Childbirth Trauma: care provider actions and interactions

A big THANK YOU  to all the women and men who shared their experiences of traumatic childbirth for Christian Inglis’ Honours study. There was so much data that Christian chose to focus on paternal mental health for his thesis and publication. Later we analysed the women’s descriptions of trauma and have recently published these findings in an open access journal. A summary of the findings is provided below:

Women’s descriptions of childbirth trauma relating to care provider actions and interactions

(You can access the full journal article free from BMC Pregnancy and Childbirth)

FINDINGS: Four themes were identified in the data: ‘prioritising the care provider’s agenda’; ‘disregarding embodied knowledge’; ‘lies and threats’; and ‘violation’. Women felt that care providers prioritised their own agendas over the needs of the woman. This could result in unnecessary intervention as care providers attempted to alter the birth process to meet their own preferences. In some cases, women became learning resources for hospital staff to observe or practice on. Women’s own embodied knowledge about labour progress and fetal wellbeing was disregarded in favour of care provider’s clinical assessments. Care providers used lies and threats to coerce women into complying with procedures. In particular, these lies and threats related to the wellbeing of the baby. Women also described actions that were abusive and violent. For some women these actions triggered memories of sexual assault.

CONCLUSION: Care provider actions and interactions can influence women’s experience of trauma during birth. It is necessary to address interpersonal birth trauma on both a macro and micro level. Maternity service development and provision needs to be underpinned by a paradigm and framework that prioritises both the physical and emotional needs of women. Care providers require training and support to minimise interpersonal birth trauma.

Thematic Map

Thematic Map

 

Paternal mental health following perceived traumatic childbirth

(Unfortunately this article is not open access – you can find the full abstract and publication details here)

RESULTS: Thematic analysis of qualitative survey data and interviews found a global theme ‘standing on the sideline’ which encompassed two major themes of witnessing trauma: unknown territory, and the aftermath: dealing with it, and respective subthemes.

CONCLUSIONS: According to the perceptions and experiences of the fathers, there was a significant lack of communication between birthing teams and fathers, and fathers experienced a sense of marginalisation before, during, and after the traumatic childbirth. The findings of this study suggest that these factors contributed to the perception of trauma in the current sample. Whilst many fathers reported the negative impact of the traumatic birth on themselves and their relationships, some reported post-traumatic growth from the experience and others identified friends and family as a valuable source of support.

Thematic Map

Thematic Map

 

 

 

 

 

 

 

 

 

 

Conclusion

It is probably no surprise to readers that the actions and interactions of care providers influence the experience of childbirth trauma. Analysing this data was difficult and at times distressing. However, it is vitally important that we shine a light on the abusive and disrespectful ‘care’ some women experience. We need to see the monster and acknowledge that we (care providers) are the monster in order to shift the culture of birth (thanks Jessie for your monster theory 😉 ). There are no excuses. I will leave you with a quote from one of the participants:

“…The most terrifying part of whole ordeal was being held down by 4 people and my genitals being touched and probed repeatedly without permission and no say in the matter, this is called rape, except when you are giving birth. My daughter’s birth was more sexually traumatising than the childhood abuse I’d experienced…”

If you have experienced birth trauma please seek support (you can find links at the bottom of this post).

Posted in birth, midwifery practice | Tagged , , | 10 Comments

Pre-labour Rupture of Membranes: impatience and risk

Amniotic sac and fluid play an important role in the labour process and usually remain intact until the end of labour. However, around 10% of women will experience their waters breaking before labour begins. The standard approach to this situation is to induce labour by using prostaglandins and/or syntocinon (aka pitocin) to stimulate contractions. The term ‘augmentation’ is often used instead of ‘induction’ for this procedure. Women who choose to wait are usually told their baby is at increased risk of infection and they are encouraged to have IV antibiotics during labour. In my experience most women agree to have their labour induced rather than wait. I wonder how many of these women would choose a different path if they were fully informed about the available evidence. Please note that this post is not about premature rupture of membranes (before 37 weeks) – this situation is not a variation of normal physiology.

The rush to start labour and get the baby out after the waters have broken is fairly new. When I first qualified in 2001 the standard hospital advice (UK) for a woman who rang to tell us her waters had broken (and all else was well) was: “If you’re not in labour by [day of the week in 3 days time] ring us back.” Over the following years this reduced from 72 hours to 48 hours, then 24 hours, then 18 hours, then 12 hours and now 0 hours. You might assume that this change in approach was based on some new evidence about the dangers involved in waiting for labour. You would be wrong.

This post is mostly based on a couple of Cochrane reviews because hospitals are supposed to base their policies/guidelines on research evidence. Obstetricians also tend to have great respect for research evidence – certainly more than other forms of knowledge midwives also use (experience, intuition, witchcraft etc.). I’ve found that a ‘good’ research review waved about with a smile works wonders when going against an institutional norm. However, please note that research reviews are only as good as the research reviewed. Research is not conducted in a vacuum, and the questions that are asked, and the methods used, tell us a lot about the social and cultural context of knowledge, and what is valued. For example in most trials the ‘doing nothing’ group is the experimental group and the ‘routine intervention that was previously introduced without evidence’ is the control group.

Outcomes: induction vs waiting 

For Baby

A Cochrane review comparing planned (induced labour) vs expectant (waiting) management concluded that neonatal infection ‘may be’ reduced. Unfortunately, the research reviewed was not great: “Only three trials were at overall low risk of bias, and the evidence in the review was very low to moderate quality.” Indeed all of the evidence in the review was rated ‘low quality’ except the evidence demonstrating no difference in the rate of death for babies between inducing vs waiting (this was the only ‘moderate quality’ research).

Whilst the review reports a slight increase (less than 2%) in ‘definite or probable’ neonatal sepsis, this needs to unpicked a little. Once the ‘probable’ portion was removed in the analysis the difference was no longer significant. It would be very interesting to know how many of the suspected (probable) cases of sepsis were merely care providers being cautious and making assumptions. For example, some symptoms associated with sepsis can be caused by other interventions – epidural increases the chance of a high temperature in both mother and baby; a stressful labour (and syntocinon) can result in low blood glucose in the newborn. It is common practice to assume infection until proven otherwise and treat accordingly. The fact that there was no difference in Apgar scores between the groups increases my suspicions in this area. Infected babies are much more likely to have a poor Apgar score and require resuscitation at birth.

The review goes on to state that: “…evidence about longer-term effects on children is needed.” And there is increasing evidence about the risks of the induction process for babies that needs to be considered by women when making a decision.

For mother

The Cochrane review did find a slight increase (1%) in the absolute risk of uterine infection for mothers who waited for labour. Bear in mind that these studies were done in hospitals which are not the best setting when attempting to avoid infection. If a uterine infection is identified early it can usually be effectively treated with antibiotics. I used to see quite a few uterine infections as a community midwife in the UK doing postnatal home visits – mostly after forceps or ventouse births. However, if the symptoms are missed, or the woman does not have access to antibiotics; or the infection is antibiotic resistant a uterine infection can be life-threatening.

The report found no difference in the rate of caesarean sections. However, the stats for first-time mothers are not separated out. This is frustrating because induction increases the chance of caesarean significantly for first time mothers (see this post). Women who have previously given birth have no increased chance of caesarean with induction. When you mix the two groups together (like most research does) you miss the outcomes for those first-timers. Interesting only 2 of the studies in the review looked a uterine rupture – a greater risk for women who have previously laboured.

The experience: induction vs waiting

Only one of the trials in the Cochrane review bothered to ask women what they thought of their experience (no surprises there). In this trial, women who had their labour augmented were more likely to tick the box saying that there was ‘nothing they disliked in their management’. There are huge limitations when using surveys to assess experiences, and a good qualitative study is needed here. For example, how can a woman compare one experience (induction) against an experience they did not have (physiological labour) – you don’t know what you don’t know. Also, if a woman believes she is protecting her baby against infection by inducing labour this may influence her perception of the management. The Cochrane review states that no trials reported on maternal views of care, or postnatal depression.

Only two of the reviewed studies (one very old 1996) looked at women’s views of care during both options. They used quantitative measurements ie. women answered questions using a scale. These studies found that women preferred induction. This in contrast to qualitative research examining women’s experiences of induction (see this post) and illustrates a problem with quantitative research – you find out what by not why. For example, what did these women understand about their situation and options? If they felt that their baby was in danger and they were doing the safest thing by inducing they would be more likely to prefer that option.

Antibiotics – just in case?

A Cochrane review of antibiotics for pre-labour rupture of membranes at or near term concluded that: “There is not enough information in this review to assess the possible side-effects from the use of antibiotics for women or their infants, particularly for any possible long-term harms. Because we do not know enough about side-effects and because we did not find strong evidence of benefit from antibiotics, they should not be routinely used for pregnant women with ruptured membranes prior to labour at term, unless a woman shows signs of infection.”

The National Institute for Clinical Excellence (UK) guideline states “If there are no signs of infection, antibiotics should not be given to either the woman or the baby, even if the membranes have been ruptured for over 24 hours.”

oral thrush

So it appears that women and babies are being given high doses of antibiotics during labour without sufficient evidence to support the practice. In addition, these antibiotics may have short term, and long term side effects. As a student midwife I was asked by a mother what would happen if her unborn baby was allergic to antibiotics. I had no idea and asked the Consultant… after a long and complex answer I realised he didn’t know either. I am guessing that most side-effects are more subtle than anaphylaxis. The effect I most often see is oral thrush in the baby and co-existing nipple thrush – and subsequent breastfeeding problems. However, more worrying are the potential long term problems associated with antibiotic exposure – most likely due to the disruption of gut microbiota and the integrity of the immune system. Another issue is the development of antibiotic resistant bacteria due to the overuse of antibiotics, which can result in infections (e.g. uterine) being difficult to treat.

Choosing to wait

Women need to be given adequate information so that they can make the decision that is right for them. I’m not sure most women are fully informed, and instead are told their baby is ‘at risk’. As we know, you can get a mother to do anything if she believes it is in the best interests of her baby. So what happens if a woman chooses to wait for labour?

Most women (95%) will go into labour within 24 hours of their waters breaking. A small minority will wait much longer than this. Ashlee whose birth I recently attended has given me permission to share her experience and photos here. Ashlee’s daughter Arden taught both her family and her midwives about patience and trust. We waited 63 hours from waters breaking to welcome her into the world. After a 2 hour, 20 minute labour she was gently born through water and into her mothers arms (notice the nuchal cord). I wonder how different this birth would have been if Ashlee had chosen to follow hospital guidelines. Instead she weighed up the information for herself and chose to stay home amongst her own familiar bacteria, and let her daughter decide when she was ready to be born.

Suggestions for waiting:

  • View the situation positively – we are all getting time to prepare for the birth and the arrival of baby. She can use the time to relax, sleep and be pampered.
  • The vagina self cleans downwards. Reduce the chance of infection by not putting anything into the vagina ie. no vaginal examinations. If a vaginal examination is absolutely necessary sterile gloves must be used.
  • Some women like to boost their immune system with nutritional supplements (eg. vitamin C, echinacea, garlic).
  • Be self-aware, connect with your baby and let your midwife/care provider know of any changes eg. feeling unwell, a high temperature, if the amniotic fluid changes colour or smell, any reduction in the baby’s movements etc.
  • I have observed Acupuncture and Bowen Therapy encourage contractions. However, if the cervix is not ready the contractions will fizzle out. If the cervix is ready, it may be enough to kick start labour. Nipple stimulation will also stimulate oxytocin (and clitoral stimulation will too).
  • Most importantly trust the process. Birth will happen.
  • Once the baby is born – keep baby skin-to-skin with mother to reduce the chance of infection by allowing the baby to become colonized by his mother’s bacteria (this applies to all births).
  • After birth be aware of signs of infection. Mother: fever, raised pulse, feeling unwell, smelly vaginal discharge, uterine pain. Baby: fever, noisy breathing, change in colour (pale), listless.

Summary

The research evidence regarding induction for rupture of membranes is poor. Giving antibiotics in labour ‘just in case’ is not supported by current evidence, and may cause problems for baby and mother. Women need adequate information on which to base their decisions regarding the management, or not, of this situation. Women who choose to wait for labour should be supported and to do so.

Posted in baby, birth, intervention, midwifery practice | Tagged , , , , , , , , , , , , | 213 Comments

Induction of Labour: balancing risks

In Australia 26% of labours are induced. The most common reason for induction is a ‘prolonged pregnancy’. That’s an awful lot of babies outstaying their welcome and requiring eviction. I am not going to get stuck into the concept of a ‘due date’ and how accurate or not they are, otherwise this will be a very long post. I also think the EDD (estimated date of delivery) is here to stay – it is deeply embedded in our culture and health care system. You can read about the history of timelines in birth here. This post will focus on induction for ‘prolonged’ pregnancy and the complexities of risk.

A quick word about risk

I don’t particularly like the concept of ‘risk’ in birth. There are all kinds of problems associated with providing care based on risk rather than on individual women. However, risk along with ‘due dates’ is here to stay, and women usually want to know about risks. Risk is a very personal concept and different women will consider different risks to be significant to them. Everything we do in life involves risk. So when considering whether to do X or Y there is no ‘risk free’ option. All women can do is choose the option with the risks they are most willing to take. However, in order to make a decision women need adequate information about the risks involved in each option. If a health care provider fails to provide adequate information they could be faced with legal action. Induction for prolonged pregnancy is not right or wrong if the choice is made by a woman who has an understanding of all the options and associated risks. As a midwife I am ‘with woman’ regardless of her choices. It is my job to share information and support decisions – not to judge.

What is a prolonged pregnancy?

Before we go any further lets get some definitions clear:

  • Term (as in a ‘normal’ and healthy gestation period): is from 37 weeks to 42 weeks.
  • Post dates: the pregnancy has continued beyond the decided due date ie. is over 40 weeks.
  • Post term: the pregnancy has continued beyond term ie. 42+ weeks.

The World Health Organization’s definition of a ‘prolonged pregnancy’ is one that has continued beyond 42 weeks ie. is post term. I am pretty sure that this was not the definition used when collecting the above induction rate statistics because most hospitals have a policy of induction at 41 weeks which is before a prolonged pregnancy has occurred. Very few women experience a prolonged pregnancy. In Australia less than 1% of pregnancies continue beyond 42 weeks and become post-term.

The idea of a prolonged pregnancy also assumes that we all gestate our babies for the same length of time. It seems that genetic differences may influence what is a ‘normal’ gestation time for a particular woman. Morken, Melve and Skjaerven (2011) found “a familial factor related to recurrence of prolonged pregnancy across generations and both mother and father seem to contribute.” Therefore, if the women in your family gestate for 42 weeks so might you. The length of gestation may also be influenced by factors such as diet (McAlpine et al. 2016)

There is still little known about what exactly initiates labour. However, science suggests that the baby secretes surfactant protein and platelet-activating factor into the amniotic fluid as the lungs become mature (Mendelson 2009; Science Daily). This results in an inflammatory response in the mother’s uterus that initiates labour.

The risks associated with waiting

In theory after term (ie. 42 weeks) the placenta starts to shut down. There is no evidence to support this notion. There is also a good physiological explanation of the development and ageing of the placenta here, which concludes that: “There is, in fact, no logical reason for believing that the placenta, which is a fetal organ, should age while the other fetal organs do not…” I have seen signs of placental shut down (ie. calcification) in placentas at 37 weeks and I have seen big juicy healthy placentas at 43 weeks. There is also the idea that the baby will grow huge and the skull will calcify making moulding (when the bones in the baby’s skull adjust), and therefore birth difficult. Again there is no evidence to support this theory and babies are pretty good at finding their way out of their mothers expandable pelvis. It is interesting that these two common assumptions about post-term pregnancy contradict each other. If the placenta stops functioning, how does the baby continue to grow so well?

The real concern with waiting beyond 41 weeks is the increased chance of the baby dying (perinatal death). And women need these statistics in order to make an informed decision. A Cochrane review summarises the quantitative research examining induction vs waiting: “There were fewer baby deaths when a labour induction policy was implemented after 41 completed weeks or later.” However, it goes on to say: “…such deaths were rare with either policy…the absolute risk is extremely small. Women should be appropriately counselled on both the relative and absolute risks.” Hands up all the women who had a discussion with their care provider about the relative and absolute risks of waiting vs induction… hmmm thought so.

Essentially according to the available research, if you are induced at 41 weeks your baby is less likely to die during, or soon after birth. However, the chance of your baby dying is small either way – less than 1%… or 30 out of every 10,000 for those waiting vs 3:10,000 for those induced. This research article reports the relative and absolute risk of stillbirth at various gestations with waiting vs induction. The authors state that 1476 women would need to have an induction to prevent 1 stillbirth at 41 weeks gestation. The substantial increase in risk occurs at 42 week onwards with a stillbirth rate of 1 in 1000 (Decker 2016).

Reviews are only as good as the research they review and there are some concerns about the quality of the available research. The World Health Organization recommends induction after 41 weeks based on this review but acknowledges the evidence is “low-quality evidence. Weak recommendation”.  Another review of the literature in the Journal of Perinatal Medicine (Mandruzzato et al. 2010) concluded: “It is not possible to give a specific gestational age at which an otherwise uncomplicated pregnancy should be induced.”

One of the main problems with quantitative research is that it rarely answers the question ‘why’, and rather focuses on ‘what’ (happens). For example, congenital abnormalities of the baby and placenta are associated with post-term pregnancy and this may account for the increased risk rather than the length of gestation (Mandruzzato et al. 2010). Quantitative research also takes a general perspective rather than addressing the risk for an individual woman in a particular situation. For example, is the prolonged pregnancy as sign of pathology or does this woman come from a family of women who have a longer gestation timeframe?

Anyhow – to pretend their are no risks associated with prolonged pregnancy (in general) is not helpful for women trying to make decisions about their options. These general risks should be part of the information a woman uses to decide what is best for her.

The risks associated with induction

It can be difficult to untangle and isolate the risks involved with induction because usually more than one risk factor is occurring at once (eg. syntocinon, CTG, epidural). I did attempt to create a mind map but it ended up looking like a spider had spun a web while under the influence. So I have stuck to a written version:

Risks associated with the actual procedure of induction

The induction process is a fairly invasive procedure which usually involves some or all of the following (you can read more about the process of induction here). There are a number of minor side effects associated with these medications/procedures (eg. nausea, discomfort etc.) There are also some major risks:

The most extreme of these risks are rare, but fetal distress and c-section are fairly common. The potential effects of uterine hyperstimulation on the baby are well known (Simpson & James 2008)- which is why continuous fetal monitoring is recommended during induction. This may also explain the association between induction and cerebral palsy (Elkamil et al. 2010)

Risks associated with factors that commonly occur during an induction

The Cochrane review (above) and 2 more recent reviews (Mishanina et al. 2014Wood et al. 2014) found reduced rates of c-section for women who were induced. This is an interesting finding and does not fit with my observations. I don’t have room in this post to provide a full critique of this research – you can find one by Sara Wickham here.

One major problem with the reviews is that the findings did not distinguish between first time mothers and women who have birthed before. And they are a different kettles of fish. A research study by Ehrenthal et al. (2010) found an increased c-section rate of 20% for women being induced with their first baby. They concluded that: “Labor induction is significantly associated with a cesarean delivery among nulliparous women at term… reducing the use of elective labor induction may lead to decreased rates of cesarean delivery for a population.” Another study by Selo-Ojeme et al (2011) found induction increased the chance of a c-section x3 for first time mothers. The researchers recommend that “Nulliparous [first baby] women should be made aware of this, as well as potential risks of expectant management during counselling.” It is now well established that there are significant risks associated with c-section for both mother and baby. Childbirth Connection provide an extensive and evidence based list.

Induced labour is usually more painful than a physiological labour. Syntocinon (aka pitocin) produces strong contractions often without the gentle build up and endorphin release of natural contractions. In addition unlike natural oxytocin, syntocinon does not cross the blood-brain barrier to create the spaced-out, relaxed feelings that help women to cope with pain (see previous post). Not surprisingly, first time mothers are more than 3x more likely to opt for an epidural (Selo-Ojeme et al. 2011) during an induction. A Cochrane review found that: “Women who used epidurals were more likely to have a longer delivery (second stage of labour), needed their labour contractions stimulated with oxytocin, experienced very low blood pressure, were unable to move for a period of time after the birth (motor blockage), had problems passing urine (fluid retention) and suffered fever and association between epidural analgesia and instrumental birth.” The review also found an increased risk of instrumental delivery, and c-section for fetal distress with an epidural.

There are significant risks associated with ventouse and forceps birth, both for the mother and baby – RANZCOG lists them here. And the risks of c-section available via the link ‘Childbirth Connection’ above. The study by Selo-Ojeme et al. (2011) also found induction = increased risk of uterine hyperstimulation; ‘suspicious’ fetal heart rate tracings; and haemorrhage following birth. Not surprisingly ‘babies born to mothers who had an induction were significantly more likely to have an Apgar score of <5 at 5mins and an arterial cord pH of <7.0’ (basically not in a good way on arrival). Another recent study by Elkamil et al (2011) ‘found that labour induction at term was associated with excess risk of bilateral spastic CP [cerebral palsy]..’ Remember we are inducing labour to prevent harm to the baby…

Again, these general risks need to be individualised for a woman. For example, if this is her first baby, induction significantly increases her chance of a c-section. If this is a subsequent baby then her chance of c-section is not increased… but her chance of uterine rupture is.

The experience of labor

Once again the Cochrane review states: “Women’s experiences and opinions about these choices have not been adequately evaluated.” This is becoming a theme across Cochrane reviews. However, one thing is certain – choosing induction will totally alter your birth experience and the options open to you. Women need to know that agreeing to induction means agreeing to continuous monitoring and an IV drip, which will limit movement. Induced contractions are usually more painful than natural contractions and the inability to move and/or use warm water (shower or bath) reduces the ability to cope. The result is that an epidural may be needed. An induced birth is not a physiological birth and requires monitoring (vaginal exams) and time frames. Basically you have bought a ticket on the intervention rollercoaster. For many women this is fine and worth the risk, but I encounter too many women who are unprepared for the level of intervention required during an induction.

There have been some studies examining women’s experience of induction. Heimstad et al. (2007) conducted a survey of women  randomised to immediate induction at 41 weeks or waiting with regular ‘fetal surveillance’. They found that women preferred induction. However, these were women who were allocated an option rather than chose one. Another survey by Childbirth Connection asked mothers about their experience of induction (not necessarily for prolonged pregnancy) – 17% of those induced felt they were under pressure to do so by health care professionals. The quotes from women make interesting reading too. A study by Hildingsson et al. (2011) found that labour induction was associated with a less positive birth experience, and women who were induced were more likely to be frightened that their baby would be damaged during birth. However, again this research was not limited to induction for prolonged pregnancy therefore the women may have had genuine pregnancy complications requiring induction.

A more recent UK study by Henderson and Redshaw (2013) found that “women who were induced were generally less satisfied with aspects of their care and significantly less likely to have a normal delivery. In the qualitative analysis the main themes that emerged concerned delay, staff short- ages, neglect, pain and anxiety in relation to getting the induction started and once it was underway; and in relation to failed induction, the main themes were plans not being followed, wasted effort and pain, and feeling let down and disappointed.”.  A German study (Schwarz et al. 2016) concluded that: “women’s expectations and needs regarding IOL are widely unmet in current clinical practiceand that “there is a need for evidence-based information and decisional support for pregnant women who need to decide how to proceed once term is reached.”

Alternatives to waiting or medical induction

Before labour begins the uterus and cervix need to make physiological changes ready to respond to contractions. It is now thought that the baby is the controller of the labour ‘on’ switch. So, the baby signals to the mother that he/she is ready, oxytocin is released and the uterus responds. In comparison to other mammals, humans have the most variable gestation lengths. This suggests that other factors such as environment and emotions (eg. anxiety) also influence the start of labour. This would make sense considering what we know about the function of oxytocin (see previous post). It is also something most midwives are aware of – a stressed out mother is more likely to go post term than a relaxed and chilled out mother. Having said that, post term is probably the normal gestation length for many women regardless of what is going on. Creating anxiety and stress around due dates and impending induction is probably counter productive to labour.

There are a number of ‘alternative’ or ‘natural’ induction methods available (BellyBelly covers most of them here). However, an induction is an induction. Trying to force the body/baby to do something it is not ready to do is an intervention whether it is with medicine, herbs, therapies, techniques… or anything else. Interventions of any kind can have unwanted effects and consequences. At least a medical induction takes place with close monitoring of mother and baby with access to medical support if a complication arises. I worry that alternative inductions do not have this level of monitoring or back up.

However, ‘interventions’ (massage, acupuncture, etc.) that are aimed at relaxing the mother and fostering trust, patience and acceptance may assist the body/baby to initiate labour if the physiological changes have already taken place.

In Summary

A significant minority of babies will not be born by 41 weeks gestation. Whilst the definition of a prolonged pregnancy is 42 weeks+, induction is usually suggested during the 41st week. Women need to be given adequate information about the risks and benefits involved with either waiting or inducing in order to make the choice that is right for them. There is no risk free option. The risk of perinatal death is extremely small for both options. I know women who have lost a baby in the 41st week of pregnancy, and women who have lost a baby as a result of the induction process. For first time mothers the induction process poses particular risks for themselves and their babies. Each individual woman must decide which set of risks she is most willing to take – and be supported in her choice.

Further resources

Maternity Choices information sheet for parents.

Sara Wickham – post-term pregnancy and induction of labour resources

Sara Wickham – ten things I wish every women knew about induction of labour

Sara Wickham – How to cancel a labour induction?

Tara’s story (44 weeks)

A news article: ‘I was pregnant for 10 months’

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Responsibilities in the mother-midwife relationship

When I facilitate workshops with midwives and students, there is always a lot of discussion and debate about professional responsibilities in the mother-midwife relationship. These debates often get heated, and the complexities of legal, professional, and ethical issues can become confusing. This post is an attempt to ‘un-confuse’ and simplify these matters a little. Please note that this post is aimed at registered midwives ie. midwives who register each year, thereby agreeing to meet professional standards. It is also about Australian midwifery and may or may not be applicable to other countries.

Midwives can get caught up in meeting the needs of the institutions they work in, and/or feeling responsible for the decisions that women make (eg. to follow or not to follow institutional recommendations). So, it can be helpful to reflect on what our core responsibilities are in the mother-midwife relationship, and how we can meet them. These core responsibilities remain regardless of the care model and/or setting.

As midwives we have guidance about our responsibilities via our professional bodies. The International Confederation of Midwives (ICM) provide a number of core documents that are reflected in national codes and standards e.g. the Nursing and Midwifery Board of Australia (NMBA). These documents are referenced when determining whether a midwife met their professional responsibilities. In this post I discuss my interpretation of these documents and the law in relation to responsibilities. I would be interested in your interpretations too so please comment.

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MIDWIVES’ RESPONSIBILITIES

“Midwifery care takes place in partnership with women and is personalised, continuous and non-authoritarian… Midwifery care empowers women to assume responsibility for their health and for the health of their families.” (ICM 2010)

In essence midwifery care is ‘woman-centred’. This means that the midwife must primarily meet the needs of the woman – not the institution, or cultural norms, or colleagues, or a personal agenda.

In order to meet their core responsibilities, midwives need to be research literate. By that, I don’t mean they need to be able to conduct research or understand complex statistics. However, they do need to be able to find evidence, evaluate it, and apply it to practice. This is why university midwifery programs include research in the curriculum (and yes, students generally hate it!). The NMBA Competency Standards for Midwives state that:

[The graduate midwife] “understands and values the imperative to base practice on evidence, is able to access relevant and appropriate evidence, recognise when evidence is less than adequate to fully inform care and identify areas of practice that require further evidence.” (NMBA 2006)

[The graduate midwife] “Values and acknowledges the importance of research and evidence; Maintains current knowledge about relevant research; Demonstrates skills in retrieving and understanding research evidence including levels of enquiry and forms of evidence… Interprets evidence as a basis to inform practice and decision making.” (NMBA 2006)

The ICM go a step further placing the responsibility of advancing midwifery knowledge on ‘all midwives’ stating that:

“The ICM further believes that all midwives have a role and a responsibility in advancing knowledge within the midwifery profession and the effectiveness of midwifery practice, essential for improvement in the health of all women and childbearing families.” (ICM 2008b)

So, like it or not – midwives need to be research literate.

Adequate Information

“Midwives develop a partnership with individual women in which they share relevant information that leads to informed decision-making, consent to an evolving plan of care, and acceptance of responsibility for the outcomes of their choices.” (ICM 2008a). “The woman is the primary decision-maker in her care and she has the right to information that enhances her decision-making abilities.” (ICM 2010).

It is essential that midwives provide women with adequate information. A failure to do so not only breaches professional standards, but can also result in legal action for assault and battery (due to invalid consent) or negligence (of information giving). The legal standards for ‘reasonable information’ are listed in a previous post; and there are also professional standards about information giving.

Firstly midwives need to be clear about how they practise, their responsibilities, and their boundaries (NMBA 2008a). For example, a woman needs to know that a private practice midwife is… “guided by the profession’s guidelines for consultation, referral and transfer – the National Midwifery Guidelines for Consultation and Referral (NMBA 2008a); and what this means if her situation is categorised as a ‘consult’ or ‘refer’. In Australia, private practise midwives can withdraw care if a woman declines consultation or referral. A woman needs to know her midwife’s threshold for withdrawing care before engaging her/his services.

When a decision is required about any aspect of care – from place of birth, to vitamin K for the newborn – adequate information must be provided about the option/procedure/intervention. In the case of a procedure – the person performing the procedure needs to gain consent ie. ensure adequate information is given. For example, if a midwife is about to start an induction process for a woman – that midwife is responsible for ensuring the woman is adequately informed. It would be nice if the person arranging the induction, or the person prescribing the medication provides adequate information… but the midwife cannot rely on this. It is her/his responsibility.

If the midwife is employed by an institution she may be obliged to offer particular options eg. a 4 hourly vaginal examination during labour. However the key word is ‘offer’. In addition to this offer, the woman needs adequate information to consent or decline the offer. If the midwife is in private practice she/he needs to inform the woman of the ‘standard’ or mainstream practise, particularly if there are state, national or international guidelines/recommendations.

For an option or intervention adequate information includes:

  • The rationale for the recommendation: why guidelines suggest the option or procedure.
  • A description of the option or procedure: what it is, how it is carried out, what it involves, etc.
  • General benefits and risks of all options: including current research, and whether guidelines are support by research.
  • Individualised benefits and risks of all options: are there different stats/research that the woman needs to consider in regard to her individual circumstances?

This information sharing must include the woman “…having the opportunity to verify the meaning and implication of information being given to her when making decisions…” (NMBA 2008b). NMBA offer further guidance stating that:

“When midwives provide advice about any care or product, they fully explain the advantages and disadvantages of alternative products or care so individuals can make informed choices. Midwives refrain from engaging in exploitation, misinformation or misrepresentation with regard to health care products and midwifery care.” (NMBA 2008b)

Lets take a look at some examples…

Eg. What a woman needs to know about induction of labour for post-dates pregnancy:

  • That most clinical guidelines recommend induction of labour at 41 weeks + because there is an increase in perinatal mortality (baby death) for pregnancies that continue beyond 41 weeks. I can see that some of you are already cringing, but this is the truth. You also need to quantify that risk for the woman in a meaningful way eg. 30:10,000 for waiting vs 3:10,000 if labour is induced (see this post). It is not adequate to just state ‘there is increased risk’ or to say that ‘the risk is small’.
  • What induction of labour involves and how it is different to physiological labour; and what would happen if she chose to wait eg. options re. monitoring.
  • The general risks and benefits of induction, and of waiting (see this post).
  • The individual risks for the woman i.e. factors that change her risks eg. is this her first baby? Are there other health concerns or issues (eg. VBAC)?

Eg. What a woman needs to know to consent to a routine vaginal examination during labour (as per a hospital guideline rather than in response to a situation):

  • That the hospital guidelines requires the midwife to offer a vaginal examination, for example, the midwife might say “The guideline in this hospital recommends that I offer a vaginal examination to you because you have been in birth suite for 4 hours. The reason for this is to attempt to estimate the progress of your labour.” (you must do this to meet your employee requirements if there is a hospital guideline or policy)
  • The evidence supporting (or not) the recommendation, and the risks and benefits of the intervention: “There is no evidence to support that a vaginal examination is an effective method of assessing labour progress because it can’t predict the future…” insert explanation about how all women have a different labour pattern… and the risks and benefits of the a VE.
  • Any individual factors that alter risks or benefits eg. if her membranes are not intact there is an additional risk of infection. In some cases a VE may be helpful to support decision making with regard to necessary intervention eg. if labour seems abnormal or the baby’s heart rate is concerning.

It can also be helpful to assert that it is the woman’s decision and that you will support her in whatever she thinks is best for her (many women think they have to follow recommendations).

It is particularly important to provide clear information when a woman is making decisions outside of recommendations or the norm. There is no risk free choice – the woman must decide which risk is most significant for her. In order to do this she needs to have adequate information. For example, if a woman is choosing to birth at home she needs information about the benefits, risks and other options. She needs know the difference between home and hospital, including how the setting might alter the management of any complications.

Information sharing needs to be documented. Like any aspect of care there needs to be evidence that it happened. For example, when gaining consent for a vaginal examination – rather than writing ‘VE with consent’, list the risks discussed (bullet points will do). Some hospitals are using consent forms for common interventions eg. VE and ARM with a list of risks for the midwife to read out and get the woman to sign. If you give the woman any information resources – write down what you gave her.

It is also important to be clear about your scope and abilities by “acknowledging one’s own strengths and limitations” (NMBA 2008b). This involves being honest with women about your experience and ability to meet her needs. For example, if you have limited experience in attending breech births, and her baby is breech – she needs to know. If she is wanting a physiological placental birth and you (the midwife) have limited experience in supporting this – she needs to know.

A word about words… I realise the word ‘risk’ is used a lot in this post. However, the reality is that as midwives we are expected to talk about ‘risk’. We can change the word for ‘chance’ in many cases – but not all. Like it or not, we operate in a ‘risk’ discourse and for legal purposes need to disclose ‘risk’ information with women. However, I avoid the word ‘safe’ when talking to women about their options. Safety is in the eye of the beholder – it is up to the woman whether she thinks a 1:1000 chance of something happening is ‘safe’ or ‘unsafe’. Saying something is ‘safe’ is a judgement and can be seen as an endorsement of a particular option.

Which brings us to the issue of bias. Information sharing needs to be unbiased, and this is extremely difficult because we are all biased and have our own beliefs and opinions. However, there are some strategies to avoid transmitting your bias whilst giving information:

  • Present both sides of the coin (see above) ie. risks and benefits of all options in a matter of fact manner ie. don’t share your personal opinions or experiences (with other women) about an option.
  • Avoid advising or recommending particular options unless a complication or pathology is actually occurring. For example, you wouldn’t recommend induction, or waiting for an uncomplicated post-dates pregnancy; but you would recommend a medical review if a woman’s blood pressure was abnormally high.
  • Ensure that the woman knows you are not invested in her decision, and that you do not want to influence her either way – say this to her.
  • When asked “what would you do?” – point out that you are not her , and not in her situation, and what you would do is irrelevant to what is best for her.
  • Avoid telling her what you did with your own pregnancy, birth, baby – again, this is not relevant to her.
  • Don’t create unnecessary fear about other options, for example if she is choosing to homebirth, it is unprofessional to tell her how awful the local hospital is. Not only can this influence her decision, but it can also make things problematic if a transfer to that hospital is needed.

A good way to assess whether you are providing un-biased information is to look at what women in your care choose to do. If all of the women you care for choose the same option – you need to consider if you are influencing them. Women are individuals and there should be a range of decisions being made.

Support

“Midwives advocate for the protection of the rights of each woman, her infant(s), partner, family and community in relation to midwifery care.” (NMBA 2006)

Once the woman has made her decision the midwife supports and advocates for her. For example, if a woman declines the offer of a vaginal examination – you simply document her decision and carry on. You may need to let colleagues know what her decision is and ensure that they respect it. In some settings you may be question or pressured about her decision – but ultimately you are fulfilling your legal responsibilities regarding consent. This trumps any institutional cultural norms or expectations.

However, for a midwife in private practise responsibilities regarding support are not so clear. If a woman chooses care outside of recommendations the midwife has the choice to carry on providing support – or ‘withdraw’ care (ACM 2013). Unfortunately this has resulted in midwives being held responsible for women’s decisions, simply by agreeing to carry on providing care.

Competent Practice

“Midwifery care combines art and science. Midwifery care is holistic in nature, grounded in an understanding of the social, emotional, cultural, spiritual, psychological and physical experiences of women and based upon the best available evidence.” (ICM 2010)

The scope of the midwife “…includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures” (ICM 2011)

The midwife needs to provide competent care within the constraints of the woman’s decisions. For example, competent management of an emergency situation will be different in a home setting compared to a hospital setting.

THE MOTHER’S RESPONSIBILITIES

Unlike midwives, women are not registered and regulated. Therefore, there are no guidance documents regarding women’s responsibilities in the mother-midwife relationship (and this section is a lot smaller!). However, if midwives meet their responsibilities (above), then women become accountable for their decisions and the outcome of their decisions.

Decisions

By law, women have the right to make decisions regarding what is done or not done to them. Midwifery should support women to take responsibility for their decisions (ICM 2010).

Many factors influence decision making, and the information a midwife provides is only one piece of the puzzle. Humans are active seekers and interpreters of information. We pick and choose, using and discarding information according to internal and external constraints and considerations. Embodied knowledge, personal experiences and other people’s experiences influence the selective designation of knowledge as authoritative or not. We often start with a conclusion, then rationalise it with evidence. We surround ourselves  with people who have beliefs and opinions aligned with our own. The internet has increased our access to information and people who will reinforce our beliefs and choices. Midwives cannot, and should not take responsibility for the sources information a woman chooses to engage with.

Most women will be influenced by the mainstream risk discourse and cultural norms. Women who make decisions against this discourse must seek information and people who will support their decisions. Some do this in response to previous experiences with the medical paradigm. Some choose the support of an unregistered care provider (or no care provider) to birth away from the medical paradigm and its intervention focus and inherent discourse about risk.

Outcome of Decisions

ICM (2008a) state that women should accept responsibility for the outcomes of their choices (if the midwife met her responsibilities). This is not about blame. It is about accepting that an outcome (good or bad) directly associated with a decision is the responsibility of the decision-maker.

Whilst midwives can be affected by outcomes – they cannot take responsibility for the outcome of a woman’s informed decision. For example, if a woman chooses an induction and the outcome is fetal distress and a c-section – this outcome is not the midwife’s responsibility. The midwife’s responsibility is providing adequate information about induction, supporting the woman’s decision to induce, and competent practice (management of the induction process, identification of the fetal distress, and alerting the medical team).

Summary

Registered midwives have a responsibility to provide information, support and competent care to women. In return, women take responsibility for making decision and for the outcome of their decisions. Whilst this appears simple, it is an incredibly complex relationship and I would be interested to read your comments about these issues.

References

ICM (2008a) international code of ethics for midwives

ICM (2008b) role of the midwife in research

ICM (2010) philosophy and model of midwifery care

ICM (2011) international definition of the midwife

NMBA (2006) national competency standards for the midwife

NMBA (2008a) code of professional conduct for midwives in Australia

NMBA (2008b) code of ethics for midwives in Australia

Posted in law, midwifery practice, opinion and thoughts, uncategorized | Tagged , , | 29 Comments

Information Giving and the Law

I was writing a blog post on induction for prolonged pregnancy but got side tracked reflecting on a recent study day I attended about law. So, I will get this out of my system before finishing the induction post.

It seems that many health care professionals are routinely putting themselves at risk of legal action in relation to information giving (or not as the case may be). Either they are unaware of the implications, or they think women will never hold them to account. This post is a very brief and basic overview of law (Australian) in relation to information giving. Although I have based the contents on McIlwraith & Madden (2010) the information is available in most law books and on the internet.

Consent

If consent is not gained prior to a procedure it could lead to an action for ‘trespass to the person’ (ie. assault and/or battery). For consent to be valid it must have at least 3 elements:

  1. be voluntary and freely given
  2. come from a competent person
  3. be specific to the treatment/procedure.

The first element is where I think most breaches take place in maternity care situations. In order for this element to be satisfied:

  • the person must not be under any undue influence or coercion
  • there must be no misrepresentation (whether deliberate or mistaken) as to the nature or necessity of a procedure.

I am sure I don’t need to list the common real life scenarios in which this element of consent is not satisfied in relation to maternity care. By the way, to sustain a civil action alleging assault and/or battery harm does not need to caused by the procedure.

Negligence – lack of information

A health care practitioner who fails to provide adequate information to a woman can be sued for negligence. In order to have a successful case the woman must demonstrate that:

  1. the health carer had a duty of care to provide the information
  2. that duty was breached by failure to provide the information
  3. the woman would not have agreed to the procedure/treatment if adequate information had been given
  4. and as a result, the woman or baby suffered harm.

What is reasonable information?

The High Court states that patients should be told of any ‘material risk’ inherent in the treatment. A material risk in relation to maternity is one:

  • to which a reasonable woman in the woman’s condition/situation would be likely to attach significance;
  • to which the health carer knows (or ought to know) the particular woman would be likely to attach significance; or
  • about which questions asked by the woman reveal her concern

Responsibilities regarding information giving are discussed in more detail in this post. And you can find more information about ‘material risk’ in this article.

What do you think?

Considering the routine use of tests and procedures in maternity care (eg. ultrasound scanning, induction, c-section, etc.) I would be really interested what readers think…

  • Are women coerced by practitioners into tests/procedures?
  • Are practitioners aware of the law, or do they rely on women not knowing the law?
  • Would common practice around information giving change if legal actions were brought against practitioners who fail to adequately inform?

Further resources/reading

Journal articles:

Goldberg, H 2008, ‘Informed decision making in maternity care’, Journal of Perinatal Education, vol. 18, no. 1, pp. 32-40.

Griffith, R 2010, ‘Giving advice and information on risks’, British Journal of Midwifery, vol. 18, no. 4, pp. 262-263.

Marshall, JE, Fraser, DM & Baker, PN 2011, ‘An observational study to explore the power and effect of the labour ward culture on consent to intrapartum procedures’, International Journal of Childbirth, vol. 1, no. 2, pp. 82-99.

O’Cathain, A, Thomas, K, Walters, SJ, Nicholl, J & Kirkham, M 2002, ‘Women’s perceptions of informed choice in maternity care’, Midwifery, vol. 18, pp. 136-144.

Websites/articles

Informed choice, consent & the law: the legalities of “yes I can” and “no I won’t” by Ann Catchlove

Birthrights

Human Rights in Childbirth

 

Posted in law, midwifery practice | Tagged , , , , , | 48 Comments

The Anterior Cervical Lip: how to ruin a perfectly good birth

Here is a scenario I keep hearing over and over: A woman is labouring away and all is good. She begins to push with contractions, and her midwife encourages her to follow her body. After a little while the midwife checks to ‘see what is happening’ and finds an anterior cervical lip. The woman is told to stop pushing because she is ‘not fully dilated’ and will damage herself. Her body is lying to her – she is not ready to push. The woman becomes confused and frightened. She is unable to stop pushing and fights her body creating more pain. Because she is unable to stop pushing she may be advised to have an epidural. An epidural is inserted along with all the accompanying machines and monitoring. Later, another vaginal examination finds that the cervix has fully dilated and now she is coached to push. The end of the story is usually an instrumental birth (ventouse or forceps) for an epidural related problem – fetal distress caused by directed pushing; ‘failure to progress’; baby mal-positioned due to supine position and reduced pelvic tone. The message the woman takes from her birth is that her body failed her, when in fact it was the midwife/system that failed her. Before anyone gets defensive – I am not pointing fingers or blaming individuals, because I have been that midwife. Like most midwives I was taught that women must not push until the cervix has fully dilated. This assumption has been taught to midwives since the 1930s and Ina May herself warned against ‘early pushing’ in Spiritual Midwifery. This post is an attempt to prompt some re-thinking about this issue, or rather this non-issue.

Anatomy and Physiology

Birth is an extremely complex physiological process but very simplistically 3 main things occur:

  1. Dilatation of the cervix
  2. Rotation of the baby through the pelvis
  3. Descent of the baby through the pelvis

But this is not a step-by-step process – it’s all happening at the same time, and at different rates. So whilst the cervix is dilating the baby is also rotating and descending.

1. Dilatation of the cervix

Presentation2The cervix does not open as depicted in obstetric dilatation models ie. in a nice neat circle (Sutton 2001). It opens from the back to the front like an ellipse. The ‘os’ (opening) is found tucked at the back of the vagina in early labour and opens forward. At some point in labour almost every woman will have an anterior lip because this is the last part of the cervix to be pulled up over the baby’s head. Whether this lip is detected depends on whether/when a vaginal examination is performed. A posterior lip is almost unheard of because this part of the cervix disappears first. Or rather it becomes difficult to reach with fingers first.

The cervix dilates because the muscle fibres in the fundus (top of the uterus) retract and shorten with contractions = pull it open (Coad 2011). This does not require the pressure of a presenting part ie. baby’s head or bottom (lets stick to heads for now). However, the head can influence the shape of the cervix as it dilates up around it. For example, a well flexed OA baby (see pic A) will create a neater, more circular cervix. An OP and/or deflexed baby (see pic B) will create a less even shape. For more about OA and OP positions see this post. Most baby’s will be somewhere between these two extremes whilst the cervix is opening and will be changing their position as they rotate.

2. Rotation

Babies enter the pelvis through the brim. As you can see from the pictures above this is easier with their head in a transverse position. As the baby descends into the cavity their head will be tilted – with the parietal bone/side of the head leading. This is because the angle of the pelvis requires the baby to enter at an angle – see picture on the right. Once in the cavity the baby has room to rotate into a good position for the outlet which is usually OA. Rotation is aided by the pelvic floor and often by pushing.

3. Descent – the urge to push

The urge to push… and I’m talking spontaneous, gutteral, unstoppable pushing… is triggered when the presenting part descends into the vagina and applies pressure to the rectum and pelvic floor. This is sometimes called the ‘Ferguson reflex’ – probably after some man. This reflex is not dependent on what the cervix is doing, but where and what the baby’s head is doing. So, if the baby’s head hits the right spot before the cervix has finished dilating, the woman will spontaneously start pushing. An alternative but common scenario is when the cervix is fully open but the baby has not descended far enough to trigger pushing. Unfortunately some practitioners will tell the woman to push and create problems instead of waiting for descent and spontaneous pushing.

Pushing before full dilatation

Because we are not telling women when to push (are we?!) they will push when their body needs to. If we are directing pushing we risk working against the physiology of birth and creating problems (see previous post). There is very little research about pushing before full dilatation. Downe et al. (2008) report research conducted in the UK in 1999, and recently Borrelli, Locatelli & Nespoli (2013) published a small observational study. These studies found that the incidence of ‘early pushing urge’ EPU (as it is referred to in the literature) is between 20% to 40%. Interesting Borrelli et al. (2013) found that the sooner the midwife performed a vaginal examination in response to a woman’s pushing urges, the more likely they were to find the cervix still there. They also found that ‘early pushing’ was much more common with primips (first labours)… perhaps because they are likely to take longer pushing, therefore be more likely to have a vaginal examination? And early pushing occurred in 41% of women with OP babies.

Spontaneous pushing before full dilatation is a normal and physiologically helpful when:

  1. Baby’s head descends into the vagina before the cervix has dilated. In this case the additional downward pushing pressure assists the baby to move beyond the cervix.
  2. Baby is in an OP position and the hard prominent occiput (back of head) presses on the rectum. In an OA position this part of the head is against the symphysis pubis and the baby has to descend deeper before pressure on the rectum occurs from the front of the head. In the case of an OP position, pushing can assist rotation into an OA position.

I am yet to find any evidence that pushing on an unopened cervix will cause damage. I have been told many times that it will, but have never actually seen it happen. Borrelli et al. (2013) found no cervical lacerations, 3rd degree tears, postpartum haemorrhages in the women with an EPU. A recent review of the available research (Tsao 2015) concluded: “Pushing with the early urge before full dilation did not seem to increase the risk of cervical edema or any other adverse maternal or neonatal outcomes.” I have encountered swollen (oedematous) cervixes – mostly in women with epidurals who are unable to move about. But, this occurs without any pushing. I can understand how directed, strong pushing could bruise a cervix. But I don’t see how a woman could damage herself by following her urges. In many ways the argument regarding pushing, or not, is pointless because once the Ferguson reflex takes over it is beyond anyone’s control. You either let it happen, or start commanding the women to do something she is unable to do ie. stop pushing.

I can only find one study that examined women’s experiences of an ‘early’ pushing urge (Celesia et. al 2016). The women in this study women were told by their midwives not to push: “In coping with EPU, women found it difficult to follow the midwives’ advice to stop pushing because this was conflicting with what their body was suggesting [to] them. Throughout their attempts to stop pushing, women were accompanied by the conflicting feelings of naturalness of going along with the pushes and discomfort of going against their bodily sensation. Women were confused by the contradiction between their physi- cal perceptions and the need to hold back pushes suggested by the midwife at the same time. Moreover, they reported difficulty in realizing what was happening. This confusion was sometimes related to the feeling of not being believed by health care professionals” (p. 23)

Telling women to push or not to push is cultural, it is not based on physiology or research. For example, in some parts of the world women are told to push throughout their entire labour (on an unopened cervix!). This is often accompanied by their midwife manually stretching the cervix too – ouch. Alternatively, in other parts of the world women are told not to push until a prescribed point in labour. It seems midwives are bossy worldwide.

When left to get on with their birth, occasionally women will complain of pain associated with a cervical lip being ‘nipped’ between the baby’s head and their symphysis pubis during a pushing contraction. In this case the woman can be assisted to get into a position that will take the pressure off the cervical lip (eg. backward leaning). When undisturbed women will usually do this instinctively. At a recent waterbirth a mother (first baby) who had been spontaneously pushing for a while on all fours floated onto her back. A little while later she asked me to feel where the baby was (for her not me) – baby was not far away with a fat squishy anterior lip in front of the head. The mother also had a feel, then carried on pushing as before. Her daughter was born around 30 mins later.

Suggestions

Avoid vaginal examinations (VEs) in labour. What you don’t know (that there is a cervical lip) can’t hurt you or anyone else. VE’s are an unreliable method of assessing progress, and the timelines prescribed for labour are not evidence based (see this post).

Ignore pushing and don’t say the words ‘push’ or ‘pushing’ during a birth. Asking questions or giving directions interferes with the woman’s instincts. For example, asking ‘are you pushing’ can result in the women thinking… am I? Should I be? Shouldn’t I be? Thinking and worrying is counterproductive to oxytocin release and therefore birth. If she is pushing, let her get on with it and shush. For more about pushing in general and a link to a great audio by Gloria Lemay see this post.

Do not tell the woman to stop pushing. If she is spontaneously pushing (and you have not coached her) she will be unable to stop. It is like telling someone not to blink. Pushing will help not hinder the birth. Telling her not to push is disempowering and implies her body is ‘wrong’. In addition, after fighting against her urge to push she may then find it difficult to follow her body and push when permitted to do so (Bergstrom 1997).

If a woman has been spontaneously pushing for a while with excessive pain (usually above the pubic bone) she may have a cervical lip which is being nipped against the symphysis pubis. There is no need to do a vaginal examination to confirm this unless she wants you to. If you suspect, or know there may be a cervical lip:

  • Reassure her that she has made fantastic progress and only has little way to go.
  • Ask her to allow her body to do what it needs to, but not to force her pushing.
  • Help her to get into a position that takes the pressure off the lip and feels most comfortable – usually a reclining position. She may be in a forward leaning position because it relieves the back pain associated with an OP presentation and be reluctant to move. This is one of the rare times a suggestion/direction is appropriate.
  • If the situation continues, and is causing distress – during a contraction apply upward pressure (sustained and firm) just above the pubic bone in an attempt to ‘lift’ the cervix up.
  • If the woman is requesting further assistance, the cervical lip can be manually pushed over the baby’s head internally – by her or you. This is extremely uncomfortable! Be aware that this may allow the baby’s head to move into the vagina before he/she has rotated which could create further problems.

Note: This nipping situation is rare and usually a cervical lip will simply move out of the way without causing any problems.

Summary

An anterior cervical lip is a normal part of the birth process. It does not require management and is best left undetected. The complications associated with a cervical lip are caused by identifying it, and managing the situation as though it is a problem.

Posted in birth, intervention, midwifery practice | Tagged , , , , , | 414 Comments

VBAC: making a mountain out of a molehill

VBAC (vaginal birth after caesarean) is big. A google search for ‘vbac’ results in ‘about 795,000’ results. Reviews, guidelines, policies and statements are being produced by every organisation with an interest in birth. Support groups and networks are growing. I am not going to add to this wealth of information. Others are doing a fantastic job and I will provide some links at the bottom of this post. This post is really aimed at putting VBAC into perspective risk-wise and discussing how we can best support women planning a vaginal birth after caesarean. I haven’t personally experienced the VBAC journey and would welcome some input from mothers who have via comments, suggestions and links. This is written from my perspective as a midwife.

With a c-section rate of around 1 in 3 (Australia) a significant proportion of women approach their subsequent birth with a scarred uterus. Of those women, 84% will have another caesarean. I can’t find the stats re. how many of these repeat c-sections are planned vs emergency. But, considering the 50-90% ‘success’ rate for VBACs, I am assuming that most repeat c-sections are planned. I wonder if more women would choose to experience a vaginal birth if they had adequate information and support from care providers who believed in them?

Guidelines suggest that women should be counselled about the risks of VBAC, and they should have additional monitoring and intervention during labour. The big concern is uterine rupture, and this is what I am going to focus on. By the way – unless I provide a reference/link you can assume I am getting my numbers from the NIH Consensus Statement (US) or Having a Baby in Queensland (Aus). Both of these resources are based on current research evidence. So, if you need the original research sources check out their reference lists.

What happens during a uterine rupture?

Considering this is the risk associated with VBAC is worth briefly describing what is involved. Uterine rupture can happen at any birth, even when no scar is present (particularly if syntocinon is used). There are two types of uterine rupture associated with VBAC (Pairman et al. 2014):

  1. Catastrophic (symptomatic) – the old scar separates long its length, the amniotic sac ruptures and the baby is pushed into the abdominal cavity. This results in significant bleeding, shock and the baby is in grave danger.
  2. Asymptomatic – the scar separates partway along its length, the amniotic sac stays intact and the baby remains in the uterus. Bleeding and shock is minimal and the baby usually survives. This is the most common type.

Here is a youtube clip of what happens during a catastrophic uterine rupture. For more information about uterine rupture (including symptoms) check out this article on BellyBelly.

Risk by numbers

Risk is a difficult concept. You can have odds of 1 in a million, but if you are the 1 it is 100% for you. It’s also impossible to eliminate all risk from life (or birth) and every option has risks attached. All women can do is choose the risk that feels right for them – there is no risk-free choice. There are many ways of presenting risk and some ways may mean more than others for individuals. For example, if we look at the overall risk of uterine rupture for a woman who has had 1 previous c-section. By overall, I mean without adding or subtracting factors which increase or decrease an individual’s risk (eg. syntocinon during labour, transverse scar). The risk can be presented like this:

  • 50 out of 10,000 will rupture
  • 9,950 out of 10,000 will not rupture
  • 1 in 200 will rupture
  • 199 out of 200 will not rupture
  • 0.5% will rupture
  • 99.5% will not rupture

Which of these versions would help you conceptualise risk? I know when I look at the picture versions of risk I assume I’m the ‘red person’. Personally I like the 99.5% intact uterus odds.

As stated above these figures are the taken from the NIH Consensus Statement (US) or Having a Baby in Queensland (Aus). A more recent UK study (Fitzpatrick et al. 2012) found an even lower overall risk of rupture – 0.2%.

The risk of rupture may be even lower in labours that are not induced or augmented (the stats above are a mixture of all labours). An Australian study (Dekker et al. 2010) found that the risk of uterine rupture during VBAC was 0.15% in spontaneous labour, 1.91% in augmented labour and 0.88% in labour induced using prostin and oxytocin. Fitzpatrick et al. (2012) also found an increase in rupture with induction and augmentation. In contrast a US study (Ouzouian et al. 2011) found no different in rupture rates between spontaneous and induced labours – but found a significantly greater vaginal birth rate following spontaneous labour. Another study (Harper et al. 2011) found an increased chance of rupture during induction when the woman has an ‘unfavourable’ cervix. There are also other risks associated with induction which need to be considered before heading down that pathway.

For women who have had multiple c-sections: Landon et al. (2006) suggest the risk of rupture rises to 0.9%. Fitzpatrick et al. (2012) also found a slight increase in risk for women how had had 2 or more previous c-sections. However Cahill et al. (2010) found that: “Women with three or more prior caesareans who attempt VBAC have similar rates of success and risk for maternal morbidity as those with one prior caesarean, and as those delivered by elective repeat caesarean.”

The story looks a little different again when you look at the mortality and morbidity caused by uterine rupture.  Guise et al (2004) conducted a systematic review of research relating to VBAC and uterine rupture. They found that uterine rupture resulted in: 0 maternal deaths; 5% perinatal deaths (baby); and 13% hysterectomy. They conclude that: ‘Although the literature on uterine rupture is imprecise and inconsistent, existing studies indicate that 370 (213 to 1370) elective caesarean deliveries would need to be performed to prevent one symptomatic uterine rupture.’

So, out of the small number of women who experience uterine rupture, an even smaller proportion will lose their baby or uterus because of it. When the uterus ruptures 94% of babies survive. The RCOG guidelines state that: “Women should be informed that the absolute risk of birth-related perinatal death associated with VBAC is extremely low and comparable to the risk for nulliparous [first baby/birth] women in labour.” 

VBAC vs planned c-section: uterine rupture

Most resources and guidelines compare the risk of a VBAC with the risks of a repeat c-section. This can be a brain-twister because of the multiple and complex risks associated with c-section for mother and baby. Childbirth Connection cover them well, so I won’t. It is also important that women know a c-section increases the chance of stillbirth in subsequent pregnancies (Moraitis et al. 2015). Having a Baby in Queensland directly compares VBAC with planned repeat c-section for a number of complications.

I’m trying to stick to the risk of uterine rupture (the ‘big’ one). So, planned c-section wins with a 2:10,000 uterine rupture rate compared to 50:10,000 for a VBAC. That’s if you are happy to take all the (more frequently occurring) risks associated with c-section in exchange.

Uterine rupture vs other potential birth emergencies

A Woman’s Guide to VBAC: Navigating the NIH Consensus Recommendations compares uterine rupture with other potential complications. You are more likely to experience a placental abruption, a cord prolapse or a shoulder dystocia (not associated with previous c-section) during your vbac than a uterine rupture. Your baby is also more likely to die from the placental abruption or cord prolapse than from a uterine rupture.

Anecdotes

Anecdotes often hold more power than numbers. I can guarantee that I will get a comment telling me about a poor outcome associated with a VBAC. They do happen (see the stats above). Unfortunately when care providers have been involved in a traumatic situation, it can be hard not to let that experience colour their perspective and approach. The memory of one uterine rupture will be stronger than all of the uncomplicated VBACs they have seen. The only uterine rupture I have personally been involved with was an induction of labour – not a VBAC. So, I emotionally associate uterine rupture with induction rather than VBAC.

Obstetricians in particular have to deal with the fall out of major complications because this is their area of expertise. They also miss out on seeing physiological births which end well because this is the realm of the midwife (I know this is different in the US/private sector). This can lead to fear-based counselling and practice, and a general fear of normal birth. It is interesting that a poor outcome associated with a c-section does not seem to elicit quite the same response – ie. fear of c-section.

When parents find themselves the 1 in how ever many, it is even more devastating. Their stories are powerful and need to be heard. However, it can be difficult for other parents to contextualise the story without also hearing stories with good outcomes.

The real risks of VBAC (according to me)

I am a bit confused about why such a huge deal is made about the risk of uterine rupture during VBAC. Why are these women subjected to serious (and often biased) discussions with fearful practitioners about the dangers of attempting birth? Why are they categorised as ‘high risk’, limiting their care options and imposing additional monitoring and intervention during their labour? If we agree that this is the right approach, then we also need to treat all women like this because the risk of placental abruption or a cord prolapse is greater than the risk of a uterine rupture during a VBAC.

To be honest, as a midwife uterine rupture is the least of my worries when caring for a woman having a VBAC. I actually think the mountain that has been built out of the risk-molehill requires more energy and attention. These women do need special treatment, but not in the form of disempowering fear-based counselling or practice. They have often had a previous traumatic birth experience and are dealing with fear from family, friends, and the medical system, in addition to their own worries. They have been labelled ‘high risk’ and are constantly reminded of the potential disaster waiting to occur. They also risk ‘failing’ if they encounter any complications or end up having a repeat c-section. This impacts on their ability to trust their body, follow their intuition and allow the physiology of birth to unfold. Often these women need more nurturing, reassurance and support from those involved in their birth.

Suggestions

During pregnancy

It is important to not only help women to prepare but also their partners and/or other close family members who may be at the birth. Often the partner was present at the previous birth, which may have been traumatic to witness. For a partner their priority is the safety of the woman they love – not a particular birth experience. Winning them over may be difficult. In some cases the decision the mother makes may be that the partner should not be present. OK – some suggestions:

  • Find out the details of her previous birth experience. If she needs debriefing help her do so, or refer to someone who can. Knowing about her previous experince and her fears can help you know what she needs during her labour.
  • Offer to discuss ‘risk’ and present the statistics in a number of ways. Find out what they (mother and partner) find most useful and empowering. I could say ‘don’t mention risk’ but to be honest ,unless she is living in a cave she will already be aware that VBAC is ‘risky’ and will need to explore this. In addition, it is a legal requirement for midwives to provide evidence based information about risk.
  • Make sure she is aware that she has a very good chance of having a vaginal birth – 72-75% if she has not previously had a vaginal birth, and 85-90% if she has (RCOG). Overall, she has a greater likelihood of a vaginal birth than a woman having her first baby and no previous c-section.
  • The RCOG guidelines state that: “Women should be made aware that successful VBAC has the fewest complications and therefore the chance of VBAC success or failure is an important consideration when choosing the mode of delivery.” Therefore it is important to consider previous birth scenarios and contexts to evaluate the chance of success for the individual woman.
  • The woman also needs information about factors that can increase her chance of VBAC eg. choosing supportive care providers (and setting) and not having her labour induced or augmented.
  • Talk about the possibility of the pregnancy going beyond the prescribed ‘due date’. This is often a feature of VBAC pregnancy. Some hospitals or midwives consider this to be a risk factor because the chance of a repeat c-section is about 9% greater (Coassolo et al. 2005). However, the risk of uterine rupture is no greater.
  • Make sure she knows that having a c-section after labour has started holds more health benefits than a planned c-section. Her baby will have had a chance to initiate labour and make the physiological changes needed for life outside the uterus. They will be less likely to suffer respiratory distress and end up in special care (Senturk et al. 2015). In addition, both mother and baby will have the important cocktail of hormones that assist with bonding. Even if she chooses a repeat c-section she can insist on going into labour first.
  • Talk to her and her partner about what actually happens if the uterus ruptures. They may be imagining all kinds of horrific scenes such as the baby bursting out of an exploding abdomen.
  • If she is worried about ‘failure’ reassure her that she doesn’t need to tell anyone she is planning a VBAC. She can say she’s not sure and will decide in labour.
  • If she is planning to birth in hospital she needs to know what the hospital policies are and decide what she will or won’t go along with. This means talking about the risks of the usual interventions such as CTG monitoring. A very clear birth statement can help the staff to support her wishes. It might be helpful to find out the VBAC rates at the hospital to gain some idea about how supportive they are likely to be during labour.
  • Encourage her to talk to other women about their experiences of VBAC, read positive birth stories and watch beautiful VBAC birth movies.
  • Do not use disempowering language such a ‘trial of scar’ or constantly refer to her birth as a VBAC. She is a woman having a baby, not a disaster waiting to happen.

During labour

The physical care of a woman having a VBAC should be no different (although I know it often is in hospital). Yes, I’m watching for signs of a uterine rupture: unusual pain, unusual contraction pattern, fetal heart rate abnormalities, unusual bleeding, a change in maternal observations etc. But, those symptoms in any birthing woman would be concerning, so this is not different care. In addition, if a woman is unmedicated and connected to her body/baby she will usually be the first to notice a problem. I have found that women having a VBAC may have additional psychological needs. For example, they may request vaginal examinations, particularly if their c-section was for ‘failure to progress’ (aka failure to wait). Even with information about how poor VEs are at indicating progress they may want that dilatation number – some non-VBAC women do too. They may also want more frequent fetal heart rate auscultation to reassure them the baby is well. In general, these women, and even more so their partners need reassurance and a birth attendant who believes in them. Of course some women don’t need any of this and choose freebirth.

Is homebirth a safe  option for VBAC?

No – birth is not ‘safe’ regardless of the setting. Different risks are associated with different options. In hospital there is greater risk of unnecessary intervention and associated complications. At home, if you are the 0.2% and need to transfer, there is the risk of complications due to a delay in medical intervention (including death of baby and/or mother). Bear in mind that this delay may also occur in a private hospital out of hours when theatre staff are not on site. Women also need to be aware that when it comes to homebirth, having a uterine scar places them in a ‘high risk’ category. The Australian College of Midwives classify a previous c-section as ‘B’ ie ‘Consult’ with a ‘midwife and/or medical practitioner or other health care provider’. This does not mean that a privately practising midwife cannot provide care. And the woman can decline a consultation if she wishes. Some midwives appear to be unaware of this, and tell women that they are not allowed to attend VBAC homebirths – this is not true. However, if you choose an eligible midwife, you may have problems securing a collaborative agreement from a medical practitioner so that you can claim medicare rebates for care. Likewise, homebirth services run from hospitals or birth centres may be unable to accept you as a client. Whilst VBAC homebirth is generally not supported in clinical recommendations, many women choose to birth at home. Keebler, et al. (2015) examined women’s reasons for choosing a homebirth after caesarean and the full text is available here.

VBACs are usually immensely healing and empowering for a woman and her partner. I wonder whether this aspect of birth is discussed at the ‘risk consultations’ along with the numbers.

You can read a birth story and watch the film here. I may be biased but this is a beautifully filmed/edited birth: Madeleine’s birth

Here is another couple’s VBAC journey (have a tissue handy). This is the most likely outcome of a VBAC – particularly a homebirth:

Further Reading/Resources

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