The road to life: neonatal transitions to extra-uterine life
Neonatal Nurse at Hamad Medical Corporation, Qatar
Midwife at Women's Hospital, HMC, Qatar
The onset of labour and birth initiates profound changes for infants. It is essential to understand these unique aspects of childbirth; doing so will equip midwives with the ability to detect deviations from expected trajectories, take appropriate actions, but most importantly support normal birth transitions. These transitions involve a complex cascade of physiological, anatomical and behavioural changes acting in concert. This article will overview essential knowledge about the early adaptive changes after birth and considers initial cardio-respiratory and metabolic responses to birth, together with how midwives can support the best possible start for infants.
A changing model of rural care
Midwifery Teaching Assistant at Robert Gordon University, Aberdeen
Consider the impact on your pregnancy, birth and puerperium of living in a remote or rural area. A substantial minority of people in Scotland live in such areas, which has considerable implications for provision of health services and the staff at the front line of the profession. In the winter of 2011, Jo Lironi joined the team of midwives at Caithness General Hospital (CGH) in the North East Highlands of Scotland. Four years later, the process to review the model of care on grounds of safety began. This led to the immediate introduction of emergency interim measures while the public health review was initiated. Having left the unit after publication of the review, she reflects on her experience in a rural consultant-led unit and its transition into midwifery-led care.
Overcoming fear of facilitating water birth: student and mentor perspectives
Midwife Researcher and PhD Student at University of Central Lancashire
Elizabeth Marie Drew
Third year Midwifery Student at University of Northampton and NHS Professionals Care Support Worker, Maternity
Water immersion for labour and birth is a powerful, low cost intervention that facilitates physiological birth. However, for some midwives – students or qualified – a lack of exposure to water births can create fearful perceptions and reduce their willingness to support women in water. This article explores the nature of this fear, and how it was overcome from the perspectives of both the mentor and student, perhaps offering useful insights for others.
Obstetric anal sphincter injuries and the role of the midwife
In charge of Special Services for Perineal Trauma, Staff Midwife, and Clinical Senior Lecturer at Henrietta Szold/Hadassah-Hebrew University, Jerusalem
PhD Candidate, Midwife and delivery room Head Nurse, Hadassah-Hebrew University Medical Center, Jerusalem
Head of Female Pelvic Medicine and Reconstructive Surgery Department of Obstetrics and Gynecology at Hadassah-Hebrew University Medical Center, Jerusalem
Lecturer and Senior Faculty Member at Henrietta Szold/Hadassah-Hebrew University, Jerusalem
TPM 2017;20(4):28-30(April 2017)
Obstetric anal sphincter injuries (OASIS) can have a very negative impact on women's health and quality of life. Literature exists concerning the role of the surgeon and physiotherapist after OASIS, but there is a dearth of literature pertaining to the role of the midwife in the management of women following an obstetric anal sphincter injury. This article examines the midwife’s role and describes a new service instituted at Hadassah-Hebrew University medical centre, Jerusalem, utilised in the early postpartum period while the woman is still in hospital, entitled Special Services for Perineal Trauma.
Midwifery management of face presentation
Judy Slome Cohain
Nurse Midwife in private practice
TPM 2017;20(4):8-11(April 2017)
The 1980 edition of Oxorn and Foote (1980) urges the midwife not to be hasty in employing cæsarean (CS) for face presentation because, with patience, babies are usually born vaginally, with better outcomes. Reviewing how to manage face presentation can prepare the practitioner for this rare event, and decrease CS management. A hundred and ninety six midwives from the US, UK, Hungary and Israel were emailed, asking them to describe their experience, if any, with face presentation. Twelve midwives responded, demonstrating the rarity of the event. Face presentation was most often diagnosed at full dilation. Mode of birth was dependent on the size of the fetus, the motivation of the woman and the experience and motivation of the practitioner, not on the position of the chin. Where the posterior chin was blocking birth, CS could be avoided by rotating the head to occiput anterior (OA) or by swimming for 45 minutes in a large birthing pool.
Physiological breech birth Evaluation of a training programme for birth professionals
Midwife and PhD candidate at City, University of London and Norfolk and Norwich University Hospital NHS Foundation Trust
Midwife at Médecins Sans Frontières
Midwife at Gloucestershire NHS Foundation Trust
Consultant Midwife for Normality at Chelsea and Westminster NHS Foundation Trust
This paper reports an evaluation of the Breech Birth Network (BBN) physiological breech birth (PBB) training programme, which has been developed out of consensus research with highly experienced health professionals. The training was delivered in four National Health Service trust hospitals in the north and south of England throughout the spring and summer, 2016. The evaluation involved pre- and post-training surveys containing a mixture of open-ended and multiple-choice questions, and rating scales. Data were analysed descriptively. The results indicated that the training addressed the concerns of the participants and was rated highly in expected usefulness for practice. Significant improvements in self-reported confidence and objectively assessed knowledge were observed. Participants found discussions and hands-on practice accompanying videos helpful, and reported concerns about lack of support and involvement of obstetric colleagues both before and after the training. The package is an effectively designed and replicable programme for introducing physiological breech practice to health care professionals.
Supporting women with perineal trauma
Midwifery Lecturer at University of Central Lancashire
Approximately 90 per cent of women in the UK who have a vaginal birth experience some degree of perineal trauma (Royal College of Obstetricians and Gynaecologists [RCOG] 2015). Recent studies have noted that perineal trauma and extensive perineal trauma rates are rising in developed countries (Dahlen et al 2015). For this reason, it is imperative that midwives and other health care professionals working within the maternity services are aware of how to support women who are at an increased risk of sustaining perineal trauma during birth. Many women experience postnatal mental health issues due to perineal trauma. These effects can have consequences on women’s everyday lives and implications for their families. With the complex physical and psychological effects of perineal trauma, it is important for midwives to be aware of these issues and know how to support women, linking with members of the multidisciplinary team when needed (Priddis et al 2012).
It's a risky business. Midwife-led care and women's perceptions of safety
Head of Midwifery and Sexual Health services at Powys Teaching Health Board
Dr Marie Lewis
Practice Development Midwife at Powys Teaching Health Board(June 2016)
This article explores the differences in perceptions of safety between midwives and women. The authors use their experience of providing midwife-led care in a local setting to discuss the impact that language and women's perceptions of safety have on the acceptance of midwife-led care.
Midwives, labour induction and the Wooden Spoon award. Part I
Marie Hastings-Tolsma, Associate Professor of Nurse Midwifery at the University of Colorado, Denver College of Nursing, Division of Women, Children and Family Health Steffie Goodman is OB Clinical Director of Metro Community Provider Network, Denver(June 2016)
Labour induction rates have rocketed, largely due to consumer demands and provider convenience. This increase has been a significant factor in rapidly increasing caesarean birth rates and adverse perinatal outcomes. It is important that midwives understand the risks associated with labour induction. Part 1 of the article provides an overview of those factors contributing to increasing induction rates and the associated risks. Midwives are challenged to consider the evidence for an intervention contributing to a cascade of birth interventions.
Mavis Kirkham, Professor of Midwifery, University of West of Scotland;
Margaret Jowitt is Editor of a midwifery journal(June 2016)
The interactions of the hormones of pregnancy, labour and birth are complex and subtle and their effects are far reaching. Within these complex interactions beta endorphin (β-end) has a key balancing function, being a hormone of relationship and a stress hormone. As well as helping the mother cope with labour, β-end enhances relationships with the newborn and the initiation of breastfeeding. Both too much endorphin and too little can create problems in labour. Optimising endorphin levels is therefore more complex than simply enhancing them and calls for midwifery skills to relieve fear so that women feel safe.
Vigilance must be a priority: Maternal genital tract sepsis
Debra Bick, Professor of Evidence Based Midwifery Practice; Sarah Beake, Research Associate; and Carol Pellowe is Senior Lecturer Infection Control, Kings College, London
Although very rare in the UK, sepsis was the leading cause of direct maternal deaths during 2006-2008, with an increase in community acquired Group A streptococcal infection (CMACE 2011). Most deaths occurred in the postnatal period and were often preceded by a sore throat or other upper respiratory infection, with a clear seasonal pattern. An associated factor was women of BME origin (black or minority ethnic origin). More than half of the deaths followed birth by caesarean section. All antenatal and postnatal women should be offered advice on the signs and symptoms of life threatening conditions, including sepsis. Information should include the importance of good hand and perineal hygiene and of the need to seek immediate medical care if feeling unwell. Relevant NICE guidance should be disseminated and implemented as widely as possible. Greater priority should be given to ensuring all women, particularly those in the most vulnerable groups, are aware of how to access timely and appropriate care.
Time’s up! Women’s experience of induction of labour
Nicky Gammie, midwife, Borders General Hospital
Susan Key, senior lecturer and lead midwife for education, Edinburgh Napier University.(June 2016)
Induction of labour is a common obstetric intervention in the UK, occurring in approximately 22 per cent of labours (Birthchoice UK 2014). Much evidence exists regarding methods, efficacy, safety and outcomes, but very little is known about women’s experience of induction of labour (National Institute of Health and Care Excellence (NICE) 2008). In this study, qualitative interviews were carried out with low risk primigravid women being induced post-maturity. Women expressed fear about the induction process, described their midwife as being their primary source of information and reported that they had sufficient information prior to admission.
Hands on or hands poised: what does the evidence say?
Petra Petrocnik, lecturer in midwifery at University of Ljubljana, Slovenia;
Dr Jayne Marshall is head of School of Midwifery and Child Health and lead midwife for education at Kingston University/St Georges, University of London(June 2016)
A majority of women will experience some degree of perineal trauma during vaginal birth. The morbidity of women related to perineal trauma can reveal in perineal pain, urinary or faecal incontinence and dyspareunia. Midwives can adopt many techniques to protect the perineum from injury. However, there are still no clear guidelines regarding the hands-on and hands-poised approaches of perineal management during the second stage of labour. The current evidence remains contradictory, so which technique should midwives adopt?
TENS (Transcutaneous Electrical Nerve Stimulation) for labour pain
Dr Richard Francis, Research Associate, Newcastle University(June 2016)
Because TENS is applied inconsistently and not always in line with optimal TENS application theory, this may explain why TENS for labour pain appears to be effective in some individuals and not in others. This article reviews TENS theory, advises upon optimal TENS application for labour pain and discusses some of the limitations of TENS research on labour pain. TENS application for labour pain may include TENS applied to either side of the lower spine, set to 200µs pulse duration and 100 pulses per second. As pain increases, TENS intensity should be increased and as pain decreases, TENS intensity should be reduced to maintain a strong but pain free intensity of stimulation. This application may particularly reduce back pain during labour.
Dancing in the grey zone between normality and risk
Professor of Midwifery at Western Sydney University(June 2016)
Childbirth is mainly grey. The most straightforward of births can lead to unexpected, heart-stopping moments - and the highest risk woman can, despite our fears, birth without any of the imagined horrors being realised. As midwives we can choose to be paralysed with fear over this, or responsive to - and respectful of - such an amazing process. This paper discusses how midwives can learn to 'dance in the grey zone', while meeting their professional obligations and protecting women's human rights. Come dance the waltz, the tango and the hip-hop with me on the dance floor created by the 'triangle of wisdom'
Midwives, labour induction and the Wooden Spoon award. Part 2
Marie Hastings-Tolsma, Associate Professor of Nurse Midwifery at the University of Colorado Denver College of Nursing, Division of Women, Children and Family Health
Steffie Goodman, OB Clinical Director of Metro Community Provider Network, Denver(June 2016)
Rates of labour induction without clear medical indication have risen exponentially. This trend has not been without consequence of increased perinatal mortality and morbidity. Midwives must understand the importance of educating pregnant women and other obstetrical providers, about the risks associated with labour induction. Maternal-child health policy that minimises unnecessary interventions is urgently needed and prevention strategies are described in the second part of this article. Midwives are challenged to consider their role in reducing unnecessary labour inductions in a rapidly changing birth culture reflecting high intervention.
Facilitating normal physiology in the presence of meconium stained liquor
Julika Hudson, midwife, Coombe(June 2016)
There is sufficient evidence to support the practice of optimal cord clamping in normal labour and birth. In this paper, the physiology of meconium stained liquor (MSL), meconium aspiration syndrome and the practice of optimal cord clamping in babies born through MSL, is discussed. Guidelines suggest not stimulating babies born through MSL, at birth, to avoid aspiration. However, the obvious stimulation resulting from early clamping and cutting the cord, leaves a baby with no choice but to inhale, but this appears to be overlooked in practice. Midwives in their role as supporters of normal physiology are in a position to question this routine intervention in the absence of any evidence to support it.
Sweet memories of a bitter experience: a parent’s view
Dr Intisar Ulhaq, Specialist paediatrician at Bristol Children’s Hospital(June 2016)
Having an extremely preterm baby is the most difficult time for parents. It becomes even more stressful if the preterm birth was unexpected. This article reflects the personal experiences of a paediatric trainee on having his first baby as unexpectedly very preterm. He shares his feelings of joy and uncertainty, which a parent can experience during these difficult times. A paediatric trainee, on the one hand, and the new parent of a sick baby on the other, this was an eye opener and gave him real insight into parents’ feelings in similar circumstances during his own clinical practice. This has motivated him to write this article to empathise with parents and share his learning points with other health professionals.
Management of umbilical cord clamping
Lucy Webbon, second year midwifery student at the University of West London(June 2016)
The Royal College of Midwives (RCM) has updated its third stage of labour guidelines (RCM 2012) to be clearly supportive of a delay in umbilical cord clamping, although specific guidance on timing is yet to be announced. It is therefore imperative that both midwives and student midwives understand and are able to integrate delaying into their practice, as well as communicating to women the benefits; only in this way can we give women fully informed choices on this aspect of care. The main benefit of delayed cord clamping is the protection it can provide in reducing childhood anaemia, which is a major issue, especially in poorer countries. A review of the evidence found no risks linked to delayed clamping, and no evidence that it cannot be used in combination with the administration of uterotonic drugs. Delayed cord clamping can be especially beneficial for pre term and compromised babies.
Midwife in Mumbai, India(May 2016)
Many of us are in the business of improving birth. Some of us are decades into our journeys of midwifery, whilst others are fresh students aspiring to give our best in this new profession. This article looks at ways to redeem birth from two aspects: for the mother; and for the midwife. I work in an international community in a developing country, in a privatised system. Although different from the UK, birth is birth. Women, their families and midwives will be able to relate to similar experiences. Ultimately my goals are likely to be the same as those in other parts of the world. I address issues of the workplaces in which we operate, the role of midwives in redeeming birth outcomes, and how we may better serve women and each other.
The benefits of optimal cord clamping
Midwifery student, Edith Cowan University, Perth, Western Australia
Associate professor of midwifery, Edith Cowan University, Perth, Western Australia(January 2016)
Optimal cord clamping is known and now widely recognised as having positive consequences for the neonate in the short- and medium term. This review of some of the key literature published over the last five years on the effects of both ECC and OCC provides an insight into the evidence on this topic. The aim of this article is to summarise the key papers on the topic of the effect of timing of cord clamping, including some of those included in the Cochrane Review as well as the majority that have been published since, to provide an up-to-date overview.
Unexpected breech: What can midwives do?
Labour ward midwife at St Mary's, Paddington, and a PhD student at City University London
Matron for antenatal and community services at Imperial College Healthcare NHS Trust(November 2015)
Approximately 1:100-150 women at term experience diagnosis of breech presentation for the first time in labour (Walker 2013). Such an unanticipated discovery is stressful for both women and the healthcare professionals who care for them. Undiagnosed breech experiences can leave midwives and women elated, distressed or disempowered. This article suggests practical ways midwifery change leaders can improve care for undiagnosed breeches within organisations: plan or scan antenatally, and identify a multi-disciplinary breech leadership team for support, reflection and collaborative professional development.
Five ways to learn to love suturing
Qualified midwife from Leicester who has practised in the UK and New Zealand, currently working as a midwifery writer in the UK and Spain(July 2015)
Suturing can be a daunting midwifery skill to learn, as it’s complex and carries great responsibility. There are lots of excellent texts on suturing available in midwifery literature, but perhaps not much on the emotional side of learning. This light-hearted article addresses the anatomy and physiology of the perineum in an engaging and easy to understand way; looks at the current evidence around the decision to suture; and shares ways the author progressed from being apprehensive about suturing to being passionate about the topic and enjoying the skill.
Pictorial estimation of blood loss in a birthing pool: An aide memoire
Midwife at Cheltenham Aveta Birth Centre, Gloucestershire Hospitals NHS Foundation Trust(April 2015)
The aim of this article is to share some photographic images to help midwives visually estimate blood loss at water births. PubMed, CINAHL and MEDLINE databases were searched for relevant research. There is little evidence to inform the practice of visually estimating blood loss in water, as discussed further on in the article. This article outlines a simulation where varying amounts of blood were poured into a birthing pool, captured by photo images. Photo images of key amounts such as 150mls, 300mls and 450mls can be useful visual markers when estimating blood loss at water births. The speed of spread across the pool may be a significant factor in assessing blood loss. The author recommends that midwives and educators embark on similar simulations to inform their skill in estimating blood loss at water births.
Fathers’ presence at caesarean section with general anaesthetic: evidence and debate
Senior lecturer in the School of Health at University of Central Lancashire
Consultant midwife in public health at Frimley Health NHS Foundation Trust
Senior research fellow in the School of Health at University of Central Lancashire(April 2015)
In the UK, debate about fathers’ presence during the birth of their baby by normal birth is largely resolved. Fathers’ attendance during caesarean section, both routine and emergency, remains controversial. This article draws upon research evidence, professional insights and the authors’ personal life experiences to contribute to the debate about the presence of fathers during caesarean births with general anaesthetic. We argue that the widespread exclusion of fathers in these circumstances may be contrary to both parents’ wishes, and clinicians should consider offering women the choice of a nominated support person. Such a person can help the mother to fill in the missing pieces of the birth experience. Moreover, where this person is the baby’s father, there may be additional familial benefits for his transition to parenthood. Further research is warranted into the presence of fathers during births that are clinically problematic.
The rise of remifentanil and the decline of midwifery autonomy
Practice development midwife
both at Blackpool Teaching Hospitals NHS Foundation Trust(January 2015)
Since the 1980s epidural analgesia has been considered the gold standard for pain relief in labour. Over the past decade there has been a growing trend in UK maternity units to offer remifentanil PCA as a fast, safe alternative for women where epidural analgesia is contraindicated. Increasingly more obstetric units and anaesthetists are extending the use of remifentanil and in many units it is now preferred over central neuroaxial blocks (Stocki et al 2014). It would appear that remifentanil is being hailed as the panacea for labour pain. Whilst discussion around the use and effects of remifentanil is very well documented in anaesthetic journals, there is very little midwifery research around this subject. Following a review of the current evidence, this article will explore the use of remifentanil in labour, consequences for women and neonates and implications for midwifery practice.
Midwifery support in labour: how important is it to stay in the room?
Dr Mary Ross-Davie
Education projects manager in midwifery in Edinburgh
Midwife at NHS Lothian bank
Consultant midwife, Dumfries and Galloway Royal Infirmary
Midwife practitioner, Dumfries and Galloway Royal Infirmary(June 2014)
This paper draws on the findings of an observational study of intrapartum care in Scotland, UK. Observations lasting up to three hours were undertaken of 49 labour episodes. Quantitative data gathered through the study identified associations between women’s feelings about the support they received and the proportion of time that their midwife was present in the labour room and between the midwife’s presence and the type of birth. Reflections on the care observed during the 104 hours of observations identified several key consequences of the midwife’s absence from the room: heightened anxiety of the woman and her birth partner; a reduction in opportunities to build rapport and offer support; and a reduction in the midwife’s ability to monitor the progress of the labour accurately. The study also found that those midwives who were out of the room more, were less supportive of the women in their care when they were in the room.
Mobility and upright positioning in labour
Third year student midwife at Cardiff University(April 2014)
A study by the Royal College of Midwives (RCM) (2010) concluded that 49 per cent of women gave birth in the supine position. The RCM advocates getting women ‘off the bed’ in its campaign for normal birth (RCM 2005a). There has been much speculation as to why women labour on the bed, with some suggesting it is because women feel it is expected of them (RCM 2012). Mobility and upright positioning in labour have countless benefits, with or without epidural anaesthesia, for both woman and fetus. The National Institute of Health and Care Excellence (NICE) supports the adoption of positions that women find most comfortable (NICE 2007). Both midwives and students should fully explain the benefits of mobility and upright positioning in labour to women, preferably antenatally, to enable them to make informed decisions as to the positions they wish to adopt when in labour.
Fearful birth? So what’s new?
Consultant midwife at Ayrshire Maternity Unit(April 2014)
Significant fear of birth (tocophobia) appears to be increasing, coinciding with an increase in requests for non-medical indication caesarean section. It can arise from previous birth trauma, or be present in late childhood or early adulthood prior to pregnancy. This article explores some of its origins, presentations, effects and the importance of using a midwifery model of care with referral to specialist services as appropriate, to facilitate a positive birth experience which will enhance the woman’s wellbeing and family life.
Time’s up! Women’s experience of induction of labour
Midwife at Borders General Hospital
Senior lecturer and lead midwife for education at Edinburgh Napier University.(April 2014)
Induction of labour is a common obstetric intervention in the UK, occurring in approximately 22 per cent of labours (Birthchoice UK 2014). Much evidence exists regarding methods, efficacy, safety and outcomes, but very little is known about women’s experience of induction of labour (National Institute of Health and Care Excellence (NICE) 2008). Qualitative interviews were carried out with low risk primigravid women being induced post-maturity. Women expressed fear about the induction process, described their midwife as being their primary source of information and reported that they had sufficient information prior to admission.