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The Magazine of The Royal College of Midwives

Midwives ISSUE 2 | 2013

Taking time out Why women are waiting for motherhood

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Midwives Volume 16 ˙ Issue 2 ˙ 2013

EDITORIAL 5 ► CATHY WARWICK The RCM chief executive on the Francis report and what lessons can be learned.

HEADLINES 7 ► NEWS Keeping active, home birth and the smoking ban... Midwifery stories hot off the press.

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12 ► GLOBAL NEWS The latest news from around the world. 15 ► IN FOCUS A look at the possible impact of the Francis report on the NHS. 16 ► RCM NEWS ULR project expansion and Agenda for Change... The latest RCM news and dates. 18 ► COUNTRY NEWS RCM UK latest news for Northern Ireland and England. 19 ► ON POLITICS Stuart Bonar looks to the 2015 elections. 20 ► WORK LIFE Amy Leversidge discusses pensions.

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OPINIONS 23 ► ONE-TO-ONE Rob Dabrowski talks to a male midwife. 26 ► ON COURSE A student explains why politics isn’t such a daunting subject. 27 ► FEEDBACK Midwifery morale, hierarchy and religion.

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28 ► RCM COMMUNITIES Discussing the illegal abortion scene in Call the Midwife.

29 ► TWEETDECK A look at what you’ve been tweeting.

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ON FOCUS 33 ► CUTTING EDGE Jan Wallis reviews the latest midwifery-related research. 34 ► HOW TO… Provide postnatal perineal care. 36 ► EBM A summary of the latest EBM papers.

The official magazine of The Royal College of Midwives 15 Mansfield Street, London W1G 9NH Tel: 0300 303 0444

EDITORIAL Editor and RCM Communities manager: Emma Godfrey-Edwards Tel: 020 7324 2751 Deputy editor: Rob Dabrowski Tel: 020 7324 2752 Assistant editor: Rebecca Grant Tel: 020 7880 7667 Sub editor: Helen Bird Tel: 020 7324 2773 News and features writer: Hollie Ewers Tel: 020 7880 6210 Professional editor: Professor Mary Steen PhD MCGI PGDipHE PGCRM BHSc CIMI RM RGN

General enquiries:


EDITORIAL BOARD Louise Silverton, Jon Skewes, Suzanne Tyler, Gail Johnson, Val Finigan, Kate Brintworth, Suzanne Truttero, Fiona Donaldson-Myles

37 ► OLDER MOTHERS Examining the issues around the increasing number of middleaged mothers. 41 ► RCM AWARDS Promoting normal birth at two Birmingham birth centres. 42 ► INDUCTION Summarising the history of induction.

PUBLISHERS Redactive Publishing Ltd 17-18 Britton Street, London EC1M 5TP Tel: 020 7880 6200 Publishing director: Jason Grant

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44 ► FETAL OUTCOMES A study looks at the results of babies born in water following induction.

ADVERTISING Divisional sales director: Steve Grice Tel: 020 7880 6220 Sales manager: Giorgio Romano Tel: 020 7880 7556 Sales executive: James Condley Tel: 020 7880 7661

DESIGN Art editor: Carrie Bremner Art director: Mark Parry

46 ► DILUTIONAL HYPONATRAEMIA Explaining the occurence, symptoms and preventive measures.

COVER Image: Peter Crowther

PRODUCTION Production executive: Aysha Miah Tel: 020 7880 6241

48 ► COMMUNICATION How has the HART tool improved communication in Northern Ireland?

MEMBERSHIP Tel: 0300 303 0444

50 ► NVP Looking at hyperemesis gravidarum.

MAGAZINE SUBSCRIPTION RATES (For non-members only, per annum) UK: £130 European Union: £175 Rest of the world: £185

52 ► MSWs Part two of the screening scenario.

MAGAZINE SUBSCRIPTION QUERIES Midwives, PO Box 2068, Bushey, Herts WD23 3ZF Tel: 020 8950 9117


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Printed by Wyndeham Peterborough Limited. Mailed by Priority, Salisbury. All members and associates of the RCM receive the magazine free. The views expressed do not necessarily represent those of the editor or of The Royal College of Midwives. All content is reviewed by midwives. Midwives ISSN: 1479-2915

06/03/2013 09:53



RCM chief executive Cathy Warwick

Editorial A lesson learned


he Francis report into the needless deaths and appalling treatment of patients at Stafford Hospital makes for depressing reading. The report catalogues how patients, often in a highly vulnerable condition, were exposed to unclean, understaffed and unsafe wards and treated in the most callous manner imaginable. What is perhaps most concerning is the system-wide failure, from ward management to the regional and local tiers of the NHS, to regulators and the DH, to spot and to act on the numerous signs that something had gone seriously wrong. It should be stressed that maternity services at Stafford Hospital were not implicated in any way by the Francis inquiry. But while maternity care does not feature in the report, there can be no cause for complacency. The analysis of the shortcomings of the healthcare system and the report’s recommendations apply across all NHS services, to every regulatory body and to the professions and other staff groups. While the fallout from the Francis report is set to dominate the policy landscape in England, be in no doubt that its impact will ripple across the rest of the UK. The RCM is working through the 290 recommendations, spread

across the 1800-page report, and considering what the key implications are for maternity and midwifery services, both for the women and families who use our services and for midwives themselves. For the RCM too, the report has generated some critical points to address. Firstly, how do we play our part in identifying services that are struggling and in getting them the help and support they need at an early stage? What can we do to help a HoM who is finding it difficult to make their voice heard? And how can we do more to support RCM members who feel that their concerns about the quality and safety of care aren’t being taken seriously? A key recommendation concerns the RCN and its ability to act both as a trade union and a professional organisation. The same question could be addressed to the RCM, to which my response would be that we have always felt that our trade union focus of supporting our members is as important as our professional focus of advocating for women to get the best possible care. Francis makes many recommendations touching on regulation and, in particular, revalidation. The RCM will be arguing that the midwifery profession already has, in our system of supervision of midwives, a mechanism through which this recommendation can be achieved.

Top picks Looking at the increasing trend of older mothers, a new tool for improving team communication and nausea and vomiting in pregnancy

The rise of the middle-aged mother (p37)

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A meeting of minds (p48)

Beyond the pale (p50)

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The latest professional news

Headlines Hot off the press / News




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Any risk to pregnant women undertaking physical activity at work is likely to be very minor, new guidelines state. The news comes following an extensive, systematic review of evidence covering such activities as lifting, prolonged standing, working long hours and shift working. The review looked into the risks of adverse outcomes, including miscarriage, preterm delivery and delivering a small-for-gestationalage baby. Jane Munro, RCM quality and audit development advisor, said: ‘For women who are pregnant with one baby, we would encourage them to remain active during pregnancy, because this brings many benefits.’ But she added: ‘Many women will want to reduce long working hours, prolonged standing and heavy physical work as their pregnancy progresses.’ The guidelines have been issued by the Health and Work Development Unit. They stress that employers should consider making ‘reasonable adjustments’ to limit excessive work demands.

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Headlines News / Hot off the press


OBESITY REPORT ACTION PLAN TO REDUCE WEIGHT PROBLEM A report by healthcare and medical professionals calls for a raft of new measures to tackle obesity. The recommendations have been set out by the Academy of Medical Royal Colleges (AoMRC). The report, titled Measuring up: the medical profession’s prescription for the nation’s obesity crisis, maps out an action plan, following a six-month inquiry. It is based around 10 recommendations for healthcare professionals, government, industry and schools, which includes £100m to be spent on increasing provision of weight management services across the country in each of the next three years. It also calls for mandatory food-based standards in UK hospitals, a ban on new fast food outlets located near schools and colleges and a


duty on all sugary soft drinks, increasing the price by at least 20%, to be piloted. Paediatrician and chair of the AoMRC Professor Terence Stephenson said: ‘It is no exaggeration to say that it is the biggest public health crisis facing the UK today. ‘It’s now time to stop making excuses and instead begin forging alliances.’ The news comes after recent obesity statistics revealed nearly a quarter of women (24%) and just over a fifth of men (22%) in the UK are classed as obese.

New figures show that the number of women choosing home birth is falling. The Office for National Statistics has released a report that reveals only 2.4% of women in England and Wales had a home birth in 2011. While the drop is very small – from 2.5% for the previous year – it has been falling since 2008. Home births plummeted in the 1960s and 1970s, when, over an 11-year period, they dropped from 30% to 4.2%.   The news comes as statistics show the baby boom continues. RCM chief executive Cathy


LEWISHAM HOSPITAL MATERNITY SERVICE CHANGES ANNOUNCED The maternity facilities at Lewisham Hospital will be replaced by a midwife-led unit, it has been announced. Health secretary Jeremy Hunt revealed the news and confirmed that the A&E department will be downgraded. The unit is only expected to be able to handle 10% of the births that the current facilities can. The cuts are part of a bid to

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. »24%

tackle debts of £150m at the neighbouring South London Healthcare NHS Trust. There has been strong opposition to the idea, with more than 15,000 taking to the streets in protest before the decision was announced. Mr Hunt said: ‘I respect and recognise the sense of unfairness people feel because their hospital has been caught up in the financial problems of its neighbour.

‘However, solving the financial crisis next door is also in the interest of the people of Lewisham because they too depend on the services which are currently part of South London Healthcare NHS Trust.’ RCM chief executive Cathy Warwick said: ‘While we are pleased to see that a midwife-led unit will remain in Lewisham and that there will be midwife-led units at the other sites, along with obstetric services, we remain deeply concerned about the consequences of this decision for the remaining maternity services in south-east London.’ 

Warwick said she hopes that the popularity of Call the Midwife could give home births a boost.      ‘The baby boom is continuing and to see the number of women giving birth at home continuing to fall, however small the drop, is very disappointing,’ she said. ‘This flies in the face of the government’s commitment to bring services closer to home and to offer women choice about where they give birth. ‘The drop since the late 1950s is staggering and we need to see that trend reversed and start moving back towards the home birth numbers seen then.  ‘The Call the Midwife drama – set in that period – has shown us a model of community-based midwifery care that we should be looking to emulate in a modern context.’

BORDER AGENCY POLICY REINSTATED The UK Border Agency has reinstated a policy on its website saying that force must not be used against pregnant women. It was reinstated just before the issue was due to be heard in the high court. The move came after campaigning and a legal challenge, including evidence and pressure from the RCM.

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17lb 8oz

The combined weight of twins born to Sara Chiad from Derbyshire



The number of births that are expected in England next year




Number of prosecutions for female genital mutilation in the UK

GLOBAL BREASTFEEDING CHARITY CALLS FOR BOOST TO SAVE LIVES The lives of 95 babies could be saved every hour if new mothers breastfed immediately after birth, it is claimed. The charity Save the Children makes the statement – equal to 830,000 lives saved per year – in a new report about global breastfeeding. It states that if babies receive colostrum within an hour of birth, it will kick start the immune system, making them three times more likely to survive. The report, Superfood for babies, adds that breastfeeding for the next six months means a child in the developing world is up to 15 times less likely to die from killer diseases, such as pneumonia and diarrhoea. However, global breastfeeding rates are stalling and even declining


→ Call the Midwife has shown us a model of community-based care that we should be looking to emulate Longstanding advice about the best practice when preparing formula milk has been restated. The chief medical officer and the director for public health nursing in England are behind the move. The advice is set out by the DH and the Food Standards Agency and states that water should be at a temperature of 70°C or above. The DH has sent out a letter to health professionals on the preparation of infant formula. It says: ‘We are aware that there has been some recent public debate about the preparation of infant formula

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FORMULA MILK ADVICE RESTATED ON TEMPERATURE using water below a temperature of 70°C. ‘This is a concern as our precautionary approach sets out best practice and aims to minimise the risks to infants. ‘This is why we, the chief medical officer and director for public health nursing in England, are writing to health professionals to raise awareness of this important issue and to restate

existing guidance.’ The letter states that the guidance is in line with WHO recommendations and aims

» 70°C


across East Asia and in some of Africa’s most populated countries, says the report.   The prevalence of traditional practices, as well as a severe shortage of health workers and inappropriate marketing techniques by some baby milk substitute companies, have contributed to this, it is claimed. Save the Children chief executive Justin Forsyth said: ‘Despite the benefits of breastfeeding being widely known in the developed world, and it being a free, natural way to protect a newborn baby, too little attention is being paid to help mothers breastfeed in poorer countries.’ The report calls for the UK government to use its hunger summit and G8 presidency in June to fund nutrition work with breastfeeding as a core component.

to ensure that the potential microbiological risks associated with these products are kept to a minimum. Using water at 70°C or above will kill harmful pathogens if they are present in the nonsterile powdered formula and will also help reduce the risk of contamination that may occur in the home. The letter concludes: ‘We want to be clear that all standard, non-specialised infant formula and follow-on formulas should be prepared in line with current best practice.’

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Headlines News / Hot off the press

SMOKING BAN STUDY SHOWS THE POSITIVE IMPACT FOR BIRTH ‘This research is encouraging but we should also be aware that many pregnant women are still exposed to second-hand smoke in domestic situations. We would hope that smokers would be considerate and refrain from smoking when pregnant women are in their immediate vicinity. ‘It is also important that when the baby is born that it spends as much time as possible – ideally all of the time – in a smoke-free environment.’ The researchers analysed 606,877 live, single-born babies

» 3.13%


delivered between 24 and 44 weeks’ gestation in Flanders from 2002 to 2011 for the BMJ study. The results show a reduction in the risk of preterm births of 3.13% on 1 January 2007 (ban on smoking in restaurants). There is a further reduction in the risk of 2.65% after 1 January 2010 (ban on smoking in bars


The birth rate in Corby, Northampton, has surged by

63% since 2002

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TOWN HAS HIGHEST BIRTH RATE INCREASE The birth rate in Corby, Northamptonshire, has surged by 63% since 2002 – the fastest level of growth in England. The increase was three times as high as the rest of the country, where the average growth rate was 21% over the same period. The statistics were revealed at the launch of the RCM’s State of maternity services report, held in parliament. Andy Sawford, Labour MP

for the area, was at the launch and expressed concern over a healthcare review in the area. An NHS consultation on the organisation of hospitals in the region is currently underway. These include hospitals in Kettering – which is used by people living in Corby – Northampton, Milton Keynes, Luton and Dunstable, and Bedford. He said he's worried that, with such a high birth rate,

serving food). The authors state: ‘Our study shows a consistent pattern of reduction in the risk of preterm delivery with successive population interventions to restrict smoking.’  They conclude: ‘These results underscore the public health benefit of smoking ban policies.’

any potential cuts that affect maternity services would be a big blow for the area. ‘What I’m doing here today is gathering evidence, so that our case is evidence based and not just an emotional one,’ he said. ‘I’ve been talking to the RCM and other experts to understand the implications for our hospitals.’ He added that he would be seeking to organise a followup local meeting with RCM representatives. Stuart Bonar, RCM public affairs advisor, said: ‘We will be more than happy to work with Andy Sawford moving forward.’


Smoking bans have led to a reduction in the risk of preterm birth, according to a study. A team of researchers investigated whether recent smoking bans in Belgium were followed by changes in preterm delivery rates.  Smoke-free legislation was implemented in the country in three phases (firstly workplaces, then restaurants, then bars that serve food) over four years. The researchers found reductions in the risk of preterm birth after the introduction of each phase of the smoking ban.  Louise Silverton, RCM director for midwifery, said: ‘There is no doubt, because it is supported by a large body of evidence, of the negative impact of smoking on the pregnant woman and her developing child and of the effects of secondhand smoke.

06/03/2013 09:56



NMC fee hike Midwives now have to pay £100 to register with the NMC. The news comes after the regulator last year

announced it was going to hike its fee from £76. Legal advice An organisation dedicated to

protecting women’s rights in childbirth has launched. Birthrights seeks to advance the dignity, privacy and autonomy of all

childbearing women. Guidelines app Clinical guidelines in women’s health are now available through the RCOG’s new app.


ICM 2014 Discounted booking rates are now available for the ICM congress, which is to be held on 1 to 5 June 2014 in Prague.

MATERNITY FUNDING £25M ALLOCATED FOR IMPROVEMENTS More than 100 hospitals are sharing a £25m fund to improve and upgrade their maternity units, it has been announced. The government money is going towards a wide range of projects that submitted applications for the cash. Several older maternity hospitals are being refurbished, including the 1970s unit at Airedale NHS Foundation Trust and one at Taunton and Somerset, which dates back as far as the 1940s. There is also funding for a large number of simple measures that improve choice for women and their experience of maternity care. The money is going towards almost 40 new birthing pools, eight new midwife-

led units and more ensuite facilities in more than 40 maternity units. It is paying for more equipment, including beds and family rooms in almost 50 units, better bereavement spaces at nearly 20 hospitals, equipment that gives women more freedom to change position in labour and facilities that allow women to choose if they want a bath or shower.  Bids were judged by a panel that included representatives from the RCM and RCOG.  Cathy Warwick, RCM chief executive, said: ‘It is great to learn about the positive changes that this extra £25m will make to many units up and down

the country.’ Applications for funding were only approved where there was evidence that local mothers and fathers wanted changes. Health minister Dr Dan Poulter said: ‘Maternity units have had to show evidence that they asked mothers and fathers about what changes they need to make – so we know these are the changes local people really want to see.’



15% Most stillbirths are potentially avoidable, research suggests. Restricted growth in unborn babies is the largest factor in stillbirth figures, but it is currently not well-recognised or predicted in most pregnancies, states a study. The risk of stillbirth is five times greater if fetal growth restriction goes undetected antenatally, researchers suggest. Up to 70% of stillbirths were recently categorised as unclassified or unexplained, and therefore, understood as unavoidable. However, inclusion of growth restriction as a category in stillbirth classifications resulted in a 15% drop in unexplained cases.

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Charlotte Bevan, research and prevention advisor for the charity Sands, said: ‘Some 17 babies die every day in the UK, before, during and shortly after birth. Many of these mothers are in lowrisk pregnancies close to or at term and the death of their baby comes as a devastating shock. ‘To discover subsequently that their baby was not low risk at all but was growth restricted and that this is a well-known risk factor for stillbirth, leaves families bewildered and struggling to come to terms with their grief.’ She added: ‘This research shows that routine antenatal care fails hundreds of families every year and action to improve care is desperately needed.’

↖ —inclusion of growth restriction as a category in stillbirth classifications resulted in a 15% drop in unexplained cases

70% ↖ —of stillbirths were recently categorised as unclassified or unexplained, therefore, understood as unavoidable

SMOKING, BREASTFEEDING AND ALCOHOL RATES Nearly a third of Scottish women smoked in pregnancy and there has been a ‘statistically significant decrease’ in breastfeeding to six weeks, figures show. The Growing up in Scotland survey reveals that 27% smoked in pregnancy – a 2% increase on the previous survey, which covered 2005-6. The proportion of women breastfeeding (although not exclusively) to six weeks was 42%, which is the same figure as the last study. However, the report says breastfeeding is ‘strongly associated with socio-demographic factors’ and when this is factored in, ‘there was a statistically significant decrease’. Gillian Smith, RCM director for Scotland, said that the report ‘highlights the invaluable role that midwives can and do play in making Scotland a healthier nation now and for future generations’.  The results also show that the number of women avoiding alcohol in pregnancy has increased, rising from 74% to 80%.

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Headlines Global news / Headlines around the world




N mak ews stor arou ing head ies nd t he wlines orld deliver a real midwifery profession into the country. It believes this is critical to finding a solution for Ágnes and improving the situation of midwives and birthing mothers. Spokeswoman Erika Schmidt said: ‘We launch this on behalf of Hungarian birthing mothers to highlight the shocking fact that Hungarian obstetric hospital nurses and licensed home birth midwives are not legally allowed to fulfill all of their professional roles.’




The Justice for Ágnes Geréb Movement has launched a new campaign drive. Ágnes was sentenced to two years in prison, with a five-year ban on practising as a midwife after providing home birth services, which were criminalised in Hungary. The campaign group is now calling on the Hungarian government to

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The Ghana Midwifery Council has been urged to consider allowing men to train as midwives. Bernard Bediako Badu, a district pharmacist, said males are performing well in obstetrics and gynaecology and there is no reason they shouldn’t do well as midwives. He explained that this would mean more midwives could be trained to serve in rural and ‘difficult-to-reach’ communities. Some midwives have backed the idea and think it would be a good way of increasing the limited number of midwives around the country. But some have spoken out against the potential move and said it ‘should be given critical thought due to the cultural and religious beliefs of people’. NORWAY



Researchers from Norway found that drinking coffee in pregnancy




A new midwifery education programme is being developed in Fiji in the hope of addressing the shortage of midwives. Fiji National University’s College of Medicine, Nursing and Health Sciences is set to upgrade its current programme to a high-quality postgraduate diploma in midwifery. College dean Professor Ian Rouse said the number of midwifery students has increased by 50% over the last couple of years. He said: ‘We have added additional tutors and are up-skilling our staff to postgraduate level in midwifery.’ Professor Rouse added that ‘it is clear that in some areas, we are short of midwives due to the increasing number of deliveries’. He concluded that having an adequate number of well-trained midwives is critical to improving maternal health in Fiji.


Mothers in one of South Africa’s poorest areas are drinking heavily to deliberately damage their unborn babies, it is claimed. There are reports that pregnant women in Eastern Cape are drinking so their babies develop Fetal Alcohol Spectrum Disorder (FASD) and they can claim disability allowance. State benefits mean an impoverished family receives the equivalent of £20 per child a month. But the current disability allowance is the equivalent of £85 a month. South Africa has had the highest number of FASD cases in the world since 2002, according to the WHO. The Foundation for Alcohol Related Research in South Africa admitted that many of the country’s women drink heavily, but added that claiming they do so to receive disability allowance is a ‘total exaggeration’.

Global news

can increase the risk of having an underweight baby. Their results also show that it may make pregnancy last longer, but only by a few hours. However, unlike some previous research, they did not find a link with premature birth. The observations come from researchers who studied detailed records of almost 60,000 pregnancies from a 10-year period in Norway. The records included information about how often the women had foods or drinks containing caffeine, from tea and coffee to bars of chocolate. They state that consuming 200mg to 300mg of caffeine a day raises the chance of the child being classed as small for the length of the pregnancy by up to 62%.

06/03/2013 09:57


International Day of the Midwife

with the RCM

5th May 2013 Help us celebrate midwifery by baking a midwifery inspired cake to raise funds for the ICM

For more information on how you can get involved visit or the RCM’s Facebook page

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05/03/2013 14:43



The Francis report / In focus

‘A FUNDAMENTAL CULTURE CHANGE IS NEEDED’ Following an investigation into a scandal-hit hospital, Midwives looks at Robert Francis QC’s wide-ranging report and its potential impact across the NHS.


THE FRANCIS REPORT will inevitably cast a long shadow, not just over Stafford Hospital (pictured) it is based upon, but the entire NHS. The hefty report maps out 290 recommendations over 1782 pages that condemn a system where there was ‘failure at every level of the NHS’. Robert Francis QC is the man behind the report, which comes on the back of a £13m investigation into the scandal. It follows ‘appalling and unnecessary suffering’ at the hospital, which ‘led to hundreds of deaths’ between 2005 and 2008. Among the hardest hitting (and hardest reading) findings are patients left sitting in their own faeces for hours, food and drink left out of reach, and hygiene so poor that relatives had to clean toilets themselves. Many of the failings at the hospital centred around patients being ‘routinely neglected’ by a trust preoccupied with cost-cutting and targets. As RCM chief executive Cathy Warwick writes in her editorial (see page 5), maternity services at the hospital are not implicated

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in the report. But this does not mean maternity services across the country won’t be affected following its publication. In a letter to the health secretary Jeremy Hunt, Francis wrote: ‘The extent of the failure of the system shown in this report suggests that a fundamental culture change is needed.’ And the report’s proposals ‘require every single person serving patients to contribute to a safer, committed and compassionate and caring service’. Francis maps out five main areas that need to change, not just at the troubled hospital, but across the entire NHS. Among these are ‘a structure of

clearly understood fundamental standards’ and ‘openness, transparency and candour throughout the system’. Cathy Warwick said the call for openness and a duty of candour is ‘an excellent suggestion’. ‘We hear far too often from midwives who are genuinely petrified about raising the alarm over poor quality of care,’ she said. ‘They fear that senior managers will come down on them hard, simply for raising concerns. ‘We need to transform the culture of the NHS so that midwives and others who need to speak out feel happy and secure in doing so.’ She added that NHS staff must

‘never again be afraid to raise concerns about standards of NHS care’ and added that the report’s publication ‘must be a watershed for the NHS’. The other key proposals in the report are ‘improved, compassionate caring and committed nursing’, ‘strong and patient-centred healthcare leadership’ and the need for more ‘accurate, useful and relevant information’. The overall drive behind the report is for an NHS that does not just provide better care for clients and patients, but a better culture of work for NHS staff. Francis recommends that new rules holding senior managers accountable for their actions would see NICE asked to set minimum staffing levels. He also calls for tighter regulation, which would cover midwives and MSWs. Following the report, David Cameron apologised for the ‘truly dreadful’ mistreatment and neglect at Stafford Hospital. He also announced that a number of other hospitals with persistently high death rates are being investigated fully. The health secretary has also spoken out, stating that one of the main lessons to be learned is to ‘never allow the needs of an institution to become more important’ than the individuals for which it is supposed to care. The government’s formal response to the report is due this month (March), but Downing Street has already stated that the government will endorse most of the findings. Midwives would like to clarify that the RCM has had no involvement in the legal challenge mounted by two Glasgow midwives around abortion, which featured in last issue’s In focus.

06/03/2013 12:02



Headlines RCM news / The latest sto stories

AGENDA FOR CHANGE CONSULTATION ULR PROJECT EXPANDS FUNDING SECURED The RCM has won funding to deliver learning opportunities through the union learning representative (ULR) project in both Wales and Scotland. The Wales Union Learning Fund will begin a three-year project for members, starting in April. The project will work with partners, local health boards and the National Leadership and Innovation Agency for Health to promote, engage and deliver more than 300 learning opportunities. It will also allow the RCM to continue to build its network of ULRs. The ULR project in Scotland will offer many learning opportunities, ranging from holding a bereavement conference to a CV writing workshop and courses on time management and stress.

UNANIMOUS VOTE ACCEPTING CHANGES IN ENGLAND An overwhelming majority of RCM branches that responded to the consultation have voted to accept proposed changes to Agenda for Change (AfC). The RCM’s consultation about proposed changes to AfC in England closed on 4 February with 94% of branches/workplaces voting to accept. A total of 70 branches/workplaces responded out of 147. Jon Skewes, director of policy, employment relations and

RCM NEWS AND DATES ANNUAL EVENT This year, the RCM annual event comes to Scotland. Taking place on 13 June at the Scottish National Gallery, Edinburgh, the event will include the Zepherina Veitch memorial lecture presented by Dr Helen Cheyne. ► For more details, please visit: annualevent2013


I-LEARN ADDITIONS i-learn, the online learning resource for RCM members, has launched three new courses. The first – ‘Midwives rules and standards 2012’ – provides an overview of the changes to the rules and standards, while the other two, ‘The deteriorating postpartum mother’ and ‘Thermoregulation – keeping the baby at the right temperature’, are aimed specifically at MSWs. ► To access these free

courses, please sign up to i-learn at: ilearn IDM: 5 MAY The RCM will be celebrating International Day of the Midwife (IDM) by inviting budding cooks to bake a midwifery-inspired cake to raise funds for the ICM. Those participating should post pictures of their finished cake, along with their name, workplace and inspiration, on the RCM Facebook page (

midwivesRCM) or email them to: marketingofficer@ The competition closes on IDM, 5 May. The baker of the cake with the most ‘likes’ will win a complimentary ticket to this year’s RCM Annual Conference in Telford. The RCM will also be using the occasion to promote the global midwifery twinning project, with seminars in each UK country. ► For more information, please visit: idm2013 ALAMY

POLICY SEMINARS The RCM hosted a free, oneday event in Birmingham on 27 February to discuss the impact of the NHS reforms on maternity services across England, among other issues. The RCM will be holding further free policy seminars across the West Midlands. ► For dates, please check:


communications, said: ‘These proposals – the result of extensive negotiation – represent the most effective way of providing stability and protecting AfC as a national system of pay, terms and conditions in the NHS. ‘Midwives believe that supporting these national changes is better than risking individual or groups of employers making their own changes to terms and conditions, therefore moving away from a UK-wide system. RCM branches have taken a pragmatic step to protect a national structure of pay, terms and conditions.’ The consultation ran from 11 January to 4 February through the RCM branch structure. The RCM has supported the adoption of the changes to NHS staff contracts in England contained in the review at the NHS Staff Council on 26 February.

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06/03/2013 09:58

Boost your learning i-learn and i-folio are the RCM’s hugely successful online learning and e-portfolio packages. They are a great benefit for members allowing access to learning anytime and anywhere.


ore than 30 free-ofcharge CPD courses are available, ranging from 10-minute tasters to 30 hours of leadership learning. Topics include a wide range of CPD subjects, courses for the RCM’s workplace representatives, regular professional updates, and two recently launched courses specifically for MSWs. Over 5000 members have now accessed i-learn, starting approximately 150 new courses and completing over 80 courses per week. CPD evidence is an important part of your working life and i-folio provides you with an online space to record it. It’s entirely private, giving you the flexibility to use it in your own way.

More than 2600 members are currently using i-folio and are finding new uses for it. Some have used it in supervisory meetings, while others have used the web display page to share events or groups they are involved with. It also offers a CV builder, where you can keep a record of your employment history, skills and experience in one place. All i-learn certificates are also automatically transferred to i-folio, helping to build an ongoing record of your CPD activity. A number of new i-learn courses are planned for this year, including more in the research series, more on parenting, a new course on genetics and regular professional updates, so please visit i-learn and i-folio regularly to check out what’s on offer.


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06/03/2013 09:59



Headlines Country news / Northern Ireland and England g




CONFERENCES We have a busy period of events planned for our members throughout 2013, with the joint RCM/RCOG/DHSSPS/PHA/LSA conference in March, the joint RCM/Sands conference in June and the annual joint RCM/INMO conference in October. We will be out and about visiting maternity units throughout NI as we hold a series of professional discussion forums looking at topics such as GBS in pregnancy and the RCM i-learn programme. We will also discuss how the maternity strategy will be implemented in NI.

BOARD RESTRUCTURE Throughout 2013 we will continue to campaign for adequate

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resourcing for maternity services; for the publication of the termination of pregnancy guidance; and for the further development of perinatal mental health services in NI. Following the establishment of the RCM board, the previous NI board has been reconstituted as the RCM NI advisory group. We have co-opted two of our student representatives onto the group and we look forward to developing closer relationships with midwifery students in NI in the year ahead.

MIDWIFERY SOCIETIES Student midwives Theresa Mason and Lauren Ramouth set up the first midwifery society at the University of Huddersfield at the start of the new year. The Huddersfield midwifery society is collaborating with the RCM to host a study day in September on normal birth. Similar midwifery societies across England are developing at a pace and the University of Salford recently launched its midwifery society, also closely affiliated with the RCM.

NEW YEAR’S HONOURS The year got off to a great start when an MBE was awarded to Vera Kelso, recently retired lead midwife for community midwifery services in the Southern Health and Social Care Trust (SHSCT). This was a well-deserved recognition of Vera’s commitment throughout her career to improve maternity services for women and their families throughout SHSCT. The former chief nursing officer, Martin Bradley, who was extremely supportive of the RCM’s campaign to develop a maternity strategy and who also supported the establishment of community midwife units in NI, was also awarded an OBE. Breedagh Hughes Director RCM Northern Ireland

also opened recently, and more than 200 births have taken place there. The message from all of us at the RCM is keep up this great midwifery led work.

GUILDFORD BRANCH Almost 100 RCM Guildford branch midwives and student midwives attended a study day facilitated by Professor Denis Walsh, which focused on the evidence for embedded practice around labour and birth. There was plenty of discussion, debate and shared learning between students and midwives at this study day.


BIRTH CENTRES Congratulations to Bristol's Cossham Birth Centre, headed up by manager Gina Augarde, which opened on 28 January. Congratulations also go to Bradford Birth Centre, which was officially opened on 1 February by The One Show presenter Anita Rani. Anita, who was born in Bradford herself, said she was extremely proud to cut the ribbon and unveil the plaque. Wolverhampton Birth Centre

Congratulations to Elaine Uppall, midwifery lecturer at the University of Salford, who recently hosted a celebration event for the excellent achievements by students at the university. This included the art in midwifery work and the successful BFI accreditation. The awards were presented by RCM chief executive Cathy Warwick. The vice chancellor, dean of the school, the RCM’s Gail Johnson and myself also attended the event. Jacque Gerrard Director RCM England


There are exciting and challenging times ahead for the health service in Northern Ireland (NI) as Transforming your care is implemented. The RCM will work with the Department of Health, Social Services and Public Safety (DHSSPS), Health and Social Care Board and Public Health Agency (PHA) to ensure that we continue to have integrated, womencentred maternity services that are focused on normalising birth in accordance with the NI maternity strategy. We will continue to work with the Belfast Health and Social Care Trust to establish a freestanding community midwifery unit in the Mater Hospital.

06/03/2013 09:59


Stuart Bonar / On politics



ark it in your diaries: 7 May 2015. That is the scheduled date of the next UK general election. It will be judgement day for the coalition government and for all 650 MPs we elect to the House of Commons. It may be more than two years away, but here at the RCM our attention is already turning to what might appear in each of the three main parties’ manifestos – their list of promises of what they will do if entrusted with power by the voters. Of course, not everything a party promises before an election gets done. You may remember that David Cameron pledged, in 2010, to recruit an extra 3000 midwives to the NHS in England. Post-election, the promise was swiftly dropped, although the number of midwives is now up over 1100 since May 2010, when Mr Cameron and his family

Stuart Bonar looks at how the next elected government could support and improve the UK’s maternity services in 2015.

moved into Downing Street. Bear in mind that while the whole of the UK elects the government in London, it is only the health system in England that falls under its control. While devolution has taken place in Scotland, Wales and Northern Ireland, placing the NHS in each part of the UK under the control of the legislatures in Edinburgh, Cardiff and Belfast respectively, England remains governed by the whole country. RCM staff attended a speech given on 24 January by Labour’s shadow health secretary Andy Burnham. In it he announced a ‘root and branch’ review of his party’s health and social care

policy. The RCM has been invited to submit ideas to it, and we look forward to doing so. The Liberal Democrats have begun formal deliberations over what will appear in their next manifesto, which must ultimately be approved by members at a party conference. The names of those who sit on that group have been published and we will submit ideas to them. The Conservatives, too, will increasingly turn to drawing up at least the headline contents of their manifesto before too long. A great deal of groundwork will be done by all three parties this year as they sketch out their plans. The challenge for the RCM is

→ It may be more than two years away, but our attention is already turning to what might appear in each of the three main parties’ manifestos 018-019_MID_HEAD_Politics_Country.indd 19

to propose something that could possibly win cross-party support, but to do so at a time when there is little or no money to throw at a problem like the deep shortage of midwives. It could simply be that we ask for things to continue as they are. The RCM’s Protect Maternity Services campaign and its annual State of maternity services reports have largely succeeded in deflecting the spending axe from maternity care; midwife numbers and student midwife numbers are up, for instance, while nurse and student nurse numbers are both down. We could simply ask for that to continue. Or maybe we could come up with some brilliant new idea. Do you have any thoughts? Maybe there is something happening in Scotland, Wales or Northern Ireland that we should roll out in England? Let me know what you think and email me at: Stuart Bonar RCM public affairs advisor

06/03/2013 09:59



Headlines Work life / Amy Leversidge

CALL THE 70-YEAR-OLD MIDWIFE? Amy Leversidge looks at the implications of the increased pension age and the prospect of a longer working life. WE ALL KNOW THAT PEOPLE are living longer, and the NHS is at the front line of providing care to an ageing population, but what will happen as the NHS workforce starts to age and staff have to work longer to receive their full pension? Some NHS staff work longer at the moment because they choose to, but how will the NHS cope when the whole workforce is working longer? In the 2015 NHS pension scheme the normal pension age will be equal to a member’s state pension age (apart from all those members who were within 10 years of their retirement age on 1 April 2012 as they are protected). That means that the normal pension age in the NHS will keep increasing as the state pension age increases. Members can retire earlier than their state pension age but their pension will be reduced for every year they go early. Currently, members who are born after 1961 have a state pension age of 67 and those born after 1978 have a state pension age of 68. The final pensions agreement included a review into the impact of working longer on both the workforce and the service the NHS delivers. According to the latest data from the Office for National Statistics, life expectancy at birth for men and women is at a record high and increases in lifespan are projected to continue (Pensions Commission, 2005). In 2010, men living in England and Wales died on average aged 85, while for women the age was 89. Over the last 50 years (1960 to 2010),

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the average lifespan has increased by around 10 years for men and eight years for women. In 2005, the Pensions Commission recommended that the state pension age should rise broadly in line with increases in life expectancy. It is projected that by 2060 there will be over 18 million people in the UK who are older than state pension age (ONS, 2011). In addition, the ratio of people in retirement to the people working is declining. Currently, there are 3.4 people aged 20 to 64 for every person aged 65 and above; by 2050 this will have fallen to 2.2 people (ONS, 2011). This is important because it is the current workforce that pays for the pensions. As life expectancy continues to increase, the government believes there is a need for a more structured framework within which to consider changes to state pension age in the

future. In the recent white paper The singletier pension: a simple foundation for saving, published by the Department for Work & Pensions (DWP), the government set out that it intends to carry out a review of state pension age every five years, with the first review taking place in the next parliament. The review will seek to provide a minimum of 10 years’ notice for individuals affected by changes to state pension age. When the new NHS pension scheme starts in 2015, it will result in NHS staff working longer, with an automatic increase in pension age if and when state pension age increases. The final pensions agreement included a review into the impact of working longer on both the workforce and the service the NHS delivers. The RCM is one of the trade unions represented on the review.

→ The 2015 NHS pension scheme dictates that the normal pension age will be equal to the state pension age 06/03/2013 10:04

The purpose of the review is to gather and examine evidence to determine the impact of the whole workforce working to state pension age and the impact on the delivery of health care to patients and clients. We need to identify any categories of worker for whom an increase in normal pension age would be a particular challenge in respect of their health and wellbeing. The review group will look at positive employer practices and behaviours that support the development of age diversity practices in the NHS and to determine the scope of pension scheme design flexibilities to support staff working to state pension age and in particular support flexible retirement. The review group will examine existing evidence about the ageing workforce, what the challenges are and what strategies employers can put in place to support the extension of working lives. There is a significant amount of research that has already been undertaken in this area.

In January 2013, the DWP published Fitness for work: the government response to ‘Health at work – an independent review of sickness absence’ in which it said: ‘As the workforce ages, an increasing number of employees will be managing long-term health conditions. This means that the way we support employee health will become increasingly important, both at work and in terms of better management of chronic health conditions.’ The NHS health and well-being review, conducted by Dr Steven Boorman and published in 2009, identified and recommended good practice to employers. It encouraged NHS organisations to develop and implement strategies for actively improving the health and wellbeing of their workforce and particularly for tackling the major health and lifestyle issues that affect their staff and workforce. The Boorman review also recommended


8 YEARS THE AVERAGE INCREASE OF LIFESPAN FOR A WOMAN OVER THE LAST 50 YEARS (1960 TO 2010) that early intervention programmes should be routinely available in all trusts for illnesses and injuries that are common in the NHS, which are suitable for effective early treatment and liable to result in long-term or recurrent absence if not treated quickly. These will include musculoskeletal disorders and mental health conditions. The Working Longer Review is already underway and we are hoping to conduct a survey of trade union members during the period of the review to gather evidence and views on working longer and on what employers can do to make it easier for staff. Here are some questions to consider: ► Do you feel there are particular categories of worker for whom an increase in normal pension age would be a particular challenge in respect of their health and wellbeing? ► Do you think there are particular challenges with regards to service delivery? ► What practices do you think employers can put in place to make it easier for NHS staff to work longer? ► If you have recently retired, or are coming up for retirement, is there anything that your employer could have done to encourage you to carry on working for longer? If you have any views on this, please email: Amy Leversidge RCM employment relations advisor

Illustration: Marta Slawinska

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For references, please visit the RCM website.

06/03/2013 10:04

The Royal College of Midwives Annual Event 2013

and Zepherina Veitch Memorial Lecture

Thursday 13 June 2013 s 12:45 pm – 4:00 pm The Scottish National Gallery s Edinburgh

The Zepherina Veitch Memorial Lecture Dr Helen Cheyne RCM Professor of Midwifery and Professor of Maternal and Child Health, University of Stirling

Professor Cathy Warwick CBE RCM Chief Executive The Annual Address to RCM Members Presentation of RCM Honorary Fellowships

All RCM members are welcome at this free event, but places are limited. To ďŹ nd out more and book your place please visit

MID13.Issue2.022.indd 1

05/03/2013 12:54



Thoughts, views and your feedback

Opinion Dave Cunningham / One-to-one

At the coalface


Dave Cunningham tells Rob Dabrowski about his unconventional career change from miner to midwife and his thoughts on being the only man in Scotland in a ‘female profession’. »

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06/03/2013 10:05



Opinion One-to-one / Dave Cunningham

“A few people don’t want a male midwife, but I know it’s nothing personal, it’s just what they want for their birth. I just treat them nicely and go and get them a female midwife”


ave Cunningham was 17 years old when he went to work down the mines. The UK was dragging itself out of the 1970s’ recession, the economy was in tatters and jobs were few and far between. ‘I worked in the mines for about four years after school,’ he says. ‘There wasn’t a lot else about at the time and the opportunity came up, so I just took it. I did it for a while, but I wasn’t very good at it, and it was never something I’d planned to do, it just sort of happened.’ Now Dave is a midwife. To be more exact, he’s Scotland’s only male midwife. If you had to pick one man from the country’s 2,567,000 male population, it’s unlikely Dave would be top of the list – he calls himself ‘a man’s man’ who likes going to the pub, watching football,

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playing golf and has ‘never cooked a thing’ in his life. But while working at the Polkemmet Colliery in Scotland, he got his first taste of health care, which would inspire him to retrain as a midwife, since which he has never looked back. ‘I was asked if I’d be in the colliery first aid team and I started taking part in first aid competitions,’ Dave tells Midwives. ‘We were competing with first aid teams from all over the country and I became the Scottish champion. You wouldn’t know what you were going to be tested on in advance – it could be an unconscious person or it could be someone bleeding severely.

I don’t think we ever had to deliver a baby though,’ he laughs. But now, 53-year-old Dave has delivered hundreds of babies after working as a midwife for 25 years. He is currently a community midwife team leader for West Lothian, based at Fauldhouse Medical Centre, and splits his time between being a day-to-day midwife and a manager. ‘It was always my plan to work for a bank, actually,’ he says. ‘Then I ended up being a midwife, whereas when my wife was younger, she wanted to be a midwife and got a position being a bank manager – so we ended up working in each other’s jobs.’ Until recently, Dave was not the only male midwife in Scotland; a few years ago there were half a dozen men scattered around the country practising the profession. But now, while there are two men working in neonatal in Scotland, he is a lone male midwife in a woman’s world. ‘I’m the only man out there actually delivering babies. I was quite surprised by that,’ he says. ‘I think the reason that I like being a midwife is that I am helping normal, young, healthy people. I work in the community and I love the fact that I can provide care at every step of the way and there’s just so much satisfaction in delivering a healthy baby.’ He adds: ‘My friends found it


All about Dave ► Worked at Polkemmet Colliery in West Lothian, which produced 4000 tonnes of coal a day in its prime

► Has two children, Donna and Paul, both of whom were born before he was a midwife

► Carries out all the same duties as his female colleagues, including breastfeeding workshops

► Knew midwifery was the profession for him one month into his training at a maternity ward in Glasgow

► Has had a few children named after him, usually following home births

► Attended the christening of one baby he had delivered

► Is often requested for subsequent births of mothers whose babies he has delivered.

06/03/2013 12:02


Dav C Dave Cunningham (pictured) is Scotland’s (picture male midwife only ma

at first and they still joke about quite strange t it even now, years on, but I’m easy-going and never let the jokes get to me.’ While Dave’s friends find his choice of career unusual, he has come across very few women that have a problem with a male midwife. ‘I think I’ve had less than 10 women who haven’t been happy about having a male midwife – most women are absolutely fine with it,’ he says. ‘A few people don’t want a male midwife, but I know it’s nothing personal. It’s just what they want for their birth, so I treat them nicely and go and get them a female midwife.’ In fact, Dave sees his unique position as a benefit, rather than a disadvantage. The self-professed ‘man’s man’ believes he can connect with fathers-to-be in a way that may not be possible for his female colleagues. He goes on to tell a story about a father who wasn’t willing to witness the births of his

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first two children. ‘We had a talk about it, I persuaded him and he actually came in for the labour and birth of his third child,’ smiles Dave. ‘He said that he just wished he had been there for the other two. I think men miss out if they don’t try it. And I think men can be more comfortable with me, in the respect that they feel they can ask me things that maybe they couldn’t ask a female midwife.’ Getting men more involved in the birth of their children is something he is passionate about. ‘You see the men come in with the women and it’s more of a partnership now; they need to be involved and it’s good that they are. Having more men involved in birth can only be positive – it is an experience that you don’t get to go through many times as a parent and I don’t want men to miss out on that.’ Dave feels lucky to be one of the few men in Scotland to have been involved in the

experience of birth so many times. ‘There have been a lot of incredible moments over the years, it’s hard to pick a single highlight,’ he says. ‘Every moment is special and I just get so much pleasure from meeting and helping people.’ But now he’s in his fifties, how much longer does Dave want to fly the flag for men in maternity services? Are we soon facing a Scotland without a single male midwife? ‘I’ll be a midwife until I retire,’ he proudly states. ‘I’m 53 years old now, and I’ll carry on until I’m 60 years old, so I’ve got at least another seven years to go.’ What then? After spending the last quarter of a decade bringing new life into the world, how will Dave cope with leaving the profession he loves so much? ‘I think that I will miss it,’ he sighs. ‘I don’t switch off; I’m always thinking about it because it is a 24-hour-a-day job and I think it’ll take me a while to get used to not being a midwife. ‘I’ve got good friends who have retired and they miss working. I don’t think they miss the stress, but they do miss the job, and I think it will be the same for me. It is a wonderful job, and it would be very sad if Scotland had no male midwives at all.’

06/03/2013 10:06



Opinion On course / Julie Bambridge


ooking back on my training, I can see an interesting pattern of learning developing. The first year was all about exploring the philosophy of being a midwife, and it seemed like we had all the time in the world. The second year brought the complications and a drastic shift in workload – the more we learned the less we knew, but there was still the knowledge that we had time on our side and the support of our mentors. I’m now in my third year and qualification is fast approaching. I have become more comfortable with providing midwifery care and I’m looking forward to clinical practice and supporting women. But now there is a different sort of learning to contend with – one that I have found difficult to quantify – and it involves politics. I am becoming more aware of the world of midwifery that extends beyond the places in which we care for women to the organisations that decide how, where and when we provide care, the groups fighting

A BROADER VIEW Is the perception of midwifery complicated by politics? Julie Bambridge urges students not to be daunted. for change and the intentions of the government. As I thought about qualifying, it occurred to me that I will be working for an employer, namely the NHS, and I needed

→ Don’t be afraid of politics – take the plunge and discover a new dimension of midwifery 026-27_MID_Oc_Course-Feedback.indd 26

to understand how it works and what its structure is. I had previously put this off because I was scared of being sucked into a world I would struggle to understand, and then the Francis report came out. I tried to read it and soon realised that the jargon around the NHS needed to be conquered. After some internet research, I had an overview of the current primary care trusts and strategic health authorities, as well as an insight into the new structure due to be launched in April (NHS Choices, 2013). I then took the plunge and looked at some of those ‘must-

find-time-to-read’ reports, starting with the RCM’s State of maternity services (RCM, 2013). I was soon up to speed with what has been happening in midwifery staffing in the last few years. I moved on to Innovation and improvement in maternity services (RCM, 2012) and found some fascinating case studies of projects in other trusts. Having read Midwifery 2020 (DH, 2010) from start to finish, I found that I could understand the impact on maternity services. I reflected on my attitude to these reports and realised I had always considered them to be written for managers and policymakers, not your average student midwife. Instead, I felt welcomed into a world in which people are working to make changes for the better and are simply letting us know what is going on. This isn’t an elitist group of academics and politicians, but real people who want us to engage with them and get involved in shaping the future of midwifery. I am looking forward to the day when we, the next generation of midwives, can contribute to the evolution of the midwifery service women deserve. Don’t be afraid of politics – take the plunge and discover a new dimension of midwifery. Julie Bambridge Student midwife Edinburgh Napier University For references, please visit the RCM website.

06/03/2013 10:07



Send your comments by email to: emma@midwives. (the editor reserves the right to edit letters)

Have your say / Feedback

We’ve got


Midwives thrives on your letters and emails. Here is a selection of the ones that caught our eye this issue. — G IN CRACK R LETTE —


I think Call the Midwife is the most wonderful TV programme I have watched. The BBC has captured the happiness and the sadness that our job brings, and it’s such a shame Jennifer Worth didn’t live to see her stories come alive. At a time when you often wonder whether this was the right career choice, it reaffirms that being a midwife is the most wonderful job in the world. Eithne Harte Senior midwife

SISTERLY LOVE I have been working as a midwife for five years and as a community midwife for almost two. In September it will be a decade since I became a student midwife, which has led me to

reflect on the changes I have seen in the midwifery hierarchy over the years. Instead of leadership coming from a sister to midwives – a matriarchal, no-nonsense, reassuring presence who would roll up her sleeves and come to our aid in times of trouble – we have the charge midwife. It seems that her role is, quite literally, to charge around ensuring staff have completed their mandatory training, annual appraisal and biannual clinical supervision. Ticking boxes is top of the agenda, with electronic evidence for everything. This kind of manager could be likened to a football club manager; they may have been a player once but have carved a career in talking a good game, often shouting orders from the bench. While sisters are not extinct, they are depleting in number. As maternity leadership shifts

CRACKING CORRESPONDENCE WINS... FEEL PASSIONATELY ABOUT AN ISSUE RAISED IN MIDWIVES OR WITHIN YOUR CLINICAL PRACTICE? Then email us your thoughts. The next cracking correspondence wins Your pregnancy companion. Your letter will be published if you win!

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focus towards bringing strategic change, with more value being placed on academic achievement and striving for targets, I wonder who is left to support and motivate the workforce. While we spend our days meeting the needs of women, surely every so often it would be fair that our management should, in turn, meet the needs of midwives? Name and address supplied Editor’s note: If you’re a midwifery manager, what is your take on this? What challenges do you face in striking a balance between professional accountability and corporate responsibility? Please get in touch and send your views to:

RELIGIOUS EDUCATION I would strongly recommend that all heads of midwifery and maternity services invite the Jehovah’s Witness Hospital Liaison Committee (JWHLC) within their regions to give a presentation about the beliefs, care and treatment of pregnant women who are Jehovah’s Witnesses to all midwifery and

medical staff within their units. We have invited our local JWHLC to present at our audit meeting for the past two years and the feedback from both midwifery and medical staff has been excellent. Such is its success that it now presents to many other departments within our trust. They are also included in the newly qualified nurse induction programme and now present to the medical students at the local university. Unfortunately, I am informed that a number of JWHLCs throughout the country have been refused access to present to maternity services upon request to do so. This is extremely regrettable as all midwives should be caring for pregnant women with specific religious beliefs using the most up-to-date and evidence-based practice, which they surely won’t have if the appropriate knowledge is not disseminated to them in the first place. Sharon E Smithson Matron/SoM Does your trust educate staff about caring for women with specific religious beliefs? Join the conversation at:

06/03/2013 12:47



Opinion RCM Communities / Latest discussions

Are you involved? Members have been discussing all things midwifery. Why not create a profile and have your say?

LINKS To post your response to this discussion, please visit: ABORTION SCENE CONTROVERSY

If you have a topic to raise or need advice from fellow RCM members, join the conversation at:

ABORTION SCENE CONTROVERSY Call the Midwife caused controversy recently with an illegal backstreet abortion scene. The broadcasting watchdog OFCOM received a number of complaints from members of the public who were angered at the content. There were claims that the hardhitting scene was ‘disgusting’ and ‘gross’, but some praised it for its imaginative editing. What did you think? Was it a step too far, or great television?


LATEST BLOGS ► Women in the UK are still denied the legal right to breastfeed at work. This needs to change, argues Amy Leversidge. ► A midwife blogs about her plans to hike up Ben Nevis for a worthy cause – the Genesis Research Trust. ► The RCM’s Stuart Bonar looks at the latest birth figures for the UK, which show yet another rise in England, and their implications.

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As a midwife, I can appreciate that while this is a very serious and gruesome matter, the BBC has depicted it in as mild a manner as possible. The public health education value of the scene is undeniable and, as a parent, I would be expecting a programme such as this to show some harsh realities of poverty and medical scenes that may prove uncomfortable to watch. I have certainly seen the soaps depict far worse messages (not that I am a fan of soaps in the slightest) and would rather something of worth, such as this, is shown. POSTED BY: A rotational midwife


I’m a Call the Midwife fan – I think it’s great Sunday evening entertainment. From the reviews I’ve read I think the poor writers can do no right. The programme has faced criticism in previous weeks for painting too much of a ‘rosetinted’ view of 1950s east London, then when it dares to do something controversial, like the

abortion storyline, it’s seen as too shocking for pre-watershed TV. Viewers can’t have it both ways, I’m afraid. POSTED BY: An RCM Communities member


I think it covered a controversial subject well. Illegal abortions occurred. POSTED BY: A birth centre midwife


As a fan of the books, especially the beautiful prose that Jennifer Worth used to depict the East End of the 1950s, I was pleased by the choice of this particular theme. I was getting slightly frustrated by the ‘jolly hockey sticks’ outlook. I thought this was nicely handled; an important reminder that poor women faced many unplanned pregnancies, as well as the bizarre decision by the newly founded NHS not to provide family planning freely. While I understand that some people do not share my morals, it is important to remember that health care should be equal and non-discriminatory. Provision of abortion and family planning was hard-won, so it is only right that we remember that not so long ago health care did not meet everyone’s needs, driving women to commit a crime, which in some cases proved fatal. Anyone who watched Toughest place to be a... Midwife will remember the terrible scene of the young woman who suffered fatally after a botched home abortion. I applaud the BBC for being brave enough to tell this (sanitised) story.  POSTED BY: A rotational midwife

06/03/2013 12:03


Tweetdeck A look at what you’ve been tweeting Who’s talking about us on Twitter and what are they saying? Follow us at:

When will the government listen? England urgently needs more midwives to ensure continuity and normality. LISTEN to @MidwivesRCM! #soms2012 From: @radical_midwife

Wow, well done to our healthy lifestyle midwives who won the innovation prize at this year’s @MidwivesRCM national awards! From: @DBH_NHSFT

@MidwivesRCM sad that it’s my last SMWG meeting today but excited for the continuing & new members’ voices for student midwives in the UK :) From: @saundersmaddie

@MidwivesRCM I hope that when I become a midwife I am as amazing as everyone that has won an award! #blessed #dream From: @Charlie_Leesing

Love waking up to a surprise parcel from @MidwivesRCM #nutritioninpregnancy #midwifery #littlethings From: @LibbellaRose

@MidwivesRCM I wonder why midwifery depts find it acceptable to do BPs in waiting rooms. I’m getting fed up of refusing it & hate attending! From: @Jade_SmithGPPA

How irresponsible is Groupon selling dopplers again? Where is the regulation of these monitors? @MidwivesRCM From: @kylie13

Bedtime reading of @MidwivesRCM magazine before a 12-hour shift #dedicatedmidwife From: @lauraduffield21

Do you have a Twitter account? If you do, why not follow your professional organisation and keep abreast of the RCM’s latest news?

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06/03/2013 12:04

t RCM ed

t RCM ed


BOOK YOUR PLACE NOW for the only UK Conference by Midwives for Midwives


This year the Royal College of Midwives Annual Conference will take place in the West Midlands at the Telford International Centre – bringing the heart of midwifery to the centre of the country. Over one thousand midwives and student midwives from across the UK will come together at the conference to discuss and debate the hot topics that are crucial to the profession. Speakers are set to include senior politicians, international and UK midwifery and maternity experts and leading thinkers in health policy. This is the midwifery professional and trade union conference led by midwives for midwives.

Call 020 7324 2771 for more details, or book your place at:

“I am delighted to see that our conference will be in Telford. It is such a good location for people from across the country to reach, and the Centre is a wonderful state of the art venue for the conference. I hope to see many midwives there in November.” Cathy Warwick, chief executive of the Royal College of Midwives

RCM i-learn

RCM i-folio

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05/03/2013 12:55

Abstract entry process is now open – don’t miss your opportunity to speak at this year’s conference: The abstract submission process is your opportunity to help shape some of the conference content. This is your chance to share your ground-breaking research, practice innovations and projects with your profession. Put forward your abstract for selection for a presentation in a concurrent session and or a poster.


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Topics for submission include: O

Women’s Experience


Safety and Quality


Research and Education


Skill Mix and Partnership Working


Innovation in Practice

Submit your entry now at

13-14 November 2013 West Midlands

05/03/2013 12:56

RCM Communities

It’s an online member benefit and a first for the RCM. Are you an RCM Communities member? No? Why not log on, create a profile, join a group or two and get involved? Originate and contribute to discussions, read the latest blogs and vote on the most recent polls… There’s information on the consultations affecting maternity care too – so why not leave your thoughts? If you have any problems or need some support, then please contact Midwives editor and RCM Communities manager Emma Godfrey-Edwards at: HTTP://COMMUNITIES.RCM.ORG.UK

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06/03/2013 10:09



Current and completed midwifery research

On focus Jan Wallis / Cutting edge

Maternal and fetal risk factors for stillbirth PAPER Maternal and fetal risk factors for stillbirth: population-based study. AUTHORS Gardosi J, Madurasinghe V, Williams M, Malik A, Francis A. PUBLICATION British Medical Journal 2013; 346: f108.

OVERVIEW ► The overall stillbirth rate was higher in mothers who smoked. ► Improved surveillance of fetal growth is necessary.

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he objective of this study was to assess the main risk factors associated with stillbirth in a multi-ethnic English maternity population of 92,218 normally formed singletons, including 389 stillbirths, from 24 weeks’ gestation, delivered during 2009 to 2011. The data were derived from 19 maternity units in the West Midlands. The stillbirth rate was 4.2 per 1000 births. Stillbirth rates were increased in first as well as third and subsequent pregnancies, compared with second pregnancies, and in mothers of African, African-Caribbean and South Asian ethnic origin. First-generation migrants had an overall higher risk of stillbirth. Maternal age differences were not significant, but social factors were. Preeclampsia and antepartum haemorrhage were strongly associated with stillbirth, whereas gestational diabetes was not. Obesity, lack of antenatal folic acid and booking after 13 weeks also presented an increased risk. The strongest factor was fetal growth

restriction (FGR), with a relative risk of 4 (95% confidence interval 2.8 to 5.7) when FGR was detected antenatally, doubling to 8 (6.5 to 9.9) when it was not detected. The overall stillbirth rate was higher in mothers who smoked (5.8 versus 3.8 per 1000 births), showing the strong interaction between smoking and FGR. However, the risk of stillbirth in pregnancies without FGR was similar to that where the mother did not smoke. During the study period, antenatal detection of FGR was 31% overall and higher in pregnancies where the mother smoked. Just over half of the stillbirths occurred after 34 weeks’ gestation. The study shows that the single largest factor for stillbirth is FGR. The researchers state that this is not currently well predicted or recognised antenatally in most pregnancies and that the findings indicate the importance of improving strategies for improved surveillance of fetal growth throughout the antenatal period. Jan Wallis Retired midwife and senior lecturer

→ Fetal growth restriction was the strongest factor for stillbirth 06/03/2013 10:10



On focus How to... / provide postnatal perineal care

— .. O. HOW T —

...provide postnatal perineal care Debra Bick and Sam Bassett examine the best way to manage postnatal perineal trauma and pain.


ost women who have a vaginal birth will sustain perineal trauma, which can range from bruising, an uncomplicated first- or second-degree tear, to a more complicated third- or fourth-degree tear or episiotomy. Women who have a second-degree or more severe tear or an episiotomy should have had their wound sutured following appropriate assessment and evidence-based management (NICE, 2007; RCOG, 2007; Kettle and Tohill, 2013). Details of the perineal trauma sustained, including information on the type of repair and where the wound is sited, should be discussed with the woman, as this will enable her to more effectively manage and monitor her own recovery. On transfer to postnatal care, all women should have an individualised care plan, developed with their midwife (NICE, 2006). A core component of postnatal care includes routinely asking women about perineal pain or other discomfort they may be experiencing, with regular observation and

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examination of the perineal area to assess progress with healing (NICE, 2006). It is essential to ensure this observation is as thorough as possible, with the woman in a comfortable position to enable the perineum to be easily viewed. All women should be offered advice on how to care for their perineum, including information on signs and symptoms of infection, which require immediate medical referral. This information should be offered within 24 hours of birth (NICE, 2006). In the first few days post-birth, women should avoid prolonged sitting or standing and encouraged to use appropriate maternity sanitary pads, which will be softer and prevent friction on perineal wounds. Women should be advised of the need to change their pads regularly during the day, washing their hands well before and after changing pads, and bathing or showering regularly to keep their perineal area clean. With optimum wound healing now known to occur in a moist environment (Boyle, 2006), practices such as advising women to

dry their perineum with a hairdryer should be discouraged. Details of who to contact if women have concerns about their perineum should be included in their care plan. Advice on a diet, with plenty of fluids, vegetables and fruit rich in vitamin C, may prevent constipation and could support wound healing, although evidence of benefit is needed. Women anxious about opening their bowels may feel more comfortable if they support their perineum just in front of their rectum with some clean tissue or a clean sanitary pad while gently pushing to open their bowels. Two to three days postpartum, or when a woman feels comfortable, the midwife should encourage her to start pelvic floor muscle training (PFMT), ensuring they are familiar with the correct technique and importance of long-term adherence. There is some evidence that, for women having their first baby, PFMT during and after pregnancy can prevent urinary incontinence up to six months postbirth (Boyle et al, 2012). PFMT may reduce symptoms among women who develop urinary incontinence post-birth and, in some cases, those who develop faecal incontinence, although effects are less clear in the long term for this symptom. Many women will be concerned about resumption of sexual intercourse. Intercourse should be resumed when women feel comfortable, which for some may be within two to three weeks of birth, but for others it could be later. It is important to offer advice on the use of contraception to all women (NICE, 2006).

Pain relief When planning a woman’s postnatal care, the midwife should note if she has risk factors for perineal pain, which include instrumental birth, perineal trauma and primiparity. At each contact, midwives should ask women about their experience of perineal pain and, if appropriate, offer advice on its management. If women continue to experience problems, midwifery contact may need to extend beyond 10 to 14 days postpartum. Macarthur and Macarthur (2004) reported that 7% of the 444 women in their study had perineal

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(Johnson et al, 2012). Some 39 (11%) of 341 women who were followed up at 21 days post-birth had a perineal wound infection as defined using two markers of infection, while 16 (5%) had all three markers. Significant risk factors included prolonged rupture of membranes and instrumental delivery. Midwives should pay particular attention to advising women with these risk factors on wound management and instigate prompt observation of perineal wounds for possible infection and dehiscence if women report any concerns about pain or perineal recovery.


Third- and fourth-degree tears

pain six weeks after giving birth. As well as pain, some women may experience other persistent symptoms, including dyspareunia (difficult or painful sexual intercourse). For most women, paracetamol will be the first line of pain management; however, women who have more severe trauma may require stronger analgesia. If a woman is unable to tolerate oral analgesia, for example if she is experiencing nausea and vomiting, an alternative, stronger analgesia may be required. Rectal suppositories were associated with reduced perineal pain in the first 24 hours post-birth and less need for additional analgesia in one Cochrane review (Heydayati et al, 2003). Many midwives will advise women to use topical applications to relieve perineal pain. Some may be more commonly used than others (for example, ice packs) – these can be administered by the woman herself. However, not all applications including local anaesthetics such as lignocaine spray, gel or cream will provide an appropriate level of pain relief (Hedayati et al, 2005).

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Non-pharmacological preparations can include cool gel pads, ice packs and bathing. While some women may prefer to use cool gel pads, there is limited evidence of the overall effectiveness of these to relieve pain (East et al, 2012) and women may need to combine the use of topical applications with analgesia. The length of time for which an ice pack is applied to the perineum is unlikely to influence the severity of pain (Oliveira et al, 2012).

Perineal wound infection Early detection of perineal wound infection is an important part of the midwife’s postnatal role. Evidence on the incidence and prevalence of perineal wound infection is limited, since information has often been collated as a secondary outcome in studies of perineal management (Kettle et al, 2002). A prospective audit of women in one English unit who had sutured perineal trauma over a three-month period aimed to identify infection using markers including pain, wound dehiscence and purulent vaginal discharge

Midwives caring for women who have sustained severe perineal trauma need to ensure their care optimises the outcomes of immediate surgical management. Although evidence from large clinical trials is not available, best practice recommends that women are prescribed broad spectrum antibiotics and prophylactic laxatives (lactulose or fybogel) for around 10 days post-birth to prevent wound infection or possible wound dehiscence (RCOG, 2007). RCOG guidance (2007) also recommends that women are offered physiotherapy and PFMT for six to 12 weeks after obstetric anal sphincter repair.

Haematoma Haematoma may occur in the vulval, vaginal or sub-peritoneal areas and is extremely painful. Although an infrequent complication, with an incidence of between one in 500 and one in 900 pregnancies (Ridgway, 1995; Villella et al, 2001), midwives need to be vigilant to signs and symptoms of haematoma among the postnatal women they care for, ensuring the whole perineal area is observed, as haematoma may be obscured or missed if detailed examination is not undertaken. Debra Bick Professor of evidence-based midwifery Sam Bassett Lecturer, King’s College London For references, please visit the RCM website.

06/03/2013 12:04



On focus EBM / March 2013

The latest research Evidence Based Midwifery is the RCM’s quarterly journal featuring in-depth research. Here is the summary of contents from the most recent issue – March 2013. substance misuse in pregnancy and recommends a specific teaching programme.


The ‘z generation’: digital mothers and their infants

Normal birth and its meaning: a discussion paper

Marlene Sinclair

Claire Clews

An editorial about how technology has permeated every aspect of modern life, including pregnancy and birth. The author looks at the concept of the ‘z generation’ and mothers-to-be who use social networking and digital resources from the moment the pregnancy is confirmed, until the arrival of the baby.

Using Foucault’s concept of power and knowledge, this research looks at how growth of authoritative knowledge and dominant discourse associated with medicine in the 20th century has transformed society’s view concerning ‘normal birth’. Discussion is placed within the context of recent NICE guidelines, published in 2011, which afford women a choice of CS birth in the absence of clinical need.

Recognising stressors and using restorative supervision to support a healthier maternity workforce: a retrospective, cross-sectional, questionnaire survey

Issues for consideration by researchers conducting sensitive research with women who have endured domestic violence during pregnancy

Sonya Wallbank

Kathleen Baird and Theresa Mitchell

This paper investigates the impact on the midwife of caring for families experiencing miscarriage and neonatal death. Following a randomised controlled pilot study, which looked at the effectiveness of offering restorative supervision to midwives, the paper explores the latest evidence of the restorative programme designed to reduce stress, burnout and improve compassion satisfaction and how this can be used to support midwives.

The authors provide a description of the process of conducting sensitive research using a framework for good practice applied to an actual research study. Data were collected from a qualitative sample of 11 women who had been pregnant in the previous two years and the data were subject to thematic content analysis. The paper concludes that researching violence is a high-risk activity for both researcher and participant.

A survey of midwives’ attitudes towards illicit drug use in pregnancy

Midwives’ experiences of home birth transfer Marion Wilyman-Bugter and Thelma Lackey

Lucy Jenkins ► RCM members have free access to EBM and the full archive online. To subscribe to the hard copy, visit:

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Midwives’ attitudes towards caring for pregnant drug users are the focus of this study. The author examines the relationships between midwives’ attitudes, experience and formal education in caring for women who abused drugs. The paper finds that there is a need for midwives to develop their knowledge and skills in working with

Midwives’ experience of home birth transfer from a planned home birth to an obstetric unit is looked into here. The authors highlight the necessity for a home birth protocol, which reinforces appropriate action with regards to transfer. This needs to include a strategy for dealing with parents who oppose transfer, and a procedure for prompt handover of care to an obstetric unit, they state.

06/03/2013 10:11



In-depth midwifery reportage and articles



Why y women are waiting for moth herhood »

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06/03/2013 10:11




The E rise of the middleaged mother Every year, the age at which women give birth increases, while the number of mothers over 40 has shot up in the last decade. Why are women waiting, and what is the impact for maternity services? Rob Dabrowski investigates.

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lizabeth Adeney hit the headlines when she became the oldest mother in the UK. At the age of 66, her son was conceived through IVF, delivered by caesarean (CS) and born into a media storm. After being turned away by private clinics on UK shores, the divorced, wealthy managing director flew to the Ukraine for fertility treatment, after which her son Jolyon was born early due to complications. While she was reluctant to discuss her pregnancy, the world was not, and debate raged everywhere from the internet to the radio to the broadsheet newspapers. Stories such as Elizabeth’s are extremely rare but are also extreme examples of an emerging trend – the rise of the middle-aged mother. Every year, the average age at which women give birth increases. It hasn’t been rocketing, but slowly and steadily inching up by just over a month every year since the early 1970s. In 1974, the average age to give birth was 26.4 years, while statistics for 2011 show the figure standing at 29.7 years (ONS, 2013). Next year, more children in England and Wales are expected to be born to mothers over 30 than under, for the first time. The most recent figures, which cover 2011, show the number of children born to mothers over 30 was 49% and it is set to have crept up to 50% by the time the figures for 2012 are released (ONS, 2013). ‘The overall rise since 1973 reflects the increasing numbers of women who have been delaying childbearing to later years,’ says an ONS spokesperson. ‘Possible influences include increased participation in higher education, increased female participation in the labour force, the increasing importance of a career, the rising opportunity costs of childbearing, labour market uncertainty, housing facts and instability of partnerships.’ But what are the implications of older motherhood for our maternity services and resources? Louise Silverton, RCM director for midwifery, states that older women may have a higher risk of complications, and she believes

06/03/2013 12:05


they are likely to ‘get more involved in their care’, tend to ‘want longer antenatal visits’ and their expectations are ‘often very high’. While this may take up more time and resources, she sees no problem with the increase. ‘I think 30 seems like a good age, because women are likely to have a higher degree of maturity,’ she says. ‘From an ideal physical point of view, the best age might be 22 years old, but I think it’s best to have a balance between optimum physical health and security, stability and maturity.’ Danny Dorling is a professor of human geography at Sheffield University who has published papers on the social and economic reasons why women delay childhood. He tells Midwives that the UK population is divided on the issue. ‘Until the massive expansion in university education, you couldn’t guess social class by the age of a child’s mother,’ he states. ‘If we look at the 1960s and 1970s, almost all women chose to have their children at the same time – in their 20s – and that is what was expected of them. ‘But that changed when more women started going to university and having professional careers. Since then, the generation of women has divided into two: those who go to university and don’t start families until they are in their mid to late d 30s and those who don’t go to university and have children in their 20s.’ He adds: ‘Our grandparents used to talk about how not to get pregnant, but now people are more n likely to discuss how to get pregnant – it’s an incredible social change from grandparents to grandchildren.’ Lowri Turner, journalist, broadcaster and mother of three, had her children between the ages of 35 and 42. ‘I spent my 20s going to university and building my career,’ she says. ‘By the time I was ready for children I was in my late 30s and I think it’s the same for many women – if they are reasonably well-off, they want to enjoy their freedom. ‘I was in an exciting job, enjoying my

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independence and it would have been upsetting to sacrifice that to have children. I think the trend will continue because women want to enjoy life before they have babies – we’ve become used to choice and aren’t willing to be barefoot and pregnant at 16 anymore.’ With the birth of her third child, Lowri joined an ever-growing group of women – those over 40 having children. While the rise in the average age women give birth has been slowly creeping up, the increase in births to women over 40 has been meteoric in comparison, and has shot up by more than 80% in England over the last decade, with statistics for the rest of the UK following suit (RCM, 2013). Looking at the age profile of mothers in the RCM’s latest State of maternity services report, this group has seen the biggest rise by far. It is followed by an increase of just


over 30% in mothers aged 35 to 39, while the only demographic to see a drop is teenage pregnancy, which was down by nearly 20% (RCM, 2013). With the likelihood of complications increasing as women approach 40, there’s an increased risk of an instrumental birth. Bearing in mind that the average cost of a CS is £2369 compared to £1665 for a vaginal birth (NICE, 2011), there are not only health implications for mother and baby, but also financial repercussions for the NHS. Professor Helen Dolk, head of the Centre for Maternal, Fetal and Infant Research at the University of Ulster, is behind research analysing mothers who give birth later in life and the risk of congenital anomalies. She tells Midwives that women who give birth later in life have increased risks, including premature birth and lower birthweight. But she stresses that the financial impact on the NHS ››

Children born to older mothers have fewer accident injuries... accidental researchers found that, rese at three years old, the rrisk of unintentional in injury declined from 36.6% for mothers aged 20, to 28.6% for mothers aged 40 m

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of fathers were aged 30 and over in 2011 ›› should not be a factor that influences advising women on the optimum age to a start family. ‘What we need is what’s best for people, not the NHS. The NHS is there to serve us; we are not there to serve the NHS. You would not ask women to have babies earlier because it’s good for the NHS, but because it’s a good thing in itself.’ She continues: ‘Biologically, women should ideally be having children before then, but you need to look at the bigger picture and social dimensions. There are lots of factors, such as career development and childcare costs, so I can’t say whether giving birth later is a good or bad thing for women, but as a society we should do what we can to make having babies earlier easier.’ While, biologically, the ideal age for most women to give birth may be in their 20s, research shows children born to older parents have a range of advantages. ‘Yes, there are of course risks for women giving birth later in life,’ says professor of human development, Edward Melhuish. ‘There are slightly increased risks of chromosomal abnormalities and complications, which are small but cannot be ignored.’ He continues: ‘But if a parent has overcome these risks, then you find that the child seems to show improved outcomes in terms of health and cognitive and social development.’ He adds that this is the case ‘across the social spectrum’ and that the benefits are equally apparent in low and high socioeconomic groups. Professor Melhuish is behind a study of more than 78,000 children, the results of which show that those born to older mothers have fewer accidental injuries, are more likely to be immunised and have fewer social and emotional problems. The researchers found that, at three years old, the risk of unintentional injury declined from 36.6% for mothers aged 20, to 28.6% for mothers aged 40, while hospital admissions dropped from 27.1% to 21.6%, respectively (BMJ, 2012). 

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of all live births were to mothers aged 30 and over


of babies were registered by parents who were married, in a civil partnership or cohabiting RECENT BIRTH STATISTICS ► In 2011, nearly half (49%) of all live births were to mothers aged 30 and over ► Nearly two-thirds (65%) of fathers were aged 30 and over in 2011 (excluding births registered solely by the mother) ► A total of 84% of babies were registered by parents who were married, in a civil partnership or cohabiting ► The standardised average age of mothers for all births was 29.7 years ► For first births, the standardised average age of mothers was 27.9 years.

But Professor Melhuish stresses that the data only covers the children up to seven years old and there may be negative factors relating to teenagers having elderly parents who aren’t as active. When asked what the ideal childbearing age is, he says: ‘I am hesitant to say. There are good reasons for saying 25 to 30 years old, but a lot of people will not feel that they are settled domestically at that age and will still want to develop their careers. ‘I think that having a career is one of the major factors for the increase in older mothers,’ he says. ‘People used to be able to achieve a stable position at work in their 20s, but now they tend to need more education and training, so they don’t even get into their chosen career until their late 20s.’ He concludes that he doesn’t see an end to the increasing age at which women give birth in the near future. ‘I think it will continue to go up,’ he says. ‘I think we are still looking at another decade of increases before there is any chance of it stabilising.’ With no sign of the age increase abating,

NICE has amended its guidelines to give women who have delayed childbirth until their early 40s the chance to start a family by IVF (NICE, 2013). Tim Child, consultant gynaecologist and director of the Oxford Fertility Unit, was part of the guideline development group and says the decision to extend IVF past the age of 39 for the first time was not taken lightly. ‘When a woman reaches her mid-30s, fertility begins to decline, even more so from her late 30s,’ he says. ‘However, many women do conceive naturally in the 40- to 42-year age group, but for those who can’t, and who have been diagnosed with the medical condition of infertility, then improvement in IVF success rates over the last decade mean that we are now able to offer cost-effective treatment with a single IVF cycle. This decision was taken after considerable discussion and close analysis of the available evidence.’ The guidelines have been broadly welcomed, with most comments very positive, and just a few words of caution. RCOG president Dr Tony Falconer praised the ‘choice for women’ that the move offers, but added that people should ‘still be aware of the increased risks associated with pregnancy at an advanced maternal age’. With the average age at which women give birth – and the number of those in their 40s trying to start families – likely to carry on increasing over the coming years, the trend shows no signs of slowing down. But, while the rise of the middle-aged mother may be with us for some time to come, stories such as that of the old-age parent Elizabeth Adeney, who gave birth at 66, are set to remain extreme examples. For references, please visit the RCM website.

06/03/2013 10:13


Setting the standard With the development of both the Serenity and Halcyon Midwifery Birth Centres, maternity at Kathryn Gutteridge and Helen Giles’ trust was transformed. The RCM award winners explain their vision for normal birth.


ix years ago, maternity at Sandwell and West Birmingham Hospitals NHS Trust was under review following a number of serious incidents. The induction rate was 43%, the CS rate was 37% and there was one woman per week admitted to critical care services. Complaints numbered between 15 and 30 per month.

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A review of practice and clinical outcomes was undertaken to try and find a way forward. The main issues were recruitment, retention and midwives’ attitudes in general. We felt that a birth centre could change all of those things. Within a short time, the trust board agreed funding of £850,000 and a project team was formed to start work on the Serenity Midwifery Birth Centre. The focus was clear – to build a service for low-risk women under the auspices of our vision, ‘your birth in our home’.



We wanted our birth centre to reflect the ‘end-of-life care’ philosophy at the start of life, in order to make the experience as stress-free and comfortable as possible for all involved. Our consultations with families told us they wanted a birthing experience, not a delivery, and one that included all the family. We also felt it was important to have an attitude of celebration in our work. Before the birth centre opened, we encouraged our midwives to think about how women and families prepare for a wedding and to try to apply the same principles. Our first baby was born amid great celebration and her mother even called the little baby girl Sakinah, which is Arabic for serenity. We understand the physiology of normal labour and how a woman’s body works, and believe it is only right that low-risk women stay under our care unless they deviate from that. Our pathway ensures that women are seen through the pregnancy, labour and postnatal period only by midwives. This reduces the risk of interventions and we feel that unless women particularly want an epidural or continuous electronic fetal monitoring, they will benefit from our care. The feedback we have received seems to confirm this. Our complaints total four in the three years we’ve been running, which reflects the satisfaction of the families we have cared for. Our clinical outcomes are also strong, with an overall normal birth rate that is the highest in the UK, according to BirthChoice UK (2011). CS rates now fall between 19% and 25%, induction of labour for post-term women is less than 14% and our VBAC success rates are 68% to 75%. Intrapartum transfers from the birth centre for the first year were 14%, with an overall normal birth rate, for both birth centre and transferred women, of 95%. Waterbirths are now around 67% and the use of pethidine is less than 3%. Overall, we feel the birth centre is meeting our objectives and we will continue to monitor our outcomes to prove it. Kathryn Gutteridge Consultant midwife and clinical lead for low risk care Helen Giles Manager of the Serenity and Halcyon centres

06/03/2013 10:18




Experiencing induction Induction of labour has been widely researched in terms of physical aspects, but few studies have explored women’s emotional experiences. Annabel Jay summarises the key findings of the past 45 years.


nduction of labour is one of the most commonly performed interventions in childbirth, affecting over 20% of all pregnancies in the UK (BirthChoiceUK, 2012). Medical aspects of induction, including pain perception, have been widely researched; however, few studies have explored women’s emotional experiences and expectations of induction. The first major UK studies to explore women’s experiences of induction were undertaken in the mid-1970s, when the number of induced births rose to over 40% (DHSS, 1977). Early studies by Lewis et al (1975) and Kitzinger (1975) found that women lacked information about induction and, consequently, were unprepared for the realities of the experience (Bramadat, 1994). A large study by the Institute for Social Studies in Medical Care conducted in 1975 provided the first wide-scale, systematic assessment of women’s views on induction (Cartwright, 1979). This study, comprising 2400 women from 24 randomly selected areas of England and Wales, found that more than half of the women whose labours were induced believed that they had no choice in the matter and two-fifths of women felt they had received inadequate information (Cartwright, 1979). It is perhaps not surprising, therefore, that induction was associated with an increased

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risk of anxiety or depression compared to spontaneous labour (Cartwright, 1979). Both this survey and Kitzinger’s (1975) work showed the importance of adequate discussion and information beforehand on the perceived quality of the induction experience (Jacoby and Cartwright, 1990). During the 1980s, two further national surveys were carried out by the Institute for Social Studies in Medical Care to survey new mothers’ views on various aspects of obstetric procedures, including induction (Fleissig, 1991). Both studies found that induction was unpopular with women, especially firsttime mothers, even when the overall birth experience was generally satisfactory (Fleissig, 1991). Furthermore, women who underwent induction were more likely to need analgesia and to feel anxious and powerless, and less likely to feel in control of their behaviour or of their treatment by staff (Fleissig, 1991). The importance of the need to feel in control is a theme that recurs in various studies from around the world and may partly explain why, at one extreme, some women choose elective induction without medical reason (where available), while women at the other extreme prefer to let nature take its course and refuse all medical intervention (Fleissig, 1991; Green et al, 1998; Homer and Davis, 1999; Out et al, 1986; Rice-Simpson et al, 2010; Westfall and Benoit, 2004). The majority of women who undergo induction will fall between these two

poles, yet all studies reviewed to date highlight the need for a sense of control, which can be directly influenced by staff attitudes in sharing information and decision-making. A questionnaire-based survey conducted in the UK by Shetty et al (2005) evaluated the expectations and experiences of a group of 450 women undergoing induction, compared

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Women are still


underinformed to a similar sized group who laboured spontaneously. Levels of satisfaction with the birth were lower in the induction group and a significant proportion felt the need for more involvement in the decision to induce. The authors identified a need for better information to avoid unrealistic expectations. Midwives and doctors were cited as the main sources of information (Shetty et al, 2005). These sentiments are echoed in a small New Zealand study exploring the influences on decision-making about induction (Austin and Benn, 2006). The authors conclude that decision-making should be a shared process and that women should be provided with balanced information to aid informed choice. Insights into women’s feelings and experiences in the lead-up to induction are found in two overseas studies. Canadian researchers Westfall and Benoit (2004) interviewed 27 women approaching postterm pregnancy who wished to avoid medical induction. The sample group fell outside the norm of the typical local population, yet the findings highlighted the sense of isolation and the need for increased social support for women who choose to challenge standard patterns of care (Westfall and Benoit, 2004). A similar sized Australian study comparing

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about induction, leading to

unrealistic aspirations

two groups of primiparous women noted that those who were booked for induction felt unprepared for the resulting shift in their expectations of childbirth and lacked meaningful information about the process (Gatward et al, 2007). The authors suggest that antenatal education could be used as a medium to enable women facing induction to adjust their expectations of labour. The subject of antenatal education to prepare for induced labour rarely occurs in the literature. Only one piece of research could be found. This US study evaluated a 40-minute education session on the relative risks of induction and spontaneous labour, which was incorporated into a standard antenatal class (Rice-Simpson et al, 2010). The ability to generalise this study is limited by the fact that participants could choose induction without medical reason; however, the outcome showed that women who attended classes were less likely to opt for induction for ‘social’ reasons. This suggests that focused


antenatal education has a positive influence on women’s understanding of induction. All the aforementioned studies have limitations; not least the personal characteristics of the women involved and the importance they might have placed on control, information and involvement in decision-making. However, this brief review highlights the scarcity of recent, research-based evidence from the UK on women’s experiences and understanding of induction. This has been identified as an underresearched area by a Cochrane review and by NICE (Gülmezoglu et al, 2006; NICE, 2008). Back in 1977, the DH stated that women should ‘have every opportunity of discussing [induction of labour] with professional advisors’ in order to ‘make a fully informed decision about it’ (DHSS, 1977). This was reiterated in the 2008 NICE guideline (NICE, 2008), yet verbal evidence from hospital-based midwives suggests that women are frequently disappointed when the reality of the experience fails to match their expectations. It would appear that, despite the growing emphasis on woman-centred care since the 1970s, women are still under-informed about induction, leading to unrealistic aspirations. In response, a small in-depth study is underway to explore first-time mothers’ understanding and experience of induction, comparing a group who attended a preinduction information class with a group who chose to abstain. It is hoped that the outcome of this study will provide fresh evidence of women’s understanding of induction and insight into the effects of pre-induction education on women’s subsequent expectations and experiences. Annabel Jay Senior lecturer/admissions tutor (midwifery), University of Hertfordshire For references, please visit the RCM website.

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he Home from Home (HFH) midwife-led unit (MLU) in the Ulster Hospital, Northern Ireland opened in August 2007 as an alongside unit. It currently provides a service for around 800 births each year, which is approximately 25% of the total births within the unit. In 2007, the admission criteria centred around low-risk women with a spontaneous onset labour. However, from May 2009, women who went into active labour following the administration of one or two prostaglandin (PGE2) pessaries were also included. This reflected the change in NICE guidance (2008). These labouring women were offered the full range of services available within the HFH, including waterbirth. The purpose of this retrospective service evaluation was to explore outcomes for babies born in water following the administration of vaginal prostaglandin.

Measuring results Ulster Hospital’s MLU now offers all women the chance of a waterbirth, even if they have been induced. But what has been the effect on fetal outcomes?

Literature review The two most relevant studies in this area are Sorokin et al (1992) and Amon et al (1999). While neither looks specifically at waterbirth, both were trials conducted in the 1990s, which looked at the effects of vaginal prostaglandin on fetal breathing and movement. Prostaglandins are produced locally in the fetal brain, other fetal tissues and the placenta through which it is secreted into the fetal blood. The production of prostaglandin by the placenta and fetal membranes increases in the last few days of fetal life; therefore the amount of fetal breathing decreases in the last few days of pregnancy (Balaskas, 2004). Harding and Hooper (2008) state that, in spontaneous or induced labour, the incidence of fetal breathing is decreased to less than 10% of the time during the latent phase and is further decreased during the active phase of labour. Johnson (1996) supports this theory and goes on to postulate that this inhibitory response would remain uninterrupted while the placenta and fetal circulation are intact and, therefore, fetal breathing would remain inhibited, even after birth into water. This would presume the absence of other contributory factors, such

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as severe hypoxia. Therefore, the main question is whether the introduction of vaginal prostaglandins artificially for the induction of labour produces the same responses as the onset of spontaneous labour. It would appear from the literature that it does. As a review of the research into waterbirth (Cluett and Burns, 2009) has shown, as long as it is performed safely, there are no adverse effects on the woman or fetus.

Planning the study Each of the four midwives who volunteered to be involved in the service evaluation had varying levels of experience in this field and tasks were delegated to reflect this. However, in order to give an overview of data collection and the relevance of statistical findings, it was arranged for a GP with a special interest in evidence-based medicine to talk to the group to ensure an understanding of the process. The following outcomes were incorporated into a data collection tool in order to best reflect newborn fetal wellbeing: ► Apgar score at one minute ► Apgar score at five minutes ► Inflation breaths required

► Positive pressure ventilation ► Cardio-pulmonary resuscitation ► Admission to neonatal unit ► Reason for admission to neonatal unit.

The research and development department within the trust gave permission to proceed with this retrospective service evaluation, for which two experts also gave their opinions. As all 124 women included had given birth prior to the start of the service evaluation, there was no influence on the treatment they received and therefore no influence on the outcomes being evaluated.

Methodology Since the admission criteria were changed, 31 women had given birth under water following administration of vaginal prostaglandins. This allowed us to retrieve information regarding their birth outcomes without influencing their treatment. In order to make comparisons, 31 women were selected for each of the three corresponding groups (groups 2, 3, and 4). ► Group 1: Waterbirth after induction of labour with one or two prostaglandin pessaries ► Group 2: Waterbirth after spontaneous onset of labour ► Group 3: Land birth after induction of

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the one-minute interval; the lowest of all the scores. This was within the ‘waterbirth – no pessary’ population.


labour with one or two pessaries


► Group 4: Land birth after spontaneous

onset of labour. Allocation to groups 2, 3 and 4 was made by checking the birth register and making note of the hospital number of the women whose details fulfilled the criteria for each group and whose birth was nearest in time to the corresponding woman in group 1. This prevented any bias as details of fetal outcomes are not recorded in the birth register. When the list of numbers was compiled, data from computer records were retrieved and recorded. As no babies required either active resuscitation or admission to the neonatal unit, only the Apgar scores were analysed. A statistician calculated the results using the following tests. Odds ratios and relative risks were considered in terms of a two category

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outcome in which an Apgar score of seven or less was considered undesirable and a score of eight or more desirable. Fisher’s exact test (Fisher, 1925) was also employed to test each of the groups against each other using the groupings above. Additionally, MannWhitney U tests (Mann and Whitney, 1947) were conducted to compare each population against each other.

Findings Overall, there was more variability at the oneminute Apgar assessment point than at the five-minute interval. Within all groups, the overall Apgar scores increased going from the one-minute to the five-minute interval. There were no Apgar scores of less than nine for any of the groups at the five-minute interval and no eventual adverse outcomes recorded. There was only one score of six, recorded at

There were no statistically significant differences between any of the four groups analysed in relation to Apgar score outcomes at the one- or five-minute assessment periods. A slight decrease was noted in terms of the relative risk of registering an Apgar score of seven or below at the oneminute assessment with pessary-induced waterbirths compared to the ‘waterbirth – no pessary’ and ‘land birth – no pessary’ groups. However, caution should be exercised given the limitations of the study with regards to the sample size. The odds ratio confidence intervals were wide-ranging, which is indicative of small sample sizes. This subject would benefit from a prospective research study using a larger sample. However, given the findings of this service evaluation, the trust will continue to offer women the opportunity of having a waterbirth following the administration of one or two pessaries, which have enabled them to become established in labour. Patricia Scott Practice development midwife, South Eastern Trust Claire Mallon Midwife, South Eastern Trust Special thanks go to Helen Wallace, Sandra Graham, Chris Wilson and Sean Mallon for their input in this study. For references, please visit the RCM website.

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A fine line Dr Siba Prosad Paul and Dr Alexander Goodman explain the circumstances in which dilutional hyponatraemia may occur, in both women and newborns, as well as the symptoms it presents with and preventative measures.


regnant women in labour are encouraged to drink plenty of fluids and may receive additional intravenous fluids. This can lead to dilutional hyponatraemia, both in the mother and her newborn baby. Although symptoms mostly remain sub-clinical, neonatal convulsions and eclampsia-like presentations secondary to excessive fluid administered in labour have been reported. In addition, neonates may suffer from irritability and poor feeding.

of maternal sepsis. Excessive administration of intravenous fluids in labour and/or fluids taken orally may cause maternal and neonatal dilutional hyponatraemia (Paech, 2005; Daggett and Shields, 1982; Singhi and Chookang, 1984). This is because even small increases in fluid intake during labour may cause hyponatraemia, due to the fact that there is a decreased tolerance of water in pregnancy (Moen et al, 2009). Although intravenous fluids are accurately documented in fluid charts, the total fluid input is not routinely calculated (which includes oral intake) and thus over-hydration may occur unnoticed and often remains under-recognised.

Consequences for women Current clinical practice Adequate hydration is considered necessary in the intrapartum period. Therefore, midwives and carers often encourage pregnant women to drink well during labour. This may lead to them drinking excessive amounts of hypotonic fluids, such as water (Zetterström, 2003). Oral fluid intake is usually adequate and additional intravenous fluids may not be needed. Intravenous fluids may be given to women in labour if spinal or epidural anaesthesia is necessary, if there are concerns with a suboptimal cardiotocograph, in the presence of maternal and/or fetal tachycardia, or in cases

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Maternal hyponatraemia can cause symptoms similar to those of pre-eclampsia, such as altered consciousness, visual disturbances and fitting. Cases have been described where women in labour or those who have just delivered have suffered grand mal seizures which were thought to be due to pre-eclampsia but were actually caused by hyponatraemia. These responded well to the administration of hypertonic intravenous saline (Paech, 1998; Jellema et al, 2009; Chapman and Hamilton, 2008). Previously, oxytocin has been hypothesised as a possible cause of these symptoms as it can cause water retention (Jellema et al, 2009).

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However, as shown in published literature, dilutional hyponatraemia, secondary to overhydration, is now increasingly being recognised as a more acceptable explanation (Jellema et al, 2009). Moen et al (2009) highlighted that a total fluid intake of over 2.5 litres during labour is associated with an increased risk of maternal hyponatraemia, which may be life-threatening and may influence uterine contractility.

the mother. Once a diagnosis of hyponatraemia has been made, neonates should be transferred to the special care baby unit. Initial management involves fluid restriction and close monitoring of serum sodium levels (blood tests) until sodium levels are normalised (Modi, 1998). The normal range of serum sodium concentration in a neonate is 136 to 145mmol/l (Tasker et al, 2008).

Addressing the issue


Effect on the neonate Although most cases remain sub-clinical and therefore undetected, dilutional hyponatraemia is not uncommon in neonates. Despite the fact that serious morbidities do not usually occur, this is not unheard of and can present as a clinical challenge unexpectedly. Possible consequences of neonatal hyponatraemia can range from mild irritability to seizures (Modi, 1998; Costa et al, 2001). Because of this wide range of symptoms, making a quick clinical diagnosis of neonatal hyponatraemia is difficult in the absence of blood tests. Neonates who are found to be fitting soon after birth, without any history of birth trauma or hypoxic ischaemic encephalopathy, should be considered to have dilutional hyponatraemia due to maternal over-hydration. This diagnosis should also be considered in neonates who are found to be hyponatraemic from blood tests prompted by a separate indication, such as a septic screen. Early detection and awareness is associated with a good outcome (Zetterström, 2003; 2002). Even when hyponatraemia is detected from blood tests, it is extremely difficult to decide that it was due to dilutional hyponatraemia in the absence of a clearly documented total fluid input, which is usually unavailable. In situations where the condition is suspected but fluid input is not documented, it is important to consult the fluid prescription chart, including those completed in theatre, and calculate the total volume of intravenous fluid received during labour in addition to the oral fluid, which will become evident once the mother is spoken to. This will avoid unnecessary blood investigations being taken from the neonate. Midwives can help the neonatal team to determine the possibility of this condition by communicating the amount of fluid received by

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In order to reduce the incidence of maternal and/or neonatal dilution hyponatraemia that is secondary to an excessive input of fluid during labour, an increased awareness is necessary among midwives, obstetricians, anaesthetists, neonatologists and women in labour. Reviews by both midwives and physicians suggest that women in labour should be given the choice to eat and drink what they wish, but should be made aware of the risks of excessive fluid intake (Gyte and Pengelley, 2007; Singata et al, 2010). Careful documentation of total volume of oral and intravenous fluid given to a pregnant woman in labour is advised so that an input in excess of two to three litres can be avoided unless clinically indicated. In situations where it is clinically indicated, neonatal teams should be made aware of the risk of dilutional

Dilutional hyponatraemia is avoidable in most cases by

careful monitoring and

clear documentation


hyponatraemia (Zetterström, 2003). As a limit of fluid input in labour has not previously been agreed, the RCOG has adopted the suggestion by Moen et al (2009) that a fluid input in excess of 2.5 litres in labour runs a risk of moderate hyponatraemia. The National Collaborating Centre for Women’s and Children’s Health (NICE, 2007) suggests that isotonic oral fluids such as ‘sports drinks’ may be more beneficial and are likely to prevent dilutional hyponatraemia; however, further studies are necessary to support this practice (Singata et al, 2010). It is important to recognise that the low-dose epidural regimens used in modern obstetric practice does not necessitate the use of a high volume of intravenous fluids to preserve the blood pressure and the volume of intravenous fluids should be judged on an individual basis (Moen et al, 2009). This itself would lower the risk of inadvertent dilutional hyponatraemia with epidural anaesthesia.

Conclusion Dilutional hyponatraemia is avoidable in most cases by careful monitoring and clear documentation of the total volume of fluid administered during labour. It should be suspected and serum sodium should be checked and corrected in women who present with unexplained eclampsia-like symptoms (women with no proteinuria and normal blood pressures). Neonatal teams should be made aware of the risk of the condition in mothers where excessive fluids were administered. An unexpectedly low sodium level in the neonate soon after birth should raise suspicion of dilutional hyponatraemia, secondary to over-hydration in labour. Increased awareness of this condition is associated with an improved outcome. Dr Siba Prosad Paul Paediatrics, Yeovil DIstrict Hospital NHS Foundation Trust Dr Alexander Goodman Obstetrics and Gynaecology, Portsmouth Hospitals NHS Trust For references, please visit the RCM website.

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ommunication can be regarded as the cornerstone of client safety. As midwives, we recognise that effective communication is instrumental in establishing not only relationships with women, but also improving our care within the wider multiprofessional team. Reports such as Saving mothers’ lives (Lewis, 2007) have consistently highlighted the need for effective communication between midwifery and obstetric teams. In a busy clinical environment, it is essential that staff have effective tools that enhance women’s experiences and promote safe care. Quite often in midwife-led units (MLUs), relationships with obstetric colleagues are uncomplicated and informal, which on occasions can lead to informal discussions in relation to the care of pregnant women. In turn, this can give rise to difficulty in distinguishing ultimate responsibility and accountability for the care delivered. Previously, the geographical location of the mother within a maternity unit would indicate the lead clinician in charge of her care. For example, if the woman was in the delivery suite, she was the responsibility of the obstetrician. However, following the review of a serious incident in Northern Ireland, it became evident that a formal process for the transfer of care between midwives and obstetricians was necessary. In 2008, the Department of Health (DH) for Northern Ireland communicated with its maternity services in relation to midwife-led care. It requested that all maternity providers ensure robust and transparent procedures are in place to demonstrate professional responsibility and accountability for the care of women within the midwife-led framework. The DH also requested that the transfer of women from midwife-led to consultant-led care should be explicit, detailed and reflected in formal referral pathways and documentation. The Southern Health and Social Care Trust established the first MLU in Northern Ireland and has since forged the way for midwife-led care in other parts of the region. This has afforded women more choice during their pregnancy and childbirth experience, which is in keeping with DH policy as far back as Changing childbirth (DH, 1993) and still

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Brenda Kelly and Shona Hamilton discuss the development of a tool to improve communication within the multidisciplinary team during the transfer of women from midwife-led to consultant-led care.

A meeting of minds 06/03/2013 12:07

Illustration: Christina Hagerfors

reflects the modern thinking of Midwifery 2020 (DH, 2010). The MLU cares for around 900 women per year. In order to address the DH’s request, a project midwife was asked to address the required actions and to do so, she focused on the need for explicit communication in relation to the transfer of maternity care. This resulted in the development of a communication tool that explicitly documented the reasons why the transfer of care was appropriate, as well as the lead professional providing maternity care. The tool detailed the process of transferring from midwife-led to consultant-led care and focused on care in labour initially. Based on the SBAR (situation, background, assessment and recommendation) tool used in other areas of midwifery and obstetric care, it was named HART to represent history, assessment, referral and transfer. The King’s Fund (2008) highlights the need for effective communication in the handover of care during a woman’s journey, whether the transfer is from midwife to obstetrician or other

048-49_MID_FEATURES_Communication.indd 49

member of the wider medical team. It states: ‘Communication is effective only if the relevant information is actually made available to, and understood by, those who need to act on it.’ The Safe births report (The King’s Fund, 2008) recommended SBAR as a structured communication tool that could be incorporated into handovers, ward rounds and emergency situations. The rationale for developing an alternative tool to SBAR was to demonstrate clearly who was the lead professional providing maternity care during the woman’s journey. The HART tool would be required when a midwife detected a deviation from the normal labour pathway, based on her clinical judgement and the guidelines in place for the care of women in normal labour. It allows midwifery staff to note their assessment of a woman’s condition on the same document required for her referral to obstetric colleagues. This assessment requires a systematic approach, thus facilitating the decision-making process. The tool was designed to enhance


clinical discussion between the disciplines with regard to the further management of the mother and her unborn baby. It also clearly documents which discipline has the responsibility for the woman’s ongoing clinical management. In doing so, the tool fulfilled all the requests from the DH in one clear document, while minimising unwieldy paperwork for the professionals. Following a multidisciplinary consultation with midwives and obstetricians, the first draft of the HART tool was piloted within the trust. Staff engagement was vital during the pilot project and feedback was invited from all the disciplines involved, which led to the final version being agreed upon and implemented. Training was provided for both the midwifery and obstetric staff in the use of the tool, which was not only beneficial for adapting it, but provided an opportunity for the multidisciplinary team to discuss issues around the transfer of care. It also enabled both professional groups to discuss any frustrations or concerns they had in relation to teamworking and professional accountability. By jointly developing this tool, each discipline gained a greater understanding of each other’s roles and responsibilities and began to appreciate each other’s philosophy and approach to care. Therefore, the benefits have been two-fold: patient safety has been enhanced through clear lines of communication and professional relationships have been strengthened through the process of joint learning. Compliance issues with the documentation and with processes and procedures relating to the transfer of care have been raised through the critical incident reporting system and these have been resolved, once again with a multidisciplinary model. The HART tool has now been adapted for use in antenatal and postnatal care, and has facilitated the roll-out of increased midwifeled care provisions across the trust. Several other trusts within Northern Ireland are now using the tool within their services, which is testament to its success. Brenda Kelly Lead midwife and supervisor of midwives, Southern Health and Social Care Trust Shona Hamilton Consultant midwife, Queen’s University Belfast and Northern Health and Social Care Trust For references, please visit the RCM website.

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Beyond the pale Despite the severity of hyperemesis gravidarum, it is often overlooked by health professionals. But the Duchess of Cambridge’s diagnosis has brought new attention to the condition, says Louise Hunt.


he news that the Duchess of Cambridge was hospitalised with hyperemesis gravidarum (HG) has helped to throw a spotlight on what is described by the charity Pregnancy Sickness Support as ‘an overlooked and under-researched’ condition. Professor Roger Gadsby, chair of Pregnancy Sickness Support and a retired GP, says many sufferers of severe nausea and vomiting in pregnancy (NVP) who contact the charity’s support network feel isolated and say that health professionals have been unsympathetic to their plight. He suggests that because approximately 80% of pregnant women experience some degree of NVP, there may be a tendency for health professionals to trivialise their experience. ‘This is a potentially very serious condition that needs to be treated with empathy and understanding, but a lot of women say they have been fobbed off and told that it is a normal part of pregnancy,’ he says. For the 30% of pregnant women at the severe end of the NVP spectrum, the potential adverse effects are anything but

050-51_MID_FEATURES_NVPs.indd 50

normal. Of these women, around 1% will be termed as suffering from HG, requiring treatment for dehydration and electrolyte imbalance. HG accounts for approximately 25,000 NHS hospital admissions a year in England and is one of the major causes of hospitalisation before 14 weeks’ gestation (Gadsby and BarnieAdshead, 2011a). Severe NVP can also have profound effects on women’s quality of life, including their ability to work, care for other children adequately, and relationships. A recent literature review by Roger Gadsby and colleague Dr Barnie-Adshead (Gadsby and Barnie-Adshead,

2011b) found 52% of sufferers said they felt depressed all or most of the time. ‘At the severest end, there is the risk of mortality if a woman feels her only escape from the suffering is a termination,’ fr t from says Roger. Data up to 199 1992 shows 25 to 59 terminations a ye year were carried excessiv vomiting in out due to excessive pregnancy, but th the current link is d is no longer unknown as the data recorded in this way, he adds. ‘Women suffering from HG in their first pregnancies are particu a particularly vulnerable group. They will most h likely have been told N is just a mild that NVP cond condition and they g over it, only will get to di discover that it con continues and gets mu worse.’ much It may also affect the decision to have mo children. ‘We more know hyperemesis tends to rrun in families like to occur in and is likely subseque pregnancies subsequent and some women will be

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reminded that this can be a problem,’ she says. ‘I think it is possible that some midwives are not as aware of HG as they should be. It is part of training, but it’s being able to use that knowledge in practice and that comes with experience and awareness. ‘It may be more obvious when a woman is acutely ill, but the difficulty is assessing a woman who is affected day after day. There is quite a wide range of experience that you can accept as normal, but once you’ve seen a woman with hyperemesis it does stick in your mind. ‘If you think a woman is at risk of HG you have to be a detective and identify pretty quickly,’ Sue adds. She suggests that midwives who think they would benefit from additional training in this area should take part in one of the study days run by Pregnancy Sickness Support, which is accredited by the RCM. Crucially, midwives should be alert to the signs of HG, which include appearing exhausted and pale, signs of ketosis, such as ‘pear drop breath’ and ketones in urine, and dehydration. ‘Midwives should be taking a full history, asking how many times she is vomiting,’ so worried about it that they don’t want to go through it again. Others want to prepare themselves as much as possible for subsequent pregnancies,’ says Roger. But there may be a chink of light, as recent research shows that early treatment can ameliorate the most severe symptoms of NVP and help to reduce hospital admissions. Roger cites a study of pre-emptive treatment, which showed that women with a history of severe NVP who had been offered anti-emetic therapy early on experienced a significant improvement in their symptoms compared to a control group with similar histories who did not take treatment (Gadsby and BarnieAdshead, 2011a). Since the thalidomide tragedy, understandably there is widespread reluctance to prescribe drugs in early pregnancy. But misinformation and misconception related to birth defect risk can lead to women not receiving appropriate treatment. Roger says midwives should be aware that there are safe and effective treatments, including antihistamines and anti-emetics, that are available. Although they are not licensed for use in pregnancy in the UK, they are used for these purposes in other countries, including the US and Canada. ‘Midwives have a role in informing women on

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Severe NVP can also have profound effects on women’s quality of life, including their ability to work, care for other children adequately, and relationships what treatment is available,’ says Roger. ‘Ideally, patients would have their emesis controlled in the community and it would only be the very difficult to control, or atypical, cases that would need to be admitted.’ For early intervention to work, he says there is ‘a huge need’ for midwives to be educated in identifying women who are at the severe end of the NVP spectrum. They also need to be alerted to a previous history of HG and, if possible, refer patients to a specialist unit or a GP or consultant with a special interest in pregnancy complications. Midwifery consultant Sue Macdonald agrees. ‘Perhaps midwives need to be

adds Sue. ‘When did she last eat? If they are worried, they should refer to a doctor. They also need to be aware of when excessive vomiting may be part of another illness or complication, such as a hydatidiform mole, or cystitis, she adds. ‘They have got to know why this woman is being sick. One of the most important things is to listen to women and not think NVP is a minor disorder and just part of pregnancy.’ For more information, please visit: For references, please visit the RCM website.

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Clarity in screening

The last issue of Midwives presented a scenario involving an MSW performing antenatal screening. Here, the RCM’s Janet Fyle explains the correct sequence of events.


he last scenario presented a situation where a midwife had asked an MSW to test a woman for sickle cell anaemia. The woman was counselled and her consent obtained by the MSW, who had apparently undertaken some previous training in this area. The woman was found to be sickle cell trait but the results were given by the MSW as ‘fine’. The infant was diagnosed with sickle cell disease and it was not clear if partner testing was offered.

The consent standards and guidance for antenatal screening identify the midwife or doctor as the most appropriate person to deal with specific issues integral to the screening process. The NHS screening programme for sickle cell and thalassaemia also emphasises the importance of obtaining family origin information as part of a comprehensive clinical assessment, in order to identify individuals and their offspring who are at risk.

What should have happened?

Was the MSW working within the limits of her role?

The simple answer is that the midwife should have carried out these tasks herself because she is responsible and accountable for providing written and verbal information, discussing the screening test and obtaining consent from the woman prior to any form of antenatal screening.

In this instance, the MSW was working outside the remit of her role. However, taking blood can be delegated to an MSW or a phlebotomist. The person who takes the blood should not engage with any discussions, but follow the specific task required as per the blood form.

052_MID_msw.indd 52

The action of the midwife in this situation could, at best, be described as inappropriate delegation. The NMC advises midwives to consider the complexity and expected outcome of the delegated tasks. This is an important test, which is potentially a step in prenatal diagnosis of women with sickle cell or thalassaemia and requires a high level of knowledge and understanding. The offer of screening and obtaining consent is part of developing the woman’s care pathway and compiling accurate documentation. It must be noted that antenatal screening is subject to incident reporting for any failures in the process. When a screening programme is introduced, it is the midwife’s responsibility to ensure she has the relevant knowledge about the purpose of the screening process, its potential impact on the pregnancy, the woman’s long-term health and that of her baby. This is in addition to ensuring that she has the required skills to undertake the process and understands that she is accountable. Similarly, in providing antenatal screening programmes, the employer has an obligation to ensure that training and education is in place and that it is clear who is eligible to perform the test.

Should the MSW have been left to discuss antenatal screening? It is not within the role or remit of the MSW to discuss issues of antenatal screening. It appears that the midwife relied on the fact that the MSW said she had some knowledge of haemoglobinopathy and performed similar tasks in her previous job. This training is for health professionals involved in antenatal and newborn screening. However, it is not unusual for affected women to have undergone sickle cell or thalassaemia testing before becoming pregnant. Some of this testing is carried out via community clinics, with consent obtained by counsellors in the community or via GPs.

RCM COMMUNITIES What do you think about the advice given? Have you ever been in this situation? Join the discussion at:

► For a reminder of the original scenario from Issue 1, please see: For resources, please visit the RCM website.



06/03/2013 10:26



The latest recruitment

Appointments M I D W I V E S

For the latest midwifery news and vacancies from the RCM please visit



Permanent residency sponsorship and relocation allowance Salary Range $AUS 54,000 - $AUS 76,000 PA Plus shift allowances and overtime The opportunity to relocate to Australia and join our midwifery team awaits you. We are currently recruiting experienced midwives to work within our Labor and delivery suites, ante natal or post natal ward, opportunities also exist for experienced midwives to work in the special care nursery. As well as working in a happy, caring and positive environment the positions come with a host of benefits including excellent overtime and shift allowances, additional payments in recognition of your post graduate qualifications. You will also qualify for tax free savings and an employer’s pension contribution of 9% of your annual salary. You will be fully supported every step of the way with your application through our consultants at Healthcare Elite Limited, from obtaining your nursing registration (if required) to visas for you and your family.

You can expect the very best support from the time you arrive, through to continuing education and career promotion opportunities. For further information about these opportunities please contact Ciaran at Healthcare Elite: 0844 800 8499 (office hours) 07896 500 104 (evenings and weekends)


To advertise on this page, please contact sales manager Giorgio Romano on: 020 7880 7556 or email:

MID.recr.indd Sec1:55

05/03/2013 13:50



Resources reviewed by Midwives’ expert reviewers

Footnotes Resources / Bookmark




Birth matters

Perinatal mental health: a clinical guide

Mayes’ midwifery (14th edition)

AUTHOR: Colin R Martin PUBLISHER: M&K Publishing PRICE: £89 REVIEWER: Roxanne Stanyon

EDITED BY: Sue Macdonald and Julia Magill-Cuerden PUBLISHER: Bailliere Tindall PRICE: £45.99 REVIEWER: Kirsty Burfot

AUTHOR: Ina May Gaskin PUBLISHER: Pinter and Martin PRICE: £9.99 REVIEWER: Nikki Syvret

As a newly qualified midwife, I was eager to get to grips with this new title from the original ‘spiritual midwife’ and was soon hooked. Testimonials are scattered throughout the book to illustrate the benefit of the positive birth story. Explorations follow, such as the adverse effects that societal changes have had on natural childbirth, how feeling relaxed and safe helps the birthing woman, and sexual childbirth. The second half broaches medicalisation and Gaskin theorises that the technology men brought – along with other reasons – directly contributed to deteriorating outcomes. Chapter six is about non-midwifery medical interventions. It is less integrated with the rest of the text and could have been omitted. The book concludes with a vision advocating changes for the US to get back to a natural way of birth. This focus on the US might not enthuse the UK reader and I admit that I was left with a desire for more of the cheerleading and rabble-rousing that hooked me in the first chapter.

054-55_MID_FOOT_Bookmarks.indd 54

I was pleasantly surprised at how compartmental, clear and readable this comprehensive volume is. The information, although at times is not easy reading, has been written and set out with effective use of colour and headings to make it more manageable. Covering an array of mental health disorders in detail, it serves as a useful reference point for midwives, as some information may not be part of their working knowledge. It also covers interesting aspects of the psychology surrounding birth, such as issues concerning obesity, body image, the partner and the midwife. I would have liked to have seen pregnancy loss tackled, however, as this is often a testing time to provide care. The price might make this inaccessible to some, which is unfortunate as it is an invaluable read for those wishing to gain a greater understanding of mental health issues surrounding pregnancy, birth and beyond.

Previously I have used another midwifery textbook, chosen due to its Pageburst access. However, Mayes’ now has this fantastic resource as well, so I was eager to see how it shaped up. I wasn’t disappointed. With an emphasis on normality in childbirth, Mayes’ midwifery is a useful tool for student midwives to refer to for theory training and, once qualified, it’s great as an easy source to refresh parts of practice. Each chapter covers the given subject precisely and informatively, and the illustrations are relevant and complement the text. For those who prefer a simpler layout and benefit from images, this is definitely the textbook for them. The new edition has casebased studies to explore, helping to consolidate learning. All the information is evidence based and there are reflective studies and multiple-choice questions for self-testing.

06/03/2013 13:17




The 3-plan: your complete pregnancy and postnatal exercise plan

Perineal assessment and repair following childbirth: the FAB training method

Midwifery practice: case book – critical illness, complications and emergencies

AUTHOR: Lucie Brand PUBLISHER: Lucie Brand PRICE: £9.99 REVIEWER: Claire Muscott

Exercise during pregnancy is beneficial to both mother and baby but planning this is not always easy. To help mothers-to-be, Lucie Brand has come up with the 3-plan. The book begins with an explanation of the plan and how it came about. It then details how the body changes during pregnancy, breaking down the different types of training involved with the plan and the benefits of each. There are several FAQs in each section and the book is very informative without overcomplicating facts. A nutrition section is included, which provides some basic information on healthy eating and meal plans. However, this is not really pregnancy specific, but useful none the less and a good reminder that nutrition is an important factor in pregnancy. The main section of the book is split into the three trimesters. The three theme is reiterated throughout, as each part of the plan has three elements, setting things out in a way that is easy to follow. With each trimester different exercises are introduced keeping it interesting and challenging and allowing for the body’s adaptations during pregnancy. There are demonstration pictures and also a plan to help the reader keep track of workouts and progress. The exercises are explained clearly with safety tips noted at the beginning of each chapter. As a mother herself, Lucie is very empathic and this is reflected in the overall tone of the book.

054-55_MID_FOOT_Bookmarks.indd 55

PRODUCED BY: St George’s University of London PRICE: £59 WEBSITE: REVIEWER: Shawn Walker

This DVD set will make a very welcome addition to perineal repair training programmes and annual updates for midwives and junior doctors. Made by the team at St George’s Hospital in London, FAB stands for Fynes and Bosanquet, the urogynaecologist and specialist perineal midwife who have developed the method. The training package takes a broad view of suturing skills, from the physical knowledge and technical aspects that must be mastered, to communication and the emotional aspects of providing woman-centred care, including usually overlooked topics such as suturing at home births and postnatal care of the perineum. The videos of pelvic floor repairs are excellent and are accompanied by helpful, detailed narratives. Filmed under surgical conditions, the videos are much easier to observe and learn from than looking over mentors’ shoulders and enable observers to develop visual acuity and enhance understanding of the repair process. Some of the case studies were more in-depth than most midwives will require, for example surgical repair for third-degree tears, but overall the accessible and practical DVDs were very easy to navigate and quickly locate topics of interest to maintain skills.


EDITED BY: Maureen Raynor, Jayne Marshall and Karen Jackson PUBLISHER: Open University Press PRICE: £24.99 REVIEWER: Andrea Taylor

I found this book extremely useful. Each chapter is a case study covering the management of a specific obstetric emergency or critical illness in a question-andanswer-style format. The book acknowledges the increasing multi-professional nature of maternity care provision, but retains a strong emphasis on core midwifery skills and standards. It covers how cases could and should be managed, reminding us of the value of multiprofessional obstetric emergency training. It is a substantial read, as each chapter covers differential diagnosis, pathophysiology and management. Each chapter is also thoroughly referenced and includes suggestions for self-assessment, preparatory, further reading and also websites. Although aimed at student midwives, this is a resource that is accessible to all involved in maternity care.

Want your book/DVD/CD reviewed? Please send a review copy to Hollie Ewers at Midwives, Redactive Media Group, 17-18 Britton Street, London EC1M 5TP. We are unable to return these copies. Would you like to be a reviewer? Please email your name, address and your area of expertise to Hollie Ewers at:

06/03/2013 12:56



Footnotes Events / Dates to remember

Diary y This page informs readers of courses, training and events relevant to midwifery.

Aqua-Natal stage 1 – introduction to teaching courses 23-24 March London

Hypnobirthing teacher training diploma course Launch of the BNF Task Force report 25-28 April London 21 May

10-11 May Leeds

16-19 May Edinburgh

Introduction to pilates and postnatal exercise 5 April London

Become a registered hypnobirthing practitioner with Katharine Graves. Cost: £697 T: 01264 731437 E: W:

T: 01943 879816 W:

Action on pre-eclampsia study days 13 June Multidisciplinary days for all those involved with the care of pregnant women. More dates available on the website. Location: Glasgow Cost: £80 full price; £40 for students. T: 01386 761848 E: W:

9-12 May Derbyshire

RCM annual event and Zepherina Veitch Memorial Lecture by Dr Helen Cheyne 13 June

The British Nutrition Foundation (BNF) is holding a conference to launch its latest Task Force report Nutrition and development: shortand long-term consequences for health. Location: Royal College of Surgeons, London T: 020 7557 7930 W: RCM legal birth conference 11 July

Professor Cathy Warwick will give the annual address at the event. There will also be a presentation of RCM honorary fellowships. Location: The Scottish National Gallery, Edinburgh Cost: Free for RCM members, but places are limited. W:

Now in its fifth year, this unique conference takes a dynamic look into the current legal issues and challenges facing healthcare professionals involved in providing maternity care. Location: London (TBC) Cost: £120 (plus VAT). T: 020 7549 2549 E: W:

ASAP: Obstetric emergencies in the community 9-10 September

RCM annual conference 2013 13-14 November

EMA education conference 29-30 November

A two-day workshop focusing on obstetric emergency in the community setting. Location: Powys Cost: £250 to £275. T: 07814 907925 E: W:

The biggest midwifery conference, led by midwives for midwives, will provide delegates with a chance to hear the latest innovations in midwifery, challenge politicians and meet regional officers, RCM staff and like-minded midwives, students, MSWs and workplace reps. Location: The International Centre, Telford E:

Profiling midwifery education through leadership and science. Location: Maastricht, the Netherlands. Cost: €285 if booked before 31 August; €325 after. T: +31 43 38 70 808 E: W:

If you would like to advertise on this page, please contact sales executive James Condley on: 020 7880 7661 or email:

056_MID_FOOTNOTES_events.indd 56

06/03/2013 10:45




UP FOR GRABS Here’s a chance to get your hands on some great giveaways with our free prize draws.

— H WORTCH £9 EA —

WIN ONE OF THREE COPIES OF CALL THE MIDWIFE – THE ALBUM An official musical companion to the series from the Demon Music Group, Call the Midwife – The Album includes the full versions of key featured songs along with incidental music from series one and two and the Christmas special. It also provides the chance to relive the best moments from the series, with original music from the programme, including many popular classics from the likes of Doris Day, Dean Martin, Petula Clark, Elvis Presley, Andy Williams and many more. There are original cast recordings from the nuns, featuring Sister Bernadette played by Laura Main, herself a trained soprano, along with the compelling title theme.

HOW TO ENTER ► To enter these competitions, please email your name, address, telephone and membership number, clearly stating which competition you are entering to: ► The closing date is 16 April. Winners are drawn at random. Only one entry per household will be accepted. The editor’s decision is final.

057_MID_comps.indd 57

WIN ONE OF FIVE COPIES OF MEDICAL DISORDERS IN PREGNANCY: A MANUAL FOR MIDWIVES (SECOND EDITION) This second edition book clearly outlines existing and pre-existing conditions that women can experience during pregnancy. The comprehensive and practical handbook edited by S Elizabeth Robson and Jason Waugh identifies issues for preconception care, defines the condition, explores possible complications, outlines recommended treatment and emphasises specific midwifery care.

This fully revised and updated edition builds on the success of the first edition by covering more subjects. It includes physiology, more illustrations and algorithms. Jointly written by medical and midwifery experts in the field, special features include a practical guide on medical disorders written specifically for midwives, an accessible, referencestyle format, which makes information quick and


Medical Disorders in Pregnancy A Manual for Midwives Edited by S. Elizabeth Robson and Jason Waugh

easy to find, and there is an emphasis on interprofessional working.

WIN ONE OF FIVE PAIRS OF TICKETS TS TO THE LONDON PET SHOW 2013 Dancing dogs, racing micro-pigs, rabbit showjumping and skateboarding chickens are among this year’s spectacular pet attractions at the London Pet Show 2013 at Earls Court Two on 11 and 12 May. The UK’s largest pet showcase will feature the wonderful world of creatures great and small, from guinea pigs to geckos,

as well as offering a fun day out for families and pet enthusiasts. A huge range of breeds and species will be on display, with some of the UK’s leading animal experts on hand to advise on pet care and choosing the right animal. It is also a chance to buy the latest goodies and gadgets for your pets. The show will be divided into four zones: Discover Dogs, Discover Cats,

— H WORT99 . 4 £3 H EAC —

— TH WORA CH E 8 2 £ —

Discover Small Furries and Discover Animals, featuring exotics and aquatics, each with its own feature areas with demonstrations, talks and activities.

06/03/2013 10:29



Footnotes Crossword / Puzzle

Test your wits on this midwifery-focused puzzle... How many did you get right? Look out for the answers in Issue 3: 2013. ACROSS








1. The initiation of biological reproduction (13) 8. Grooves, for example, of the placenta (5)







9. Shortened form of what was once called ‘infantile paralysis’ (5) 10. ------ Salts, magnesium sulphate (5) 11. Beyond what is normal (5) 12. ------’s Grip, used to palpate the lower pole of the uterus (6)






13. An excess of tissue fluid (6) 15. A branch, such as that of the pubic bone (5) 18. The claw of a bird of prey (5)













20. Employed to care for children (5) 21. Nodule or swelling (5) 22. Describes an accessory lobe of the placenta (13)



Crossword 07: Jan Wallis

Last issue’s answers

DOWN 1. They undertake the care of children for reward (6,7)

7. Qualified person who cares for babies (8,5)

2. Midwives must adhere to these (5)

14. Used to obtain blood for the Guthrie test (6)

3. A pelvic bone (5)

16. Hyperactive (5)

4. Tincture used as an antiseptic for wounds (6)

17. Method of communication via the internet (5)

5. More than enough (5)

18. A teacher (5)

6. A small endocrine cell in the pancreas (5)

19. Fleshy folds surrounding the vagina (5)

058_MID2_13_FOOTNOTES_crossword.indd 58

06/03/2013 12:07

MID13.Issue2.059.indd 1

05/03/2013 12:48

Ghphg]^kiZmb^gmlpbma chronic anal fissure avoid the toilet…

Ma^hgermk^Zmf^gmeb\^gl^]li^\bÛ\Zeer_hkk^eb^_ h_iZbgZllh\bZm^]pbma\akhgb\ZgZeÛllnk^1 Rectogesic® (4mg/g Glyceryl Trinitrate) Abbreviated Prescribing Information. Please refer to the Summary of Product Characteristics (SPC) before prescribing.Presentation: Rectal Ointment containing 4mg/g Glyceryl Trinitrate (GTN). Indications: Relief of pain associated with chronic anal fissure. Posology: A 2.5cm strip of ointment is measured onto the end of a finger using the dosing line on the external carton. The finger may be protected by a finger cot, cling film, or other appropriate means. The covered finger is inserted gently into the anal canal up to the first joint and the ointment applied circumferentially. Not for use in children under the age of 18 years. Contraindications: Hypersensitivity to glyceryl trinitrate or any of the excipients in the ointment, or a known idiosyncratic reaction to organic nitrates. Concomitant treatment with sildenafil citrate, tadalafil, vardenafil and with nitric oxide (NO) donors such as other long-acting GTN products, isosorbide dinitrate and amyl or butyl nitrite. Postural hypotension, hypotension or uncorrected hypovolaemia; migraine or recurrent headache; increased intracranial pressure; aortic or mitral stenosis; hypertrophic obstructive cardiomyopathy; constrictive pericarditis or pericardial tamponade; marked anaemia or closed-angle glaucoma. Warnings and Precautions: Use with caution in patients with severe hepatic or renal disease. Excessive hypotension, especially for long periods of time should be avoided. Paradoxical bradycardia and increased angina pectoris may accompany GTN-induced hypotension. Alcohol may enhance the hypotensive effects of GTN. Careful clinical and haemodynamic monitoring must be carried out in patients with acute myocardial infarction or congestive heart failure, to avoid the potential hazards of hypotension and tachycardia. Treatment should be stopped if bleeding associated with haemorrhoids increases. Interactions: The following may potentiate the blood pressure lowering effects of Rectogesic®: other vasodilators, calcium channel blockers, ACE inhibitors, beta blockers, diuretics, antihypertensives, tricyclic anti-depressants, major tranquillisers and consumption of alcohol. Coadministration with dihydroergotamine may increase the bioavailability of dihydroergotamine and

glyceryl trinitrate 4mg/g Rectal Ointment

Win the war on pain, start living again

lead to coronary vasoconstriction. Concurrent administration of glyceryl trinitrate may cause a reduction of the thrombolytic activity of alteplase. The possibility that ingestion of acetylsalicylic acid and non-steroidal anti-inflammatory drugs might diminish therapeutic response to Rectogesic® cannot be excluded. Acetyl cysteine may potentiate the vasodilatory effects of GTN. Concomitant treatment with heparin will decrease heparin efficacy. Pregnancy and Lactation: Rectogesic® should not be used during pregnancy and is not recommended during breast-feeding. Driving and Using Machinery: Patients should be cautioned about driving or using machinery whilst using Rectogesic®. Undesirable Effects: Very Common; Headache. Common; Dizziness, nausea. Uncommon; Diarrhoea, anal discomfort, vomiting, rectal bleeding, rectal disorder, pruritus, anal burning/itching, tachycardia. Syncope, crescendo angina and rebound hypertension have been reported but are uncommon. (Please see SPC for a comprehensive list of side effects). Overdose: May result in hypotension and reflex tachycardia. Since hypotension associated with nitroglycerin overdose is the result of venodilation and arterial hypovolaemia, therapy should be directed towards increasing central fluid volume. Passive elevation of the patient’s legs may be sufficient, but intravenous infusion of normal saline or similar fluid may also be necessary. Overdose may also cause methaemoglobinaemia, this should be treated with methylene blue infusion. Pack Size and NHS Price: 30g tube £34.80 Legal Category: POM Further information is available from the Marketing Authorisation Holder: ProStrakan Limited, Galabank Business Park, Galashiels, TD1 1QH, UK. PL 16508/0037. Date of Preparation: March 2012

Adverse events should be reported. Reporting forms and information can be found at Adverse events should also be reported to ProStrakan Ltd on 01896 664000.

Reference: 1. BNF 63 March 2012 Date of preparation: September 2012. M011/1170

MID13.Issue2.060.indd 1

05/03/2013 12:49

midwives issue 2 - rcm  

midwives issue 2

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