop an individualised care plan. However, this can also pose from the limitations of their initial a challenge to the ideal principal of quality of care through continuity. Current hospital practices aim home environment to overcome these through effective handover, documentation and good communication. PROFESSIONAL RESOURCES Examples of client-led barriers include: fear of In 2013 a leaflet was produced on behalf of the being judged or stigmatised; fear for personal and Department of Health (DH): ‘Identifying and family (back home) safety if they do participate with supporting victims of human trafficking; guidance service provision; lack of language services; limited for health staff’, one of the few documents that understanding or incorrect perceptions of the role currently exist to assist healthcare workers. of healthcare teams, social services and the police; Although the leaflet describes signs and symptoms lack of time professionals have to assess the whole of trafficking, defines the pertinent issues and of a trafficked woman’s situation; and concern over suggests a referral to the Salvation Army (managers payment for healthcare. Zimmerman et al (2003: 66) state that those “providing health services to sex workers emphasised how difficult it is to even ask women about trafficking-related issues because they feel so22 Tizard, TPM, April 2016, vol.19, issue 4

WOMEN TRAFFICKINGlimited in their ability to assist women or to refer of policy, legislation and ethical concerns. The fact Practice pointsthem to other resources”. Today, more than 10 years that there is no specific guidance for midwives tolater, we have the ability to refer to frontline follow, and limited knowledge and understanding of • Enquire about whether yourresponders, but it is suggested that healthcare the deeper issues on the trafficking of women, local trust has a policyprofessionals are largely in the same predicament. hampers midwives’ ‘readiness’ to engage fully in pathway for trafficked women holistic care, reveals incongruence to the If the healthcare professionals have limited underpinning ethical framework of The Code (NMC • Familiarise yourself with theunderstanding of the resources and organisations 2015) and Midwifery 2020 report (Chief Nursing DH leafletavailable to trafficked women, how is it possible for Officers of England, Northern Ireland, Scotland and http://tinyurl.com/juy8lrrtrafficked women to receive the information and Wales (CNOs) 2010). tpmhave the confidence required to initiate changes to • Use professional intuitiontheir lives? REFERENCES when assessing womenNON-JUDGEMENTAL APPROACH Antonovsky A (1996). ‘The salutogenic model as • Take the time to reflect on the a theory to guide health promotion’. Health whole picture: what’s missing?Many midwives may view a trafficked woman as Promotion International, 11(1): 11-18. http:// What doesn’t add up?afraid, anxious and paralysed by the constraints of tinyurl.com/go48jx6her situation, which is of course likely; however, • Act on your thoughts and takeHossain et al (2010) remind us that many of these Baldwin S, Eisenman D, Sayles J et al (2011). any concerns to a managerwomen had the self-belief and confidence to move ‘Identification of human trafficking victims in healthaway from the limitations of their initial home care settings’. Health And Human Rights, 13(1): 36-49. • Passionate about this topic?environment, whatever that may have been. In this http://tinyurl.com/jmp2c3q Start a new initiative in yourway a salutogenic approach can be utilised: rather areathan view the woman as powerless, healthcare CNOs (2010). Midwifery 2020 Deliveringprofessionals can help enable manageability, Expectations, 1st edition. London: Midwifery 2020comprehensibility and meaningfulness by Programme. http://tinyurl.com/kdp3emnencouraging a woman’s belief in her ability to movetowards better health (Antonovsky 1996). In helping DH (2013). Identifying and supporting victims ofthe woman to find ways to cope with her situation human trafficking: guidance for health staff, 1st edition.and access resources, the professionals may reignite London: DH. http://tinyurl.com/bnjrnssher belief that change can happen. However, it issuggested that a holistic salutogenic concept also Fyle J (2013). ‘How midwives can identify andrequires services which promote health generally, support trafficked women’. Nursing Times, 109(24): 25.which are readily and easily accessible to all, and http://tinyurl.com/zurrv7ywhich include forging trusting relationshipsbetween healthcare provider and the service user. HMG (2015). The modern slavery Act, London:Indeed in 2003, Zimmerman et al identified that Crown. http://tinyurl.com/jbkf8flhealthcare workers felt that trafficked women’soverall welfare depended on quality services that Hossain M, Zimmerman C, Abas M et al (2010).focused on general health promotion, alongside ‘The relationship of trauma to mental disordersother practical forms of assistance aimed at among trafficked and sexually exploited girls andestablishing women’s self-determination (such as women’. American Journal of Public Health, 100(12):legal aid, community support and language lessons). 2442-2449. http://tinyurl.com/ja2szyvAgain this highlighted the need for effective multi-agency working in order to facilitate the Lee K (2004). ‘Globalisation: what is it and howreintegration of women into society. What is does it affect health?’ The Medical Journal of Australia,important, it seems, is the all-encompassing 180(4): 156-158. http://tinyurl.com/j84e66krequirement for a holistic approach to care. Macy R and Graham L (2012). IdentifyingFAILURE IN CARE? domestic and international sex-trafficking victims during human service provision. Trauma, Violence,Patient safety and protection from harm are and Abuse, 13(2): 59-76. http://tinyurl.com/hazuef5paramount but complex factors that require deepunderstanding and this is often a factor in NCA (2016). National referral mechanism statistics –determining the success or failure of the care end of year summary 2015. London: NCA.provided. The concurrent positive and negative http://tinyurl.com/jm4aryqimplications of globalisation on public health add toits complexity and, arguably, it could be construed NICE (2010). Pregnancy and complex social factors,that effective healthcare provision is becoming clinical guideline 110, 1st edition. London: NICE.much more difficult to deliver, lost in the intricacies NMC (2015). The Code, London: NMC. http://tinyurl.com/jnq63o8 Zimmerman C, Yun K, Watts C et al (2003). The health risks and consequences of trafficking in women and adolescents findings from a European study, 1st edition. London: London School of Hygiene and Tropical Medicine. http://tinyurl.com/ hhpqq3r Tizard, TPM, April 2016, vol.19, issue 4 23

MATERNAL DEATH Samantha Whelan Community and research midwife at the Pennine Acute NHS Trust The emotional impact of a maternal deathThis article explores the COMMUNITY MIDWIFERY feelings, which may add pressure to the midwifeemotional impact that when trying to balance her personal andmaternal death has upon The primary role of a community midwife is to care professional self throughout the grieving processmidwives - in particular for women and their families throughout the (Wright 1996). The midwife’s feelings are likely tocommunity midwives - and childbirth continuum. Community midwives tend to include shock, anger, bargaining, depression andhow they cope with grief and become embedded within the geographical area finally acceptance of the loss (Kubler-Ross andcritical incident stress. This is where they practise, often caring for women in and Kessler 2005).because there is little written friends of the same family. Community midwiveswithin the literature about the are in a privileged position of caring for and CRITICAL INCIDENT STRESSexperiences of community supporting women throughout their pregnancy,midwives following a present at their births if they opt for a home birth, The personal consequences and initial reactionsmaternal death. The and witness a new family unit at home. Community experienced by midwives when there has been ainspiration for writing this midwives report it is this that gives them a sense of sudden death in the workplace are often referred toarticle comes from Samantha’s fulfilment and job satisfaction (Hunter 2006). There in the literature as ‘critical incident stress’. This is aown experience as a is a negative aspect to the role of a community broad term that is used to describe cognitive,community midwife. Points for midwife and this is usually when they need to physical, emotional and behavioural responsesdeveloping practice are also support women through pregnancy loss, such as a when individuals are exposed to extreme situationsconsidered. miscarriage or a stillbirth. Midwives are also that would not normally occur in their life or involved in the care of mothers who die, either workplace, such as a maternal death (Caine and Ter- during pregnancy, labour or postnatally. However, Bagdasarian 2003). such traumatic events are relatively uncommon in the UK when compared with other countries (World PSYCHOLOGICAL IMPACT Health Organization (WHO) 2015), so community midwives are not often required to offer support to The distress that midwives experience following a bereaved families. maternal death may impair their overall well being. Some midwives experience flashbacks. In addition THE GRIEVING MIDWIFE it has been suggested that the impact on midwives who are pregnant when the death occurs can Regardless of where they practise, having cared for contribute to a fear of their own upcoming a woman who then dies, midwives experience the childbirth. For students, especially direct entry same feelings as lay people, and they usually need students who may have no prior experience of a to go through a grieving process. A maternal death death in the workplace (unlike short course students can have a particularly detrimental effect on the who may have experienced death on a nursing community midwife, her grief and sense of loss even ward), a maternal death will likely lead to lasting greater than that of others not in the community psychological effects (Mander 2004). For midwives (Mander 2004). This is because continuity of carer and students this can include panic attacks, lack of and relationship-building are fundamental stamina, sleep disturbance and poor concentration principles of providing good midwifery care (Hunter (Caine and Ter-Bagdasarian 2003). et al 2008). So when a death occurs, the midwife may experience a blurring of personal and professional EXPOSURE TO MATERNAL DEATH boundaries during the grieving process. It is also often anticipated by the public, and midwifery It is probably assumed that the more exposure to a peers, that professionalism will override personal critical incident, such as a maternal death, the less the emotional, physical, cognitive and behavioural24 Whelan, TPM, April 2016, vol.19, issue 4

MATERNAL DEATHimpact. However, a qualitative study conducted in move forward. Brosche (2007) says the developmentUganda by Muliira and Bezuidenhout (2015) of a team of professionals who can apply theconcluded that, even when midwives are exposed to principles of debriefing the staff during this processmaternal death on a regular basis, feelings of stress, is essential, because it may reduce the effects ofanxiety and poor mental well being are still evident. critical incident stress, reduce post-traumatic stressUnfortunately, regardless of where, how or when a syndrome and facilitate midwives to work throughmaternal death occurs, the impact and subsequent the grieving process. However, to enable this toexperience of critical incident stress is widely felt. In happen a leadership culture that encouragesaddition it has been suggested by Caine and Ter- midwives to reflect within a non-blame culture isBagdasarian (2003) that this may lead to poor necessary (Garko 2007).practice, which can have a detrimental effect uponthe women. Ultimately midwives may be putting CONCLUSIONtheir professional registration at risk. It is clear from the evidence that midwives who areCOPING STRATEGIES exposed to a maternal death, experience a myriad of feelings in the workplace and in their personal lifeThere are wide variations in the coping strategies (Caine and Ter-Bagdasarian 2003). It is unlikely thatused by midwives when dealing with critical a midwife will ever get over the death of a mother.incident stress following the death of a woman. However, to enable midwives to deal with their grief,Some of this will depend on the midwife’s own or cope with clinical incident stress following aexperience of death in her personal life (Cook and maternal death, policies within the workplace thatPhillips 1988). These include, but are not limited to: enable midwives to openly share their experiencesincreased or decreased appetite, increased without fear of blame need to be developed (Broscheconsumption of alcohol and smoking. Additionally, 2007). tpmsome midwives develop a rigid routine as a way ofbringing order back to their chaotic feelings, and use REFERENCESavoidance tactics in the workplace as a way ofprotecting themselves from further exposure to a Brosche T (2007).‘A grief team within a healthcaresudden death (Muliira and Bezuidenhout 2015). system’. Dimensions of Critical Care Nursing, 26: 21-28.Some midwives also avoid discussing the incidentand sharing their feelings with their peers, as a way Caine R and Ter-Bagdasarian L (2003). ‘Earlyof protecting their colleagues. Mander (2004) identification and management of critical incidentsuggests that this is because death in midwifery is a stress’. Critical Care Nursing, 23: 59-65.taboo subject. However, midwives should beencouraged to share their feelings to try and dispel Cook B and Phillips S (1988). Loss and bereavement,maternal death as a taboo subject. This is because it London: Austen Cornish Publishers.may help them cope and process their feelings. Inaddition, sharing their emotions, experiences and Garko C (2007). ‘Painful lessons: when a motherknowledge may educate colleagues who have had dies, staff must grieve – and then learn’. Ass Women’sno exposure to a maternal death. Health Obstetric and Neonatal Nursing, 11: 357-361.SUPPORT FOR MIDWIVES Hunter B (2006).‘The importance of reciprocity in relationships between community-based midwivesEvidence suggests that staff should be offered a and mothers’. Midwifery, 22: 308-322.formal debrief following a maternal death, but theycan be reluctant to participate in this for fear of Hunter B, Berg M, Lungren I et al (2008).divulging gaps in their practice, which may lead to ‘Relationships: the hidden threads in the tapestry ofblame (McReady and Russell 2009). However, after maternity care’. Midwifery, 24: 132-137.liaising with midwifery colleagues from around theUK I have found that many midwives, especially Kubler-Ross E and Kessler D (2005). On grief andcommunity midwives who may not be directly grieving: finding the meaning of grief through the fiveinvolved in the critical incident on the unit, are not stages of loss, New York: Scribner.offered emotional support via a formal pathway.When considering how many midwifery staff may Mander R (2004). ‘When the professional getsbe continuing to practise with the burden of a personal – the midwife’s experience of the death ofmaternal death, whether they were involved in the a mother’. Evidence Based Midwifery, 2: 40–45.incident or not, it is paramount that support isoffered to them. This is because midwives need the McReady S and Russell R (2009). ‘A nationalopportunity to process their feelings before they can survey of support and counselling after maternal death’. Anaesthesia, 64: 1211-1217. Muliira R and Bezuidenhout M (2015). ‘Occupational exposure to maternal death: psychological outcomes and coping methods used by midwives working in rural areas’. Midwif, 31: 184-190. WHO (2015). World health statistics, Geneva: WHO. Wright B (1996). Sudden death: a research base for practice, 2nd edition. NewYork: Churchill Livingstone. Whelan, TPM, April 2016, vol.19, issue 4 25

SURVIVING RAPEStudent midwifeThe author wishes to withhold her name, as writing the article has contributedto her recovery and she is now ready to move forward from this experienceWe are vulnerable, too My transition to becoming a student midwife has not been straightforward: I bring baggage. I was raped 11 years ago and buried it, so did not consider that becoming a midwife would pose any problems. Little did I know that this journey would make me question my own experiences of pregnancy and motherhood, and would bring the rape and subsequent termination to the forefront of my mind, forcing me to confront issues that I would have preferred to leave unearthed. Reading around the subject has helped me to understand emotions that have surfaced, and put a name to how I am feeling, yet certain procedures in practice make me uncomfortable. It is thought that 20 per cent of women aged 16-59 have experienced a sexual assault of some type since turning 16 (Rape Crisis 2015), so being sensitive to vulnerabilities faced by service users, students and colleagues is crucial. I do not make recommendations for practice, but the reference list provides a starting point for those who wish to read more extensively.Everything I am, and everything I have seen, remember the details; but the experience hangs I bring to midwifery. I am a 'survivor' of around my neck like an albatross. It is my cross to rape, although some days I feel as though I bear and I loathe who I am because of it. Physical can barely keep my head above water. pain is easier to feel, easier to live with. A slice in myGarratt (2011) wrote about the potential sequalae of arm, a scratch on my hand: mutilation offers respitechildhood sexual abuse (CSA), and it is the same for as well as a reminder of the damage done. He laidrape: inability to trust others, feelings of shame, the first bricks in the fortress I have since builtpowerlessness, fear of intimate relationships, around myself for protection, yet secretly I want aflashbacks and dangerous sexual practices. Both hug from that one person who isn't scared to holdCSA and rape have long-lasting effects: depression, me until they break me. Some days I wonder whylow self-esteem, and destructive behaviours, nobody can see that I am drowning.including self-harm (Squire 2003; Hanan 2006;Garratt 2011). INSIGHTMY EXPERIENCE Reading around the subject of survivors of abuse and their experiences of maternity care has givenI was raped when I was 20 years old. He was me an insight into my own experience (Montgomerysupposed to be a friend; he walked me home, made et al 2015a; 2015b). I concealed the rape andsure I got inside my house safely, then raped me. termination from everyone: friends, family,Afterwards he was apologetic. He'd broken me and midwives. I desperately wanted to be the easiestall I wanted was to scrub my body clean. An even woman to care for and hated having to makecrueller blow was finding out he'd left me pregnant. demands on the midwives, and elements of myAs I write this I feel devoid of all emotion apart from labour reminded me of the feelings I associate withthe shame at what he did to me and the termination rape. I couldn't bear my husband being near and II had subsequently. sent him away so I could be alone to labour. I felt disempowered, particularly by the staff's insistence My memory has spared me somewhat: I don't26 TPM, April 2016, vol.19, issue 4

SURVIVING RAPEMAURO FERMARIELLO/SCIENCE PHOTO LIBRARY that I had an epidural early on: I dreaded the longer I spend without doing one, the bigger the immobility and the increased vulnerability this obstacle it becomes in my mind. When is consent presented. I gave birth shortly after shift change and fully informed? How do I ensure that the balance of had unknown midwives pinning me to the bed. I power tips in favour of the woman? How can I carry was bruised the length and breadth of my body for out a procedure that makes me feel as though I am weeks, with fingerprints covering my arms. I looked abusing my position? These are the questions I and felt as though I had been attacked, but for years torment myself with on the bad nights when sleep I have shouted about my positive birth experience. won't come. My default coping strategy is 'block it out, pretend it didn't happen'. Last week came my biggest test yet: fetal blood sampling (FBS). I have vivid pictures in my mind of AND SO TO MIDWIFERY... the FBS being performed, not once but twice. The scene of power and submission being enacted, the A decade of denial meant that I approached my tears rolling down the woman's face. She wasn't studies without a care in the world, but midwifery crying for her unborn baby's safety – I know because has made me feel as though the contents of my brain she told me when I visited her on the postnatal ward have been tipped onto the floor: a million drawing the next day. It was the internal examination for the pins I'm trying to negotiate my way through. FBS that was the end of the road for her, and the Practice placements have revealed scars and opened second one was even worse. I was strong for her, yet old wounds, and I wonder why, when I am so inside I was crumbling and I sobbed all the way traumatised by my own experiences, I was drawn to home that night. This experience brought home midwifery – and love it wholeheartedly. There are everything that I had been dreading this year. good days and bad days in practice, and mercifully the latter are few and far between – the days when I I was strong for her, yet inside I was can't bear to hear my own name said aloud, when I want to peel the skin away from my flesh, when crumbling and I sobbed all the way making eye contact with other people makes me want to turn out the lights. For those days I have a home that night team of courageous and loving women who have already picked me up countless times and THE FUTURE: RECOMMENDATIONS FOR encouraged me to stick with it. PRACTICE Abdominal palpation was the first hurdle at Rape has altered the trajectory of my life and has which I fell. It was not the issue of touch that had devastating consequences, but it has led me to bothered me, but rather the feeling of power and midwifery and has made me who I am today. I need >>>> dominance as women lay prone on a bed and I palpated. Vaginal examinations (VE) are my next hurdle. They make me want to run away, and the TPM, April 2016, vol.19, issue 4 27

SURVIVING RAPE to use my experience and reflect upon it to inform no reaction; I felt judged. The second one told me my future practice. Three distinct concerns are that she had been waiting for me to approach her pivotal for me: consent; being with woman; and non- about the subject as she hadn't wanted to push me. judgemental care. She didn't read the original reflection upon which this piece is based as she didn't think I was ready to • Gaining consent – I have triumphed over share it, but she appreciated that I trusted her abdominal palpations in the past few months. I enough to send it. We then went on to have a approach them with confidence and kindness, conversation during which I cried and she gave me asking the woman whether she would like to get on practical advice. The point is that sometimes you the bed so I can have a feel to see where her baby is, don't need to know the details in order to be talking to her while I palpate. Her consent allows me empathetic and compassionate. I haven't even to proceed, both mentally and physically. uttered the word rape aloud to her: she didn't care what had happened to me and didn't judge me. Will I know that I may never conquerVEs. My mentor what I know about a woman's life alter the way in has suggested that I either approach it as a purely which I treat her? No. Everyone deserves kindness, clinical procedure (we both know this is not an respect, dignity, love, help, compassion, freedom of option), or to be so completely focused on the choice – mothers, midwives, students. I deserve it no woman that I talk her through it every step of the more and no less because somebody decided to rape way. The Nursing and Midwifery Council (NMC) me. Code demands that fully informed consent be obtained before any procedure (NMC 2015), yet I My final thought is this: if you find out about me have occasionally seen practitioners with their then please don't pity or judge me, don't patronise gloves already on, while looming large over a me by telling me the rape wasn't my fault. I know it woman and telling her why a VE needs to be wasn't, it was definitely his. You don't know how I performed.The manner in which I gain consent, and feel, or why I am scared of the dark, why I don't trust the use of both verbal and non-verbal you easily, why I value friendships so fiercely, why I communication is at the forefront of my mind; care so passionately about the work I do, why my women need to be given the power and the voice to brain never seems to give me a minute's peace, why express their concerns and ask questions before they I self-harm sometimes, why I hate myself some days, are touched, before they are subjected to a why I cherish a good day because another one may procedure that is presented as a foregone be a long way off. I don't pretend to know the conclusion. women I meet, and I think they sense that I see them as individuals. To me their life story is largely Everyone deserves kindness, respect, irrelevant: they are all women and I am here to do the same job for them all. tpmdignity, love, help, compassion, freedom of REFERENCES choice – mothers, midwives, students Garratt L (2011). Survivors of childhood sexual abuse • Being with woman - I remember how lonely it and midwifery practice: CSA, birth and powerlessness, felt to wake up after general anaesthetic following Abingdon: Radliffe Publishing Ltd. the termination. I don't remember a single person who was kind to me or who sat and talked to me. Hanan MR (2006).‘An experience of sexual abuse, grief and its effects on childbirth’. MIDIRS Midwifery As a student the thing I love the most is talking Digest, 16(1): 37-41. to women. All shifts are rewarding, but the most gratifying was spent with a postnatal woman with a Montgomery E, Pope C and Rogers J (2015a).‘The history of self-harm and depression: I listened as she re-enactment of childhood sexual abuse in talked and held her hand as she cried. I have learnt maternity care: a qualitative study’. Bio Med Central so many things about midwifery in the past year, but Pregnancy and Childbirth, 15: 194. the biggest lesson is that being a decent person counts for so much and may just be the thing that Montgomery E, Pope C and Rogers J (2015b). ‘A makes someone's day. feminist narrative study of the maternity care experiences of women who were sexually abused in • Non-judgemental care – I recently let two childhood’. Midwifery, 31(1): 54-60. people read about my experiences and had two very different reactions.The first read my email and gave NMC (2015). The Code, London: NMC. http://tinyurl.com/jnq63o8 Rape Crisis (2015). Statistics, London: Rape Crisis. http://tinyurl.com/zuvkyw9 Squire C (2003). ‘Childbirth and sexual abuse during childhood’. In: Squire C (ed). The social context of birth, Abingdon: Radcliffe Medical Press.28 TPM, April 2016, vol.19, issue 4

MIDWIFERY BASICS: PRECEPTORSHIPMegan Blease Kerry Taylor ACTVITY 1 As a preceptor, reflect back toPreceptorship support Midwifery lecturer at when you first startedmidwife at East Lancashire University of Central suturing. How did you learnNHS Trust Lancashire to suture? How did you feel? Do you have any tips that you7. Perineal suturing could pass on to your preceptee or other midwives Preceptorship is the 15th series of ‘Midwifery basics’ targeted at practising midwives. The aim of these that may help them to learn? articles is to provide information to raise awareness of the impact of the work of midwives on women’s experience, and encourage midwives to seek further information through a series of activities relating to the topic. During the transition from student midwife, the newly qualified practitioner (NQM) is required to obtain experience of perineal suturing. With exposure varying from student to student and inconsistency in teaching methods between hospital trusts, the NQM can be left feeling apprehensive and unsupported to learn this skill. Suturing is a major and sometimes traumatic event for childbearing women, whose experience can vary greatly, depending upon many factors, including environment, skill of those suturing, effective analgesia and waiting times. In this penultimate article of the series, Megan Blease and Kerry Taylor address the current issues and provide learning hints and tips for NQMs learning and practising the skill.INTRODUCTION PREPARATION, EXPLANATION AND CLASSIFICATIONNo two births are the same and perineal traumavaries from woman to woman. Whilst it is common As perineal pain is one of the most commonlyduring vaginal birth, known to occur in almost 85 reported maternal problems, its effects can impactper cent of births (Royal College of Midwives (RCM) on postnatal recovery (Bick et al 2012; National2012), perineal trauma will not always require Institute of Health and Care Excellence (NICE)intervention. Yet it is the management of 2014). Contributing factors include severity ofintervention that has the greatest effect on women. trauma, technique of repair, type of suture usedWithin your midwifery education, it is likely you will and the skill of the practitioner (RCM 2012). It ishave been exposed to perineal trauma, witnessed important to consider the woman’s wishes prior toperineal repair or even had hands-on practice commencing perineal repair. Consent is key, asexperience in workshop sessions or with direct with any intervention, and a full explanation ofsupervision. However, once qualified, you are the procedure and after care is necessary to ensure alead professional for birth, and the responsibility for fully informed decision. Prior to commencingsuturing may lie with you; this can be a daunting suturing, a clear assessment of the severity ofprospect to begin with. trauma or episiotomy should be considered (See Box 1). As with any skill, suturing develops withexperience. Exposure to learning opportunities and It is recommended if the extent of perineala clear understanding of current evidence and local trauma is uncertain, a second opinion shouldpolicies will support you in the process. obtain from a more experienced practitioner; this may be a midwife or doctor. In cases where a third- This article addresses key points in helping you or fourth degree tear is suspected, obstetric reviewto develop your skill in performing perineal is necessary. As a newly qualified midwife, it issuturing, and looks at the role of the midwife in normal to need help in accurately assessing >>>>providing effective perineal care. Blease and Taylor, TPM, April 2016, vol.19, issue 4 29

MIDWIFERY BASICS: PRECEPTORSHIP ACTVITY 2 Box 1 Severity of the perineal injury DEBATING THE EVIDENCEIf you are a preceptee, howdo you feel about suturing? • First degree – injury to the skin only Debates surrounding many areas of suturing canDo you feel confident in • Second degree – injury to the perineal muscles cause further confusion when developingclassifying the degree of tear? confidence in suturing. It is widely researched thatIf you have started to suture, but not the anal sphincter the use of absorbable sutures is the most effective atwhat aspects do you feel you • Third degree – injury to the perineum involving reducing perineal pain, when compared with non-could improve on and in absorbable sutures (Kettle et al 2010; RCM 2012).which ways? the anal sphincter complex: Kettle et al (2007) concluded that the continuous 3a less than 50 per cent of external anal suturing method for episiotomies and second ACTVITY 3 sphincter thickness torn degree tear repair was best practice in reducingHow do you feel you can 3b more than 50 per cent of external anal short-term pain. However some consider that topractise suturing more sphincter thickness torn ensure optimal wound healing, continuous suturingeffectively? What 3c internal anal sphincter torn needs to be limited to the posterior vaginal wall andopportunities are there in • Fourth degree – injury to the perineum skin, with interrupted sutures to deep andyour trust to learn this skill? involving the anal sphincter complex (external superficial muscles. The evidence to support this,Do you have any tips to help and internal anal sphincter) and anal however, remains slim.The accurate assessment andothers learn to suture more epithelium appropriate repair of perineal trauma requires greateffectively? How can you gain skill and competence, ensuring tissues andmore experience suturing? Royal College of Obstetrics and Gynecologists structures are aligned correctly to promote healing (RCOG) 2015 and minimise morbidity (Bick et al 2012; Dahlen and Homer 2008).The support of sufficient schooling and perineal trauma, and one-to-one support will be hands-on experience had been shown to improve required when learning to develop the skill of skills and the understanding of perineal anatomy suturing (See Box 2). (Wilson 2012). Yet incorporating these within mandatory education can prove time-consuming, Within a clinical environment with high levels costly and without evidence base. It is, however, of activity, developing this skill can be challenging, considered that attendance at such sessions within and seeking opportunities for experience, wherever the preceptorship period can enhance confidence, possible, is key. If suturing exposure is not familiarity and understanding. This helps ensure encouraged or facilitated, the skill may not be that, as a newly qualified midwife, you feel more achieved within the period of preceptorship. confident to gain further hands-on experience. However, it is desirable to obtain such experience whilst in an area of support. If the clinical skill has TO SUTURE OR NOT TO SUTURE? not been developed during preceptorship, it could directly affect care, increasing both lack of Inconsistency in practice can prove a challenge continuity and waiting times for suturing. when learning a new skill, and suturing is no exception. Second-degree tears are not always Experience may be sought in other ways, such sutured, although evidence is limited to support this as attendance at perineal suturing workshops to (RCM 2012; Cioffe et al 2010). The RCM (2012) practise within a safe learning environment, advises that practitioners must be cautious when surrounded by others who wish to enhance their leaving trauma un-sutured, with careful knowledge and skills. Structured hands-on consideration given to the woman’s wishes, and learning can be effective in helping to identify clearly documented discussion, with risks explained. perineal trauma, with an increased vigilance in the Non-suturing of a second-degree tear could result recognition and detection of third- and fourth in poorer cosmetic results, although there is limited degree tears (Wilson 2012). Sub-standard perineal evidence to suggest any impact upon healing and trauma assessment and repair can lead to both pain at six weeks, urinary stress incontinence or short- and long term morbidity for women, resumption of sexual activity (Cioffi et al 2010). whereas a high level of theoretical knowledge and clinical skill can ensure that perineal tissues and REDUCING PAIN AND DISCOMFORT structures are aligned correctly to promote healing (Ismail et al 2013). On the other hand, learning With pain and waiting times causing the most cannot simply be done in a classroom, and clinical significant discomfort to women in suturing, skills can only be developed with hands-on consideration should be given to the effectiveness of experience facilitated by effective preceptorship per rectal anti-inflammatory analgesia and the and clinical support. benefits of reducing the interval between birth and suturing (East et al 2012). Certain situations causing delays may be unavoidable, such as the practice of allowing one hour following pool birth, the need for >>>>30 Blease and Taylor, TPM, Aprl 2016, vol.19, issue 4

MIDWIFERY BASICS: PRECEPTORSHIP Box 2 Step by step guide to suturing • Ensure each stitch is 5-10mm away from the ACTVITY 4 wound edges Whilst suturing how do youPreparation set up your environment? Do• Determine the type of trauma sustained (shown in • Continue with continuous non-locking sutures, you think about your own ensuring there are no areas of dead space until the posture as well as the comfort Box 1); ensure a per rectum examination is hymenal remnants are reached; use one more of the woman? What performed at this stage to assess the grade of tear suture at the hymenal ring challenges do you have when• Fully inform the woman and her birthing partner suturing and what do you of the process and the need for suturing. Gain her • To tie off the posterior vaginal wall layer, return think you could do differently consent further back and insert another stitch, using the to overcome these?• Ensure the woman is in a comfortable position and surgeon’s square knot; cut off both ends of the there is a suitable light source (this may need to be suture material ACTVITY 5 adapted dependent on where the birth has taken How do you advise women place) • If a fully continuous approach is adopted, return afterwards about ongoing• Prepare all the equipment (as shown in Box 3) that the needle back through the sutured posterior care of their perineum? How you require before assisting the woman into vaginal wall and locate the deepest point of the can we improve this advice? lithotomy deep muscle wound• Place all of your equipment onto a clean trolley, using a sterile technique Suturing the deep muscle layer• Check and count all swabs, instruments and • Having located the deepest point of the deep sutures with your assistant• If assistance is available, ask for help to support muscle wound, take a large ‘bite’ of muscle from you both sides, tying off with a surgeon’s square knot• Ensure the woman has inhalation analgesia to and cut off hand for when it is needed and offer to continue • Continue with the same until as close to the skin skin-to-skin, dependent on maternal choice layer as possible, ensuring no areas of dead space• Gain consent to help the woman adjust her are left position to ensure comfort and correct suturing position Suturing the skin layer• Support the woman into lithotomy and ensure she • If the muscle layer is closed and there is no gaping, is comfortable with modesty maintained until the start of the procedure the skin may be left• Once all the equipment is prepared, wash hands • If skin requires suturing, take a small ‘bite’ in the and apply the sterile gown and gloves provided• Ask the person helping you (if available) to adjust superficial muscle layer close to the skin apex, with your lighting and ensure this is done in a sterile a smaller needle manner • Then with the suture needle facing upwards take a 5-10mm ‘bite’ of the subcutaneous layerInfiltrating the perineum • Take a similar ‘bite’ on the opposite side, slightly• Ask the woman to use the inhalation analgesia as lower than where the previous suture exited, and continue in this way until the hymen ring is she wishes and inspect the perineum again to reached locate the apex • Then insert the needle back into the vagina, behind• Gain consent and infiltrate the perineum the hymenal remnants• Using a 20ml syringe with 20mls of 1 per cent • Complete the repair by tying a final knot within the lidocaine and a large needle, begin by inserting the vagina – not at the forchette, but further behind needle along the posterior vaginal wall• Retract the needle but do not remove and infiltrate After suturing is complete the deep and superficial muscles with a ‘fanning’ • Check all sutures again and a final check of the motion• Continue to do this until nearer the skin and ensure perineum to ensure no areas have been missed or analgesia is injected along the subcutaneous skin blood loss can be observed line • Gain consent and give PR analgesia, if appropriate• Repeat for both sides • Explain the perineal care and procedure performed• Ensure five-10 minutes are allowed for the • Document clearly the suturing notes analgesia to take effect, and test the area before Count and check swabs, needles and instruments commencing suturing with your assistantSuturing the posterior vaginal wall Box 3 Equipment you will need for suturing• Inset the first suture 5-10mm above the apex to • lithotomy poles (or a • a filter needle secure the first stitch and secure the first stitch suture bed) • a needle for with a surgeon’s square knot (Instructions listed in Box 4) • a sterile flat surface infiltration• Cut off the shorter end and leave the end attached or trolley • aquagel to the needle, leaving 1-2cm • PR anti-inflammatory • a suturing set (with • water instruments) • sterile swabs • 2.0 suture • a suturing pack • 4.0 suture • a 20ml syringe • 20ml 1 per cent lidocaine Blease and Taylor, TPM, April 2016, vol.19, issue 4 31

MIDWIFERY BASICS: PRECEPTORSHIP ACTVITY 6 Box 4 How to tie a surgeon’s square knot a preceptorship development package, whilst othersHow do you assess the may not.healing process of a perineal • Using the forceps, take hold of the loose end oftear? What do you advise suture material In summary, where possible, this vital skillwomen about this process? should be developed at a very early stage in order to • Wrap the longer end of material three times improve confidence and, in turn, women’s ACTVITY 7 around the forceps in a clockwise motion experiences and outcomes. tpmHow would you manage asituation where a woman • Pull to allow the knot to slip off the forceps and REFERENCESdeclined suturing? What are secure the stitchthe guidelines in your area? Bick D, Ismail K, Macdonald S et al (2012). ‘HowWhat does your Head of • Repeat in an anti-clockwise motion and then good are we at implementing evidence to supportMidwifery advise? clockwise again for a total of three times the management of birth related perineal trauma? A UK wide survey of midwifery practice’. BMC • Once the knot is complete, cut off if Pregnancy and Childbirth, 12(57): 1-10. appropriate, or cut shorter end if undertaking a continuous suture Cioffi J, Swaine J and Arundell F (2010). ‘The decision to suture after childbirth: cues, related further inspection of the perineum or, of course, factors, knowledge and experience used by through maternal choice. However, where possible, midwives’. Midwifery, 26: 246-255. suturing should be done in a timely manner, avoiding unnecessary delay. Dahlen H and Homer C (2008). ‘What are the views of midwives in relation to perineal repair?’ EDUCATION Women and Birth, 21(1): 27-35. Certain antenatal and intrapartum measures could East C, Sherburn M, Nagle C et al (2012).‘Perineal be offered to help alleviate perineal discomfort and pain following childbirth: prevalence, effects on reduce the likelihood of tears, as discussed by East postnatal recovery and analgesia usage’. Midwifery, et al (2012): perineal massage, the use of warm 28(1): 93-97. packs, the use of water in labour and maternal position in the second stage can all make a Ismail K, Kettle C, Macdonald S et al (2013). ‘The difference. Further research may also be needed to PEARLS study: enhancing immediate and longer- consider the association between constipation in term assessment and management of perineal pregnancy and perineal trauma. The intensity of trauma: a matched pair cluster trial’. BMC Medicine, perineal pain and discomfort women experience is 11(209). http://tinyurl.com/zhzc44c often unexpected and unprepared for (Way 2012). It is for this reason that effective communication and Kettle C, Hills R and Ismail K (2007). ‘Continuous written ante- and postnatal information can aid versus interrupted sutures for repair of episiotomy support. or second degree tears’. Cochrane Database of Systematic Reviews, 4(4): CD000947. DOI: CONCLUSION 10.1002/14651858.CD000947.pub2. As the most commonly reported postnatal problem, Kettle C, Downswell T and Ismail K (2010). perineal pain and trauma are significant in women’s ‘Absorbable suture material for primary repair of birthing experience. The accurate assessment and episiotomy and second degree tears’. Cochrane appropriate repair of perineal trauma require a high Database of Systematic Reviews, Chichester: John level of skill and competency and, as midwives, we Wiley and Sons. are responsible for the majority of births (Bick et al 2012; NICE 2014). It is for this reason that more NICE (2014). Intrapartum care: care of healthy attention needs to be paid to promoting a high level women and babies during childbirth. Version 2, London: of skill, as well as keeping up to date with current NICE. evidence. Changes in perineal management in the UK – such as reduction in the use of episiotomies – RCM (2012). Evidence based guidelines for midwife have impacted upon midwives’ competence and led care in labour - Suturing the Perineum, London: confidence, particularly the newly qualified (Dahlen RCM. http://tinyurl.com/jekfsba and Homer 2008). There continues to be further room for development and research into the RCOG (2015). The management of third and ongoing issues. In the meantime opportunities fourth degree perineal tears. Greentop Guideline No should be sought to observe, learn and practise the 29, London: RCOG. http://tinyurl.com/jr3rrc2 skill until the practitioner achieves full competence and confidence. For some this will be supported by Way S (2012). ‘A qualitative study exploring women’s personal experiences of their perineum after childbirth: expectations, reality and returning to normality’. Midwifery, 28: e712-e719. Wilson A (2012). ‘Effectiveness of an educational programme in perineal repair for midwives’. Midwifery, 28: 236-246.32 Blease and Taylor, TPM, Aprl 2016, vol.19, issue 4

GUIDELINE COMMENTARY Hannah Rogers Practice development midwife/trainee consultant midwife at Guy’s and St Thomas’ HospitalMBRRACE - Confidentialenquiries into maternal death‘Saving lives, improving mothers’ care - surveillanceof maternal deaths in the UK 2011-2013 and lessonslearned to inform maternity care 2009-2013’.Knight et al (2015). Guideline commentary takes its place alongside Cochrane corner and Research unwrapped as part of our evidence series. The aim of Guideline commentary is to support you to critique and utilise newly published guidelines, enabling translation of appropriate recommendations to practice.The objective is to scrutinise recent guidelines to encourage an understanding of the key issues, recommendations and midwifery practice implications. This month, Hannah Rogers looks at the new MBRRACE report and is struck by the addition of mental health disorders as a cause of death. She also considers the proportion of women who suffer morbidity.INTRODUCTION sombre and upsetting read. It is also a source of education in the form of anThe most recent MBRRACE report (Knight et al2015) is a substantial read at over 90 pages update on maternity topics and current clinicalcontaining detailed analysis of the maternal death affairs.The UK maternal mortality rate is lower thanrate over the past three years. For the first time the in previous years: between 2011-2013, it was nine perreport examines the reasons why women with 100,000, an overall figure of 214 maternal deaths.Thismental health disorders die. Not only is it the first edition focuses specifically on deaths in the UK andtime death from mental health has been reviewed in Ireland from psychiatric causes, deaths due tosuch a way, it is also the first report of any kind into thrombosis and thromboembolism, malignancy,deaths associated with mental health disorders in homicides and late deaths. This article provides anthe world – which seems surprising. It is to be hoped account of the MBRRACE report summarising eachthat MBRRACE will continue to review and publish of the chapters, highlighting the learning points andin depth the deaths of women who die from mental including some of the recommendations forhealth disorders. midwifery practice. This report is an opportunity for readers to reflect WHAT THE NUMBERS DO AND DON’Ton their practice in terms of clinical skills, TELL USknowledge and communication between colleagues.Due to the nature of the review, it makes for a Firstly we should consider a maternal death rate of >>>> Rogers, TPM, April 2016, vol.19, issue 4 33

GUIDELINE COMMENTARY nine per 100,000 in context: the converse is that women about the impact of mental health on their 99,991 per 100,000 women do not die. It is a tragedy wellbeing, as part of routine enquiry at booking, but that some women die: they leave behind a bereaved again in pregnancy and in the postnatal period. family and a baby without a mother. From the learning outlined in this document we have the Recommended tools such as the Whooley opportunity, like previous editions, to apply the questions (Whooley et al 1997; National Institute of learning from this report to the women we care for Health and Care Excellence (NICE) 2014) provide a in the future to prevent deaths, but also – framework when asking women about how they are importantly – to prevent unexpected morbidity. feeling: Identifying the women who suffer morbidity from the 99,991 per 100,000 is difficult and, whilst locally ● During the past month, have you often been it will be reported via clinical governance, there isn’t bothered by feeling down, depressed, or a national forum for this to be raised. Learning from hopeless? near-misses and unexpected poor outcomes on a national level will have learning opportunities, just ● During the past month, have you often been as learning from the cases when women die. bothered by having little interest or pleasure in doing things? Whilst we should acknowledge the significant decrease in the maternal death rate since the last ● Is this something you feel you need or want help report (2009-2011) – 10 per 100,000 and 253 deaths with? overall (Knight et al 2014) – and celebrate the reduction, we cannot take it for granted that the These questions are a useful screening tool and trend will continue and deaths decrease further. It guide for midwives. Our role includes being is highlighted that there were no deaths from receptive to how women present during influenza during 2012-2013, which may have appointments and using our midwifery contributed to the reduction in the maternal death interpersonal skills. Asking these questions will only rate over the past three years.This is reflected in the be effective if they are asked in an appropriate overall reduction in deaths from sepsis and again, manner: training and knowing where and how to whilst we should acknowledge the reduction, we refer on to are essential. MBRRACE acknowledges should not become complacent and forget the the role of specialised mental health services, but for lessons learnt from past reports. women who don’t meet specialised care needs criteria, an alternative service provision is needed.We must talk to women about why we Improved access to psychological therapies (www.iapt. nhs.uk/) is a service that prioritises pregnant orare asking these questions, in order to newly birthed women, accepting self-referrals and referrals from health professionals. demystify mental health Routine screening is a learning point from MENTAL HEALTH MBRRACE and, whilst we are routinely asking these questions at booking, we need to be sure that The chapter on mental health includes five years of women are asked again. Repeat asking of the data (2009-2013), which explains why the deaths questions during the ante- and postnatal period is from suicide appear high (total 101). Familiar themes best practice, but we must also talk to women about emerge, reflecting women who miss appointments why we are asking these questions, in order to or do not engage in care, as being over represented; demystify mental health and help women to so, too, are the women who book late in pregnancy. understand that we consider their mental well being This isn’t new knowledge; we know this group of to be important. We explain to women why we ask women experiences poorer outcomes from barriers for a urine sample at each antenatal appointment, so affecting how accessible our services are. More to we should be informing women why we ask about the point we have known this for a while and service mental health. provisions still need to change. The learning here is for service planners and commissioners; action THROMBOSIS AND THROMBOEMBOLISM needs to be proactive rather than reactive. There is a chapter dedicated to the prevention and MBRRACE identifies that we need to talk to treatment of thrombosis and thromboembolism. This is a complex subject but, as the leading cause of direct deaths, it is a topic midwives need to understand; most importantly, how to identify women who have predisposing factors and how to undertake a risk assessment. The RCOG green top guideline (2015) contains a thorough account on reducing the risk of venous thromboembolism (VTE) during pregnancy and the34 Rogers, TPM, April 2016, vol.19, issue 4

GUIDELINE COMMENTARYpostnatal period. This is an excellent resource for • Syncope or collapsefurther reading. • Tachycardia • HypoxiaVenous thromboembolism can T Cerebral vein thrombosishappen early • Headache • SeizuresThe need for pre-pregnancy counselling is called for.Such services are difficult to establish, particularly Following on from our care, women who haveif a woman is not planning a baby or not aware she had operative births should be informedis at risk. Knowing that 12 out of the 48 women who appropriately prior to starting a combined oraldied of a VTE did so in early pregnancy, is a stark contraceptive pill - this is a midwifery prompt toreminder that first trimester screening is essential ensure that discharge information to women isand the use of a standard VTE assessment form at accurate and clear to our GP colleagues.booking, crucial. Re-assessing the VTE score witheach hospital visit can then highlight any changes Re-assessing the VTE score with each hospitaland result in a referral to the obstetric team. visit can highlight any changes and result in a referral to the obstetric team For women who are taking low molecular weightheparin (LMWH) and require planned induction of MALIGNANCYlabour (IOL) or operative birth, part of our role asmidwives is to notify the team if a delay starting the Cancer does not discriminate against pregnancy,IOL occurs, so that the LMWH can be restarted or and this thought-provoking chapter pushes anythe woman prioritised. reader outside their comfort zone. It is an interesting read and one that is clear in stating that if cancer isVenous thromboembolism can happen suspected in pregnancy then investigation shoulddespite vaginal birth continue to happen in the same way it would for non-pregnant women.This is a topic that, thankfully,Out of 48 women who died from a VTE, half of the many have had minimal exposure to in pregnancy;women had aVTE in pregnancy and half postnatally. it is therefore an educational read. The majority ofFor the women who had a VTE postnatally, it was women who died from cancers did so after the birth,surprising to know that 50 per cent had given birth within a period of three months-one year. Initialvaginally. Without generalising, as midwives we thoughts are, of course about the women, who got torejoice when a woman defies the odds and achieves meet their babies, albeit for a short period of time.a vaginal birth and, without introducing defensive Thoughts then go to the midwives and the healthpractice, we cannot ignore any pre-existing risk professionals who cared for these women and who,factors just because a woman has birthed vaginally. no doubt, built relationships. In such cases, aInstead a review of the post-birth VTE is required, support network should be offered for the midwivesparticularly when a complicated vaginal birth has and professionals who cared for the woman and heroccurred (postpartum haemorrhage, long labour family.with epidurals, operative birth). HOMICIDES >>>>Venous thromboembolism can happenwithout risk factors Domestic abuse and homicides continue to feature within the report. Thirteen women were murderedA topic such as VTE is complex and hospitals often between pregnancy and up to six weeks post birth.have specialised teams and ‘high risk’ midwives who Another 23 women were murdered in the yearcare for such women but, as 17 per cent of the following birth, highlighting that this is a risky timewomen who died from VTE did not have a risk for a woman experiencing domestic abuse. Thefactor, it is highlighted that VTE events can occur in period post six weeks and beyond is outside the rolewomen without risk factors, and so baseline of the midwife, but we know that women often needknowledge is required. repeated screening for domestic abuse before they are able to confide in someone. We have a Symptoms of an event include: responsibility, as midwives, to ensure that women T Deep vein thrombosis are asked about domestic abuse in a safe • Left iliac fossa/groin/buttock pain • Non-specific lower abdominal pain • Painful swollen leg (lower leg or whole leg) • Redness/oedema of leg T Pulmonary embolism • Chest pain (sudden onset) • Breathlessness (sudden onset) • Dizziness Rogers, TPM, April 2016, vol.19, issue 4 35

GUIDELINE COMMENTARYenvironment on more than one occasion during our CONCLUSIONcare.This provides a number of opportunities for thewoman to tell us if she feels she is in danger. This MBBRACE report is an insightful read, with learning points for all involved in maternity care: Asking about domestic abuse can be challenging medical directors, heads of midwifery,and, just like asking other sensitive questions, commissioners, doctors, allied health professionals,requires specific education. For midwives who do and of course us – midwives. For the women whonot feel confident, then targeted education should died in pregnancy or soon after giving birth this readbe available, in addition to time spent with a enables something of their lost life to be learnt andsafeguarding midwife to learn in practice. shared. Learning points are continuously embedded within the report. Many of the learning points have Domestic abuse can affect everyone, but as the been stated previously and require a new way to bereport states, some women are more likely to suffer addressed or accounted for, but there are newabuse: some women will accept a level of abuse as learning points. With the focus on mental health for‘normal’, which is why, when screening for abuse, the first time it provides an excellent opportunity forgiving information about different types of abuse us all to examine our own practice and reflect onshould be included. Picking up clues may assist in how/if we can change it, to better support theidentifying a woman who is experiencing abuse: women we care for. ● women who book late The new format in reporting maternal death ● women who miss appointments requires some adaptation, but essentially means ● repeat attendance at hospital during pregnancy data will be provided on an annual basis, rather than triennially. For 2016, data on UK maternal deaths or postnatally for non-specific reasons or from 2012-2014 will be issued and will include abdominal pain deaths and severe morbidity from cardiac causes, severe morbidity from psychiatric causes, deathsLATE DEATHS from pre-eclampsia and eclampsia and related causes and deaths in early pregnancy occurring inThe report also focuses on late deaths, during a the UK and Ireland. The addition of morbidity isperiod of six weeks-one year following birth (14 per very much welcomed. tpm100,000). It was reported that these women often hada combination of long standing medical needs and REFERENCESco-morbidity, resulting in a complex pregnancy.Having a socially complex life adds to the challenges Knight M, Kenyon S, Brocklehurst P et al onin providing maternity care. A quarter of these behalf of MBRRACE-UK (2014). Saving lives,women died from mental health-related causes. improving mothers’ care – lessons learned to inform future maternity care from the UK and Ireland Confidential Although the woman’s care after six weeks is enquiries into maternal deaths and morbidity 2009-2012,outside the role of the midwife, we have a joint Oxford: National Perinatal Epidemiology Unit,responsibility to ensure that the woman is physically University of Oxford.and mentally as well as possible prior to the transferof care to the GP and health visitors. Knight M, Tuffnell D, Kenyon S et al on behalf ofRecommendations from MBRRACE include better MBRRACE-UK (2015). Saving lives, improvingcommunication with every woman about her mothers’ care – surveillance of maternal deaths in the UKpostnatal care plans, particularly follow-up 2011-2013 and lessons learned to inform maternity careappointments. For this be effective, our from the UK and Ireland Confidential enquiries intocommunication systems (electronic and otherwise) maternal deaths and morbidity 2009-2013, Oxford:need to in place and working, to avoid this being a National Perinatal Epidemiology Unit, University ofweak link in how we communicate with our Oxford.colleagues. NICE (2014). Antenatal and postnatal mental health: An MBRRACE learning point for midwives clinical management and service guidance. Clinicalincluded our key role in acknowledging the women guideline 192, London: NICE. http://tinyurl.com/who repeatedly attend hospital or contact the m7rkwsemidwifery team postnatally, as a ‘red flag’occurrence. We are accustomed to this being a RCOG (2015). Reducing the risk of venoustrigger antenatally, particularly for the woman who thromboembolism during pregnancy and the puerperium.attends for nonspecific reasons, but now this needs Green top guideline 37a, London: RCOG. http://to be extended to the postnatal period and tinyurl.com/hkr568qhighlighted to the team. Knowing that a quarter ofthe women die from mental health-related causes Whooley MA, Avins AL, Miranda J et al (1997).during this time period, we really need to be talking ‘Case-findings instruments for depression’. Journalto women about mental health at the point of of General International Medicine, 12(7): 439-445.discharge from our care.36 Rogers, TPM, April 2016, vol.19, issue 4

THINKING OUTSIDE THE BOX Sara Wickham Independent midwifery lecturer and consultantThe importance of everydaybirth wisdomIn this column, Sara Wickham takes a sideways look at issues relevant to midwives, students, women andfamilies, inviting us to sit down with a cup of tea and ponder what we think we know. This month, Sarashares details of a study which identified rituals undertaken by midwives looking after women in labour.Such studies, she argues, can be vital to helping us understand the nature of what we do in everydaypractice as well as being a way of recording our knowledge for future generations.Ilove research papers that tell me things I already age where the technocratic approach to birth know. I especially love those that tell me things dominates and there is less emphasis than I think I already know about everyday midwifery there should be on valuing a more holistic approach practice that I don’t think about on a daily basis to caring for childbearing women, good midwiferybut which, when I read about them, I realise are knowledge is recorded for future generations ofreally, really important. I love such papers for lots of women and midwives. As a perpetual optimist, I likereasons but, now that I am thinking about it, two of to think that there will come a time when ourthose reasons stand out. daughters and sons will stand up and shout out a resounding ‘no’ to the over-medicalisation of birth. The first reason is because such research makes When that time comes, they’re going to need sourcesme think about what I do. Most of us inevitably end of wisdom in order not to have to reinvent theup wandering through our days doing things fairly proverbial wheel.automatically and without really thinking aboutthem, so any kind of trigger to ponder our activities I am very passionate about ensuringcan bring vital insight, learning and a freshperspective from which we can, if we choose, allow that good midwifery knowledge isour practice to evolve. recorded for future generationsPASSING ON THE KNOWLEDGE A THORNY MIDWIFERY PROBLEMThe second reason I love papers that tell me thingsI think I already know is because other people are With that as an introduction, I’m now a tiny bit waryalso going to be able to read that information. I’m that the authors of the latest paper that I read andnot saying that because I necessarily want to change loved for the reasons above are going to think I’m >>>>anybody else’s practice today. (I don’t think that’spossible even if I did; we can only change ourselves.)But I am very passionate about ensuring that, in an Wickham, TPM, April 2016, vol.19, issue 4 37

THINKING OUTSIDE THE BOX saying that their findings are old hat, which is very and labour progress. These practices could contradict the much not the case. Reed et al (2016) have focused rites of passage by disrupting aloneness and reinforcing light on an eternally thorny problem, which I am external wisdom” (Reed et al 2016: 1). confident that many TPM readers will be able to relate to, but their approach is insightful and new. When you read such passages, as a midwife, the statements might seem really obvious. Yet such The problem is this: there are things that we, as mysteries of midwifery are really not obvious to the midwives working in a modern world, are outsider until researchers unpack what is going on. compelled to do to women in labour, such as Even our textbooks rarely contain the kind of data listening to the baby’s heartbeat and assessing the that research studies like this one offer; hence the woman’s progress. But, even if we are really focused value of doing that unpacking and then writing it on ensuring normality rather than looking for down. pathology, and even if we are really unobtrusive, careful, gentle and quiet, we know that these things EVERYDAY WISDOM can cause anxiety and distress to women. The midwives whose voices can be heard in Reed et “Anderson found that assessments intended by al’s (2016) paper describe rituals that will also seem midwives to confirm normality sometimes conveyed the everyday to many readers.They talk about how they message that there may be problems. For example, create a dark, undisturbed environment for women, auscultating the foetal heart generated concern for some and how they ensure that women stay hydrated women about their baby's wellbeing. This concern without disturbing their labour, by asking if they interfered with women's ability to ‘let go’ during birth.The would like a drink every five minutes.The answer to midwives in Blix's study reported that their clinical the latter question, in case you are at the beginning assessments could disturb the labouring woman and of your midwifery career and haven’t learned it yet, interfere with the birth process. Leap suggests that is to simply offer the woman a drink, ideally with a midwives are trained to ‘do things’ to women during straw in it so that she doesn’t have to hold the cup labour, including clinical assessments, soothing touch, herself. If she drinks, then she wanted a drink. If she and building rapport by talking. However, Leap argues doesn’t drink, then she doesn’t want a drink. Don’t that this well intentioned approach can interfere with the wait for a, ‘no thank you’. No language – and more physiology of labour by disrupting the woman's importantly, no thinking – required. Simple? Yes. instinctive behaviours” (Reed et al 2016: 2). Clearly written down in places that student midwives can easily access? Not so much. Simple?Yes. Clearly written down in AVOIDING INVASIONplaces that student midwives can easily Both the midwives and mothers who were access? Not so much interviewed for this study saw certain examinations as defensive, invasive and having the potential to REFLECTING ON RITUALS disturb labour. These included listening to the fetal heart and abdominal and vaginal examination. In this research, lead author and midwife Rachel There is, the authors identified, a tension between Reed interviewed 10 midwives and 10 women (who the two different rites of passage that were had all experienced physiological, uncomplicated described, and another valuable element of research birth in a range of settings) about their experiences. papers like this one is that they give us language and All lived in South East Queensland, Australia, at the tools with which to talk about and frame such time of the study. The findings highlighted complex tensions.The authors of this paper aren’t saying that interactions between mothers and midwives, and the they have the answers. But the fact that they have notion of rituals, which some readers may be identified the questions and added to the familiar with from the work of Robbie Davis-Floyd perspectives from which we can discuss the issues (2003), is used to describe the words and actions that is immensely helpful to those of us who want to midwives enact when looking after women in labour. reflect on our own practice and record the essentials of holistic midwifery for future generations. tpm One of the findings in this study that stood out for me was the identification of two different types REFERENCES of ritual: Davis-Floyd RE (2003). Birth as an American rite of “Rites of passage were synergistic with women's needs passage, 2nd edition. Berkley: University of California during birth and involved managing distractions and Press. reflecting internal wisdom. Rites of protection involved performing clinical assessments to determine wellbeing Reed R, Rowe J and Barnes M (2016). ‘Midwifery practice during birth: ritual companionship’. Women and Birth, In press: doi:10.1016/j.wombi. 2015.12.00338 Wickham, TPM, April 2016, vol.19, issue 4

Supporting your SuccessMyles Textbook for Midwives• Designed to enable midwifery practitioners • Streamlined chapters with similar themes and to provide safe and competent care, which is approach help consolidate your learning tailored to the patient’s individual needs • Over 500 on-line multiple-choice questions to• Extensively illustrated to assist visual learning enable readers to test their knowledge with additional ‘pull out’ text-boxes to highlight key informationFor 20% o this title, go to www.elsevierhealth.co.uk and enter code PM

LETTERSLetter from Henrietta OtleyDennis Walsh’s article in the March edition of TPM ‘Midwives,gender equality and feminism’ (The Practising Midwife March 2016)reminded me of my motivation for deciding to train as a midwife inmy mid-thirties. Idealistic about the political force for good that Iperceive midwifery to be with its ability to make a real impact onwomen’s experiences and lives, the reality of the environment ondelivery suite and the postnatal ward on student placements wasdisappointing. During my training I learned to adjust my sights andeventually, when qualified, I felt I could be a positive advocate forthe women in my care, more by stealth behind the closed doors ofthe labour room than because there was a supportive, forward-thinking feminist ethos in the staff room. Ten years on it saddens me to realise that, looking at my careeras a whole, including 15 years elsewhere pre-training, the midwifery environments I have worked in have been the least feministof any I have known. This has informed my move now from midwifery to the Family Nurse Partnership. I have seen highly skilledmidwives disempowered by the backbiting, defensive, fearful atmospheres in which they work, ones where everyday sexism anda thoughtless disregard for women’s needs and rights is commonplace. Until midwives are coming into women’s birth, ante- andpostnatal rooms from a supportive, respectful, positive staffroom handover, it will be hard to role-model the sort of care that womenshould expect and will make them feel powerful in their roles as mothers and in society. Dennis Walsh is right to suggest a feminist call to arms of midwives, but asserting powerful values in an environment whichthwarts them has proved harder for me than I could ever have anticipated in the face of a patriarchal medical hierarchy whichseems to be more often endorsed by the anxious and weary women who work within it, than challenged.Hen OtleyFamily Nurse Partnership in SwindonREVIEWSMyles midwifery anatomy and physiology for the various activities. Although many of the activities areworkbook self-explanatory, it is helpful to quickly read through to ensure the reader gets the maximum benefit. Jean Rankin The variety of different activities keeps the reader 2013, Churchill Livingstone, 238pp, interested and caters to all learning styles. Each chapter is £23.99, pbk, ISBN 978 0 7020 4339 0 formated to closely align with the book and is structured to allow the reader to dip in and out, doing as much or as little at The aim of this book is to assist a time, as suits them. student midwives to learn and consolidate their knowledge of The answer section at the end of the book is of benefit, in anatomy and physiology related to that it allows the reader to monitor their progress, as well as pregnancy and childbirth, as well as providing a resource for those who may not be in possession of the neonate. It is designed to the full text version mentioned above. complement the full text edition ofMyles Textbook for Midwives, but can also be used if the reader This book is an great resource for student midwives fordoes not have access to this edition. self-directed revision, but may also be of use in a classroom A ‘How to use this book’ section is provided at the setting for guided learning.beginning of the book, presenting descriptions and instructions Vicki Freeman Midwife in Auckland, New Zealand40 TPM, April 2016, vol.19, issue 4

For free inclusion*, send your listing to: [email protected] with ‘diary’ in the subject line *Subject to availability DIARYApril www.uk-sands.org/ 18-19 May Primary care and July October13 April Positive birth individual- bookings public health conference, 1 July Maternity, midwifery 14 October Bereavementmovement: Continuity of Birmingham, free of and baby: Midwifery care training workshop,care conference, London. 4-5 May Virtual charge. Info: http://sterling exchange. Birmingham, London, £85 / £65 Info:Contact: milli@ international day of the events.co.uk/about-pc.html free of charge. Info: www.uk-sands.org/birthinsight.co.uk midwife. Events around the www.maternityandmidwif individual-bookings country including: King’s June ery.co.uk/events/birmingha18 April Supporting women College London, free of 10 June Bereavement care m-2016/ 17-21 October ICM regionalwith learning difficulties charge. Info: https:// training workshop, Cardiff, conference, Lesotho: Theduring pregnancy. vidofmid.wordpress.com/ £85 / £65 Info: 7 July RCM Legal birth sustainable developmentEdinburgh, £10+VAT/ www.uk-sands.org/ conference: women’s goals: African midwives£20+VAT. Info: http:// 5 May International day of individual-bookings choice. London, early bird rising to meet thetinyurl.com/jhz2ghk the midwife. Events around £115+VAT, thereafter challenges. Further details the country including: 14-17 June Management of £130+VAT. www. bond to follow.21 April Waterbirth study King’s College London, free the labour ward. London. solon.com/media/71395/rcday. Bracknell, £40/£30. of charge. Info: www.event Info: http://tinyurl.com/ m-legal-birth-2016.pdf 19-20 October RCM annualInfo:www.waterbirthstudy brite.co.uk/e/international- zmgfnye conference: safety,day.co.uk Contact: 0845 519 day-of-the-midwife-tickets- September standards, experience.7981/07964879216 22487290090 16 June Begin before birth: 23 September Bereavement Harrogate. Info: the importance of care training workshop, www.rcm.org.uk/rcm-22-23 April Mama 14-16 May Midwifery pregnancy and the early Birmingham, £85 / £65 Info: annual-conference-2016conference. Troon, Ayrshire, symposium: Young years for child www.uk-sands.org/£225 (£210 early bird before midwives in the lead, development, London, individual-bookings December1st Feb 2016). Info: Copenhagen. Info: £150/£95. Info: www. 2-3 December Europeanwww.mama- http://212.121.127.104/news/ symposia.org.uk/main/ 27 September Maternity, midwives association fifthconference.co.uk ?nid=321 main.asp midwifery & baby: international education Midwifery exchange. conference. London, earlyMay 16-19 May Women deliver: 23 June Problems in the Manchester, free. www. bird £280 (to 30 June) /3 May Bereavement care 4th global conference, first trimester, London, maternityand midwifery. £335 (from 1 July). Info:training workshop, Copenhagen. Info: £25/£Free. www. symposia. co.uk/events/ manchester- http://tinyurl.com/Newcastle, £85 / £65 Info: http://wd2016.org/ org.uk/main/main.asp 2016/ hv8rmnd CONTRIBUTE TO THE SEMINAR AGENDAS FOR THE 2016 FORUMS Your opportunity to share your work with colleagues from around the UK. We are looking for papers that demonstrate innovative best practice and research. BIRMINGHAM 2016 FRIDAY 1ST JULY MANCHESTER 2016 THURSDAY 27TH SEPTEMBER For further information or details regarding submitting a paper please visit www.maternityandmidwifery.co.uk or contact [email protected]

LAST WORD Amanda Chinery Mother and doula in LancashireFilling empty spaces with sadnessHIDING FROM THE WORLD which helped a little once, but sessions were SUPPORT OF A MIDWIFE limited, so that was that.I don’t remember much from my second She listened. She understood mypregnancy or birth; and even less of the early Finding out that I was pregnant again vulnerability and accepted me, broken as Idays of being a mother to two. I don’t terrified me. I knew before I did the test. felt; I was accepted. That was important. Iremember any of the midwives or health never felt judged by her. Knowing I had hervisitors who came to see me. I wasn’t far from I’ve never felt I could have an abortion, so in my corner from that point was a crucial partmy family, but felt a million miles away from that wasn’t an option. Could I be a good in my recovery.them. I couldn’t reach out to anyone; looking mother? Dare I even try?back now I don’t remember even wanting to. When I had my baby I had fantasticI felt I was lost within myself, unable to I can’t remember who suggested I go to support. Life was very different; although Iprocess how I felt, hiding from the failure of see the Public Health Midwife. I poured all of had the fear of it all returning, it graduallyhaving no feelings for my baby. I battled on, this out to her, and much more. I couldn’t hold lessened as time went on. I bonded with thishiding from everyone what I felt inside. it in any longer: people needed to know how baby; I loved her – big difference there I felt if they were to help me avoid it again. I straight away. It took time to believe I couldWALKING AWAY made the decision to be honest about my be a better mother this time. vulnerability instead of hiding behind theIt was just before my child’s first birthday that tough exterior that I’d had many years to perfect. As a midwife, never underestimate theI walked out of the door and away from the I must have been there for two hours and I difference you can make in someone’s life.children that I felt were much better off just cried and talked, cried and talked. And she Their window of opportunity is open; if theywithout me. I had failed them both by this let me. are ready, help them to take it. tpmpoint. I had become a dark hole of sadness,anger and disappointment in myself, with no Learn the secrets of success! 101 Tipshope for the future. I just didn’t see one. I wasa bad mother and they were better off without Are you wondering how to start your research or dissertation for Planning, Writingme. I had no way of knowing how to manage journey, swimming through a sea of papers or looking for help and Surviving Yourmy feelings; I was terrified that if people knew knitting your discussion together? Do you need advice for gettinghow I felt, my children would be taken away the most out of your tutor or ideas to help you keep on track with Dissertationfrom me – and yet I left them. What strikes your thinking, writing and analysis? What is critical analysis, in fact,me now is the confusion that I must have felt, and how do you do that while still having a life?completely torn inside. The 101 tips in this book cover a wide range of areas from how to Sara Wickham I had no difficulty filling the empty spacewithin me with alcohol and drugs. It took the create a good question and keywords to what to do when someonepain and guilt away and sometimes everyemotion. I was numb, feeling nothing. And at publishes a ground breaking new study on your topic the week before you’re due tothat time I felt this was exactly what I needed. submit your work. Written in an accessible, friendly style and seasoned with rst-TRYING TO FIND SOLUTIONS hand advice and comments from others who have trodden the path, this bookThe following years weren’t pretty. Failedattempts to get my children back, numbing combines sound, practical tips from an experienced academic with reminders of thethe pain of failure. Falling and getting back upagain. I don’t know what kept me going value of creativity, chocolate and naps as investments in your work.because many times I didn’t want to live anymore. I did, however, start to understand just Available from Amazon in paperback or e-book RRPwhat was going on. I tried several anti- More information at www.sarawickham.com £9.99depressants on and off, never feeling theywere really helping. I had some counselling,42 Chinery, TPM, April 2016, vol.19, issue 4

Don’t miss an issue Subscribe today The Practising April 2016 Volume 19 No 4 MIDWIFE The best job in the world www.practisingmidwife.co.uk Now also VULNERABILITIES available February 2016 The Practising MTheIPDraWctisiInFg E IN THIS ISSUE: The best job in the world online he Practising MIDWIFE March 2016 April 2016 Supporting younger The best job in the world Volume 19 No 3 mothers toMIDWIFEThe best job in the world breastfeed: linking to CPD module online Midwives coping with FGM How can we make a difference in substance misuse? Midwives are vulnerable, too: the impact of rape Volume 19 No 2 COMING SOON - Visit your new online community and learning zone to develop, prepare and share your practice www.practisingmidwife.co.uk Volume 19 No 4STANDING OUTwww.practisingmidwife.co.uk www.practisingmidwife.co.uk VULNERABILITIESwww.practisingmidwife.co.uk THE HEART OF THE MATTER IN THIS ISSUE: IN THIS ISSUE: IN THIS ISSUE: To find out more visit Atrial fibrillation: www.practisingmidwife.co.uk Building resilience: linking to CPD Supporting younger and click on bullying module online mothers to “find out more about online” The culture of breastfeed: Creating a midwifery linking to CPD professional profile Humanising module online midwifery care Leadership The place of Midwives coping reflection in with FGM compassionate care PLUS! How can we make Getting picked - COMING SOON - Visit your new online community and learning zone to develop, prepare and share your practice a difference in recruitment and substance misuse? selection advice: www.practisingmidwife.co.uk Midwives are linking to CPD vulnerable, too: module online the impact of rapeVisitwyowur wne.wpornalicnteicsoimnmgumniitydawndifleea.rcnoin.guzkone to develop, prepare and share your practice COMING SOON - Visit your new online community and learning zone to develop, prepare www.practisingmidwife.co.uk and share your practiceName Instruction to your bank or building society to pay Direct Debits Please complete parts 1 to 6 to instruct your bank or building society toAddress make payments directly from your account (UK ONLY). Postcode Country 1 Enter full name of bank or building society To: The ManagerJob title (if applicable) Name of bank/building societyInstitution (if applicable) 2 Name of account holderTelephone Email 3 Bank/building society sort codeRates Please tick the rate appropriate to you 4 Bank/building society account noFor printed version only save £5 if you pay by Direct Debit (UK personal rate only) – lower rates in 5 Reference (office use) Originator’s identification no 2 5 8 7 7 2brackets 6 Instructions to your bank/building society: Please pay FastPay Ltd re Medical Education Solutions Ltd from the accountPersonal rates detailed in the Instruction subject to the safeguards assured by the Direct Debit guarantee.I Fully qualified UK £65 ( £60) I Europe/Eire £75 I Online only £50 ( £45)I Student UK £50 ( £45) I Europe/Eire £65 I Online only £40 ( £35)I Rest of world (surface) £100 I Rest of world (airmail) £130 I Online only £50Student’s course ends:Institutional ratesI UK £134 ( £129) I Online only £123 ( £118)I Europe/Eire (airmail) £144 I Online only £123I Rest of world (airmail) £190 I Online only £123Back copies - p & p extra (Please call number below) Signature DateI UK £7 I Europe/Eire £9.50 I Rest of world £12.50 Some banks and building societies may not accept Direct Debit instructionsPAYMENT OPTIONS – Four ways to pay! Please return this form to: TPM Subscriptions, 66 Siward Road, Bromley BR2 9JZ.1 Direct Debit (UK only) I Please complete the Direct Debit instruction opposite.2 By credit card/debit card (circle required option) Credit card hotline 01752 312140 The Direct Debit guarantee This guarantee is offered by all banks and building societies that take part in theCard number: Direct Debit Scheme. The efficiency and security of the Scheme is monitored and protected by your own bank orStart date: Expiry: 3 digit security code: Issue no (switch only): building society. If the amounts to be paid or the payment dates change, Medical Education Solutions Ltd will notify you 10 working days in advance3 BACS I 40-22-26 / 42634317 / HSBC Medical Education Solutions Ltd. of your account being debited or otherwise agreed. If an error is made by Medical Education Solutions Ltd or your bank or building society, you are Please put your NAME as reference guaranteed a full and immediate refund from your branch of the amount paid. You can cancel a direct debit at any time by writing to your bank or4 Cheque I I enclose a cheque payable to Medical Education Solutions Ltd building society. Please also send a copy of your letter to us.You can also call our credit card hotline 01752 312140Please return this form to: TPM Subscriptions, 66 Siward Road, Bromley BR2 9JZ.

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