Research (Bias) and Maternity Care

Updated: July 2019

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 (Reed, Sharman & Inglis 2017). 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.

2. 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.

3. 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.

4. 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)?

5. 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.

6. 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.

7. 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.

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 | Tagged , | 13 Comments

Childbirth Trauma: research findings

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 published those findings.

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.

Thematic Map

Thematic Map

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.

Comment

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. 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).

Paternal mental health following perceived traumatic childbirth

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

Findings

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.

Thematic Map

Thematic Map

Conclusion

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.

Posted in birth, midwifery practice, publications | Tagged , , | 17 Comments

Pre-labour Rupture of Membranes: impatience and risk

Updated: July 2019

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.

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.). 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.

Please note that this post is not about premature rupture of membranes (before 37 weeks)

The 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; and 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 two of the studies in the review looked a uterine rupture during induction – 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.

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.

You can read more about induction in my book Why Induction Matters

Why_Induction_Matters_-_Pinter___Martin_Publishers

Posted in baby, birth, intervention, midwifery practice, pregnancy | Tagged , , , , , , , , , , , , | 225 Comments

Post-Dates Induction of Labour: balancing risks

Updated: August 2019

In Australia 33% of labours are induced (40.5% of first time mothers). The most common reason for induction is to prevent 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 ‘due dates’ or rather ‘guess dates’ here – I discuss estimating birth dates in my book. This post will focus on induction of labour to prevent a ‘prolonged’ pregnancy and the complexities of risk in this situation.

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 (guess) 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. However, induction is usually offered when a pregnancy becomes post-dates with the aim of preventing it becoming ‘prolonged’. Therefore, very few women experience a prolonged pregnancy – in Australia only 0.6% of pregnancies continue beyond 42 weeks.

The idea of a prolonged pregnancy assumes that all women naturally gestate their babies for the same length of time. However, it seems that genetic differences may influence what is a ‘normal’ gestation time for a particular woman. For example, 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).

The initiation of labour is likely caused by the baby who secretes surfactant protein and platelet-activating factor into the amniotic fluid as their lungs mature (Mendelson 2009; Science Daily). This results in an inflammatory response in the mother’s uterus that initiates labour.

The risks associated with waiting for spontaneous labour

Ageing placenta?

Some people believe that the placenta has a best before date and starts to deteriorate after 40 weeks resulting in reduced nutrition and oxygen for the baby. There is evidence that the structure and biochemistry of the placenta changes as pregnancy develops. Some scientists interpret these changes as the placenta growing and adapting to meet the changing needs of the baby: “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…” Others argue that these changes are due to the ageing and deterioration of the placenta. However, tests of placental function show no changes in post-dates pregnancies (Madruzzato et al. 2010). In practice, 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. Sophie Messenger write more about ‘the myth of the ageing placenta’ here.

Big baby

People also have concerns that the baby will grow huge and therefore be difficult to birth. There is evidence that babies continue to grow bigger the longer they gestate, and this contradicts the above theory about the ageing placenta. If the placenta stops functioning, how does the baby continue to grow so well? Big babies are pretty good at finding their way out of their mothers expandable pelvis. The research about complications relating to big babies suggests that it is the interventions carried out when a baby is assumed to be big – rather than the actual size of the baby – that mostly contributes to complications (Sadeh-Mestechkin et al. 2008; Blackwell et al. 2009; Peleg et al. 2015).

Meconium liquor

There is an increased chance that the baby will pass meconium as his/her bowels mature. I have written about this scenario in another post.

Perinatal death

The general rate of perinatal death (stillbirth + newborn death) increases as pregnancies advance beyond term. The rate remains small but is statistically significant. For example a systematic review and meta-analysis (Muglu et al. 2019) reported that: “The overall gestation-week-specific prospective risk of stillbirth steadily increased with gestational age, from 0.11 per 1,000 pregnancies at 37 weeks to 3.18 per 1,000 at 42 weeks gestation… The risks of newborn death remained constant between 38 and 41 weeks, and only increased beyond 41 weeks” [but remained less than 1 per 1,000].

Post-dates induction of labour reduces the general rate of perinatal death. A Cochrane Review summarises the 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…

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 the Cochrane Review above 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 in some cases, 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 gestational timeframe? For a woman who has previously gestated to post-term without complications, there is no increased chance of an adverse outcome (Kortekaas et al. 2015).

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). In addition, there are differences in outcomes and risks between women who have previously laboured, and women having their first baby. It is important for women to consider their own individual factors and how they alter their individual risk profile. Care providers should also share individualised information when discussing induction options.

General risks associated with the induction procedure and medications

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 more significant 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)

Induced contractions are usually more painful than a physiological contractions. Syntocinon (pitocin) produces strong contractions without the gentle build up and endorphin release of natural contractions. The National Institute of Clinical Excellence (UK) state that health care professionals should discuss this with women when offering induction “recognising that women are likely to find induced labour more painful than spontaneous labour”.

Most research comparing induction with spontaneous labour combines populations of ‘experienced’ labourers with first timers. These studies report conflicting findings. For example, some studies report a lower chance of c-section with induction for this mixed group (Gülmezoglu et al. 2012; Mishanina et al. 2014Wood et al. 2014). In contrast, more recent studies have found increased rates of c-section with induction (Zhao, Flatley, Kumar 2017; Ekéus & Lindgren 2016). A 2019 review compared the timing of induction for low risk pregnancies – 41 weeks vs 42 weeks (Rydahl, Eriksen & Juhl 2019). The review used stricter inclusion criteria than previous reviews to “enhance the methodological quality and increase the relevance for contemporary maternity care”; and reported that: “Induction at 41+0-6 gestational weeks compared to 42+0-6 gestational weeks was found to be associated with an increased risk of overall cesarean section.”

Risks for women who have had a previous labour

Women who have laboured before respond more effectively to syntocinon (pitocin) because they have more oxytocin receptors in their uterine muscle. Therefore, this group of women are more likely to experience a successful induction and avoid c-section. They are likely the reason for lower or similar rates of c-section the mixed group research discussed above. However, they are at increased risk of hyperstimulation with prostaglandin medication and/or syntocinon. So doses are usually smaller and very carefully monitored to avoid fetal distress. Women who have given birth vaginally before, are also at increased risk of perineal tearing if they have syntocinon induced contractions.

Risks for women having their first labour induced

Inducing a first labour requires higher rates of syntocinon, and the length of labour is usually longer. It is not surprising that first time mothers are more than 3 x more likely to opt for an epidural during an induction (Selo-Ojeme et al. 2011); and epidural analgesia increases the chance of ending up with an instrumental birth – ventouse or forceps (Anim-Somuah et al. 2018)

The majority of research comparing induction (IOL) with spontaneous (SP) labour in populations of first time labourers report increased c-section rates:

Another US study (Ehrenthal et al. 2010) reported that after “adjusting for maternal demographic characteristics, medical risk, and pregnancy complications. The contribution of labor induction to cesarean delivery in this cohort was estimated to be approximately 20%.” This brings up interesting risk comparisons relating to c-section vs the risk of post-dates perinatal death (see above). For example, induction is recommended because there is a less than 0.3% chance of perinatal death in post-dates pregnancies (see above). However, the chance of a significant complication during c-section (eg. hysterectomy) is higher than the chance of perinatal death in a post-dates pregnancy; and after a c-section the chance of stillbirth during a subsequent pregnancy increases to 0.4% – again, a higher rate than a postdates pregnancy.

A recent study causing a stir is the ARRIVE RCT trial (US) which reported lower c-section rates in the induction group (18.6% vs 22.2%). This one study is now being used to justify recommending early induction at 39 weeks – primarily because the findings align with cultural norms and preferences (see this post re. implementation of research findings into practice). Whilst I don’t want to give this study unwarranted attention… it keeps popping up in conversations, workshops, and presentations. Like the perineal bundle – it is an unavoidable topic in the birth world. So here goes (briefly)… recommendations based on the trial are problematic in a number of ways. The findings and recommendations have been constructively critiqued by academics, midwives and obstetricians (Dekker 2018; Carmichael & Snowdon 2019; Davis-Tuck et al. 2018; Scialli 2019). In summary, the main points are:

  • Only 27% of eligible women agreed to participate – Findings can only be applied to women who are willing to have a medically managed birth.
  • 94% of the woman were cared for by private obstetricians in US medical settings – Findings cannot be applied to other types of care providers and settings which have much lower rates of c-section and higher rates of spontaneous vaginal birth.
  • Care providers were not blinded – Knowing about the trial my have altered their practice.
  • IOL reduced c-section rates by 4% – This cannot be used to recommend IOL to prevent c-section. Other factors have a much more significant effect on c-section rates eg. continuity of midwifery care; place of birth; intermittent auscultation in labour; etc.
  • The primary outcome measure for this study was perinatal outcome (ie. the baby) – IOL made no difference to the immediate outcomes for the baby, and the study did not address the long-term harm of early birth for the baby (eg. brain development).

In relation to the primary outcome measure – perinatal outcomes. Another study (Selo-Ojeme et al 2011) found that outcomes for the baby were worse when a first labour was induced: “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“. 

The experience of induction

Research into induction tends to focus on physical outcomes rather than women’s emotional/psychological experiences of the process.

Choosing induction will totally alter the 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. This does not mean you have to hand over control of your decisions or your body; and in my book I include a chapter on creating a birth plan for induction of labour.

There have been some studies examining women’s experience of induction. A 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.”

A recent systematic review (Coates et al. 2019) of qualitative research into women’s experiences of induction of labour concluded that induction “is a challenging experience for women, which can be understood in terms of the gap between women’s needs and the reality of their experience concerning information and decision-making, support, and environment. “

Alternatives to medical induction

Waiting for spontaneous labour

Around 90% of women who wait for spontaneous labour will give birth before 42 week, and only 1% will go beyond 43 weeks (Gülmezoglu et al. 2012). Most guidelines recommend additional monitoring of the baby – however no form of monitoring reduces the chance of complications (Gülmezoglu et al. 2012).

‘Natural’ induction?

There are a number of ‘alternative’ or ‘natural’ induction methods available (I have a chapter discussing the evidence for various methods in my book). However, trying to get the body/baby to do something it is not ready to do is still an intervention whether it is with medicine, herbs, therapies, techniques… or anything else. Interventions of any kind can have unwanted effects and consequences. Medical inductions take place with close monitoring of mother and baby and access to medical support if a complication arises. 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.

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.

You can read more about induction in my book Why Induction Matters

Why_Induction_Matters_-_Pinter___Martin_Publishers

Further resources

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Responsibilities in the mother-midwife relationship

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

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

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

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MIDWIVES’ RESPONSIBILITIES

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

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

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

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

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

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

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

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

Adequate Information

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

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

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

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

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

For an option or intervention adequate information includes:

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

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

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

Lets take a look at some examples…

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

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

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

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

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

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

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

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

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

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

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

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

Support

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

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

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

Competent Practice

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

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

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

THE MOTHER’S RESPONSIBILITIES

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

Decisions

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

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

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

Outcome of Decisions

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

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

Summary

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

References

ICM (2008a) international code of ethics for midwives

ICM (2008b) role of the midwife in research

ICM (2010) philosophy and model of midwifery care

ICM (2011) international definition of the midwife

NMBA (2006) national competency standards for the midwife

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

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

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

Information Giving and the Law

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

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

Consent

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

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

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

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

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

Negligence – lack of information

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

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

What is reasonable information?

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

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

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

What do you think?

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

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

Further resources/reading

Journal articles:

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

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

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

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

Websites/articles

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

Birthrights

Human Rights in Childbirth

 

Posted in law, midwifery practice | Tagged , , , , , | 49 Comments

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

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

Anatomy and Physiology

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

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

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

1. Dilatation of the cervix

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

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

2. Rotation

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

3. Descent – the urge to push

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

Pushing before full dilatation

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

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

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

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

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

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

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

Suggestions

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

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

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

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

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

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

Summary

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

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