Understanding and assessing labour progress

I have previously written about how the current framework for understanding and assessing labour progress is inaccurate, not supported by evidence, and fails to incorporate women’s experience of birth. This post is in response to readers asking me to write about how to assess labour progress without vaginal examinations or palpating contractions.

The elements required to assess labour progress are:

  • An understanding physiology – knowing what is going on inside.
  • Facilitating and supporting (not disturbing) physiology.
  • Being focused on the woman and engaging all of your senses: sight, hearing, smell, touch and intuition to read the signs (this requires you to be quiet and receptive rather than busy and ‘doing’).
  • Ideally knowing the woman beforehand – this assists you to assess her individual behaviours and understand her experience better.
  • Accepting that any assessment can be inaccurate, and that individual women may not display the ‘usual’ signals of progress.

The following is a general guide only. Please note that this post is about physiological, undisturbed birth ie. does not apply to women who have altered physiology eg. induction, epidural, etc. Women who are being medically managed require medical assessment.

I am using ‘childbirth as a rite of passage’ as a framework for understanding what is going on during the birth process. The physiology in this post is really an overview and does not delve deeply into the complex hormonal interplay during birth which includes the baby. If you want to know more please see the bibliography/reference list at the end of the post.

Glossary / Overview of key players

  • Oxytocin (OT): love, bonding, reduction of stress; healing; uterine contractions
  • Beta-endorphins (BE): pain relief; activation of reward centres in brain, altered state of consciousness – ‘transcendence’
  • Epinephrine and Norepinephrine (E-NE) aka adrenaline and noradrenaline : stress hormones (shorter-term activation)
  • Cortisol: stress hormone (longer-term activation)
  • Prolactin (PRL): mothering hormone; lactation
  • Eustress: beneficial / physiological stress as opposed to pathological stress

SEPARATION

…the first phase of separation comprises symbolic behaviour signifying the detachment of the individual or group either from an earlier fixed point in the social structure or a set of cultural conditions (a ‘state’).
– Turner 1987, p. 5.

amanda-greavette-water-marked-images-27-350x414

Art by Amanda Greavett: http://amandagreavette.com

The first phase of the childbirth rite of passage involves the mother separating from the outside world and focussing within. Towards the end of pregnancy women begin to focus inwards in preparation for the birth. Physical separation occurs particularly in early labour when the mother secludes herself in her birth space and seeks to minimise distractions (external stimulation). Ritual separation from society during pregnancy and birth is common throughout history, and across cultures.

Physiology (what is happening inside)

Levels of PRL, progesterone and BE rise during pregnancy reaching high levels at the beginning of labour. In addition the maternal stress response decreases. This supports feelings of calm, and a focus that is inwards and towards family.

It appears that the baby initiates labour and the mother’s body responds. OT levels rise and uterine contractions become stronger and noticeable to the mother (the uterus contracts during pregnancy before labour). Initially they can be irregular in length, strength and the time in-between. The cervix is softening and opening, and the baby may begin to rotate and settle into the pelvis. BE increases further in response to the pain of contractions. The excitement/anxiety/anticipation (eustress) of early labour increases the release of E-NE. The balance between inward focus (OT + BE) and alertness (E-NE) allows the woman to remain aware of her surroundings and keeps her neocortex active. This facilitates her ability to do what is needed to ‘separate’ eg. organise her other children, call her midwife, travel to hospital, etc. If her OT + BE / E-NE balance tips towards E-NE her contractions may stop altogether until the balance is restored. This mechanism enables women in early labour to stop contracting in response to danger in the same way as other mammals do.

It can take many hours or even days for this early labour phase to tip over into established labour.

Assessment (what you might see)

  • Eyes open between and during contractions.
  • Evidence of neocortex functioning – the ability to hold a conversation and answer questions and/or to engage with external activities eg. using her iphone to time contractions.
  • Excitement and anxiety.
  • She may be keen to get settled into her birth space (see this post).
  • Contractions slow or stop in response to a journey to hospital or other stressful/distracting situations.
  • A bloody-mucousy show may occur as cervix opens.
  • Posture remains the same as in late pregnancy (pelvis still stable) ie. able to easily walk upright between contractions.

LIMINALITY

The attributes of liminality or a liminal personae (“threshold people”) are necessarily ambiguous, since this condition and these persons elude or slip through the network of classifications that normally locate states and positions in cultural space. Liminal entities are neither here nor there; they are betwixt and between the positions assigned and arrayed by law, custom, convention, and ceremonial.
– Turner 1969, p. 95.

birth4

Art by Amanda Greavett: http://amandagreavette.com

After the separation phase, a person undergoing a rite of passage enters the liminal phase (or transitional phase) where they are often said to ‘be in another place’ (Turner 1967, p. 98). The intense experience of labour requires mothers to ‘undo’ their usual state of consciousness, behaviours, and their connections to the external world. They often describe being ‘in their own world’, in an altered state of consciousness. This space is located within the labouring mother. As mothers progressively move more deeply into this internal world they shut out the external world further, maintaining and increasing separation. The physiological processes involved in birth create a naturally liminal state – the rhythmic contractions + birthing hormones. Both mother and baby are journeying in this ‘in-between’ world.

During the liminal phase, Turner (1987, p. 5) suggests that a person is unstructured, at once both de-structured and pre-structured. Women in labour act in ways that reflect their unstructured nature. The extreme physical process of birth involve the body functioning in a way that is unlike the everyday functioning of the body. In addition, behaviours are often inconsistent with the ‘everyday’ cultural norms. For example, making ‘animalistic’ noises, as being naked in front of strangers, lying down in hospital corridors, etc.

As the liminal phase peaks there is an undoing, dissolution and decomposition of self (Turner 1987). This point in labour is traditionally known as ‘transition’.

Physiology (what is happening inside)

As OT increases contractions become stronger and more powerful. In response, cortisol and BE increase to very high levels to relieve pain and reduced stress. The natural BEs (opiates) help to create a trance-like state where the woman’s focus is within and she is drowsy and less aware of her surroundings. Her neocortical functioning is reduced and her limbic system (instincts) are heightened. Her labour is now established.

The baby is rotating around and moving down through her pelvis. The Rhombus of Michaelis moves up and backwards to increase capacity in the pelvic mid cavity and outlet. As the pelvis ‘opens up’ it becomes unstable – and the woman moves instinctively to accommodate the movement of her pelvis and baby. The waters may break as the cervix opens enough for the forewaters to bulge into the vagina.

As labour progresses and reaches it’s powerful ‘peak’ there is a surge of E-EN to counter-act some of the BE effects. This prepares the mother to be alert enough protect her baby immediately after birth. The body’s response may be the fetal ejection reflex resulting in very powerful contractions and a quick birth. However, for most women this surge of E-EN is experienced as ‘transition’ – a feeling of fear, overwhelm and general freak out.

Once the cervix is fully open there may be a lull in contractions as the uterus ‘reorganises’ itself around the baby as he/she moves down. As the baby descends further pressure is applied to nerves deep in the pelvis resulting in spontaneous pushing. Contractions become increasingly expulsive as soft tissue stretches increasing the release of OT. The pain generated from the perineal tissues stretching initiate instinctive behaviours that protect the perineum. PRL, OT and E-EN levels increase further as the birth approaches ready to assist the initial bonding process.

Once the baby’s head is born there is likely to be a pause allowing the baby time to rotate or change position to get the shoulders through the pelvis. The baby is usually born with the following contraction.

Once labour has established a strong pattern you would usually expect the baby to be born within 18 hours (depending on contraction pattern and the individual situation).

Assessment (what you might see)

  • Her contraction pattern becomes increasingly stronger (based on her response to them). Note that contractions may not necessarily become closer, but they will become increasingly powerful. There should be a shift in the pattern/power every 2 hours (as a general rule).
  • She will be in ‘her own world’ – she may have her eyes closed and doze off between contractions ie. look stoned. She may cover her eyes with a cloth or bury her head into something (eg. pillow).
  • She is less able to respond to questions or anything else that requires her neocortex to function. Her communication (if there is any) will be short and to the point eg. ‘water!’ rather than ‘Can you please pass me the water’. If you ask a question (best not to) it might take a while for her to answer and she will not speak during a contraction.
  • Her movements and sounds will be instinctive and rhythmical. She is likely to vocalise during contractions – often the same noise with each one, and/or make the same movements each time.
  • Her inhibitions reduce. It is during this phase that the previously shy woman rips all her clothes off and crawls about naked.
  • At this point the hormonal symphony is in full swing and it is very, very difficult to stop or slow contractions. A significant stress at this point may generate a fetal ejection reflex but it is unlikely to stop contractions.
  • As the baby moves downwards and her pelvis becomes less stable (opening), her posture will change. She will want to hold onto things (and people) when standing/walking. She will not be able to sit directly on her bottom. She will walk leaning slightly with a ‘waddle’ as the pelvis tips.
  • If she is in an upright/ forward leaning position, you may be able to see / feel the ‘opening of her back’ as the Rhombus of Michaelis moves.
  • purple line might be visible between the woman’s buttocks as the baby’s head descends.
  • During transition you may see fear as she reaches out for reassurance and support. However, some women do not, and instead feel this on the inside without their care provider being aware of it.
  • During transition E-EN can cause a dry mouth and she might suddenly be very thirsty. High levels can also cause vomiting as the stomach empties in the fight or flight response.
  • As the cervix opens to its full capacity you might see a bloody/mucous show and the waters break.
  • There may be a ‘rest and be thankful’ phase after transition where contractions slow and the woman rests as the baby descends into her pelvis.
  • She might mention pressure in her bottom, or that she need’s to poo. And you may see poo as the baby compresses the rectum and squeezes it out.
  • Contractions become expulsive and the pattern will change. Her noises and behaviour will also change.
  • If you are able to visualise her perineum (and you really don’t need to) you will see signs of the baby’s head descending through the vagina – gaping anus and vulva, flattened perineum, bulging bag of waters (if still intact), the baby’s hair/head, etc.
  • As the baby’s head stretches her perineal tissue she will hold back her pushes, gasp, scream, close her legs, and/or hold her baby’s head in – protecting her perineum.
  • One the baby’s head is born you may see him/her rotate or wriggle then be born with the next contraction (there should be some movement or change with the next contraction).

INCORPORATION

Undoing, dissolution, decomposition are accompanied by the processes of growth, transformation, and the reformulation of old elements in new patterns.
– Turner 1987, p. 9.

01-1

Art by Amanda Greavett: http://amandagreavette.com

In all rites of passage, the third phase involves re-assimilation or incorporation of the person back into society in their new state (van Gennep 1909/1960). The state of motherhood and personhood (for the baby) happens immediately following birth. However, the reintegration of mother and baby back into society occurs progressively. In some cultures women have extended periods of separation from society following birth before being reintegrated. However the transformative nature of birth is not limited to a change of status to ‘mother’. Turner (1987) also identified the power of the liminal phase as a process for inner growth and transformation. Mothers incorporate the birth experience into their sense of self, resulting in empowerment, and for some, healing.

Physiology (what is happening inside)

At the moment of birth both mother and baby have high levels of and BEs, OT and E-NE. Along with PRL, this combination provides the perfect recipe for mother-baby bonding and connection – BEs (pleasure, reward, dependency) + OT (love and bonding) + PRL (mothering behaviours) + E-NE (alertness). Skin-to-skin contact and mother-baby interactions enhance the production of OT and PRL priming the breasts for milk production. High BEs contribute to the euphoria that many women experience following birth.

The placenta transfers the baby’s blood to the baby and the process of placental separation begins. The baby instinctively seeks his/her mother (looking into her face) and crawls to the breast – feet stimulating the uterus to contract. Skin-to-skin contact regulates the baby’s temperature, breathing and heart-rate and provides a sense of safety reducing stress hormones produced at the end of labour.

After birth E-NE declines significantly but cortisol declines slowly. Cortisol may promote PRL effects on milk production (extreme stress levels inhibit milk production).

Assessment (what you might see)

  • Immediately following birth the mother may appear ‘stunned’ and there may be a moment (or 2) before she picks up her baby and brings him/her towards her.
  • Baby is alert and instinctively interacts with mother and seeks the breast
  • Mother and baby interact.
  • You may see a gush of blood as the placenta separates (more about placental birth here).
  • After some time focussing on baby, the mother may begin to shift her focus back to the outside world; often beginning with her partner/family, then other birth support (including midwives etc), before moving on to those outside the room.

The above information is not rocket science, and anyone who has spent time with women during physiological birth will already know it (even if using the technocratic approaches to assessment). I think it is time to own our (women’s) knowledge and start shifting the discourse of ‘stages of labour’ and cervical measurements. This means changing how we talk/write about labour with women, other care providers and students.

References / Bibliography

Dixon, L, Skinner, J & Foureur, M 2013, ‘The emotional and hormonal pathways of labour and birth: integrating mind, body and behaviour’, New Zealand College of Midwives, vol. 48, pp. 15-23.

Sakala, C, Romano, AM & Buckley SJ 2016, ‘Hormonal physiology of childbearing, an essential framework for maternal-newborn nursing’, JOGNN: http://www.sciencedirect.com/science/article/pii/S0884217515000520

Reed, R, Barnes, M & Rowe, J 2016 ‘Women’s experience of birth: childbirth as a rite of passage’ International Journal of Childbirth, vol. 6, no. 1, pp.46-56.

Reed, R, Rowe, J & Barnes, M 2016 ‘Midwifery practice during birth: ritual companionship’ Women and Birth, vol. 29, no. 3, pp. 269-278.

Turner, V 1967, The forest of symbols: aspects of Ndembu ritual, Cornell University, New York.

Turner, V 1969, The ritual process: structure and anti-structure, Transaction Publishers, Rutgers, New Jersey

Turner, V 1987, ‘Betwixt and between: the liminal period in rites of passage’, in LC, Mahdi, SF Foster, & M Little (eds), Betwixt and between: patterns of masculine and feminine initiation, Open Court Publishing Company, Illinois, pp.3-19.

————–

How monkey mama does it – Kate Evans

Hormonal physiology of childbearing (resources) – Transforming Maternity Care

Dr Sarah Buckley’s website

Womb Ecology – Michel Odent

Posted in birth, midwifery practice, uncategorized | Tagged , , , , | 9 Comments

Research (Bias) and Maternity Care

A peacock feather was believed to protect the birthing woman and ease labour pains

Peacock feathers were believed to ease birth pains

The childbearing experience has always been unpredictable and potentially dangerous. In response, humans have sought ways to create a sense of control and minimise danger. Practices (actions) aimed at creating a sense of control reflect the culture from which they arise. Historically, women relied on a spiritual connection to the Goddess/es, rituals (rites of passage and rites of protection); wisewomen and remedies from nature. The current approach emerges from Science and Research (the new religion?) and sustains a technocratic approach to birth. Risk and danger are considered to be located within the woman (rather than her environment or others) and practices aim to identify danger and control it from the outside. This new approach claims to be rational, effective and underpinned by research evidence.

From evidence-based-practice to research-based-practice

By the end of the 1900s ‘evidence based practice’ was an established concept in medicine and health care in general. However, it was never meant to be purely ‘research based practice’: “Evidence based medicine is not restricted to RCT and meta-analyses. It involves tracking down the best external evidence with which to answer our clinical questions” (Sackett et al 1996). Whilst the emphasis was on ‘external’ evidence it did involve taking account of the individual ‘patient’ and the experience and skill of the practitioner.

Along with the shift towards research based practice came an increasing emphasis on quantitative research. If you are unsure about the different between quantitative and qualitative research – see this summary and this cartoon:

Quantitative research purports to be objective and is underpinned by Popperian philosophy and principles. Popper’s (1961) philosophy of science maintains that scientific knowledge develops in an incremental and linear fashion whereby ‘truths’ are systematically tested. Truths or hypotheses cannot be proven, only falsified, and scientific theories can be objectively tested to measure how much truth or falsity they contain. How neat and tidy!

In keeping with this idea of being able to objectively measure humans and their experiences the Pyramid of Evidence was devised. This pyramid illustrates the hierarchy of ‘quality’ relating to research evidence. As you can see the more (allegedly) objective the research, the greater the quality and the greater the weight given to the findings. However, reality is a lot more complex and subjectivity and bias permeate all research:

“Research is carried out within paradigms of knowledge. Everything from the research question; the research framework; the methodology; the interpretation of findings; and the implementation of the findings into practice is influenced by the paradigm of knowledge in which the research is conducted.” (Kuhn 1970)

This blog post takes a critical look at quantitative research – the purported foundation of modern maternity care. There are also issues with qualitative research, however qualitative philosophy and methodology acknowledges the element of bias as part of the research design.

  1. CHOOSING A RESEARCH TOPIC

Money

Researchers do not generally carry out research in their spare time funded by the goodness of their heart. Research requires money to pay for time and resources. Competitive grants are offered by a variety of organisations – government, charity and industry. Research topics are influenced by the requirements and criteria dictated by grant providing organisations. For example, government funded grants will usually focus on government health priorities such as the treatment of diabetes, heart disease, etc. Therefore, it would be much easier to obtain a grant to study the management of gestational diabetes than to study psychosocial outcomes of maternity care. Government health priorities reflect culture (and health lobby groups eg. industry). For example, the joint leading cause of maternal death in Australia is psychosocial morbidity (cardiovascular disease is the other). There is a clear link between how women are treated by care providers and mental health outcomes (Harris & Ayers 2012). However, women’s mental health is not a cultural priority in Australia.

Another source of funding for research comes from the industries that develop and sell interventions (eg. technology and medications). This has resulted in major issues in the area of pharamacology (see Ben Goldacre’s book). In the maternity context there are no companies offering grants to find out about the benefits of birth without medication or intervention – there is no profit in physiological birth.

Problem focus

 Research plans and grant applications require the identification of a ‘problem’ – there is usually a section subtitled ‘describe the research problem’. This creates a focus on pathology rather than on wellness. For example, a study aiming to investigate why ‘x’ institution has a high rate of physiological births and great outcomes is less likely to get a grant than a study aimed at trialling a medical intervention to reduce the high PPH rates in another institution. However, former study may result in important findings that could help to improve the latter.

Research partners

Most government grants require a government health employee to be listed as a researcher on the grant application. Frequently this results in a manager from the institution becoming a named ‘researcher’ (although sometimes they contribute nothing to the research process). This looks great on the managers CV and allows the rest of the research team to access samples (women) and data (whatever information they are collecting/measuring). However, as a representative and employee of the institution they may have a vested interest in ensuring that the research topic and findings do not reflect badly on the institution. This can influence the research topic because some topics (the interesting ones) will be off the agenda of the institution… more on this later re. disseminating the findings.

  1. FORMULATING A RESEARCH QUESTION

Once a research topic/problem has been identified, a research question is created. Again, the question that arises reflects the cultural paradigm in which the research is taking place. A study by Phipps, Charlton and Dietz (2007; 2009) provides a perfect example of this. The problem: high rates of intervention due to first time mothers being unable to push their babies out within the (non-evidence based) hospital prescribed timeframe. The question arising from this problem became ‘can women be taught how to push more effectively’ and women were randomly allocated to antenatal education sessions aimed at teaching them how to push effectively. This reflects a paradigm in which women’s bodies are considered the problem. An alternative paradigm would have resulted in examining the problem of using prescriptive timeframes to define individual birth processes.

  1. DESIGNING THE RESEARCH

Physiology as experimental

Usually in quantitative research the control group is the group that does not get an intervention. This control group is compared to the experimental group that gets the intervention. However, this is usually the opposite in maternity care, reflecting a culture in which intervention is the norm. Initially routine interventions during birth were introduced as part of the general medicalisation of childbirth, without any supporting research evidence (Donnison 1988). These interventions continue to be carried out until research is conducted to support a change in practice. Therefore, research in maternity care is often carried out to support not performing an intervention that was initially introduced without research evidence. For example, women were routinely subjected to vulval shaving, enemas and episiotomies until research demonstrated it was safe to not abuse women this way. In such studies, the control group is the group subjected to the intervention, with the experimental group not receiving the intervention.

Confounding factors in complex human experiences

Research is often conducted with the assumption of simplicity as a framework. The origin of this assumption is Descartes’ concept of dualism, that the body could be studied as a separate entity to the social, psychological and spiritual aspects of a person. This approach ignores the complexity of cause and effect in individual human subjects and varying situations.

Confounding variables are factors that influence the relationship between x and y. Research design aims to reduce confounding variables. This is easier when carrying out research in laboratory conditions where you can control the environment and any interactions with the subject (eg. bacteria in a petri-dish). However, pregnancy, birth, breastfeeding, mothering, and maternity care are incredibly complex. In most cases it is impossible to limit confounding factors. For example, when designing research comparing active management of placental birth vs physiology, it is not possible to isolate the effects of administering an oxytocic medication or not. The ‘management’ is being carried out on a complex human, by a complex human, in a complex environment, all of which may influence the outcome. For example, a practitioner who is used to active management but now has to carry out physiological management may find this challenging… their approach and interactions are likely to be influenced by their feelings. This partly explains the different outcomes in different studies with different participants and settings (see this post).

RCT, blind arms and ethics

It can be argued that the gold standard  or research – randomised controlled trials – are often unethical in maternity care. For example, it would be unethical to randomly allocate a woman to a particular birth setting (and her feelings about her birth setting would alter her outcomes). Considering what we know about placental transfusion immediately after birth, and the importance of adequate blood volume for newborns, it would be unethical to randomly allocate newborns to have premature clamping of their cords (and many mother’s would refuse consent).

It is also considered good research design for both the practitioner (person administering the intervention) and the subject (person getting the intervention – or not) to be ‘blind’ to this ie. not know. This works well in the case of medications ie. neither the doctor nor the patient know whether the pill is the experimental medication or a placebo. However, it is virtually impossible to ‘blind’ practitioners or women to interventions. Women and their care providers will know if an intervention is carried out or not eg. active management of the placenta, episiotomy, premature cord clamping.

  1. INTERPRETING THE RESULTS

The cultural paradigm also influences how researchers and the media interpret the results of studies. In particular, the creation of links between factors assumed by cultural understandings to be linked ie. presenting correlations as causations. The classic example of this is the relationship between ice-cream sales and shark attacks. There is an correlation between increased ice-cream sales and increased shark attacks. However, ice-cream does not cause shark attacks – both of these factors are influenced by how the weather effects human behavior (eating ice-cream and swimming in the ocean).

In relation to maternity care identifying cause and effect are even more difficult due to the complex nature of the issues. For example, there is a general consensus that obesity is associated with poor outcomes for women and babies and the solution is to reduce BMI. However, this raises further questions: is obesity the direct cause of poor outcomes? Is obesity a symptom of some other heath related disorder that is the causal factor of obesity? Is the treatment of obese women the cause of poor outcomes (increased stress/shaming, surveillance, intervention)?

  1. RECOMMENDATIONS ARISING FROM THE FINDINGS

Once a study has been concluded the researchers offer recommendations arising from their study. Again, these recommendations are influenced by the cultural paradigm. An example of this is the recommendations resulting from research into early labour (discussed in this post). Women admitted to hospital in early labour = increased intervention and decreased normal birth. The recommendation is therefore to limit the time a woman is exposed to the hospital system… not change the hospital system to better accommodate the needs of women in early labour.

  1. DISSEMINATION OF FINDINGS

The aim of research is to publish the findings and contribute to the evidence-base for practice. However, whether, and how research findings are disseminated is influenced and controlled by a number of factors. In particular the ‘interested parties’ (see above ‘research partners’) can prevent or manipulate publication. For example, to access data held by an organisation the researcher is likely to have signed an agreement that publications relating to that data must be approved by the organisation. I know more than one researcher who has been unable to publish interesting results because they have been blocked by the organisation they had an agreement with. The Union of Concerned Scientists have published a report detailing how corporations obstruct, distort and supress research. Techniques include: terminating and suppressing research; intimidating or coercing scientists; ghost writing scientific articles; publications bias ie. only allowing certain results to be published (Ben Goldacre also discusses this in his book).

Good journals use a peer review process to ensure quality research dissemination. However, peer reviewers are humans and are also influenced by the cultural paradigm and their own emotions. An article that is not aligned with the philosophy/views of a journal or a particular reviewer will be more likely to be rejected. For example, an article reporting findings that demonstrate midwifery continuity of care resulted in poor outcomes (I am making this up) would be more likely to be published in a medical journal than a midwifery journal. And some topics are difficult to publish anywhere.

  1. IMPLEMENTING RECOMMENDATIONS INTO PRACTICE AND DECISION MAKING

Evidence based practice?

The final step – implementing evidence into practice is perhaps the least successful step in maternity care research. The discipline of obstetrics was awarded the ‘wooden spoon’ by Archie Cochrane in 1979. In response Iain Chalmers et al. published the first edition of ‘effective care in pregnancy and birth’ in 1989. However, it seems that not much has changed.

“Despite claims of EBP, practices are underpinned by an established hierarchy of understanding and practice, rather than by research.” (McCourt 2009)

It is easier to introduce and maintain culturally based practices that lack evidence, than to introduce evidence based practices that challenge the cultural norm. For example (and I have stuck to the ‘gold standard’ of Cochrane reviews relating to ‘normal’ birth here): Common practices that lack evidence include routine vaginal examinations; amniotomy to shorten labour; routine antibiotics for rupture of membranes; use of a partogram; admission CTG and CTG during labour; (I could go on).Uncommon practices supported by evidence include midwife-led continuity of care; warm compresses to reduce perineal trauma; skin-to-skin contact; optimal cord clamping (aka ‘delayed’); warm water immersion; (I could go on).

Organisations and the staff working in them rely on clinical guidelines to guide practice. However, so called ‘evidence based guidelines’ are anything but. If you take a look at most clinical guidelines and follow the reference trail you will find that they cite another clinical guideline, which cites another clinical guideline… and you end up at a dead-end with no actual research in site. Prusova et al. (2014) published an article about this situation: RCOG ‘Green-top Guidelines’: 9-12% based on Grade A evidence. Whilst the article focuses on the RCOG – this is widespread across maternity care guidelines.

Evidence based decision making?

When it comes to how individual women make decisions about their maternity care – research is also fairly low on the list. Below is a quote from a previous post that is relevant here:

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.

A WAY FORWARD

I am not advocating discarding research. I am a researcher myself and believe that this type of evidence can, and does shift practice. Midwives need to contribute to, and understand the evidence-base for practice from the woman’s perspective. The International Confederation of Midwives position statement ‘The Role of the Midwife in Research’ provides guidance on this:

  • all midwives have a role and a responsibility in advancing knowledge within the midwifery profession and the effectiveness of midwifery practice…
  • Research on the childbearing cycle maintain a holistic approach that includes the physiological, psycho-social, cultural and spiritual aspects of the health of women and babies
  • Midwives design/participate in studies that support and promote holistic care as well as evaluating the effects of using technology as an intervention during pregnancy and birth

We also need to be able to discuss research with women – not just quote statistics. More importantly we need to acknowledge and respect all the other forms of evidence that operate when a woman makes a decision about what is best for her – in particular her own embodied knowledge.

This post is published in French here.

References

Cochrane AL (1989). Foreword. In: Chalmers I, Enkin M, Keirse MJNC, eds. Effective care in pregnancy and childbirth. Oxford: Oxford University Press.

Donnison, J 1988, Midwives and medical men: a history of the struggle for the control of childbirth, 2nd edn, Historical Publications, London.

Kuhn, TS 1970, The structure of scientific revolutions, University of Chicago Press, Chicago.

Phipps, H, Charlton, S & Dietz, HP 2007, ‘Can antenatal education influence how women push in labour? A pilot randomised control trial on maternal antenatal teaching for pushing in the second stage of labour (PUSH STUDY)’, paper presented to Big Bold & Beautiful: Australian College of Midwives 15th National Conference, Canberra, Australia, 25-28 September 2007.

Phipps, H, Charlton, S & Dietz, HP 2009, ‘Can antenatal education influence how women push in labour? A pilot randomised control trial on maternal antenatal teaching for pushing in the second stage of labour (PUSH STUDY)’, Australian and New Zealand Journal of Obstetrics and Gynaecology, vol. 49, pp. 274-278.

Popper, KR 1961, The logic of scientific discovery, Basic Books, New York.

Prusova, K, Tyler, A, Churcher, L & Lokugamage 2014, ‘Royal College of Obstetricians and Gynaecologists guidelines: how evidence based are they?’ Journal of Obstetrics and Gynaecology, DOI: 10.3109/01443615.2014.920794

Sackett, DL, Rosenberg, WMC, Gray, JAM, Haynes, RB & Richardson, WS 1996, ‘Evidence-based medicine: what it is and what it is not’, British Medical Journal, vol. 312, pp. 71-72.

Posted in midwifery practice, uncategorized | Tagged , | 12 Comments

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 , , | 14 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. You can read more about research bias in maternity care in this post.

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 be 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 (79%) will go into labour within 12 hours of their waters breaking and 95% will be in spontaneous labour within 24 hours  (Middleton et al. 2017). 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 , , , , , , , , , , , , | 218 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’

Posted in baby, birth, intervention | Tagged , , , , , , , , , , | 252 Comments

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.

Evernote_Premium

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