TPM DECEMBER 2016

December 2016 Volume 19 No 11 www.practisingmidwife.co.ukMIND MATTERS IN THIS ISSUE: Mothers in immigration detention - the most vulnerable and the hardest to reach Linking to CPD module online. Take a sneak preview on page 12 inside Twins, postnatal depression and me Head start: cranial osteopathy for common baby problems Taking the plunge: the benefits of aquanatal exerciseNew website now live! Visit the online home of TPM for further articles, modularised eLearning,a supportive community, archive and more at www.practisingmidwife.co.uk

Philips new Avalon cableless fetal monitoring systemWouldn’t it be great to have no cables at all in your OB department while enhancing mum’s maternal experience?Welcome to the new and improved wireless fetal monitoring solution from Philips – The brand new Philips Avalon CL allowsyou to measure MP, NiBP and SpO2 with WATERPROOF transducers along with the capability of measuring the fetal heart rateof triplets.Built-in Philips Avalon Smart Pulse technology also provides an additional safety net by enabling you to measure maternalpulse when you use a Toco transducer.
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CONTENTSThis month in The Practising Midwife6 Editorial 18 Twins, postnatal depression 29 Taking the plunge: the benefits and me of aquanatal exercise8 Article of the month Mothers in immigration detention: Having suffered from postnatal When Anita Johnson met and the most vulnerable and the hardest depression after giving birth to twins, interviewed aquanatal teacher Cathy to reach this second year student midwife stresses Charles, she discovered a host of benefits the need to bring depression into the for pregnant and postnatal women Having spent over three years examining open in order to support women the experience of pregnant women in 32 Research unwrapped immigration detention centres – 21 Head start: cranial osteopathy Mindfulness and perinatal mental principally the infamous Yarl’s for common baby problems health: a systematic review Wood in Bedfordshire – Sara Randall explains how babies can In her appraisal of this qualitative Phoebe Pallotti benefit from osteopathy to alleviate research article, Alys Einion finds that and Morag Forbes residual damage from the birthing mindfulness may be helpful to midwives, describe their process as well as pregnant women, in managing disturbing stress. findings 25 Hypnosis and hypnobirthing for labour – a critical selective 35 Reviews12 Article of the month module narrative review 36 Diary questions 38 Overseas opportunities Immigration detention At a time when fear of childbirth is on the increase, Alys Einion focuses on Take a look at the questions and answer hypnobirthing as a means of coping with options for this month’s featured module, the experience of labour and birth then go online to take the assessment and download the certificate for your revalidation portfolio14 Midwifery basics 2. Professionalism, public confidence and course application Jancis Shepherd looks at professionalism in the context of maintaining public confidence and considers the attributes necessary for application to pre-registration midwifery education4 TPM, December 2016, vol.19, issue 11

PLUS EXTRA ONLINE CONTENTSNow available online at www.practisingmidwife.co.ukDECEMBER MODULE Midwifery support for asylum seekersOF THE MONTH: and refugees Read the module, take the assessment, then download your certificate for CPD, appraisal and revalidation.PLUS! THIS MONTH’S perception of the role of the NEW! AROUND THE And more…EXTRA FEATURE midwife, gets realistic about what CONFERENCESARTICLE: is possible, reveals the secret to a Read the latest news stories that happy workplace and finds that it Breast milk provides life- matter to midwives, students andA midwifery approach to is still ‘The best job in the world!’ long health protection related professionals. Theseemotional wellbeing and mental stories will be updated during thehealth in pregnancy THINKING OUTSIDE 11th International Breastfeeding month to bring you news andWith experience in contrasting THE BOX and Lactation Symposium 2016 information as it comes to lightNepal and Poole, UK, Jilly Ireland A potpourri of festiveexplores the question of mental ponderings on women, Berlin, 22 April 2016health and emotional wellbeing in birth and midwiferypregnancy and early motherhood, Lisa Bryant provides an insightfuland concludes that talking about report direct from the conferencemental health issues is beneficialto midwives as well as mothers NEW! NEWSPLUS! THIS MONTH’S L Extraordinary, rareEXTRA COMMUNITY phenomenon: superfoetationARTICLES:VIEWPOINT L Woman with learning disabilities to have a caesareanBeing kind to ourselves section, against her wishesRebecca Knapp explores the At this festive time, Sara Wickham L Breastfeeding crucial to publicwhole question of midwives’ shares some of the things that health she learned during the past year, including new words, new Visit the website to... knowledge in the realms of anatomy and physiology and a PREPARE shocking pregnancy and reindeer- related fact For practice, examinations, appraisal, revalidation: all in the eLearning section, the place to go for CPD. DEVELOP Extend and expand your skills by reading authoritative and thought- provoking articles from this month and the archive. SHARE Enjoy your Community Zone, where you will find blogs and opinion articles, plus links to Facebook and Twitter. See what’s coming up in Events (and remember to let us know about your forthcoming events by writing to [email protected]). TPM, December 2016, vol.19, issue 11 5

VIEWPOINT Matters of the mind “Motherhood is a handicap but also a strength; a trial and an error; an achievement and a prize.” (Oakley 1979: 308) In October, this year, I became a mother for the third time. As I write I am deep in the heart of my postnatal experience, following a difficult pregnancy plagued with severe nausea and vomiting, and an exhilarating but challenging birth. My experiences have reminded me of the tension between both the fragility and power of childbearing and motherhood. As I continue to tackle the myriad of physical set-backs, alongside the joys of mothering moments, I recall the sentiments of Ann Oakley (1979) presented above. Such is the catastrophic change and impact in all areas of our life: physically, emotionally, socially and spirituality. Our individual childbearing and rearing journeys are unique. However, the more research I read, the more childbearing women, midwives and students I listen to and observe, the more emphatically I believe that caring for our own and others’ minds really does matter. Perhaps it matters more than anything. Other midwives (60.9 per cent) and maternity support workers (78.3 per cent) agree that emotional support is the most important element of postnatal care, as reported in the survey conducted by the Royal College of Midwives (RCM) (2014). Recent research, reports and guidance call for us to improve perinatal mental health to advance public health outcomes for all. These resonating calls to offer enhanced emotional support create a huge challenge for maternity services and midwives. When considering matters of the mind, it is important that we can offer time to women and their families, throughout the childbearing continuum, to explore their emotional and psycho-social adaptations and wellbeing. We must offer space to listen to the families in our care – offering opportunities for containment and appropriate referral to wider services. Yet, how can we offer more support without more time and staff to deliver the care required? To capture this time, we must continue to lobby for more midwives, maternity support workers, doulas and wider specialist mental health services. We can make a difference by speaking out, campaigning and continually raising the issues at local, national and international levels. As we work on increasing time and resources we must use what we have around us. Making minds matter requires more than asking questions; we must start meaningful, mother-centred conversations at any and every opportunity or contact. Finding out about the wider specialist services available, referring and collaborating with them. We can also build social capital within communities by connecting mothers and families through local support groups and children’s centres. This month we focus on emotional and psycho-social health and wellbeing for mothers, families and midwives. We present articles that explore mind matters for women and families with complex social needs, and the development of services to make a difference. Alongside the articles featured in print, we have online articles and modules to support your practice – we hope you enjoy. RCM (2014). Maternal mental health. Pressure Points: the case for better postnatal care, London: RCM. Oakley A (1979). Becoming a mother, New York: Schocken Books6 TPM, December 2016, vol.19, issue 11

Midwives: How can we talk to INFORMATION ONmothers in a way they understand? Pain Relief in Labour Anaesthesia for C-Section Don’t let language be a barrier when Epidural Information Card helping women in your care Pain Relief Comparison Card Headache after Spinal / Epidural Raised BMI GA for Unplanned C-Section RA for Unplanned C-Section Videos and podcasts available \"Brilliant resource, could save the nhs a fortune.\" - Carol Ann, Midwife \"Fantastic site, I feel I no longer have to short-change our non-English speaking mothers.\" - Delegate at RCM Conference Do you have one place where you can access the required information on pain relief? LabourPains.com is the free, mobile-friendly public information website of the Obstetric Anaesthetists’ Association (OAA). Created specifically for expectant parents as well as midwives and healthcare professionals. The information on LabourPains.com has been written by a multi-disciplinary group, ensuring that you can offer your patients information which is trustworthy, unbiased and scientifically proven. With information available in over 40 languages, the site is an excellent resource, so why wait, spread the word about this amazing resource!Follow us on Twitter @LabourPainsOAA

ARTICLE OF THE MONTHARTICLE OF THE MONTH Phoebe Pallotti Morag ForbesLead article each month,taking you from the Lecturer in Maternal Care Family Nurse atjournal to the websitefor a module on the at the University of Leeds Lewisham andsubject. Greenwich NHS TrustThis month:Mothers in immigration Phoebe Pallotti and Morag Forbes are two experienced midwives who volunteered for a charity that worksdetention: the most for the health rights of people in immigration detention. They both have other experience of this clientvulnerable and the group and they both hold diplomas in Tropical Midwifery. Over more than three years, Phoebe and Moraghardest to reach have been visiting and calling on pregnant women in immigration detention, most often in the infamous detention centre, Yarl’s Wood, in Bedfordshire, where a recent Channel Four documentary was secretlyGo to the module at filmed.The centre has a small health care facility, but there are no midwifery staff employed there, thoughwww.practising women were often referred to the local maternity unit.midwife.co.uk This article explores the situations of the pregnant women who are detained in the UK and considersTry out our sample how they may better be supported.questions on page 13then go to the website Volunteering as midwives supporting the midwives, more than most. We feel that theseto complete the module health rights of people in immigration women’s experiences need to be more widelyand gain a certificate for detention centres was one of the most known and the impact of detention on their healthyour revalidation rewarding things we have ever done; in and pregnancies recognised, to prevent this everportfolio addition we were short listed for an RCM award this happening again. year for our work with the charity. However, it is also one of the most tragic settings either of us has ever THE WOMEN worked in. Without exception, the women we worked with at Since July 2016, pregnant women (except for Yarl’s Wood, and for whom we prepared medico- those held at the border) can only be detained for legal reports on their pregnancy health for use by a maximum of seven days from the point that the their legal team, were vulnerable in one way or Home Office is satisfied the woman is pregnant. another. We have used a data set of 64 pregnant We now hope that far fewer – if indeed any – women from routinely kept records. These include pregnant women will be detained for any length of all the women who contacted the charity from time. However, women in the immigration system detention from July 2013 to March 2016. We are as a whole are the most vulnerable, and often, unsure as to how many pregnant women in total because of frequent moves due to dispersal and were detained by the Home Office, as official temporary accommodation and due to language statistics are not available for the entire period, but barriers and severe psychological trauma, they will we estimate that we were referred somewhere continue to be a hard-to-reach group who need between one sixth and one third of all pregnant our support, as compassionate and caring women detained.8 Pallotti and Forbes, TPM, December 2016, vol.19, issue 11

Figure 1 MOTHERS IN IMMIGRATION DETENTION 18 (The category ‘Other pathology’ 16 includes presentations of severe 14 parasitic infection, brain tumour, 12 FGM and complicated twin 10 pregnancy) 8 6 4 2 0PoOAtobHrhdaeoPoerDbVmmspeitaaVbSpFtnlSetoHirtyOieaeuherblinbmgeiHPosricmclechestdipToesiiiooiUapidSsiBonntgpHidTannIxyDyslsBgegP Hb <90gT/BL DiabeHtIeVsFigure 2 12 Proven disruption Mis-prescribed Suspected Suspected DVT 10 to care antimalarials ectopic delay delay 8 6 4 2 0 No antimalarials given We provided maternity specialist medico-legal women reported being raped prior to detention.assessments for some of these women, and others Their medical and obstetric presentations werewere seen by the exceptional doctors who also often extremely complicated and we usually worriedvolunteer for the same charity. The data are taken about their immediate wellbeing, as well as theirfrom their own verbal histories and from access to pregnancy care needs. The graph in Figure 1 showstheir medical records. Due to the chaotic nature of some of the symptoms and previous illnesses thatmedical care of women while in the immigration these women suffered from.detention and dispersal system, these records werefar from comprehensive or complete so, in truth, GREATER VULNERABILITY, POORER CAREtheir health needs may have been even greaterthan shown here. In this article we present It is clear that this group of women was much moredescriptive statistics of their health and social likely to experience complicated pregnancy andsituations and the length of their detention – and severe mental illness than most women we usuallyeventual outcomes. encounter in our midwifery practice.Their needs are high and complex and unfortunately they did not Of the 64 women, there were four reported cases often receive the care that they needed while inof a history of torture, with documented scars; eight detention. Figure 2 shows a summary of the issues inreported cases of severe domestic violence; seven care that were documented for these women. Wewomen claimed that they were trafficked; and five found from a personal point of view that they were >>>> Pallotti and Forbes, TPM, December 2016, vol.19, issue 11 9

ARTICLE OF THE MONTH also much less likely to receive compassionate basic Figure 3 care, such as accessing suitable and palatable food or uninterrupted sleep, than we felt they should Asylum seeker have received. Overstayer / Article 8 Unknown In this graph, the most common issue was that antimalarials were not offered prior to an attempt to woman, as appropriate. This advice did not appear remove women to their country of origin. to be acted upon by the health care facility at Yarl’s Considering the greatly increased risk to life of Wood. As a team and as individuals we consistently contracting falciparum malaria in pregnancy, this reported what we felt the issues in care were, via our was an important issue. The ‘Proven disruption to normal supervisory procedures as midwives, as well care’ indicates that a vital appointment (such as an as volunteers and through the RCM in a three-year- anomaly scan) was missed because they were long awareness-raising and lobbying campaign. detained. We also found that when antimalarials However, the health care facility is a privately run were prescribed, they were sometimes not organisation and we were not successful in getting appropriately given; for instance, mefloquine was our concerns addressed. offered in the first trimester; they were given other malarials that are strongly contraindicated in DID DETENTION SERVE A PURPOSE? pregnancy; or they were given mefloquine when they also presented with a history of depressive or Our charity’s ‘Expecting change’ report (Tsangarides psychotic symptoms. A less common but much and Grant 2013) found that immigration detention more concerning finding was that there were delays of pregnant women in the UK was “ineffective, to addressing potential obstetric emergencies, such unworkable and damaging”. As shown in Figure 3, as suspected ectopic pregnancy or DVT, after the the vast majority of women were claiming asylum, woman had alerted staff to symptoms. In one case, cases that can be lengthy to process, and this a woman who had presented several days before resulted in some extended detentions. Article 8 with classic signs of ectopic pregnancy was found to refers to the Equality and Human Rights Commission have ruptured when she was eventually allowed to ‘right to a family life’ and usually meant that the go to the local hospital. Similarly, a woman told us woman had a partner with the right to live in the UK that she had called an ambulance because of and was seeking leave to remain because of this. persistent and worsening haematemesis (vomiting blood). The ambulance was turned away at the The mean length of detention of 56 of the facility’s gates. pregnant women was 54 days, whereas the interquartile range (a better summary measure thanThe health care facility is a privately run the mean in skewed data) was 46 days. The range of detention was from two to 200 days. There wereorganisation and we were not successful missing data on the date of release for eight of the women. The graph in Figure 4 shows the pattern of in getting our concerns addressed length of detention for the whole group. MENTAL HEALTH Of the 64 women detained (shown in Figure 5) In practice, every woman we have seen at Yarl’s Wood has presented with symptoms that made us concerned for their mental health. The 2011 Centre for Maternal and Child Enquiries (CMACE) report specifically considered the impact of deteriorating mental health in pregnancy and the postnatal period (CMACE 2011), and this is of overwhelming importance for women seeking asylum, because of their traumatic histories. In collaboration we chose to use the Edinburgh Postnatal Depression Scale (EPDS) to gain more detail on the women’s mental and emotional wellbeing. In view of the fact that the diagnosis is outside of our midwifery practice, we then advised specialist mental health assessment for each10 Pallotti and Forbes, TPM, December 2016, vol.19, issue 11

MOTHERS IN IMMIGRATION DETENTIONFigure 4 12 10 8 6 4 2 0211111111110987654321000000000000987564321-----------00000000021111111111---------0987654321098756423199999999999999999999 0-9Figure 5 the outcome of their asylum or immigration cases in the community. In our professional opinion it greatly increased the likelihood of women suffering from deteriorating mental and physical health Voluntary return As is clear from this information, detention did Remains detained not serve its primary stated purpose: that of Removed deporting women; and in our professional opinion Released it greatly increased the likelihood of women suffering from deteriorating mental and physicalonly two were deported (removed). One left the health. We are so hopeful that the recent rulingUK voluntarily and, as of March 2016, six remained will prevent more women being detained, but evenin detention. We believe that these women have when not detained, this client group continues tonow all been released. Therefore at least 86 per struggle to access the care they need (CMACEcent of women had an outcome that was not 2011). As midwives, we need to continue toaffected by detention – they were released to await advocate for the most vulnerable and the most hidden mothers in our care. tpm REFERENCES CMACE (2011). ‘Saving mother's lives: 2006-08. The eighth report on confidential enquiries into maternal deaths in the United Kingdom’. British Journal of Obstetrics and Gynaecology, 118 (s1): 1-203. Tsangarides N and Grant J (2013). Expecting change: the case for ending the detention of pregnant women, London: Medical Justice. Pallotti and Forbes, TPM, December 2016, vol.19, issue 11 11

MODULE OF THE MONTHTHIS MONTH’S MODULE: Needs of women seeking asylum andMIDWIFERY SUPPORT FOR ASYLUM refugeesSEEKERS AND REFUGEES National guidelines for care in pregnancy address the additional needs of vulnerable women who demonstrate poorer outcomes than the rest of the population. ‘Recent arrival in the UK’, ‘asylum seeker or refugee status’, ‘difficulty speaking or understanding English’ are examples of ‘complex social factors’ (National Institute for Health and Care Excellence (NICE) 2010). These groups of women may especially benefit from continuity of carer and from intensive and supportive midwifery involvement. In addition to gold standard antenatal care, it is important to consider the following factors when supporting women who are seeking asylum or who already have refugee status: As a • Mental health needs, especially post-traumaticresult they may have less optimal pre-pregnancy stress disorder (PTSD). Diagnosis of depression andhealth and more complicated obstetric histories than other mental illness is outside of our professionalwomen who have lived in the UK for some time. remit as midwives, but training in and use of aFurther, the reasons they fled their homes and the validated screening tool, such as the Edinburghprocess of getting to the UK may have been Depression Scale may help you in deciding when totraumatic, and mental health needs are a priority for make an antenatal or postnatal mental healththis group of women. The Refugee Council states that referral.the UK asylum system is very complicated and verytough, and sometimes there is poor decision making • Symptoms of PTSD include panic attacks,on asylum cases (Refugee Council 2015). For instance insomnia, nightmares, 'flash backs' (reliving ain 2015, 38 per cent of appeals were upheld in the traumatic experience), general symptoms ofrefugees’ favour (Home Office 2015). depression, feelings of isolation and guilt; but presentation can be extremely varied. Many women find the process of seekingasylum itself to be very distressing, especially if they • People who have suffered traumatichave been arrested and detained. experiences may not be able to tell a coherent story about their history, as trauma may affect the way memories are created and stored. This can sometimes lead to asylum seekers being disbelieved by the immigration services because they cannot present a reliable testimony about what has happened to them. Further, a difficult birth with interventions can contribute to trauma-related mental illness, so sensitive and woman-centred birth planning and continuous care in labour from a trusted midwife are crucial for these women.Go the website at Any woman recently arrived from a country in the tropics who presents as acutely unwell should beand take this assessment; once you have offered a malaria test. Falciparum malaria (the mostanswered all the questions correctly, severe form) is much more likely to lead to mortalitydownload your certificate to keep in your or serious morbidity in pregnancy, and earlyrevalidation folder. detection and treatment are key to effective management. Similarly, a pregnant woman whose asylum claim has failed should not be deported to a tropical country without consideration of anti- malarial prophylaxis, which must usually be started several weeks before departure. There are limited anti-malarial drugs available in pregnancy and12 Pallotti, TPM, December 2016, vol.19, issue 11

MIDWIFERY SUPPORT FOR ASYLUM SEEKERS AND REFUGEESthere are no recommended options for a pregnant a) Travel historywoman in the first trimester or a pregnant woman b) Medical and obstetric historywith concurrent mental illness. For a recently c) Mental health screeningarrived asylum-seeking woman, a detailed travel d) All of the abovehistory should be sensitively taken at booking andat any admission. Women who have spent time in a a) A woman seeking asylum has the same carerefugee camp or time in the tropics are at a much needs for birth as any other womanhigher risk of contracting infectious and/or tropicaldiseases. Similarly a detailed obstetric history is b) A woman seeking asylum may havevery important; in particular previous caesarian additional care needs for birthsection performed in other countries, as the uterineincision may be classical (top to bottom) which has c) Women seeking asylum should be offered aimplications for informed decisions about VBAC. consultant-led birth, as we cannot be sure of their obstetric history • Appropriate translation services should alwaysbe used, face-to-face, where possible. Use of male d) Women seeking asylum should be offered theinterpreters should always be discussed with the lowest cost service, in case they then have towoman and her family first, as this may be a barrier pay for their careto disclosure of physical or mental problems. a) Used when making important decisions? • Secondly, descriptions of physical and b) Used when the woman does not have a friendemotional pain can be very culturally specific, so itis important to discuss symptoms in detail to ensure or family who can translate for her?that you understand what is concerning the woman. c) Used for every appointment, face to face if a) Emergency care only possible? b) Maternity care if they pay for it d) Used for inpatients only? c) Free and full NHS care until their case is a) It is not possible to suffer from malaria in the decided UK d) They are entitled to NHS care for which they b) Malaria does not affect pregnancy need to pay c) A traveller may later develop malaria, which may be more severe in pregnancy d) There is currently no available treatment for malaria in pregnancy a) True b) Falsea) Trueb) Falsea) Flashbacks, nightmares, panic attacks, errors REFERENCES in memory Home Office (2015). National statistics quarterlyb) Psychosis and delusion release, London: Crown. www.gov.uk/government/c) Dizziness and fatigue statistics/immigration-statistics-july-to-september-d) Chest pain and muscle ache 2015a) True NICE (2010). Pregnancy and complex social factors.b) False CG 110, London: NICE. www.nice.org.uk/ guidance/cg110a) 15 per centb) 50 per cent Refugee Council (2015). The facts about asylum,c) 1 per cent London: The Refugee Council. www.refugeecouncil.d) 23 per cent org.uk/policy_research/the_truth_about_asylum/fa cts_about_asylum_-_page_5 Pallotti, TPM, December 2016, vol.19, issue 11 13

MIDWIFERY BASICS: BECOMING A MIDWIFE Jancis Shepherd Lead Midwife for Education at University of West London Becoming a midwife is the 16th series of ‘Midwifery basics’ targeted at practising midwives and midwifery students. The aim of these articles is to provide information to raise awareness of the impact of professionalism on women’s experience, consider the implications for midwives’ practice and encourage midwives to seek further information through a series of activities relating to the topic. In this second article of the series, Jancis Shepherd considers why professionalism is an issue in maintaining public confidence, why midwives need to demonstrate good health and good character and how applicants are selected for midwifery courses to meet these attributes.ACTIVITY 1 WHY IS PROFESSIONALISM AN ISSUE? PUBLIC EXPECTATIONConsider how a student Reviewsmidwife may inadvertently With the integration of expert patient groupsbreach professional Within health care, professionalism is undergoing (service users) in health care, the promise ofboundaries. How can this be scrutiny due to the recognition that public personalised care (DH and Public Health Englandavoided? confidence has been eroded in recent years following (PHE) 2014) and the empowerment of women in a number of enquiries, reports and reviews their childbirth choices, the bar for care excellence (Department of Health (DH) 2013; Nursing and and professionalism is high.Therefore it is essential Midwifery Council (NMC) 2014; 2015a; Kirkup 2015). that the recruitment process identifies applicants with attitudes that can be developed for professional Electronic communication practice to fulfil these expectations. Recruitment to a midwifery course has to meet the NMC standards The context in which midwifery care is given is one for pre-registration midwifery education (2009). of striving for excellence with finite resources: a These include consideration of educational society where communication through electronic attainment, assessment of numeracy and literacy, means is readily available and boundaries are where possible a face-to-face interview and becoming more fluid. Similarly to the findings of demonstration that applicants have good health and Morrow et al, who noted (2011: 24) ‘the Internet and good character sufficient for entry and participation social media were discussed as a threat to the in a course leading to qualification as a midwife boundary between professional and private selves, (NMC 2009). and this extended to privacy’, the boundary between midwives/students and clients may be similarly WHAT ARE GOOD HEALTH AND GOOD blurred. Texting and using social media within CHARACTER? professional roles may cause confusion over professional and personal use, and midwives may be At face value these sound easily attainable and most unaware of how widely messages can spread via social people would describe themselves as having good media. Midwifery students need to understand the health and being of good character. However, this is advantages and disadvantages and be encouraged a statement with a more complex meaning. to exercise responsible use of social media. As the NMC has a primary duty to safeguard the14 Shepherd, TPM, December 2016, vol.19, issue 11

PROFESSIONALISM, PUBLIC CONFIDENCE AND APPLYING FOR A COURSEpublic, the definition of ‘good health and good Good character ACTIVITY 2character’ is such that it attempts to ensure that Consider your use of socialapplicants to the course and who are currently In addition to the standards identified in the NMC media. How might you need tostudying, display the professional attributes and Code (2015b), each applicant seeking to join the adjust this to ensure youbehaviour required in The Code (NMC 2015b).These register must declare any pending charges, remain within the NMC Codeattributes are a pre-requisite for NMC registration convictions, police cautions or decisions made by (2015b) and within the NMC(an applicant having to declare their fitness to any other regulatory body. The NMC will consider (2016) guidance on using socialpractise on initial registration, at registration any conduct issues that would breach The Code media responsibly? Reviewrenewal and if they are readmitted to the register). (NMC 2015b). your local Trust guidelines onAt the initial registration, good health and good social media use to ensure thatcharacter have to be verified by a third party, which Some areas of behaviour may cross between the you also follow theseis the duty of the Lead Midwife for Education (NMC student’s professional, personal and social life, and2009). Midwives are then expected to continue to this is also framed within The Code, by whichmaintain their good health and good character and students and practitioners are bound.abide by The Code (NMC 2015b); self declaration ofcontinuing good health and character is part of the At its best, the NMC code and its standards canNMC revalidation process. If an incident occurs be seen as a way of promoting professionalism;whereby the registrant’s good health or good however where there is a failure to meet thesecharacter is not maintained, the expectation is that standards this will bring a practitioner’s fitness tos/he will inform the NMC (NMC 2015c). practise into question either as conduct or competence concerns.NMC definition APPLICATION TO MIDWIFERY COURSESThe Code (2015b) sets the standards of health andcharacter expected of registrants: to uphold all the Aspiring students need to follow the applicationstandards that are integral to being a professional. process to meet the Universities and CollegesStandard 20 requires midwives to uphold the Admissions Service (UCAS) system. The aim is toreputation of the profession, act honestly and with recruit students with values that match those of theintegrity, keep to the laws of the country and maintain NHS, and that will lead to a student upholding thepersonal health in order to undertake the role (See Box 1). values and standards of the NMC Code (2015b). It is a fundamental requirement for a midwife to The process >>>>be of sufficient character and health to be capable ofsafe and effective practice, without restriction. The Potential applicants who meet or expect to meetNMC (2015d) states that this does not necessitate the (subject to examination results) the course entryabsence of a health condition or disability. criteria, apply via UCAS, supplying their academic qualifications, their personal statement and reference. The applications are then screened for suitability, and applicants selected for shortlistingBox 1 Standard 20: Uphold the reputation of your profession at all times20.1 Keep to and uphold the standards and values 20.7 Make sure you do not express your personal ACTIVITY 3set out in the Code beliefs (including political, religious or moral Being a student midwife can20.2 Act with honesty and integrity at all times, beliefs) to people in an inappropriate way be stressful, and take its toll ontreating people fairly and without discrimination, 20.8 Act as a role model of professional behaviour health and wellbeing; identifybullying or harassment for students and newly qualified nurses and the support mechanisms that20.3 Be aware at all times how your behaviour can midwives to aspire to are in place for students andaffect and influence the behaviour of other 20.9 Maintain the level of health you need to those that may need to bepeople carry out your professional role developed20.4 Keep to the laws of the country in which you 20.10 Use all forms of spoken, written and digitalare practising communication (including social media and20.5 Treat people in a way that does not take networking sites) responsibly, respecting theadvantage of their vulnerability or cause them right to privacy of others at all timesupset and distress 23.2 Tell us and any employers as soon as you can20.6 Stay objective and have clear professional about any caution or charge against you, or if youboundaries at all times with people in your care have received a conditional discharge in relation(including those who have been in your care in the to, or have been found guilty of, a criminal offencepast), their families and their carers (other than a protected caution or conviction) Shepherd, TPM, December 2016, vol.19, issue 11 15

MIDWIFERY BASICS: BECOMING A MIDWIFEand attendance at selection.The aim within selection THIS TIME, NEXT TIMEis to choose applicants who demonstrate that theyhave the personal attributes and potential to: be This article has considered why professionalism iskind, caring and competent midwives; achieve the an issue in maintaining public confidence, whyknowledge, skills and professional attitudes for safe midwives need to demonstrate good health andand competent practice within the pre-registration good character and how applicants are initiallymidwifery standards (NMC 2009); and achieve a selected for midwifery courses to meet theseminimum of a Bachelor of Science Midwifery requirements. The next article in the series willdegree. continue by considering issues of personal conduct that may arise during course application includingRegistration application for Disclosure and Barring Service clearance screening. tpmSuccessful completion of the course, the signing ofthe Declaration of good health and character (NMC REFERENCES2009), meeting the NMC screening requirements of DH (2012). Compassion in practice. nursing,good health and character and the fee payment willlead to successful registration as a midwife with the midwifery and health care staff. Our vision and strategy,NMC. Both during midwifery education and oncequalified, the expectation is that the student and London: The Stationery Office.midwife will meet the professional standards set inThe Code (NMC 2015b). DH (2013). Patients first and foremost, the initialJoint recruitment government response to the report of The MidAs midwifery courses comprise both theory and Staffordshire NHS Foundation Trust public inquiry,clinical practice, university and practice partnershave a joint responsibility for selection. A joint London: The Stationery Office.recruitment and selection policy needs to follow therequirements of Health Education England (HEE) DH and PHE (2014). A framework for personalised(2014) to recruit applicants who it is believed canuphold the values of the NHS constitution (care, care and population health for nurses, midwives, healthcompassion, courage, commitment, competence andcommunication – the six Cs) (DH 2012), and meet visitors and allied health professionals, London: Crown.the requirements for admission to pre-registrationmidwifery courses (NMC 2009). Local processes to HEE (2014). Values based recruitment framework,achieve this are formally agreed. London HEE.Values based selection Kirkup W (2015). The report of the Morecambe BayApplicants will be assessed using a Values BasedRecruitment (VBR) strategy (DH and PHE 2014) that investigation, London: The Stationery Office.is designed to elicit the desirable qualities. Literacyand numeracy will be assessed and a face-to-face Morrow G, Burford B, Rothwell C et al (2011).interview or multiple mini interviews, conducted.Two references are required, preferably an academic Perceptions of professionalism in health care professionals,reference at UCAS application and employment/character reference later. Following successful offers London: Health and Care Professions Council.and acceptance, applicants will complete aconfidential occupational health appraisal to ensure www.hpc-uk.org/assets/documents/ 10003771that they are physically and psychologically fit toenter the course and participate in clinical practice. Professionalisminhealthcareprofessionals.pdfProtecting the public and ourselves NMC (2009). Standards for pre registrationApplicants will receive relevant immunisations midwifery education, London: NMC.before entering clinical practice. NMC (2014). Quality assurance framework, In order to protect the public, prior to courseentry and before clinical practice can be started, extraordinary LSA review. Princess Elizabeth Hospital,applicants are required to have a ‘clear’ enhancedDisclosure and Barring Service (DBS) check. Health and Social Services Dept, Guernsey, London: NMC. NMC (2015a). Quality assurance framework, England, Scotland, Northern Ireland, Wales. Extraordinary LSA review, Healthcare Inspectorate Wales, LSA with Betsi Cadwaldr, University Health board, London: NMC. NMC (2015b). The Code. Professional standards of practice and behaviour for nurses and midwives, London: NMC. NMC (2015c) Revalidation. How to revalidate with the NMC. Requirements for renewing your registration, London: NMC NMC (2015d). Character and health decision making guidance, London: NMC. NMC (2016). Guidance on using social media responsibly, London: NMC. https://www.nmc.org.uk/globalassets/sitedocument s/nmc-publications/social-media-guidance.pdf16 Shepherd, TPM, December 2016, vol.19, issue 11

* * 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 c ontributes 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 MmuIltDivitWamiInVbrEanSd RECOMMEND MOST† Before Conception Original Plus Omega 3 Breast-feeding *2016-09-13_ADPRGPROFP_E 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 Unit Sales 52 w/e 18th June 2016 www.pregnacare.com

POSTNATAL DEPRESSIONA second year student midwifeI am a mother to four-year-old twin girls. Life since their birth has not been easy and postnatal depressionhas blighted our relationship. So, too, has it affected the relationship I have with friends, family, myhusband, myself. My reasons for becoming a student midwife were numerous, but my experiences as apregnant woman and a new mother were pivotal in that decision.Whilst screening tools are recommended to detect postnatal depression, depression does not fit a scoringsystem neatly, and is experienced differently by everyone. In addition, women suffering may falsify results(I did) and may not consent to use of the tools. Women's subjective experience of pregnancy, birth andmotherhood is crucial, and PND needs to be spoken about in the antenatal period in order to overcomethe associated stigma and to encourage women's self-efficacy in reporting symptoms. I am a student midwife. I am a mother of MY EXPERIENCEidentical twin girls. Despite having two healthy newborns to take home Whilst the first role will change as my training at the end of a five-day hospital stay, the past fourand career progress, the latter will not. On May 20th years have been characterised by ugly regret,2011 I became a mother of twins, and no matter what ruinous envy and savage guilt. I should feel grateful,else changes in my life, that is one eternal truth. I will happy, blessed. I should, but I don't. I regret my lostalways be a mum; and nobody tells you that it will identity, I envy women who only had one baby tochange you in ways you could never imagine. grow, to take home, and I feel guilty that, when oneNobody mentions that you may not revel in of my daughters was taken to the neonatal unit forpregnancy or fall head-over-heels in love. her very first night of life, I was relieved. The overriding feeling is that of shame: I am ashamed Postnatal depression (PND) and anxiety affect 15- that I feel this way.20 per cent of all maternities in the UK (NationalInstitute for Health and Care Excellence (NICE) The truth is that nobody tells you the truth.2014), although PND has a higher prevalence among Nobody tells you that you may hate your body, bemothers of twins and triplets: 20 per cent are embarrassed by your bump, have an altereddiagnosed with PND, and a further 20 per cent think relationship with your partner and your friends.they have suffered, but without diagnosis (Fraser Nobody tells you that you would rather die than2010). Infants of mothers with untreated PND have admit you can't manage, that when your babies arean increased risk of long-term impaired behavioural older and you finally find the courage to ask for help,and social development (Henshaw et al 2009) and people won't want to hear the message behind yourwomen risk prolonged depression and negative words. Few people want to acknowledge theexperience of motherhood (Camp 2013). As such, uncomfortable truth that you are not coping or,PND is a public health issue and concerns all of us worse still, are unhappy. You want someone whoas future and current midwives. won't judge you when you say that you don't love18 TPM, December 2016, vol.19, issue 11

POSTNATAL DEPRESSIONyour children, aren't happy with what you've got, my husband sleeping in the bed next to me, and Iwant to go to bed in the middle of the day, throw can't tell him. I feel as though I am trying to treadyourself from the nearest open window, walk out fast-flowing water, alone. Some days it takes all mythrough the door (alone), never to return. These are strength not to hurt myself. Depression is bleak: it'suncomfortable statements that we do not burden not being able to look at photos of your kids; notpeople with. We should, but too often the person being able to remember the first few years of theirlistening replies,“Of course you love them”. lives; not knowing what they looked like as newborns; not remembering the love you should No I don't, listen to me! have felt; not knowing how to hug them better. I look Until I started my midwifery training I thought I back and cannot believe that the person I once waswas an awful mother.The fact is that guilt and shame has got so lost. I genuinely love life: I love to travel,and anger have clouded my mind. I felt subsumed read, write, run, paint, visit new places, meet newby this new role as a mother of twins: strangers people. These things have been buried, butapproached me to say “Poor you”,“Rather you than occasionally there are glimpses of that person I onceme”, “I had a twin. She died”. I wanted to run the was. I am afraid that that person is long-dead. Apushchair over the people who thought that 'double lecturer gave me a great piece of advice: accept yourtrouble' was a helpful comment.Twins aren't double own 'normal'. This is what I am trying to achieve:trouble – not even close. Everything is heightened trying to balance the rubbish with the good stuff, toand the lows are catastrophic. The times I pleaded stop torturing myself for who I am, and writing iswith two tiny babies to go to sleep; the night I fell giving me the courage to speak out.asleep on top of the baby monitor to block out thenoise; and the thousands of other moments were NOTES FOR PRACTICEdevastating, they shattered my world, further erodedmy self-worth. There seem to be few recent studies that focus on The thing about depression is that it is women's subjective experiences of postnatalexperienced differently by different people, and depression. Over-reliance on screening tools such assometimes there are good days and even great days. the Whooley questions and Edinburgh PostnatalI don't have days when I can't pull myself out of bed; Depression Scale (EPDS) may mean that midwivesquite the contrary: I am often awake hours before overlook women's individual experiences (Edhborgthe alarm goes off, counting down the minutes until et al 2005). Whilst screening tools may have theirI can legitimately start my day. I have days when I place, depression does not fit neatly into a scoringam so driven and focused that it scares me, and system. Women may be reluctant to discussothers when I literally can't bear to say my own depressive symptoms if they feel midwives arename aloud. completing a check-list of postnatal questions rather A relaxation class at university turned my world than focusing on them as individuals (Royal Collegeupside down and I have spent most of this year of Midwives (RCM) 2014). Women who arecoming to terms with being unwell. Often I live with desperate not to be found out lie; I did. I wasa tangible, physical pain that I can feel like a lump petrified that somebody would discover how I wasin my throat and a knot in my stomach, I can't bear feeling and question my ability to mother my >>>>Pebble UK Support Hosiery Suppliers 19 Helps Prevent Leg Fatigue, Swelling & the Onset of Varicose Veins. Flat seams that will not dig into your tummy or show under clothes. Preggers tights’ unique stretch top, gives sense of stability for active mums-to-be & can be worn under or over the belly. Super, soft material is breathable & provides help to support bump & lower back. Microcool wicking process quickly evaporates moisture from the skin for comfort & hygiene. True gradient compression delivers controlled pressure from the Ankle up, to promote FIXXIVFPSSH¾S[ See our full range of Maternity Compression Tights, Stockings & Knee Highs, in a choice of (mmHg) compressions.FREEPHONE 0800 433 4757 www.pebbleuk.com TPM, December 2016, vol.19, issue 11

POSTNATAL DEPRESSION children. Women may feel that PND is incongruous symptoms to look out for, a plan in case she needed with their role as a mother and hide their depression help; we talked about mental health with courage for fear of stigmatisation and judgement (Grier and and warmth – we didn't sweep it under the carpet or Geraghty 2015). It has been suggested that women assure her that everyone feels the same with a new with depressive symptoms are more likely to baby. Maybe they do, maybe she feels worse. I hope withhold or withdraw consent for PND screening she has the tools in her belt and enough courage and (Brealey et al 2010); thus, an astute midwife could support to get help if she needs it. deduce that non-consenting is as pertinent as a significant screening result. That woman's journey is not my journey; I don't pretend to understand how she was feeling. My As a couple they had information, experience of PND has taught me more than any number of hours in a classroom ever could, and I symptoms to look out for, a plan in case would give anything to not have experienced it, to have a 'normal' relationship with my daughters.she needed help; we talked about mental On a particularly bleak day someone asked me health with courage and warmth why I wanted to become a midwife. At that moment I was so low that I no longer knew the answer. Now On average, women have contact with a midwife I have remembered why: if I can help one woman for 10 days after birth (Brealey et al 2010), so while who experiences the things that I have experienced PND may present any time in the first year as a mum, then that is sufficient. The woman I postpartum, midwives still have a role to play in its mentioned above told me I will make a good detection and disclosure. Midwives can help to midwife; to her I made a difference, and that is remove the stigma by discussing PND in both enough for me. tpm routine antenatal appointments and parent education classes (NICE 2008; Camp 2013) and this REFERENCES may go some way to enhancing self-efficacy. A Brealey S, Hewitt C, Green J et al (2010). woman who recognises the symptoms of PND, considers it as separate from her role as a mother, ‘Screening for postnatal depression – is it acceptable and knows how and where to access help, is a woman who may be better able to obtain support to women and healthcare professionals? A long after the involvement of the midwifery team has ended. Midwives need to signpost symptoms to systematic review and meta-analysis’. Journal of partners, families, friends. Those closest to the woman will be more likely to identify Reproductive and Infant Psychology, 28(4): 328-344. uncharacteristic behaviour and mood. Camp M (2013). ‘Postpartum depression 101: I recently applied this knowledge to a primiparous woman I met in practice. Fiercely teaching and supporting the family’. International intelligent, friendly, well-travelled, quick-witted, professional, hilariously funny, a history of mental Journal of Childbirth Education, 28(4): 45-49. health concerns, I watched her unravel over the course of three days in our care. I discussed signs of Edhborg M, Friberg M, Lundh W et al (2005). PND with her and her husband, helped her with feeding, encouraged skin-to-skin when she felt able 'Struggling with life: narratives from women with to, made plans for breastfeeding support groups, signposted services. She needed love and friendship signs of postpartum depression’. Scandinavian Journal in the middle of the night, a cup of tea while she was feeding, someone to laugh with when the baby of Public Health, 33: 261-267. urinated on his own face, someone to hold her hand as she cried, an extra hand to put a hair band in Fraser E (2010). Postnatal depression: a guide for when balancing a baby on her breast. We gave her that. What I also hope we gave her was a set of tools, mothers of multiples, Aldershot: TAMBA. self-efficacy. As a couple, they had information, www.tamba.org.uk/document.doc?id=279 Grier G and Geraghty S (2015). ‘Mind matters: developing skills and knowledge in postnatal depression’. British Journal of Midwifery, 23(2) 10-14. Henshaw C, Cox J and Barton J (2009). Modern management of perinatal psychiatric disorders, London: RCPsych. NICE (2008). Antenatal care for uncomplicated pregnancies. CG62, London: NICE. www.nice.org.uk/guidance/cg62 NICE (2014). Antenatal and postnatal mental health: clinical management and service guidance. CG192, London: NICE. www.nice.org.uk/guidance/ cg192/chapter/introduction RCM (2014). Maternal mental health: improving emotional well-being in postnatal care, London: RCM. www.rcm.org.uk/sites/default/files/Pressure %20Points%20-%20Mental%20Health%20- %20Final_0.pdf20 TPM, December 2016, vol.19, issue 11

CRANIAL OSTEOPATHYSara RandallOsteopath, Midwife and Lactation ConsultantCranial osteopathy is the gentlest form of osteopathy and is particularly suitable for babies where it isused to address a range of problems. It relies on gentle touch and manipulation for both workingdiagnosis and appropriate management of tension patterns in order to release stresses and tensionsthroughout the whole body. First we will look at the basic principles underlying the discipline, then at how it can be used inpractice for managing conditions such as colic and generally unsettled babies, torticollis, feedingchallenges and constipation.AN OVERVIEW restrictions may be detected and such restrictions may have detrimental effects on theNo discussion of cranial osteopathy could be body.complete without mentioning the father of the 3. Dural mobility of the reciprocal tensiondiscipline, William Garner Sutherland. An membranes that encase the central nervousosteopathic doctor, Sutherland was the first system. Trained cranial osteopaths are able toosteopath to recognise the importance of cranial release tension in these membranes and doingrhythms as an indicator of health (Sutherland 1939). so influences many structures throughout theHe taught that the human system has at its essence body.a force that, towards the end of his career he termedthe ‘breath of life’. He called his concept the ‘primary The aim of the osteopath is to resolverespiratory mechanism’ (PRM), a rhythmic motionconsisting of five components. Although initially these dysfunctions, and once this hasdescribed in relation to the head, it is not confinedto it; it is an ebb and flow that occurs throughout the been achieved the problems associatedbody and which has an important influence onhealth, particularly when there are changes to its with them will be healedstrength and frequency. The five components ofPRM are: 4. The mobility of cranial bones: although 1. Central nervous system motility that is not seemingly fused together, cranial osteopaths are connected with respiration or the cardiovascular pulse. Essentially it is a coiling and uncoiling of able to feel these move slightly in concert with the brain where the spinal cord moves up and down. the reciprocal tension membranes and 2. Fluctuation of the cerebro-spinal fluid. This can consequently are able to manipulate them. >>>> be palpated along its route by trained cranial osteopaths. Any changes in pressure caused by Randall, TPM, December 2016, vol.19, issue 11 21

CRANIAL OSTEOPATHY 5. Involuntary motion of the sacrum (the tail bone) associated diaphragm that plays a role in the between the hip bones (ilia). movement of body fluids and air. Fascial torsions affect circulation and impact on health. If the Since Sutherland’s time, cranial osteopathy has diaphragms are rotated in alternating directions,been developed extensively. However, it is still their physiological function will be compromised.underpinned by these principles. Essentially, cranial The aim of the osteopath is to resolve theseosteopathy addresses the anatomy and physiology dysfunctions, and once this has been achieved theof the cranium, the central nervous system, problems associated with them will be healed.cerebrospinal fluid, and how these interrelate withthe whole body, the overall aim being prevention CRANIAL OSTEOPATHY FOR BABIESand managing disease, and the enhancement ofhealth. Birth is a traumatic time for a baby. Even before birth tensional patterns such as those described above An alternative approach is the common occur in the uterus, and during the birthing processcompensatory pattern (CCP) originally described by the baby is subjected to huge forces as it passesZink and Lawson (1979) and which forms the basis through the birth canal, twisting and turning as itof a respiratory and circulatory care model. squeezes through the pelvis. This causes variousEssentially this is an alternating pattern of fascial compressions on the skull and spinal column and,preferences. Fascia are bands of fibrous connective while many of these will relieve spontaneously, intissue that enclose and support muscles and other many babies some will remain. While this canorgans. While they are able to absorb stress, fascial happen in an easy birth, when the labour isstrains are disruptive to the body’s homeostatic prolonged, forceps or ventouse are used, or if theremechanisms and alternating fascial patterns can is an emergency caesarean section, the problems areoccur. Zink and Lawson’s CCPs are based on the likely to be exacerbated. Untreated, these patternsjunctional areas between the pelvis, thorax and can lead to a variety of problems such as colic,cranium: the lumbosacral complex; the thoracic difficulty sleeping and feeding.inlet; the thoracic outlet; and the upper cervicalcomplex. Each of these four junctions has an With a cranial osteopathic assessment of the baby, potential problems associated with in-utero22 Randall, TPM, December 2016, vol.19, issue 11

CRANIAL OSTEOPATHYtensions and birth can be group. Theidentified and an osteopathic overallmanagement programme to reduction in cryingrelieve them implemented. time was 63 per cent, and sleeping improvementINFANTILE COLIC, was 11 per cent. This group also placed fewerEXCESSIVE CRYING demands for attention on their parents.Colic or excessive crying is a UNSETTLED BABIES AND SLEEPINGdistressing condition for parents and DIFFICULTIESbabies. Occurring in around 20 percent of otherwise seemingly healthy Some babies find it difficult to settle and go to sleep.babies, it manifests as intense and frequent It is typical for newborn babies to sleep for betweencrying, typically starting during the first few weeks two and three hours between feeds, but some babiesand persisting for up to six months. Colicky babies are unable to. Such babies may have cranial andare usually red and flushed when they cry, upper neck problems, due to pressures exerted onfrequently clenching their fists and arching their the head and neck during birth, as already described.bodies. Typically, they cry for over three hours a day, This may cause pain and discomfort when the babyoften in the evening. is in particular positions: for instance it might cry when lying on its back but is able to sleep while While there isn’t a consensus on the causes of the being held or lying on its front.condition, it appears to be associated withgastrointestinal discomfort. The osteopathic view is In such cases cranial osteopathy can be highlythat the condition is caused by cranial dysfunction effective at diagnosing and relieving the underlyinginduced by the birthing process, which creates problems in similar ways to those described above.tensions and pressures that can affect the vagusnerve, which in turn affects the stomach. Cervical BREASTFEEDING PROBLEMSspine rotation patterns can form from an asynclitic For a newborn baby breastfeeding is a complexhead presentation where the vertex, being thesmallest diameter, does not present as hoped for and process, requiring the co-ordination of six out of 12so essentially a 'crooked neck' occurs. This can beuncomfortable for the baby and can also irritate or cranial nerves, 60 muscles and 22 bones that connectcompress the vagus nerve via muscles andligaments. at 34 sutures. It isn’t at all surprising that various The cranial rhythmic impulse (CRI), or more breastfeeding problems can result from birthsimply the cranial rhythm, is one of the body’s subtlerhythms identified by Sutherland (1939); by trauma.assessing this, it is thought possible to determinecranial dysfunction.To verify this, the CRI of a group These can manifest in various ways, but generallyof 139 babies was measured before discharge fromhospital and at two and six weeks (Kotzampaltiris et relate to problems latching. Possibly the baby prefersal 2009). Taking the group as a whole, the amount ofexcessive crying was 41.7 per cent. While there was one breast, and refuses the other, which can beno correlation between excessive crying and CRI atbirth, there was a strong correlation between painful for the mother. Latching problems can haveexcessive crying and abnormal CRI at two weeks:infants with excessive CRI at two weeks were 6.8 various causes; for instance:times more likely to exhibit excessive crying thaninfants with normal CRI. • Problems with the shoulders and lower neck lead Excellent results have been reported on the the baby to have a preferred side to turn to, andcranial osteopathic management of infantile colic(Hayden and Mullinger 2006). A group of 28 infants so latch to a preferred breastreceived either no intervention or cranial osteopathyover a period of four weeks, and their parents kept a • Strains to the muscles in the throat and jaw candiary of the time they spent crying, sleeping andbeing held. The infants who received osteopathy occur during birth as the neck is bent backwards.showed a large reduction in crying and animprovement in the time spent sleeping, while no This can lead to latching difficulties >>>>significant changes were recorded in the control Randall, TPM, December 2016, vol.19, issue 11 23

CRANIAL OSTEOPATHY • Problems with the palette caused by imbalance important to treat it; left untreated it can become a of its fine structures can create difficulty in chronic condition with potential complications. sucking and latching There are several possible causes: • Moulding of the skull can affect the muscles that • Dehydration caused by insufficient fluid intake – control the tongue, again causing difficulties with the latch can occur when baby is teething or unwell An osteopathic assessment would identify these • Dietary change – such as moving from breastproblems, which should be amenable to correction milk to formulaby gentle manipulation designed to help muscle • Medication – for instance from Gavisconstrains and correct the alignment of cranial bones(Westcott 2004). Recent studies have also provided prescribed as a treatment for refluxevidence that breastfeeding problems are improved • Psychologic factors – deliberately withholdingusing cranial osteopathy. A literature review ofvarious case studies and clinical trial (Fry 2014) stoolsshowed improvements in up to 80 per cent of babies • Birth traumaafter two weeks, and other research (Smith andKroeger 2009; Ohm 2006) indicates that cranial While the first three causes may be treated byosteopathic management of breastfeeding babies traditional means, constipation due to birth traumacan help resolve the following problems: may be managed using cranial osteopathy. If the other possible causes do not obviously apply, an • Latching difficulties osteopathic assessment is recommended. • Unco-ordinated sucking and difficulty with the FINALLY suck-swallow-breathe sequence • Preference for one breast or a single feeding Cranial osteopathic assessment and management is a proven route for dealing with a wide range of position common baby problems that relate to the birthing • Needing to nurse constantly or difficulty process. The human baby has evolved to be robust and able to deal with the rigours of being born; transferring milk even though apparently however, many babies endure residual birthing nursing damage that is readily managed through the gentle • Problems bottle feeding in addition to touch of trained cranial osteopaths. Cranial breastfeeding osteopathy has been demonstrated to be entirely safe and highly effective. tpmINFANTILE TORTICOLLIS REFERENCESInfantile torticollis or twisted neck can occur innewborn babies as a result of positioning in the Fry LM (2014). ‘Chiropractic and breastfeedingwomb, following a difficult childbirth or if forceps dysfunction: a literature review’. Journal of Clinicalhave been used. The baby is likely to have difficulty Chiropractic Paediatrics, 14(2): 1151-1155.turning its neck and may display a tilted head.Whilst this may be present at birth, it might not Hayden C and Mullinger B (2006). ‘A preliminarybecome apparent for several months. assessment of the impact of cranial osteopathy for the relief of infantile colic’. Complementary Therapies The problem lies with the sternocleidomastoid in Clinical Practice, 12(2): 83-90.muscle that runs on the sides of the neck betweenthe ears and the collarbone. Pressure on one side Kotzampaltiris PV, Chou KJ, Wall SP et al (2009).can cause it to tighten, giving a twisted appearance ‘The cranial rhythmic impulse and excessive cryingand making it difficult to turn the head. If the of infancy’. The Journal of Alternative andcondition isn’t addressed, it can result in craniofacial Complementary Medicine, 15(4): 341-345.asymmetry. The condition can also lead todifficulties breastfeeding. Ohm J (2006). ‘Breastfeeding difficulties and chiropractic’. Pathways to Family Wellness, (11): 24-25. Cranial osteopathic management of torticolliscan be highly effective. Intervention typically Smith LJ and Kroeger M (2009). Impact of birthinginvolves a combination of cranial realignment, practices on breastfeeding, 2nd edition. Massachusetts:gentle spinal mobilisation and soft tissue therapy. Jones and Bartlett.CONSTIPATION Sutherland WG (1939). The cranial bowl: a treatise relating to cranial articular mobility, cranial articular lesionsConstipation in babies is fairly common, affecting and cranial technic, California: Free Press Company.around 15 per cent of babies. Typical signs aredelayed stools which tend to be small, dry and hard; Westcott N (2004). ‘The use of cranial osteopathypain and straining; particularly foul-smelling stools; in the treatment of infants with breastfeedingand poor appetite and reduced energy levels. It is problems or sucking dysfunction’. Australian Journal of Holistic Nursing, 11(1): 25-32. Zink GJ and Lawson WB (1979). ‘An osteopathic structural examination and functional interpretation of the soma’. Osteopathic Annals, 7: 12-19.24 Randall, TPM, December 2016, vol.19, issue 11

HYPNOSIS AND HYPNOBIRTHING FOR LABOURAlys EinionAssociate Professor of Midwifery at Swansea UniversityThe provision of woman-centred care is at the heart of midwifery practice, and there appear to beincreasing numbers of women choosing alternative forms of support for their childbearing journey.Women are often fearful of the experience of labour and birth, and in particular express concern aboutpain and its management; the literature shows that fear of childbearing is associated with increasedpain (Leeman et al 2003). Although there are many pharmacological and non-pharmacologicalapproaches to managing the pain of labour, these depend on availability, women’s preferences, and onthe woman’s perception of their efficacy. This literature review focuses on the use of hypnosis, including complex programmes of antenatalpreparation known as hypnobirthing, as a means of coping with the experience of labour and birth.A key word search of the literature was carried out to identify published research and literature on thistopic. The articles chosen for critical review will be evaluated and explored.BACKGROUND AND CURRENT DEBATES actively, and perhaps because they experience more >>>> one-to-one support when using such approaches.According to Porter (2004), as consumers ofmaternity care, women are moving towards Fear of childbirthalternative pain relief approaches to labour to avoidthe use of drugs. Labour pain is a complex, The term hypnobirthing is generic, but presentedsubjective experience that has many different thus: HypnoBirthing, it is a trademark registered indimensions, but pain relief approaches within America by Marie Mongan and the researchmedicine tend to focus on blocking the sensory reported in this article by Swencionis et al (2012) doesdimension (immediate perception of pain) without relate specifically to this particular programme ofdealing with affective dimensions (feelings of hypnobirthing.unpleasantness associated with pain and futureimplications) (Lowe 2002). As Burns (2013) shows, the Mongan method of hypnobirthing (White 2007) has been in use for Hypnosis can either be carried out by a trained about 25 years, and is derived from theories firsthypnotherapist or carried out as a form of self- proposed by Grantly Dick-Read, in his seminal workhypnosis (Landolt and Milling 2011). As Simkin and Childbirth without fear (1959/2013). The prevalence ofO’Hara (2002) show, women enjoy these fear of childbirth, and the fact that this fear is sociallycomplementary approaches, perhaps because they constructed is discussed in eloquent but criticalfeel more in control when they address their own pain terms. Therefore “one of the first principles of good Einion, TPM, December 2016, vol.19, issue 11 25

HYPNOSIS AND HYPNOBIRTHING FOR LABOUR midwifery is to protect a woman in labour from fear- maternal stress during pregnancy can result in a producing words and actions”(Dick-Read 1959/2013: range of effects, especially adverse outcomes at 66). He identified the fear-tension-pain cycle linking birth, but argue that these outcomes can be the physiological responses of the body, when the improved by the use of relaxation. woman is frightened, to increased tension, which in turn brings about increased pain (Dick-Read Therefore, it would seem that the use of hypnosis 1959/2013). could be regarded as a positive contribution to promoting health and wellbeing in pregnancy and The use of hypnobirthing, by which is meant the birth, with the potential for good effects for both application of structured approaches to using self- mother and infant. hypnosis in labour and birth, is one way that women and their caregivers can avoid the use of such ‘fear- CRITICAL REVIEW OF SELECTED producing words and actions’. Women can cope RESEARCH with pain during labour if they are in an Aims and objectives environment where they can produce natural endorphins and can enable their own bodies to work Swencionis et al (2012) set out to compare specified as they were designed to, in order to bring their child birth outcomes for mothers who used hypnobirthing into the world (Leap et al 2010). with data from national US surveys. Gedde-Dahl and Fors (2012: 60) set out to “test the impact of the Midwives were used more frequently, use of relaxation techniques during the last part of pregnancy”. Werner et al (2012: 347) set out towomen used hospitals less and birthed at establish the effects of “training in self-hypnosis on the use of epidural analgesia during birth and self- home or in birthing centres more often reported labour pain”. Downe et al (2015: 1227) set out to discover “the effect of a group self-hypnosis Eradicating fear programme undertaken in the third trimester of pregnancy on rates of epidural use in labouring The point of hypnobirthing is to access subconscious nulliparous women.” Phillips-Moore (2012) doesn’t responses and to eradicate fear at this level (Burns clearly state a research aim, but it appears to be to 2013). Graves (2014) describes it as women achieving examine the benefits of the hypnobirthing method, a state of relaxation, release of fear, increased in particular within her sample of Australian confidence and positivity which results in a more women. positive experience of birth: “Hypnobirthing works because, by helping us to let go of our fears, it Main findings and conclusions enables the body to work in the way it is evolved to do, efficiently and comfortably” (Graves 2014: 13). Swencionis et al (2012) found that women who used Thus the main aim is to release fear and make pain hypnobirthing had fewer intravenous fluids, had not inevitable during labour (Phillips-Moore 2012). less use of: continuous fetal monitors, drugs to speed Instead, women develop confidence in their ability up labour, artificial rupture of the membranes, pain to birth. relieving drugs and epidural anaesthetic, fewer cases of caesarean birth, and were less likely to have Hypnobirthing works by changing deep input from obstetricians. The research also showed responses to experiences, removing negative that midwives were used more frequently, women associations (Beebe 2014). Beebe states that hypnosis used hospitals less and birthed at home or in for labour and birth includes three elements: birthing centres more often. At the same time, they antenatal preparation and conditioning; achieving also found that women had their babies at longer hypnotic states during labour and birth; and having gestations, and had babies with a larger birth weight someone to support and advocate for the birthing (Swencionis et al 2012). They found that there was woman during labour and birth. also a reduction in the use of medical induction of labour. Their conclusion is that there needs to be Using hypnosis techniques, either provided by a more research done comparing women who use trained hypnotherapist or through self-hypnosis hypnobirthing and those who don’t, but argue that techniques, is linked to anaesthesia and pain relief this approach may offer “significant benefits” in general (Cyna et al 2006). Any approaches that (Swencionis et al 2012: 138). help to reduce fear and stress must be beneficial for childbearing women and their infants, because Downe et al (2015) found that hypnosis did not stress has negative health outcomes (Beddoe and reduce the use of epidural analgesia, but two weeks Lee 2008). Urech et al (2010), for example, show that after birth, those who had undergone hypnosis had reduced levels of fear and anxiety about childbirth. Similarly, Werner et al (2012) found that women who had been through a short course of training in self-26 Einion, TPM, December 2016, vol.19, issue 11

HYPNOSIS AND HYPNOBIRTHING FOR LABOURhypnosis did not use less epidural analgesia or Burns D (2013). ‘Hypnobirthing in Ayrshire’.report less pain or more positive experiences of Midwifery Matters, 138: 18.having their babies. However, they used midwiveswho were not very familiar with hypnosis.This might Cyna AM, Andrew MI and McAuliffe GL (2006).have affected the intervention, as midwives’ ‘Antenatal self-hypnosis for labour and childbirth: abehaviours might have disturbed the self-hypnosis. pilot study’. Anaesthesia and Intensive Care, 34(4): 464-But they found that the women in the study had 469.more babies born at term, more babies born withoutinduction or intervention, and were slightly less Dick-Read G (1959/2013). Childbirth without fear,likely to opt for epidurals (Werner et al 2012). They London: Pinter and Martin Ltd.argue that more research is needed, particularly withstaff trained to support self-hypnosis properly. Downe S, Finlayson K, Melvin C et al (2015). ‘Self- hypnosis for intrapartum pain management in Gedde-Dahl and Fors (2012) found that a self- pregnant nulliparous women: a randomisedadministered process of relaxation had a positive controlled trial of clinical effectiveness’. British Journalimpact on women’s experience of wellbeing one day of Obstetrics and Gynaecology, 122(9): 1226-1234.after birth. They argue that their intervention mightenhance key factors such as self-efficacy, personal Gedde-Dahl M and Fors EA (2012). ‘Impact ofcontrol and fulfilment of expectations, and argue that self-administered relaxation and guided imagerythere would have been reduced levels of distress in techniques during final trimester and birth’.pregnancy due to the effects of relaxation. They Complementary Therapies in Clinical Practice, 18(1): 60-65.conclude that it would be a good idea to promote theuse of relaxation and guided imagery during Graves K (2014). ‘Hypnobirthing’. Aims Journal,pregnancy, as a means of enhancing women’s 26(4): 12-13.experience of birth (Gedde-Dahl and Fors 2012).Phillips-Moore (2012) shows that those women who Landolt AS and Milling LS (2011). ‘The efficacy ofused hypnobirthing had low rates of caesarean, a hypnosis as an intervention for labor and deliveryslightly higher percentage of ventouse and forceps, pain: a comprehensive, methodological review’.and lower use of pain medication, with most feeling Clinical Psychology Review, 31(6): 1022-1031.that their pain was controllable.There were very highsatisfaction rates. Leap N, Dodwell M and Newburn M (2010). ‘Working with pain in labour: an overview ofCONCLUSIONS evidence’. NCT New Digest, 49: 22-26.The literature seems to indicate that some women Leeman L, Fontaine P, King V et al (2003). ‘Theexperience less medical intervention and higher nature and management of labour pain Part I:rates of satisfaction when using these kinds of Nonpharmacologic pain relief’. American Academy oftechniques. No adverse effects have been identified, Family Physicians, 68(6): 1109–1112.and there seems to be research that shows that usinghypnotic techniques might support women’s ability Lowe NK (2002). ‘The nature of labor pain’.to exercise choice, cope with anxiety and promote American Journal of Obstetrics and Gynaecology,wellbeing and a positive birth experience. 186(S1): S16-24. It is clear that for midwives and other Phillips-Moore J (2012). ‘Birthing outcomes frombirthworkers, hypnobirthing and similar techniques an Australian HypnoBirthing Programme’. Britishmight enhance the ability to support women to Journal of Midwifery, 20(8): 558-564.retain a sense of self, autonomy, control and self-efficacy during childbearing. Holistic maternity care Porter J (2004). ‘Analgesia in labour: alternativeis about respecting women’s ultimate authority over techniques’. Anaesthesia and Intensive Care Medicine,their own bodies and their birth experience, and any 5(7): 235.activity which enhances this must be a positivecontribution to midwifery practice. tpm Simkin PP and O’Hara M (2002). ‘Nonpharmacologic relief of pain during labour:REFERENCES systematic reviews of five methods’. American Journal of Obstetrics and Gynecology, 186(S1): S131-157. Beddoe AE and Lee KA (2008). ‘Mind-bodyinterventions during pregnancy’. Journal of Obstetric, Swencionis C, Rendell LR, Dolce K et al (2012).Gynecological and Neonatal Nursing, 37(2): 165-175. ‘Outcomes of HypnoBirthing’. Journal of Prenatal and Perinatal Psychology and Health, 27(2): 120-139. Beebe KR (2014). ‘Hypnotherapy for labour andbirth’. Nursing for Women’s Health, 18(1): 48-58. Urech C, Fink NS, Hoesli I et al (2010). ‘Effects of relaxation on psychobiological wellbeing during pregnancy: a randomized controlled trial’. Psychoneuroendocrinology, 35(9): 1348-1355. Werner AA, Uldbjerg N, Xahariae R et al (2012). ‘Self-hypnosis for coping with labour pain: a randomised controlled trial’. British Journal of Obstetrics and Gynaecology, 120(3): 345-353. White K (2007). ‘HypnoBirthing: the Mongan Method’. Australian Journal of Clinical Hypnotherapy and Hypnosis, 28(2): 12-24. Einion, TPM, December 2016, vol.19, issue 11 27

Supporting your SuccessSkills for Midwifery Practicez Presents over 150 essential z Ideal for use as a basis for teaching midwifery procedures in an easy- and assessment to-read, quick reference format z Explains the underlying physiologyz Refers to the latest evidence and associated with pregnancy and research, including current national childbirth and international guidelines )RURȆWKLVWLWOHJRWRwww.elsevierhealth.co.uk and enter code PM20www.elsevierhealth.co.uk

AQUANATAL EXERCISE IN PREGNANCYAnita JohnsonSenior Lecturer in Midwifery atUniversity of West of England at the time of the interviewIn this article, Anita Johnson carried out an interview with Cathy Charles, a midwife and aquanatal teacherin Wiltshire, to explore the benefits of aquanatal exercise in pregnancy and the postnatal period; this isparticularly pertinent at a time when there is a focus on mental wellbeing and rising obesity and caesareansection rates. Anita wanted a first-hand account from a midwife trained in water-based fitness and herexperiences of delivering aquanatal classes to pregnant women. Following Anita’s own experience ofparticipating in the aquanatal class and Cathy’s entertaining interview she hopes it may encouragemidwives to promote this form of exercise and to pursue recognised training to deliver their own classes.Aquanatal exercise for pregnant and hockey and ran several marathons. Once I became a postnatal women has been around for more midwife, aquanatal just seemed like the obvious than 30 years. However, with the current thing to do. Originally an enlightened manager paid focus on mental wellbeing and rising for my aquanatal course. I also went on to qualify toobesity and caesarean rates, it seems an appropriate teach aquafit to the general public and became atime to look again at the benefits it has to offer. fully-fledged water-based fitness instructor.” She is now a member of the Register of ExerciseINSPIRATION Professionals (REPS), the national UK public fitness register.Cathy Charles is an aquanatal teacher in Wiltshire.We met before the class was due to start one early BENEFITS OF AQUANATAL EXERCISE >>>>spring evening, with the sun setting slowly in the skyoutside. With its ornate ceiling, this is the oldest pool Cathy’s passion and enthusiasm are palpable as shein the country. It was hot and humid, with the promotes the benefits. “Aquanatal is both exercisefamiliar smell of chlorine releasing pent up and relaxation in water. Water is about 10 timesmemories of childhood and stories of bygone days. more resistant than air, so we work much harderThe roof of the swimming pool had to be admired than on dry land which gives a great muscular andand the water lay silent and still in anticipation of cardiovascular workout. It has an anti-gravity effect,future activity. to some extent. It supports the body and it’s very difficult to make jerky movements that can cause Cathy has been a midwife for 25 years. She is also injury, especially to joints. This is particularlya ventouse practitioner and co-editor of a midwifery beneficial for pregnant women.”handbook. Her career has included roles in clinicalrisk management and clinical audit and she was a Other benefits include reduction in back pain,Supervisor of Midwives. Not surprisingly, I wanted promotion of healthy weight gain, fluid balance,to know more about her digression into water-based improved sleep, enhanced wellbeing, social contact,fitness and how her work as a midwife supported cardiovascular health, maintenance of mobility andthis. muscle tone and pelvic floor control (Association of Chartered Physiotherapists in Women’s Health “I have been teaching aquanatal for 20 years. I (ACPWH) 2010).always enjoyed fitness classes, and I played county Johnson, TPM, December 2016, vol.19, issue 11 29

AQUANATAL EXERCISE IN PREGNANCYTARGET GROUPS group some 30 minutes later. Certainly I was not the slim being of my youth, and I had the battle scars ofI have known Cathy professionally for over 20 years four births, so I fitted in, with no problem. Anotherand her personality is infectious. Her charisma lends one of my not-so-strong points is that I have veryitself to running a group with women of all ages, poor co-ordination, so before I knew it, I was goingshapes and sizes. She is full of stories, such as the one way and the class the other, which one of thetime when a pregnant woman doing a star jump women reassured me was because I hadn’t beensplit her swimsuit from bra to crotch, like curtains before.Very kind, but I beg to differ: this was normal.parting on the opening night of a play. The woman An hour later and with much hilarity I had workedapparently laughed, shrugged and carried on, through the routine and stepped out of the pool withdeciding it was now a very revealing bikini. Cathy the rest of the group; pink, raging with endorphins,also recalls the day when a naked man accidentally energised and feeling very pleased with myself!blundered out of the changing room to realise hewas poolside, with 15 astonished pregnant women Cathy, unlike many instructors, gets into the pool.looking up at him. This she told me helps her to work at their level, talk directly with individuals and correct poor posture. For all the laughter, Cathy takes the needs of the Also she can get the speed right.women very seriously. Is this a class just for womenor are partners involved (as is commonplace these “There’s nothing more irritating than andays in antenatal education), I want to know? instructor telling you to go faster when you can’t move against the resistance of the water, any faster. “Two of the groups we have been trying to target Also being in the pool lets me sense if I am going tooare women with a higher body mass index (BMI) slowly and we’re all feeling a bit cold.” She goes onand teenagers. Both these groups tend to have body to say the downside is the group not being able toimage issues. We tell women they don’t have to wear see the exercise being demonstrated so she oftena swimsuit – they can come in leggings and T shirts, hops out to demonstrate on dry land and then hopsas long as they’re not too baggy, as they can flop back in again. I, for one, benefited from this.around in water and get in the way. We’ve had goodsuccess with the higher BMI women but less so with TRAINING AS AN AQUANATAL TEACHERteenagers. We try to encourage them to come with a Aquanatal can be taught either by healthfriend if they want, but those women are probablynot going to be comfortable with men around, so professionals (mainly midwives andwe’ve kept it girls only.” physiotherapists) who have done their two-dayTHE CLASS ITSELF training, or by level two/three fitness instructorsHaving been told to bring my costume and towel, Iwasn’t surprised to find myself in the water with the who have also done their aquanatal training. Many local council leisure centres now demand that all instructors are REPS registered. Unfortunately30 Johnson, TPM, December 2016, vol.19, issue 11

AQUANATAL EXERCISE IN PREGNANCYaquanatal is not currently recognised by REPS and available on training as an aquanatal teacher:this can present problems for those health qualified midwives and health professionals can doprofessionals who have only the aquanatal the two day training recognised by the RCM forqualification. continuing professional development. You will find that there are providers who promote themselves as Cathy feels strongly that this situation should be offering a unique programme of courses specificallychallenged.“Midwives and physiotherapists are the devised for midwives and health and fitnessperfect people to teach aquanatal. There is nothing professionals for pregnancy and the postnatalwrong with a mainstream fitness instructor going on period. There is even a university course nowto teach aquanatal – that is great, but health offering pregnancy aquatics as part of a 20-creditprofessionals are likely to have a deeper level of module.education about the pregnant and postnatal body, soit is crazy that they can be excluded from teaching in VIEWS OF THE WOMENsome localities.” While Cathy is REPS registered,many of her aquanatal midwife colleagues are not. As we changed back into our clothes, I asked theShe told me of the hard case she put forward to her women why they came. I wasn’t surprised to be toldown district council to ensure she was able to have that they came because Cathy made it such good fun,aquanatal midwives covering for her. I could sense the relationship and rapport between them all. They also said that it enabled them to meet “I stressed how great it is to have a midwife other pregnant women, helped them to keep fit,running the class, and emphasised the amount of improved backache, prepared them for labour andeducation we have. Most midwives are qualified at overall it made them feel good about themselves.level three these days, after all. I boggled themanagers with talk about symphysis pubis As for Cathy, she attributes her success to her roledysfunction and blood pressure, and how women model and mentor Pat Spring, now over 70, who stillmay have questions on continence and sex, which a teaches aquanatal and aquafit. She cites her as afitness instructor may be less able to answer. living example of the benefits of water-basedBasically I made it sound like midwives were the best exercise and hopes both of them are still teachingthings since sliced bread (which we are!) and that into their 80s. So do I. tpmevery organisation should employ a few. I was thenasked if I would consider teaching dry land exercise REFERENCESas well, so they clearly got the message!” ACPWH (2010). Aquanatal guidelines: guidance onFURTHER INFORMATION ON COURSES antenatal and postnatal exercises in water, London: ACPWH.Women and midwives can look for their nearest class http://pogp.csp.org.uk/ publications/aquanatal-by doing a simple search for ‘aquanatal’ which will guidelines-guidance-antenatal-postnatal-exercises-show a list of providers. Information is also readily water Johnson, TPM, December 2016, vol.19, issue 11 31

RESEARCH UNWRAPPED Alys Einion Associate Professor of Midwifery at Swansea UniversityResearch unwrapped is a popular series to help readers make sense of published researchby undertaking a detailed appraisal of an article in a careful and considered manner. In doingso we can advance our knowledge and understanding of a research topic and apply it to ourpractice.This process is designed to assess the usefulness of the evidence in terms of decisionmaking and application to practice.The research being discussed here is a systematic review of articles which look at theimplementation of mindfulness approaches and whether these can enhance or improvemental health and wellbeing in pregnancy and childbearing; it was evaluated using thecritical appraisal skills programme (CASP) (2013) tool for assessing systematic reviews. Mental health during pregnancy and and supporting autonomy. Although systematic childbirth is enjoying an increased reviews can be limited in the nature of their findings level of focus within maternity because they are often restricted to randomised services at present. I chose this article controlled trials, in this paper, the inclusion of ‘grey’ because, rather than simply identifying the literature broadens the scope of the review and provides a useful overview of some of the ways thatThey discuss the use of behavioural approaches mindfulness has been tested in maternity care. that can promote mental health, citing BACKGROUND mindfulness as one of these approaches Hall et al (2016) effectively set the scene for their problems associated with perinatal mental health, it review by linking mental health to stress in looks at a useful, complementary approach to pregnancy, referring to literature which links stress promoting mental health, thus reflecting the general to adverse or unwanted pregnancy outcomes. They philosophy of midwifery, of woman-centred care then discuss the rates of anxiety and depression within the pregnant population, and discuss the use of behavioural approaches that can promote mental health, citing mindfulness as one of these approaches. Hall et al define mindfulness as “the intentional, accepting and non-judgemental focus of32 Einion, TPM, December 2016, vol.19, issue 11

MINDFULNESS AND PERINATAL MENTAL HEALTHone’s attention on their present moment emotions, contacted via email requesting the full text. Thethoughts and sensations” and state that “the seven search terms are provided in an easy-to-read table,attitudinal factors that are fundamental to and differentiated according to which database theymindfulness include: non-judging, patience, were used in, which again shows great transparency.beginner’s mind, trust, non-striving, acceptance andletting go” (Hall et al 2016, citing Kabat-Zinn 1990). Assessment of qualityAlthough it is useful to include these definitions, itmight also have been helpful to explore what each Those studies included were “assessed forof these means in practicality, as the theories methodological quality and risk of bias” by twounderpinning mindfulness approaches are complex. reviewers, using “standardised critical appraisal instruments from the JBI Meta-Analysis of Statistics Hall et al (2016) then discuss various approaches Assessment and Review Instrument”(Hall et al 2016:to mindfulness training, including Mindfulness 63). It would have been useful to have moreBased Stress Reduction (MBSR), Mindfulness Based information about this approach, and similarly, withCognitive Therapy (MBCT), Mindfulness Based data extraction and synthesis of results, the authorsCognitive Behavioural Therapy (MiCBT), used a pre-designed form, but it would have beenAcceptance and Commitment Therapy (ACT) and good to provide the content of this form for theDialectical Behavioural Therapy (DBT), all of which reader. It certainly seems that enough was done touse mindfulness as a means of improving awareness assess the quality of the studies, as required by theof self, feelings and sensations, supporting stress- CASP tool (CASP 2013). They explorecoping strategies and affecting how people respond methodological quality and risk of bias critically andto challenging situations. identify the specific weaknesses of each study where relevant.METHODOLOGY Women considered the interventionsHall et al (2016) provide a clear description of theirapproach, which aids in establishing the rigour and useful and helpful with coping withreliability of their review.They clearly describe theireligibility criteria, which focus on mindfulness stress associated with pregnancy andtraining, but allow for mindfulness being combinedwith other therapeutic approaches.They focused on childbirthpregnant women, and looked at outcomes ofperinatal mental health, including“perceived stress, FINDINGSanxiety, depression and mindful awareness”(Hall et Emotional effects of mindfulnessal 2016: 63).They had a range of quantitative designsin their inclusion criteria.They give a clear indication The authors first looked at the effects of mindfulnessof how articles were screened for inclusion, which interventions. The findings are split up into sub-includes two independent researchers, thus headings, which makes it easy to pinpoint specificenhancing the reliability of their choices. A sign of outcome measures. Firstly, perceived stress isquality here is that the two achieved total agreement discussed, and the authors state that only one studyon their choices of studies to include. showed a statistically significant reduction in this measure. In relation to anxiety, four studies showedIdentification a statistically significant reduction in anxiety, and for depression, two studies showed a statisticallyClear signposting of how studies were identified is significant reduction after mindfulnessalso included, another sign of quality in a systematic interventions. In relation to mindful awareness, tworeview, which would also allow for replication. The studies showed a statistically significant increase insearch strategy is provided, and the authors cite the this measure.databases accessed. The critical appraisal skillsprogramme (CASP) (2013) states that it is important Mindfulness as clinical interventionto consider if all relevant studies would have beenincluded, and that the review should include Next, the authors looked at clinical use, and foundrelevant bibliographic databases, following up that these types of intervention were generallyreference lists, contacting experts and searching for accepted by clients, with some studies showing goodunpublished and non-English language studies.The satisfaction scores (Hall et al 2016). The authors alsoauthors did search the ‘grey’ literature but have not report on some qualitative findings which showincluded non-English language articles or women enjoyed the interventions, but also that for >>>>unpublished articles, which could be considered alimitation of the review. However, if the full text of arelevant study was not available, authors were Einion, TPM, December 2016, vol.19, issue 11 33

RESEARCH UNWRAPPED some women in some studies the interventions were supporting maternal mental health. However, it is perceived as excessively lengthy. The studies also clear from the wider literature that other work is showed that women considered the interventions being done in this area, using mindfulness as a useful and helpful with coping with stress associated means of addressing mental health in pregnancy. For with pregnancy and childbirth (Hall et al 2016). example, Warriner et al (2012) discuss a workshop Women also found the social support associated with that explored the potential of using mindfulness as attending the training helpful, but in interventions a basis for antenatal education, focusing on that required daily home practice, they found this supporting good mental health. They discuss how difficult to maintain. this practice can help to break patterns of negative thinking and showed that their pilot workshop hadMidwives are already expected to have a very positive responses, with a high degree of acceptability to parents and to midwives in the UK wide range of expertise in both holistic (Warriner et al 2012). and high-risk midwifery, and there may MIDWIVES be an argument for this being included Byrne et al (2014) also discuss the integration of mindfulness approaches into antenatal classes andwithin midwifery education in the future show that they are of some benefit. However, as a midwife, this raises the question of midwife skill in WHAT WE CAN LEARN FROM THIS this domain. Midwives are already expected to have Benefits and limitations a wide range of expertise in both holistic and high- risk midwifery, and some midwives may find it a It is clear that there is a diverse range of approaches challenge to also develop skills in mindfulness. to using mindfulness alone and with other therapeutic and psychological approaches, as a But Hunter (2016) also shows that mindfulness means of promoting perinatal mental health. This training can be of benefit to midwives themselves, review shows that whilst the studies cannot be particularly in coping with the stress of their work. considered high quality in terms of research trials to So there may be an argument for this being included support recommendations about using mindfulness within midwifery education in the future, if more training in this way, they do provide evidence of research supports this practice. Certainly, anything benefit and therefore justify further research in this that provides a relatively low-cost means of area. For midwives, this review shows that improving midwives’ and mothers’ stress must be a mindfulness can be used for promoting perinatal positive contribution to the midwife’s toolkit. tpm mental health with some positive outcomes. REFERENCES There are a number of limitations in the studies included, as identified by Hall et al, including small Byrne J, Hauck Y, Fisher C et al (2014). sample sizes, lack of control, and a lack of ‘Effectiveness of a mindfulness-based childbirth generalisability, but there is some evidence to show education pilot study on maternal self-efficacy and that women find the approaches useful.The fact that fear of childbirth’. Journal of Midwifery and Women’s the studies do not represent the diversity of the Health, 59(2): 192-197. pregnant population, however, is a significant limitation (Hall et al 2016). CASP (2013). Systematic review checklist, Oxford: CASP. Impact http://media.wix.com/ugd/dded87_a02ff2e3445f4952 992d5a96ca562576.pdf The impact of this kind of intervention is also something to be considered. Hall et al cite studies Hall HG, Beattie J, Lau R et al (2016).‘Mindfulness that use online approaches, but also show studies and perinatal mental health: a systematic review’. that suggest that face-to-face interventions might be Women and Birth, 29(1): 62-71. more cost effective (but these studies were not carried out on pregnant women). It seems that whilst Hunter L (2016). ‘Making time and space: the such interventions might offer benefit, there is not impact of mindfulness training on nursing and enough evidence yet of their true potential value for midwifery practice. A critical interpretative synthesis’. Journal of Clinical Nursing, 918-929. Kabat-Zinn J (1990). Full catastrophe living, New York: Dell Publishing. Warriner S, Williams M, Bardacke N et al (2012). ‘A mindfulness approach to antenatal preparation’. British Journal of Midwifery, 20(3): 194-198.34 Einion, TPM, December 2016, vol.19, issue 11

REVIEWSSupporting women for labour support. During the early 2000s, and after readingand birth: a thoughtful guide and respecting Nicky’s work, I supported student midwives to develop a leaflet for parents, usingNicky Leap and Billie Hunter these concepts and language.2016, Routledge, 254pp, £24.99, pbk, ISBN: 978 0 In addition to having page after page of practical41552429 2 and theoretical knowledge, this book is entwined with reminders of the importance of self-care andIn the maternity world globally, midwives kindness, compassion and respect. This is thefrequently feel under pressure and short of time. magic ingredient when supporting childbearingDoulas and doctors witness it, and women and women. The authors have included differentfamilies using services report negative approaches, dependent a woman’s birthconsequences of it. As a midwife myself, I worked preferences or journey. There are strategies andthrough decades of trying to negotiate competing tips for supporting a woman wanting a normal,demands and, because of a shortage of midwives physiological birth to those planning a caesareanand lack of continuity of care, supporting women birth. The text includes useful resources to helpin labour with no interruption was always a women who are traumatised from or fearful ofchallenge. When the mother–midwife birth, or who are experiencing or expectingrelationship has to be built within short time complications. Crucially, the book covers the needframes due to lack of continuity, reading birth for sensitive compassionate support for thoseplans, assessing a woman’s emotional needs as women suffering from the loss of their baby,well as caring for her physical wellbeing, cansometimes feel impossible. And we know the Reflective activities that facilitate the practiceconnection we make when we are in the of ‘walking in the shoes of others’, helpprivileged position of being an uninvited guest at practitioners to consider the perspectives andthe most important time in a woman’s life, can emotions of co-workers, as well as the mothersaffect the mother-infant bond forever. and families they serve. As This wonderful new book part of this, the reader isprovides some solutions. True sometimes prompted to readto its title, the content serves stories, maybe with others,well as a ‘thoughtful guide’ and then to explore their ownstimulating readers with ideas practice, reflecting on specificfor practice, for reflection and papers mentioned in thefor self-care. The book is chapter.unique in that it coverspractical and emotional Each chapter has aaspects of caring for postscript, relating to thechildbearing women, and is content from that section.perfect for midwives, doulas Chapter 5’s PS is superblyand anyone providing written by student midwifematernity care, or supporting Meg Hitchcock. Mega woman having her baby. describes in beautiful detailThroughout the book, stories, how she observes thedrawings, evidence boxes, communication flow betweenpostscripts, tips and ideas mother and midwife, byappear like hidden gems in a watching their eyes.richly crafted text – they provide insights into the Yes, this ‘dip-in-and-out’ book is key, andthoughts and experiences of others, and I always should be cherished by every student midwife,find it is these nuggets that help me to remember. midwife and doula. It is a treasure chest of inspiration, tenderness, evidence, and wise words. The book pays attention to the language used Thank you Nicky and Billie, my copy will beby maternity care workers and others, travelling the world, and shared widely!encouraging positive, empowering connotations. Sheena Byrom OBEThis is something close to my heart. ‘Coping with Midwifery consultant, member of the RCM's Betterlabour’ and ‘working with pain’ are the phrases Births initiative, Chair of Iolanthe Midwifery Trustwhich underpin the philosophies for providing Reviews, TPM, December 2016, vol.19, issue 11 35

REVIEWSPregnancy loss and the death of ababy: guidelines for professionals(4th edition)SANDS, updated and edited by AmandaHunter; based on original text by JudithSchott, Alix Henley and Nancy Kohner2016, Tantamount, 487pp, £19.99, pbk, ISBN: 978 190992916 6This wonderful manual deserves a place on every reminded that they need to provide support inbirth unit, in every SCBU and NICU, and in every order to enable the resources of midwives who areinstitution where midwives are educated. Whilst walking alongside traumatised parents to beits purpose is to provide guidance for midwives in replenished.supporting mothers, fathers and families throughpotentially the most distressing experiences they The text is brought to life with frequentwill ever have, there is so much that is relevant to quotes, from mothers and fathers, that highlight both the kind of exceptional care which made a encounter with a childbearing family. The huge difference to their ability to cope, and sub- standard care.text echoes the themes of the ‘Better Births’ review(2016), namely that the essential elements of high The manual concludes with guidance onquality care are good communication, informed legal requirements relating to stillbirth andchoice and individualised care. neonatal death, a selection of forms such as,‘Form to give to parents who take the baby’s body out of Although this is a long manual, it is easy to the hospital’, a list of ‘Useful organisations’ and annavigate. The 25 chapters are succinct and sub- excellent reference list.divided into clearly focused sections. Summariesof key points are plentiful and helpful, starting I think that there is a huge amount that canwith ‘Sands principles of bereavement care’ (p11). be learned from this book about midwifery careTheory (such as chapter 3 ‘Loss and grief’) never in general, as well as about care for mothers andtakes precedence over its application in practice. fathers who are grieving. As has often been said,Midwives (and others) are guided through if we can get care right for the most vulnerable‘difficult conversations’ when mothers and fathers parents, then it will be right for everyone.need to make agonising decisions on issues suchas whether to terminate a pregnancy, or withdraw Mary Nolanlife support from a severely compromised baby. Professor of Perinatal Education University of Worcester The manual never loses sight of the need ofthe carers to be cared for. Managers are constantlyDIARYDecember conference- 2017 February neilstewartasso bristol-070217-2-3 December 2016/event- January 1 February ciates.co.uk tickets-1865179European summary- 20 January Maternity, 0006midwives 6324523e71b94 PROMPT 3 Train midwifery and 7 Februaryassociation 3d28e37a6e769 the trainers. baby Bereavement Marchfifth 108f53.aspx London. Info: conference. care training 16 Marchinternational rcog.org.uk/eve London, free of workshop. PROMPT 3 Plus.education 10 December nts Contact: charge. Info: Bristol, £85 / London. Info:conference. Breaking bad 0207 772 6245 / www.maternity £65. www. rcog.org.uk/London, £335. news. ARC [email protected] andmidwifery.c eventbrite.co. events Contact:www.cvent.co professional g.uk o.uk 0207 324 uk/e/sands- 0207 772 6245 /m/events/euro training day. 4330 / 07984 bereavement- [email protected] London. 188166 / care-training- org.uk-association- [email protected] karen.stewart@ workshop-36 Reviews, TPM, December 2016, vol.19, issue 11

LONDON|2017 PROGRAMME NOW ANNOUNCED PLENARY SPEAKERS SO FAR INCLUDE Roy Lilley Independent health policy analyst, writer, broadcaster and commentator on health and social issues Stephanie Michaelides Senior Lecturer, Middlesex University London Conference Chair: Sue Macdonald Midwifery Consultant and Educationalist For more information visit www.maternityandmidwifery.co.ukLearn the secrets of success!Are you wondering how to start your research or dissertation journey, swimming through a seaof papers or looking for help knitting your discussion together? Do you need advice for gettingthe most out of your tutor or ideas to help you keep on track with your thinking, writing andanalysis? What is critical analysis, in fact, and how do you do that while still having a life?The 101 tips in this book cover a wide range of areas from how to create a good question andkeywords to what to do when someone publishes a ground breaking new study on your topicthe week before you’re due to submit your work. Written in an accessible, friendly style andseasoned with rst-hand advice and comments from others who have trodden the path, thisbook combines sound, practical tips from an experienced academic with reminders of the valueof creativity, chocolate and naps as investments in your work.Available from Amazon in paperback or e-book RRP £9.99More information at www.sarawickham.com TPM, December 2016, vol.19, issue 11 37

Midwifery jobs in INTENROVWIE!WINGSydney, AustraliaAre you looking for a change in lifestyle? Join the team atSouth Western Sydney where you will be close to pristinebeaches, metropolitan life, national parks and more…much much more!Geneva Healthcare is proud to partner with NSWHealth in recruiting experienced Midwives fromthe UK to join them in Sydney for facilities withinSouth Western Sydney Local Health District.There are five dynamic and innovativematernity units, annually delivering morethan 11,000 babies as well as providing qualityantenatal and postnatal care. A range ofmidwifery and collaborative models of care areoffered, including Midwifery Group practice,Midwifery Support Programs, Language specificmidwifery clinics, high risk midwifery models,foetal maternal unit and continuity ofmidwifery care clinics. Benefits: • A commitment to your on-going education and professional• Visa sponsorship with development that will take your opportunities of permanent career to another level residency* • Relocation package available*• Salaries amongst the highest for Midwives in Australia *conditions apply• Salary packaging – this is where part of your earnings are tax free, meaning more disposable incomeGeneva Healthcare will assist Apply online, or contact Shane King:you every step of the way. Fromlicensing, to migration, to all the UK free phonenecessities to get you going onceyou’ve arrived. You will have a 0800 404 7591dedicated consultant, and ourservice to you is free! email: [email protected] www.genevahealth.com

Now that you have read this month’s print journal, go online for a wholepackage of EXTRA FEATURESWelcome to THE PRACTISING MIDWIFE online!Whether you are a midwife, a student midwife or even an aspiring midwife,there is plenty for you at your new website – in addition to what you canread in print!AMAZING! Anyone can see the Featured article and complete the Featured CPDmodule each month!GREAT VALUE! As a subscriber, you can access ALL articles and modules.FANTASTIC RANGE! We have uploaded a huge amount of content so far –so there is something for everyone – and we have much more to add in thecoming weeks and months.ESSENTIAL FOR YOU! Visit your website for the following features:• Midwifery A-Z – an illustrated dictionary of midwifery terms• eLearning – interactive CPD modules. Test your knowledge, then use the certificate as proof of CPD for annual appraisal and professional revalidation – or use the modules to revise and prepare for pre-registration examinations• Current issue – read All this is included in your articles from the latest amazing value issue of The Practising subscription, so don’t Midwife and archived delay: visit your website issues from the past today at www.• Community zone – practisingmidwife. Blogs, Facebook, Twitter, co.uk EventsPHOTO:RORY YEATES RIDDOCH

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