TPM JULY - AUGUST 2013

THE BEST JOB IN THE WORLDwww.thepractisingmidwife.com Volume 16 no 7 • July/August 2013Public healthSmoking in pregnancyand beyondVitamin D deficiencyUnintended teenagepregnancyContraception

tablets 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® were also found to have, relative to placebo, increased levels of iron, vitamin B1 and vitamin D3. Specially formulated by experts, Pregnacare® replaces a usual multivitamin and provides a careful balance of 19 essential vitamins and minerals. It includes the recommended 10mcg vitamin D and also 400mcg folic acid which contributes to maternal tissue growth during pregnancy. Plus iron which contributes to normal red blood cell formation and normal function of the immune system. Originally developed with Conception Breast-feeding ‘Plus’ Dual Pack Original Prof. A. H. Beckett† OBE, PhD, DSc (1920-2010) Professor Emeritus, University of London Important: some pregnancy formulas do not include the exact 10mcg vitamin D, as recommended by the Department of Health for all pregnant and breast-feeding women.ADPRGTRADEP13-05-13E Pregnacare® is the prenatal 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 QUEEN’S AWARD † Professor Beckett is not cited in the capacity of a health professional, but as a product inventor and former Chairman of Vitabiotics. ††Based on a survey of 1000 midwives. For more information on this research, please visit www.pregnacare.com/mostrecommended FOR ENTERPRISE IN www.pregnacare.com INNOVATION

Contents4 EDITORIAL midwives with information which could help5 COMMENT Working together for public health prevent babies contracting GBS infection Elizabeth Duff 31 Delegation and beyond: what happens when things go wrong? As a follow up to his article6 REVIEWS exploring midwives’ position in ensuring mothers’ and babies’ wellbeing, Mark Solon investigates7 NEWS areas of civil and criminal liability for midwives10 Sponsored elective placement to Uganda12 Smoking in pregnancy: where are we now? 33 Latex allergy for women’s health care Greater Cathy Ashwin, Jayne Marshall and Penny Standen exposure to natural rubber latex in the health care consider measures which have been introduced setting has led to increasing cases of latex allergy, to reduce the number of women smoking in and finds Joanne Fletcher after pregnancy 37 The wonder of breast milk A report from the 8th16 Dietary intake of vitamin D is not enough Valerie International Breastfeeding and Lactation Hemmings offers a guide for midwives to help Symposium by Sioned Hilton, highlighting three women avoid vitamin D deficiency areas of development in understanding21 “You’re wha...?!” Áine Aventin and Maria Lohan 42 AROUND THE CONFERENCES MaMa conference argue that being inclusive of young men is key in Phoebe Pallotti reports preventing unintended pregnancies 44 PROFESSIONAL DEVELOPMENT24 Contraception: a guide for midwives Sarah Snow 46 LAST WORD Freedon for birth and the plight of describes the range of contraceptive devices Agnes Gereb Valerie Gommon asks for your available, to support midwives in advising women suggestions as to what can be done27 Group B streptococcus infection: risk and 47 INFORMATION FOR YOUR ONLINE ACCESS! prevention Jane Plumb and Ginny Clayton presentEditorial advisory board © 2013 Medical Education Solutions Ltd. 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Midwives meeting the challengeTPM has had a long tradition of promoting Public health and raising awareness of the many Helen Baston and Julie Wray,health challenges that face our population. Public health is high on the government’s agenda Joint Editorsfor health service policy and rightly so. With the establishment of Public Health England inApril 2013 and as local authorities take up the reigns of responsibility for the public health oftheir communities, we are entering a new era. Developing an evidence base for public healthinterventions in maternity services to enhance the quality and effectiveness of care for themother, baby, father and families is a real test for us all. What is heartening is the passion andtenacity that midwives have to take on the challenges of encompassing this knowledge intheir everyday practice. In this month’s issue we feature midwives’ endeavours towards creating an evidence baseand improving public health. For example Aine Aventin and Maria Lohan discuss theireducational resource aimed at young fathers. In this paper we can see how education is pivotalto increasing men’s sense of inclusion and involvement in the lives of their children. We alsohave Cathy Ashwin et al exploring recent media campaigns and social policies focused onsmoking in pregnancy and the general population. Midwives need to be aware of currentpolicies with regard to smoking cessation as we know that there are huge potential maternaland child health benefits. These are just a couple of highlights – enjoy reading and reflecting upon all the papers.Midwives play a huge role in public health and hopefully during the summer you will have achance to take some well earned rest and recuperation – invest in your own health as thatmatters, too! We are delighted to announce the launch of our online version of the journal this month;see the inside back cover for details.CONTACT: 020 8313 9617 SUBSCRIPTIONS: 01752 [email protected]: 66 Siward Road, Bromley BR2 9JZ All subscription enquiries or back issue orders should be addressed to: TPM Subscriptions Department, Proact Marketing, 12 Mary Seacole Road,Joint Editors The Millfields, Plymouth PL1 3JY. Tel: 01752 312140; fax: 01752 313162;Helen Baston PhD, RN, BA (Hons), RM, ADM, MMedSci, PGDipEd email: [email protected] Midwife: Public Health/ Supervisor of Midwives, SheffieldTeaching Hospitals NHS Foundation Trust [email protected] Personal subscription rates (5% direct debit discount in brackets): UK £60Julie Wray PhD, ONC, RN, RM, ADM, MSc, PGCE (HE) (£57); First year of qualification £50 (£47.50); Student (10% direct debitSenior Lecturer, School of Nursing, Midwifery and Social Work, discount) £36 (£32.40); Europe/Eire £70; rest of world £95 (surface) orUniversity of Salford [email protected] £120 (airmail). Institutional/library rates: UK £134; Europe/Eire (airmail) £160; rest of world (air mail) £190. Payment can be made by chequeManaging Editor: Laura Yeates [email protected] payable to ‘The Practising Midwife’ or by credit/debit card: Mastercard,(editorial/author submissions) Visa, American Express and Switch. TPM is published 11 times a year.News Editor: Francesca Robinson [email protected], Copyright: © Medical Education Solutions Ltd, 2013. All rights reserved. No01962 862972 part of ‘The Practising Midwife’ may be reproduced in any material form (including photocopying or storing in any medium by electronic meansAdvertising Manager: Margaret Floate and whether or not transiently or incidentally to some other use of [email protected], 01483 824094 publication) without the written permission of the copyright holder except in accordance with the provisions of the Copyright, Designs andPublisher: Ian Heslop [email protected] Patents Act 1988, or under the terms of a licence issued by the Copyright Licensing Agency Ltd, 90 Tottenham Court Road, London, England W1P 0LP. Applications for the copyright holder’s written permission to reproduce any part of this publication should be addressed to the publishers. Printed in Great Britain by Williams Press, Maidenhead ISSN 1461-3123 Disclaimer: The sentiments expressed by the contributors and advertisers in The Practising Midwife do not necessarily reflect the views of either the Editors or the Editorial Advisory Board.

THE PRACTISING MIDWIFE • July/August 2013 5 Comment Elizabeth DuffWorking together for public healthPublic health is the health within a community. Midwifery resulting in the pregnant woman avoiding antenatal care. Thecare focuses on the individual, yet it promotes the health of a ‘guilt’ argument also influences midwives: if a womancommunity by keeping mother and baby in a state of perceives pressure to breastfeed, for example, and shewellbeing. The association between midwifery and public struggles with this, feelings of failure may undermine herhealth is getting stronger. confidence in being a parent. Midwifery 2020 (Department of Health (DH) 2010) stated Working with other health professionalsconfidently that midwives could expect a greater public The midwife’s dilemma was encapsulated in a recent newshealth role, supported by those who plan and commission flurry about carbon monoxide (CO) tests for pregnant women.maternity services to help them reduce inequalities and A news report (Quinn 2013) said the tests are backed byimprove maternal and family health. Three years later it is midwives, although the Royal College of Midwives (RCM) hadquestionable as to whether this support is forthcoming. not supported the use of them as women might feel guilty; the RCM felt that GPs should encourage women to stopPromoting healthy lifestyles smoking instead.Public Health England (PHE), launched in April 2013,prioritises ‘supporting families to give children and young Cathy Warwick, RCM chief executive, said that midwivespeople the best start in life’ and ‘helping people to live more are vital in helping to reduce smoking in pregnancy, and inhealthy lives by reducing … smoking, … poor diet, poor mental order to do so, there need to be more midwives andhealth’ (PHE 2013: 1). Who is to do this? Other UK countries continuity of care.suggest it is midwives: one theme of the Welsh maternitystrategy being to ‘promote healthy lifestyles, for pregnant What will help solve the midwife’s dilemma as to whetherwomen, which have a positive impact on them and their to prioritise personal or public health? Greater staff numbersfamily’s health’ (Welsh Government 2011: 3). and more continuity would help - a bit. Support from service planners, as called for in Midwifery 2020 (DH 2010), makesWorking with women sense too. Cathy Warwick rightly says that GPs must play theirThe midwife is required to work ‘in partnership’ with the part. Genuine joined-up thinking across public health,woman, according to the international definition of the primary care and individual care providers, backed by socialmidwife (International Confederation of Midwives (ICM) marketing messages designed to reach their audiences,2011). Often this makes sense, as both have the goal of a safe should bring it all together. Midwives care for individualand healthy pregnancy and birth. But the midwife must also women and their families, and those individuals make up therespect the woman’s choices and these can be in conflict with public. Time and effort should not be wasted wonderingthe best evidence-based options. The ICM suggests the key which one to serve. TPMconcepts defining the midwife’s role include ‘working withwomen … to overcome those cultural practices that harm Elizabeth Duff is a freelance writer on maternity and family carewomen and babies.’ Do ‘those cultural practices’ include, forexample, smoking cigarettes? Or feeding babies under six Referencesmonths on fluids and foods not usually recommended? Orchoosing a caesarean section birth that’s not clinically DH (2010). Midwifery 2020: delivering expectations, London: DH.indicated? ICM (2011). International definition of the midwife, The Hague: ICM. PHE (2013). Public Health England bulletin 30 April 2013: 2013027, A midwife may use her professional judgement to decidethat promoting a lifestyle message, such as smoking London: PHE.cessation, will not only be futile in terms of the woman Quinn B (2013). ‘Breath tests targeting smoking in pregnancy backed bycomplying but may damage the trust between them, midwives’. The Guardian, 12th May. Welsh Government (2011). A strategic vision for maternity services in Wales, Cardiff: Crown.

Reviews A social history of families. This approach creates a book rich in fact as well maternity and as rich in description. By offering insights into the childbirth: key themes in perspectives of mothers, midwives and doctors this book maternity care creates a balanced reflection on the issues affecting the history of the maternity services. Key themes addressed in Tania McIntosh the book include: maternal deaths, place of birth, intervention in childbirth, maternal autonomy, the status 2012, Routledge, 188pp, £24.99, pbk, of the midwife, inter-professional boundary disputes and ISBN: 978-0415561631 the politics affecting the maternity services. Ironically, these same topics continue to feature in present day This insightful text offers a discourse around the maternity services. comprehensive history of the evolution of the maternity This book is a useful resource for anyone interested in the history of maternity services whether in a personal orservices in England. professional capacity. It offers a wealth of information to help us understand how and why twentieth centuryThe author’s background as both a midwife and historian maternity care is structured and practised as it is.ensures that the book is informative and readable. Patricia HealyShe explores the maternity services within the wider social Postdoctoral Researcher at the National University ofcontext of the time, the political context of healthcare, the Ireland Galwayregulatory and educational context of midwives anddoctors, and the lived experiences of women and their Care of the newborn neonatal care are included in the chapters on feeding, by ten teachers neonatal abstinence and cultural and religious aspects; and the need for information for midwives and parents on (international students’ screening, immunisation and resuscitation are handled sensitively. edition) Hilary Lumsden and Debbie The only chapter I feel could have a different direction is the Holmes (editors) initial chapter on parenting and attachment. This chapter starts well but then considers loss and bereavement and the 2010, Hodder Arnold, 208pp, needs of bereaved parents. I feel more could be said on £23.99, pbk, ISBN: 978-0340971550 promoting positive parenting and attachment and how this enhances the ongoing development of the baby. Care of the newborn by ten teachers is a colourful The format of each chapter is replicated starting with an collection of 16 chapters, all overview and ending with key points. There are casebeautifully presented with tables, illustrations, images and histories for readers to conceptualise care for somephotographs to engage the reader and depict the text. It chapters. The references reflect UK policies and guidancewould be a useful addition to any midwife’s bookshelf including the Nursing and Midwifery Council, Nationalwhether they are a student or qualified. Institute of Health and Care Excellence, Centre for Maternal and Child Enquiries and the Department of Health but thereThe preface states that the strength of the book’s expertise is also World Health Organization guidance andis the range of practice and geographical regions of the ten international research.authors; however, only one is from outside England. The last chapter on frequently asked questions brings theThe chapters reflect contemporary midwifery care of the book to a comprehensive close. This book is well worthnewborn: physiological aspects of the newborn, such as reading.transition to extrauterine life, thermal care and jaundice areall covered well with the aforementioned art work to Sam Chenery-Morrisillustrate these processes; recognising deviations from Senior lecturer at University Campus Suffolk, Ipswichnormal physiology, such as birth injury, infections andrespiratory problems are covered in detail; social factors of

News analysis July/August 2013 • 7Midwives should help women to make informedchoices about caesarean births says NICETHE RISING CAESAREAN rate has been in a CS because of anxiety about childbirth teams under much greater strain at athe news recently as experts look at new should be offered a referral to a time when there are increasinglyways of bringing the numbers down. healthcare professional with expertise reduced resources,\" she said. in perinatal support. The National Institute for Health and Dr Matt Wilson, National Institute forCare Excellence (NICE) has addressed Pippa Nightingale, Head of Health Research clinician scientist andthe issue with the publication of a new Midwifery, Imperial College Healthcare senior lecturer in anaesthesia at thequality standard which contains nine NHS Trust and member of the NICE University of Birmingham, said data onmeasures to improve the care of topic expert group says: \"As a midwife all maternal deaths in the UK, collectedwomen who may need, request or have working in a busy London hospital, I via the UK's Confidential Enquiry intohad the procedure. know that some women request a Maternal and Child Health (CEMACH) planned CS because of fears that their suggested that whilst overall maternal It recommends that women who care will not be good enough and mortality remained rare, there had beenrequest a caesarean section (CS) should concern that they will not receive some changes in the pattern ofhave a documented discussion with enough support during labour and mortality. Maternal cardiac disease wastheir midwife about the risks and delivery. more likely to result in birth by CS andbenefits of the operation compared was now a primary cause of maternalwith a vaginal birth. \"However, after a discussion of all the mortality and there was also pros and cons of both types of birth, compelling evidence that maternal The aim is to ensure pregnant and having been assured of one to one obesity created an additional risk ofwomen can make an informed decision midwifery support and a personal birth unplanned intervention.about their planned mode of birth. plan, many will often choose to try a vaginal birth.” On a positive note, he said that NICE says that one of the reasons for substantial advances had been made inthe increasing CS rate – currently 25 per Medical specialists who discussed the the effectiveness and provision ofcent of all births in the UK - is that some rising CS rate at the annual congress of epidural analgesia over the past fewwomen are concerned that they will not the European Society of Anaesthesiology decades.receive adequate care and support in Barcelona in June warned that thereduring labour and birth. is an increasing need for safe emergency Tony Falconer, President of the Royal anaesthesia for these operations. College of Obstetricians and The new guidance says that if women Gynaecologists said complex caesareanare given the opportunity to discuss Dr Geraldine O'Sullivan, lead clinician births required the presence of seniortheir anxiety about childbirth with a for obstetric anaesthesia, Guy's and St medical staff, and supported the casemidwife who can answer their Thomas' NHS Foundation Trust, London, for more consultants on labour wards.questions and understand their said better intrapartum fetal “This may impact on lowering the CSconcerns in a supportive manner, these monitoring, fears of medico-legal rate and will improve safety for motheranxieties can often be reduced to the claims and maternal demand could all and baby,” he said.point where the woman is able to be factors driving up the CS rate.choose a planned vaginal birth. Louise Silverton, the Royal College of Whatever the cause, she said it was Midwives Director for Midwifery, said: In addition, the quality standard likely that, in the near future, ““The maternity system as a whole alsorecommends that a consultant should performance indicators will be devised needs to be examined because otherbe involved in decisions surrounding to help evaluate each hospital's CS rate. interventions around birth such asboth planned and unplanned CSs and to induction of labour are likely to lead toalso advise about the potential benefits She argued that even a small a caesarean birth. The NHS should alsoand risks. reduction in the UK-wide CS rate of 25 be ensuring that women have one-to- per cent would result in large one care in labour.” After a CS, women and their partners reductions in costs as each operationshould be able to discuss the costs the NHS approximately £500 to I The quality standard for caesareanimplications for future pregnancies so £1000 extra compared with a vaginal section is at http://tinyurl.com/they are able to make more informed birth. m5ywouedecisions about planning their families. \"The increased CS rate is putting A further quality standard statement anaesthesia, obstetric and midwifesays that pregnant women who request

News analysis8 • July/August 2013NMC is given the go ahead for reformsto fitness to practise rulesTHE GOVERNMENT has agreed in close cases at investigation stage. consideration by the Government butprinciple to implement two urgent The final phase of a FTP case would these two changes were importantlegal changes, which will make the still be heard by an independent and they were grateful that they hadNursing and Midwifery Council’s panel, which always comprises at been acted on swiftly.(NMC) fitness to practise process (FTP) least one nurse or midwife, and atfaster, more consistent and more least one lay member, advised by a Cathy Warwick, Chief Executive ofeconomical. legal assessor. the Royal College of Midwives, said: Jackie Smith, Chief Executive and “The proposed changes have the The reforms follow the Registrar of the NMC, said: “We potential to improve the FTPcommitment made by Prime Minister, warmly welcome this. We at the NMC processes. This should make them lessDavid Cameron, to “sweep away” the are 10 years behind in how we can time consuming, less expensive andNMC's outdated and inflexible investigate concerns about the FTP of will I hope enhance public protection.”decision making process. nurses and midwives because of our outdated legal framework. The Prime Health Minister Dr Dan Poulter MP The proposed changes are: Minister is delivering on his promise said: \"Following the Francis Report, we of reform, made when the Francis have worked hard with the NMC to• to bring in a system of Report was published. explore how it can strengthen its FTP professional case examiners to “Our first concern is to make the procedures to improve patient safety. make decisions at the right decisions. Then, we need the investigation phase of the process power to review cases where this may \"We are now working with the NMC to decide if cases should proceed not have been the case.” on proposals to make the process to a final public hearing. The NMC She said further changes to the more efficient and flexible — ensuring expects this to allow more NMC’s legal framework that they had that if patients do have concerns consistency of decisions and it asked for were still under about a nurse, their case is expects the process to be faster investigated quickly and fairly.” and more cost-effective; The changes will take at least a year• a new power to review decisions to to introduce.Early Down’s test could reshape antenatal screeningA NEW NON-INVASIVE test that analyses fetal DNA in a Professor Kypros Nicolaides, of King’s College London,pregnant woman’s blood and can accurately detect Down’s who is leading the research, said: “This study has shownsyndrome and other genetic fetal abnormalities earlier in that the main advantage of cfDNA testing, compared withpregnancy has been developed by UK researchers. the combined test, is the substantial reduction in false positive rate. Another major advantage of cfDNA testing is The test is the first to prospectively demonstrate the the reporting of results as very high or very low risk, whichfeasibility of routine screening for trisomies 21, 18, and 13 makes it easier for parents to decide in favour of or againstby cell free (cf) DNA testing. invasive testing.” A paper in the journal Ultrasound in Obstetrics and At £400 per test, the new screening is too expensive toGynecology (Nicolaides et al 2013) says there is evidence adopt nationally at present, but the researchers hope thethat the test is superior to the current combined test pilot will persuade pharmaceutical companies to cut the(amniocentesis and chorion villus sampling) and could price.reshape standards in prenatal testing. References Tests done in 1,005 pregnancies at 10 weeks had a lowerfalse positive rate and higher sensitivity for fetal trisomy Nicolaides K, Wright, L, Poon A et al (2013). ‘First-trimester contingentthan the combined test done at 12 weeks. Both cfDNA and screening for trisomy 21 by biomarkers and maternal blood cell-freecombined testing detected all trisomies, but the estimated DNA testing’. Ultrasound in Obstetrics and Gynecology, DOI:false-positive rates were 0.1 per cent and 3.4 per cent 10.1002/uog.12511.respectively.

News analysis July/August 2013 • 9Women may birth alone ifindependent midwifery is outlawedWOMEN WILL FREE birth if independent to have mandatory professional An Independent review in 2010 of themidwifery is made illegal, Independent indemnity insurance (PII). requirement to have insurance orMidwives UK (IMUK) has warned. indemnity as a condition of registration Employed midwives will be covered as a healthcare professional, pointed The issue was raised on BBC Radio 4’s by their employer’s insurance but out that the lack of insurance forWoman’s Hour by independent midwife independent midwives have not been independent midwives was due to aErika Thompson, who was speaking able to obtain PII since 2002 and will fault in the commercial insuranceabout the problems independent therefore be unable to continue to market and not a failing in practicemidwives will face in October this year, practise when the legal changes come (Scott 2010). The report recommendedif workable, affordable insurance into force. The Department of Health that the Government should helpcannot be found. (DH) is currently considering the facilitate a solution. findings of a public consultation on the Representing IMUK on the issue, which closed in May. IMUK representatives met withprogramme, Ms Thompson said: Health Minister Dan Poulter in May to“Women have been telling us that due During the Woman’s Hour debate Ms ask for help. After the meeting a DHto previous bad experiences in the NHS Thompson said finding a solution to the spokesman said: “The Governmentthat they would rather birth alone that insurance issue would encourage non- wants to support independentto repeat the experience. It is working midwives back to the midwives and is working with IMUK toimportant that women have a safe profession. find the best solution. The minister isalternative.” sympathetic and will do what he can.” “We save the health service in excess The Government has signalled that it of 10 million per year currently so Referencesintends to pass the Health Care and helping us find insurance will beAssociated Professions (Indemnity cheaper for the Government and more Scott F (2010). Independent policy review ofArrangements) Order 2013 making it a politically beneficial than seeing ourcondition of registration for midwives demise,” she said. indemnity and insurance, London: DH.Women in Scotland to be offered smoking testPREGNANT WOMEN IN SCOTLAND are Healthcare Improvement Scotland New figures from the Health andto be offered carbon monoxide said: “We know that there’s still lots of Social Care Information Centre (HSCIC)monitoring early in their pregnancy as work to be done to ensure mothers (2013) show a continual fall sincepart of the new Scottish Patient Safety and babies are protected from the 2006-2007 in the number of women inMaternity Improvement Programme. harmful effects of smoking.” England smoking at the time of birth. Midwives will then be able to refer But Jackie Mitchell, national officer However the data also reveal a linkmums-to-be with raised carbon for The Royal College of Midwives in between smoking and deprivation –monoxide levels to specialist stop Scotland said the test is a good idea the prevalence of pregnant womensmoking support services and give only if it is optional. smoking has been highest in the Norththem additional care during the East for the last six years. The highestpregnancy, if required. “The difficulty in England is the prevalence rate of women smoking at guidelines are saying the tests should the time of birth was Blackpool PCT The Scottish Government says that be given to all women and carried out (29.7 per cent) and the lowest wasthe number of quit attempts made by at their first appointment with the Westminster PCT (2.9 per cent).pregnant women rose last year, thanks midwife.to better education and cessation Referencesservices. However, almost a fifth of “That can be a critical time whenpregnant women continue to smoke. the midwife is trying to establish a HSCIC (2013). Statistics on women's smoking relationship. The last thing we want to status at time of delivery: England, Quarter 4, Joanne Matthews, Head of Safety, risk is the trust between the midwife 2012-13, Leeds: HSCIC.Scottish Patient Safety Programme, and the pregnant woman.”

Uganda placements As she and fellow students prepare for a fortnight’s placement in Uganda, Sadie Elliott describes her thoughts and fearsAnxiety compared with that of contracting the infection.As I sit to write this article, just a little over a week awayfrom travelling to Mbarara in Uganda, the reality of what Malaria and HIVlies ahead seems all too stark. With our ‘professional Our biggest fears about the trip are the high prevalence ofenquiry’ to write (specific to the Hull University course), it malaria and HIV within Africa and our area of travel. It ishas been so easy to brush any thoughts of our impending documented that half the world's population live in oradventure aside. Now that our professional enquiry has travel to areas where huge numbers become infected (CDCbeen completed and handed in, Uganda is at the forefront 2012). We are all taking ample supplies of anti-malarialof our minds and the first thing we talk about when we are medication, malaria being a disease that is preventable andtogether. Yesterday, as we sat after the hand in, at this treatable (CDC 2012).pivotal point in our final year, it was clear that we all feltanxious about our trip. We have concerns about HIV; 59 per cent of those infected with HIV within Africa are women aged 15-24 andVaccines it is primarily these women with whom we shall haveOur preparation for the trip seems to have gone on for such contact during our clinical placement (Amfar 2009).a long time: the fundraising, planning and organising have Personal protective equipment (PPE) has been kindlyall been lengthy. Not to mention the countless vaccinations donated to us by the University of Hull and we have agreedwhich have been administered over the past three months. that as long as we are well prepared, the risk of contractingThe question of vaccines encouraged a lot of debate the virus should remain low when dealing with bodilybetween us, each of us having differing views as to which fluids.ones were necessary. Yellow fever was a must, as thedisease is spread by the direct bite of a mosquito and can Differencescause bleeding, multiple organ failure, and is fatal in 20-50 Although we have recognised that there are many potentialper cent of cases (Centers for disease control and risks surrounding our journey, it will be made worthwhileprevention (CDC) 2012). Rabies, cholera and meningitis by the contact we shall have with women and theirwere added extras and we each had to make decisions families. Seeing how different cultures live and having theabout whether to have these. When Becky developed a opportunity to embrace their lifestyles, albeit for only amild case of meningitis after having her vaccine, the rest of brief time, will no doubt imprint on us and broaden ourus became unsure as to whether to go ahead. However, experience. Witnessing different practices and working in aafter talking it over with our practice nurses and doing a different model of care from our own will help us developlittle research, we discovered that, as Uganda is part of the as healthcare professionals.sub-Saharan meningitis belt, the risk of side effects is low Through speaking with Grace Nambozi (the link lecturer for Mbarara University) and in discussion with Dr Jeremy Jolley

The Practising Midwife is sponsoring four studentmidwives from Hull University to undertake anelective placement in Uganda. We continuefollowing their progress on these pages.(the international coordinator for the Faculty of health and Deathsocial care at Hull University) it has become apparent that Another fear is that, while in Uganda, we may encounterpractice will differ greatly from what we are used to here in our first neonatal or maternal death. This thought leaves usthe UK. Maternity wards have been described to us as: feeling very apprehensive as, although we shall have eachoften full to overflowing and many women both in the other for support, our extended support network will beantenatal and postnatal period, spilling over onto thousands of miles away and not readily accessible.mattresses on the floor to encompass the care of allwomen. We do agree, however, that while we are in Uganda, we shall take the opportunity for what it is: an immense Grace suggested that while we are in Mbarara, we make learning experience that will stay with us for a lifetime. Itthe most of all learning opportunities, as we shall will also give us a deeper appreciation as student midwivesundoubtedly come across some situations and conditions of what our National Health Service offers and provides,that, in the UK, we shall only ever read about in literature. which gives us many reasons to be proud to be entering into this privileged profession. TPM We have have been given advice by people with expertisein international placements and first hand experience of Sadie Elliott is a third year student midwife at Hull Universityliving and working in the country and the clinical area. Theyhave suggested that we may find the social class barriers a Referenceslittle hard to overcome, as midwives in Uganda are viewedas having high status, and can often treat marginalised and Amfar AIDS research (2009). Fact sheet: the global HIV/AIDS epidemic,disadvantaged women with a degree of dominance, which New York: Amfar.again is not how we have been taught to practise. CDC (2012). Impact of malaria, Atlanta: CDC.An overcrowded ward with mattresses on Families camping outside the hospital to take care of theirthe floor to accommodate more women relatives once the doctors, midwives and nurses have finished giving care

12 • Smoking in pregnancy July/August 2013 • THE PRACTISING MIDWIFESmoking in pregnancy, whereare we now?Cathy Ashwin, Jayne Marshall SUMMARY The harmful effects of smoking during pregnancy haveand Penny Standen consider been well documented within the literature (Eastham and Gosakanmeasures which have been 2010; British Medical Association (BMA) 2004). However, althoughintroduced to reduce the the number of women smoking during pregnancy has fallen overnumber of women smoking in the last few years, this still remains a major health concern for bothand after pregnancy women and their families. This paper aims to explore recent media campaigns and social policies focusing on smoking in pregnancy and the general population. Midwives need to be aware of current policies with regard to smoking cessation to enable high quality evidence based information and support to be provided at an optimum time in women’s lives. Keywords Smoking, pregnancy, media, social policy, support Authors Cathy Ashwin, midwife lecturer and admissions tutor, Jayne Marshall, associate professor, director of learning beyond registration and post graduate taught courses (midwifery) and Penny Standen, professor of health psychology and learning disabilities and head of school, community health sciences, all at the University of NottinghamD espite a high public profile, Despite a high public 2010. Since then, figures have shown a M smoking remains a major profile, smoking steady decline: statistics in 2011/12 public health concern in remains a major public recorded 13 per cent of pregnant 2013. It was responsible for health concern in 2013 women smoking at the time of birthapproximately 86,500 deaths in England (Health and Social Care Informationalone between 1998 and 2002 (National million for infants (Godfrey et al 2010). Centre (HSCIC) 2012). Nonetheless, theInstitute for Health and Care Excellence The focus on reducing the incidence current government target is to aim for(NICE) 2006). The risk factors for smoking a greater reduction to 11 per cent byare particularly high in certain groups of women smoking during pregnancy 2016 (DH 2011).such as the young, women and some was introduced in the UK by theethnic minority groups. In addition to publication of Smoking kills, a The power of advertisingthe health risks for women and families government white paper (DH 1998), Advertising is a powerful influence,through smoking during pregnancy and which aimed to reduce the number with the unattractive nature of smokinginto the postpartum period, there are from 18-23 per cent to 15 per cent by often at the forefront of stop smokingsubstantial costs to the National Health campaigns. With no overt evidence ofService (NHS). Recent reports estimated the detrimental effects of smoking onthe costs to exceed £60 million pounds health, cigarette smoking amongfor maternal outcomes and up to £23.5 women rose in popularity during the

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14 • Smoking in pregnancy July/August 2013 • THE PRACTISING MIDWIFEearly nineteenth century (Tinkler 2006). By the mid 1970s... groups of smokers. This should include By the mid 1970s the health risks to visual, audio, spoken and multilingual advertising campaigns resources such as information leaflets,the pregnant woman and fetus were DVDs and contact with smokingwidely discussed, and advertising began in earnest to cessation specialist advisors. Healthcampaigns began in earnest to encourage campaigns aimed at the young arewomen to stop smoking. However, encourage women to currently being promoted, with theevidence would suggest that this was intention of fewer younger mothersonly for the duration of the pregnancy, stop smoking either starting or resuming the habit ofwith scant regard for the long term. smoking (British Heart FoundationFollowing a survey in 1979, Action on Parliament proposes to extend this to (BHF) 2012; European Institute ofSmoking and Health (ASH) described cover 75 per cent. ASH (2012) welcomes Women’s Health (EIWH) 2013).pregnancy as ‘the nine month stopper’ this initiative and would also supportin an attempt to encourage women to plain packaging. Conversely, supporters The impact of societal factorsstop smoking, though they wanted of smoking argue that plain packaging Smoking bans in public places have anmore focus on using this as a means to would not discourage smoking and may effect on smaller communities andstopping permanently (Elliot 2011: 149). even encourage the sale of illegal societies as a whole, both within the UK cigarettes (Caunt 2013). Hammond et al and in many other countries in the The advertising of tobacco products (2012) examine the use of tobacco developed world. The UK banon billboards, in the press and at packaging as a source in the health implemented between 2006 and 2007sporting events was banned in 2003 campaigns to promote smoking (starting in Scotland) changed opinion(HM Government 2002); television cessation which is discussed within the for many on the acceptability ofadvertising had ceased much earlier World Health Organization (WHO) smoking among the general populationwith the implementation of the (2005) framework convention on and, to an extent, individual smokers,Independent Broadcasting Authority tobacco control. In order to determine not least childbearing women and their(IBA) act (IBA 1964), followed by later whether packaging does impact upon families. The evidence supports theEuropean directives (European Union the decisions made by smokers, the view that the ban on smoking in public1989). The Audiovisual media services Government has proposed studies to places has had a substantial impact forimplemented in 2007 (European ascertain the validity of these many women, making it easier not toCommission 2011) is now the suppositions (DH 2011). smoke when at work or socialising, asgoverning body for media advertising noted in the following quotation from awithin Europe. Television is now used as Health campaigns recent study (Ashwin 2013: 159):a medium for advertising health warnings Tobacco control programmes whichas to the dangers of smoking. Wakefield include mass media campaigns can be ‘…you are not actually socialisinget al (2013) suggest that the power of effective in changing smoking when you smoke because you havetelevision-based smoking cessation behaviour in adults (Bala et al 2009). to go away and have a cigarette, so Icampaigns not only encourages However, Bala et al (2009) concluded think that helps a lot.'stopping smoking but also continuing that the effectiveness of suchabstinence following initial success. campaigns was difficult to quantify (Paula aged 26) long term as it could depend upon the More recent restrictions on intensity and duration of the campaign. WHO’s (2005) Framework conventionadvertising and the sale of cigarettes Other factors considered to influence for tobacco control aimed to protectand tobacco products have been the outcomes were demographic everyone from the harmful effects ofimplemented by the Health Act of 2009 variables such as age, ethnicity, gender smoking on health, and the social and(HM Government 2009). Further and educational attainment. In environmental impact, including thegovernment policies included a ban on addition, Guttierrez (2012) purports, in enormous economic consequences. Thecigarette vending machines in 2009 order to generate significant changes in results of this treaty are already reapingand, from October 2012, cigarettes smoking behaviour, health campaigns benefits as highlighted in a studycould no longer be on view in large shops. must include various interventions and undertaken in Scotland (Mackay et alSmaller shops and business premises modes of relaying information across all 2012). The study revealed not only ahave until 2015 to implement this rule. reduction in the number of people smoking but also a significant fall in the The packaging of cigarettes has also number of preterm and small forcome under scrutiny and the current gestational age babies born since therequirements are for health warnings tocover 40 per cent of a pack. The European

THE PRACTISING MIDWIFE • July/August 2013 Smoking in pregnancy • 15ban was introduced in 2006. As midwives we are in tobacco control plan for England, London: DH. the privileged position Eastham R and Gosakan R (2010). ‘ReviewStopping smoking in pregnancy of being able to informIn 2010, NICE produced guidance for and support women in smoking and smoking cessation inhealth professionals on the issues of stopping smoking pregnancy’. The Obs and Gyn, 12(2): 103-109.smoking in pregnancy and following EIWH (2013). Women’s health and tobaccochildbirth (NICE 2010). This has been an smoking in the population. TPM control, Dublin: EIWH.important step in raising awareness of Cathy Ashwin is midwife lecturer and Elliott R (2011). Women and smoking since 1890,the continued support necessary to admissions tutor, Jayne Marshall is New York: Routledge.maintain postpartum abstinence and associate professor, director of learning European Commission (2011). Audio Visualreduce the risk of postpartum relapse. beyond registration and post graduate Media Services Directive 2007, Strasbourg: taught courses (midwifery) and Penny Council of the European Union (CEU). Several recommendations were made Standen is professor of health psychology European Union (1989). The European Directiveas to how referrals to smoking cessation and learning disabilities and head of 89/552/EEC, Luxembourg: CEU.services should be initiated and, for school, community health sciences, all at Godfrey C, Pickett KE, Parrott S et al (2010).long term benefit, extended to include the University of Nottingham Estimating the costs to the NHS of smoking inother close family members (NICE 2010). pregnancy for pregnant women and infants,Indicators for success suggested that References University of York: Public Health Consortium.supporting women to stop smoking Guttierrez KK (2012). Mass media interventionsshould involve multi-professional ASH (2012). Facts at a glance, London: ASH. to stimulate and promote smoking cessation,collaboration, as has been proven in Ashwin C (2013). An exploration of women’s London: NICE.other areas of healthcare arising from Hammond D, Wakefield M, Durkin S et al (2012).government initiatives (DH 1998; DH experiences of postpartum relapse to smoking. ‘Tobacco packaging and mass media1999; DH 2003). A phenomenological study. Unpublished PhD campaigns: research needs for articles 11 and Thesis: University of Nottingham. 12 of the WHO framework convention on NICE (2010) recommend that all Bala M, Strzeszynski L and Cahull K (2009). tobacco control’. Nicotine and Tobaccopregnant women who smoke be given ‘Mass media interventions for smoking Research, 15(4): 817-831.brief intervention support by midwives cessation in adults’. Cochrane Database of HM Government (2002). Tobacco advertisinginitially at the booking appointment Systematic Reviews, 1: DOI: 10.1002/1465185 and promotion act, London: Crown.and at subsequent antenatal visits. 8.CD004704.pub2. HM Government (2009). The health act: tobacco.Women requiring greater support BHF (2012). Policy statement- passive smoking, Section 21, London: Crown.should be referred to specialist smoking London: BHF. HSCIC (2012). Statistics on smoking, England,cessation services. BMA (2004). Smoking and reproductive health. Leeds: HSCIC. The impact of smoking on sexual, reproductive IBA (1964). The television act 1964, London: Crown.Conclusion and child health, London: BMA. Mackay DF, Nelson SM, Haw SJ et al (2012).Smoking has held a significant place in Caunt JC (2013). TMA response to the APPG on ‘Impact of Scotland’s smoke-free legislationhistory, being presented as glamorous smoking and health inquiry into the illicit on pregnancy complications: retrospectivethrough the power of advertising or, trade in tobacco, London: TMA. cohort study’. Pub Lib Sci (PLoS), 9: e1001175.more commonly in today’s society, DH (1998). ‘Smoking kills. A white paper on NICE (2006). Brief interventions and referral forregarded as unacceptable, with known tobacco’, London: The Stationery Office. smoking cessation in primary care and otherserious health risks. The risks are DH (1999). Making a difference: strengthening groups. Public health guidance 1, London: NICE.particularly relevant to pregnant the nursing, midwifery and health visiting NICE (2010). How to stop smoking in pregnancywomen who are risking their own contribution to health and health care, and following childbirth. Public healthhealth and that of their unborn fetus, as London: The Stationery Office. guidance 26, London: NICE.well as any existing children. As DH (2003). Building on the best: choice Tinkler P (2006). Smoke signals. Women, smokingmidwives we are in the privileged responsiveness and equity in the NHS, London: and visual culture, Oxford: Berg Publishers.position of being able to inform and The Stationery Office. Wakefield MA, Bowe SJ, Durkin SJ et al (2013).support women in stopping smoking at DH (2011). Healthy lives, healthy people: a ‘Does tobacco–control mass media campaignsuch a vulnerable stage in their lives. exposure prevent relapse among recentTherefore, as autonomous and quitters?’ Nicotine and Tobacco Research,accountable practitioners, we need to 15(2): 385-392.keep abreast of current policy, research WHO (2005). Framework convention for tobaccoand media campaigns in order to control, Geneva: WHO.promote the long term cessation of

16 • Vitamin D July/August 2013 • THE PRACTISING MIDWIFEDietary intake of vitamin D isnot enoughValerie Hemmings offers a SUMMARY The National Diet and Nutrition Survey (Batesguide for midwives to help et al 2011) show adult females have low levels of vitaminwomen avoid vitamin D D. Many women in midwives’ care may be vitamin Ddeficiency deficient. The aim of this article is to update midwives’ knowledge of vitamin D in line with their statutory role as a midwife, so they can recognise deficiency and make women aware of the consequences for themselves and their baby. Keywords Vitamin D, midwife’s role, vitamin D deficiency Authors Valerie Hemmings, senior midwifery lecturer at Anglia Ruskin University at the time of writing, now retiredIntroduction It is within the role of asthma (Barrett and McElduff 2010).Many women in midwives’ care are the midwife to informlikely to be vitamin D deficient, as all women at booking Types and sources of vitamin Dreported in the National Diet and of the importance of There are 2 types of vitamin D: D2 andNutrition Survey (Bates et al 2011). maintaining vitamin D D3. The natural source, vitamin D3Dietary intake of vitamin D is often (cholecalciferol) is considered to be theinsufficient (Bates et al 2011). It is possible that they may be experiencing best as it is the most active form ofwithin the role of the midwife to signs of vitamin D deficiency. Other vitamin D. It is formed by the actions ofinform all women at the booking potential signs are tooth decay and hair the ultraviolet rays in sunlight on aappointment of the importance of loss (Holford 2004). Deficiency can be cholesterol based compound which ismaintaining adequate vitamin D stores confirmed by measuring circulating naturally present in the skin.during pregnancy (National Institute of serum levels of 25-hydroxyvitamin D Cholecalciferol is converted into activeHealth and Care Excellence (NICE) 2008). (25(OH)D) (Holick 2009). Maternal vitamin D (calcitrol), which the body can vitamin D deficiency increases the risk use via enzymes first in the liver, then inVitamin D in pregnancy of pre-eclampsia (Bodnar et al 2007) the kidneys (Haas and Levin 2006).Vitamin D is important for the and caesarean section (Lapillonneabsorption and use of calcium and 2010). It also predisposes newborns to Vitamin D2 is obtained from food andphosphorus, both necessary for the skeletal problems and is associated also requires conversion by the liver andformation of healthy bones and teeth with childhood wheeze, eczema and then by the kidneys before it becomes(Haas and Levin 2006). The recommended fully active (Balch 2006).daily amount of vitamin D for pregnantwomen is 10mcg (Henry 2007). The best food source for vitamin D is oily fish such as salmon, sardines, When women complain that they pilchards and trout (British Dietetichave backache, joint pain and stiffness, Association (BDA) 2008). It ismuscle cramps or twitching, it is recommended that women should eat at least one portion of oily fish (140g)

THE PRACTISING MIDWIFE • July/August 2013 Vitamin D • 17per week (Bates et al 2011) although • when outdoors, those who cover up skin’s production of D3. Therefore these UK_PMMAdvert_BabyD_VE2.0_Jun-13pregnant women should not have more women require longer exposures tothan two such portions (Food Standards for religious or cultural reasons, or for sunlight to make the same amount of MAgency (FSA) 2002). necessity, such as in cold weather in vitamin D3 than light-skinned women winter (Hark and Deen 2006), or who (Holick 2004);Vitamin D supplementation always wear sunscreen above factorAnimal-derived forms of vitamin D are eight (BDA 2008). For these women, to • women who are obese: vitamin D3 isthe recommended form of ensure adequate amounts of vitamin D3supplements as they are converted by they should be advised to expose their fat soluble and any excess that isthe body into fully active vitamin D3. face and arms to the sun for fifteen produced during exposure to sunlightAlthough supplements are available minutes three times a week (Balch can be stored in the body fat and usedcontaining plant-derived forms of 2006). This should occur between 10.00 when little is produced in the skinvitamin D they are converted by the and 15.00 when the ultraviolet rays in (Holick 2004). There is some evidence,body into fully active vitamin D2 which sunlight are more abundant and strong however, that the increased amounts ofdoes not appear to have all the same (Holick 2004). Although some exposure subcutaneous fat in obesity mayfunctions as vitamin D3. Therefore, the without sun protection is required for actually prevent the release of vitaminanimal-derived forms of vitamin D3 the production of adequate amounts of D3 into the circulation (Wortsman et alappear to be the most desirable vitamin D3 care needs to be taken to 2000). Although a small study, it doessupplementation form (Haas and Levin prevent skin damage. Individuals with provide evidence as to why some obese2006). Cod liver oil, although a good light skins should only be exposed to women may be at increased risk ofsource of vitamin D3 should be avoided the sun for between five and 15 vitamin D deficiency.in pregnancy, as it may contain high minutes until their skin becomeslevels of vitamin A which has been slightly pink. It is then recommended Conclusionassociated with an increased risk of that they apply a sunscreen in order to Midwives need to take an active role incertain congenital malformations (NICE prevent the2008). damaging effects of chronicWomen most at risk of vitamin D excessive exposuredeficiency to sunlight (HolickThe risk of vitamin D deficiency is 2004);greater for some women, including: • women with CMO recommendation compliant1• women whose diet is low in vitamin darker skins, such Prescribable or can be bought atD: women who consume no oily fish, as those of African- any UK Pharmacydairy products, egg yolks, vitamin D- Caribbean andfortified margarine or breakfast cereal South Asian origin, Hypoallergenic(BDA 2008); as they have increased skin- Colourless and tasteless• women on restricted diets and strict melanin pigmentation. Suitable for pregnant womenvegetarians (or vegans) may also be at Melanin evolved as does NOT contain Vitamin Arisk as plant foods are fairly low in D2 a natural sunscreenalthough mushrooms and dark leafy (Holick 2004); its t: 0845 303 8631 1 Recommended by Chief Medical O cers’ as the dailygreens contain small amounts of primary function is www.korahealthcare.com supplemented dose for infants, young children and adultsvitamin D (Haas and Levin 2006); to absorb the (Ref CEM/CMO/2012/04) ultraviolet rays in• women who have limited skin sunlight before Concentration 1000IU/ml (25μg/ml) they reach theexposure to sunlight: women who tissues below the A food supplement is not a substitute for a healthy diet.spend a great deal of their day indoors, outer layer of the Baby D should be consumed as part of a varied andsuch as the housebound (NICE 2008), skin (Thibodeau balanced diet and healthy lifestylethose who work in offices (Henry 2007) and Patton 2012).and those who spend little time This influences theoutdoors such as teenagers who maylack outdoor exercise (Balch 2006);





20 • Vitamin D July/August 2013 • THE PRACTISING MIDWIFEpreventing vitamin D deficiency. They Barrett H and McElduff A (2010). ‘Vitamin D and London: Dorling Kindersley.are in an ideal position to achieve this pregnancy: an old problem revisited’. Best Holford P (2004). New optimum nutrition bible,as they work in partnership with Prac and Res Clin Endocr and Metab, 24: 527-women and provide a woman-centred, 539. 2nd edition, London: Piatkus.individualised approach to care Holick MF (2004). ‘Sunlight and vitamin D for(Nursing and Midwifery Council (NMC) Bates A, Lennox A, Bates C et al (eds) (2011).2004). Midwives need to be able to National diet and nutrition survey : headline bone health and prevention of autoimmunerecognise signs of vitamin D deficiency results from years 1 and 2 (combined) of the diseases, cancers and cardiovascular disease’.and highlight to women the rolling programme (2008/2009–2009/10), Am Jour Clin Nutr, 80: 1678S-1688S.importance of maintaining adequate London: Department of Health. Holick MF (2009). ‘Status: measurement,vitamin D stores during pregnancy. interpretation, and clinical application’.Making women aware of the consequences Bodnar LM, Catov JM, Simhan HN et al (2007). Annals of epidemiol, 19(2): 73-78.of vitamin D deficiency for themselves ‘Maternal vitamin D deficiency increases the Lapillonne A (2010). ‘Vitamin D deficiencyand their baby is part of the statutory risk of preeclampsia’. Jour Clin Endocrinol and during pregnancy may impair maternal androle of the midwife (NMC 2004). TPM Metab, 92(9): 3517-3522. fetal outcomes’. Med Hypotheses, 74: 71-75. NICE (2008). Antenatal care: routine care for theValerie Hemmings was senior midwifery BDA (2008). Vitamin D – the unique vitamin, healthy pregnant woman. Clinical guidelinelecturer at Anglia Ruskin University at the www.bda.uk.com/ foodfacts/ VitaminD.pdf 62, London: NICE.time of writing; she is now retired Accessed 24th June 2012. NMC (2004). Midwives’ rules and standards, London: NMC.References FSA (2002). Eating while you are pregnant, Thibodeau GA and Patton KT (2012). Structure London: Crown. and function of the body. 14th edition, StBalch PA (2006). Prescription for nutritional Louis: Elsevier Mosby. healing, 4th edition, New York: Avery. Haas EM and Levin B (2006). Staying healthy Wortsman J, Matsuoka LY, Chen TC et al (2000). with nutrition, Berkeley: Celestial Arts. ‘Decreased bioavailability of vitamin D in obesity’. Am Jour Clin Nutr, 72: 690-693. Hark L and Deen D (2006). Nutrition for life, London: Dorling Kindersley Ltd. Henry JA (2007). British medical association: new guide to medicines and drugs, 17th edition,

THE PRACTISING MIDWIFE • July/August 2013 Unintended teenage pregnancy • 21“You’re wha...?!”Áine Aventin and Maria Lohan SUMMARY The importance of including fathers in reproductiveargue that being inclusive of planning, pregnancy and childbirth cannot be overstated and it isyoung men is key in preventing increasingly recognised that addressing their sense of exclusion fromunintended teenage maternity services requires further action. One very overlooked area,pregnancies however, is in helping young men, alongside their partners, in preventing an unintended teenage pregnancy. The UK has the highest rate of teenage pregnancy in Western Europe and, while teenage men are seen as half of the problem, they are rarely regarded as half of the solution. We argue that education is an essential part of the process of increasing men’s sense of inclusion and describe If I were Jack, an educational resource about unintended teenage pregnancy which has been developed specifically for young men. Keywords Young fathers, unintended teenage pregnancy, teenage pregnancy, RSE resources, sex education Authors Dr Áine Aventin, research fellow and Dr Maria Lohan, senior lecturer at the School of nursing and midwifery, Queen’s University BelfastIntroduction Further improvements teenage pregnancy and helping young MThere is perhaps no single service more could reduce fathers’ men as well as young women avoid animportant to engendering the feelings of being an unintended teenage pregnancy.engagement of fathers in reproductive ‘outsider’ when ithealth and the lives of their children comes to pregnancy Unintended teenage pregnancythan the maternity services (Shaw and and childbirth Despite the fact that, in recent years,Lohan 2012). While great strides have the rate of teenage pregnancy hasbeen made in recent years in the including fathers and has begun to begun to decline in the UK, it is still theobstetric and midwifery professions in promote the inclusion of fathers as a highest in Western Europe, with aroundpromoting the inclusion of men in core part of midwifery services (RCM 40,000 women under the age of 18antenatal education and health 2011). One area of men’s involvement becoming pregnant every year; close toappointments as well as during the in reproduction that has been half of these pregnancies end in legalbirth of the baby, research suggests neglected, however, is in relation to abortion (Office for National Statisticsthat further improvements could (ONS) 2012; Northern Ireland Statisticsreduce fathers’ feelings of being an and Research Agency (NISRA) 2011;‘outsider’ when it comes to pregnancy Information Services Division Scotlandand childbirth (Dolan and Coe 2011; (ISD) 2010). While becoming a teenageDeeney et al 2012; Miller 2011). The parent does not necessarily result inRoyal College of Midwives (RCM) negative life course outcomes,understands the importance of unintended teenage pregnancy is

22 • Unintended teenage pregnancy July/August 2013 • THE PRACTISING MIDWIFEassociated with social exclusion, Unintended teenage effects of various types of disadvantage.disadvantage and significant social, Men's adolescent years are a criticalemotional, health and economic costs pregnancy is associated opportunity to promote positivefor adolescents, their infants and relationships and this is likely to have asociety. The reduction of unintended with social exclusion, sustained impact throughout theirteenage pregnancy rates is therefore adult years and would also benefit theirfirmly on the policy agenda and, disadvantage and sexual partners.increasingly, researchers andpractitioners are recognising that significant social, If I were Jacktargeting young men is an important, Working in consultation with healthyet sorely neglected part of this process emotional, health and and education experts and end-users,(Ross et al 2010; Lohan et al 2010; including teachers, young people andLohan et al 2011). economic costs for parents, researchers at Queen’s University Belfast and the MedicalEducating young men about adolescents, their Research Council Social and Publicpregnancy Health Sciences Unit GlasgowTeenage men are currently much less infants and society developed an evidence-based, theory-likely than young women to receive informed, educational resourceeducation in relation to pregnancy comfort with speaking about targeted specifically at young men butprevention in schools, and research pregnancy is important. An unintended also appropriate for use by youngsuggests that parents are much more pregnancy can be an immense crisis in a women. The resource educates younglikely to have discussed sex and young man’s life, leaving him uncertain people about unintended teenagepregnancy with their daughters than or confused about how to make pregnancy and its potentially negativewith their sons (Hyde et al 2010). When decisions about the pregnancy (Lohan consequences. It aims to help themteenage men do receive education et al 2011). The way that women cope avoid unintended teenage pregnancyrelating to pregnancy, the lessons with an unintended pregnancy is and to increase their sense ofusually focus on girls, ignoring the fact strongly influenced by their partners confidence in their ability tothat boys have different perspectives and the support of a male partner can communicate their feelings andand attitudes towards the gender ease the emotional burden of an intentions about pregnancy. The If Inorms, and values that will influence unintended pregnancy. In addition, were Jack educational resource includestheir responses to pregnancy (Aventin addressing teenage men’s pregnancy an interactive video drama (IVD) whichand Lohan in press). education is an important mechanism tells the story of an unexpected for promoting positive development pregnancy from a teenage man’s Yet there is also recognition that and improving the lives of all young perspective (Aventin et al 2013). As theyoung men’s understanding of and adults, especially those suffering the

THE PRACTISING MIDWIFE • July/August 2013 Unintended teenage pregnancy • 23young person views the IVD they are Young fathers can too Carmel Kelly (Queen’s University Belfast)encouraged to put themselves in Jack’s easily become and Dr Marion Henderson (Medicalshoes and consider how they would feel marginalised in relation Research Council, Glasgow).in his situation. In this way, the resource to pregnancy planningencourages reflection and anticipatory and outcome decisions, Referencesthinking about unintended pregnancy during the birth of theirand its potential consequences. baby and in the post- Aventin A and Lohan M (in press). ‘I’m all right, natal period Jack’. Every Child Journal.Teaching resourceIt also contains classroom materials for partner and the infant is also a very Aventin A, Lohan M, O'Halloran P et al (2013). If Iteachers featuring four detailed lesson important missing link in addressing were Jack educational resource, Belfast:plans with specific classroom-based the high rates of unintended teenage Queen's University Belfast.and homework activities, including pregnancy in the UK. Midwives dealgroup discussions, role plays, with the consequences of unintended Deeney K, Lohan M, Spence D et al (2012).worksheets and a parent-pupil exercise teenage pregnancies every day and are ‘Experiences of fathering a baby admitted to(the parent survey); a 60-minute also involved in pregnancy prevention neonatal intensive care: a critical gendertraining session for teachers wishing to education. The If I were Jack resource analysis’. Social Science and Medicine, 75(6):implement the intervention; a 60- may be of interest to midwives in 1106-1113.minute information and discussion developing targeted information forsession for parents/guardians delivered young men. TPM Dolan A and Coe C (2011). ‘Men, masculineby relationships and sexuality identities and childbirth’. Sociology of Healtheducation (RSE) teachers; and detailed Dr Áine Aventin is research fellow and Dr and Illness, 33(7): 1019-1034.information brochures and fact sheets Maria Lohan is senior lecturer at theabout the intervention and about School of nursing and midwifery, Queen’s Hyde A, Carney M, Drennan J et al (2010). ‘Theunintended teenage pregnancy in University Belfast silent treatment: parents’ narratives ongeneral, for schools, teachers, teacher sexuality education with their adolescenttrainers, young people and parents. I Note The current phase of the If I children’. Culture Health and Sexuality, 12(4):While the resource has been designed were Jack project is funded by the UK 359-371.to be used in the classroom it has Economic and Social Research Councilpotential for use in other settings and (RES-189-25-0300), the Irish Health ISD (2010). Teenage pregnancy, Scotland: ISD.will be freely available online following Service Executive’s Crisis Pregnancy Lohan M, Cruise S, O’Hallorohan et al (2010).evaluation. Programme and the Public Health Agency Northern Ireland. The resources ‘Adolescent men's attitudes in relation toConclusion will be piloted in Northern Ireland pregnancy and pregnancy outcomes: aMore intensive efforts are required to during the 2013/14 academic year, with systematic review of the literature frompromote and improve young men’s a view to future rigorous evaluation of 1980–2009’. Jour of Adolesc Health, 47(4):connections with their partner’s its effectiveness and final roll-out of 327-345.pregnancy and their own materials, which will be freely available Lohan M, Cruise S, O’Hallorohan et al (2011).responsibilities in relation to to the public. Further details on the If I ‘Adolescent men's attitudes and decision-reproductive and pregnancy related Were Jack resource, including excerpts making in relation to an unplannedplanning. Young fathers can too easily from the IVD, are available from: pregnancy. Responses to an interactive videobecome marginalised in relation to www.qub.ac.uk/IfIWereJack drama’. Social Sci and Med, 72(9): 1507-1514.pregnancy planning and outcome Miller T (2011). ‘Falling back into gender? Men’sdecisions, during the birth of their baby The If I were Jack research team also narratives and practices around first-timeand in the post-natal period, especially includes Dr Peter O’Halloran and Dr fatherhood’. Sociology, 45(6): 1094-1109.in cases where they or their partners are NISRA (2011). Young person’s behaviour andunder the legal age of sexual consent attitudes survey, Belfast: NISRA.(16 years). In addition we argue that ONS (2012). Conception statistics in England andinvolving young men in education Wales 2010, Newport: ONS.about pregnancy prevention and the RCM (2011). Reaching out: involving fathers inlife-changing consequences of having a maternity care, London: RCM.teenage pregnancy for them, their Ross N, Church S, Hill M et al (2010). The fathers of children born to teenage mothers, Glasgow: Children 1st and the Glasgow Centre for the Child and Society. Shaw C and Lohan M (2012). Understanding fatherhood in the 21st century. Man matters policy briefing paper No. 2, Belfast: Workers’ Educational Association.

24 • Contraception July/August 2013 • THE PRACTISING MIDWIFEContraception: a guide formidwivesSarah Snow describes SUMMARY Women will generally spend more of their reproductive lifetimethe range of preventing pregnancy than experiencing it. The choice of contraceptive methodscontraceptive devices can be confusing for women, each one having its own set of advantages andavailable, to support disadvantages. For new mothers, a method of contraception is important if amidwives in advising reasonable gap between pregnancies is the desired outcome. Given thatwomen ovulation can resume four weeks following childbirth, midwives have a clear role in the provision of up to date contraceptive health advice to women, including the availability of emergency contraception. Midwives, especially those working in the community, also need to be familiar with the range of contraceptive health clinics in their locality, together with a working knowledge of the various services offered by them. Keywords Emergency contraception, lactational amenorrhoea, oral contraceptive pill, barrier methods Author Sarah Snow, programme leader and lead midwife for education at the University of WorcesterP ractising midwives have a Condoms are penis during intercourse, protecting clear responsibility to dependent on correct against pregnancy and sexually facilitate women’s use, their effectiveness acquired infections (SAIs), has been contraceptive choices in the being greatly reduced used since ancient Egyptian timespuerperium, although this may be a when associated with (Family Planning Association (FPA)source of anxiety for practitioners the intake of drugs or 2010). Originally made from a variety ofunfamiliar with contraceptive health or alcohol substances, including sheep intestines,unsure of their scope of practice. The condoms became more user friendlyEU Directive 2005/36/EC states that midwives in their practice and following the vulcanisation of rubber inone of the activities of the midwife is encourages further reading. the late 1800s (FPA 2010).the ‘provision of sound family planninginformation and advice’ (World Health Barrier methods An excellent and cheap method ofOrganization (WHO) 2009: 6). This These are condoms, both male and contraception that also affordsarticle is therefore a contribution female, plus the diaphragm (also protection from most SAIs, includingtowards such provision and is intended known as a ‘cap’). A sheath to cover the HIV (Faculty of sexual and reproductiveto support midwives in counselling healthcare (FSRH) 2012), condoms arewomen about the range of dependent on correct use, theircontraceptive choices available to effectiveness being greatly reducedthem. It is not an exhaustive guide to when associated with the intake ofcontraceptive health as that remit is drugs or alcohol. Anecdotally, menoutside the scope of this paper. Instead, complain that condom use during sexthe article offers a summary of reduces the sensation and this iscontraceptive methods, that supports perhaps the biggest obstacle to their use. However, all contraceptive health

THE PRACTISING MIDWIFE • July/August 2013 Contraception • 25clinics will promote the use of condoms, The cervical sponge only pill. This method can also be used Meven if hormonal methods are the main used by the ancient by women in the early postnatal periodmethod of choice, as they are around 98 Jewish community was (FSRH 2009). However, the mostper cent effective when used correctly considered to be the effective method of EC is theand will protect the couple from most effective intrauterine device (copper coil) thatcommon infections such as Chlamydia. contraceptive method works by preventing implantation and until the advent of the may be used up to five days after The female condom can be a viable modern diaphragm unprotected sex. Key advice foralternative, especially for well- midwives to offer women is that EC ismotivated couples, although UK sales opportunities to support other aspects free at all contraception clinics. Otherfigures are extremely low (Burt 2005). of the woman’s sexual health during provision, for example at someThere are a number of possible reasons the same consultation. pharmacies, will incur a cost.for this, including their relatively highcost. Many women also find them Emergency contraception Hormonal methodsawkward to fit properly and noisy Ovulation can occur as early as 28 days The development of the oralduring sex (Boston Women’s Health following childbirth and, given that contraceptive pill in the 1960sBook Collective (BWHBC) 2005). sperm can survive for seven days in the represented a huge advance in fertility female genital tract, contraception is control for women and remains one of Diaphragms and caps vary in size and therefore required from 21 days (FSRH the most popular contraceptiveshape but their essential function is the 2009). However, women may not be methods today.same – if fitted correctly, they cover the aware when their fertility has returnedcervix and form an effective barrier to in the first months after giving birth, The history of oral contraception hassperm. Like the male condom, especially when coping with the been associated with controversy,diaphragms have been around in a demands of a new baby. Unprotected including two breast cancer scaresvariety of forms since ancient times sex is therefore a possibility and a (Bromham 1996). Although the risk ofwhen the use of substances to occlude potential source of acute distress for breast cancer is slightly increased forthe cervix were widely used to reduce both women and their partners. Where women taking the pill, it reduces thethe risk of pregnancy. a woman is breastfeeding, lactational risk of other cancers (Cancer Research amenorrhoea as a contraceptive UK 2013) and should be contextualised According to London (2012), the method is 98 per cent effective, in terms of the risk of pregnancy to ancervical sponge used by the ancient provided certain conditions exist: the individual woman. It is also worthJewish community was considered to woman is fully and exclusively noting that contemporary pills containbe the most effective contraceptive breastfeeding; the baby is less than six significantly lower levels of hormonesmethod until the advent of the modern months old; and the woman’s periods than their predecessors - a pill taken bydiaphragm. have not resumed (FSRH 2009). women in the 1960s equates to seven pills today (FPA 2010). When used with the addition of Although breastfeeding can be anspermicide, the diaphragm’s effective contraceptive, emergency Where there is good complianceeffectiveness ranges between 92-96 per contraception (EC) will always be an (women adhere to the method correctlycent (FSRH 2012). However, their use invaluable resource for women, and and consistently) the pill is over 99 permay not be readily tolerated by some midwives should therefore be confident cent effective (FPA 2013). Although thewomen because they take practice to to advise how to access it. There are method is contraindicated for someuse properly and can be ‘fiddly’ (FPA three options for EC, the most women - for example the combined pill2013). Conversely, other women may commonly used being a progestogen- is not suitable for women whofind them particularly appealing experience focal migraine (FSRH 2009) -because control of barrier contraception it has few problematic side effects andlies with them. is therefore well tolerated by the majority of women. However, any Midwives should advise women to discussions with women about thewait for six weeks after the birth of method should include a discussion oftheir baby before using the missed pill ‘rule’ and other eventsdiaphragms/caps to ensure a good ‘fit’ that reduce its effectiveness, such asover the cervix; parity may reduce their vomiting and diarrhoea. Midwiveseffectiveness (FSRH 2012). Diaphragm should note that common antibioticsfitting and assessment is ideallyperformed by a contraceptive healthpractitioner because of the

26 • Contraception July/August 2013 • THE PRACTISING MIDWIFEdo not compromise the effectiveness of No single method of example, LARC affords high protectionthe oral contraceptive pill. When against pregnancy, but none againstwomen conceive whilst taking the oral contraception is perfect sexually acquired infections (FPA 2013).contraception pill, it is inevitablybecause of user failure (FPA 2013). and therefore midwives Finally, remember that no single method of contraception is perfect and For women seeking to resume taking should always refer therefore midwives should always referthe pill following the birth of their baby, women to specialist contraceptivea progestogen-only pill (POP) is a women to specialist health services to enable an individualversatile option as it can be taken by choice based on needs andthe woman if she is breastfeeding and contraceptive health circumstances. TPMimmediately in the puerperium. ThePOP can generally also be used by services to enable an Sarah Snow is programme leader and leadwomen with conditions that preclude midwife for education at the University ofthe use of the combined pill, for individual choice based Worcesterexample hypertension. Newergenerations of the POP afford women on needs and Further resourcesgreater flexibility and enhanced I www.fpa.org.uk/reliability. For example, desogestrel has circumstances I www.fsrh.org/a 12 hour window for women toremember to take it, as opposed to 3 example, suggest that the fitting is Referenceshours with other POPs. desogestrel also done by an experienced practitioner atinhibits ovulation and for women a contraceptive health clinic, usually BWHBC (2005). Our bodies ourselves: a newanxious to control their fertility who during a dedicated clinic service with an edition for a new era, New York: Touchstone.may not be able to use the combined appointment system. Also, midwivespill, this pill is therefore an excellent can advise that the procedure generally Bromham D (1996). ‘Another pill scare - shouldchoice. causes less discomfort for women who we audit its impact?’ Audit Unit News, 1(4): 2-3. have experienced childbirth.Long acting reversible Burt K (2005). ‘Whatever happened to thecontraception (LARC) Other than the copper coil, LARC femidom?’ The Guardian, 23rd August.These methods are the contraceptive employs the use of progesterone andinjection, implant and intrauterine affords contraceptive protection from Cancer Research UK (2013). The contraceptivecontraceptive devices (hormonal or 12 weeks to 10 years. The long action is pill and cancer risk, London: Cancer Research UK.copper coils). The National Institute for therefore appealing and the methodsHealth and Care Excellence (NICE) suitable for a broad range of women. FPA (2010). Contraception: past, present and(2005) encourages practitioners to Side effects include irregular bleeding, future, London: FPA.discuss LARC with women as part of any which may be unacceptable for somecontraceptive health consultation women and, for implant users, is FPA (2013). Diaphragms and caps: your guide,because the methods enjoy high primarily responsible for around a London: FPA.efficacy, are not dependent on the user quarter of early removals (FSRH 2007).and are cost effective. FSRH (2007). Clinical guidance: intrauterine However, there are other contraception, London: FSRH. Women need to wait four weeks after interventions that can help andthe birth of their baby before a coil can therefore midwives should encourage FSRH (2009) Clinical guidance: postnatal sexualbe inserted in order to ensure safe and women to return to the contraceptive and reproductive health, London: FSRH.appropriate fitting (FSRH 2007). clinic and seek further advice. Usually,However, other LARC methods can be many women become amenorrhoeic FSRH (2012) Clinical guidance: barrier methodsused earlier on in the puerperium, for with continued use of a LARC method for contraception and STI prevention, London:example the contraceptive injection. and this may be perceived by some as a FSRH. distinct advantage. As part of any Some women are understandably contraception discussion with women, London K (2012). The history of birth control,anxious about having a coil or implant the advantages need to be carefully Yale: Yale-New Haven Teachers Institute.fitted and midwives are therefore in a balanced alongside any anxieties. Forgood position to provide sound NICE (2005). Clinical guideline: long-actinginformation and support. They can, for reversible contraception, London: NICE. WHO (2009). European Union standards for nursing and midwifery: information for accession countries, 2nd edition, Geneva: WHO.

THE PRACTISING MIDWIFE • July/August 2013 Group B streptococcus • 27Group B streptococcusinfection: risk and preventionJane Plumb and Ginny Clayton SUMMARY Group B Streptococcus (group B Strep or GBS) is the UK’spresent midwives with commonest cause of severe early-onset (up to six days) infection ininformation which could help babies. GBS is a normal body commensal, colonising the gut andprevent babies contracting GBS vagina. GBS may pass to babies around childbirth; although most areinfection unaffected, some develop severe infection. GBS is also a recognised cause of stillbirth and puerperal sepsis. Most GBS infection in babies is of early onset and most of these infections are highly preventable with the targeted use of intrapartum antibiotic prophylaxis. This article reviews current UK guidelines and prevention strategies. Keywords Group B Streptococcus, infection, prevention, intrapartum antibiotic prophylaxis (IAP), early onset GBS neonatal sepsis (EOGBS), late onset GBS neonatal sepsis (LOGBS) Authors Jane Plumb, chief executive of a GBS charity and Ginny Clayton, NHS hospital midwife and trustee of a GBS charityNeonatal GBS infection Some survivors suffer •pre-term labour and birth MSeventy five per cent of neonatal GBS long-term disabilities: (Heath et al 2009)infections occur in the first six days of following GBSlife, 25 per cent occurring later (seven- meningitis, 50 per cent Late onset GBS neonatal sepsis (LOGBS)90 days) (Heath and Schuchat 2007). suffer disabilities which Occurring from seven-90 days, it are severe in 25 per usually results in meningitis and/or One in 10 babies with GBS infection cent of babies septicaemia. LOGBS can be acquireddies (Heath et al 2004), and some from the mother or others (Jordan et alsurvivors suffer long-term disabilities: •previous sibling diagnosed with 2008). Risk factors include:following GBS meningitis, 50 per cent invasive GBS infectionsuffer disabilities which are severe in 25 pre-term birthper cent of babies (Bedford et al 2001). •positive maternal antenatal GBS culture (vaginal, rectal or urine) ••a positive maternal antenatal GBSEarly onset GBS neonatal sepsis maternal intrapartum fever culture(EOGBS)This is from birth to six days and ••prolonged rupture of membranes Recognising GBS infectionusually presents, within 24 hours of (>18 hours) Symptoms for EOGBS and LOGBS maybirth, as septicaemia or pneumonia, be vague and include:resulting from vertical transmission ofa GBS colonised mother to her baby gruntingduring or shortly before birth (Heathand Schuchat 2007). Recognised risk •lethargyfactors include: •impaired consciousness •irritability •poor feeding; vomiting ••very high or low heart rate

28 • Group B streptococcus July/August 2013 • THE PRACTISING MIDWIFE hypotension At present, too often unless it gets into the ‘wrong place’, swabs are taken from such as the urinary tract. Antibiotics •hypoglycaemia the high vagina and cannot eradicate GBS carriage. ••abnormal (high or low) cultured on standard agar plates, missing up Effect of UK guidelines temperature to half of GBS carriers Reduced EOGBS incidence was anticipated following the introduction •abnormal (fast or slow) breathing Prolonged rupture of membranes of the RCOG’s 2003 risk-based rates with cyanosis (defined as >18 hours by NICE, >24 prevention guideline, but that has not hours by RCOG) and pre-term labour happened. In fact GBS infection inLOGBS may additionally present with (<37 weeks’ gestation) are recognised babies aged from birth to 90 dayssigns of meningitis, such as convulsion, independent risk factors for EOGBS increased between 2003 and 2011 bystiff neck or a high pitched cry. (Colbourn and Gilbert 2007). 15 per cent to 0.63 cases per 1,000 live births. The incidence in babies agedPrevention There are no specific treatments to from birth to six days showed noIntrapartum antibiotic prophylaxis (IAP) prevent LOGBS; like other bacterial significant change at 0.38 cases persignificantly reduces the incidence of infections, GBS may be transmitted 1,000 live births (HPA 2004; 2012b).EOGBS. Many developed countries offer through skin-to-skin contact, soIAP to pregnant women with known rigorous hand-washing is critical before An audit of 171 UK obstetric units’GBS carriage or risk factors for EOGBS. handling newborn babies. GBS protocols showed significantMost of these countries offer GBS variation compared with RCOGscreening to women in late pregnancy GBS is carried in the bowel and guidelines (RCOG and London School of(Edmond et al 2012). vagina and is harmless for the carrier Hygiene and Tropical Medicine (LSHTM) 2007). An update including actual The National Institute of Health and practice would establish the currentCare Excellence (NICE) (2008), the UK situation better to inform policy.National Screening Committee (NSC)(2012) and the Royal College of Potential improvements toObstetricians and Gynaecologists prevention(RCOG) (2012) recommend that not all More EOGBS could be prevented bywomen be offered routine antenatalscreening for GBS. Figure 1: Laboratory reports to Health Protection Agency (Guy 2013) The ‘gold standard’ method forsample taking and culture (HPA 2012a)comprises swabs being taken from thelow vagina and rectum, then culturedusing an enriched culture medium(ECM). Such test results are verypredictive of GBS carriage when takenwithin six weeks of birth (Yancey et al1996). ECM testing is available privatelyand will soon be available on the NHS.However, at present, too often swabsare taken from the high vagina andcultured on standard agar plates,missing up to half of GBS carriers. NICE (2012) and RCOG (2012)recommend that IAP should be offeredto women who have •had a previous baby with invasive GBS infection •GBS colonisation, bacteriuria or infection during this pregnancy •intrapartum fever

THE PRACTISING MIDWIFE • July/August 2013 Group B streptococcus • 29antenatal screening using vagino-rectal Fifty-80 per cent of women are neither told about GBS norswabs and culturing on ECM than using EOGBS would have about testing. So how can they, withrisk factors (many women with risk been preventable had their health professionals, make anfactors don’t carry GBS). The proportion existing guidelines informed choice?of women offered antibiotics in labour been followedwould remain similar (Daniels et al We believe that:2011). baby, have been allayed (Law et al 2005). •women should be informed about In a UK study (Vergnano et al 2010), GBS as part of routine antenatal67 per cent of babies with EOGBS were NICE clarified the situations in which care;born to mothers with one or more IAP should be offered (NICE 2012) andknown GBS risk factors but only 21 per what action to take for babies born in •women should be offered a ‘goldcent of women received correct IAP. higher risk situations or with signs of standard’ ECM GBS test at 35-37Fifty-80 per cent of EOGBS would have infection. Improved education of health weeks’ gestation;been preventable had existing professionals is critical for theseguidelines been followed, but the risk- guidelines to be effective. •women with GBS colonisation,based strategy may be too complex and bacteriuria or infection during thedifficult to understand, and therefore Conclusion current pregnancy, or with otherpoorly implemented. GBS is the commonest cause of serious risk factors for EOGBS, should be infection in newborn babies. EOGBS is offered IAP. While inappropriate use of broad- usually preventable. Yet pregnantspectrum antibiotics promotes Midwives can helpantibiotic resistance, USA studies have Midwives are uniquely well placed tonot found increased antibiotic help EOGBS prevention by:resistance from IAP using narrow-spectrum benzylpenicillin for GBS (Stoll •informing pregnant women aboutet al 2005). Similarly, concerns about GBS and its prevention;major allergic reactions to penicillin,potentially devastating to mother and •ensuring that mothers of babies at raised risk of EOGBS are offered IAP as soon as labour has started; •informing parents what signs of GBS infection to look for in their baby postnatally, and when to seek an urgent medical review. TPM Jane Plumb is chief executive of a GBS charity and Ginny Clayton is a NHS hospital midwife and trustee of a GBS charity Useful resources I http://www.gbss.org.uk/ I http://www.nhs.uk/chq/pages/2037. aspx?categoryid=54 I http://tinyurl.com/kh497dq I http://tinyurl.com/n8tf9dvAdam Cheshire, pictured on day two, was born after a normal pregnancy with no Acknowledgements Mrecognised risk factors for GBS infection. Adam had GBS meningitis and has been I The authors are grateful to Philipleft with hearing, sight and developmental disabilities Steer, emeritus professor, Imperial College and consultant obstetrician, Chelsea and Westminster Hospital, London and Alison Bedford Russell, neonatal consultant, Birmingham Women's Foundation Trust, for their helpful contributions to this article.

30 • Group B streptococcus July/August 2013 • THE PRACTISING MIDWIFEReferences streptococcal bacteraemia, England, Wales treatment of early-onset neonatal infection, and Northern Ireland: 2011'. Infection reports, London: NICE.Bedford H, de Louvois J, Halket S et al (2001). 6(46): 1-21. RCOG (2012). The prevention of early onset 'Meningitis in infancy in England and Wales: Heath PT, Balfour G, Weisner AM et al (2004). neonatal Group B Streptococcal disease (2nd follow up at age 5 years’. Brit Med Jour, ‘Group B streptococcal disease in UK and Irish edition), London: RCOG. 323(7312): 533-536. infants younger than 90 days’. Lancet, RCOG and LSHTM (2007). The prevention of early 363(9405): 292-294. onset neonatal Group B Streptococcal diseaseColbourn T and Gilbert R (2007). ‘An overview of Heath PT, Balfour G, Tighe H et al (2009). ‘Group in UK obstetric units, London: RCOG. the natural history of early onset group B B streptococcal disease in infants: a case Stoll BJ, Hansen NI, Higgins RD et al (2005). ‘Very streptococcal disease in the UK.’ Early Hum control study’. Arch Dis Child, 94(9): 674-680. low birth weight preterm infants with early Dev, 83(3): 149-156. Heath PT and Schuchat A (2007). ‘Perinatal onset neonatal sepsis: the predominance of group B streptococcal disease’. Best Pract Res gram-negative infections continues in the NatDaniels JP, Gray J, Pattison HM et al (2011). Clin Obs Gyn, 21(3): 411-424. Institute Child Health & Human Development ‘Intrapartum tests for group B streptococcus: Jordan HT, Farley MM, Craig A et al (2008). Neonatal Research Network, 2002-2003’. The accuracy and acceptability of screening’. Brit ‘Revisiting the need for vaccine prevention of Pediat Infect Dis Jour, 24(7): 635-639. Jour Obs Gyn, 118(2): 257-265. late-onset neonatal group B streptococcal UK NSC (2012). Antenatal screening for Group B disease: a multistate, population-based Streptococcus carriage. Policy positionEdmond KM Kortsalioudaki C, Scott S et al analysis’. The Pediat Infect Dis Jour, 27(12): statement, London: UK NSC. (2012). ‘Group B streptococcal disease in 1057-1064. Vergnano S, Embleton N, Collinson A et al (2010). infants aged younger than three months: Law MR, Palomaki G, Alfirevic Z et al (2005). ‘The ‘Missed opportunities for preventing group B systematic review and meta-analysis.’ Lancet, prevention of neonatal group B streptococcal streptococcus infection’. Arch Dis Child Fet Neo 379(9815): 547-556. disease: a report by a working group of the Ed, 95(1): F72-F73. Medical Screening Society’. Jour Med Screen, Yancey MK, Schuchat A, Brown LK et al (1996).Guy R (2013). Unpublished data in personal 1(2): 60-68. ‘The accuracy of late antenatal screening communication. NICE (2008). Antenatal care: routine care for the cultures in predicting genital group B healthy pregnant woman, London: NICE. streptococcal colonization at delivery’. ObsHPA (2004). 'Pyogenic and non-pyogenic NICE (2012). Antibiotics for the prevention and Gyn. 88(5): 811-815. streptococcal bacteraemia, England, Wales and Northern Ireland: 2003'. Communicable Disease Report Weekly, 14(16): 13-22.HPA (2012a). 'Processing swabs for Group B Streptococcal carriage'. Bacteriology, B58: 2.2.HPA (2012b). 'Pyogenic and non-pyogenic

THE PRACTISING MIDWIFE • July/August 2013 Civil and criminal liability for midwives • 31Delegation and beyond: whathappens when things go wrong?In the second of two articles, SUMMARY Both midwives and maternity support workers can be confusedMark Solon investigates about who is liable if a task is delegated and something goes wrong. Withareas of civil and criminal proper understanding of roles and a knowledge of which tasks can and can’tliability for midwives be delegated, however, the midwife should be protected, particularly as in practice the NHS body will have vicarious liability in the event of any claim. Clinical negligence training identifies the risks and responsibilities involved – and, leaving aside issues of delegation, training should also instil common sense safeguards against incurring criminal liability, which is independent from any professional or civil sanction. Keywords Delegation, responsibility, liability, maternity support worker Author Mark Solon, solicitor and Managing Director of a legal training firmI f a midwife delegates a task to a There is no simple, There is some clarification in the M maternity support worker and short, catch-all guide RCM’s booklet, The role and something goes wrong, what are and when people are responsibilities of maternity support the implications? working under workers. It lists the tasks which MSWs Denise Linay, head of organising and pressure, it’s easy to see can perform (from sterilising feedingengagement at the Royal College of why there is confusion equipment to removing an epiduralMidwives (RCM), comments: “I believe about delegation catheter) and those which they can’tthat there are fewer incidents arising (from diagnosing pregnancy tonow that maternity support workers feel liable for every action of the MSW episiotomy). It also refers the reader to(MSWs) are more aware of their limits when in fact she isn’t. a further 19 documents on midwives’of responsibility, and midwives have and MSWs’ roles and the general areabecome more confident in the role of *Sometimes, of course, delegation is of delegation. There is no simple, short,the MSW and the tasks that they can simply not an issue – for example, only catch-all guide and when people areundertake, but this is still an area midwives and medical practitioners can working under pressure, it’s easy to seewhich needs work to ensure a uniform care for a woman in labour. Midwifery why there is confusion aboutapproach and to avoid uncertainty. is one of the few roles in health that delegation. cannot be delegated.”Who is responsible? When to delegate“A MSW may be delegated a task on The Nursing and Midwifery Council’sone shift, but the midwife on the next (NMC) code of conduct for registeredshift may decide not to delegate. It may nurses and midwives includes thecome down to the midwife’s confidence following points on delegation (NMCin the process of delegation – she may 2008):

32 • Civil and criminal liability for midwives July/August 2013 • THE PRACTISING MIDWIFE • You must establish that anyone delegating, and that the MSW Accountability you delegate to is able to carry out understands the scope of the task, A midwife must not delegate a task to your instructions. then the MSW is responsible for his or an MSW which requires midwifery her own actions and decisions; education: to do so could jeopardise her • You must confirm that the however, the midwife remains registration. The midwife is also officially outcome of any delegated task is accountable for the overall accountable if she fails to check that the likely to meet required standards. management of the MSW. MSW is qualified and competent to carry out the delegated task. • You must make sure that everyone If there is a change of circumstances, you are responsible for is the MSW should seek advice; However, a crucial fact is pointed out supervised and supported. meanwhile, the midwife must act by Andrew Andrews, Medico-Legal instantly if she believes that anyone is Director of a legal training company Technically, if a midwife has assured being put at risk by a MSW’s actions. and a lawyer with a distinguishedherself of these points before record in healthcare training: ‘As long as the midwife has delegated competentlyCriminal liability – where does the midwife stand? and support is available to the MSW, the midwife shouldn’t attract personalBarrister Lesley Manley comments: accountability if something goes wrong. Where the employer has theMidwives are accountable to their professional regulatory body, the Nursing and authority to delegate an aspect of care,Midwifery Council (NMC). They are accountable to their employer. And finally, it is the employer who is accountablethey are accountable as individuals in law – so, in addition to protecting for the delegation. So in reality, anythemselves from civil liability, midwives must remain alive to the fact that they, claim will be against the NHS bodyin common with all citizens, are potentially liable to prosecution under the concerned, which will carry vicariouscriminal law and to stand trial in the Crown Court. liability.’Tragically, as in the case last year of an experienced midwife who failed to refer a He continues: ‘Education formother to a specialist doctor when the baby’s heart rate dropped during birth, midwives in the area of clinicalthe midwife may be called to account at an inquest. The NHS at the trust negligence covers when and how theconcerned is being sued for negligence by the mother of the child who died. midwife is answerable. It’s in the interests of all the stakeholders -The responsibility of the practising midwife not to engage in unsafe practices society, the woman, the employer andand to raise concerns regarding them should be viewed in the context of the health regulator – for midwives tocriminal as well as civil law. be fully educated in this area. The MSW is not expected to recognise the limitsA number of criminal offences could potentially be alleged against a midwife, of his or her own competence: alldepending upon the circumstances. The midwife has in effect two clients: the responsibility which is delegatedmother and the baby. Criminal charges can range from assault to wilful neglect. outside the range of a MSW’s competence comes back to theA recent example (although not birth-related) occurred last year when a nurse midwife. In that circumstance, theand midwife was found guilty in the Crown Court of manslaughter by gross MSW is not professionally answerable.’negligence following the death of a baby boy following a circumcision operation TPMnegligently performed. Mark Solon is a solicitor and ManagingThere is an increasing drive to improve standards of care by regulating conduct Director of a legal training consultancyand criminalising failure in a healthcare setting. ReferencesThe Report of Robert Francis QC as a result of the inquiry relating to the Mid-Staffordshire NHS Trust makes important recommendations that, if NMC (2008). The code: Standards of conduct,implemented, will impact on the practising midwife in a number of ways. Theyrelate to education, training, staffing levels and the creation of statutory duties performance and ethics for nurses andand criminal offences. Midwives should keep a careful eye on how these mattersprogress. midwives, London: NMC.The NMC’s Code of Conduct sets out clearly the duties and responsibilities of RCM (2011). The role and responsibilities ofthese healthcare professionals. Certainly it is easier to defend allegations ofcriminal conduct if the midwife can demonstrate that the Code was adhered to maternity support workers, London: RCM.and that at all times the midwife was acting in the interest of safeguarding thehealth of the woman and child.

THE PRACTISING MIDWIFE • July/August 2013 Latex allergy • 33Latex allergy inwomen’s health careGreater exposure SUMMARY Latex allergy in midwifery and women’s health care is not ato natural rubber new concept, with numerous case reports documenting adverselatex in the health reactions in pregnant women to natural rubber latex in the birthingcare setting has led room. The practising midwife, nurse and sonographer need to beto increasing cases of latex aware of the signs and symptoms of latex allergy and the implicationsallergy,finds Joanne Fletcher of a severe reaction to latex not only to the woman but also the unborn child. Keywords Latex allergy, women’s health, maternity, gynaecology, pregnancy Author Joanne Fletcher, consultant nurse gynaecology at Sheffield teaching hospitals NHS TrustIntroduction The increased use of health care setting in products that are MThe concept of latex allergy is well protective gloves leads used on a daily basis. The Britishdocumented in health care. Thousands to the sensitisation of Association of Dermatologists describesof everyday healthcare products are many patients and an allergy as occurring when anmade from natural rubber latex (NRL), health care workers to individual has a hypersensitivity to asuch as gloves, urinary catheters and NRL foreign substance and anintravenous cannulas. The introduction immunological reaction occurs thatof universal precautions in the 1980s to midwifery and women’s health care. causes a detrimental effect. In the caseprevent the transmission of HIV and of latex allergy this would suggest thatHepatitis B and C saw the use of What is latex allergy? a reaction occurs when an alreadyprotective gloves in health care increase NRL is protein that is derived from the sensitised individual is exposed todramatically (Monitto et al 2010). Hevea braziliensis tree which undergoes certain protein chemicals in NRL.Today’s health care worker will probably extensive processing using a number of However, it is also thought thatnot even think twice about using protein containing chemicals (Johnson sensitising exposure alone isprotective gloves. However, the 1999) before it finally arrives in the insufficient to cause an allergy, andincreased use of protective gloves leads several other factors appear toto the sensitisation of many patients contribute to this process such as anand health care workers to NRL. This atopic history, food allergies and allergyarticle reviews what latex allergy is, the to certain chemicals contained in NRLincidence of latex allergy, how it products (Monitto et al 2010).presents and the implications for Individuals with repeated exposure topractice, with a particular focus on NRL are also thought to be more

34 • Latex allergy July/August 2013 • THE PRACTISING MIDWIFEsusceptible (Johnson 1999). This is It is still thought that Box 1 Those at greatest risk of latexparticularly important in the health the biggest allergy from exposure to NRLcare setting where there is the potential contributing factor tofor repetitive skin or mucous membrane the increase in latex Patients with spina bifida requiringcontact with NRL. allergy was the repeat catheterisations and surgery universal introductionExposure of latex glove use in Patients with genito-urinaryAlthough there were documented cases health care anomalies requiring repeatof severe latex allergy in the 1980s, the catheterisationsincidence actually peaked in the 1990s NRL than the general population (seewith 25-50 per cent of children with Box 1). Healthcare workersspina bifida or patients withgenitourinary anomalies (up to 60 per However, it is still thought that the Patients with an occupationalcent) developing NRL sensitisation biggest contributing factor to the exposure to NRL such as hair dressers,(Monitto et al 2010). This is due to the increase in latex allergy was the those in food preparationincreased exposure of mucous universal introduction of latex glove usemembranes to NRL from operations and in health care. In 1996 the Department Patients with a history of atopy suchcatheterisations (Dakin and Yentis of Health issued guidance that the NHS as hayfever, asthma, dermatitis or1998). Patients with atopy show an should only purchase gloves that met a food allergy to bananas, kiwi fruitsincidence of 57 per cent (Dakin and defined specification and quality and avocadosYentis 1998). The incidence in health assurance standards in the hope ofcare workers during this time was Women – possibly due to a geneticreported to be 17 per cent compared to predisposition, increasedthe general population incidence of 1 occupational exposure or greaterper cent (Turjanmaa and Makinon- mucosal contact with latex throughKiljunen 2002). It is no surprise then barrier contraceptives and routinethat health care workers, who are gynaecological and obstetricmainly women of reproductive age, examinationshave a higher incidence of allergy to Patients requiring multiple surgical procedures Patients with a history of anaphylaxis of uncertain aetiology, especially if associated with previous surgery, hospitalisation or dental visits (Levy et all 1992; Dakin and Yentis 1998)The use of latex free gloves in preparation for speculum examination reducing the incidence of latex allergy (Medical Devices Agency (MDA) 1996). Nevertheless, it took a directive from the National Patient Safety Agency (NPSA) in 2005 for most health care settings to develop strategies and protocols for protecting their staff and patients (NPSA 2005). Signs, symptoms and presentation Reactions to NRL vary widely and depend upon the amount and type of exposure. The proteins contained in NRL and the processing chemicals can cause irritants and allergies at the point of contact, in addition powder contained in latex gloves can make the NRL proteins airborne where it can be

THE PRACTISING MIDWIFE • July/August 2013 Latex allergy • 35Table 1 Types of reaction to NRL Symptoms Midwives and nursesClassification Reaction should make latex allergy assessment aReaction Skin irritation. This is not an Flaky, itchy skin, localised swelling. routine part of theirType 1 allergic condition, and the practice effects are reversible. Early symptoms – urticaria, pruritis, eczema, rhinitis, conjunctivitis. inhaled when gloves are put on or Irritation and immediate removed (Johnson 1999). This can be a sensitivity, localised or Asthma can occur if mucous particular issue in the operating theatre systemic reaction. membranes are affected during or birthing room. Once a reaction has inhalation. occurred, future allergic reactions to Occurs immediately or up to products containing lower levels of 30 minutes after direct skin Anaphylactic shock (generalised latex can occur. Table 1 shows the types contact/exposure from air urticaria, respiratory distress, of reaction to NRL and symptoms. particles. bronchial wheezing due to laryngeal oedema and Treatment and management Can be life threatening as bronchospasm, flushing, Management of latex allergy depends contact with the respiratory hypotension, vomiting, abdominal upon the type of reaction: tract can lead to breathing pains, diarrhoea, tachycardia, angio- Type 1 cases - anaphylactic shock difficulties. oedema, and possibly requires immediate resuscitation with cardio-respiratory arrest and intravenous hydrocortisone, adrenaline death). or ephedrine. Type 4 cases - treatment of contactType 4 Delayed hypersensitivity to Contact dermatitis – including dermatitis is managed with one or more of the chemicals pruritis, oedema, erythema, antihistamines (oral or topical), whilst in NRL. vesicles, drying papules and asthma-like reactions are managed crusting and thickening of the skin. with bronchodilators. More common and less serious than Type 1. Future prevention: those who are thought to be latex allergic should be Response generally occurs six to 96 hours after contact and is usually confined to the site of contact. Type 4 reactions can, however, M develop into Type 1 reactions.

36 • Latex allergy July/August 2013 • THE PRACTISING MIDWIFEoffered testing and advised of the extremely important that the health revealed no recent severe latex allergicimplications of latex allergy. Most Type care worker checks and documents a reactions in pregnant women, it is well1 sufferers will be advised on the use of woman’s latex status prior to documented that severe latex allergyan adrenaline device such as an Epipen. commencing a vaginal examination or can be potentially life threatening to a referring for an ultrasound scan where woman and her unborn child. MidwivesImplications for women’s latex transvaginal probe covers are used and nurses should make latex allergyhealthcare to protect the individual woman from assessment a routine part of theirThere have been a few case reports of cross infection of bodily fluids. practice in order to prevent adverseanaphylactic shock specifically related reactions in the gynaecology setting,to midwifery care (Eckhout and Ayad Transvaginal sonography is antenatal period and delivery room. TPM2001, for example). The women had not recommended as the first type ofreported any previous allergy to latex; assessment for women with pain and Joanne Fletcher is consultant nursehowever in all cases an anaphylactic bleeding in early pregnancy ( National gynaecology at Sheffield teachingreaction occurred during routine Institute of Health and Care Excellence hospitals NHS Trustobstetric vaginal examination when (NICE) 2012). Therefore, latex free probelatex gloves were used. All of the covers and gloves should be routinely Further resourceswomen required intravenous available. Sahu and Raine-Fenning British Association of Dermatologistsresuscitation with hydrocortisone, (2010) also recommend that the latex www.bad.org.ukephedrine or adrenaline, more intensive allergic patient should ideally befetal monitoring due to fetal distress or scanned first on the list, as this limits Referencesbradycardia and transfer to the potential exposure from prior patientsoperating room in case an emergency and procedures. However, in a busy Bowyer RVS (1999). ‘Latex allergy: how tocaesarian section was required. Whilst clinic, placing latex allergic women at identify it and the people at risk’. Jour of Clinall of the women recovered and the the beginning of a list may not be Nurs, 8(2): 144-149.babies were born safely, there have feasible, especially if this is the firstbeen incidents of poor fetal outcome appointment and the woman’s latex Dakin MJ and Yentis SM (1998). ‘Latex allergy: aeven when the mother has survived. status is unknown to the referrer. strategy for management’. Anaesthesia, 53: 774-781. These incidents are not surprising Recommendations for practicegiven that a woman may be exposed to Given the higher incidence of latex Eckhout GV Jr and Ayad S (2001). ‘AnaphylaxisNRL at work, during gynaecological allergy in women, it should be routine due to airborne exposure to latex in aexaminations, for prevention of practice to ask all women if they are primigravida’. Anesth, 95(4): 1034-1035.conception (condom use) and possibly latex allergic prior to gynaecologicalrepeated vaginal scans or vaginal examinations, transvaginal scans, in the Johnson G (1999). ‘Avoiding latex allergy’. Nursexaminations during pregnancy and family planning setting and at Stand, 13(2): 49-54.birth, to the extent that she become antenatal appointments. Their responsesensitised to NRL. It is therefore should be clearly documented in Levy DA, Charpin D, Pecquet C et al (1992). ‘Allergy to latex’. Allergy, 47: 579-587. hospital records and in midwifery hand held records. Women with MDA (1996). Latex sensitisation in the healthcare spina bifida or genito-urinary setting, London: MDA. conditions requiring repeated Monitto CL, Hamilton RG, Levey E et al (2010). catheterisations, or ‘Genetic predisposition to natural rubber those with allergies latex allergy differs between health care to certain fruits workers and high risk patients’. Anesth Analg, should be treated 110(5): 1310-1317. with caution if their latex status is NICE (2012). Ectopic pregnancy and miscarriage, unknown. London: NICE. Conclusion NPSA (2005). ‘Protecting people with allergy Whilst a review of associated with latex’. Patient safety the literature has information 08, London: NPSA. Sahu B and Raine-Fenning N (2010). ‘Ultrasound and the risk of nosocomial cross infection’. Ultraso Obs Gyn, 36: 131-133. Turjanmaa K and Makinon-Kiljunen S (2002). ‘Latex allergy: prevalence, risk factors and cross-reactivity’. Methods, 27(1): 10-14.

THE PRACTISING MIDWIFE • July/August 2013 Breast milk • 37The wonder of breast milkA report from the SUMMARY This is a summary of key topics that were presented at the8th International 8th International Breastfeeding and Lactation symposium inBreastfeeding and Copenhagen, Denmark in April 2013. The article reports on work fromLactation three well known and respected spokespeople within the followingSymposium by areas: latest recommendations for research based practice; the uniqueSioned Hilton,highlighting components of human milk; and the value of human milk in neonatalthree areas of development in intensive care units.understanding Keywords Breast milik, research, developments, oxytocin, ankyloglossia, NICU Author Sioned Hilton, lactation consultant and education manager at a breastfeeding advisory companyIntroduction Between 25-44 per cent function of the infant’s tongue. The MOngoing research into the science of of those affected incidence of tongue tie is relativelybreastfeeding ensures that our struggle to maintain a common with a range of 0.02-10.7 perunderstanding of breastfeeding is good latch, have cent reported in the literature. Betweenconstantly improving. The belief that inefficient milk transfer 25-44 per cent of those affectedone of the most natural of products – and poor growth struggle to maintain a good latch, havehuman milk – is the key to giving the inefficient milk transfer and poorbest start in life was certainly the challenges associated with growth. Maternal challenges are alsooverriding message at this year’s ankyloglossia (tongue tie) are present documented in studies with Professorsymposium, which brought together in the infant (Geddes et al 2008; Garbin Geddes citing that more than 89 per430 delegates from 46 countries to et al in press). cent of mothers of infants with alisten to and interact with peers. posterior tongue tie present with nipple Geddes identified pain, insufficient pain, 84 per cent with latch difficulties The conference has become a milk and difficulty with getting a good and 80 per cent with longer feeds.highlight in the breastfeeding calendar latch as possible reasons why mothersand this year again it delivered truly stop breastfeeding. However, she Professor Geddes used ultrasoundinsightful presentations. Translating expanded on this discussion by imagery from her research to furtherthe research into best practice still introducing ankyloglossia as another explain. She first demonstrated theremains a challenge, but the contributing (and often critical) factor mechanics of an infant sucking at thesymposium certainly demonstrates that is associated with feeding breast with ‘normal’ anatomy. Shethat progress continues to be made. difficulties. illustrated through visuals how the nipple expands evenly; how theAnkyloglossia and breastfeeding Ankyloglossia is characterised by the downwards and upwards movement ofAssociate Professor Donna Geddes presence of a sub-lingual frenulum that the tongue creates an intraoral vacuumworks with the Hartmann human changes the appearance and/or with effective removal of milk from thelactation research group; she is milk ducts (see figures 1 and 2); therenowned for her work around the position of the nipple in relation to theanatomy and physiology of lactation. hard and soft palate junction (HSPJ);Her latest research looks more closely and showed that there is no markedat the difficulties faced when indentation of the nipple. When

38 • Breast milk July/August 2013 • THE PRACTISING MIDWIFEcompared to the ultrasound images The effect of oxytocin the breast milk ejection reflex andtaken from an infant with a tongue tie on the breastfed infant uterine contractions, but recent researchthere are marked differences. There is a is still relatively has shown that oxytocin is not justvisible restriction of the tongue unknown isolated to breastfeeding and labour.movement, causing subsequent painand trauma to the nipple. The images is the ideal. However, she said that She explained that oxytocin is ashowed that with an anterior tongue completing the procedure within the peptide produced in the supraoptictie, the nipple base was compressed, first three weeks postpartum should (SON) and paraventricular nuclei (PVN)forcing a pointy wedge shape at the tip still support maternal milk production of the hypothalamus and that it isof the nipple, therefore contributing to and successful breastfeeding outcomes. transported to the posterior pituitarymaternal nipple pain. Delaying division beyond this point may gland to be released into the blood increase the risk of low milk supply, stream. She also linked oxytocin withTreatment decreased maternal breastfeeding neurons in and extending from the PVNGeddes moved on to talk about the confidence, and strengthen to many important regulatory areascontroversy surrounding the treatment entrainment of atypical tongue affecting social interaction and stress,for tongue tie. Due to there being no movements, possibly decreasing the as well as the regulation of the activityuniversal definition, a diagnosis is potential benefits of frenotomy. of the autonomic nervous system.difficult to determine. The developmentof a tool to help recognise tongue tie Donna Geddes supports the early Professor Uvnäs-Moberg referred tohas been designed (Hong et al 2012) confirmation of tongue tie, whether it is calm and connection when discussingwhich defines that a posterior tongue posterior or anterior, and encourages the effect of oxytocin on the mother,tie is thick fibrous cord, whilst a lingual early intervention of frenotomy. She and talked about emotions such astongue tie is not very prominent. She was, however, very clear that further trust, empathy and love – all of whichspoke openly about the benefits of a research in this field is warranted. naturally affect maternal behaviour andfrenotomy, explaining that it is a bonding. She went on to say, however,relatively simple, low risk procedure. Oxytocin and human milk that, unlike the mother, the effect ofShe referenced a recent double-blind Professor Kerstin Uvnäs-Moberg from oxytocin on the breastfed infant is stillrandomised controlled study to University of Agricultural Science in relatively unknown. She explained thatdocument the immediate effect of Sweden has committed her research to although the breastfed infant showstongue tie division. It confirmed that the hormone oxytocin, which was the similar behavioural and physiologicalfrenotomy improved feeding in infants first hormone to be isolated, in the effects to the mother, there has rarelythat had experienced difficulty and that 1950s. It is known to be associated with been a measurable release of oxytocinthis was sustained (Berry et al 2012). in their blood circulation duringShe added that the optimal age for Figure 2 Upwards suckling and skin-to-skin contact. Thisdivision is still not clear but suggested raises the question about wherethat early intervention in the first week oxytocin circulates in the infant and supports the growing understandingFigure 1 Downwards that oxytocin is released within the PVN in the infant brain without releasing oxytocin into the circulating system. M This new understanding exposes that oxytocin not only has an important regulatory role during birth and breastfeeding in the mother, but it also supports and develops a regulatory role within the infant, supporting the development of bonding, Interactive behaviours, stress levels and may optimise behaviour and the physiology of the newborn. This ultimately enhances the discussion on breast milk and adds to the increasing list of the benefits of breastfeeding.



40 • Breast milk July/August 2013 • THE PRACTISING MIDWIFEPre term and sick infants These parents were milk technicians track maternal milkImprovements in science and medicine production and fortify milk underhave resulted in premature babies able to give something sterile conditions. The milk technicianshaving a much improved chance of also perform human milk nutrientsurvival. Professor Diane Spatz from unique to protect and analysis and have the ability to makeChildren’s Hospital of Philadelphia skimmed milk for infants with(CHOP) was faultless in her passion and assist with their baby’s chylothorax.innovation in this area. fight for survival At the heart of her work was a clear Professor Spatz opened by saying passion for education and support forthat in 2012 the American Academy of explained that at CHOP 60 per cent of the families to ensure they understandPaediatrics (AAP) declared that the their infants are born by caesarean the medicinal values of breast milk,decision to breastfeed should not be section (CS) and told us that those which will therefore encourage them toviewed as a lifestyle choice but rather mothers initiate double pumping using really consider this option.as a public health issue. She continued this technology immediately. Thein this vein when she claimed that the results have been remarkable with Inspiring symposiumuse of mothers’ own milk is a medical mothers who had a CS yielding higher As ever the symposium deliveredintervention for the most vulnerable volumes of milk than those who had a inspiring and thought provokinginfants and must form part of their spontaneous vaginal birth. In addition presentations and provided materialongoing care. the target daily milk yield for and knowledge to take back to the breastfeeding mothers is 750 mls in 24 workplace to share with colleagues, and Professor Spatz believes that when hrs, coming to volume within the first best practice to take from in everydayan infant is admitted to the special care seven days postpartum, often with work in order to fully supportnursery their family must be presented yields greater than 1000mls. breastfeeding mothers. This new andwith the facts about why providing updated research provides delegateshuman milk for their child is essential. Vulnerable babies with an insight into a newly developingFamilies come from all over the world to Professor Spatz is committed to understanding of the breastfeedingreceive care at CHOP and, thanks to demonstrating that breastfeeding infant and ensures we are able to feelProfessor Spatz, the care provided is success can be achieved even with the fully informed in our line of work. TPMpioneering. Having led the creation of a most vulnerable infants, and talked ofprenatal lactation consultation her commitment to helping mothers Sioned Hilton is lactation consultant andprogramme to educate families achieve success in transitioning to education manager at a breastfeedingregarding the science of human milk for direct breastfeeding if that is their advisory companycritically ill infants, this is now a personal goal. She also talked aboutstandard practice of care that has colostrum care for oral hygiene and Referencesresulted in 98-99 per cent of infants explained that at CHOP this is initiatedbeing treated having human milk - this immediately as soon as drops are Berry J, Griffiths M and Westcott C (2012). ‘Ais over 20 per cent higher than available and even in the most critical double blind, randomised, controlled trial ofbreastfeeding initiation rates in the of infants when oral and gastric feeds tongue-tie division and its immediate effectUSA. This programme has been a are not appropriate. She showed a on breastfeeding’. Breastfeeding medicine, 7:success thanks to the commitment of video clip of oral care with a critical 189-193.experienced staff including the nurses, infant; the powerful messages thatmidwives, obstetricians and surgeons. came from these parents was that they Garbin CP, Sakalidis VS, Chadwick LM et al (in were able to give something unique to press). ‘Evidence of improved milk intake Professor Spatz explained that to protect and assist with their baby’s after frenotomy – a case study’. Pediatrics.support the ultimate goal to provide fight for survival.mothers’ own milk, she gets them Geddes DT, Langton DB, Gollow I et al (2008).pumping early and, often due to the She closed by talking about the ‘Frenulotomy for breastfeeding infants withcomplex nature of the infants born, development of a human milk ankyloglossia: effect on milk removal andthey continue pumping long term. She management centre (HMMC) in 2012, a sucking mechanism as imaged bytalked about a breast pump which state of the art milk lab where trained ultrasound’. Pediatrics, 122: e188-194.mimics the sucking pattern of anewborn baby and therefore triggers Hong P, Lago D, Seargeant J et al (2010).milk production to ensure that a good ‘Defining ankyloglossia: a case series ofmilk supply is established. She anterior and posterior tongue ties’. International Journal of Pediatric Otorhinolaryngology, 74(9): 1003–1006.

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Around the conferences Phoebe Pallotti presents highlights from The MaMa conference Friday and Saturday 26th and 27th April 2013. Assembly Rooms EdinburghIntroduction The CNST scheme, since research on physiological labour, andThe main themes of the Mama its inception, has this lack of knowledge and experienceconference, approached from a variety neither reduced claims is made worse by our lack ofof angles, were the importance of nor improved outcomes transparency as we struggle to protectsalutogenic approaches to in maternity, although normal birth in hospital units.conceptualising birth (such as Dr Mary it has led to an increaseRoss Davies' assertion that we talk in tocophobia in both Sheena Byromabout 'needs' rather than 'risks' for midwives and women Sheena Byrom described defensivewomen) and the importance of the practice as indefensible. Referring to herright environment in giving women “Trust and patience are the key to a current research with Soo Downe, inpower and space to enable birth helper – it is not what a helper which they found that the Clinicalphysiological labour, as discussed by does, but what she doesn't do.” Sheila Negligence Scheme for Trusts (CNST)Sheila Kitzinger and Denis Walsh. Kitzinger received a well deserved led to a record-centred, rather than a standing ovation. woman-centred pattern of care, SheenaSheila Kitzinger MBE stated that the CNST scheme, since itsSheila Kitzinger's presentation on her Professors Denis Walsh and Soo inception, has neither reduced claimsnew book Birth and sex: the power and Downe nor improved outcomes in maternity,the passion (2012) was inspiring. The Both Denis Walsh (introduced by Gillian although it has led to an increase inbook examines different cultural Smith as the George Clooney of tocophobia in both midwives andattitudes to childbearing and female midwifery) and Soo Downe also women.sexuality and how our own attitudes discussed the importance of the placehave changed and negatively affected of birth and the recent Birthplace study Byrom's advice on courageouswomen’s experience of birth. (Brocklehurst and Birthplace in England practice was: collaborative group (BECG) 2011), in Kitzinger drew parallels between sex terms both of the protection of •birth is not risk free, but neither isand unmedicated birth, in the physiological labour and the avoidance it a risky businesspsychology, the biophysiology and the of unnecessary interventions. Walshvocalisation and facial expressions of also discussed the 'culture of •uphold your own philosophy – beboth. When we lose the peace and the surveillance' in hospitals as a barrier to brave – don't over treatnatural rhythms of birth through self- open improvement of care and a causeconsciousness, caused by well of midwives 'doing good by stealth' •guidelines are just that – guidanceintentioned 'help', it becomes hard (Kirkham 1999). There is a paucity of - they are not lawwork; pushing stops being instinctive keep good, not excessive, recordsand becomes a conscious effort. •highlight unsafe workload issues Sheila Kitzinger’s conclusions were •access supportive supervisionthat we need to rid ourselves, as a •listen to women and their familiessociety and as a profession, of the ••acknowledge that litigationshame of the sexuality of birth, and weneed to allow women to control their happens (Robertson 2011)own labours. Her final comment was: don't manufacture fear ••if you are going to push boundaries, gain support and plan well •safety is always paramount, but proceed with courage, not fear.

Professor Kerstin Uvnas-Moberg success”. He ended with a critical conference, and I will be going back forand Dr David Hutchon remark on the current advice for the more next year! TPMThere were some useful updates on management of the third stage, whichevidence, particularly by Kerstin earned him rapturous applause. Phoebe Pallotti is a midwife at SheffieldUvnas-Moberg on the wonders of Teaching Hospital and trustee of aoxytocin and by David Hutchon Extras midwifery charity(obstetrician) on delayed cord In addition to all this courageousclamping. The evidence on the harm of research, there were belly dancing Referencesimmediate cord clamping is sessions from Lisa Logan, a 'pelvic flooroverwhelming, both in terms of party' from physiotherapist and stand- Brocklehurst P and BECG (2011). ‘Perinatal andhypovolemia for the infant and the up comedian Elaine Miller and maternal outcomes by planned place of birthdifficulty of resuscitation with a exhibitions from many midwifery for healthy women with low riskclamped cord. Hutchon discussed how, organisations, including AIMS. Over pregnancies: the Birthplace in Englandin babies who have suffered birth £300 was raised for the conference’s national prospective cohort study’. Brit Medhypoxia, the delay in clamping is of sponsored charity towards work in Jour, 343: d7400.even more benefit. His conclusion was supporting midwifery education andthat “The establishment of pulmonary research, for which the charity’s chair Kirkham M (1999). ‘The culture of midwifery ingas exchange before the failure of gave a speech of thanks. the National Health Service in England’. Jourplacental respiration is the key to of Adv Nurs. 30(3): 732-739. It was an inspiring and courageous Kitzinger S (2012). Birth and sex: the power and the passion, London: Pinter and Martin.Marsden M-300 baby scale £225SPECIAL OFFER +VATHigh Accuracy Premium Baby Scale (or £245 with rucksack)• 2g accuracy Quote PM2013 to• Lightweight and portable get your special• Long battery life offer price!Tel: 0845 130 7330 Designed and engineered in UKE-mail:Twitter:www.marsden-weighing.co.uk

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46 July/August 2013 • THE PRACTISING MIDWIFELAST WORDFreedom for birth and theplight of Agnes GerebValerie GommonO n 20th September 2012, I resonates with the Wendy Savage case (unannounced) four times a day to hosted two showings of in the UK (Savage 2007). Later Agnes check that she is home. In another the film Freedom for birth, worked in a group midwifery practice country this situation would be dealt which describes midwife where women paid a one-off fee for with by a professional hearing.Agnes Gereb’s determination to help their care. No-one was turned away andwomen choose how to give birth. I the fee was for life so, whether a woman Supporting Agnesfound the film incredibly moving and I had one child or 10, she had paid for all I felt privileged and humbled to havefelt overwhelmed by the terrible things her care. After some difficult cases, met such a strong woman. She told methat are happening world wide, with Agnes was arrested and imprisoned. that she still has energy and still wantswomen being coerced into making to be a midwife – I am so impressed withdecisions against their wishes. Campaign her strength and so angry about what In the past home birth was alegal (not the Hungarian authorities have done toAgnes Gereb covered by the law) in Hungary, but the Agnes. I wish there was something thatI was outraged about the case of Agnes authorities were unsupportive of it. we could do to support her but, evenGereb, the Hungarian midwife who has Agnes has been backed by a massive though many high profile British andfaced imprisonment followed by ongoing world-wide campaign by the many international midwives and childbirthhouse arrest for supporting women in thousands of women she has cared for, campaigners have visited Agnes, theretheir choice to give birth at home. including a BBC journalist and his appears nothing that we can do to family for whom Agnes acted as change the situation; I would welcome At that time, I had been planning to midwife. Because of the campaign, any suggestions that you may have. TPMgo to Hungary and now I felt a strong home birth is now legal; however onlydesire to visit Agnes to show my an obstetrician can give permission, Valerie Gommon is an independentsupport; so I made contact and we which rarely happens. midwife and lecturer at Milton Keynesarranged to meet. College Imprisoned Once in Budapest, Agnes invited me It is frightening that a midwife can be Referencesin, we hugged and I knew it would be treated as a criminal for doing her job.easy to talk with this fellow midwife. Agnes spent 77 days in prison and has Savage W (2007). Birth and power: a savage now been under house arrest for two enquiry revisited, Middlesex: Middlesex When she began her career, Agnes and a half years; she is unable to leave University Press.wanted to be a midwife but, because her home, to work or earn, to shop orthere was no midwifery in Hungary, she visit family. Police come to her home I Watch Freedom for birth, atchose to train as an obstetrician. Agnes www.oneworldbirth.net/the-film/was vilified by colleagues, because ofher belief in physiological birth, which

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