Monday, 26 March 2012

Who wants a cherry on the top?

Is choosing or knowing your midwife really as important as the evidence says it is? We are informed by studies that knowing the midwife improves outcomes with all variables….you know, less caesarean sections, less babies in special care, more women achieving normal birth, less hospital stays, more breastfeeding, more satisfaction with the process……I am sure the list can go on but already it is clear to see a cost saving, and far less complaints maybe, if all these things were reduced? How much money could be saved by the implementation of continuity of care? The Government know it, the NHS knows it, the trusts know it, the mangers know it and the midwives know it. But do the women know it? Does it matter to women that they get to know the midwife who will be caring for them at the birth or is all they want is a knowledgeable, caring, kind midwife?

Currently Neighbourhood Midwives is trying to make changes to the way maternity services are delivered by setting up an employee-owned social enterprise organization. They state that their primary purpose is to provide an NHS commissioned caseload midwifery homebirth service, based in the local community, “wherever it is required”……

Wherever it is required? Surely the question should be; is it required?

In order to gain the relevant information to answer this exact question, a colleague who is working on the implementation of Neighbourhood Midwives asked this question on the Facebook page “One Born EveryMinute-The Truth”;

 “Does it matter to you that you don't know the midwife who will look after you in labour? If not, why? If you could have a choice and choose a midwife whom you knew and who could care for you throughout your pregnancy, would you choose this option”?

As would be expected on a page that is primarily about evidence based midwifery practice, there were quite a few women raving about having the option of knowing ones midwife and continuity of care.  To be fair there were also a lot of comments from women who had amazing experiences but who did not know their midwife and then some women were saying that it really doesn’t matter as long as the midwife is kind and caring.

I have been thinking about the final comment as I remember having the exact conversation with a mentor many years ago when I was a student midwife. The mentor told me that “all women want is a king caring midwife.” However this was also the same midwife who said “the important thing is a live healthy mother and baby,” when we were discussing birth plans.  Well of course I do not think we could argue either of those points because both are important and any birth would be unbearable without either. But why does anything have to be sacrificed? Why can’t women have it all? Why can’t lots of things be equally important? Why can’t importance have parallels?

 I love really using analogies so I will compare it to going to a restaurant and choosing a dessert…..

OK I really want a dessert the type of which I know is sold in another restaurant and which I absolutely adore.  They do something similar here and I have tried it at this restaurant too but here it’s not quite the same.  It is not a fancy dessert in fact it’s been around for years, including at this place but in the other restaurant it is so utterly special because it is with a fresh cherry on the top. The cherry makes it exquisite to taste. Lots of people want it with a cherry too but as it has never been available they settle for the dessert as it is served here. Despite asking for a cherry I am told by the waiter that sorry I cannot have a cherry. What he knows and everyone else knows is that the fresh cherry has loads of health benefits and is exquisite to taste but according to the restaurant  owner they would have to install an expensive machine to de stone the cherries. Even though they know that people will come to the restaurant from far and wide and rave about it and that in the long run their takings will improve they think “oh well it’s been ok for most people for all this time so we will keep the dessert as it is”.  There are some people that eat at the restaurant who love the dessert as it is, they say it is perfectly good enough and cannot for a second believe that a cherry would make any difference. Some diners say all that matters is that the dessert tastes nice and so let’s just leave it as it is………

But I know the truth, and all those other diners who have tried it at the other place, knows the truth, is that they have never experienced it with a cherry on top, that if only others would try it a different way they would widen their eyes and say “oh my oh my the other way was good I admit but oh how delightful how exquisite and how memorable is this desert with the cherry on the top……and healthy too…. wow we are having it all…..

Who wouldn’t want midwifery care with a cherry on the top?

Friday, 23 March 2012

Meconium stained liquor

In a note regarding last week’s OBEM I asked why it was that a multiparous woman being induced for postdates was being subjected to continuous monitoring,(EFM). It was clear that she had been induced by prostaglandin suppository alone and was not on a syntocinon drip. I had a discussion with an NHS labour ward colleague and was able to rule out that EFM, in this case, was linked to induction process so I was confused. However what I obviously missed and what was subsequently pointed out on Facebook page, One Born Every Minute-The Truth, was that there was meconium stained liquor seen during the birth. (note to self wear your glasses next time)

So I thought I would pose this question; is meconium stained liquor always a reason to constantly monitor a baby in labour? I think I am correct in saying that finding meconium in the amniotic fluid is a reason that is often cited to transfer from a home birth, midwifery led unit or birth centre to a consultant led unit and also to commence EFM (information taken from local trust guidelines). The labour therefore has shifted from a normal one to an abnormal one, from low risk to high risk and maybe the course of the woman’s birth and or birth plan completely changed because of the meconium alone.

There is plenty of information on what meconium is and what harm it can do (Google it) so I want to focus on the changes it brings to the course of labour and whether those changes are indeed always necessary.

According to the National Institute for Clinical Excellence, (NICE) continuous EFM should be ADVISED for women with significant meconium-stained liquor, which is defined as either dark green or black amniotic fluid that is thick or tenacious, or any meconium-stained amniotic fluid containing lumps of meconium. Whereas continuous EFM should be CONSIDERED for women with light meconium-stained liquor depending on a risk assessment which should include as a minimum their stage of labour, volume of liquor, parity and the fetal heart rate. Nice also states that “significant meconium stained liquor” is an indication for transfer to an obstetric unit. It seems that NICE are definitely about defining and describing different categories of meconium which may change the advice given and or choice of care.

We can presume, from reading individual Trusts guidelines, listening to women’s stories and of course watching good old OBEM that labouring women are told that there IS meconium and therefore they need to be constantly monitored due to it being a risk factor for baby, but are they told ALL the details and given a choice?

Are women informed that the meconium in the water is light and that as they are having a 2nd or subsequent baby the labour may be quick and that if baby has no problems with his /her heart rate it is recommended that continuous EFM be only CONSIDERED? Are women told that the need for EFM is not absolute, and furthermore that in her particular case, it has been considered and there is no reason to constantly monitor the baby as long as all else stays well? Her birth plan does not have to change she can remain moving around and being intermittently monitored at home, in a birth centre or indeed in the hospital of her choice?

I have reviewed a very recent research paper (2012) which was published in the International Journal of Paediatrics and reviewed 133,000 births between 37 and 43 weeks complicated by meconium stained liquor. With a bit of mathematics I have changed the percentages into numbers and this is what the study found.

Meconium in the water is a relatively uncommon problem and in this study affected only 8 in every 100 births, and of those babies less than 7 in 10,000 became ill. In terms of mortality rates, the chances of meconium related death in childbirth was 2 in 100,000.

Other studies have quoted different statistics but in all recent evidence the incidence of meconium aspiration syndrome is similarly very low. That is not to say that it is to be dismissed lightly as it can cause extremely serious illness and fatalities in the extreme cases.

The issues once again are informed choice. Some parents would want to act on the chance they could be one of the 2 in 100,000 who child dies or even one of the 7 in 10,000 whose child is ill but equally importantly some would want to make choices based on the likelihood of them being one of the 998,000 or of the 9,993 who could continue with their plan of a normal non-medical birth.

Either way they should be given the facts in order to make a choice

Thursday, 22 March 2012

Medical Help for the few?

I watched OBEM last night mostly with a smile on my face and the occasional “oh no why?” so lets start with what was really good….I thought the story of Cody was a real positive story about pre-eclampsia. As Billie admitted herself whilst most women have heard about it and know it to be a problem, many are not informed about how bad it can be. It’s a shame given what we know about kangaroo care that Cody and Billie did experience it for the first hold as it would have been an amazing example of excellence but again maybe it was done at another time and we just did not see it due to editing.

The same for the story about the baby with the cleft lip. Brilliant information giving. TV has as the ability to normalise situations (which can be a double edged sword) so by seeing the sweet baby, seeing his lip and how well it was repaired, may go a long way to helping women who are also told their baby may be similarly affected. It appears that Carolyn was induced post dates but we know no more so we cannot make presumptions whether or not it was an informed choice. (note to self add stuff about the evidence and risks of induction of labour) However Carolyn was constantly monitored during the birth. Why? Following birth the cord was cut for no apparent valid reason and baby was immediately removed from his mother. Why?

The midwife who was with Tania I felt did an excellent job of support sitting with her (off the bed) talking and encouraging her. She was however being constantly monitored. Why?

However... cushion hit TV when another midwife gave incorrect information by saying women ”should progress at 1cm per hour” There is NO EVIDENCE of this. This is outdated, discredited information that can cause harm. Some woman will progress faster and some slower and as long as all is well, the clock has no part to play in a normal labour. Once again I would like to mention the Royal College of Midwives campaign for normal birth. If the midwives do not want to read complicated and or deep research papers then the RCM make the evidence simple. I got really excited to see Tania have good midwifery support, sitting on a ball, resting for a while on the bed, then all fours for 2nd stage……then it all fell apart when a midwife (not the primary one) said “lets turn you over” and once again constant monitoring, Valsalva and a shouting match. No need for any of it……she would have done just as brilliantly leaving her alone to push under her own steam. The fact the baby was OP (back to back) just adds weight to the argument that she was an amazing woman who was quite able to give birth to her baby without interference.

Amazing stories, lovely babies and a missed opportunity once again to normalise birth for the majority and show medical help for the few.....

Also published on One Born Every Minute The Truth facebook page

Thursday, 8 March 2012

All midwives do is sit around and eat

Since my last blog the, One Born Every Minute- the Truth, Facebook page has grown and grown.... not all of the lively discussion on there has been praise for the page mind you, maybe that is because it has touched a nerve for some.  Understandably I suppose because if I was a midwife who uses, for example, the Valsalva manoeuvre or who has never helped a woman birth other than on the bed (yes they are out there) or who always attaches a fetal monitor, or always cuts a cord, of course I would take all the criticism personally too, (although I may just then look to change my practice).  Tongue in cheeks comments aside though, that is not the intention of the page. The purpose is not to condemn the midwives rather than some of the practices which, if keep on being seen over and over on TV without being challenged, will continue to be regarded as ok and as normal by both women and health care professionals.  It is important to challenge bad or discredited practice, indeed it is part of the midwives rules to do so, or it will never stop and women will always be exposed, depending on who cares for them, to sub-standard care.  
I actually thought last night was pretty ok, with some exceptions which I will come on to later. I thought  it was ok however only because as a midwife who has worked in similar situations and in a labour ward I can see through the editing, where conversation have taken place and things missed out. But can the women who are regularly watching and to whom a labour ward is a very unfamiliar place see it the same way?

I want to first consider how it showed the midwives. It was all very relaxed and calm.....But if I was a midwife working in a consultant unit it would make me reflect on all the days and nights I felt like I was trying to be two people and it may just make me pretty cross.   It showed the midwives sitting, eating chocolates, chatting; talking and getting on lovely.......a true reflection? I do not think so….All midwives know how it is in a consultant unit most of the time. The truth is (I bet) the majority of the time they are rushing around with a million things to do, the office is empty, they are rushed off their feet and hardly get time for a cup of tea let alone a rest and a when it IS busy thus and women for whatever reason are alone in the room, because we know that does happens and at times, is unavoidable, what exactly will those women be thinking? They just might be thinking that the midwife is leaving them alone, vulnerable, scared and wondering how long the labour is going to go on for, in order to eat chocolate and bemoan the size of their thighs! How is this painting midwifery in the NHS in a true light?  What is this doing to the political appeal for more midwives? Some of the midwives who have been challenged enough on, One Born Every Minute- TheTruth, to speak out have argued that it is entertainment only, that most things can be blamed on editing and that what we see is not really happening (non evidence based practices, Valsalva manouvre, constant monitoring, encouraging epidurals, unkind or untrue things being said). Well I tend to agree with you on this one gals......the bit about midwives sitting around chatting and eating choc? That bit I give you really is pure it not?

Tuesday, 6 March 2012

I am so mad at some of the things I see and hear on One Born Every Minute I have set up a facebook page to talk about pleased that in just a couple of days it has over 800 likes!! so here it is and also here is my first bit of ranting on the subject One Born Every Minute..The Truth

Factual or fiction?

The Channel 4 television show One Born Every Minute won a BAFTA in 2010 under the category of Best Factual Series.  A definition of the word factual is:

"The available body of facts or information indicating whether a belief or proposition is true or valid".

Whilst it may be assumed that  the audience knows that editing has taken place, especially those who are aware of the time involved in the labour/birth of a baby, there is no doubt that what is being seen, said, and done is fact for it is happening as we are witnessing it. What is questionable is whether or not these “facts” or the actions and words of the professionals involved are true or valid? Turn that into professional speak and it could be asked if the words and actions are evidence based.   Are they in line with the rules and codes of the governing bodies of the professionals involved? If the answer is no then surely there are further issues to be considered and questions to be asked.

During the Wednesday 29th March episode, Midwife Zoe Leonard was encouraging long sustained breath-holding whilst caring for Vicki who was pushing in the second stage of labour.   This practice is known as the Valsalva Manoeuvre which involves prolonged breath-holding.

With prolonged breath-holding there is an increase of the maternal intrathoracic pressure by forcible exhalation against the closed glottis, which causes a trapping of blood in veins preventing it from entering the heart. When the breath is released, the intrathoracic pressure drops, the trapped blood is quickly propelled through the heart producing an increase in the heart rate and blood pressure and followed by a slowing of the heart rate. All of this disrupts the blood flow to the uterus and ultimately to the baby which then shows up or is interpreted on the fetal heart monitor as fetal distress.

There is no evidence that the Valsalva Manoeuvre shortens the second stage, decreases fatigue or minimizes pain. The evidence suggests that it alters the contractile pattern of uterine smooth muscle, leading to inefficient contractions and failure to progress. Studies suggest that encouraging women to believe in their ability to push the baby out may be as important as the type of breathing. 

Studies published between 1992 and 2009 show that the physiological effects of Valsalva Manoeuvre can include: impeded venous return; decreased cardiac filling and output; increased intrathoracic pressure; affected flow velocity in middle cerebral artery; raised intraocular pressure; changed heart action potential/repolarization; increased arterial pressure; increased peripheral venous pressure; altered body fluid pH, which contributes to inefficient uterine contractions; decreased fetal cerebral oxygenation.  The World Health Organisation, (WHO) concluded that it is a dangerous practice and should cease.

Later in the same programme when interviewed, Midwife Zoe said that babies can, if left too long in labour, "get tired" (labour ward talk for become hypoxic) if the 2nd stage goes on too long.  There is no evidence to support better outcomes when time limits are imposed on any stage of labour. More importantly, Zoe is obviously not aware of the evidence around her practice with efforts to encourage Vicky to birth her baby quickly.  Is Zoe disregarding them the evidence in favour of dangerous practice? Either way she is in breach of her Nursing and Midwifery Council Code, (NMC) as according to Rule 6- Responsibility and sphere of practice, the guidance indicates that practice should be based on the best available evidence and that a midwife must make sure that the needs of the woman and baby are her primary focus.  The NMC code of professional conduct: Standards for conduct, performance and ethics (2010) states that a midwife must keep her knowledge and skills up to date.

This programme needs more editing in order to stop showing bad or dangerous practice. Whilst the programme makers must be delighted in their ability to pull in large audiences, the success of other birth programmes has demonstrated it does not always need sensationalism and car crash births in order to do so.  It must not be forgotten that the viewers may include new and impressionable midwives who may get the message that it is fine to copy what they see and for women to accept as normal what they too may be exposed to or ask to do when they face childbirth.  Questions needs to be asked and they include; why are awards being given for dangerous practice and are the NMC watching?


 Martin C 2009, Effects of Valsalva manoeuvre on maternal and fetal wellbeing, British Journal of Midwifery, vol. 17, no. 5, pp. 279-85

Nursing Times  95:15, April 15, 1999.

WHO (1996) Care in Normal Birth: a Practice Guide.