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

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

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

Anatomy and Physiology

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

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

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

1. Dilatation of the cervix

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

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

2. Rotation

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

3. Descent – the urge to push

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

Pushing before full dilatation

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

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

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

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

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

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

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

Suggestions

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

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

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

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

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

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

Summary

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

Posted in birth, intervention, midwifery practice | Tagged , , , , , | 429 Comments

VBAC: making a mountain out of a molehill

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

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

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

What happens during a uterine rupture?

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

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

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

Risk by numbers

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

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

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

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

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

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

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

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

VBAC vs planned c-section: uterine rupture

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

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

Uterine rupture vs other potential birth emergencies

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

Anecdotes

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

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

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

The real risks of VBAC (according to me)

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

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

Suggestions

During pregnancy

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

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

During labour

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

Is homebirth a safe  option for VBAC?

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

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

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

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

Further Reading/Resources

Posted in birth, intervention, midwifery practice | Tagged , , , | 331 Comments

In Celebration of the OP Baby

Updated: February 2018

How many times have you heard “I had to have an epidural/c-section/ventouse/etc. because my baby was facing the wrong way”? An occipito posterior (OP) position occurs when the baby enters the pelvis facing forward with his back towards his mothers back. The back of the baby’s head is referred to as the ‘occiput’ and is in the back of the pelvis against the sacrum. Between 15-30% of babies start labour in an OP position, but less than 5% will remain in this position at birth (Sizer & Nirmal 2000). An OP position is associated with medical intervention during labour: syntocinon infusion; epidural; forceps; ventouse; c-section. This post will discuss whether an OP position is actually a problem, or if the problem lies in our beliefs about, and management of this common position.

A bit of anatomy and physiology

I’m assuming that readers of this blog are midwives, doulas, and/or birth nerds  who have an understanding of the pelvis. If you don’t, it doesn’t really matter – knowing the names of the bones doesn’t help you understand how the pelvis works. Basically, the pelvis is shaped in a way that requires the baby to rotate during labour. If you look in textbooks you will find diagrams with exact measurements of various pelvic diameters – this is nonsense as every woman’s pelvis is different. I find it is more helpful to consider that there are 3 areas of the pelvis: the brim, the cavity and the outlet. These areas have slightly different shapes, as I’ve tried to demonstrate below: The baby usually enters the brim with her head mostly facing sideways ie. transverse  (to fit the shape). It doesn’t really matter which way the baby’s head is when entering the brim – once her head is in the cavity she can rotate. The downward pressure of the contractions, and the tension and shape of the pelvic floor will guide her into a direct occipito anterior (OA) position and through the outlet. A very small number of babies will rotate to a direct OP position and come out facing the front of the pelvis (see below).

Usually the baby will take the shortest rotation into a direct OA position. So, a baby entering the pelvis in a ROA (back = front/right) does this:

Whereas a baby entering the pelvis in an ROP (back = back/right) position does this:

Of course OP and OA babies may use this turning space to do all kinds of interesting things from turning OA to OP, to rotating all the way around the back of the pelvis to end up OA. The baby will work out the best way to move through her mother – even if we don’t understand it.

Being born OP

Some babies are born in the OP position either because they stay in that position, or because they rotate into that position during labour (from OA). You can watch the birth of a big OP baby in ‘The Birth of Beau‘.

The ‘problems’

Labour pattern

It is difficult enough for a woman with a baby in an OA position to fit prescribed patterns of labour progress. A baby who enters the brim in an OP position may not fit quite so snuggly on the cervix and this may lead to:

These situations only become problematic when we apply generalised expectations about how labour should be to an individual woman, baby and situation. The solution is often to augment labour with syntocinon – increasing the risk of fetal distress and increasing pain ie. creating a problem. Another solution is to encourage the woman to get into various positions to assist with rotation. However, the use of prescribed positions to ‘fix’ an OP position is not supported by research (Desbriere et al. 2012; Science & Sensibility).

Pain and interventions

Some women will experience pain differently when their baby is in an OP position. However, it is difficult to determine if this experience of pain is due to the position of the baby, or other factors. A study by Lee, Kildea & Stapleton (2015) into back pain in labour concluded: “The assumed relationship between fetal position and back pain in labour is a dominant discourse, albeit one which is lacking in empirical credibility.” Plenty of women with an OA baby complain of back ache in labour, whilst many with an OP baby do not. Unfortunately, women are told that an OP labour is ‘worse’, and are told horror stories like the one I started the post with. Given the psychological and emotional aspect of pain perception this cannot be helpful. Every birth experience is also different. I cared for a mother during two births. Her first baby was in an OP position and she had a four day stop-start pattern before labour established. Apart from being tired she coped well with the pain throughout. Her second baby was OA and labour established quickly. She was shocked and distressed by how much more pain she experienced with her OA baby compared to her previous OP baby.

Women with an OP baby are more likely to opt for (or be pursuaded to have) an epidural. This is not surprising, considering they are led to believe their labour will be more painful. They are also more likely to be subjected to interventions that increase pain and risk. For, example, a woman with an OP baby is less likely to meet prescribed progress timeframes, and therefore, have her labour induced or augmented by ARM and/or syntocinon (pitocin). An ARM reduces the fluid surrounding the baby, making rotation more difficult, and increases pain. Syntocinon increases the risk for mother and baby in many ways, and increases pain. These interventions further increase the chance that an epidural will be needed. Once an epidural is inserted, the ability of the baby to rotate into an OA position is reduced (Lieberman et al. 2005). The woman is unable to instinctively move her body and work with her baby to rotate him. In addition, the pelvic floor is anaesthetised and loses it’s tone, taking away the resistance that assists rotation.

Early urge to push

As the OP baby descends through the pelvis the back of his head puts pressure on nerves creating an urge to push. This pushing may be the body’s way of helping the baby to rotate by increasing downward pressure onto the cervix and pelvic floor – the baby is able to pivot against this tension. However, this urge to push is managed as a problem, and the result is often an epidural. See this post about pushing before full dilatation of the cervix.

Blame

Women can blame themselves for their baby being in an OP position. They question what they did (spent too long in the car) or didn’t do (scrub floors). Often the advice they are given antenatally about ‘optimal fetal positioning’ implies that they have control over the position their baby is in, when there is no research evidence to support this notion. In fact, the little research that has been done demonstrates that hands and knees posturing in pregnancy makes no difference (Hunter, Hofmeyr & Kulier 2009Kariminia et al. 2004). I have even heard of women being told that their baby has assumed an OP position because of their unresolved emotional issues!

Suggestions

We need to stop defining OP as a problem or a ‘malposition’. It is a common variation to the more common OA position, and the OP baby is probably in that position for a good reason. When caring for a woman with an OP baby:

In Pregnancy

  • Reinforce the woman’s trust in her body and baby to birth.
  • Discuss the possibility that her labour may be different (not better or worse) and might not fit general expectations about labour patterns/progress.
  • She can try a variety of techniques to encourage the baby to turn (even though the research suggests it may be ineffective). You can find some suggestions here. However, if he doesn’t respond it’s because he has chosen his optimal position for labour. He will turn once he gets into the pelvic cavity in labour, or he may even be born OP.
  • Tell her birth stories and connect her with other women who have experienced positive OP labours.

In labour

  • Trust the mother and her baby to birth.
  • Provide an environment where she can instinctively move and work with her baby to rotate her.
  • Don’t tell her not to push if she is spontaneously pushing – regardless of cervical dilatation.
  • Back pain can be relieved by: a forward leaning position (Stremler et al. 2005); warm water; sterile water injections; gentle sacral pressure. Avoid applying strong pressure to the sacrum as this may reduce the space available in the pelvis for rotation.
  • If the woman requests help or would prefer you to ‘do’ something there are a number of techniques you can use to create more space in the pelvis. I have provided a list here. Note that these techniques/positions are about increasing the space in the pelvis rather than rotating the baby – they provide an opportunity rather than making the baby move.
  • Occasionally, despite everything a baby will become ‘stuck’… and this happens to babies in an OA position too. In this situation more invasive interventions such as digital rotation (Reichman et al. 2008); instrumental birth or c-section may be necessary.

In summary

An OP position is not wrong or a problem. It is not caused by anything the woman does or does not do. Instead, it is a common variation that occurs when a baby gets into the ‘optimal position’ for her journey through her mother’s unique body. After all, she has more knowledge about the interior of her mother’s pelvis than we do. If we want to improve the experience and outcomes associated with an OP position we need to rethink our approach to it. Let’s celebrate the OP baby’s wisdom and allow the birth to unfold as it needs to, only intervening if it is truly required.

Further resources:

You can download a review of research relating to ‘management’ of OP by Simkin (2010) here.

Posted in baby, birth, midwifery practice | Tagged , , , , , , , , | 197 Comments

The Placenta: essential resuscitation equipment

Resuscitation Equipment

Updated: January 2018

Knowledge about the short-term and long-term benefits of ‘delayed cord clamping’ is finally making it into practice. Midwives and in some cases obstetricians are realising the importance of allowing the placenta to finish circulating blood before intervening. I personally don’t like the term ‘delayed cord clamping’ and prefer the term ‘premature cord clamping’ to describe the alternative practice. However, whatever you choose to call it, babies are benefitting from the practice. The main physiological benefits are summed up in a Cochrane review that concluded there were:

“…some potentially important advantages of delayed cord clamping in healthy term infants, such as higher birthweight, early haemoglobin concentration, and increased iron reserves up to six months after birth.”

The review also notes that ‘delayed clamping’ is associated with an increased risk of jaundice in the newborn. However, a recent study by Mercer et al. (2017) found no association between ‘delayed’ cord clamping and jaundice. I also wonder whether giving an injection of syntocinon/syntometrine while the placenta is still circulating blood to the baby may influence the risk of jaundice. IV syntocinon/pitocin in labour has been linked to jaundice since the 1974s (do a google search for more research). All the studies in the Cochrane review were carried out in hospitals where the vast majority of women have an oxytocic injection for management of the third stage. I very rarely come across anything more than mild jaundice following a physiological birth. Anyone need a research topic?

Resuscitation and premature cord clamping

This post explores the the practice of premature clamping when a baby is perceived to need resuscitation. I often hear birth stories which include “They (or I) had to cut the cord because the baby needed resuscitation”. In hospital-based neonatal resuscitation workshops practitioners are taught to 1. assess the baby, 2. summon help 3. clamp and the cut cord, 4. take the baby to resuscitaire, etc. For obvious reasons resuscitating a baby is stressful, and I understand the benefits for midwives and doctors of doing it on a nice neat, ‘clean’ area without worried parents watching and/or asking questions. However, this approach makes no sense if you consider the physiology of transition to extrauterine life, or the importance of the mother in the baby’s transition and any necessary resuscitation.

The physiology of newborn transition

This is extremely complex and probably very boring for those not interested in science/physiology. So, if you want a full scientific version please see the article by Mercer and Skovgaard (2002). Here’s the simple version…

The baby/placenta has a separate blood system from the mother. The placenta does the job of the lungs by exchanging gas (oxygen and carbon dioxide) via the intervillous space between the baby’s and the mother’s blood system. Before birth, a third of the baby/placenta blood volume is in the placenta at any given time to facilitate this gas exchange.

After birth the ‘placental’ blood volume is transferred through the pulsing cord into the baby increasing the baby’s circulating blood volume. This has two major effects:

  1. Provides the extra blood volume needed for the heart to direct 50% of it’s output to the lungs (8% before birth). This extra blood fills the capillaries in the lungs making them expand to provide support for the alveoli to open. It also aids lung fluid clearance from the alveoli. These changes allow the baby to breath effectively.
  2. Increases the number of circulating red blood cells which carry oxygen. This increases the baby’s capacity to send oxygen around the body.

This transfer of blood volume from placenta to lungs takes place over a number of minutes following birth. Textbooks will tell you 3-7 minutes, but I have felt some cords pulse for longer than that. While these changes take place, oxygen continues to be provided by the placenta until the baby is ready to begin breathing. Stem cells are also transferred into the baby during this time. There is a theory, and some evidence that these stem cells play an important role in repairing any damage caused during birth. They may actually protect against cerebral palsy! Dr Mercer discusses this in more detail here. You can read my opinion on ‘cord’ blood collection in this post.

Most babies will initiate breathing quickly after birth and premature clamping of the cord will usually have no immediately noticeably effects. However, a recent study found that healthy self-breathing newborns are more likely to die or be admitted to SCN if cord clamping occurs before or immediately after onset of spontaneous breathing (Ersdal et al. 2014). Most babies are able to compensate for their lack of blood volume by readjusting their circulation to direct the smaller blood volume to the important organs. The effects of a reduced blood volume will be subtle but present (see the above Cochrane review). If you get a chance to hear Karen Strange speak about neonatal transition to extrauterine life – take it. She shows photos of the heel capillaries of a baby who has had premature cord clamping compared to a baby who has not. The small blood capillaries are collapsed – they have shut down in order to send the reduced blood volume to the important organs.

The need for resuscitation

There are two reasons that caregivers decide to abandon ‘delayed cord clamping’ and clamp/cut a cord in order to resuscitate a baby. In both cases this action creates difficulties for the baby. In the first it can actually create the need to resuscitate.

1. Lack knowledge, patience (and a bit of panic)

This often happens when a baby is slower to initiate breathing. The baby is still being oxygenated by the placenta but is waiting while the effects of an increased blood volume kick in. This is particularly common with waterbirth babies. These babies have good tone and slowly turn from bluish to pink. It can be difficult to even notice them begin to breathe. Their colour change may be the only obvious indication that they are making the transition. The cord pulses at the same rate as the baby’s heart, so feeling (or watching) it will reassure you that all is well. Unfortunately the usual response to this situation is to clamp and cut the cord in order to resuscitate the baby. The outcome will be that baby responds to the interruption of placental flow and the stressful journey away from mother by crying. A worse outcome is that without the placental circulation the baby is unable to complete their transition and becomes a compromised baby requiring resuscitation (see below).

This film is of an outdoor birth (the mother didn’t make it to her birth tent). The baby makes an unhurried transition supported by placenta circulation:

This baby is also able to make a gentle transition to breathing:

2. A compromised baby

This is a baby who has had a rough time during birth and might require a little external support to make the transition. This situation is often a result of interventions during birth such as directed pushing, artificial rupture of membranes, syntocinon/pitocin. It may also be a result of a tight nuchal cord reducing blood flow just before birth (a loose one does not do this). A compromised baby is floppy and heading from a blue colour to a white colour. They may also have passed meconium during the birth, and their heart rate is slow and/or dropping. This baby could probably do with a bit of help, but most importantly they need their placental circulation. While the cord is intact the baby is still receiving some oxygen, which is better than none. In addition, the extra blood volume and red blood cells will help to circulate any oxygen the baby gets into the lungs via external methods of resuscitation. You can see a very compromised baby being resuscitation with the placental circulation in this movie:

Here is another film of Rixa Freeze’s surprise unassisted birth where she resuscitates her own baby. You can read the full birth story and see part1 on her blog. Rixa had learned newborn resuscitation:

Here is a film of an unassisted birth where a mother instinctively resuscitates her own baby:

 

The importance of the mother and family in resuscitation

It is important that the mother, father or any other significant person is involved in the resuscitation of a compromised baby.

For baby

A baby has spent months inside his mother and learned her voice and smell. She has also learned the voice of her father and/or other family members. To be held close, spoken to and stroked is often enough to initiate breathing. Even if further measures are needed, being held by her mother skin to skin, rather than being put on a flat resuscitaire has got to be nicer.

For mother, father and/or other family members

Being able to see and touch your baby is probably less stressful than having her ‘worked on’ over the other side of the room. Being involved in assisting the baby’s transition reinforces the power of the parents. Fathers are often very proud to be the one who encourages baby’s first breath by blowing gently in her face. In addition, mothers often instinctively know how to help their baby. I remember one mother telling me she felt her baby needed to be in a certain position on her chest. When she moved him his breathing regulated perfectly.

Suggestions

  • Try and ensure that the baby does not arrive compromised by minimising unnecessary interventions.
  • Do not clamp or cut the cord.
  • Give the baby time to transition – if the cord is pulsing the placenta is providing oxygen… relax and reassure the mother if she needs reassurance.
  • Do not clamp or cut the cord.
  • If the baby requires assistance, start small – gentle stimulation, talking, blowing in his face (all can be done by a parent).
  • Do not clamp or cut the cord.
  • If further measures are needed, take the resuscitation equipment to the baby and resuscitate him in his mother’s arms.
  • Did I mention – Do not clamp or cut the cord.

Note: Routine suctioning of the baby is totally unnecessary, invasive and could potentially create problems by stimulating a vagal response (a drop in the heart rate).

I often hear that care providers are unable to perform resuscitation with the cord in tact in a hospital setting because of how the equipment is set up (ie. fixed to a wall). I think this will change. There is increasing awareness of the impact of premature cord clamping – lawyers are looking for claims. Paramedics in Queensland now resuscitate newborns without cutting their umbilical cord. If paramedics can do this in less than ideal settings, why can’t hospital staff? Hospitals need to start making equipment/staff fit around the needs of the baby – not the other way around. An interesting qualitative study explored clinicians perceptions or neonatal resuscitation beside the mother (Yoxall et al. 2015). However, implementing an evidence based practice should not depend on clinicians perceptions of that practice.

Summary

Babies are born with their own resuscitation equipment. The placenta not only helps the baby to transition, but assists with resuscitation if needed. There is no reason to clamp and cut the cord of a baby who needs help. Doing so will create more problems for the baby and mother. Anything that needs to be done can be done with back-up from the placenta, and the involvement of the mother.

Further readings/resources

Mercer and Erickson-Owens (2014) – ‘Is it time to rethink management when resuscitation is needed?’ Journal article

On Nuturing Hearts Birth Services’ website you can see a sequence of amazing photos taken of a cord after birth as it finished transferring blood.

Nicholas Fogelson (Obstetrician) gives a very clear presentation of the research regarding premature clamping in a lecture. The ethics of the research is questionable but hopefully the findings will help to inform a change in practice.

Very interesting and thought provoking interview with Dr Mercer

Science and Sensibility review the evidence

Posted in baby, birth, intervention, midwifery practice | Tagged , , , , , , , , , | 109 Comments

The Human Microbiome: considerations for pregnancy, birth and early mothering

This post was co-authored by Jessie Johnson-Cash and based on her presentation at the USC Midwifery Education Day.

The human microbiome is rather fashionable in the world of science at the moment. The NIH Human Microbiome Project has been set up to explore correlations between the microbiome and human health and disease. To date the human microbiome as been associated with, amongst other things obesity, cancer, mental health disorders, asthma, and autism. In this post I am not going to provide a comprehensive literature review – this has already been done, and the key reviews underpinning this discussion are: Matamoros et al. (2012) ‘development of intestinal microbiota in infants and its impact on health’ and Collado et al. (2012) ‘microbial ecology and host-microbiota interactions during early life stages’. Instead I am going to focus on what this means for pregnancy, birth, mothering and midwifery.

What is the human microbiome?

Based on a chart by Matamoro et al. 2013. Adapted and extended by Jessie Johnson-Cash.

Based on a chart by Matamoro et al. 2013. Adapted and extended by Jessie Johnson-Cash.

Considerations for mothers and midwives

The following are not research based recommendations – the research is yet to be done. They are more considerations/questions arising from the developing knowledge around the human microbiome.

Pre-conception and Pregnancy

The commonly accepted belief that the the baby inside the uterus is sterile (whilst membranes are intact) is being challenged. It seems that maternal gut microbiota may be able to translocate to the baby/placenta via the blood stream (Jiménez et al. 2008; Metamoros et al. 2013; Prince et al. 2014; Rautava et al. 2013Zimmer 2013). And the unique ecosystem of bacteria in the placenta may originate from bacteria in the mother’s mouth. Women’s gut microbiota change during pregnancy and this impacts on metabolism (Koren et al. 2012Prince et al. 2014). So ideally, women need to head into pregnancy with a healthy microbiome and then maintain it. Unfortunately our modern lifestyle is not very microbiome friendly, and many of us have dysbiosis (an imbalance in gut bacteria). Dysbiosis and too much of the ‘wrong’ bacteria has been linked to premature rupture of membranes and premature birth (Fortner et al. 2014; Mysorekar & Cao 2014; Prince et al. 2014). Gum disease (bacteria) has also been linked to pre-term birth. Suggestions:

Birth

There is a difference between the microbiome of a baby born vaginally compared to a baby born by c-section (Azad, et al. 2013; Penders et al. 2006Prince et al. 2014). During a vaginal birth the baby is colonised by maternal vaginal and faecal bacteria. Initial human bacterial colonies resemble the maternal vaginal microbiota – predominately Lactobacillus, Prevotella and Sneathia. A baby born by c-section is colonised by the bacteria in the hospital environment and maternal skin – predominately Staphylocci and C difficile. They also have significantly lower levels of Bifidobacterium and lower bacterial diversity than vaginally born babies. These differences in the microbiome ‘seeding’ may be the reason for the long-term increased risk of particular diseases for babies born by c-section.

The environment in which the baby is born also influences their initial colonisation. A study by Penders et al. (2006) found that term infants born vaginally at home and then breastfed exclusively had the most ‘beneficial’ gut microbiota. It is likely that these babies only came into contact with the microbiota of their family during the key period for ‘seeding’ the microbiome. No one has researched waterbirth and the microbiome yet. Might it dilute the bacteria? The chance of colonisation and infection with group B streptococcus (GBS) is reduced with waterbirth (Cohain 2010Neugeborene et al. 2007). This may be due to dilution of the GBS or additional colonisation of the baby with beneficial bacteria. Another future research topic is caul birth and the microbiome. Does a baby born in the caul miss out on colonisation via the vagina?

What we do know is that antibiotic exposure alters the microbiome in adults (see above). When a woman is given antibiotics in labour her baby also gets a dose. In 2006 a medical expert review (Ledger 2006) raised concerns about prophylactic antibiotics in labour. A study in 2011 found that antibiotics given in labour increased the incidence of antibiotic resistance when treating late-onset serious bacterial infections in infants (Ashkenazi-Hoffnung et al. 2011). A more recent study found that antibiotics given during labour or a c-section are associated with infant gut microbiota dysbiosis (Azad et al. 2016). This is concerning considering the number of women/babies given antibiotics in labour (eg. for ‘prolonged’ rupture of membranes or for ‘epidural fever’). Add to that the use of prophylactic antibiotics for c-sections = a significant proportion of women and babies being exposed to antibiotics around the time of birth. Suggestions:

  • A vaginal birth in the mother’s own environment is optimal for ‘seeding’ a healthy microbiome for the baby (Penders et al. 2006).
  • Minimise physical contact by care providers on the mother’s vagina, perineum and the baby during birth.
  • Avoid unnecessary antibiotics during labour. If antibiotics are required consider probiotics for mother and baby following birth.
  • If the baby is born by c-section… Research is currently being undertaken into the use of vaginal swabs* to ‘seed’ c-section babies. The preliminary results are that the microbiome of swabbed babies are more similar to vaginally born babies. The protocol the researchers are using is:
    1. take a piece of gauze soaked in sterile normal saline
    2. fold it up like a tampon with lots of surface area and insert into the mother’s vagina
    3. leave for 1 hour, remove just prior to surgery and keep in a sterile container
    4. immediately after birth apply the swab to the baby’s mouth, face, then the rest of the body (you can see photos of this process here)
  • If a baby is born by c-section it is even more important to encourage and support their mother to breastfeed. It may also be worth considering additional probiotic intake.

*There has been a bit of hysteria about the safety of vaginal swab seeding in the media. I will leave it to Sara Wickham to address (rant about) this one.

Postnatal

After birth, colonisation of the baby by microbiota continues through contact with the environment and breastfeeding. There are significant differences in the microbiota of breastfed babies compared to formula fed babies (Azad, et al. 2013; Guaraldi & Salvatori 2012). Beneficial bacteria are directly transported to the baby’s gut by breastmilk and the oligosaccarides in breastmilk support the growth of these bacteria. The difference in the gut microbiome of a formula fed baby may underpin the health risks associated with formula feeding. In the short term, infant colic may be associated with high levels of proteobacteria in the baby’s gut (wish I’d know this 20 years ago!). Suggestions:

  • Immediately following birth, and in the first days, baby should spend a lot of time naked on his/her mother’s chest.
  • Avoid bathing baby for at least 24 hours after birth, and then only use plain water for at least 4 weeks (Tollin et al. 2005).
  • If in hospital, use your own linen from home for baby.
  • Minimise the handling of baby by non-family members during the first weeks – particularly skin to skin contact.
  • Exclusively breastfeed. If this is not possible consider probiotic support.
  • Avoid giving baby unnecessary antibiotics (Ajslev et al. 2011; Penders et al. 2006). Again, if antibiotics are required probiotics need to be considered.
  • Probiotics may also be beneficial for babies suffering from colic.

Summary

The more we understand about the human microbiome the more it seems fundamental to our health. Pregnancy, birth and breastfeeding seed our microbiome and therefore have a long-term effect on health. More research is needed to explore how best to support healthy seeding and maintenance of the microbiome during this key period. I have discussed a number of considerations and suggestions arising from what we already know. I welcome any comments, discussion and further suggestions from readers.

Further reading and resources

Posted in baby, birth, midwifery practice, pregnancy | Tagged , , , , , , , , , , | 119 Comments