TPM MAY 2013

THE BEST JOB IN THE WORLDwww.thepractisingmidwife.com Volume 16 no 5 • May 2013ComplementarytherapiesThe benefits of mother and baby yogaClinical hypnosis – an individualised therapyCompression stockings to reduce thromboembolism

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Contents4 EDITORIAL 28 An English midwife in Arkansas Part 3 - differences in practice In the final part of the5 COMMENT Square pegs into round holes? series, Chantal Woog considers her experience Kenneth Finlayson of maternity care in America from the midwife’s point of view and compares it with that of the UK6 NEWS10 Clinical hypnosis for labour and birth: a 31 Keeping them safe In the first of two articles, Markconsideration Charlotte Kenyon looks at the Solon describes the key position which midwivesforms which clinical hypnosis can take and hold in terms of ensuring mothers’ and babies’concludes that this is a very indvidualised wellbeingtherapy 33 RESEARCH UNWRAPPED The lived experiences of14 Mother and baby yoga is good for you Cheryl midwives with spirituality in childbirth: manaMacDonald describes the benefits for both mothers from heaven Susan Crowther unwraps a recentand babies of postnatal yoga research paper19 We’ve got it covered! Graduated compression 37 MIDWIFERY BASICS Breastfeeding prematurestockings Midwife Cerian Llewelyn explains how babies In this eighth and final article of the series,graduated compression stockings can help Joyce Marshall considers some of the key issueschildbearing women to avoid serious complications related to breastfeeding premature babiesassociated with hypercoagulability 42 PROFESSIONAL DEVELOPMENT/26 Back to back: postnatal osteopathic care Chris OVERSEAS OPPORTUNITIESJohnson explains that earlier trauma to the body, 44 DIARYas well as a difficult or lengthy labour and birth,can require therapeutic treatment to resolve 46 LAST WORD A letter to future me Dawn Stonepostnatal back problems imagines herself in years to come and hopes she will make a great midwifeEditorial advisory board © 2013 Medical Education Solutions Ltd. 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Complementing care options Helen Baston and Julie Wray, Joint EditorsThe notion of applying a complementary therapy (CT) in a maternity context implies that it isadding to and enhancing the range of care options already available. It would be hoped that We are grateful tosuch a therapy is therefore used alongside personal continuous support to a woman at Johanna and Dylan forwhichever point she is during her pregnancy, labour or postnatal period. the cover photo Of concern is the issue that not all women have the option of CT either to be used alongsideconventional care or as an adjunct or alternative to mainstream choices. Then there is the converse situation whereby complementary therapies are the only optionfor women aiming to avoid pharmaceutical intervention. We know that there is no such thing as real choice unless balanced information is availableabout it and it is readily accessible. Having choice enables women to have an active role inmanaging their health. Providing choice, however, requires health professionals to have anunderstanding of what is available, whom it is suitable for and how it can be accessed.Midwives need to have confidence in the choices they are offering. Evidence from randomisedcontrolled trials will not be possible for many CT interventions. It is therefore important thatoutcomes from developments that employ CT must be scrupulously documented and widelydisseminated, to facilitate further practice developments. We are a long way from providing maternity services that are equitable across all providers.Whilst clinical hypnosis for support during labour (see Kenyon), for example, or othercomplementary therapies may be available in some maternity units, they are not yet widelyavailable for all women. Midwives and other practitioners need to share their knowledge toextend the menu of choices they can offer. This month’s issue of The Practising Midwifecertainly provides some examples of ways that care choices can be extended.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 Facebook is a registered 0LP. Applications for the copyright holder’s written permission to trademark of Facebook, Inc. 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.Subscribe today – 01752 312140

THE PRACTISING MIDWIFE • May 2013 5 Comment Kenneth Finlayson Senior research assistantSquare pegs into round holes?A s a midwifery researcher There are fundamental incorporate some of the distinctive and homeopath, I’m often philosophical properties of CAM highlighted above. asked about the evidence for complementary and Progressalternative medicine (CAM) in differences between the Progress is being made. ’Pragmatic’maternity settings. More specifically holistic properties of designs incorporate the real worldI’m asked, ‘Where are the double practice of a given CAM techniqueblinded randomised controlled trials many CAMs and the rather than isolating specific features(RCTs) showing a significant difference reductionist principles to make it better fit into an RCTbetween a CAM and a placebo?’ At mould. Thus, trials can explore athis point we move on to shaky of biomedical science particular condition by comparingground, not because there are usual care with a CAM interventionrelatively few RCTs that support CAM and measuring differences inuse in maternity care, but because the outcome; for example, a self-double blinded RCT is rarely the most hypnosis training package vs usualsuitable method to test the effectiveness of CAM. antenatal care for pain relief during labour. However, CAM researchers need to be wary of compromiseLimitations of RCTs for the study of CAMs in their endeavours to establish evidence. Outcome measuresThere are fundamental philosophical differences between the for CAMs must include wellbeing scales to capture theirholistic properties of many CAMs and the reductionist holistic nature and not defer to the narrow, clinically focusedprinciples of biomedical science. Even the House of Lords standards indicative of high quality RCT design. The Visualselect committee acknowledges that there may be specific analogue scale (VAS), for example - a commonly used painfeatures of CAM which make it less amenable to testing by assessment score - may be ideal in an epidural RCT but wouldconventional methods, especially RCTs (House of Lords 2000). not be suitable for a similar RCT using self-hypnosis. Asking aThe blinding of participants is an obvious stumbling block as, labouring woman to arbitrarily assess her level of pain on aoften, the practitioner is intimately involved in the therapy. score of 1-100 is one thing, but asking her do it when she’sStandardisation is also an issue – drugs can be given in supposed to be in a state of hypnosis is…disruptive!specific, measurable quantities as part of a trial, but while it is With this in mind, CAM researchers must continue topossible to deliver, say, aromatherapy in the same quantifiable develop designs and methods more appropriate to the holisticway, there is no therapeutic reason to do so. The recognition paradigm and, in doing so, shift the emphasis away from theof patients as individuals, a key tenet of many CAMs, does not conventional RCT as the sole arbiter of evidence in healthcarefit well with the generalisable, reductionist features of RCTs. A research. Evidence of effectiveness will only be valid oncehomeopath, for example, may treat 10 women with morning CAM is evaluated according to its own principles. TPMsickness and prescribe a different remedy each time. Kenneth Finlayson is Senior research assistant in Midwifery studies at the University of Central LancashireEvidence lackingResearchers into both CAM and conventional biomedicine Referencesagree that CAM studies should achieve certain standards. House of Lords Select Committee (2000). Select committee on science andHowever, this should not come at the cost of integrity. technology sixth report, London: Parliamentary copyright.Reviews will continue to conclude that the evidence for CAM Jones L, Othman M, Dowswell T et al (2012). ‘Pain management forin various maternity contexts is ‘insufficient’ or ‘lacking in women in labour: an overview of systematic reviews’. Cochrane databasequality’ (Jones et al 2012) until assessments of quality of systematic reviews, 3: DOI: 10.1002/14651858.CD009234.pub2.I The views expressed in Comment do not necessarily represent the views of the editors

6 • May 2013 News analysisGovernment’s response to Francis Inquiry failsto address shortage of midwives says RCMTHE QUALITY OF PATIENT CARE must be Stafford Hospital they were “dismayed” that thethe focus of maternity and other NHS Government had not adopted theservices in an overhaul of health and revalidation. The Francis report said that Francis Report’s recommendation thatcare in response to the Francis Inquiry, a system of revalidation for nurses NICE set minimum safe staffing levelssays the Department of Health (DH). would be “highly desirable”. for the NHS and this should underpin services the NHS provides, including A culture of compassion will be a key The DH says revalidation for nurses maternity services.marker of success, spelling an end to and midwives must be introducedthe distorting impact of targets and box when the NMC turns around its current “For more than a decade, the NHS inticking, says the DH in its response (DH poor performance. In the meantime England has had a shortage of2013) to the report into failures of care appraisals should be strengthened, midwives and this was a hugeat the Mid Staffordshire NHS made more consistent and explicitly opportunity missed and wasted toFoundation Trust (2013). include values and behaviours. address safe staffing levels,” she said. The report, Patients first and Other recommendations include The RCM also believed theforemost, says maternity units will be banning compromise agreements Government had missed another crucialencouraged to strive to be the best, the which could stop midwives and other opportunity by not introducing thebasic values of dignity and respect will staff speaking out on matters of public registration and regulation of maternitybe central to midwives’ training and, if interest and making the Care Quality support workers. “Overall, thethings go wrong, patients and their Commission adopt a new peer review Government’s report raises morefamilies will be told about it. model for assessments that will take questions than it answers,” said into account whether patients are being Professor Warwick. There will be a new regulatory model listened to and are treated with dignityunder an independent Chief Inspector and respect. Dr Tony Falconer, president of theof Hospitals with Ofsted-style ratings Royal College of Obstetricians andfor hospitals and individual The Government will make further Gynaecologists (RCOG) said the collegedepartments. This will enable changes to the NHS Constitution would play a role in establishingprospective mothers to rate the quality incorporating further recommendations scorecards to help the new chiefof maternity services in individual units. from the Francis report. inspectors. “This is a very positive step forward which has our full support. The A new statutory duty of candour will Health Secretary Jeremy Hunt said RCOG is currently developing clinicalbe introduced for hospitals and a code the Government’s response to the indicators and outcomes data to assistof conduct and training standards will inquiry was the beginning of a trusts to detect problems.”be introduced for maternity support fundamental change to the system. “Iworkers. can pledge that every patient will be An NMC spokeswoman said: treated in a hospital judged on the “Revalidation of nurses is a major focus Midwives and other healthcare quality of its care and the experience of for us at present and we have a targetprofessionals will in future be held its patients. They will be cared for in a of introducing it in 2015 although wemore accountable and the introduction place with a culture of zero harm, by do not yet know what form it will take.of legal sanctions at a corporate level is highly trained staff with the right We are currently looking at a systembeing considered for providers who values and skills.” that is risk based, economical andknowingly generate misleading proportionate.”information or withhold information Cathy Warwick, chief executive of thefrom patients or relatives. The Nursing Royal College of Midwives (RCM), said Referencesand Midwifery Council (NMC) and otherprofessional regulators have been asked DH (2013). Patients first and foremost: the initialto tighten and speed up theirprocedures for breaches of professional government response to the report of the Midstandards. Staffordshire NHS Foundation Trust public Revalidation will be introduced fornurses and midwives with a scheme inquiry http://tinyurl.com/c5baev4which will build on medical Mid Staffordshire NHS Foundation Trust (2013). Report of public inquiry - chaired by Robert Francis QC. http://tinyurl.com/anb9zme

News analysis May 2013 • 7VSO in urgent call to recruitmissing millennium midwivesWITH LESS THAN A YEAR TO GO until shortages for the long term. students, Alice worked with VSO GP Drthe United Nation’s Millennium “I urge experienced midwives to Alex Burns to support permanent staffDevelopment Goals (MDGs) expire in working in a nearby hospital improve2015, VSO is calling for UK midwives consider volunteering. You could help its obstetric and paediatric care.to volunteer in sub-Saharan Africa, to hospital staff identify solutions tohelp the region meet its target to problems, train new students or work Alice said: “The amount of death Ireduce the number of women and in health ministries in countries with saw was quite shocking.babies who die in childbirth. the greatest need, such as Sierra Approximately 14 women die every Leone, Malawi and Ethiopia.” day in child birth in Sierra Leone. I saw Globally, each year approximately women with severe conditions such as350,000 expectant mothers die in VSO’s partner Francess Fornah, fistula, ruptured uterus andchildbirth or during pregnancy and of Head of the Makeni School of postpartum haemorrhage. This is notthese women, 99 per cent die in Midwifery in Sierra Leone, said: “My something health professionals havedeveloping countries. Many of these midwifery school in Makeni trains to deal with often in the UK.deaths could be prevented by state community health nurses toimproving the education and skills of become midwives, responding to the “There are not enough trainedhealth workers. appalling lack of skilled birth surgeons to perform emergency attendants, especially in the rural caesareans or midwives who know Over the past few months leaders areas of Sierra Leone. Previously only how to deliver complicated births andfrom around the world, including the state registered nurses could train to this is something I have been able toUK Prime Minister David Cameron, be midwives, many of whom then address as a volunteer.have been meeting to discuss the went on to complete further trainingframework which will follow the eight and go into other fields, leaving us still “One of the most useful and simpleMDGs in 2015. Despite progress short of practising midwives. things I shared was how to use thetowards overall poverty reduction, World Health Organization (WHO)many countries are far from meeting “Our aim is to train new midwives partograph. This documentationgoals four and five: to reduce who remain in their communities, system has saved many women’s lives.maternal and child mortality rates. particularly in rural areas, helping women to give birth safely. VSO has “The midwives I trained are now VSO works in countries with some helped us to provide high quality qualified and either working inof the world’s highest rates of training and give midwives the Makeni or in the provinces, givingmaternal mortality, to address severe competencies and confidence to do women in rural communities access toworkforce shortages and help save just that, but we need more support vital health care services. I amlives. The organisation needs more from other volunteers to share their confident that I passed on goodmidwives and other health skills in schools, universities and practices, gained from my many yearsprofessionals to share their life-saving hospitals across Sierra Leone.” in the NHS.”skills and educate health workers indeveloping countries. Alice Waterman joined the Makeni Alice has continued to deliver short School of Midwifery as a midwife intensive courses in Sierra Leone with VSO UK director, Angela Salt, said: tutor in 2010 where she trained more the Liverpool School of Tropical“VSO’s health volunteers overcome than 130 students. With only two Medicine. She met eight of her formermany challenges to make a real midwifery schools in the country, students in February this year and onedifference in improving maternal and many babies are born by poorly of them has become so highly skilledchild healthcare. They introduce trained health workers, so teaching that Alice selected her as an in-simple techniques that save lives and students the latest neonatal and country trainer.pass on their skills so more trained emergency skills is vital.health professionals can fill these I Find out more at In addition to teaching the new www.vso.org.uk/volunteer

8 • May 2013 News analysisMothers need more support with breastfeedingNEW GOVERNMENT DATA and research children aged 12 to 18 months. This will ensure that any problems areinto hypernatraemia have revealed that equates to an intake of 2.3g salt per day picked up at an early stage.”many mothers need more support from for children aged 12 to 18 months,midwives to encourage them to exceeding the population Meanwhile the BFI, which isbreastfeed. recommendation for this age group of concerned about the marketing no more than 2g salt per day. practices of infant formula companies, More than one in five babies is never has published new guidance to helpbreastfed and only four in 10 babies are Rosie Dodds, NCT senior policy midwives understand some of thebreastfed beyond six months, according adviser, said this statistic indicated that techniques that formula companies useto the latest figures from the diet and parents needed to know which in trying to gain their endorsementnutrition survey of infants and young manufactured foods have too much salt (UNICEF UK BFI 2013). These includechildren published by the Department to be suitable for toddlers. free gifts, study days, hospitality andof Health (Food Standards Agency (FSA) free conference places.2013). She said she was also disappointed that nearly a third of babies younger The document explains how midwives The survey reveals that only a than six months were given follow-on can recognise the way these techniquesminority of infants are breastfed long milk which is only suitable for babies can undermine breastfeeding andterm. Of those women who continued older than this. “The heavy advertising increase formula sales.to breastfeed beyond 10 months only of follow-on milks is likely to be the15 per cent of the babies were main factor influencing parents. NCT BFI director Sue Ashmore said:breastfed at 10-11 months and only 8 believes this advertising should be “Formula companies in the UK todayper cent continued for longer than 12 stopped,” she said. use very sophisticated marketingmonths. techniques to associate their products Meanwhile new research published with trusted and respected individuals Candy Perry, healthcare business in the Archives of Disease in Childhood or organisations, thereby gainingdevelopment director of the parenting (Oddie et al 2012) has attracted interest tremendous commercial benefit fromcharity NCT, said the data showing that for highlighting the relationship the so-called “halo-effect” of thesemany women stopped breastfeeding between a lack of support for associations.after the first few weeks and months breastfeeding and neonatalwas a concern. “We know that most hypernatraemia. “When it comes to influencingwomen stop breastfeeding before they mothers over how they might want towould have liked, indicating that many The study reveals that if mothers do feed their babies, health professionals,are still not getting all the help they not get adequate support to establish particularly midwives and healthneed,” she said. breastfeeding properly then visitors, are extremely valuable to complications can sometimes arise, formula companies because of their Another worrying statistic from the such as dehydration, which can lead to trusted status and constant access tosurvey is that nearly a third of infants severe hypernatraemia. new parents. Commercial companies(32 percent) aged four to six months will go to extreme lengths to get theirconsumed follow-on formula, which is The authors of the paper noted that brand or product associated with suchnot recommended before six months. hospitals which were accredited as Baby influential members of the community, Friendly showed no extreme cases of however subtly or indirectly.” Complementary foods were dehydration.introduced before the age of three Referencesmonths for 10 percent of children and They recommend that a safety netbefore five months for 75 per cent of needs to be put in place by healthcare FSA (2013). Diet and nutrition survey of infantschildren. facilities to ensure that babies are successfully breastfeeding. This should and young children, 2011, London: Crown. The survey highlights data on salt involve regular contact with the motherconsumption. For those children who in the early days to check how Oddie S, Craven V, Deakin K et al (2012). ‘Severehad food other than milk, most parents breastfeeding is going and the(83 per cent) reported never adding salt condition of the baby, including weight, neonatal hypernatraemia: a populationto the child’s food. Although mean daily stooling and the number of wet nappiesintakes of sodium were only 85 per cent in a given time period. based study’. Arch dis child fetal neonatal ed,of the recommended maximum levelsfor children aged four to six months, A Baby Friendly Initiative (BFI) http://tinyurl.com/cuna7ys Epub ahead ofthey increased to 181 per cent for spokesman said: “This should be standard practice across the NHS, and print UNICEF UK BFI (2013). A guide for health workers working within the international code of marketing of breast milk substitutes, London: UNICEF.

News analysis May 2013 • 9Should we be using misoprostol toprevent postpartum haemorrhage?THERE HAS BEEN against the addition of misoprostol to (RR 0.49, 95 per cent CI 0.37–considerable division in the the essential medicines list (EML) 0.66). However, the quality of thematernal health community highlight the potential for studies within the review wasover the addition of inappropriate (where misoprostol is variable, with only twomisoprostol to the World used for a reason other than PPH randomised controlled trials.Health Organization (WHO) prevention – for example to induce Furthermore there was limitedModel Lists of Essential labour or as an abortifacient) or evidence on adverse effects orMedicines in 2011 (WHO incorrect (such as administration prior the potential for incorrect or2011). As the 19th Expert to the birth of the baby) use of the inappropriate use of misoprostolCommittee (EC) meeting on tablets. Other concerns relate to tablets (Hundley et al 2013).the Selection and use of adverse effects (that may includeessential medicines was fever and/or chills, nausea and Some have suggested thatapproaching in April, the vomiting, diarrhoea and pain), and the these issues are sufficient tostrength of feeling possibility that community question whether misoprostolintensified, as evidenced by distribution of misoprostol may should remain on the EML andthe discussions in a recent detract from the message about the have called for its removalBritish Journal of Obstetrics and importance of facility birth. (Pollock and Sevcikova-BrhlikovaGynaecology Twitter Journal club on 2013). Others argue that Pollock andHundley et al’s systematic review One of the main problems is the Sevcikova-Brhlikova have(2013). So what is the issue? limited evidence available, particularly misinterpreted the evidence and that regarding misoprostol distribution withdrawing misoprostol will put lives In some low and middle income outside the context of clinical trials. at risk (Blum 2013; Weeks et al 2013).countries, such as Bangladesh and Hundley et al’s systematic review The decision by the EC will have aEthiopia, more than two thirds of found that misoprostol was significant impact on misoprostol usewomen give birth at home, in rural associated with a significant in the community and the lives ofcommunities without access to a reduction in the incidence of PPH (RR some of the poorest women. The caseskilled birth attendant (SBA). In such 0.58, 95 per cent CI 0.38–0.87), was considered at a meeting in WHOcircumstances postpartum additional uterotonics (RR 0.34, 95 per headquarters, Geneva, in early Aprilhaemorrhage (PPH) remains one of cent CI 0.16–0.73) and referral for PPH and the decision is eagerly awaited bythe main causes of maternal death. all in the maternal health community.Oxytocin is acknowledged as theuterotonic of choice; however Referencesmisoprostol has attracted interestbecause it is inexpensive, does not Blum J (2013); Pollock A and Sevcikova-need to be refrigerated (an importantconsideration in rural areas where Brhlikova P (2013); Weeks A et al. (2013) -electricity is unavailable), and it can beadministered by the woman or a non All papers available at: http://tinyurl.com/skilled attendant without additionalequipment or training. Advocates d3elubjsuggest that distributing misoprostolto women in areas without SBAs could Hundley V, Avan B, Sullivan C et al (2013).reduce maternal deaths due to PPH,with one model suggesting as much ‘Should oral misoprostol be used to preventas a 38 per cent reduction. Those postpartum haemorrhage in home birth settings in low resource countries? A systematic review of the evidence’. British Journal of Obstetrics and Gynaecology; 120(3): 277-287. WHO (2011). Model lists of essential medicines, Geneva: WHO.

10 • Hypnosis May 2013 • THE PRACTISING MIDWIFEClinical hypnosis for labourand birth: a considerationCharlotte Kenyon considers SUMMARY Labour pain is one of the most important factors in shapingthe forms which clinical women’s experiences of birth. Choice around pharmacological relief can behypnosis can take and complex. Clinical hypnosis is a non-pharmacological option which a number ofconcludes that this is a very women have chosen to use, often paying privately to do so. Self hypnosisindividualised therapy allows women the opportunity to take control of this technique. Research findings relating to the therapy vary; some trials have found positive effects by way of a reduction in use of pharmacological pain relief, oxytocin use and shortened first stage of labour. Inclusion of the therapy as a means to invoke relaxation and counter the effects of stress and anxiety alone may be valid reasons for consideration of its use. This article outlines the framework used in clinical hypnosis and discusses some of the issues relating to the evidence base for it. Keywords Clinical hypnosis, labour, birth, pain relief, relaxation Author Charlotte Kenyon, supervisor of midwives and senior lecturer at the University of HuddersfieldIntroduction Evidence suggests that relief for more than a century and hasLabour pain is one of the most hypnosis has a positive been used for birth in the Unitedimportant factors in shaping women’s effect on the Kingdom since the early 1950s (Michaelexperiences of birth. Negative experience of pain and 1952). Since then, various models haveexperiences can be associated with reduces analgesia and been developed and gained popularity.post-traumatic stress, postnatal anaesthetic use Although research findings vary,depression (PND), future requests for evidence suggests that hypnosis has aelective caesarean section and al 2013). Therefore, there is an positive effect on the experience ofdecisions about family size (Werner et increasing desire to explore non- pain and reduces analgesia andal 2012). The pain experience is pharmacological alternatives (Smith et anaesthetic use (Smith et al 2006;influenced by diverse factors including al 2006; Werner et al 2012). One such James 2009; Landolt and Milling 2011).environment, expectations and stress alternative which has been the focus of Clinical hypnosis is not broadlyand anxiety levels. Pharmacological interest is clinical hypnosis. available through the NHS andrelief presents a complex choice for therefore women have tended to seeksome women and pharmacological Hypnosis has been used for pain private providers to meet their choiceoptions are limited because they can to use either individualisedcross the placenta. Epidural hypnotherapy or recognised models ofanaesthesia, which can afford total hypnosis. This article does not discusspain relief, has associations with slow specific ‘hypnobirthing’ models, butprogress in labour and increased explores some of the general principlesinstrumental birth rates (Hasegawa et of clinical hypnosis and the available

THE PRACTISING MIDWIFE • May 2013 Hypnosis • 11evidence. Hypnosis will induce a awareness (James 2009). Hypnosis in Use of hypnosis for birth usually deeply relaxed state to which therapy takes place is termed counteract the effects ‘hypnotherapy’. This has been defined as:starts in the third trimester and focuses of stress and enhanceon preparation for birth. However, feelings of control in “The use of a therapeutic protocolclinical hypnosis can be used the mother which utilizes a relaxed and focusedthroughout the whole fertility cycle. A state of awareness (hypnosis) tonumber of women use it alongside IVF, term for a therapy which has an deliver therapeutic suggestions toit can be used as a therapeutic individualised and adaptable approach. achieve a previously identifiedapplication to help manage psycho- Professional opinions differ as to outcome.”emotional issues, it can be adapted to whether hypnotic trance altersmeet individual women’s needs in the consciousness or not (Johnson and (James 2009: 239).antenatal period and there is potential Hauck 2011), though there is generalfor use alongside conventional agreement that when ‘in hypnosis’ Some people fear that hypnosis willtreatments for smoking cessation and clients are in a state of deep relaxation cause loss of control, particularly asalcohol abuse. At the most simplistic but have heightened subconscious their opinions of hypnosis are formedlevel, hypnosis will induce a deeply from stage and television performancesrelaxed state to counteract the effects in which subjects are seen to be underof stress and enhance feelings of the control of the hypnotist. In reality, ifcontrol in the mother (Jallo et al 2008; suggestions or instructions are made inJames 2009). hypnosis which are not agreeable to the client they have no effect.What is hypnosis?The term ‘clinical hypnosis’ is a generic Process of hypnosis Prior to commencement of hypnosis, Limbs & ThingsHomeopathic Remedies and M Creams for Pregnancy,Childbirth and the newbornThe Helios Homeopathic Childbirth kit contains 18 safe and gentle SimMomTMhomeopathic remedies specifically for use during pregnancy, labourand postnatal symptoms. Each kit is accompanied by an information An advanced full body birthing simulator.booklet giving an introduction to homeopathy, an A-Z of complaints Includes: Mother and baby, interchangeablethat can be treated and a materia medica section detailing the main pelvic modules, and software for running multipleuses of each remedy. Our natural plant based creams are formulated birthing training scenarios with complicationsto ease varicose veins, piles and stretch marks and soothe nappy rash, Visit our website for more informationcradle cap and other minor skin complaints and first aid situations. www.limbsandthings.comPlease contact HeliosTelephone:01892 537254 T: +44 (0)117 311 0500 E: [email protected]: [email protected]: www.helios.co.uk Developed in par tnership:

12 • Hypnosis May 2013 • THE PRACTISING MIDWIFEthere should be a discussion which into hypnotic trance. complete control over the process.incorporates issues relating to consentand the desired therapeutic outcomes. Hypnotic suggestions Evidence baseDuring this discussion the therapist can When in hypnosis, pre-agreed As with many complementaryestablish understanding of ways in therapeutic suggestions will be given. therapies, the individualised nature ofwhich the woman relaxes. This helps to These might be anything from the the therapy makes it challenging todetermine whether the individual has a suggestion to imagine feelings of develop a robust evidence basevisual, auditory or kinaesthetic confidence and comfort, to the use of sufficient for conventional clinicalmodality and is then used to develop an pleasant imagery during contractions. practice. Where research is undertakenindividualised protocol for hypnosis. Suggestions which refer to a state using formulaic scripts, results may be which will be experienced after affected by the use of a one size fits all Hypnosis has an agreed framework of hypnosis are referred to as post- approach to a therapy which by itsfour stages: induction, deepening, hypnotic suggestions. Other techniques nature is individualised. Few trials arehypnotic suggestion and awakening. which are used during hypnosis include randomised, and those which are areFigure 1 offers a graphic representation techniques such as ‘glove anaesthesia’, also seen to have limitations becauseof the deepening state of relaxation in a technique whereby a state of hypnosis may not be appropriate orhypnosis. numbness is created in the hand and desirable to everyone. It may also be then transferred to other parts of the less effective for women who do notInduction body as needed, for pain relief. have a psychological need for it (LandoltInduction establishes the hypnotic and Milling 2011; Werner et al 2012).trance as the client is guided into a Awakening Non-randomisation may also biasstate of relaxation. Individuals who Following the therapeutic intervention findings as a self-selecting group mayhave a visual modality might be guided the client is woken. Awakening includes experience a greater perceived effectusing instructions such as “Imagine you further suggestions for ego (Landolt and Milling 2011). No recentcan see your chest rise and fall with strengthening. These will be tailored to studies could be found which employedeach breath you take”, auditory individual needs but frequently include individualised hetero-hypnosis; findingsindividuals would be guided using suggestions to wake feeling confident from older studies also differ dependingsound, such as “Listen to the sound of or refreshed. on whether hetero- or self-hypnosis isyour breathing” and kinaesthetic used (Rock et al 1969; Cyna et al 2006;individuals might be guided through This form of hypnosis, hetero- VandeVusse et al 2007; Landolt andtouch. hypnosis, involves two individuals: the Milling 2011). hypnotherapist and woman; butDeepening women can also be taught self- Current findings relating to clinicalDeepening is a continuation of the hypnosis. This is a learned skill which hypnosis in labour and birth vary. Oneinduction which guides the client can be developed over time and then recent randomised study found nodeeper into relaxation and ultimately used as desired. It gives the woman impact at all (Werner et al 2012). However others suggest that hypnosis Figure 1 Graphic representation of hypnosis does have a positive effect, through a measured reduction in epidural and Pre-hypnosis Post-hypnosis pharmacological pain relief usageDepth of Induction Awakening (Mehl-Madrona 2004; Cyna et al 2006;relaxation VandeVusse et al 2007; Landolt and Milling 2011). Other positive effects Deepening on length of first stage of labour, reduced levels of intervention and use Hypnotic suggestion of oxytocin for augmentation have also been reported (Mehl-Madrona 2004). In order to support women in making an informed choice about clinical hypnosis for labour and birth, a robust evidence base is needed. Current findings should be considered

THE PRACTISING MIDWIFE • May 2013 Hypnosis • 13promising rather than conclusive. A instrumental delivery, and neonatal short- Michael AM (1952). ‘Hypnosis in childbirth’. Britrandomised controlled trial is currently term outcome’. Jour anesth, 27(1): 43. med jour, 1(4761): 734-737.underway in the form of the so-called Jallo N, Bourguignon C, Taylor AG et al (2008).SHIP trial (SHIP 2013). It is anticipated ‘Stress management during pregnancy: Rock N, Shipley T and Campbell C (1969).that further conclusions will be drawn designing and evaluation a mind-body ‘Hypnosis with untrained, nonvolunteerupon the completion of this trial, which intervention’. Fam comm heal, 31(3): 190-203. patients in labour’. Int jour clin exp hyp, 1(17):will provide further evidence to support James U (2009). ‘Practical uses of clinical 25-36.or negate the inclusion or development hypnosis in enhancing fertility, healthyof this therapy in existing midwifery pregnancy and childbirth’. Comp ther in clin SHIP trial (anticipated 2013). Self-hypnosis forcare provision. TPM pract 15(4): 239-241. intra-partum pain: a feasibility study, DOI: Johnson ME and Hauck C (2011). ‘Beliefs and 10.1186/ISRCTN27575146.Charlotte Kenyon is supervisor of opinions about hypnosis held by the generalmidwives and senior lecturer at the public: a systematic evaluation’. Am jour clin Smith C, Collins C, Cyna AM et al (2006).University of Huddersfield hyp, 42(1): 10-20. ‘Complementary and alternative therapies for Landolt AS and Milling LS (2011). ‘The efficacy of pain management in labour’. Coch data sysReferences hypnosis as an intervention for labour and rev, 4: CD003521. delivery pain: a comprehensiveCyna AM, Andrew MI and McAuliffe GL (2006). methodological review’. Clin psych rev, 31(6): VandeVusse L, Irland J, Healthcare WF et al ‘Antenatal self-hypnosis for labour and 1022-1031. (2007). Hypnosis for childbirth: a childbirth: a pilot study’. Anaes inten care, Mehl-Madrona L (2004). ‘Hypnosis to facilitate retrospective comparative analysis of 34(4): 464-469. uncomplicated birth’. Am jour clin hyp, 46(4): outcomes in one obstetrician’s practice, Am 185-197. jour clin hyp, 50(2): 109-119.Hasegawa J, Farina A, Turchi G et al (2013). ‘Effects of epidural analgesia on labor length, Werner A, Uldbjerg R, Zachariae R et al (2012). ‘Self-hypnosis for coping with labour pain: a randomised control trial’. Brit jour obs gyn, 120(3): 346-353.More information.Less guesswork.75% More than 500 ng/mL 99% Less than 10 ng/mL of fFN? There is a 75% of fFN? There is a 99% chance she’ll deliver chance she won’t deliver before 34 weeks.1 in the next 14 days.1For more information, visit Hologic.com.

14 • Mother and baby yoga May 2013 • THE PRACTISING MIDWIFEMother and baby yogais good for youCheryl MacDonald SUMMARY Mother and baby yoga is becoming more and more popular in thedescribes the benefits western world, as postpartum mothers discover the benefits of being able tofor both mothers and ‘work out’, bond with their baby and relax, all in one session.babies of postnatal yoga Postnatal yoga can offer calm and a sense of wellbeing, helping mothers to improve and stabilise their emotional health and to bond. Additionally the mother is able to focus on her relationship with her baby, rebuild the weakened pelvic floor, strengthen the abdominal muscles and even alleviate back and neck pain. For babies, yoga can aid digestion and alleviate colic; help to strengthen tiny limbs; improve sleep patterns; and enhance their ability to interact with their mother and other people. Keywords Postnatal yoga, baby yoga, postnatal wellbeing, emotional health Author Cheryl MacDonald, qualified yoga teacher and baby massage instructor trainerT here are many Yoga literally translated when practised together. As new M misconceptions of what yoga means ‘union’, referring mothers very quickly come to realise, is and is not. It is not to the union of body activities from now on will involve their necessary to be able to put and mind baby, and what better opportunity toyour legs around your head, be a ‘hippy’ embrace this than in the yoga class?or a certain type of person to practise yoga session, but it can also be so muchyoga. Yoga is becoming more and more more: it can strengthen the body Postnatal, baby yoga and mother andwidely practised and I have found, in an dramatically; and allow the practitioner baby yoga classes are now widelyongoing survey of mothers, that some to find mental clarity and peace of available across the UK, although yogawomen turn to yoga as a safe, gentle mind. Clearly these calming and with a baby is no new thing. Baby yogaand effective method of relaxation and strengthening properties are of great and massage have been practised forphysical strengthening during value during the perinatal period. thousands of years in India and, evenpregnancy and postpartum for the first today, yoga and massage with a babytime (YogaBellies 2012). Postnatal and baby yoga are as important as a daily bath in India. Postnatal and baby yoga are two Yoga literally translated means distinct areas of therapy but work best The benefits of yoga for the‘union’, referring to the union of body postpartum woman have been widelyand mind through the use of the recognised in the past twenty years inbreath. Yoga is generally viewed as the western world as the practice ofslow, gentle stretching or people sitting yoga has been adapted to work withcross-legged and breathing deeply. the female body. Just as duringThese can be important aspects of a pregnancy, mothers have to be kind to their bodies and take things at a gentler

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16 • Mother and baby yoga May 2013 • THE PRACTISING MIDWIFEpace, they must learn to gradually build The benefits of yoga for in buggies, cots and car seats orback up to their normal level of activity the postpartum woman bouncing chairs. But babies can becomepostpartum (Larson and Howard 2002). stressed and stiff just like adults. The purpose of baby yoga is to strengthenYoga and postnatal depression have been widely the baby’s body, encourage flexibility MThe social aspects of postnatal yoga are and teach the principals of relaxation atfantastic for mothers, too. Not only are recognised in the past an early age. Sessions also alternatethey able to meet up with others and between stimulating a baby’s brain‘get out of the house’, it also helps twenty years in the development and helping them toincrease their confidence as a mother relax. Baby yoga also teaches the babyand helps rebuild their pre pregnancy western world to self soothe and how to become calmform. Importantly, postnatal yoga has and still (Garabedian 2004.) At the endalso been shown to help alleviate and Some mothers go directly into of a mother and baby yoga session,prevent the symptoms of postnatal intense physical exercise regimes in mothers often find that their baby isdepression (Read and Rickwood 2010). order to regain their pre pregnancy happily exhausted, relaxed and fast shape and lose their mummy bump, but asleep. Yogic practices such as asana this is not helpful: the focus should be(physical postures) and pranayama primarily on gently rebuilding the pelvic In a baby yoga session, the teacher(breathing techniques) are now floor and lower abdominal muscles. will show the mother how torecognised across the world as effective These muscles must be exercised in manipulate her baby’s body in a verytreatment for depression. A regular unison and one cannot be strengthened gentle way in order to achieve theyoga practice can reduce the production effectively without focusing on the desired outcome of the posture. Forof stress hormones when a mother is other also. I have found that mothers example, a posture may be practisedexposed to stressful situations, such as can neglect the rebuilding of the pelvic with the focus on alleviating colic, orlack of sleep and being overwhelmed by floor, and return to sit ups and another focusing on strengthening thethe responsibility of motherhood (Ram strenuous work out regimes as soon as baby’s arms and back so that they may2009). By practising these techniques, possible. This results in a weakened begin to hold themselves up in thethe breath steadies and the brain’s pelvic floor, abdominal muscles which correct position for crawling.automatic impulse to create stress have not recovered (mothers who jumphormones is massively reduced. into sit ups may end up with a ‘six pack’ Mother and baby yoga sessions and protruding lower abdominals) and There are many variations to the By practising deep relaxation or yoga very often ongoing lower back pain structure of a ‘postnatal’ or ‘baby yoga’nidra, cortisol activities in the nervous also. By strengthening the pelvic floor class. It is vital that mothers are advisedand endocrine systems are balanced and lower abdominals, we help of the differences in these classes towhich reduces the body’s reaction to strengthen the lower back and integrity make sure that they get the most fromstress. As a result, the body produces of the spinal cord. the sessions. A postnatal yoga class willfewer stress hormones (adrenaline, focus on the postpartum mother andnoradrenaline and cortisol) and mother ‘Baby’ yoga not the baby.becomes calm and at peace (Streeter et ‘Baby yoga’ refers to the practice ofal 2010). yoga asana (physical postures) for baby. A baby yoga class focuses on yoga for Thousands of years ago, yoga masters the baby, aiming to help them growBeginning postnatal yoga based adult yoga postures on the strong and healthy, often as anWomen should be advised to wait six- movements that new babies make extension of a baby massage class. Thiseight weeks postpartum after a normal naturally as they begin to move about is a not a postpartum yoga class andbirth or 10 weeks after a caesarean (this can be clearly seen in the happy the focus in on the child rather than thebirth before starting yoga. The most baby pose: where the yoga subject lies mother.important thing is that mothers listen on their back and grabs their toes –to their bodies and are guided by how something babies do a lot!) The best postpartum yoga classesthey personally feel. They should also be involve a mixture of yoga for motheradvised not to exercise the pelvic floor Newborn babies today are often and baby. Ideally the class shouldmuscles until there is no pain in that constricted in ways they were not in involve postnatal yoga postures,region: bruised muscles should never be days gone by. Babies spend a lot of time helping to strengthen mothers’ mindsexercised and the same applies to the and bodies, as well as incorporatingpelvic floor. babies into the yoga practice with asana to help their bodies as well.

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18 • Mother and baby yoga May 2013 • THE PRACTISING MIDWIFEMother and baby yoga classes of this specific training in these areas. Ideally, Buddha baby: the workout for new moms,kind are superior in that they those teaching postnatal yoga have New York: Bantam Books.encourage mother and baby bonding completed a 200 hour yoga teacher Ram N (2009). Yoga alleviates postpartumand communication, and they help training qualification accredited by depression: http://tinyurl.com/covo2m4 Lastmothers understand that their baby organisations such as the Independent accessed 2nd April 2013.must now be incorporated into every yoga network (IYN) or Yoga alliance in Read S and Rickwood D (2010). ‘The role ofaspect of their life. Yoga with baby is the first instance. The teachers should community-based groups in the preventionthe most yogic thing they will ever do then have had subsequent training in of and recovery from postnatal depression’.as they quickly come to realise that the areas of postnatal yoga and/or baby In: Hussain I (ed): Women and depression,everything involves their baby now. yoga, depending on what they teach. Newcastle upon Tyne: Cambridge ScholarsOften a baby will cry or want to feed Mothers should always make sure their Publishing.during the session and so the mother teacher is associated with a reputable Sharp, A (1996). ‘Postnatal depression’. Inmay not have the session she hoped organisation and is qualified to work Kendrick T, Tylee A and Freeling P (eds). Thefor. Yoga breathing techniques and safely and sensitively with post birth prevention of mental illness in primary care,relaxation are also taught in class, mother and baby. TPM New York: Cambridge University Press.which help a mother to relax with her Streeter CC, Whitfield TH, Owen L et al (2010).baby and to embrace this new Cheryl MacDonald is a qualified yoga ‘Effects of yoga versus walking on mood,responsibility. teacher and baby massage instructor anxiety and brain GABA levels: a randomized trainer controlled MRS study’. Jour alt comp med,What to look for in a mother and 16(11): 1145-1152.baby yoga teacher References YogaBellies (2012). Birth outcomes survey: surveyIt is vitally important that anyone collating the results of the effects of perinatalteaching postpartum or baby yoga is a Garabedian H (2004). Itsy bitsy yoga, London: yoga on birth outcomes and babyqualified yoga teacher, who has had Simon and Schuster. development, http://tinyurl.com/d6sa7nx Larson J and Howard K (2002). Yoga mom,FIRST STEPS NUTRITION TRUSTIndependent and objective information for health care professionals to support good nutritionfrom pre-conception through the rst ve years. First Steps Nutrition Trust takes no commercial funding and o ers free, unbiased downloadable resources. Eating well in pregnancy: A practical guide to support teenagers A practical guide for those who support young women in pregnancy with case studies, recipes, simple advice and food photographs.Also available: Infant Milks in the UK: A practical guide for health professionals A regularly updated report outlining the composition of infant milks in the UK.To download any of our resources and to sign up for our newsletter go to www. rststeps nutrition.orgFIRST STEPS NUTRITION TRUST FIRST STEPS NUTRITION TRUST FIRST STEPS NUTRITION TRUST

THE PRACTISING MIDWIFE • May 2013 Hypercoagulability • 19We’ve got it covered! Graduatedcompression stockingsMidwife Cerian Llewelyn SUMMARY Hypercoagulability is a well documented feature of pregnancyexplains how graduated and contributes to the increased incidences of venous thromboembolismcompression stockings can help (VTE) in pregnancy. Thromboembolism remains a leading cause ofchildbearing women to avoid maternal death in the UK, though it’s predicted that up to two thirds ofserious complications associated these deaths could be prevented if appropriate thrombophylaxsis iswith hypercoagulability adopted. This article aims to further midwives’ knowledge in relation to thromboprophylaxsis, focusing in particular on graduated compression stockings (GCS). It aims to assist midwives in identifying those women at high risk of developing a VTE, explain the way in which compression stockings can reduce thromboembolism and provide advice on their application and the clinical observations required. Keywords Graduated compression stockings, venousthromboembolism, thromboprophylaxsis, compression hosiery Author Cerian Llewelyn, a midwife at Withybush HospitalBackground Risk factorsIncreased clotting factors evident in pregnancy have likely evolved in order As well as the hypercoagulability ofto protect women from the bleeding challenges that childbirth and pregnancy which all women experience,pregnancy present. However this hypercoagulation also serves as the major women can be identified as being at anreason for the increased risk of thromboembolism in pregnancy (Bremme increased risk of developing a VTE due to2003). Thromboembolism remains a leading cause of direct maternal the presence of one or more welldeaths in the UK (Centre for maternal and child enquiries (CMACE) 2011). researched risk factors (RCOG 2009) (SeeDuring pregnancy the risk of venous thromboembolism (VTE) is increased Box 1).four to five fold when compared to the non pregnant state (Pomp et al2008) and this risk increases further in the six week postpartum period Multiple risk factors increase the risk(Heit et al 2005). Venous thromboembolism accounts for 1.1 deaths per of thromboembolism and it is imperative,100,000 births, or a total of 10 per cent of all maternal deaths (James et al therefore, that women undergo a2005). It is suggested that up to two thirds of obstetric VTEs can be continued documented assessment ofprevented with appropriate thrombophrophylaxis (Royal college of risk factors. These should be consideredobstetrics and gynaecology (RCOG) 2009). Several studies have concluded at an early gestation (if possible prethat the use of low molecular weight heparins (LMWH) combined with the conceptually), during any hospitalappropriate use of graduated compression stockings (GCS) prove most admission or with the development ofeffective in preventing the development of VTE (Duhl et al 2007). Whilst the intercurrent problems and immediatelyefficacy of LMWHs is well researched and supported and is usually the first postpartum (Jacobsen et al 2008).line in thromboprophylaxis (RCOG 2009), this article focuses on the use ofGCS as a mechanical method of thromboprophylaxis usually alongside the Dual preventionuse of LMWH and not replacing it. Women who present with an increased risk of VTE should be provided with appropriate and timely M

20 • Hypercoagulability May 2013 • THE PRACTISING MIDWIFE Box 1 Risk factors for VTE Thromboembolism Size matters M In order for GCS to work effectively, Previous venous thromboembolism remains a leading cause correct measuring is essential as Thrombophilia selecting stockings that are too small Medical conditions (including heart or of direct maternal can result in tissue damage and, if lung disease, cancer, nephritic stockings are too large, there is no syndrome) deaths in the UK apparent therapeutic benefit (The Intravenous drug use Australia and New Zealand working Age >35 below the knee and thigh length; whilst party on the management and Obesity: BMI >30 the NICE guidelines support the use of prevention of venous thromboembolism Smoking thigh length graduated stockings for (ANZVTE) 2010). Correct measurements Gross varicose veins non-obstetric inpatients undergoing are determined by accurately Paraplegia surgery (NICE 2010), there is little measuring the ankle measurement and Multiple pregnancy/assisted evidence of the relative effectiveness of thigh circumference (if thigh length) or reproductive therapy knee and thigh length stockings, calf circumference (if knee length); both Pre eclampsia especially in relation to the pregnant the thigh and calf should be measured Caesarean section population. Obstetric patients also have at the greatest part and the appropriate Postpartum haemorrhage >1 litre the added issue that thigh length size selected according to the Prolonged labour stockings can easily become bloodstained. manufacturer guidelines. Complicated operative vaginal birth The RCOG advocates the use of thigh Surgical procedures length stockings (RCOG 2009); however, Consent Hyperemesis/dehydration due to the high rate of non-compliance Prior to application of the stockings it is Admission or immobility >3 days associated with thigh length stockings, imperative that consent be gained, the Systemic infection the use of knee length stockings should woman being fully informed as to the Long distance travel >4 hours be considered as they provide better indication and the purpose of the GCS; comfort, less association risk and this should also promote compliance Source: RCOG 2009 therefore promote better compliance. from the woman. The contraindications Graduated compression stockings are should be considered and discussed andthromboprophylaxis. Bates et al (2012) particularly important for those women the woman informed as to the possibleconcur that pharmacological prophylaxis for whom LMWH is contraindicated signs and symptoms of a DVT (localised(LMWH) combined with mechanical (including patient refusal, recent stroke, tenderness or pain, colour changes,prophylaxis (GCS) is superior in high risk of major haemorrhage or abnormal swelling, warmth of thepreventing thromboembolism active antenatal bleeding) and in affected area, dilation of the vein orcompared to just one method alone. combination with LMWH for those pyrexia). women deemed particularly at risk ofHow GCS work VTE (RCOG 2009). Applying the stockingsGraduated compression stockings are Position the hand into the heel pocketdesigned to achieve a pressure gradient Contraindications of the hosiery.from the ankle to the knee or thigh When considering the need for GCS,which strives to mimic the deep leg vein arterial insufficiency is an absolute Turn hosiery inside out.calf muscle pumps (highest pressure at contraindication, but arterial disease,the ankle). Studies have demonstrated gangrenous conditions, vascular •• Position the stocking over the heelthat GCS significantly improve venous disease, pulmonary oedema, and foot, ensuring the heel is inemptying in pregnant women; they lymphoedema, calf circumference the pocket.increase the blood flow whilst exceeding 56cm (including gross legdecreasing the lumen diameter of the oedema), dermatitis and extreme leg • Extend the stocking to its fullsuperficial and common femoral in deformity are all relative length (ensuring that it is wrinklepregnancy and the early postnatal contraindications. Caution should be free, as this may cause irregularperiod (Büchtemann et al 1999), exercised when assessing women’s pressure on the limb and couldtherefore reducing the formation of suitability for GCS. result in tissue damage).deep vein thrombosis (DVT). Thesestockings are available in two lengths: • Advise women not to roll stockings down, as this may result in a tourniquet effect on the femoral circulation, which could potentially result in a DVT (Winslow and Brosz

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22 • Hypercoagulability May 2013 • THE PRACTISING MIDWIFE 2008). Studies have Chest, 141(2s): e691S-736S. demonstrated that GCS Bremme K (2003). ‘Haemostatic changes in • Health professionals should significantly improve monitor the leg for any signs of venous emptying in pregnancy’. Clin haem, 16(2): 153-168. early tissue damage as a result of pregnant women Büchtemann AS, Stein A, Volkert B et al (1999). the GCS. during hospital admissions or long ‘The effects to compression therapy on • For hygiene reasons the stocking periods of immobility and for six-12 venous haemodynamics in pregnant women’. should be removed once a day but weeks post birth. If deemed appropriate Brit jour obs gyn, 106: 563-569. for no more than 30 minutes. for women to be discharged home CMACE (2011). ‘Saving mothers' lives. Reviewing wearing GCS, it is imperative that they maternal deaths to make motherhood safer: • The capillary refill time (CRT) are fully informed and, on a practical 2006-2008’. Brit jour obs gyn, 118(s1): 1-205. should be completed on the limbs level, are able to change the stockings Duhl A, Paidas M, Ural S et al (2007). 30 minutes following the initial unaided or have appropriate support to ‘Antithrombotic therapy and pregnancy: application of the stocking. If the help them apply GCS correctly. consensus report and recommendations for CRT is more than two seconds the treatment of venous thromboembolism’. Am stockings should be removed and More research needed jour obs gyn, 197(5): 457.e1-21. the appropriate measurements Much of the expert advice that exists in Heit J, Kobbervig C and James A (2005). ‘Trends and stocking size be rechecked obstetric guidelines today has derived in the incidence of venous thromboembolism and, if relevant, the medical team from authors reviewing data from large during pregnancy or postpartum: a 30 year should be informed. studies, including a Cochrane review population study’. Annual int med, 143(10): and several other studies in relation to 697-706. • The stockings should be removed if the use of GCS in the hospitalised non Jacobsen AF, Skjeldestad FE and Sandset PM the woman complains of pain or pregnant patient and then relating it to (2008). ‘Incidence and risk of venous cramping in the legs, and the the pregnant population (Sachdeva et al thromboembolism in pregnancy and medical team should be informed. 2010). There is a clear need for further puerperium: a register-based case-control research into this area; however, despite study’. Am jour obs gyn, 198(2): 233.e1-7. • Legs should be measured every the limited available research, many James AH, Tapson VF and Goldhaber SZ (2005). three days to detect any changes obstetric units encourage the use of GCS ‘Thrombosis during pregnancy and the in size or changes to the condition for high risk women as the association postnatal period’. Am jour obs gyn, 193(1): of the leg. risks are low and the potential benefits 216-219. could be significant. TPM NICE (2010). ‘Venous thromboembolism: • Skin can become dry as result of reducing the risk’. Clin guid 92, London: NICE. the stockings, so women should be Cerian Llewelyn is a midwife at Withybush Pomp ER, Lenselink AM, Rosendaal FR et al encouraged to use emollients (not Hospital (2008). ‘Pregnancy, the postpartum period oil based products) to help and prothrombotic defects: risk of venous maintain skin integrity. References thrombosis in the MEGA study’. Jour thromb haemost, 6(4): 632-637. • Stockings should be hand or ANZVTE (2010). Best practice guidelines for RCOG (2009). ‘Reducing the risk of machine washed in low Australia and New Zealand, 4th edition, thromboembolism during pregnancy and the temperatures every three days or Melbourne: Health Education and puerperium’. Green top guid 37, London: sooner, depending on need, and Management Innovations. RCOG. should not be dried over a direct Sachdeva A, Dalton M, Amaragiri SV et al (2010). heat source in order to maintain Bates S, Greer M, Middeldorp S et al (2012). ‘VTE, ‘Elastic compression stockings for the remedial effect. thrombophilia, antithrombotic therapy, and prevention of deep vein thrombosis’. Coch pregnancy: antithrombotic therapy and data sys rev, 7: DOI: • As with all women postnatally, prevention of thrombosis, 9th edition: 10.1002/14651858.CD001484.pub2. mobility and hydration should be American college of chest physicians Walker I, Greaves M and Preston F (2001). discussed and encouraged and this evidence-based clinical practice guidelines’. ‘Investigation and management of heritable is particularly relevant for those at thrombophilia’. Brit jour haem, 114(3): 512-528. an increased risk of VTE. Winslow EH and Brosz DL (2008). ‘Graduated compression stockings in hospitalized • It is important to keep a postoperative patients: correctness of usage documented account of the and size’. Am jour nurs, 108(9): 40-50. indication for GCS, accurate measurements and any other relevant information. Walker et al (2001) suggest thatwomen who present with risk factorsfor VTE should be advised to wear GCS

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26 • Osteopathy May 2013 • THE PRACTISING MIDWIFEBack to back: postnatalosteopathic care Chris Johnson SUMMARY There is growing recognition of the role that osteopathy can play in explains that the treatment of women during pregnancy (King et al 2003; Sandler 1996; earlier trauma Green 2000). It is usual for the osteopathic training colleges to run a pregnancy to the body,as clinic and give students the opportunity to focus on the particular changes thewell as a difficult or lengthy body will go through from a neuro-musculo-skeletal view point during thislabour and birth,can require unique period of a woman’s life. Also, osteopathy can help make a difference intherapeutic treatment to a woman’s overall antenatal care by using gentle procedures to help alleviateresolve postnatal back many common pregnancy related ailments. A recent literature review (Lavelleproblems 2012) found that this included not only relief of pain for a variety of musculo- skeletal conditions but also a reduction in the duration of labour and the avoidance of some complications of labour. To date, there has been less of a focus on what osteopathy can provide women postnatally; indeed, within the profession, there has been little research carried out in this area. However, many osteopaths are confident in the results they can achieve working with postnatal mothers, based on a sound working hypothesis of osteopathic principles. Keywords Osteopathic principles, postnatal, osteopathy, strains, stress Author Chris Johnson, osteopath in SheffieldI t is crucial to consider each birth Juggling various roles home and family and work can often as unique in order to understand within the home and mean a mother’s own needs easily get the symptoms a mother may family and work can overlooked or significantly present with. In essence, birth is a often mean a mother’s downgraded.mutual process between mother and own needs easily getbaby, each affecting the other overlooked or Consideration also needs to be givenphysically, emotionally and spiritually, significantly to the mother’s health before andregardless of whether the birth itself is downgraded during her pregnancy, to be able tonormal, perhaps a home birth or, by effectively treat her postnatally.contrast, an emergency caesarean uninterrupted bonding time with her Pregnancy results in changes in asection under general anaesthetic. baby. Juggling various roles within the woman’s posture and often these changes result from accommodationsRecovery of the body physiology from previousCulturally, in Western society, there is a traumas or habits. Then, due to growthdrive for the mother to get on with in the size of her uterus, along withbeing a mother, often without the hormonal changes, her body strugglesopportunity to allow her body to to deal with these efficiently.recover from the momentous event ithas been through, nor to allow Effects of labour The labour position, the position of the

THE PRACTISING MIDWIFE • May 2013 Osteopathy • 27baby as it presents, the type of experiences can also have a deleterious when healing is considered to beanalgesia and the mother’s emotional effect on her own pelvic soft tissues. working on more than just a physicalstate can all contribute to the effects of level, which comes back to the core oflabour, and the potential therefore for Postnatal strains osteopathic philosophy. TPMany resulting stresses and strains being Coupled with these potential Chris Johnson is an osteopath in Sheffieldimposed on her body. Left unresolved, consequences, the mother is suddenly Acknowledgementchronic compensations can build up launched into a new role of nursing herwhich, if significant, will challenge her baby. The intense nature of this period Special thanks go to my osteopathic colleaguebody framework sufficiently to cause usually means lots of sitting, holding Taj Deoora MSc, DO (Hons), Dip Phyt, for herpersistent symptoms. positions for long periods of time while guidance with this paper. cradling and/or feeding her baby, and Looking at the body in this way is no bending her neck forwards in the Referencesdifferent from how osteopaths would process of gazing and bonding with herlook at any other kind of musculo- child. This often exacerbates the pain Green J (2000). ‘Osteopathy in pregnancy andskeletal complaint. she may be experiencing around her childbirth’. The practising midwife, 3(7): 38-43. pelvis and can cause great discomfort in Soon after birth, the relaxin hormone her upper back and neck, particularly King HH, Tettambel MA, Lockwood MD et al (2003).levels reduce to allow the ligaments, through long periods of breastfeeding. ‘Osteopathic manipulative treatment in preespecially around the pelvis to resume natal care; a retrospective case control designtheir normal tone, thus allowing the Osteopathic treatment study’. Journal of the American Osteopathicpelvic bones to return to their normal Clear consideration of the breadth of Association, 103(12): 577-582.position. However, during the process of influences is the key for directing alabour, with the spread of the sacrum, treatment approach. The gentle and Lavelle JM (2012). ‘Osteopathic manipulativecoccyx and pelvic bones allowing for efficacious nature of osteopathic treatment in pregnant women – a review ofthe descent of the baby, it can be easy treatment means that many of the literature on the use and effectiveness ofto see how a malposition, or long physical challenges the mother has OMT during pregnancy’. Journal of the Americanlabour, or previous injury to the endured, leaving a residual impact on Osteopathic Association, 112(6): 343-346.maternal pelvis may result in the her physiology, can be addressed andpostnatal re-alignment of pelvic bones steered towards a more complete sense Sandler SE (1996). ‘The management of low backbecoming incomplete. Consider also the of function, balance and overall health. pain in pregnancy’. Manual therapy, 1(4):effect that forceps intervention may Early osteopathic treatment postnatally 178-185.have upon the pelvis when the can play an important role in helping toligamentous structures have already resolve many of the stresses and strains Further resourcesbeen stretched, often to a maximum acquired through pregnancy, birth and www.osteopathy.org.uk Generalcapacity. Long labours can put excess early motherhood. Osteopathic Counciltraction on soft tissues. Quick births can www.cranial.org.uk Register of osteopathsput stress on the ligaments, fascias and Many women carry physical andmuscles of the pelvic floor. With the use emotional scars to varying levels from © Kampfner Photographyof an epidural causing the labouring their experience of childbirth. This canwoman’s own pain feedback get in the way of experiencing ‘being’mechanisms to be interrupted, the with their child to its fullest capacity,inability to sense and gauge how much and for some, have a negative effect inforce to use, and how and where to consideration of future pregnancies.direct that force, can place great stresson her pelvic soft tissue structures. This Addressing and resolving some ofmay be compounded if she has been these physical dysfunctions can havelying on her back for a long period of far reaching implications,time, not being aware of excessivestretch and pressure on her backand pelvis. If the mother is fearfulduring her labour forwhatever reason, thetension she

28 • An English midwife in Arkansas May 2013 • THE PRACTISING MIDWIFEAn English midwife in ArkansasPart 3 – differences in practice In the third of three SUMMARY In the final instalment of this three part series articles,Chantal Woog detailing my experiences as an English midwife receiving considers her experience maternity care in America, this article discusses specific of maternity care in differences in practice between the UK and America from the America from the perspective of a midwife. Here I focus on the implications of anmidwife’s point of view and compares approach to care that views pregnancy and birth as a conditionit with that in the UK to be managed rather than a physiological process, with care that focuses on pre emptive measures. I also consider the role of the midwife with regards to scope of practice and the benefits of this. Keywords Choice, risk, fear, continuity of care, midwife Author Chantal Woog, a midwife currently living in Arkansas, AmericaH aving shared with Birth can be frightening 2005). Gaskin (2011) believes that fear readers my experience of and challenging but it is a key factor in childbirth in the USA preparing for birth in can also be one of the and believes that this is mainly due to Arkansas, as well as the most powerful and ignorance. She believes that knowledgebirth itself, this final article will deeply fulfilling is empowering and seeks to addressdiscuss some of the differences, from experiences of a this fear. Talking to Holly, a labour anda midwife’s perspective, and how this womans’ life birth nurse, she feels that she ishas ultimately caused me to reflect on working in a culture where womenpractice in the UK. There are many Powerful experience have lost sight of the importance ofaspects of my experience that I could Birth can be frightening and birth; they are unable to trust theirdiscuss but the most pertinent ones to challenging but it can also be one of bodies and ultimately defer to theme are: the high risk approach to care the most powerful and deeply fulfilling medical profession for guidancein labour (specifically for low risk experiences of a woman’s life (Morris through the childbearing journey.women), highlighting the Having experienced pregnancy anddifference between the medical and labour care in Arkansas, as well asmidwifery models of care and having had countless discussions onultimately the unique role of the the topic with friends and randommidwife and our extensive scope of strangers (often sparked by my obviouspractice which enables UK midwives to bump), I feel that I can agree with bothprovide, where possible, continuity of of these sentiments. I have concludedcare. that it is not the fault of the mothers

THE PRACTISING MIDWIFE • May 2013 An English midwife in Arkansas • 29but rather the environment in which Unnecessarily refuse advice (Nursing and Midwiferycare is delivered as well as the practices Council (NMC) 2004). Price (2006)governing this. categorising a mother as explains that focusing on the abnormalAnticipation and fear can be disabling. UnnecessarilyBased on my experience, pregnancy andbirth are treated as a ‘condition’ to be high risk ignores categorising a mother as high riskmanaged rather than a physiological individual factors and ignores individual factors andprocess. This is increasingly apparent as ultimately limits her control and choiceterm approaches and obstetriciansperform cervical assessments from 36 ultimately limits her over her care. Personal choice andweeks in an attempt to predict when control and choice over responsibility highlight the mother aslabour will start. The date of birth is an agent of free choice who haspredicted and an expectation is set,rather than allowing nature to take its her care ultimate control in decision makingcourse and await the event. During my (Davis 2003). Working as a communitypregnancy I had many pregnant friendsand was often amused by the topics of midwife, I have attended the homeconversation that generally includedweekly updates of their cervical births of several mothers who werechanges. Many were disappointedwhen labour did not commence as strongly advised to give birth in apredicted by their doctors and evenprior to term, induction soon became nature of medical care it is difficult for a hospital - but it was ultimately theirthe next topic of conversation. Itbecame increasingly apparent to me mother to refuse certain routine choice, made after lengthy discussionsthat these mothers were alreadystarting to doubt their bodies’ ability to practices as her obstetrician can regarding the associated risks. Inlabour and with this came fear. Furtherto this, practices in labour care, which ultimately refuse to look after her as he contrast to the midwifery model of careinclude intravenous access and nil bymouth, highlight labour as dangerous may consider the potential for litigious provided in the UK, my experience andand an event to be managed. I believethis further engrains in mothers’ minds repercussions too great. It appears that research of maternity care here appearsthe ‘danger’ of labour, thus confoundingtheir fear. it is this fear rather than what is right paternalistic in nature, and there seems MThe nature of care for the individualWhen I asked during my delivery suitetour why I could not eat in labour, the that shapes care. Itnurse informed me that it was “in case Ihad to have a tube put down my throat is clear from myin the event of an emergency caesareansection”. It is not surprising that women experience that No.1 supplier of essential midwiferyare fearful. Of course, risk is an some aspects of care products in the U.K.inevitable part of pregnancy, labour and can be negotiated -birth and it is impossible to remove itentirely, but as midwives we are but they do have to DOPPLERS THERMOMETERSconstantly risk assessing so as to ensure be asked for.appropriate assistance is sought andreferrals made should deviations from Midwifery vs SCALES MEDICAL BAGSthe norm occur. Due to the privatised medical models Unique elements of Timesco o er a complete range of general medical products: the midwifery - as Stethoscopes | Sphygmomanometers | Pulse Oximeters opposed to the medical - model of Diagnostic Products | Resuscitation Products | Suction Devices care, acknowledge and address the For more information, pricing and social, cultural, samples please call 01268 297 700 psychological, or email [email protected] ethical and political aspects of birth (Morris 2005). Midwives provide holistic care that is embedded in choice; our rules state that we must respect mothers as individuals as well as their right to

30 • An English midwife in Arkansas May 2013 • THE PRACTISING MIDWIFEto be a one-size-fits-all approach. It is In focusing primarily on different professionals, withunfair to categorise all women as high appropriate referrals as indicated ofrisk and this ultimately fails to address the abnormal are we at course.the individual characteristics of eachmother. risk of adopting Contrast I am equally frustrated and fascinatedWhen the focus is on abnormality America’s more at the differences in practices betweenReflection of my experience in Arkansas two such developed countries, andhas made me understand the benefits medicalised approach although I had numerous hurdles tofor midwives of practising with national overcome, overall I had a positive birthguidelines that acknowledge pregnancy to maternity care? experience (thanks in no small part toand birth as generally very safe, endorse the individuals mentioned in thethe provision of choice regarding birth birth, where is the education in normal preceding articles). The heart oflocation for low risk mothers and aspects of midwifery care such as water midwifery is concerned with the carerecognise the benefits of midwife led births and improving support to and support of women and their babiescare settings (National institute of mothers in labour? as well as supporting choices (Royalhealth and clinical excellence (NICE) College of Midwives (RCM) 2012). My2007). The more rigid approach to risk Continuity of care experience in Arkansas has highlightedmanagement in the USA presents a This experience has also made me the unique and wonderful role we playstark contrast to the UK midwifery reflect on the full role of the midwife. in caring for women during this lifemodel of care that focuses on Specifically that we are able to provide changing time, as well as thepromoting labour and birth as normal antenatal, intrapartum and postnatal importance of respecting their choicesand safe events and I am reminded of care. In addition many midwives are and requests. Being plunged into anour approach to risk management and able to carry out neonatal environment that has minimal regardprocesses of ensuring quality examinations, enabling the mother and for personal choice and mothers’healthcare delivery. In my experience, baby to have continuity of care. It may autonomy, I am reminded of thehospital based training sessions focus not always be the same midwife, but a important role midwives have inon obstetric skills drills and CTG midwife nonetheless. empowering mothers throughout theirtraining. Price (2006) believes that pregnancy, birth and journey intothese focus on pathology and Following discharge from hospital my motherhood. TPMabnormality with an ultimate focus on baby was seen twice in the first twoobstetric care rather than midwifery weeks by a paediatrician. These routine Chantal Woog is a midwife currently livingcare. The benefits of such training are of check ups are no different from the in Arkansas, Americacourse highly valuable, however in routine postnatal assessments carriedfocusing primarily on the abnormal are out by midwives in the UK. Having a Referenceswe at risk of losing sight of the different practitioner provide care forimportance of learning normal my baby (again a doctor with a focus on Davis D (2003). ‘Spoilt for choice: consumingmidwifery care such as developing our a medical model of care), created a maternity care’. Brit jour midw, 11(9): 574-skills in supporting mothers in labour disjointed atmosphere. The doctor 578.and promoting normal birth? Are we at appeared preoccupied with vaccinationrisk of adopting America’s more schedules and vitamin supplements Gaskin I (2011). Birth matters, USA: Sevenmedicalised approach to maternity rather than how we were adapting to Stories Press.care? The abnormal cannot be made life as a new family. Yet again thisnormal but Price (2006) questions if we medical model of care further Morris S (2005). ‘Is fear at the heart of hardare becoming too expert at making the highlighted the wonderful and unique labour?’ Midirs. 15(4): 508-511.normal abnormal. There seems to be a role of the midwife; we are able totrend towards focusing on high risk provide care throughout the antenatal, NICE (2007). ‘Intrapartum care - care of healthyaspects of maternity care, particularly intrapartum and postnatal period that women and their babies during childbirth’.for mandatory training. All of these enable the mother, baby and family Clin guid 55, London: NICE.study days reflect important skills for a unit to be our focus, rather thanmidwife to have, but in the interest of allocating specific aspects of care to NMC (2004). Midwives’ rules and standards.maintaining competency in normal London: NMC. Price L (2006). ‘Risk obsession on the labour ward’. Midw matters, 108: 12-13. RCM (2012). Minimising risk [online]. Available at: http://tinyurl.com/crvx9xw Accessed 2nd September 2012.

THE PRACTISING MIDWIFE • May 2013 Mothers’ and babies’ wellbeing • 31Keeping them safeIn the first of two articles, SUMMARY The social aspect of health and wellbeing is as important asMark Solon describes the measuring blood pressure. It is important to record in writing any concerns.key position which Some of the worst failures in safeguarding and child protection have occurredmidwives hold in terms of when professionals have lost sight of the child and concentrated instead onensuring mothers’and their relationship with the adults. Where a child is either suffering from or atbabies’ wellbeing risk of significant harm, that child’s interests override those of their parents or carers. Although an unborn child has no legal rights until it is separate from its mother, following publication of a number of documents, midwives are now obliged to take particular steps to protect vulnerable children once they are born. Keywords Record concerns, safeguarding, social aspects of midwifery, vulnerable babies Author Mark Solon, solicitor and Managing director of a legal training consultancyI t is a sad but inescapable fact that Midwives often form An NHS practitioner handbook for M in addition to midwives’ more close relationships that safeguarding children points out that: obvious nurturing role they have allow them to build a “The risk of maltreatment is greater a front line duty to safeguard picture of domestic life, where parents have multiple andvulnerable children and adults from relationships, possible complex needs; especially the ‘toxicharm and abuse (Nursing and substance abuse and trio’ of substance abuse, mental healthMidwifery Council (NMC) 2013). overall attitudes problems and domestic abuse” (Solent towards the child-to-be NHS Trust et al 2011: 4). Many midwives The Government is currently working will meet parents and families withon reforming the child protection and overall attitudes towards the child- these issues in the course of their work.system and midwives are at the very to-be.heart of its strategy, charged with Social rolepicking up early on a range of issues There is a growing sense that midwivesthat may endanger a mother and/or understand that their role is of socialher born or unborn child. importance as much as it is medical. Dr Catherine Powell, Consultant Midwives are in a unique position. (designated) nurse safeguardingUnlike social workers they see all children, who will be speaking at themothers and their babies, and often Royal College of Midwives’ (RCM) andform close relationships that allow Bond Solon’s Legal birth conference inthem to build a picture of domestic life,relationships, possible substance abuse

32 • Mothers’ and babies’ wellbeing May 2013 • THE PRACTISING MIDWIFEJuly, where this issue will be discussed, While an unborn child Children are keysaid: “The…social aspect of health and The Practitioner handbook furtherwellbeing is as important as measuring still has no legal rights reminds us that: “Some of the worstblood pressure. failures in safeguarding and child until it is separated protection have occurred when “We have to recognise the fantastic professionals have lost sight of the childjob that midwives do but also be very from its mother, there and concentrated instead on theirclear about their role and relationship with the adults.responsibilities.” are now clear steps that “Where a child is at risk of, or Powell emphasises that at least one midwives must put in suffering from significant harm, thehome visit ought to be conducted by a interests of the child override those ofmidwife and that the father ought to be place to protect a their parents or carers (Solent NHS Trustincluded: “Seeing a home is really et al 2011: 9).”helpful and it can make a big difference vulnerable child once itseeing parents within the home Examples of this include a mothersetting,” she said. is born who reports domestic violence to her midwife but does not want any actionNot missing the point to provide police protection. taken against her partner; as domesticIn headline cases such as Baby Peter, For midwives’ own protection as well violence poses serious risks to the childwho died in August 2007 after suffering as well, there is a duty to protect thea catalogue of abuse, Powell points out as that of the child it is important to child and so the partner will bethat events rarely happen overnight. record in writing any concerns about a prevented from further violence.While there is no suggestion in that child’s welfare and to make good, clearcase that midwife action could have notes of any subsequent discussions, But while an unborn child still has noprevented his death, opportunities action taken and the reason for those legal rights until it is separated from itsclearly were missed by healthcare actions. If no further action is to be mother, there are now clear steps thatprofessionals collectively. taken it is important to record the midwives must put in place to protect a reasons for that. vulnerable child once it is born. Andrew Andrews MBE, medico-legaldirector for Bond Solon who will be In the ‘Working together to safeguard Munro’s recommendations – whichchairing a simulated case conference at children’ report 2010 - commissioned by are awaiting Government responsethe Legal birth conference added: “It is the Government in its attempt to after a lengthy period of consultation -a question of being aware because if reform child protection – the report’s have put the focus of care firmly backyou think about it, the current author Professor Eileen Munro said: on the child. It is as yet unclear exactlyindicators are that one in four children “While professionals should seek, in what the newly reformed childare sexually abused. Abusers are general, to discuss any concern with the protection system will look like. Buttrusted and known to their victim.” child and family and, where possible, more than ever, midwives will be seek their agreement to making referral expected to be vigilant on behalf ofWhen there are concerns to local authority children’s social care, those who are too small or tooMidwives who do have concerns of any this should only be done where such vulnerable to stand up for themselves.kind need to discuss these with their discussion and agreement-seeking will TPMnamed safeguarding midwife. These not place a child at increased risk ofconcerns can range from actual suffering significant harm.” Mark Solon is a solicitor and Managingevidence of abuse to ‘contextual’ director of a legal training consultancyconcerns over severe financial hardship, Legally, an unborn child has no status,tensions between the mother and and this explains much of the focus Referencesfather, or even problems in the local historically being on the mother, who iscommunity. If it is decided that these able to do what she wishes to her body DfE (1989). The children act, London: Crownconcerns must be escalated, it falls to during pregnancy without legal copyright.the practising midwife to report them consequence. Andrews said:to children’s social care or, in an “Historically this issue wasn’t of prime NMC (2013). Introduction to safeguardingemergency, the police, who have concern because in reality you can’t adults, London: NMC.powers under the Children Act 1989 safeguard the fetus (a child to be).”(Department for Education (DfE) 1989) Solent NHS Trust, NHS Portsmouth and NHS Southampton City (2011). Everyone’s responsibility. Safeguarding children, Southampton: Solent NHS Trust.

THE PRACTISING MIDWIFE • May 2013 Researchunwrapped • 33Linhares CH (2012).‘The lived experiences of midwives withspirituality in childbirth: mana from heaven’. Journal of midwiferyand women's health, 57(2): 165-171.Research unwrapped is a popular series to help readers make sense of Susan Crowtherpublished research by undertaking a detailed appraisal of an article in a unwraps a recentcareful and considered manner. In doing so we can advance our research paper onknowledge and understanding of a research topic and apply it to our a transcendentalpractice. This process is designed to assess the usefulness of the evidence phenomenological enquiryin terms of decision making and application to practice. It is important into midwives and spiritualitythat the appraisal is critical and that midwives are evaluative in theirreading of research. This month’s paper appraises a phenomenological study that explores In an age ofthe meaning of midwives’ lived experience of spirituality. information overload,Phenomenology is about uncovering meaning and focuses on lived we need to knowexperiences. As such phenomenology is an important research quickly whether anmethodology that reflects midwifery values. article is going to match the questions we haveH ow you approach Drawing the reader in or the general interest appraising and scrutinising The title reflects the research area that we wish to any research paper is completed and the report. The abstract pursue important. Since we come is constructed as a research reportto our reading with unique aspirations, which provides quick and easy access to paper. It is easy to establish thehistory and preconceived notions, being the subject matter, methods, credentials of the author as midwifefocused is central to gaining what you philosophical underpinnings, findings practitioner and associate professor inwant from the reading of any research. and conclusions. This is vital to nurse and midwifery education in theBeginning with three basic questions is contemporary article writing when state of Hawaii. In addition, a quickhelpful: there is so much to read. Researchers, glimpse of the reference list practitioners and students require demonstrates extensive use of What is this research about? logical and coherent abstracts to assist associated and pertinent literature. at the scanning stage when reading a •• What are the three-five key pile of papers. In an age of information Introduction of the research points? overload, we need to know quickly The introduction explains the purpose whether an article is going to match the of the study and identifies spirituality in • Finally - so what…? questions we have or the general interest area that we wish to pursue. Once you have attuned your thinkingto reading a research article, it is On first reading through Linhares’important to be drawn in from the paper, it is evident that this is a credible,start. With this in mind I turn to well structured, academic and scholarlyLinhares’ published research. M

34•Researchunwrapped May 2013 • THE PRACTISING MIDWIFEhealth care as a growing interest area. notions to the realm of academic structured throughout and easy toThere is no defined research question, research and publication can prove follow. The themes emerged in abut the purpose of the study as seeking difficult and this paper has addressed coherent fashion from the data samplesa description of a phenomenon is this well. However, on reading the provided. A good article isclearly stated as: “the essence of the article, the reader may disagree with grammatically cohesive: paragraphslived experiences of nurse-midwives who the interpretations and definitions should attempt to adhere to a simplehave experienced the phenomenon of given. This is not a problem as it reflects pattern of statement, explanation,spirituality in their practices when they the nature of phenomenology example and author’s opinion. This ishave attended births” (Linhares 2012: methodology; the important thing is the case in the majority of this article165). The author has repeated the that you, as the reader, know how the which, although it comes from a PhDstudy's purpose both in the abstract word ‘spirituality’ is used for the thesis (these can be a challenge forand introduction. purposes of the study. authors to condense into publishable wordage limits), has achieved clarityDefinitions of terms Finding the gap and succinctness without losing essential depth of meaning.Central to the paper is the notion of The review identified the paucity of Ethicsspirituality. Definitions of spirituality literature on spirituality and birth. There is a statement that ethical approval was gained before participantare explored so that the reader knows Examining the evidence that is recruitment was undertaken, and the name of the ethical approving authoritywhat the author means by the term. published and identifying the gaps is included. The study appears to have been conducted ethically. As the originalControversial and difficult words in good academic practice. The next step research report is referenced, I was also able to access the full PhD thesis onlinepublications require explanation. This is is to examine how the author wants to and determine ethical processes.especially important when notions and address the gap, once established. Methods and methodology In qualitative research, methods andexperiences such as spiritually can Linhares’ paper describes how the methodology are often split into two. Methods are the nuts and bolts of aseem ineffable. Bringing difficult present research attempts to fill the study: how it was logistically done. Methodology, on the other hand, is an gap in the examination of the philosophical underpinnings of a study. The knowledge. Due to methodology includes the philosophers that provide the depth of thinking in the nature of the the phenomenological research. This is apparent in doctoral work like Linhares’CENTRE FOR research topic, study; after all the Ph in PhD stands forULTRASOUND STUDIES there is a scarcity philosophy. of published The methods for the study wereUltrasound Education and literature and this rigorously described and justified. SomeTraining at the AECC, is acknowledged in of the philosophical underpinningsBournemouth the article. This were made explicit, which is an acknowledgment essential aspect of phenomenologyApplications are now being accepted until is also another research (Crowther 2011; Thomson et alAugust 16th 2013 for the following important aspect 2011). Phenomenology belongs to aprogramme: of reviewing branch of philosophy that examines the research on lived experiences in a particular andPgCert, PgDip or MSc Medical Ultrasound* meticulous way. The central tenet is to reveal the meaning of lived experiences,This part-time innovative programme has been rarefied topics. Itdesigned by a team of ultrasound experts. helps you, as the reader, to positionA exible programme with opportunities to study: the research paper in the publishedt

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THE PRACTISING MIDWIFE • May 2013 Researchunwrapped • 35which fits the purposes of this study. as a valuable part of the study itself generalisations as such but common MThere are different types of (Smythe 2011). When reading themes that resonate when read andphenomenological study that are phenomenological studies it is heard by others. Despite thisunderpinned by different philosophical important to be able to position where reservation the sampling, and how thetraditions. This study used a the author is situated in this analysis unfolded, are adequatelytranscendental phenomenological philosophical difference. covered in the article.approach that involves identifying andputting aside the investigators’ Linhares provides sufficient evidence Analysisassumptions, notions and experiences. of her own personal experiences of The data analysis is appropriate to theThis process is named ‘bracketing’. spirituality and birth and the meaning research design methods andBracketing is believed to help ensure that has for her; it is easy to ‘see’ the methodology. Wonderful samples fromthat analysis of data is not influenced researcher in the context of the study. the interview data are provided toby the investigator’s personal This published article on the study illustrate the descriptive work of theinterpretation, allowing any findings to reveals this well and positions the analysis. The findings represent a crossbe more objective. For example, research in the Husserl tradition of section of the participants. AlthoughLinhares states how she attempted to transcendental phenomenology. more analysis is always morebracket out her own story before the informative, I am aware that journalstudy through the use of a personal Sampling and data collection reporting of qualitative results isjournal. The process of journaling in this The logic of sampling is explicit and an constrained by wordage.methodology provides the investigator explanation of when sampling and data Phenomenology is essentially descriptivethe means to identify what collection were sufficient to address the and interpretative, and wordage canunderstandings she brings to the study purpose of the study, provided. The therefore be very limiting in publication.and exclude these pre understandings notions of saturation and redundancy However Linhares has addressed this byfrom the findings. The rationale for this are described and are a common publishing related articles that examineapproach is to see the phenomenon feature of qualitative research. Yet such different aspects of her work. Theseuninfluenced by her personal terms are also challenged in the other publications are referenced in thisexperiences and history. However there phenomenological research community. article for readers to pursue further.are varying approaches to It can be argued that the numbers ofphenomenological research and this participants are unimportant: what is The analysed data supported theability to bracket out preconceived important is gathered data from themes presented in the article:notions and prior judgements is participants who experience thedebated (Laverty 2003). For example, phenomenon. This allows for an • Belief in the existence of a higherthe interpretive or hermeneutic uncovering of the phenomenon powerphenomenological approach would experienced, so that plausible The essence of spiritualityembrace all that the researcher brings interpretation can be made. Phenomenology does not seek • Birth is spiritual • The essence of midwifery •• Relationships

36•Researchunwrapped May 2013 • THE PRACTISING MIDWIFEThe findings, discussion this topic. She has contributed to filling 'phenomenological nod' or an 'aha’ the gap and enhanced her discussion moment; the moment on reading whenand conclusion are with others’ work that examines related you say 'Oh I see what you mean.' issues concerned with midwifery and Linhare indirectly challenges us throughcoherent and spirituality. her study to reflect on our experiences as midwives by drawing our attentionbelievable in relation to Discussion and conclusion to spirituality in midwifery. This study The discussion is thought-provoking could have implications for furtherthe presented data and appropriate. In the discussion research, midwifery education and section following the data and analysis, parent education. The bubbling up of Each of these themes arose from the other published articles are addressed further questioning is an outcome oflived experiences of Linhares’ and compared. The critical research phenomenological research whenparticipants. The data provided reviewed in the introductory sections is plausible interpretations are presenteddemonstrate the plausibility of the linked to other knowledge and is (Smythe 2011). For example, I am leftgenerated themes and the analysis integrated throughout the discussion. wondering if all midwives wouldprovides food for thought to us as appreciate and endorse the findings ofmidwives. The conclusion is appropriate, brief this study? What about the lived and to the point. A criticism would be experience of spirituality of others atTrustworthiness and authenticity that if I was a reader who only read the birth? This research paper, however,There were explicit and adequate conclusion and not the discussion, then provides an opportunity for practisingprocesses employed for ensuring the the major thrust of the research would midwives to ponder the spiritualtrustworthiness and authenticity of the be missed: if the conclusion meanings of their profession. It is astudy. Credibility, transferability, insufficiently reports on the key points, paper that can stir us to moredependability and confirmability used we may miss the ‘So what?’ of the contemplative thinking. TPMin place of validity and reliability were paper. The assumption is that if it isdescribed (Crowther 2011). For example important to the published research, it Susan Crowther is senior lecturer ina detailed description of the research features in the conclusion. In the midwifery at AUT University, Auckland,process is included in this study to conclusion, it is necessary to restate the New Zealandestablish transferability. Dependability purpose and thrust of the work, alongand confirmability were established with the key points and the ‘So what?’ Referencesthrough the inclusion of an expert in in order to leave the reader pondering.phenomenology who provided an However this does underline the need Crowther S (2011). 'Reading, evaluating andexternal audit to the study. This process to read an article in its entirety, as the interpreting phenomenological research'. Thehelps ensure that descriptions and conclusion is not necessarily the whole pract midw, 14(5): 36-39.interpretations are plausible and arise message condensed.from the data. The findings, discussion Laverty SM (2003). 'Hermeneuticand conclusion are coherent and Final thoughts phenomenology and phenomenology: abelievable in relation to the presented The research provides further findings comparison of historical and methodologicaldata. that reveal that birth is something considerations'. Int jour qual meth, 2(3): 1-29. more than the industrialised andLimitations technological phenomenon it appears Linhares CH (2012). ‘The lived experiences ofThe limitations of the study are to have become. Acknowledgment that midwives with spirituality in childbirth:discussed. Linhares acknowledges that something about birth is meaningful is mana from heaven’. Jour midw and womthis was a study on Hawaii with a small uncovered in this study. Voice is given to health, 57(2): 165-171.population of midwives, involving midwives who recognise and articulateparticipants with a limited range of the spiritual meanings in their work Smythe EA (2011). 'From beginning to end: howreligious and cultural backgrounds. with birth. There can be a personal to do hermeneutic interpretiveHowever she presents her discussion recognition and remembrance on phenomenology'. In Thomson G, Dykes F andand findings in a way that challenges reading phenomenological studies such Downe S (eds). Qualitative research inthe research community to expand on as this one. You can be left reflecting on midwifery and childbirth: phenomenological your own personal and professional approaches, London: Routledge. experience. That is the aim of this type of study: the invocation of a Thomson G, Dykes F and Downe S (eds) (2011). Qualitative research in midwifery and childbirth: phenomenological approaches, London: Routledge.

THE PRACTISING MIDWIFE • May 2013 Breastfeeding challenges • 37 MIDWIFERY BASICSInfant feeding8. Breastfeeding premature babies ‘Infant feeding’is the twelfth series of‘Midwifery basics’ targeted at practising midwives.The aim of these articles is to provide information to raise awareness of the impact of the work of midwives on women’s experience and encourage midwives to seek further information through a series of activities relating to the topic. In this eighth and final article,Joyce Marshall considers some of the key issues related to breastfeeding premature babies.ScenarioBaby Jack was born by caesarean section at 29 weeks gestation as his mother Lynne had pregnancy induced hypertension.Lynne enjoyed holding Jack against her skin immediately after birth in the operating theatre as he seemed calm and relaxedalthough she was amazed at how small he seemed. Lynne is keen to start expressing breast milk for Jack and has asked themidwife what she should do.Introduction Specific biofactors such Breast milk: ‘a medicine’ forHaving a premature baby can be a very as IgA, lactoferrin, premature babiesfrightening and traumatic experience lysosyme, growth Breastfeeding is the optimal choice forfor parents (Arnold 2010). They may be factors and enzymes in all babies, but being fed breast milk isanxious and concerned about the human milk all especially important for prematurehealth and even survival of their infant contribute to decreased infants. Specific biofactors such as IgA,and may spend long periods of time rates of infection in lactoferrin, lysosyme, growth factorsseparated from them (Renfrew et al premature infants and enzymes in human milk all2009). Mothers with a baby in the contribute to decreased rates ofspecial care or neonatal unit make the infection in premature infants (Hurst Mtransition to motherhood in an and Meier 2010).unfamiliar and medicalisedenvironment (Flacking et al 2006) and Hazards of formula feedingmidwives caring for families of There are many hazards of formulapremature babies can do much to feeding affecting a broad range ofsupport them at this difficult time. outcomes, for premature infants, such

38 • Breastfeeding challenges May 2013 • THE PRACTISING MIDWIFE MIDWIFERY BASICSas delayed brainstem maturation, The composition of breastfeed, will be keen to express at Mpoorer visual acuity and increased milk from mothers of least some breast milk for their baby,incidence of retinopathy of prematurity premature infants once they understand the importance(Arnold 2010; Hurst and Meier 2010; differs from that of of this (Hurst and Meier 2010). SomeWalker 2011). mothers of term babies; mothers may be happy to express their it is higher in many milk but might never want toNectrotising enterocolitis nutrients for about the breastfeed and it is important forOne of the most important issues to be first two to four weeks midwives to support mothers in theseaware of is that premature babies who decisions and whatever level ofare fed formula rather than human milk human milk have also been shown to commitment they feel able to give,are around six to 10 times more likely to have better neurodevelopmental without judging them (Hurst and Meiersuffer from nectrotising enterocolitis outcomes at 18 months of age than 2010).(NEC) than babies who are fed either those not fed human milk in a dose-their mother’s milk or donor human dependent relationship (Vohr et al Activity 1milk (Lucas and Cole 1990; McGuire and 2006). This study of 1035 low birth Consider what you would say to aAnthony 2003). Nectrotising weight infants showed that the more mother about the importance ofenterocolitis is a disease of prematurity breast milk the infants ingested, the providing breast milk for her baby.that causes significant mortality and higher the mental developmental, Would it be useful to considermorbidity. It is a condition that, if psychomotor and behaviour scores breast milk as a medicine?allowed to progress, can lead to (Vohr et al 2006). Download and read Miracle et alischaemia, gangrene and possibly (2004).perforation of the intestine (Arnold Beneficial milk http://tinyurl.com/bp3m9ls2010). The risk of developing NEC is Premature infants have greaterhighest in infants born at earlier nutritional needs than full term infants, Expressing milk for prematuregestations. Lucas and Cole (1990) partly because of the immaturity of babiesestimated that 400 cases and 100 their digestive systems (Arnold 2010). A mother of a premature infant willdeaths could be prevented each year if The composition of milk from mothers need to initiate and maintain lactationinfants were fed human milk. of premature infants differs from that until their infant is able to suckle fully of mothers of term babies; it is higher at the breast. This may be for severalBenefits of human milk in many nutrients for about the first weeks or even months at a stressfulDigestion two to four weeks (Arnold 2010). time. It may therefore be important forThe gut of the premature infant is midwives to provide emotional supportimmature and human milk contains For all these reasons premature as well as information to enablecomponents that help it to mature babies should be fed human milk unless mothers to persevere to achieve theirwhereas formula does not (Walker medically contraindicated. goals. Although having a baby2011). Components in human milk are prematurely does not appear to limitthought to promote closure of the Informed choice mothers’ ability to produce milk, manyjunctions between cells in the lining of Parents of premature infants have a of the factors that often occur as part ofthe gut and aid the digestion of right to factual information about the the overall experience are known toproteins and carbohydrates; whereas effects that human milk feeding will inhibit the production of prolactin, suchundigested casein in the gut from have so that their feeding decision can as maternal complications, tiredness,formula can attract neutrophils that be based on current evidence. Most stress and irregular breast milkprovoke an inflammatory response and mothers, even if they do not intend to expression (Hurst and Meier 2010). Theopening of the junctions between cells shortened gestation may meanin the gut wall, allowing invasion and hormones do not reach maximumdamage to the premature infant’s levels and lactogenesis II may befragile gut (Walker 2011). delayed, which may result in low milk supply in the early days after birthNeuro development (Arnold 2010).Extremely low birth weight infants fed

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40 • Breastfeeding challenges May 2013 • THE PRACTISING MIDWIFE MIDWIFERY BASICS Activity 2 Kangaroo care enable them to settle (Arnold 2010). Based on your knowledge of the The baby is placed in a fetal position physiology of lactation, what increases exclusivity of between the mother’s breasts vertically suggestions might you make to a or diagonally with only a nappy and mother who is concerned that the breast milk feeding at maybe booties and a hat on, covered volume of milk she is expressing is with a blanket and the mother’s low? Where and how is expressed every time point up to clothes. There is no need to limit time breast milk stored in your unit? spent skin to skin unless the mother 18 months requests or the baby shows signs ofAdequate supply distress (Hurst and Meier 2010; NyqvistMothers should start to express breast stored, the milk fat rises to the top, so 2013). Since 2003 kangaroo care hasmilk as soon as possible after birth and mothers should be encouraged to been recommended as part of highshould express frequently in the first gently mix the milk before pouring it quality neonatal care (World Healthfew days (eight to 10 times daily) (Hurst into sterile storage containers, Organization (WHO) 2003).and Meier 2010), with at least one otherwise the baby may receive milkbeing at night between 02.00 and 06.00 with very different calorific content at Activity 3when prolactin levels are highest different feeds (Hurst and Meier 2010). Search the internet using a phrase(Walker 2011). It may be helpful for such as ‘kangaroo care’ ormothers to express near the baby or Kangaroo care and milk production ‘expecting a premature baby’ andhave a photograph or an item of the Skin to skin or kangaroo care is an look at the information mothersbaby’s clothing to help to stimulate important aspect of care for premature may access. A range of books andoxytocin to enable the milk to flow. The infants, and documented benefits DVDs is available to mothers;aim should be to produce a milk volume include: stability of vital signs, consider which of these you feelof 750-1000mls a day at the end of the increased parent-infant interaction, would be useful to mothers offirst week to 10 days, regardless of the faster neuro-behavioural maturation premature babies whom you mayinfant’s needs at that time (Hurst and and improved sleep patterns (Hurst and care for as a midwife.Meier 2010). This will help mothers to Meier 2010). It also provides readyproduce an adequate ongoing supply. It access to the breast, improves milk Mothers’ experiencesmay be helpful to start by hand supply (Moore et al 2012) and can Mothers of premature babies inevitablyexpressing and collecting drops of mean that the mother is more experience negative and conflictingcolostrum by syringe from the nipple responsive to her baby’s cues. Evidence emotions which are more severe with(UNICEF UK Baby Friendly Initiative (BFI) from a systematic review suggests that increasing prematurity (Arnold 2010).2009) but after this a hospital grade kangaroo care leads to increased The most stressful aspects of neonatalelectric pump is likely to be needed, and duration of breastfeeding of premature care for a mother of a premature babypumping both breasts at the same infants after discharge home (Renfrew are separation and her inability to fullytime, most effective (Renfrew et al et al 2009); and, in a small study in the care for her baby (Boucher et al 2011;2009). USA, Hake-Brooks and Anderson (2008) Flacking et al 2006). Most mothers are found that kangaroo care increased separated from their baby as facilitiesExpressing fully exclusivity of breast milk feeding at for rooming in are limited. Flacking et alAt least 50 per cent of the calories in every time point up to 18 months. (2006: 74) found that this resulted inhuman milk come from lipids and the Kangaroo care has also been shown to women feeling like a visitor andlipid concentration increases decrease the length of hospital stay ‘unimportant to the infant’ and thatthroughout a single milk expression (Gregson and Blacker 2011). their emotional needs to be close to the(Hurst and Meier 2010). It is therefore infant were not met. Holding their babyimportant that mothers know this and The transfer of an infant to the skin-to-skin and breastfeeding can be aare encouraged to continue pumping mother’s chest for kangaroo care can be step towards normalcy and willuntil the flow of milk ceases, as the last a stressful event and therefore the strengthen the relationship betweenfew drops to be expressed will be high duration of kangaroo care should the mother and baby (Flacking et alin calories. When expressed milk is generally be longer than an hour to 2006). The new UNICEF BFI standards incorporate this at the Stage three

THE PRACTISING MIDWIFE • May 2013 Breastfeeding challenges • 41 MIDWIFERY BASICSGood support can make gold’. What information will Lynne need (eds). Breastfeeding and lactation, London: to enable her to establish a good milk Jones and Bartlett.a real difference to both supply? What kinds of breast pumps are Lucas A and Cole TJ (1990). 'Breast milk and available in your unit? Would Lynne neonatal necrotising enterocolitis'. Thehow women feel and to have unrestricted access to Jack in your Lancet, 336(8730): 1519-1523. unit? McGuire W and Anthony MY (2003). 'Donortheir ability to supply human milk versus formula for preventing Conclusion necrotising enterocolitis in preterm infants:breast milk for their Having a premature baby is a very systematic review'. Archives of disease in stressful life event for women and childhood - fetal and neonatal edition, 88(1):baby families. Providing good support can F11-F14. make a real difference to both how Miracle DJ, Meier PP and Bennett PA (2004).assessment by including standards that women feel and to their ability to 'Mothers' decisions to change from formulamust be met in relation to parents’ supply breast milk for their baby. to mothers' milk for very-low-birth-weightexperiences in the neonatal unit. This Midwives have a key role to play in infants'. Journal of obstetric gynecology andincludes unrestricted access to their ensuring that women have correct neonatal nursing, 33(6): 692-703.baby, encouragement to touch and evidence-based information to enable Moore ER, Anderson GC, Bergman N et al (2012).respond to their baby; and to hold their them to make important infant feeding 'Early skin-to-skin contact for mothers andbaby skin-to-skin (UNICEF UK BFI 2012). choices, emotional support to help their healthy newborn infants'. CochraneIn addition to support from health them to cope and practical support to database of systematic reviews, 5: CD003519.professionals, mothers may benefit help them learn the skill of milk DOI: 10.1002/14651858.CD003519.pub3.from mother-to-mother support or expression. TPM Nyqvist KH (2013). 'Breastfeeding pretermsupport from trained peer counsellors infants'. In: Genna C.W (ed). Supportingwhich can reduce anxiety and improve Dr Joyce Marshall is senior lecturer in suckling skills in breastfeeding infants,breastfeeding outcomes (Hurst and midwifery at the University of London: Jones and Bartlett.Meier 2010). Huddersfield Renfrew MJ, Craig D, Dyson L et al (2009). 'Breastfeeding promotion for infants in Activity 4 References neonatal units: a systematic review and Consider what emotional support economic analysis'. Health technology you would offer to a woman who Arnold LDW (2010). Human milk in the NICU: assessment, 13(40): 1-146. had given birth to a premature policy into practice, London: Jones and UNICEF UK BFI (2009). The UNICEF UK Baby baby if you were the midwife Bartlett. friendly initiative training pack, London: caring for her on the postnatal UNICEF UK BFI. ward. What support is there for Boucher CA, Brazal PM, Graham-Certosini C et al UNICEF UK BFI (2012). Guide to the Baby women in the neonatal unit in (2011). 'Mothers' breastfeeding experiences Friendly Initiative standards, London: UNICEF your place of work? Does this in the NICU'. Neonatal network, 30(1): 21-28. UK BFI. support continue once the baby is Vohr BR, Poindexter BB, Dusick AM et al (2006). at home? Flacking R, Ewald U, Nyqvist KH et al (2006). 'Beneficial effects of breast milk in the 'Trustful bonds: a key to \"becoming a mother\" neonatal intensive care unit on theReflection on the scenario and to reciprocal breastfeeding. Stories of developmental outcome of extremely lowJack will benefit from ongoing skin to mothers of very preterm infants at a neonatal birth weight infants at 18 months of age'.skin contact with his mother. Despite unit'. Social science and medicine, 62(1): 70-80. Pediatrics, 18(1): e115-123.him being so small, Lynne is confident Walker M (2011). Breastfeeding management forthat she can care for him. She is aware Gregson S and Blacker J (2011). 'Kangaroo care the clinician: using the evidence, London:that he feels calmer and more settled in pre-term or low birth weight babies in a Jones and Bartlett.when she is holding him. She has postnatal ward'. British journal of midwifery, WHO (2003). Kangaroo mother care: a practicallearned how to hand express and now 19(9): 568-577. guide, Geneva: WHO.has some colostrum for Jack; she smiledas the midwife referred to it as ‘liquid Hake-Brooks SJ and Anderson GC (2008). 'Kangaroo care and breastfeeding of mother- preterm infant dyads 0-18 months: a randomized, controlled trial'. Neonatal network, 27(3): 151-159. Hurst N and Meier P (2010). ‘Breastfeeding the preterm infant’. In: Riordan J and Wambach K

Professional development The Royal College of Midwives Annual Legal Birth: A ConferenceThursday 11 July 2013£120 + VATAt the Royal College of Physicians, London NW1 4LEFor more information on the fth annual legal conference for midwives:visit www.bondsolon.com/midwives-conference-londoncall 020 7549 2549Stay connected with British Medical Acupuncture Societycurrent midwifery practice FOUNDATION COURSES INYou can now develop your midwifery skills and WESTERN MEDICAL ACUPUNCTUREknowledge while continuing to work and earn London, *Experienced medicallyHow? Bristol, York trained lecturersStudy Midwifery and Women’s Health at our University Glasgow• Flexible study options Birmingham *100 Free needles• Specialist clinical training Manchester *Extensive course notes• State-of-the-art facilities DublinWant to know more?Visit go.herts.ac.uk/mwh-pmmor call us on 01707 284956 Suitable for regulated nurses & midwives New for Acupuncture in 2013 PREGNANCY & CHILDBIRTH London 20 September 2013 Book online: www.medical-acupuncture.co.uk Tel: 01606 786782 E: [email protected]

IMARY CA RE & PU22-23 May 2013 PRNEC Birmingham, UK LT H BLIC HEARegister free of charge today for the UK’s hottest eventfor primary, community and public health.www.primarycare2013.co.ukA dedicated two day mother and baby programme including:• Keynote address from RCM President, Professor Lesley Page• Pain and bleeding in pregnancy• Sepsis• Placenta praevia• Pelvic dysfunction• Cholestasis• Eating disorders during pregnancy• Natural birth• Managing fear of childbirth• Managing emergencies including postpartum haemorrhage and maternal collapse• Fetal alcohol syndrome• Newborn blood spot screening• Promoting breastfeeding, bonding and attachmentOrganised by Sterling Events@PrimaryCare13 View the conference programme andPrimary Care 2013 register at www.primarycare2013.co.uk or for further information call 0151 709 8979

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46 May 2013 • THE PRACTISING MIDWIFELAST WORDA letter to future me Dawn StoneA lthough perhaps now a I hope your love of tools to shape you for next time. But distant memory, I hope you midwifery and what of those positive experiences? I still remember your student determination to be a hope you are adept at identifying days and what they felt like. good midwife have not strengths and positive attributes fromThe sheer panic and exhilaration, the wavered your care, rather than always seeing themassive highs and massive lows, and a negative. Likewise, I hope yousense that somehow, despite all of this, remember what a burden it was, and remember to compliment your studentsyou are in the right place at the right take the time to work through the and give them confidence andtime working towards the right goal. document with your students, rather encouragement to keep going – mentors than making them feel a nuisance for can more readily identify weaknessesPassion asking you to sign some things for and forget to celebrate strengths.I hope you still recognise the passion them.you see as you meet first year student Role modelmidwives, seeing the world of Recognising positives I have no doubt you are still taken abackmidwifery for the first time and full of I hope you remain a reflective by the emotions and power of birth,determination. While you may no practitioner, learning from the negative and what a difference kindness andlonger be as naïve or idealistic as you and positive. As a student, you were a compassion make. In the wake ofonce were, I hope your love of natural reflector when political debate and structural reform ofmidwifery and determination to be a traumatic or difficult the NHS, don’t believe the press thatgood midwife have not wavered. situations tell you midwives and nurses have presented stopped caring. It’s not the case, and it I like to think you’re a kind but fair themselves, and never will be. Be a role model for yourmentor; perhaps not everyone’s friend, used them as students and, slowly but surely, practicebut someone who hasn't lost the art of learning can and will change. Busyness shouldwelcoming and supporting and who never be an acceptable excuse for poortakes the time to smile and say hello. care.Often as a student, especially in a newplacement, a few kind words go a long Most importantly, I hope you stillway to relieving anxiety and fear. love midwifery, as well as caring for women, and empowering them andBurden their families as they move through thisI bet you’re glad to see the back of your life-changing process of pregnancy andpractice document! Carrying that folder birth. I know that even if everythingaround for three years was no fun and else has changed, this won't have.no good for your back! It was anightmare to try to balance learning on TPMplacement and seizing interestinglearning opportunities with trying to Dawn Stone is a second year studentget the boxes ticked. I hope you midwife at London South Bank University

World’s first of its kind Pregnacare® trialpublished 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 nnutrient 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 fof rmulated by expetrs, 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 iimmmmuunnee ssyystem. Originally developed withConception Breast-feeding ‘Plus Dual Pack Original Prof. A. H. Beckett† OBE, PhD, DSc (1920-2010) Professor Emeritus, University of London Important: some pprregnancy formulas do not ininccluluddeethtehexeact 10mcg vitamin D, as recommended by the Department of Health for all pregnant and breast-feeding women.Pregnacare® is the prenatal multivitamin brand midwivesrecommend 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† 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/mostrecommendedwww.pregnacare.com

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