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Midwifery Digest

March 2014, volume 24, number 1

research/education midwifery pregnancy labour & birth postnatal infant nutrition neonatal & infancy worldwide maternity services news & reviews

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Contents Housekeeping ............................................................................................................................... 1 Contents ...................................................................................................................................... 2 Editorial ....................................................................................................................................... 4


Hot Topic Delivering the impossible? The contradiction of maternity care provision .................................... 7 Tania McIntosh


Research/Education A guide to the MIDIRS ReferenceDatabase ................................................................................. 13 Michelle Brumby Complex interventions and their implications for systematic reviews: a pragmatic approach ...... 15 M Petticrew, L Anderson, R Elder et al — Reviewed by Tania McIntosh Systematic reviews of complex interventions: framing the review question.................................. 17 JE Squires, JC Valentine, JM Grimshaw Quantifying circulating hypoxia-induced RNA transcripts in maternal blood to determine in utero fetal hypoxic status ........................................................................................................... 18 C Whitehead, W Tinn Teh, SP Walker et al A preliminary survey of the use of complementary and alternative medicines in childbearing women .................................................................................................................... 19 C Jones, J Jomeen, O Ogbuehi


Midwifery Prenatal smoking cessation intervention and gestational weight gain .......................................... 25 MD Levine, Y Cheng, PA Cluss et al — Reviewed by Cathy Ashwin The effects of acute exercise on tobacco cravings and withdrawal symptoms in temporary abstinent pregnant smokers ....................................................................................................................... 27 H Prapavessis, S De Jesus, T Harper et al Obesity, pregnancy outcomes and caesarean section: a structured review of the combined literature ..................................................................................................................... 35 A Dignon, T Truslove — Reviewed by Ailsa McGiveron Information needs, seeking behaviors, and support among low-income expectant women .......... 37 H Song, EM Cramer, S McRoy et al — Reviewed by Cathy Ashwin Having a baby in Scotland 2013: women’s experiences of maternity care. Volume 1: national results: an official Statistics publication for Scotland .................................... 38 H Cheyne, S Skår, A Paterson et al


Pregnancy Bumps & Beyond — the way forward? ....................................................................................... 39 Ailsa McGiveron Parents’ perceptions of antenatal groups in supporting them through the transition to parenthood ............................................................................................................................. 45 Hilary Pilcher, Anita Hughes Obesity — challenging student midwives to be positive role models for a healthy lifestyle .......... 52 J Bothamley, C Kelly, T Wright et al Hyperemesis, gastrointestinal and liver disorders in pregnancy ................................................... 54 L Miller, K Gilmore


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Labour and Birth Go with the flow: a comparison of early and delayed umbilical cord clamping .......................... 61 Charlotte Salter Comparison of administration of single dose ceftriaxone for elective caesarean section before skin incision and after cord clamping in preventing post-operative infectious morbidity .. 65 S Kalaranjini, P Veena, R Rani — Reviewed by Michelle Anderson Vaginal examination during normal labor: routine examination or routine intervention? ........... 67 H Dahlen, S Downe, M Duff et al


Postnatal Supporting bereaved families: what can be done to ease parents’ grief?....................................... 77 LeighAnne Hedges A day in the life of a bereavement maternity support worker ...................................................... 81 Charlotte Wallace, Lorraine Herbert The prevention of early-onset neonatal group B streptococcal disease ......................................... 83 D Money, VM Allen Cultural issues in perinatal care................................................................................................... 84 B Chalmers


Infant Nutrition Randomized trial of exclusive human milk versus preterm formula diets in extremely premature infants ........................................................................................................................ 87 EA Cristofalo, RJ Schanler, CL Blanco et al Breast milk and gut microbiota in African mothers and infants from an area of high HIV prevalence ................................................................................................................................... 91 R González, I Mandomando, V Fumadó et al Telephone-based support prolongs breastfeeding duration in obese women: a randomized trial ...................................................................................................................... 92 EM Carlsen, A Kyhnaeb, KM Renault et al


Neonatal & Infancy Examination of the newborn — medical or holistic screening tool? ............................................ 93 Linda Jones Body perception in newborns ...................................................................................................... 98 ML Filippetti, MH Johnson, S Lloyd-Fox et al Investigation and management of non-immune fetal hydrops...................................................... 99 V Désilets, F Audibert The risk of stillbirth and infant death by each additional week of expectant management stratified by maternal age .......................................................................................................... 112 JM Page, JM Snowden, YW Cheng et al

119 Worldwide Maternity Services The Perineal Tears Project: a quality assurance and practice improvement project to reduce obstetric anal sphincter injuries ................................................................................................. 119 Angela Swift, Joan Webster, Rebecca Kimble et al Psychopathological symptoms and locus of control in women with low-risk pregnancies ......... 125 CP Puente, FJC Monge, DM Morales

133 News & Reviews Did you miss it? ........................................................................................................................ 133 Book reviews ............................................................................................................................. 134 Author index ............................................................................................................................. 135 Subject index ............................................................................................................................. 135

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From the Editor In the December Digest the focus of the Hot Topic centred on the 20 year anniversary seminar of the Changing childbirth document. The seminar gave rise to the suggestion that whilst changes had been made within the scope of choice and control for women there was still a long way to go. Furthermore, the recommendations made at the time of the document’s inception are still relevant today. They remain the stepping stone to move us into the realms of truly women-centred care, taking into account the individual needs and diversity of the childbearing population. Following on from the previous discussion, this edition’s Hot Topic explores the contradiction in the current provision of maternity care for women in England. In the recent Public Policy Exchange Symposium (2014) discussing quality, safety and choice, the issues surrounding the complexities of delivering a world class midwifery service were raised. McIntosh (p7) invites us to consider what this really means in terms of choice: do women, and midwives to an extent, really have this choice or do the complexities of situation and policy impede this progression? What appears to be emerging is a three dimensional pull, which in theory should attract to each other like magnetism; however, in reality these factors are struggling to achieve cohesion: safety and quality, financial constraints and place of birth. These three factors must be viewed in their entirety and balanced against each other; one cannot work successfully in isolation. Inequality in provision of services must also be considered, for example, although the number of midwifery-led units has increased from 87 in 2007 to 152 in 2013 (NAO 2013), in some areas these units are not being supported and are closing, the latest casualty being the midwifery managed unit in Grantham, Lincolnshire. Women who previously chose to birth in the unit now have to travel a considerable distance to the nearest consultant-led unit.


To move these ideas into reality, we need to gain greater insight into the issues impeding this process and build upon the things that are working well. We still need to find out what it is that women really want during their childbearing experience. Cheyne et al, following the 2013 CQC report, has begun to move this forward in the recent survey undertaken. Women’s experiences were explored and encouragingly the responses have indicated that some improvements have been made since the previous survey. Women on the whole felt that they received a better standard of care in respect of personalised treatment and confidence. Nevertheless, there were still omissions in the levels of communication and information received. The debate also continues over the differences between continuity of care and continuity of carer. In supporting women during pregnancy to achieve a successful and positive experience, we must consider the complex needs that are now causing concern for both women and the health professionals caring for them. In the paper by McGiveron (p35) the topic of obesity is raised, one of today’s complex issues facing many women when embarking upon pregnancy. Ailsa McGiveron is one of a small number of midwives

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who has specialist knowledge of obesity in pregnancy, is passionate about the issue and has developed an extremely successful weight management programme for pregnant women, supporting them in eating healthily, not only during pregnancy but into the postnatal period. Ailsa is of the belief that if we can support women to adopt a healthier lifestyle during pregnancy and encourage new ways of thinking about their diet, then this will not only help the individual woman but also reduce the risk of obesity in their children and subsequently in future generations. An alternative stance relating not only to obesity but also to choices in regard to breastfeeding is needed. What say or rights do infants have in their mode of feeding? For infants to achieve the ‘highest standards of health’ they should be exclusively breastfed for a least the first six months of their lives (WHO & UNICEF 2003). Breastfeeding also reduces the risk of childhood obesity, alongside the protection against many childhood illnesses and disease. In a very recent article, Gribble and Gallagher (2014) consider the rights and choices of mothers and infants in safeguarding situations where there is a risk of separation leading to possible cessation of breastfeeding. Withholding the right or option of breastfeeding puts the infant at risk of both a psychosocial and health-related disadvantage from the outset, therefore increasing health inequality and potential life-long sequelae. Examples of real life situations pertaining to safeguarding cases are illustrated in Gribble and Gallagher’s paper (2014) and make for thought-provoking debate surrounding such issues, see p133. Working together utilising innovative ideas and contemporary evidence-based research through

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networking and the sharing of ideas will help to shape and build the best possible support we can give to all women, incorporating all their diverse needs. What better way to share these ideas than through the forthcoming 30th Triennial International Confederation for Midwives (ICM) Congress which is to be held in Prague June 1-5 this year. This event brings together the largest number of midwives in one place and time from all corners of the globe, to share excellence, not only in practice but also in education and research. The opportunity to network with like-minded midwives opens our eyes to the successes and challenges faced in other countries. Therefore, the theme for this year is well suited — ‘Midwives: improving women’s health globally.’ This theme reflects the Millennium Development Goal 5 (MDG): to improve maternal health. The wide range of presenters will bring together some exciting new ideas and innovations that we can then consider implementing into our own practice areas. I look forward to meeting both old acquaintances and new friends at the ICM Congress, which I shall be writing about in the September issue.

References Gribble KD, Gallagher M (2014). Rights of children inrelation to breastfeeding in child protection cases. British Journal of Social Work. National Audit Office (NAO) (2013). Maternity services in England. London: HMSO. maternity-services-england/ [Accessed 3rd February 2014] Public Policy Exchange Symposium (2014). Quality, Safety, Choice: Delivering a world class midwifery service, 30 Jan 2014 Symposium Proceedings. WHO, UNICEF (2003). Global strategy for infant and young child feeding. Geneva: WHO, UNICEF.

Cathy Ashwin, principal editor. © MIDIRS 2014.


Š Fotolia


Delivering the impossible? The contradiction of maternity care provision Tania McIntosh Introduction

This paper explores the contradiction of maternity care provision in England. The contradiction arises because rhetoric and policy related to the maternity services has, since the early 1990s, enshrined the simple and powerful concept of woman-centred care, but the reality of practice has foregrounded a risk averse agenda increasingly focused on medicalisation. The principle of woman-centred care has at its heart a commitment to choice and control by women over their experience of the childbearing year. Despite this clear and oft-restated aim, the reality of care provision and of the experience of maternity is often very different. The caesarean section rate has risen from around 10% of deliveries in 1990 to 25% in 2011(BirthchoiceUK 2014),* and the concept of ‘complexity’ rather than ‘choice’ appears to drive decision making across the service. This paper explores the dissonance between words and action in the service and the contradictions it leads to. It does this by exploring a trio of recent reports which have examined the state of the maternity services from different perspectives. The first report, Maternity services in England, was published by the National Audit Office (NAO 2013). It was concerned primarily with assessing the extent to which the health service in England, through the Department of Health (DH), got value for money in the delivery of maternity services. The second report examined by this paper is a report by the Care Quality Commission (CQC 2013), National findings from the 2013 survey of women’s experiences of maternity care, which reported on the experiences of women who birthed in February 2013. A report published on behalf of the Scottish government used an adapted version of the CQC survey to explore women’s maternity care experiences in Scotland (Cheyne et al 2014). The final report is that published by the House of Commons Public Accounts Committee (HCPAC 2014) which explored the organisation and funding of the maternity services. All three reports were debated at a meeting held in London in January 2014 which considered the state of maternity services (Public Policy Exchange (PPE) 2014). This paper

suggests that the reality of maternity service provision continues to lag behind in philosophies of care, and furthermore that practice is driven by needs and expectations not accounted for in the rhetoric around choice and women-centred care. If in the 21 years after the publication of Changing childbirth (DH 1993), commitments to choice, control and continuity, as enshrined in that report, have not been met, it is time to examine whether we are going about the right way to meet them, or more fundamentally, whether they retain any meaning as guiding principles.

Background The Hot Topic in the December 2013 edition of MIDIRS Midwifery Digest (McIntosh 2013) explored the development of policy around maternity care in England culminating in Changing childbirth (DH 1993). The paper demonstrated that there have always been diverse strands of influence and expectation working on the development of policy. Midwives, obstetricians, consumers and politicians all had different views and different priorities. In the early 1960s the discourse of risk, as espoused by obstetricians and paediatricians in particular, took root as the guiding principle in the development of policy and the delivery of care. By the early 1990s a growing belief that notions of risk and safety should not be the only determinant in maternity meant that Changing childbirth (DH 1993) was able to develop a different rhetoric. The Changing childbirth report, endorsed by clinicians, politicians and consumers alike, used a new and radical language of choice, control and continuity to describe the direction of

*Equivalent figures are 26% for Wales, 26.6% for Scotland and 30% for Northern Ireland.

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Hot Topic

maternity care (DH 1993). These ‘three Cs’ were intended to be the principles around which care was developed. Alongside these was the intention that midwives should utilise their full range of clinical skills as the ‘lead professional’ in the care of women who were deemed to be at low risk of medical and obstetric complications. At the same time, there was the growing acceptance, at least in some quarters, that birth did not mean a high-tech hospital-based experience. As the Winterton report, which preceded and fed in to Changing childbirth (DH 1993), famously commented: ‘On the basis of what we have heard, this Committee must draw the conclusion that the policy of encouraging all women to give birth in hospital cannot be justified on the grounds of safety… Given the absence of conclusive evidence, it is no longer acceptable that the pattern of maternity care provision should be driven by presumptions about the applicability of a medical model of care based on unproven assertions.’ (House of Commons Health Committee 1992:xii) Given the wide ranging support for the principles of Changing childbirth, which laid down that ‘The woman must be the focus of maternity care’ (DH 1993:8), it might be assumed that the service has developed over the following 20 years in such a way as to enshrine this principle. The objective was to support and improve the experience of all women, including those from marginalised or minority groups, as well as the articulate educated middle classes. Succeeding official reports certainly continued to endorse the arguments and rhetoric of Changing childbirth (DH 1993). Maternity matters (DH 2007) set out the same issues and solutions, with targets for improvements in care to be achieved by 2009. The intention was to: ‘…improve the quality of service, safety, outcomes and satisfaction for all women through offering informed choice around the type of care that they receive, and improved access to services whilst ensuring continuity of care and support.’ (DH 2007:7) This commitment was linked to the National Service Framework for children, young people and maternity services (DH 2004) which had been published three years previously and which set as its maternity standard: ‘Women have easy access to supportive, high quality maternity services, designed around their individual needs and those of their babies’ (DH 2004:6). Other reports built on these principles, including Midwifery 2020, (Midwifery 2020 2010) which explored the contribution midwives could and should make to the delivery of care. They concluded that: ‘A midwife’s focus is to enable all women and their families to have a positive and safe experience of pregnancy, birth and early parenting’ (Midwifery 2020 2010:22). 8

The landscape of maternity since the early 1990s has therefore seemed clear and unchanging. Stakeholders all subscribe to the belief that maternity care should be physically safe and psychologically fulfilling. Women and families should be at the centre of care provision, and their choices and needs should be paramount in the organisation and delivery of service. The problem is, however, that these principles, which sound so obvious and so simple, have proved virtually impossible to implement. A trio of contemporary reports have put this issue into context and are discussed below.

NAO report: Maternity services in England The stated aim of the NAO report published towards the end of 2013 was to: ‘…examine whether the Department of Health is achieving value for money from its spending on maternity services, and look at the performance and management of these services’ (NAO 2013:2). It began by setting out what it described as the ‘key facts’ of maternity care including those associated with place of birth, cost and risk: • 694,241 live births in England in 2012 • £2.6bn was the cost of maternity care in 2012-13 • 87 per cent of women gave birth in obstetric units in hospital in 2012 • £482 million was the cost of clinical negligence cover for maternity in 2012-3 • 152 midwifery-led units in June 2013, an increase from 87 in April 2007 • 1 in 133 babies are stillborn or die within 7 days • 79 per cent of women are within a 30-minute drive of both an obstetric unit and a midwiferyled unit, compared with 59 % in 2007 • 28 per cent of maternity units reported that they closed to admissions for halfa day or more between April and September 2012. (NAO 2013:4). These measures in themselves demonstrate the confused, and confusing, state of the maternity services. The report is exploring risk (negligence cover, rate of perinatal mortality) and choice (availability of services) alongside the total cost of provision. It is not clear which is the most important measure, or whether there is an acknowledgement that improving one measure may have knock-on effects on others. The NAO drew on the objectives for maternity care set out by the DH in its Maternity matters report (DH 2007): • to improve performance against quality and safety indicators • for mothers to report a good experience • to encourage normality in births by reducing unnecessary interventions MIDIRS Midwifery Digest 24:1 2014

Hot Topic

• to promote public health with a focus on reducing inequalities • to improve diagnosis and services for women with pregnancy-related mental health problems. (DH 2013:7) The NAO noted that the DH sought to achieve these objectives through offering choice, providing continuity of care, and providing an integrated service (DH 2013:7). In assessing the extent to which these aims were met in a way which provided value for money the NAO report made one issue clear however: ‘The Department [of Health] did not fully consider the implications of delivering the ambitions set out in its strategy for maternity services. The Department has failed to demonstrate that it satisfactorily considered the achievability and affordability of implementing the strategy. There are potential tensions between different elements of the strategy, such as between choice and quality-and-safety considerations. Reconciling these different elements is challenging for NHS bodies. The Department intended that strategic health authorities and primary care trusts would monitor maternity services through the established NHS performance management arrangements. The Department has not regularly or comprehensively monitored national progress against the strategy.’ (DH 2013:10) In other words, since the early 1990s there has been a contradiction inherent in a service which foregrounds both safety and choice. One of the problems with this is that these two aspirations are not necessarily compatible. It may be possible to have a service which maximises both safety and choice, but it cannot be assumed that the two will go hand in hand. In the 1970s for example, a belief that hospital birth represented the safest option for birth, resulted in a diminution of choice for women around place and style of birth (McIntosh 2012). Although this belief in hospital birth was later shown to be at best simplistic and at worst wrong, the principle that putting safety first meant that choice had to come second has continued in the maternity services. However as the NAO report argued, even this is not the whole story. Regardless of which principle of care is given top billing by policy documents, the DH failed to ensure any kind of meaningful accounting for service provision. This means that there is no way of measuring whether the current service is achieving its stated aims, as there is very little monitoring or audit in place.

CQC report: National findings from the 2013 survey of women’s experiences of maternity care The NAO report used evidence from the CQC to report on women’s experiences of maternity care. The

CQC undertake a national survey triennially, and comparison across surveys allows change over time to be explored.** The most recent report suggested that in some areas the maternity services had made improvements; more women than in the previous survey said they felt listened to, were treated with kindness, and had confidence and trust in the people caring for them during the intrapartum period (CQC 2013:2). Negative experiences of care were however also related to communication and information giving. The concept of continuity of care provoked mixed reactions.*** For some women the idea of continuity of carer was significant; it mattered a lot to be seen by the same midwife and when this did not happen it affected their experience and perception of the quality of their care. Women who reported seeing the same midwife described higher levels of satisfaction, as might have been expected. There was however a third group of women, who did not receive continuity of care but for whom this was not a problem; they also reported satisfaction with their care (CQC 2013:7). Table 1 Source: CQC 2013:8 Whether women saw the same midwife… Yes Yes, but would have preferred not to No, but I wanted to No, but I did not mind Number of respondents



34% 1%

27% 1%

28% 37% 22839

26% 46% 22599

Women linked the provision of continuity of care to not just emotional satisfaction but also to consistency of care of information giving. This implies that they had made a distinction between continuity of carer, which was not perhaps so vital, and continuity of care (eg being given consistent information or support) which mattered a lot. One respondent quoted in the report said that: ‘After-care could have been better by seeing the same midwife. I was given differing information from the four different midwives I was seen by – very contradictory and confusing. This caused emotional upset to myself and difficulty to the rest of my family. Continuity of care was non-existent.’ (CQC 2013:9) When it came to choice the survey found that women felt they were offered some choices about place of birth. Thirty-seven per cent of primiparous women reported they were offered a home birth, 57% a hospital and 37% a midwife-led unit/birth centre. The proportions dropped in all categories for multiparous women, perhaps implying that their previous obstetric history now shut them out of

**The survey questions all women giving birth in one month; in this case February 2013. The Scottish survey (Cheyne et al 2014) surveyed women who delivered in February and March 2014. ***The reports discussed all talk about ‘continuity of care’ although it is clear that they are often conflating this with ‘continuity of carer’. The former implies consistency or message, the latter of personnel.

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Hot Topic

particular options (eg it is possible that women with previous caesarean births might not be offered the option of home birth in a future pregnancy).

be around reducing perinatal deaths, for example, whereas continuity of care was a wish rather than a firmly plotted, or costed, target.

Public Accounts Committee report: Maternity services in England


The Public Accounts Committee of the House of Commons is tasked with scrutinised public spending, and in this capacity explored the condition of maternity services in England (HCPAC 2014). Its summary echoed the findings of both the NAO (2013) and CQC (2013) reports in highlighting the strengths and weaknesses of contemporary maternity care: ‘The vast majority of women have good outcomes from NHS maternity services and most rate the care they receive as excellent or very good. However, performance and outcomes could be much better. The rate of stillbirths and babies dying within seven days of birth is higher in England than in the other UK nations, there is significant variability in the quality of care between trusts, and there are persistent inequalities in the experiences of different groups of women. When NHS maternity care goes wrong, the impact can be devastating for those affected and costly for the taxpayer. Nearly a fifth of spending on maternity services is for clinical negligence cover. The Department of Health (the Department) published Maternity Matters, its strategy for maternity services, in 2007 and yet still has little grip in key areas and little assurance about performance.’ (HCPAC 2014:4) The committee took oral and written evidence from a variety of stakeholders including the Royal College of Midwives (RCM), NCT and the Royal College of Obstetricians and Gynaecologists (RCOG). Overall the committee found that the DH had an over-reliance on the findings of the CQC report (2013) in making policy. The DH did not appear to be cognisant of other sources of evidence about the state of the maternity services, including reports from NCT and the National Federation of Women’s Institutes (NFWI) which might have deepened and contextualised debates about the service (NFWI & NCT 2013). On the issue of choice, for example, although 87% of women gave birth in consultant-led units in 2012, only a quarter wanted to do so and only half of the women who wanted to give birth at home were able to do so (NFWI & NCT 2013). Furthermore the Public Accounts Committee reported confusion among interested stakeholders about which documents were actually supporting policy around maternity care (a policy document covering Wales was developed in 2011 with implementation across the period 2011–2015 (Welsh Government 2011). The DH suggested that the key objectives of Maternity matters were still important drivers, although the committee noted drily that the department failed always to make a distinction between ‘objectives’ and ‘aspirations’ in maternity care. Objectives might 10

Surveys and reports can seem dry and formulaic, far removed from the realities of a short-staffed labour suite, or a bulging-at-the-seams postnatal ward. However for the maternity services, and for midwives, there are some shocking and fundamental issues buried in these slickly produced documents. They are all designed, one way and another, to hold a mirror up to the service and in doing so to hold policy makers to account. The fact that the DH has no meaningful control over either its policy objectives or how and where money is spent in the maternity services, matters not just to accountants and politicians but to midwives and women. The NAO (2013) report highlighted how variable maternity services are across the country, both in terms of outcomes and expenditure. Overall these three reports highlight several issues in the philosophy and delivery of maternity care. These may be summarised as three areas of contradiction: • Safety and choice • Uniformity and individuality • Simplicity and complexity.

Safety and choice Government reports and official rhetoric have as objectives both safety and choice, which rather implies that they are always compatible. This is not necessarily the case however. Both the NAO (2013) and HCPAC (2014) reports noted that service provision was dependent on notions of safety. This meant that units might be closed to admissions for a period of time if they were too overloaded or short staffed to provide safe care. Inevitably such closures have an immediate knock-on effect on the provision of choice for women, who may find themselves diverted to a different unit in labour to that for which they had booked care. On a longerterm basis the arm’s length position taken by the DH allows local commissioning bodies to choose how to organise services. Some areas may choose to concentrate services in a few large hospitals with the aim of ensuring the levels of consultant cover recommended by the RCOG. This arguably might add to the safety of provision for high-risk maternities, but the concomitant closure of smaller units would affect choice for everyone else. Evidence stretching back to the 1970s suggests that for some women physical safety is not the only consideration, and other factors such as psychological well-being impact on the experience of maternity (McIntosh 2012). In these situations ‘choice’ is not an optional extra once safety has been ensured, but a fundamental part of the whole package. Interestingly the CQC survey focused on concepts of choice, participation in decision MIDIRS Midwifery Digest 24:1 2014

Hot Topic

making and issues of communication; it did not ask women for their views or expectations around safety (CQC 2013:3). This implies that safety is seen as a concern for practitioners, but somehow not for women.

Uniformity and individuality At the meeting held in London in January 2014 to discuss the NAO committee report in particular (PPE 2014) Carmel Bagness, the midwifery and women’s health advisor at the Royal College of Nursing, commented on the growing commitment of maternity services to ‘personalised’ care. In its simplest form this is another way of describing the provision of one-to-one care in labour. Taken more broadly it suggests another contradiction at the heart of maternity services. Women are promised provision which is women- and family-centred, responsive to the needs of the individual whatever her social or obstetric circumstances. This would suggest that care pathways would necessarily be different for every maternity, with as many possibilities as there are women. Even if this is fanciful, it certainly seems to point to the requirement for services to be locally mediated and flexible taking into account the particular circumstances of women in a given area at a given point in time. Set against this is the concern of the NAO and PAC that the service is actually too fragmented, too variable, and too different in terms of spend, provision and outcomes. The NAO drew attention to wide variations across the country both in terms of practice (eg rates of caesarean birth, induction of labour and instrumental delivery) and management (eg numbers of midwives, bed occupancy). The call by the NAO and PAC is for greater control by the DH over what is expected of a maternity service and how it should be achieved. This would make measurement and auditing potentially easier, but would not allow for the complexities of local conditions and health needs.

Simplicity and complexity The final area of contradiction highlighted by the trio of reports under discussion is that of the tension between simplicity and complexity in service provision. Most commentators are agreed that effective maternity care relies on a positive relationship between women and their caregivers. This is enhanced by good communication, by the provision of choice, and for some women by continuity of care. At its heart maternity care relies on these deceptively simple human elements. Maternity is, however, becoming increasingly complex both for individuals and for communities. Changing demographics mean that older women are starting families, and are coming to maternity with a greater likelihood of pre-existing health needs. The birth rate has been rising for nearly ten years and has not yet plateaued, and immigration is impacting on provision. The range and reach of complexities have MIDIRS Midwifery Digest 24:1 2014

a significant effect on the cost and type of provision required. They are linked to complexities within the midwifery workforce which is agreed to be around 2300 midwives below strength and which has an aging workforce at one end and problems of student attrition and recruitment at the other (HCPAC 2014). Models of care espoused as producing greater levels of safety and satisfaction for women, such as case loading schemes which offer one-to-one care, can leave midwives exhausted and burned out (Young 2011). The evidence suggests that some women may want continuity, but many midwives are unable or unwilling to work that way.

Conclusion This paper has explored the findings of three recent pieces of work examining the functioning of the maternity services. The reports under examination all looked at different aspects of policy and experience, but drew some similar conclusions about the strengths and weaknesses of the service as presently configured. Maternity provision is greatly valued by women and families, and in the vast majority of cases provides a service which is safe and supportive. It is challenged however by a variety of contradictions which impact on policy and practice. The difficulties are caused by trying to provide a service which is everything to everyone and compounded by increasing budgetary pressures. These issues matter not just to policy makers but to midwives who are striving to provide the best possible service and to women who expect and deserve a high level of care. It is up to all those involved in maternity care to debate the challenges and contradictions inherent in the service. Looking forward it is time to reach a consensus about what we want from a maternity service and how in practical terms it might be achieved, in order to avoid the constant challenge of trying to deliver the impossible.

References BirthchoiceUK (2014). Caesarean rates. http://www.birthchoiceuk. com/Professionals/Frame.htm [Accessed 4 February 2014]. Care Quality Commission (CQC) (2013). National findings from the 2013 survey of women’s experiences of maternity care. maternity_report_for_publication.pdf [Accessed 12 February 2014]. Cheyne H, Skår S, Paterson A et al (2014). Having a baby in Scotland 2013: women’s experiences of maternity care. Volume 1: national results. [Accessed 10 February 2014]. Department of Health (DH) (1993). Changing childbirth: Part 1: report of the Expert Maternity Group. London: DH. Department of Health (DH) (2004). National Service Framework for children, young people and maternity services. London: DH. Department of Health (DH) (2007). Maternity matters: choice, access and continuity of care in a safe service. London: DH.


Hot Topic House of Commons. Health Committee (1992). Second report [session 1991-1992]. maternity services. Volume 1: report together with appendices and the proceedings of the committee. [Chair: Nicholas Winterton]. [The Winterton Report]. London: HMSO. House of Commons Public Accounts Committee (HCPAC) (2014). Maternity services in England. Fortieth report of session 2013-14. London: The Stationery Office Ltd. McIntosh T (2012). A social history of maternity and childbirth: key themes in maternity care. Abingdon: Routledge. McIntosh T (2013). Changing childbirth: consigned to the ‘shelf of history?’ MIDIRS Midwifery Digest 23(4):415-20. Midwifery 2020 (2010). Midwifery 2020: delivering expectations. London: Midwifery 2020 Programme. government/uploads/system/uploads/attachment_data/file/216029/ dh_119470.pdf [Accessed 13 February 2014]. current-news-and-events/more-midwives/research-findings [Accessed 10 February 2014]. Public Policy Exchange (2014). Quality, safety, choice: delivering a world-class midwifery service, [Symposium]. 30th January 2014, Broadway House, Westminster, London. http://www. [Accessed 10 February 2014] Welsh Government (2011). A strategic vision for maternity services in Wales. Cardiff: Welsh Government. dhss/publications/110919matstrategyen.pdf [Accessed 10 February 2014]. Young CM (2011). The experience of burnout in case loading midwives:an interpretive phenomenological study. [Unpublished PhD thesis] Auckland University of Technology.

National Audit Office (NAO) (2013). Maternity services in England. London: NAO.

McIntosh T. MIDIRS Midwifery Digest, vol 24, no 1, March 2014, pp 7–12.

National Federation of Women’s Institutes (NFWI), NCT (2013). Support overdue: women’s experiences of maternity services.

Original article. © MIDIRS 2014.


MIDIRS Midwifery Digest 24:1 2014

Research / Education ORIGINAL

A guide to the MIDIRS Reference Database Michelle Brumby, joint head of Information Services, MIDIRS When MIDIRS was born almost thirty years ago, our subscribers received photocopied ‘information packs’ in the post rather than the glossy journals they’re used to now. But despite the crude nature of that first midwifery offering, the process behind it was anything but and led to the creation of the MIDIRS Reference Database. A behemoth of midwifery information, the Reference Database has belied its humble roots to become the largest of its kind in the world. Back in early 2011, MIDIRS unveiled a new and improved Reference Database. With a fresh new interface and extended functionality, the new Database made accessing essential information an easier and more interactive experience. Since the relaunch two years ago, a staggering 32,000 new records have been added to the Database, which currently contains around 203,000 references covering all topics relating to maternity care, including: • Preconception care • Pregnancy • Antenatal care and education • Labour and birth • Infant feeding • Postnatal care • Transition to parenthood • Care of the infant from birth to two years • Maternity services • Midwifery practice.

So, if you are new to MIDIRS or just need a reminder of what a fantastic resource it is, here is a quick guide to help you to g et the most out of the Database. Is the database full text? We would love to offer full text access to our information to all our subscribers, but unfortunately the costs are prohibitive and we would rather keep subscription costs down. Database subscribers do get full text access to MIDIRS Midwifery Digest articles and we always let you know if an article is available free to view online.

Searching the Database There are three ways of finding information: • Basic search • Advanced search • Browsing our search packs. Basic search The basic search is a great place to start – especially if you just beginning your research or are happy to browse through a wide range of results. Simply type your search term into the box (Fig. 1) Search results can be sorted by relevance, by newest or oldest articles and also by article type, for example original article, systematic review, guidelines etc (Fig. 1).

Did you know? The first article to be added to the Database was a book chapter by Robinson S, Golden J and Bradley S – ‘The role of the midwife in the provision of antenatal care’ from Effectiveness and satisfaction in antenatal care, published in 1982.

The Database is updated on a daily basis and approximately 1000 new article abstracts are added every month by MIDIRS team of information specialists, who scan over 400 information sources*.

Fig 1

*Information sources include print and online journals, books, official statistics, Cochrane reviews, government publications/reports from other professional bodies (eg RCM, RCOG, NMC), clinical guidelines (eg NICE, Department of Health etc), parliamentary reports, consumer information, news items, audiovisual materials, conference proceedings and other ‘grey literature’.

MIDIRS Midwifery Digest 24:1 2014


Research / Education

Advanced search The advanced search lets you build your search query quickly and easily by using interactive, field-based searching. This allows you to better focus your search and save yourself valuable time. With the advanced search, you can combine searching specific fields such as author, article title or abstract to retrieve more targeted results. For example, to find the systematic review by Ryan et al (2013)1 published in Midwifery journal, enter ‘Ryan’ in the first search field and choose [Author] from the Select a field dropdown menu, enter ‘midwife-led’ in the [Title] field and ‘Midwifery’ in the [Publication] field (Fig 2).

Live Database help from MIDIRS Information specialists as you search – just click to chat with us!

Browsing MIDIRS Search Packs

Figure 2

Ryan P, Revill P, Devane D et al (2013). An assessment of the cost effectiveness of midwife-led care in the United Kingdom. Midwifery 29(4):368-76.


Clicking on search options will expand the search further, giving you the option of sorting your results by relevance, by newest or oldest articles or by article type (eg original research, systematic review, guidelines etc). Search results are listed in sets of ten. To move on to the next set of results, click on page numbers or ‘Next’ or ‘Last page’ links at the bottom of each page. Each article results is displayed in its own tabbed box (Fig 3). Each reference has an author abstract or summary written by one of the MIDIRS Information team.

If you are having trouble finding what you’re looking for or don’t have the time to search, our pre-prepared Search Packs are a great way of providing easy access to over 560 key midwifery topics. To search our Search Packs, follow these three simple steps: • Select your main area of interest (eg breastfeeding, postnatal care) • Select a sub-category (eg promotion and support) • Select the title of the Search Pack you wish to view. Each search pack provides you with a list of bibliographic references and article abstracts. You can then use this list to source full text from your university or Trust library, or order photocopies direct from MIDIRS. Tip!

• Use ‘Boolean’ searching to combine words and phrases using the words AND, OR and NOT in order to limit, broaden or define your search. • Use AND to narrow your search and include only articles containing both terms (eg vitamin D AND pregnancy) • Use OR to widen your search and include articles containing either term (eg Down syndrome OR trisomy 21) • •Use NOT to exclude terms (eg postpartum haemorrhage NOT developing countries).

Figure 3

Tip! You can ‘truncate’ search terms to retrieve articles containing variations of a term by using an * (asterisk). Simply enter the first few letters of your search term followed by the asterisk, eg breast* will retrieve breastfeeding, breastfed and breastfeed.


Tip! Keep it simple. Try not to type whole sentences or paste article titles into the search box. Simple terms such as ‘water birth’ or ‘continuity of care’ will retrieve more results.

MIDIRS Midwifery Digest 24:1 2014

Research / Education

Still can’t find what you’re looking for? If you are struggling to find the information you need, or simply don’t have time to look, MIDIRS team of information specialists can conduct a Bespoke Search of the Database on your behalf – contact us on 0117 925 1791 to discuss your requirements or fill in the order form on the Information Services pages of the MIDIRS website. Alternatively email the Information team at Don’t forget – you can also get instant access to our Information team by using our new live chat service – available in the bottom right have corner of all our Information pages. We are online Monday to Friday during office hours but you can still submit queries out of hours and we will get back to you as soon as we are back in the office.

The Database facts

• Type: Bibliographic • Number of records: approx. 203,000 • Update frequency: Updated daily (approx. 100 records added each day) • Coverage: Earliest record 1857 with comprehensive coverage from 1988 • Subject coverage: Midwifery profession and practice worldwide, preconception care, pregnancy, antenatal care and education, labour/ birth, postnatal care, infant feeding and care of the infant up to two years of age • Sources scanned: Over 400 journals and other sources scanned for inclusion.

How do I sign up? To sign up to the MIDIRS Reference Database, email or fill in the subscription form online at Brumby M. MIDIRS Midwifery Digest, vol 24, number 1, March 2014, pp 13-15. Original article. © MIDIRS 2013.

Complex interventions and their implications for systematic reviews: a pragmatic approach Petticrew M, Anderson L, Elder R, Grimshaw J, Hopkins D, Hahn R, Krause L, Kristjansson E, Mercer S, Sipe T, Tugwell P, Ueffing E, Waters E, Welch V Complex interventions present unique challenges for systematic reviews. Current debates tend to center around describing complexity, rather than providing guidance on what to do about it. At a series of meetings during 2009–2012, we met to review the challenges and practical steps a reviewer could take to incorporate a complexity perspective into systematic reviews. Based on this, we outline a pragmatic approach to dealing with complexity, beginning, as for any review, with clearly defining the research question(s). We argue that reviews of complex interventions can themselves be simple or complex, depending on the question to be answered. In systematic reviews and evaluations of complex interventions, it will be helpful to start by identifying the sources of complexity, then mapping aspects of complexity in the intervention onto the appropriate sources of evidence (such as specific types of quantitative or qualitative study). Although we focus on systematic reviews, the general approach is also applicable to primary research that is aimed at evaluating complex interventions. Although the examples are drawn from health care, the approach may also be applied to other sectors (eg social policy or international develop¬ment). We end by concluding that systematic reviews should follow the principle of Occam’s razor: explanations should be as complex as they need to be and no more. Petticrew M, Anderson L, Elder R et al. Journal of Clinical Epidemiology, vol 66, no 11, 2013, pp 1209–1214. Author abstract. © Elsevier Ltd 2013.

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Pregnancy ORIGINAL

Bumps & Beyond – the way forward? Ailsa McGiveron Obesity is one of the greatest public health challenges of the 21st century. According to the World Health Organization (WHO) its prevalence has tripled in many countries of the European region since the 1980s (WHO 2013), and the numbers of those affected continue to rise at an alarming rate. More than 1.4 billion adults are overweight and at least 300 million women are classed as clinically obese (WHO 2013). England, along with the rest of the United Kingdom (UK), has one of the highest rates of obesity within Europe (European Commission 2011). There was a marked increase in the proportion of women that were obese, from 16% in 1993 to 26% in 2011 (HSCIC 2013). Modern living ensures every generation is heavier than the last — a trend known as ‘Passive Obesity’ (Foresight 2012). Human biology is becoming overwhelmed by the effects of today’s ‘obesogenic’ environment, with its abundance of energy-dense foods, motorised transport and sedentary lifestyles. The people of Britain are getting heavier simply by living in the Britain of today. Being overweight is becoming the norm. The rate of increase in overweight and obesity, in both adults and children, is so striking that it is forecast that by 2050 Britain could be a mainly obese society (Foresight 2012). This increase in prevalence of obesity in the general population is a serious public health concern. The National Health Service (NHS) costs attributable to overweight and obesity related conditions are projected to reach £50 billion per year by 2050 (Foresight 2012). People who are overweight have a higher risk of developing type 2 diabetes, heart disease and certain cancers (Kopelman 2007 cited in Foresight 2012). Excess weight can also make it more difficult for people to find and keep work, and it can affect self-esteem and mental health (Foresight 2012). As the number of obese women increases, so does the number of women who are obese at the start of their pregnancies and this has, and will continue to have, a serious impact on maternity services. Obesity in pregnancy has serious implications for both the mother and her infant and increases the demand on maternity unit resources. The scale of maternal obesity deems it necessary to plan service delivery and identify ‘at risk’ groups to target priority areas for intervention. MIDIRS Midwifery Digest 24:1 2014

Half of pregnant women in the UK are overweight (Body Mass Index (BMI) of >25–29.9kg/m2) or obese (BMI of >30kg/m2) (WHO 2013). This is associated with an increased risk of poor pregnancy outcomes and long term ill health for both mother and baby. Obesity is now the most commonly occurring risk factor in obstetric practice (Krishnamoorthy et al 2006). Lewis (2011) found that half of the women who died during pregnancy, childbirth or within 42 days of childbirth were either overweight or obese. In addition, when considering obesity alone, 30% of mothers who died from direct causes were obese as were 24% of women who died from indirect causes: 27% overall (Lewis 2011). In terms of the impact of maternal weight on specific causes of death, it was most significant for mortality from thromboembolism, where 78% of the mothers who died were overweight or obese. There are no current guidelines for weight gain in pregnancy in the UK; recommendations are often based on the United States’ Institute of Medicine guidelines (IOM 2009) which propose weight gains of: • 11.5–16kg for healthy weight women • 7–11.5kg for overweight women • 5–9 kg for obese women. Obesity arises from a combination of consuming too many calories and not taking enough physical activity (FSA 2009). Ideally, women would optimise their weight before pregnancy. However, it is acknowledged that up to 50% of pregnancies are unplanned (Schünmann & Glasier 2006, Nettleman et al 2007, Rowlands 2007). The Foresight report (2012) identifies pregnancy as a critical period 39


Putting you first is at the heart of everything we do Š Lincolnshire Community Health Services NHS Trust. 40

MIDIRS Midwifery Digest 24:1 2014


to address obesity in a woman’s life course and to initiate behaviour change. It is increasingly recognised that pregnancy and the early years are the intervention opportunities most likely to impact on the obesity epidemic. Women who start their pregnancies with a BMI >30kg/m2, have poorer pregnancy outcomes than the general population. The complications of obesity during pregnancy have far reaching implications for both mother and newborn. Obesity in pregnancy is associated with an increased risk of miscarriage, gestational diabetes, pre-eclampsia, thromboembolism, instrumental delivery, caesarean section and maternal death (CMACE & RCOG 2010). In addition, the baby faces a higher risk of congenital anomaly, obesity (in later life) and fetal death (Ramachenderan et al 2008). Maternal obesity, unsurprisingly, is associated with increased maternal costs (Galtier-Dereure et al 2000). All pregnant women with a booking BMI >30kg/ m2 should be provided with accurate and accessible information with regards to the risks associated with obesity in pregnancy and how they may be minimised (CMACE & RCOG 2010). The concept of a healthy diet can be confusing to many women as is the advice they subsequently receive. Midwives often find the subject of obesity difficult to approach as it is such an emotive subject. Midwives are concerned with building trusting relationships with women but when the topic of obesity is raised, barriers are often created at a time when many women feel at their most vulnerable. Many midwives find broaching the subject difficult because of their own issues with weight and often give it a cursory mention and then leave well alone. However, most women who are obese are fully aware they are, but do not have the means, resources or awareness of how to deal with it. Therefore, women may want, and certainly need, health professionals to address the subject directly. The individual of course, has to make the decision to change familiar patterns of behaviour. This cannot be achieved without education and support provided by midwives at the outset. The CMACE& RCOG guidelines (2010:6), state that: ‘Women should be made aware of the importance of healthy eating and appropriate exercise during pregnancy in order to prevent excessive weight gain and gestational diabetes. Dietetic advice by an appropriately trained professional should be provided in early pregnancy.’ In addition, the Nursing and Midwifery Council’s code of conduct (NMC 2008:1) states that midwives have a responsibility to ‘work with others to protect and promote the health and wellbeing of those in your care, their families and carers, and the wider community’, and to ‘support people in caring for themselves to improve and maintain their health’. In order to do this, midwives need robust training and support on the subject in order to deliver consistent MIDIRS Midwifery Digest 24:1 2014

information and provide the vital support. Local NHS Trusts are expected to develop services so that pregnant obese women can be identified and their associated issues addressed. However, resources, staffing, funding and workload were reported as issues that would affect the implementation of any recommendations and determine their impact (Smith et al 2010). The Royal College of Midwives (RCM) in partnership with Slimming World produced a leaflet, which was given to all midwives, containing comprehensive guidelines to steer them through the process of discussing weight issues. There is a lack of published evidence on the management of obesity during pregnancy. Tackling it requires far greater change than anything tried so far. Maternity service health care practitioners and community service providers have identified that partnership work and community public health services are essential in the development of interventions for maternal obesity since it is a public health problem rather than an isolated maternity issue. However, little is known about how maternity services can best work with external agencies and with obese pregnant women to improve their experience and health outcomes. Whilst specific maternal obesity targets do not exist, a number of related public service agreement targets would benefit from interventions directed at reducing the prevalence of maternal obesity (Khazaezadeh et al 2011). These include reducing the childhood obesity rate, increasing breastfeeding initiation rates and reducing health inequalities to tackle infant mortality by optimising maternal nutrition. In Lincolnshire, an antenatal weight management service called ‘Bumps & Beyond’ was devised in response to the publication of the CMACE & RCOG guidelines (2010) and the growing number of women booking with a BMI >30kg/m2 at Lincoln County Hospital, part of United Lincolnshire Hospitals (ULH) NHS Trust. Whilst there were several weight management services in the local area, pregnant women were excluded from these and there were limited exercise opportunities. Lincolnshire Community Health Services (LCHS) provided funding for one midwife with a degree in nutrition to research the idea of an antenatal weight management service for Lincolnshire. How could this group of women reduce the risks they face? Pregnant women are supported to give up smoking in pregnancy, why not help them with weight management? Is this viable? Does anything like this exist and can one person set up a successful service on limited funding? An audit was carried out to compare the pregnancy outcomes for two cohorts of women: one cohort having a BMI 20–24.9kg/m2 and the second with a BMI 30–40kg/m2. Both cohorts were primigravida, non-smokers with no medical histories. Table 1 (below) shows some of the results:



Table 1 Results of audit showing outcomes for women with BMI 20–40kg/m2 Condition

BMI 20–24.9kg/ m2

BMI 30–40kg/m2

Induction of labour (IOL)



IOL for raised blood pressure



Raised blood pressure






Antepartum haemorrhage



Difficult to scan/monitor*



Emergency caesarean section






Premature labour



Postpartum haemorrhage



* A sentence saying ‘difficult to scan/monitor/palpate’ being recorded in the hospital notes at least once during pregnancy

The results clearly showed that obese pregnant women have poorer pregnancy outcomes than those women with a normal BMI. Time was allocated for research into similar initiatives around the country and how they approached the challenge of supporting this group of women. In addition, pregnant obese women were questioned with regards to how they would view such a service, whether they would favour face-to-face consultations or group consultations, where they would choose to attend for appointments and the terminology they would prefer. The initiative was designed in such a way that the women would be seen regularly throughout their pregnancies for continued support. To avoid any unnecessary stigmatisation the initiative was named ‘Bumps & Beyond’. It was felt that the name encompassed the ethos of the service, which is to promote confidence in women to make positive changes in their lifestyle for the benefit of themselves, their babies and their families as they grow and develop. Bumps & Beyond was designed to provide constant support throughout pregnancy. This was fundamental in building a trusting relationship with the women who are undertaking the intervention. One-to-one support and advice is provided over seven sessions from approximately 16 weeks of pregnancy, with a final postnatal visit at six weeks. It was decided that for the service to be a success, a team approach was essential. The pilot site for the initiative was Lincoln County Hospital. Bumps & Beyond work closely with midwifery managers and consultants. There is a dedicated obstetric consultant who is responsible for seeing all pregnant women with a BMI ≥35kg/m2 for a plan of care in her specialist clinic. A specific obesity proforma — a care pathway — for women with a BMI ≥30kg/m2 was 42

designed in accordance with the Clinical Negligence Scheme for Trusts (NHSLA 2012). This is completed by a midwife at the first hospital contact and placed in the main hospital maternity notes, readily available for all staff to refer to when caring for the individual. This care pathway has removed potential barriers for those referring women to the service. This, and the training the midwives have received from the healthy lifestyle midwife (HLM), has enabled them to have a more frank and informative discussion with women about healthy weight management during pregnancy. The HLM lead designed a session booklet containing information and advice based on the seven sessions, a copy of which was given to each attender, and a Bumps & Beyond logo was also designed. The service was launched in April 2012 when LCHS secured funding from Public Health to employ a HLM on a full-time, permanent basis. This means that LCHS provide the service for ULH NHS Trust, free of charge. Women with a BMI 30–34.9kg/m2 are seen in all consultant clinics by antenatal clinic midwives who have received training from the HLM on how to discuss the increased risks and complications faced by obese pregnant women and how they can limit their weight gain in pregnancy. The midwives discuss with the women how to make small but positive changes to their lifestyles and hence help to limit weight gain in pregnancy. This ‘brief intervention’ includes advice on taking regular exercise throughout pregnancy and the benefits this provides both physically and mentally. Bumps & Beyond work closely with exercise specialists and health trainers and have links with council run exercise referral schemes and walks. Women can be referred to these schemes both antenatally and postnatally and in addition, health trainers are able to provide continued support around the subject of healthy eating postnatally. Women who have a BMI >35kg/m2 see the HLM when they attend hospital to see the consultant for their plan of care. The HLM discusses the risks they face in pregnancy due to their obesity before they see the consultant. The Bumps & Beyond intervention is explained and the women are encouraged to attend from approximately 16 weeks of pregnancy on a oneto-one basis. The HLMs work closely with anaesthetists, obstetric physiotherapists and infant feeding coordinators to provide a care package suited to this group of women. The service in Lincoln proved very successful and in April 2013 Bumps & Beyond was launched in Boston, also part of ULH NHS Trust. Currently, an advisor is completing her training to launch the service in Grantham and Gainsborough, the next area to benefit from Bumps & Beyond. The service has a HLM lead, a HLM and two healthy lifestyle advisors who are not midwives. The service has been adapted for the Boston area in which it is running, enabling the HLM lead to oversee the service and the advisor to concentrate on the intervention. MIDIRS Midwifery Digest 24:1 2014


The antenatal clinic midwives have been trained to complete the obesity proforma for each woman and to discuss the risks with them. The woman is subsequently contacted by the HLM and advisor to arrange an appointment with Bumps & Beyond. The intervention is based around seven one-toone appointments. The content of each session is structured but is easily adaptable to the woman’s needs and knowledge. Sessions cover subjects such as basic nutrition, exercise, food labels and shopping, cooking, breastfeeding, behaviour change, maintaining change and coping with lapses. Goal setting is the key to the changes and the women are encouraged to set their own goals at the end of the first session for the forthcoming few weeks. The outcomes for every woman with a BMI >35kg/ m2 have been analysed by Nottingham University research department for the first 18 months of the service and they have stated that: ‘There is strong evidence that the intervention is an effective way of controlling and preventing weight gain in severely obese women. Continuation of the service is likely to bring about significant decreases in the occurrence of poor pregnancy outcomes associated with obesity.’ In addition they concluded that, for women with a BMI ≥35kg/m2, the intervention reduced the risk or incidence of pregnancy complications by 67%, raised blood pressure by 87%, pre-eclampsia by 96% and labour complications by 75%. Women who had a healthy, uncomplicated pregnancy gained less weight (6.4kg) than those who did suffer complications (9.0kg), highlighting the importance of weight management. Women in the non-intervention group (those who declined the intervention or who failed to attend appointments), were 1.6 times more likely to have complications than women who completed the intervention. The intervention had a dramatic effect upon the risk of hypertensive complications and specifically pre-eclampsia. Women who did not attend the intervention were ten times more likely to develop hypertensive complications and ten times more likely to develop pre-eclampsia. Results also showed that women whose labours were induced were, on average, 4kg heavier than women who experienced spontaneous labour, again indicating the importance of weight management. The data was suggestive of a beneficial effect on postpartum haemorrhage, with the intervention reducing the risk by 43%. With regard to breastfeeding, those who completed the intervention were 3.2 times more likely to initiate breastfeeding at birth, than women who did not attend. When considering weight gain, it was found that all non-intervention women gained weight during pregnancy (range 1–26kg), but 21% of the intervention actually lost weight (up to 4kg). The two groups were of similar weight at booking, non-

MIDIRS Midwifery Digest 24:1 2014

intervention 105kg and intervention 107kg. Women in the intervention group gained significantly less weight from booking to 36 weeks (less than half). It was reported that 92% of the intervention women either lost weight or gained less than 9kg. Evaluation of the service by the women who have attended is very positive. Comments made include, ‘what an amazing programme’, ‘it has had a positive effect on my whole family’, ‘this has changed my attitude to food and a healthy lifestyle’, ‘where was this service in my last pregnancy?’ and ‘I would recommend this service to anyone’. When designing the service, the appointment venue was of paramount importance. When women were questioned, they stated that they would prefer the appointments to be held at hospital venues as they would view this as ‘more important than Children’s Centres and it would encourage them to attend’. Bumps & Beyond hold their appointments within the antenatal clinics at the hospitals and also in the LCHS health shops around the county to provide alternative venues. These are in high streets and are centrally located in towns and cities and have again, proved popular. Setting up and launching Bumps & Beyond has not always proved easy! Funding is the main issue. Bumps & Beyond is funded by Public Health until March 2014. Currently, the decision to recommission the service has not been announced. The design of the service was very much a personal decision. Bumps & Beyond is currently the only service of its kind. The HLM lead designed the service around how she would like a service to be if it was one she could access. Time restrictions and work load were an issue. At the launch of the service at LCH the HLM lead ran the clinics, promoted the service, trained the midwives and laid the groundwork for the launch of the service at Boston Pilgrim Hospital until the appointment of a second HLM. Client resistance at the initial consultant appointments can prove challenging. However, this is generally because the woman is not aware of the risks her weight is having on her pregnancy. Many engage quickly once these have been discussed and embrace the intervention. Those who do not join the intervention, often sadly go on to gain too much weight and develop complications. Now the service has been available for over 18 months, women are attending for the second time. Some of the women who have attended the intervention before, contact the HLMs saying, ‘please tell me this service is still available!’ Some of the women who declined the service the first time around, now ask to join when pregnant the next time. As the service goes from strength to strength, Bumps & Beyond want to expand into pre-conception advice and support and educate teenagers in schools about the risks of obesity in pregnancy. The HLM lead has



been interviewed on local radio about the service and why it is important and has also appeared on ITV’s ‘Daybreak’ programme to discuss the issues around obesity in pregnancy and the development of Bumps & Beyond. Calories appear to be the new ‘tobacco’. Midwives cannot ignore this issue and need to tackle it head on. Should the situation concerning obesity in the UK remain, or indeed get worse, it would be natural to assume that so too will the strain on maternity services. There is clearly a case for early intervention. As with the majority of health issues, prevention is better than cure. Although midwives generally enter the picture post-conception, women need advice and support to prevent excessive weight gain in their pregnancy and hence, prevent them entering subsequent pregnancies with excess weight, only to gain more weight and put their following pregnancy at risk. Ailsa McGiveron, healthy lifestyle midwife lead, Lincolnshire Community Health Services. Ailsa McGiveron designed and implemented ‘Bumps & Beyond’, an antenatal weight management service in Lincolnshire to support obese pregnant women to limit their weight gain in pregnancy. More information is available at: Public/content/bumps-beyond

References Centre for Maternal and Child Enquiries (CMACE), Royal College of Obstetricians and Gynaecologists (RCOG) (2010). CMACE/ RCOG joint guideline: management of women with obesity in pregnancy. London: CMACE/RCOG. European Commission (2011). Eurostat. Overweight and obesity BMI statistics. index.php/Overweight_and_obesity_-_BMI_statistics [Accessed 28th October 2013]. Food Standards Agency (FSA) (2009). Eat well, be well. http:// [Accessed 1 November 2013]. Foresight (2012). Tackling obesities: future choices - project report. 2nd ed. London: Government Office for Science. Galtier-Dereure F, Boegner C, Bringer J (2000). Obesity and pregnancy: complications and costs. The American Journal of Clinical Nutrition 71(5) (Suppl 5):1242s-8s. Grant R (2012). A weighty issue. Midwives 5:42-3

Statistics on obesity, physical activity and diet: England 2013. Leeds: HSCIC. [Accessed 17 December 2013]. Institute of Medicine (IOM) (2009). Weight gain during pregnancy: re-examining the guidelines. Washington DC: National Academy Press. Khazaezadeh N, Pheasant H, Bewley S et al (2011). Using serviceusers’ views to design a maternal obesity intervention. British Journal of Midwifery 19(1):49-56. Krishnamoorthy U, Schram CMH, Hill SR (2006). Maternal obesity in pregnancy: is it time for meaningful research to inform preventive and management strategies? BJOG: An International Journal of Obstetrics and Gynaecology 113(10):1134-40. Lewis G ed (2011). Saving mothers’ lives: reviewing maternal deaths to make motherhood safer: 2006-2008. The eighth report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG: An International Journal of Obstetrics and Gynaecology 118(Suppl 1):1-203. Nettleman M, Brewer J, Ayoola A (2007). Reasons for unprotected intercourse in adult women: a qualitative study. Journal of Midwifery & Women’s Health 52(2):148-52. NHS Litigation Authority (NHSLA)(2012). Clinical Negligence Scheme for Trusts (CNST). Maternity. Clinical Risk Management Standards. Version 1 2012/13. London: NHSLA. Nursing and Midwifery Council (NMC) ( 2008). The code: standards of conduct, performance and ethics for nurses and midwives. London: NMC. [Accessed 17 December 2013]. Ramachenderan J, Bradford J, McLean M (2008). Maternal obesity and pregnancy complications: a review. Australian and New Zealand Journal of Obstetrics and Gynaecology 48(3):228-35. Rowlands S (2007). Contraception and abortion. Journal of the Royal Society of Medicine. 100(10):465-8. Schünmann C, Glasier A (2006). Measuring pregnancy intention and its relationship with contraceptive use among women undergoing therapeutic abortion. Contraception 73(5):520-24. Smith R, Evans R, Kathrecha P (2010). Fieldwork on weight management during pregnancy and after childbirth. Report to the National Institute for Health and Clinical Excellence. London: Greenstreet Berman. World Health Organization (WHO) (2013). Obesity and overweight factsheet. Geneva: WHO.

McGiveron A. MIDIRS Midwifery Digest, vol 24, no 1, March 2014, pp 39-44. Original article. © MIDIRS 2014.

Health and Social Care Information Centre (HSCIC) (2013).


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Labour & Birth ORIGINAL

Go with the flow: a comparison of early and delayed umbilical cord clamping Charlotte Salter The most suitable time to clamp and cut the umbilical cord after delivery has been questioned for many years; however an answer has not been reached (Mercer 2001). Researchers, midwives, obstetricians and neonatologists have debated the optimum timing of umbilical cord clamping for decades. The Resuscitation Council (UK) (2010) has changed its guidance and now suggests the umbilical cord should be left unclamped for at least one minute after delivery in an uncompromised infant, as this improves iron status of term infants during early infancy. Umbilical cord clamping should be delayed for up to three minutes in preterm infants as increased blood pressure, fewer blood transfusions and a reduced risk of intraventricular haemorrhage can result. Clamping and cutting the cord immediately after delivery has been shown to interrupt the normal physiological process of placental transfusion and separation; this can lead to complications in the mother and deprives the baby of cord blood. We have been disrupting this process since the 17th century, so why does this practice still continue when we know there is a better alternative? The following article, exploring this issue, is from a dissertation undertaken during midwifery training at Anglia Ruskin University.

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compromised neonates suggests resuscitation measures should take priority until research suggests otherwise. These guidelines follow recommendations from the European Resuscitation Council (Richmond & Wyllie 2010), who have adopted the 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations (Wyllie et al 2010). They state that DCC for at least a minute improves the iron status of term newborns and DCC for up to three minutes with uncompromised preterms causes increased blood pressure during stabilisation, decreased risk of intraventricular haemorrhage (IVH) and reduces the number of blood transfusions required (Resuscitation Council (UK) 2010, Wyllie et al 2010).


Pregnancy and birth are normal physiological events; medical interventions are only necessary if beneficial to mother or baby (DH 2004, DH 2007, Gurnsey & Davies 2010). There is no evidence that early cord clamping (ECC) benefits mother or baby; it is an intervention which interrupts the physiological process. Gallagher & Hutchon (2010) explain that delayed cord clamping (DCC) is the allowance of normal physiological placental transfusion and not a medical intervention. The National Institute for Health and Clinical Excellence (NICE 2007) recommends clinical intervention only if labour is not progressing normally, so why, if there is a beneficial alternative, is ECC routinely practised? The debate surrounding the most appropriate time to clamp and cut the umbilical cord (hereafter referred to as the cord) after the birth of a baby has been explored for decades but a conclusive answer has not been reached (Mercer 2001). Whether to clamp the cord immediately after delivery, wait until pulsations cease or somewhere in between remains a controversial issue among midwives, obstetricians, neonatologists and researchers. The Resuscitation Council (UK) (2010) guideline utilises current best available evidence and recommends DCC for at least a minute for uncompromised neonates. Lacking evidence for


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NHS Trusts, national guidelines (eg NICE 2007, RCM 2012) and research studies differ greatly in their definitions of ECC and DCC. However, the general consensus is that ECC occurs soon after delivery, typically within 10–15 seconds. Research studies show that timings for DCC vary between 30 seconds and five minutes after delivery (Cook 2007). NICE guidelines (2007) show more consistency, stating that DCC should occur when pulsations cease. Many people have explained the potential complications of ECC. For example Erasmus Darwin (1801:302) stated: ‘Another thing very injurious to the child, is the tying and cutting the naval string too soon; which should always be left till the child has not only repeatedly breathed, but till all pulsation in the cord ceases. As otherwise the child is much weaker than it ought to be; part of the blood being left in the placenta, which ought to have been in the child.’ Despite this information being available and the fact that ECC is clearly not a physiological process (Hutchon 2008), this practice still continues today. It is difficult to know when cord clamping was introduced into practice. Inch (1985) states that cutting the cord before placental delivery and separating mother and baby originates from the 17th century. She suggests this probably occurred to enable removal of the baby, allowing care to be centred on the mother until complete placental delivery (Inch 1989, Edwards & Wickham 2011). The cord was cut in order to observe for signs of placental separation and descent e.g. cord lengthening. Women were routinely delivered on the bed, soiling the sheets, therefore to prevent this cord clamping commenced (Inch 1989, Johnson & Taylor 2010). Weeks (2007) states that ECC was integrated into active management without a specific rationale and may have entered by default as it was already standard practice. ECC was combined with the prophylactic use of syntometrine and controlled cord traction to create active management (Duley et al 2009). This practice means midwives deliver the placenta rather than via maternal effort. Syntometrine was developed and introduced in the 1960s as the drug of choice for active management (Wallis 2004). It causes uterine muscle contractions leading to haemostasis via the living ligature action. There are some side effects associated with syntometrine, eg hypertension (Baskett 2000). Controlled cord traction was introduced by doctors to help separation and expulsion of the placenta before the cervix closed (Spencer 1962, Wallis 2004). These three components became active management and are used today to reduce the risk of postpartum haemorrhage (PPH), which has been the third most common cause of maternal death in the UK (Lewis 2007). A number of randomised controlled trials (RCTs) 62

have been used to assess the effectiveness of active management in reducing PPH risk. Prendiville et al (1988) and Rogers et al (1998) both compared active and physiological management of the third stage. At face value, the results from both trials show that a higher percentage of women experience a PPH with physiological (17.9%, 16.5%) compared to active management (5.6%, 6.5%). However, both these studies have been shown to have flaws; the main issue being women receiving mixed management —not completely active or completely physiological management. Kashanian et al (2010) showed no significant difference between the groups for blood loss but more women in the active group (40) required treatment for excessive bleeding compared to the physiological group (27). The researchers state further, larger studies are needed as these results contradict others. Active management, including ECC, is currently recommended to all women; physiological management is only suggested if women ask for it and are low risk. The NICE guidelines have not been updated since 2007 (NICE 2007), but when they are, Kashanian et al’s (2010) study should be considered. Although the complete package of active management has been shown to reduce PPH risk, it is difficult to distinguish between components and explain which are responsible for this success, especially as ECC may have been incorporated because it was already standard practice. The main complication associated with physiological management (DCC) is the increased risk of PPH. Ali (2008) wrote about cord clamping timings and commented that ECC is an essential part of active management, thought to reduce PPH risk, but it does not say whether it is the timing or other components which reduce this risk. However, the World Health Organization (WHO 2007) say the cord should not be clamped sooner than necessary due to its benefits (ideally three minutes after delivery), suggesting the components of active management need reviewing. Eichenbaum-Pikser & Zasloff (2009) commented that ECC does not aid PPH risk reduction as it is not a formal part of active management. RCTs have found active management reduces PPH risk when compared to physiological management (Prendiville et al 1988, Rogers et al 1998), but studies focusing on cord clamping have found this has no effect. Ceriani Cernadas et al (2006) looked at PPH as a secondary outcome. Blood loss was collected immediately following delivery until postnatal transfer; this could have affected the results as there was no specific time period. However, they found no significant difference between the groups. The mean blood loss (mls) and PPH (%) were 265mls/26.8% (ECC), 250mls/22.2% (one minute) and 300mls/25.4% (three minutes).

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Various reviews conducted have found the same results as above. Van Rheenen & Brabin (2006) and McDonald & Middleton (2008) found no significant differences between cord clamping timings and mean blood loss or PPH occurrences. Abalos (2009) discovered the same results when looking at 11 trials. ECC was generally performed <1 minute; DCC varied between 1 minute and placental descent. Walsh (1968) conducted a study with similar results: 117 women were assigned either ECC (0â&#x20AC;&#x201C;9 seconds, 59) or DCC (1.5â&#x20AC;&#x201C;11 minutes, generally after pulsations stopped, 58). Maternal blood loss was measured for two hours after birth. The results showed a significantly higher blood loss with ECC; 12 mothers experienced a PPH compared to three with DCC. The author mentions oxytocic drugs were only given to women who had a previous PPH and indicates the results were unaffected by this. She also explains higher blood loss was due to disruption in placental separation. Botha (1968) found a heavier blood loss was more likely if the cord was clamped, possibly because it created a longer third stage. The uterine cavity and placental site size reduce following the babyâ&#x20AC;&#x2122;s delivery and the contraction and retraction process of the myometrium (uterine muscles) continues from the first and second stages of labour. This same physiological action, influenced by naturally produced oxytocin, expels the placenta and controls maternal blood loss (Harris 2004, Harris 2011). There are two slightly different theories explaining how the placenta is delivered, but both are affected by cord clamping. The first theory explains how the contraction and retraction process reduces the uterine cavity and placental site size. It examines the role of the muscle fibres cutting off the placental blood supply and the formation of a retro-placental clot completing the separation process (Botha 1968, Harris 2004, Coad & Dunstall 2005, McDonald 2009). The second theory identifies three phrases of placental delivery and concentrates on how the myometrium thickens to separate the placenta (Krapp et al 2000, Johnson & Taylor 2010, Harris 2011). Both theories explain how the oblique muscle fibres contract, sealing torn blood vessels and preventing excessive maternal haemorrhage following blood flow restriction (Coad & Dunstall 2005, Johnson & Taylor 2010, Harris 2011). If the cord is clamped, counter-resistance occurs, consequently trapping fetal blood in the placenta and preventing transfer to the newborn. Compared to an unclamped cord, the placental size does not decrease; therefore the uterus cannot contract and retract as effectively, slowing separation. Any delay could increase haemorrhage from the torn maternal blood vessels and the cervix could close leading to a retained placenta (Botha 1968, Inch 1989, Johnson & Taylor 2010). DCC has been shown to benefit the baby without compromise to the mother. However, any obstetric MIDIRS Midwifery Digest 24:1 2014

emergencies affecting the mother and situations resulting in fetal blood loss, eg placenta praevia, vaso praevia and placental abruption, necessitate ECC; nevertheless, these situations are quite rare (Cook 2007, Hutchon 2008). The optimum length of time the cord should be left intact is unknown. As stated above, the Resuscitation Council (UK) (2010) recommends DCC for at least one minute for uncompromised term infants; however, the RCOG (2009) state the cord should not be clamped any earlier than is necessary based on the clinical situation. This suggests the cord should be left intact for as long as possible, allowing full transfusion of blood to the baby. Edwards & Wickham (2011) state that blood in the cord and placenta is not extra blood, but belongs to the baby and is needed for successful transition into extrauterine life. Evidence has shown term infants receiving DCC have improved haematocrit values and iron status without adverse effects such as polycythaemia, hyperbilirubinaemia or anaemia (Ceriani Cernadas et al 2006, Chaparro et al 2006, van Rheenen & Brabin 2006, Jahazi et al 2008). For preterm infants, due to increased blood volume, DCC leads to better blood pressure control, higher haematocrit levels and reduction in blood transfusions. It was also shown to reduce the risk of intraventricular haemorrhage and sepsis and increase cerebral oxygenation (Rabe et al 2004, Mercer et al 2006, Baenziger et al 2007). These findings support the guidance from the Resuscitation Council (UK) (2010). There is no evidence relating to compromised infants, it is therefore difficult to establish the best time to clamp and cut the cord in such cases. The Resuscitation Council (UK) (2010) suggests resuscitation should take priority over placental transfusion; however, while the cord is intact it is still supplying the infant with oxygen, so why are we cutting their lifeline? Some authors have suggested performing resuscitation while the cord is complete because the baby is receiving oxygen which could be crucial to their survival (Weeks 2007, Buckley 2009). This practice requires acceptance of new ideas and change for professionals, especially those working on high-risk units where ECC and active management are the norm. Resuscitation with the cord intact should eventually be implemented, but DCC needs to become routine practice first. It has also been suggested DCC should be practised during a caesarean section, particularly if it is an emergency as these infants are likely to be compromised (Coggins & Mercer 2009). But again DCC needs to become standard practice for normal deliveries so that health professionals feel comfortable with this management. It is clear that clamping and cutting the cord before placental delivery interrupts the normal physiological process of placental transfusion and placental


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delivery. Since the 17th century we have been disrupting this normal process by clamping the cord (Botha 1968). Why should we continue this practice when we now know better? Charlotte Salter studied midwifery at Anglia Ruskin University and gained a BSc Hons degree in 2012. She is currently working as a registered midwife in Essex.

References Abalos E (2009). Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes: RHL commentary. The WHO Reproductive Health Library. Geneva: World Health Organization. Ali E (2008). Timing of cord clamping: what do you think? MIDIRS Midwifery Digest 18(3):338-40. Baenziger O, Stolkin F, Keel M et al (2007). The influence of the timing of cord clamping on postnatal cerebral oxygenation in preterm neonates: a randomised, controlled trial. Pediatric 119(3):455-9.

Gallagher A, Hutchon D (2010). Delayed cord clamping should be more widely practised. [Online] (25 February 2010). http://fn.bmj. com/content/95/1/F59/reply [Accessed 5 February 2014]. Gurnsey J, Davies S (2010). A care pathway for the physiological third stage of labour. Essentially MIDIRS 1(4):32-6. Harris T (2004). Care in the third stage of labour. In: Henderson C, Macdonald S eds. Mayes’ midwifery: a textbook for midwives. 13th ed. Edinburgh: Baillière Tindall: Chpt 30. Harris T (2011). Care in the third stage of labour. In: Macdonald S, Magill-Cuerden J eds. Mayes’ midwifery. 14th ed. London: Baillière Tindall: 535-50. Hutchon D (2008). Views and counter views: a view on why immediate cord clamping must cease in routine obstetric delivery. Obstetrician & Gynaecologist 10(2):112-6. Inch S (1985). Management of the third stage of labour - another cascade of intervention? Midwifery 1(2):114-22. Inch S (1989). Birthrights: a parent’s guide to modern childbirth. 2nd ed. London: Green print.

Baskett T (2000). A flux of the reds: evolution of active management of the third stage of labour. Journal of the Royal Society of Medicine 93(9):489-93.

Jahazi A, Kordi M, Mirbehbahani NB et al (2008). The effect of early and late umbilical cord clamping on neonatal hematocrit. Journal of Perinatology 28(18):523-5.

Botha M (1968). The management of the umbilical cord in labour. South African Journal of Obstetrics and Gynaecology 6:30-3.

Johnson R, Taylor W (2010). Skills for midwifery practice. 3rd ed.

Buckley S (2009). Gentle birth, gentle mothering: a doctor’s guide to natural childbirth and gentle early parenting choices. Berkeley (CA): Celestial Arts. Ceriani Cernadas J, Carroli G, Pellegrini L et al (2006). The effect of timing of cord clamping on neonatal venous hematocrit values and clinical outcome at term: a randomised, controlled trial. Pediatrics 117(4):e779-86. Chaparro C, Neufeld LM, Tena Alavez G et al (2006). Effect of timing of umbilical cord clamping on iron status in Mexican infants: a randomised controlled trial. Lancet 367(9527):19972004. Coad J, Dunstall M (2005). Anatomy and physiology for midwives. 2nd ed. Edinburgh: Elsevier Churchill Livingstone. Coggins M, Mercer J (2009). Delayed cord clamping: advantages for infants. Nursing for Women’s Health 13(2):132-9. Cook E (2007). Delayed cord clamping or immediate cord clamping?: a literature review. British Journal of Midwifery 15(9):562-71. Darwin E (1801). Zoonomia: the laws of organic life: volume 3. 3rd ed. [e-book] London: J. Johnson. Available via: ozqe4pt [Accessed 5 February 2014]. Department of Health (2004). National Service Framework for children, young people and maternity services: maternity services. London: DH. Department of Health (2007). Maternity matters: choice, access and continuity of care in a safe service. London: DH. Duley LMM, Weeks AD, Hey EN et al (2009). Clamping of the umbilical cord and placental transfusion [SAC Opinion Paper 14]. London: RCOG. Edwards N, Wickham S (2011). Birthing your placenta: the third stage. 3rd ed. Association for Improvements in the Maternity Services (AIMS). Eichenbaum-Pikser G, Zasloff J (2009). Delayed clamping of the umbilical cord: a review with implications for practice. Journal of Midwifery & Women’s Health 54(4):321-6.


London: Churchill Livingstone Elsevier. Kashanian M, Fekrat M, Masoomi Z et al (2010). Comparison of active and expectant management on the duration of the third stage of labour and the amount of blood loss during the third and fourth stages of labour: a randomised controlled trial. Midwifery 26(12):241-5. Krapp M, Baschat AA, Hankeln M et al (2000). Gray scale and color Doppler sonography in the third stage of labor for early detection of failed placental separation. Ultrasound in Obstetrics & Gynecology 15(2):138-42. Lewis G ed (2007). Saving mothers’ lives: reviewing maternal death to make motherhood safer – 2003-2005: the seventh report of the Confidential Enquires into Maternal Deaths in the United Kingdom. London: CEMACH. McDonald S (2009). Physiology and management of the third stage of labour. In: Fraser D, Cooper M eds. Myles textbook for midwives. 15th ed. London: Churchill Livingstone/Elsevier: Chpt 29. McDonald S, Middleton P (2008). Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database of Systematic Reviews, Issue 2. Mercer J (2001). Current best evidence: a review of the literature on umbilical cord clamping. Journal of Midwifery & Women’s Health 46(6):402-14. Mercer J, Vohr BR, McGrath MM et al (2006). Delayed cord clamping in very preterm infants reduces the incidence of intraventricular hemorrhage and late-onset sepsis: a randomized controlled trial. Pediatrics 117(4):1235-42. National Institute for Health and Clinical Excellence (2007). Intrapartum care: care of healthy women and their babies during childbirth. London: NICE. Prendiville W, Harding JE, Elbourne DR et al (1988). The Bristol third stage trial: active versus physiological management of the third stage of labour. British Medical Journal 297(6659):1295-300. Rabe H, Reynolds G, Diaz-Rossello J (2004). Early versus delayed umbilical cord clamping in preterm infants. Cochrane Database of

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Labour & Birth Systematic Reviews, Issue 4. Resuscitation Council (UK) (2010). 2010 Resuscitation guidelines. London: Resuscitation Council (UK). Richmond S, Wyllie J (2010). European Resuscitation Council guidelines for resuscitation 2010: Section 7 resuscitation of babies at birth. Resuscitation 81(2010):1389-99. Rogers J, Wood J, McCandlish R et al (1998). Active versus expectant management of the third stage of labour: the Hinchingbrooke randomised controlled trial. The Lancet 351(9104):693-9. Royal College of Midwives (2012). Evidence based guidelines for midwifery-led care in labour: third stage of labour. London: RCM. Royal College of Obstetricians and Gynaecologists (2009). Prevention and management of postpartum haemorrhage. Greentop guideline no 52. London: RCOG. Spencer P (1962). Controlled cord traction in management of the third stage of labour. British Medical Journal 1(5294):1728-32. van Rheenen P, Brabin B (2006). A practical approach to timing

cord clamping in resource poor settings. British Medical Journal 333(7575):954-8. Wallis L (2004). The third stage maze: which practice pathway for optimum outcome? In: Wickham S ed. Midwifery: best practice 2. Edinburgh: Books for Midwives: Chptr 5.5. Walsh S (1968). Maternal effects of early and late clamping of the umbilical cord. The Lancet 1(7550):996-7. Weeks A (2007). Umbilical cord clamping after birth: better not to rush. BMJ 335(7615):312-3. World Health Organization (2007). WHO recommendations for the prevention of postpartum haemorrhage. Geneva: WHO. Wyllie J, Perlman JM, Kattwinkel J et al (2010). Part 11: Neonatal resuscitation: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation 81(Suppl 1):e260-e287.

Salter C. MIDIRS Midwifery Digest, vol 24, no 1, March 2014, pp 61-65 Original article. © MIDIRS 2014.

Comparison of administration of single dose ceftriaxone for elective caesarean section before skin incision and after cord clamping in preventing post-operative infectious morbidity S Kalaranjini, P Veena, R Rani Purpose: To compare the efficacy of ceftriaxone before skin incision and after cord clamping in preventing post-operative infectious morbidity and neonatal outcome in elective caesarean section and to determine the effect of antibiotic prophylaxis before skin incision on neonatal outcome. Methods: Our study was a randomised controlled trial conducted among 874 women undergoing elective caesarean section from October 2010 to July 2012. These women were randomly categorised into two groups with 437 women in each group. Group 1 received single dose of ceftriaxone 1 g intravenously 15–45 min before skin incision. Group 2 received the antibiotic after cord clamping. Primary outcome measures were maternal post-operative infectious morbidities like surgical site wound infection, febrile morbidity, endometritis, urinary tract infections and neonatal sepsis. Results were analysed using Chisquare test and unpaired t test. Results: Surgical site wound infection occurred in 3 women in group 1 (0.7 %) and 6 women in group 2 (1.4 %). Fever occurred in 9 women in group 1 (2.1 %) and 5 in group 2 (1.1 %) with the p value of 0.419, not statistically significant. Urinary tract infection occurred in 9 women in group 1 (2.1 %) and 7 women in group 2 (1.6 %) with the p value of 0.801. None of the women in either group developed endometritis. About 20 neonates [10 neonates (2.3 %) in group 1 and 10 neonates (2.3 %) in group 2] required NICU admission after caesarean delivery. The reasons for admission were respiratory distress, prematurity and congenital anomaly. About 0.9 % of neonates in group 1 and 1.8 % in group 2 developed neonatal sepsis with positive blood culture (p = 0.388). Conclusion: Timing of administration of prophylactic antibiotics for elective caesarean section either before skin incision or after cord clamping did not have significant difference in the occurrence of post-operative infectious morbidity. No adverse neonatal outcome was observed in women who received the antibiotic before skin incision. Kalaranjini S, Veena P, Rani R. Archives of Gynecology and Obstetrics, vol 288, no 6, 2013, pp 1263–1268. Author abstract. © Springer-Verlag Berlin Heidelberg 2013. MIDIRS Midwifery Digest 24:1 2014


Labour & Birth

Reviewed by Michelle Anderson The World Health Organization recommends that caesarean section (CS) rates should be no more than 15%, however, in the developed world figures suggest they are nearer 20% (Opoien et al 2007, Lamont et al 2011). Caesarean sections are associated with significantly high post-operative infection rates; most commonly wound infections, urinary tract infections and endometritis (Lamont et al 2011). There have been numerous studies conducted to assess the efficacy of prophylactic antibiotics in reducing the incidence of maternal infections, most commonly focusing on the administration of broad spectrum antibiotics pre skin incision or narrow range antibiotics after cord clamping (Lamont et al 2011). Concerns have also been documented on how prophylactic antibiotics may affect neonatal outcomes and whether broad spectrum pre skin incision antibiotics may mask infection in newborn infants. This review examines a randomised controlled trial comparing the administration of ceftriaxone, a broad spectrum antibiotic, for elective CS before skin incision and after cord clamping in preventing post-operative maternal and neonatal infectious morbidity. The study was carried out in India at the Jawaharlal Institute of Post Graduate Medical Education And Research over a period of eight months. The women who were participating (n=874) were randomly assigned to two groups using sealed sequentially numbered envelopes (SNOSE). SNOSE only establishes minimum methodological requirements with regards to allocation concealment as it requires manual handling in the allocation process (Schulz & Grimes 2002). Manual handling of randomisation procedures evokes criticism towards the study design as interference and manipulation when allocating participants to groups may increase the risk of bias, hence affecting the reliability and quality of the study. Blinding was not carried out and would probably have been difficult to achieve due to the researchers themselves performing the operative procedure 66

and administering the antibiotics. Group 1 received a single dose (1g) of intravenous ceftriaxone 15–45 minutes before skin incision prior to the procedure commencing, whilst Group 2 received exactly the same antibiotic after cord clamping. Exclusion criteria included women with a history of diabetes, severe anaemia, BMI>25, ruptured membranes, retro positive patients, women on immune suppressant medication, and those allergic to ceftriaxone. Women who underwent emergency CS were also excluded from this study. Parameters examined were age, parity, period of gestation, indication of CS and post-operative complications such as endometritis, febrile morbidity, wound infection, urinary tract infection, and other serious infections such as sepsis. Women were followed up on postnatal day four before being discharged from hospital. Statistical data were analysed using the statistical package for the social sciences (SPSS); the two groups were compared using Chi-square test. Fisher’s exact test was used when the expected cell was <5 and the unpaired t-test was used for continuous data. The two tailed p-value of <5 was considered statistically significant, and a 95% confidence interval relative risk was calculated for wound infection rate, urinary tract infection and neonatal sepsis rate. The results from this study revealed that there was no significant difference found between the time of antibiotic administration and maternal or neonatal infection. The incidence and types of infections found were;

Group 1 • • • • •

Wound infection = 3 (0.7%) Urinary tract infection = 9 (2.1%) Pyrexia = 9 (2.1%) Endometritis = 0 eonatal admission to special care = 10 (2.3%).

Group 2 • • •

Wound infection = 6 (1.4%) Urinary tract infection = 7 (1.6%) Pyrexia = 5 (1.1%)

• •

Endometritis = 0 Neonatal admission to special care = 10 (2.3%). It is not stated whether the episodes of pyrexia were directly associated with wound infections or urinary tract infections, or rather a stand-alone complication of CS itself. Pyrexia, however, was used as a marker to diagnose urinary tract and wound infections; therefore it is questionable as to whether the increase in maternal temperature should be included in the results analysis. Interestingly the neonatal admission rate was the same for Group 1 and Group 2, yet factors such as prematurity and congenital anomalies contributed to this; therefore it was not in any way related to the management of antibiotic administration. Large scale studies have found that the use of preincision, broad spectrum antibiotics are not associated with an increase in neonatal infection (Kaimal et al 2008, Yildirim et al 2009), which does offer some support to the findings in this study. There are significant weaknesses in this study that should be acknowledged; the first is the exclusion of emergency CS. This is especially important to consider as more emergency CS are performed in the UK than elective CS; up to date statistics show 15% for emergency CS and 10% for elective CS (RCOG 2013). One could argue that emergency CS was excluded due to the higher risk associated with developing post-operative infections (Lamont et al 2011), however it is because of this that the efficacy of antibiotics needs to be researched further in both clinical scenarios as there is no difference in the type of antibiotic used or in the time of administration. There is also no detail stipulating whether complications arose during the operation, such as postpartum haemorrhage, which may also increase the incidence of infection. Although the researchers state a baseline haemoglobin had been taken prior to commencing the CS, they do not state at exactly what point this took place and how close it was to the commencement of the operation,

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nor do they give mention to baseline bloods which would analyse white blood cell count and c-reactive protein. These at least would provide markers for any potential infection that was in the process of developing prior to CS. Interestingly, discharge from the hospital post CS was day four; this was also the cut off point for the researchers to follow up any infectious morbidities. However, this then does not take into account women who may have gone on to develop post-operative infections at home; this is especially significant as up to 80% of infections occur after discharge from hospital (Lamont et al 2011). Nonetheless this figure may be subject to demographics as in the UK women, if well, can be discharged from hospital after 24-hours post elective CS (NICE 2011). Although this study makes for interesting reading, its findings should be interpreted with caution due to the flaws and weaknesses within the study design. The results of this research prove inconclusive as to whether the administration of prophylactic antibiotics should be administered pre skin incision or after cord clamping,

therefore it is suggested that further reading be undertaken to gain a wider perspective on this subject. To add something more concrete, the most recent UK NICE guidelines state that prophylactic broad spectrum antibiotics should be given pre skin incision, and that antibiotics post skin incision are less effective in preventing maternal post-operative infections, which occur in 8% of women (NICE 2011).

References Kaimal AJ, Zlatnik MG, Cheng YW et al (2008). Effect of a change in policy regarding the timing of prophylactic antibiotics on the rate of postcesarean delivery surgical-site infections. American Journal of Obstetrics and Gynecology 199(3):310-12. Lamont RF, Sobel JD, Kusanovic JP et al (2011). Current debate on the use of antibiotic prophylaxis for caesarean section. BJOG: An International Journal of Obstetrics and Gynecology 118(2):193201. National Institute for Health and Clinical Excellence (2011). Caesarean section: full guideline. London: NICE. http://guidance. [Accessed 15 February 2014] Opoien HK, Valbo A, Grinde-Andersen A et al (2007). Post-cesarean surgical site infections according to CDC standards: rates and risk factors. A prospective cohort study. Acta Obstetricia et Gynecologica Scandinavica 86(9):10971102. Royal College of Obstetricians and Gynaecologists (2013). RCOG statement on emergency caesarean rates. London: RCOG. rcog-statement-emergency-caesareansection-rates [Accessed 15 February 2014] Schulz KF, Grimes DA (2002) Allocation concealment in randomised trials: defending against deciphering. The Lancet 359(9306):614-8. rhl/LANCET_614-618.pdf [Accessed 15 February 2014] Yildirim G, Guyngorduk K, Guven HZ et al (2009). When should we perform prophylactic antibiotics in elective cesarean cases? Archives of Gynecology and Obstetrics 280(1):13-8

Michelle Anderson, editor Essentially MIDIRS. © MIDIRS 2014.

Vaginal examination during normal labor: routine examination or routine intervention? H Dahlen, S Downe, M Duff, G Gyte REPRINT

Despite a continuing lack of good quality studies of the effect of routine vaginal examination, it is often routinely used in clinical practice. Indeed, internationally respected authorities such as the U.K. National Institute for Health and Clinical Excellence (NICE) continue to recommend the offer of a vaginal examination when a woman enters a hospital in suspected established labor and 4 hourly vaginal examinations as labor progresses. In this article, we explore historical and clinical drivers for the wide¬spread implementation of routine vaginal examination in labor to predominantly assess the dilation of the cervical os and examine some of the reasons for continuing use of the procedure, current critiques of its routine use, and possible alternatives for assessing labor progress. We discuss the possibility that both covert and overt knowledge operate in the assessment of labor progress, and we consider the con¬sequent potential for dissonance between what midwives actually do and what they record as having been done. The final discussion theorizes these findings and suggests alternative ways of framing labor progress for the future. Keywords: vaginal examination; labor progress; cervical dilation; behavioral cues

Introduction The use of vaginal examination during normal labor, most commonly to determine progress, has become so common in resource-rich countries in the past MIDIRS Midwifery Digest 24:1 2014

50 years that it is rarely questioned and generally considered good clinical practice. Midwives who rarely undertake vaginal examinations during normal labor and birth describe being viewed as a rebel 67

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because the artistic, intuitive side of midwifery is not valued in the institutional setting (Winter, 2002). However, the use of frequent scheduled vaginal examination is still listed as unlikely to be beneficial in A Guide to Effective Care in Pregnancy and Childbirth (Enkin et al., 2000, p. 503). The World Health Organization (WHO, 1996) has recommended that the numbers of vaginal examinations be limited to those that are strictly necessary when labor is progressing normally, and the latest National Institute for Health and Clinical Excellence’s (NICE, 2007) intrapartum guidelines state that professionals should “be sure that the vaginal examination is really necessary, and will add important information to the decision making process” (p. 17). A Cochrane Systematic Review has just been published into the effect of routine vaginal examinations for assessing progress of labour to improve outcomes for women and babies (Down, Gyte, Dahlen & Singata, 2013). Only two small studies were found. We concluded in this review that on the basis of women’s preferences, vaginal examination seems to be preferred to rectal examination. For all other outcomes, we found no evidence to support or reject the use of routine vaginal examinations in labor to improve outcomes for women and babies. Despite a continuing lack of good quality studies of the effect of routine vaginal examination, it has persisted and even increased in prevalence, not least because of the increasing spread of the partogram/ partograph. A recent study showed that during an average 8-hr labor, an average of three vaginal examinations were performed (range = 0–11; Cheyne et al., 2008). Examination of the evidence for the use of the partogram, which provides an organizational rationale for performing regular vaginal examinations, also revealed a lack of data on its efficacy, particularly in high-resource settings (Lavender, Hart, & Smyth, 2013). This makes the persistence of the vaginal examination to assess cervical dilation even more puzzling, especially because it is potentially out of step with reforms in maternity care to increase normal birth by minimizing routine interventions such as continuous electronic fetal monitoring, augmentation, induction of labor, and cesarean section (National Health Service [NHS] Wales, 2006; NICE, 2007; NSW Health, 2010; Scottish Government, 2009). This article explores the drivers for the widespread implementation of routine vaginal examination in labor to assess the dilation of the cervical os, its continuing use, the current critiques of its routine use, and possible alternatives. The final discussion theorizes these findings and suggests alternative ways of framing labor progress for the future, including potential future research.


How vaginal examination in labor became routine

A historical perspective Vaginal examination has been performed on women throughout history. There are early records from the writings (Gynecology) of Soranus of Ephesus (98–138 A.D.); according to these records, a vaginal examination was undertaken in the context of care during difficult labors. There is reference to instilling warm sweet olive oil to help make “difficult passages moistened to slipperiness” and to “relaxing the orifice of the uterus” with “greasy substances” (Temkin, 1956, p. 70). Vaginal examinations were used for difficult manipulations and to determine the presenting part in obstructed labor, but not as a matter of routine. Likewise, Trotula, writing during the 11th century A.D., describes using vaginal examination during difficult births when the “child does not come out in the manner in which it ought” (Green, 2002). Others, such as the German midwife Justine Siegemund (1636–1706; Siegemund, 2005, p.74) and the French midwife Madame du Coudray (1563–1636; known as the King’s Midwife), warn against “too much vaginal meddling. The best thing is to wait patiently, alert to all cues” (Gelbart, 1998, p. 33). In 1671, English midwife Jane Sharp described how to examine the cervix to assess for dilation and in particular to identify the presenting part (Sharp, 1999). An early 1900s U.K. midwifery textbook advised midwives to make plenty of abdominal examinations and noted that it was “probably also necessary to make more than one vaginal examination” in the case of unusually long labors (defined as 24 hr or more; Gregory, 1923). In 1939, the authors of an obstetric textbook noted that vaginal examinations should be carried out as infrequently as possible and, at most, only once or twice throughout a labor (Munro Kerr et al., 1939). Continuing the theme of the vaginal examination as an assessment of the degree of pathology in unusual cases, as opposed to a routine measure in normal childbirth; in 1952, Nixon suggests that after “24 hours of labor a vaginal examination should always be done.” It appears routine, regular examination of the cervix (vaginal and/or rectal) by midwives or obstetricians did not occur until after Friedman’s studies in the 1950s (Duff, 2005). As Sookhoo and Biott (2002) observe, prior to the mid-1970s, midwives working in resource- rich maternity care systems mainly focused on external methods of assessing women’s progress in labor, such as abdominal palpation. This provided an assessment of fetal descent by palpation, and by proxy via the descending location of fetal heart sounds through the maternal abdomen (Bastian, Keirse, & Lancaster, 1998; Munro Kerr et al., 1939). In 1972, the widely used midwifery textbook by Myles advised that “vaginal examination should not MIDIRS Midwifery Digest 24:1 2014

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be necessary during every labor” (Myles, 1972, p. 271). At other times in history, regulations prevented midwives from performing examinations altogether in some countries (Kroska, 1985). Most of the records on labor management are written by authors practicing in resource-rich countries. In this context, “normal science” thinking prevails (measuring, counting, and recording, and thus making visible) and becomes a prerequisite of acceptable clinical practice (Kuhn, 1962). In contrast, there are a few accounts of labor care in other parts of the world that offer an insight into assessment of labor progress where such linear thinking is not predominant. In one rare example of an alternative approach to judging labor progress, Jordan (1980) reported in her study of Yucatan midwives that vaginal examination was not performed at all. It is not clear from this account if an alternative assessment tool other than observation was used.

The stimulus for routine assessment of the dilation of the cervical Os It appears that the stimulus for regular, routine use of vaginal examination to assess labor progress by assessing cervical dilation emerged from the series of studies undertaken by Friedman and his colleagues into the nature of labor progress (Duff 2005). This is despite the fact that the early work, at least, was conducted predominantly using rectal examinations. The studies included graphical representations of labor progress (Friedman, 1954, 1955) and assessment of the effect of alert and action lines to flag cases where intervention/transfer might or should be undertaken (Philpott, 1972; Philpott & Castle, 1972a, 1972b; Studd, 1973). Over the two decades that followed Friedman’s initial work, further developments embedded routine cervical assessment into contemporary clinical practice (Philpott & Castle, 1972a; Studd, 1973), particularly with the active management of labor approach (O’Driscoll & Meagher, 1986; O’Driscoll, Stronge, & Minogue, 1973). This work was prompted by a concern for maternal and fetal morbidity and, indeed, mortality consequent on very prolonged labors experienced by women with limited access to specialist facilities. The intention was to try to determine indicators to promote transfer of women sooner rather than later for life-saving intervention. For this reason, several of the early studies took place in Africa. Friedman’s main focus was to “evaluate the effects of various factors on the course of labor” (Friedman, 1954, p. 1568). To do this, he had to establish a “normal” course of labor, which, in his words, had not previously been described “scientifically.” He selected cervical dilation as the most important variable to monitor the progress of labor because he concluded that it was a “simple, reproducible and relatively objective” measure (Friedman, 1954, p. 1568). This led to the development of the partogram, MIDIRS Midwifery Digest 24:1 2014

which is a preprinted form, the aim of which is to provide a pictorial overview of the progress of labor and to alert health professionals to any problems with the mother or baby (Lavender et al., 2008). The premise of the partogram was that recording dilation of the cervical os throughout labor, based on regular vaginal examinations, would give a direct measure of uterine activity and therefore provide the most reliable indicator of labor progress. By 1973, Studd claimed that the partogram was being used in 50% of all teaching hospitals in the United Kingdom.

Creating the rules of labor progress There are several significant limitations with Friedman’s research, including selective sampling (exclusion of large numbers of women), use of frequent rectal examination at the height of a contraction, and high levels of intervention in birth (use of supine position, sedation, and frequent augmentation of labor). Despite this, the parameters for normal labor progress have been redefined based on his data, not only in the populations in which the work was undertaken but also in most formal maternity care systems across the world. These parameters are reinforced by the routine use of vaginal examination and consequent intervention if a labor strays outside the boundaries of what is deemed to be normal progress. This creates a perfect circle of cause and effect so that labors that are physiologically longer than the standard “norm” are redefined as abnormal or even pathological. Friedman labelled lack of cervical dilation over time as inertia, assuming that periods of no obvious dilation were indicative of pathology. He also noted that labor progress as measured cervically was curvilinear — the pace of change was relatively slow at the outset, accelerating in the so-called “active” phase and then slowing again toward the end of the first stage. This visual image has increasingly been reified into a straight line of fairly uniform progress, as charted on the partogram. Indeed, despite text book definitions of progress that include a wide range of signs, symptoms, and maternal behaviors (Davis, 2004; Fraser & Cooper, 2003; Henderson & Macdonald, 2004; Varney, Gegor, & Kriebs, 2004). The current NICE intrapartum care guidelines on progress in labor cite uniformly steady cervical dilation of at least 2 cm every 4 hr from 4 cm onward as one of the cardinal signs of labor progress (NICE, 2007, p. 24). The NICE guidelines also suggest that women should be offered a vaginal examination every 4 hr (NICE, 2007, p. 27). WHO suggests the use of the partogram with cervical dilation of 1 cm an hour as the standard for assessing progress in labor (WHO, 1994, p. 22) but notes that varying parameters are used between and within different countries across the world. The widespread assumption that a regular increase in cervical dilation throughout labor is a cardinal


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marker of the normal physiology has been challenged by a retrospective analysis of the labors of nulliparous women having home births. This study described several plateaus in dilation during the first stage, after which labor generally resumed and completed normally, without the need for external intervention (Daviss, Johnson, & Gaskin, 2002). In an even more detailed analysis of labor progress in primiparous women, Duff (2005) found a “zigzag” effect in the early portion of the labor curve, showing a tendency for the dilation progress curve to flatten or even decelerate at times. Under the same clinical conditions, multiparous women demonstrated a much smoother pattern of labor progress. Duff also showed differences in dilation patterns between women who were induced and those who were not.

Continuing the reification of cervical dilation norms: active management of labor Over time, the drive to reduce maternal and infant morbidity and mortality from very long labors has been translated into a desire to reduce the length of all labors into ever more tightly defined limits. For example, Table 1 sets out the changes in average length of the different phases of labor cited in two different editions of the same midwifery textbook in 1958 (Myles, 1958) and 1975 (Myles, 1975). As Myles acknowledges, it is impossible for this change to have taken place physiologically over one generation. She attributes the difference to the rapidly increasing use of oxytocin in labor in the United Kingdom in the 1970s (Myles, 1975). Thus, the norms attributed to physiological (normal) labor appear to have been reified by the use of a labor accelerant. To conform to these new norms, all those individual women whose labors are physiologically longer than this become subject to augmentation to ensure that the new norms are met at a population level. Table 1 Average length of the phases of labor in two editions of Myles’ Textbook for Midwives (1958 & 1975) MYLES (1958) LENGTH IN HOURS 1st Stage 2nd Stage 3rdStage Total P0 12.50 2.00 0.50 15.00 P1+ 8.50 1.00 0.50 10.00 MYLES (1975) LENGTH IN HOURS 2nd Stage 3rdStage Total 1st Stage P0 11.00 0.75 0.25 12.00 P1+ 6.50 0.50 0.25 7.00

An example of this tendency is the active management of labor (AML) approach, as championed by O’Driscoll and colleagues in Ireland, with the aim that “an assurance can be given to every woman who attends this hospital that her first baby will be born within 12 hours” (O’Driscoll et al., 1973, p. 135). This approach was introduced to the National Maternity Hospital in Dublin, when the cesarean section rate was around 5%. Persistently low rates of


cesarean section under this regime led other obstetric services to use active management of labor to reduce rates of cesareans. However, the Dublin approach to AML was multifactorial (Brown, Paranjothy, Dowswell, & Thomas, 2008; Downe & Dykes, 2009). Some of the key components included strict definition of labor onset, routine amniotomy, strict rules for diagnosing slow progress, early use of Syntocinon, and, crucially, one-to-one support. The most up-todate Cochrane review of the efficacy of this approach (Brown et al., 2008) has concluded that the package of interventions tested varied across the included studies, with continuous support for women in labor being one of the elements that was known to make a difference independently of the package as a whole. Unfortunately, where AML has been generalized, it is usually the clinical components designed to speed up labor that have been adopted, without the continuous support element. This has led to outcomes at variance to those in the original AML site (Frigoletto et al., 1995). Although the AML approach has fallen out of favor in many settings, the belief that “the shorter the labor is the better it must be” is still very prevalent and high levels of oxytocin are being used as a consequence (Khalil et al., 2004; Selin, Almström, Wallin, & Berg, 2009).

The developing critique Reliability of vaginal examination Evaluations of the reliability of cervical dilation assessment have been performed in models (Huhn & Brost, 2004; Phelps et al., 1995; Tuffnell, Bryce, Johnson, & Lilford, 1989) and in clinical practice (Buchmann & Libhaber, 2007). Accuracy was around 50% in models (Phelps et al., 1995) and less than 50% in studies involving women (Buchmann & Libhaber, 2007). Buchmann & Libhaber (2007) found that clinician experience contributed to greater accuracy. Consistency was also an issue. A study of a group of 508 women found inconsistent findings between examiners. This was noted to cause distress in women and resulted in loss of confidence in their health care provider (Ying & Levy, 2002). These findings have clinical implications, especially if decisions on the need for augmentation of labor or cesarean section are made on the basis of the vaginal examination. Infection There are concerns about the introduction of infectious agents to mother and baby during vaginal examination especially where there is prelabor rupture of membranes (Imseis, Trout, & Gabbe, 1999). There is a reported link between the number of vaginal examinations a woman has and the incidence of puerperal sepsis (Imseis et al., 1999; Maharaj, 2007; Seaward et al., 1998). A recent study, however, did not find a link (Cahill et al., 2012). MIDIRS Midwifery Digest 24:1 2014

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Painful contractions Following vaginal examinations, women often report an increase in painful contractions, possibly because of the effect of prostaglandin release with cervical stimulation and resulting uterine activity. There is evidence that vaginal examination increases plasma prostaglandin concentrations (Mitchell et al., 1977). Women’s experiences The move historically from rectal examination to vaginal assessment was partly initiated by women’s dislike of the rectal procedure. However, there is evidence that although most women are satisfied with their vaginal examination experience (Lewin, Fearon, Hemmings, & Johnson, 2005), especially if they trust the examiner to respect them as individuals and maintain their dignity (Lai & Levy, 2002), some find it to be painful and distressing (Bergstrom, Roberts, Skillman, & Seidel, 1992; Buckley, 2003; Clement, 1994; Devane, 1996; Flessig, 1993; McKay & Barrows, 1991; Roberts & Woolley, 1996; Winter, 2002). In few women, posttraumatic stress disorder has been associated with vaginal examination especially following a history of fetal loss, invasive obstetric or gynecological procedures, or sexual abuse (Duddle, 1991; Menage, 1993, 1996). These extreme responses may be unusual, but every woman is important. However, it is also clear that some women request vaginal examination in models of care where they are not routinely done because they want to know what is happening to their bodies so they can gauge their labor (Dixon, 2011). Where vaginal examinations are not routine, women need reassurance that their labor is moving toward birth (Dixon, 2011). Midwives practice and views Midwives, in a study undertaken by Lewin and colleagues, reported that many women had vaginal examinations to confirm the onset of second stage despite clear clinical signs indicating this (Lewin et al., 2005). The authors speculated that the rationale for this practice was based on misunderstandings of local guidelines and on reliance on traditional, ritualistic practice. Sookhoo and Biott (2002) found that an overreliance on cervical dilation seemed to be more prevalent in circumstances where choice and individual judgement were perceived to be limited. They suggest that the fundamental difference between the active management of childbirth model and expectant management is the degree of the professional’s confidence in maternal physiology. The privately practicing U.K. midwives interviewed by Winter (2002) seem to reinforce this position, arguing that vaginal examinations disrupt labor and that they are done just to complete partograms. Other studies demonstrate that some midwives practicing in mainstream maternity care also consider that vaginal examinations are carried out too frequently, and that they are associated with adverse effects in some MIDIRS Midwifery Digest 24:1 2014

women, including psychological trauma or infection (Clement, 1994). There is evidence that in certain models of care or places of birth (such as birth centers and home birth), vaginal examination is used much less frequently, or not at all (Pastore, 1990).

Alternative approaches to assessing progress in labor Cervical technologies In their review of methods of assessment of cervical dilation published between 1951 and 1978, van Dessel report that 19 different cervimetric techniques were documented, although some were never applied in clinical studies (van Dessel, Frijns, Kok, & Wallenburg, 1991). Today cervical assessment technologies are still being developed (Molina & Nicolaides, 2010; Nizard et al., 2009). They tend to fall into four categories: (a) mechanical methods, (b) electromechanical methods, (c) electromagnetic methods, and (d) ultrasound methods. The disadvantages, other than often being unreliable, include the invasive nature of some of the interventions, pain associated with some of the techniques, unknown effects on the fetus of the intensive use of imaging technologies, the potential economic implications of purchasing new equipment, and the risk of infection where the measurement technique includes the introduction of devices to the vagina or cervix. Behavioral cues It has been proposed that the progress of labor can be assessed by observing women’s behavioral cues (Bleier, 1971; Gaskin, 1980) including vocalization (Baker & Kenner, 1993), skin discoloration (Byrne & Edmonds, 1990), and behavioral changes (Burville, 2002). Burville (2002) developed a Gantt chart from her interviews with midwives demonstrating changes in breathing, conversation, mood, energy and movement, and posture over the periods of late pregnancy, latent/prelabor, early labor, early active labor, and active labor. These behavioral data were then added to clinical signs—such as vaginal discharge, progress on the anal cleft line, contractions, findings on abdominal palpation, and cervical dilation—to produce a global assessment of progress. Other writers suggest that reported sensations and experiences inform the midwife better than physical cues (Walsh, 2010). The potential for a composite tool based on maternal behavioral cues was examined in Australia (Duff, 2005). The study involved 179 women (94 primiparous women and 85 multiparous women) using a labor assessment tool (LAT). Duff (2005) developed a model for labor assessment based on “observed” behavior (how the woman responds to her external and internal environment) and “communicated” behavior (how the woman uses words or makes sounds) and then into subgroups 71

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of “between” and “during” contraction behaviors. These were further differentiated for behaviors in spontaneous and induced labors. No further validation work using the LAT has however been undertaken. Other physiological cues Other clues to labor progress have been developed on the basis of close and careful observation of laboring women. A purple or anal cleft line has been described as appearing at the edge of the anal margin when the cervix is approximately 2 cm dilated, and then moving up following the natal cleft as the cervix dilates, ending at the nape of the buttocks when the women’s cervical is fully dialated (Byrne & Edmonds, 1990; Hobbs, 1998). The physiology of this might be associated with pressure of the descending fetal head on local blood vessels, causing consequent pooling and dilation and external visibility. A recent study showed a medium positive correlation between the length of the purple line and both cervical dilation and station of the head (Shepherd, Cheyne, Kennedy, McIntosh, Styles, & Niven, 2010). Prioritizing of vaginal examination over behavioral cues Anecdotally, there is a dissonance between what midwives observe in labor from women’s behavior and the standard norms of practice with which they are expected to communicate. In an activity undertaken in Australia & New Zealand, with more than 700 midwives who were involved in normal birth workshops over the past 2 years, midwives were asked to write for 5 min without stopping about how they know a woman is progressing in labor (Dahlen & Caplice, 2012). Most attendees wrote about behavioral cues with very few mentioning vaginal examination. Participants were then asked what information they drew on to make decisions about labor progress, or to communicate the state of labor to other relevant clinicians. In direct contrast to earlier findings, vaginal examination featured frequently (Dahlen & Caplice, 2012). These findings reveal an interesting disconnection between the highly valued and reported behavioral cues in the workshop and the prioritizing of vaginal examination in communicating progress in clinical practice. Midwives who were confronted with this during the exercise responded with dismay that their experiential knowledge was not valued highly, even by themselves. Indeed, two levels of knowledge seemed to be operating — the covert and the overt.

What is happening in clinical practice? This article was inspired during the process of designing the protocol for a Cochrane systematic review on the effectiveness of vaginal examination. One of the reviewers challenged the authors of this article with the comment that vaginal examination and use of the partogram are inevitably part of the same intervention package. We were unsure 72

if this was always the case and sent an e-mail to two international midwifery discussion lists (the International Confederation of Midwives [ICM] midwife research list and the normal birth research list) asking two questions: (a) “In your experience, is vaginal examination ever used on its own without using a partogram?” and (b) “Where the partogram is used as a record, are all the elements of it usually used in a decision on whether to intervene?” This generated a lively debate. Twenty-six responses were received including an interesting dialogue between participants from 15 different countries (Table 2). There was a great deal of variation between the midwives’ responses. For many of these respondents, vaginal examination was not done only in conjunction with the partogram, although when labor was established, vaginal examination findings were more likely to be recorded on a graphical chart. Respondents also raised the issue of “quickie” vaginal examinations, previously reported by Stewart (2008). These were done frequently, quickly, and were not recorded. They were more often reported to occur later in labor. There was a tendency for partogram use to be less frequently reported by participants working in midwife-led units, birth centers, and home birth. Working in a continuity of midwifery care model seemed to also reduce the use of partogram. On the other hand, midwives from developing nations such as in Africa and Papua New Guinea spoke strongly of the value of the partogram in reducing adverse events. Some respondents reported using action and alert lines and others did not when making decisions. Several noted that, although in principle all elements recorded on the partogram should be taken into consideration when deciding to intervene in labor, in reality dilation of the cervical os was often used independently of other indicators (Table 2). One of the participants in the normal birth research list summarized the complexity of this issue as follows: A vaginal examination is part of the whole and should not be performed on a prescribed basis i.e. [sic] every 4 hours per se but when all other observations do not complete the whole picture for you as the attending midwife and you need to know as it [vaginal examination] will/may alter/guide your plan. Although this was a small sample of midwives and not undertaken as conventional research, it provided us with some useful insights into the diversity of views and importance of taking into consideration the context birth occurs in when having this debate.

Toward a new way of thinking It appears to be the case that cervical assessment is a valuable component of the decision-making process for transfer in rural and remote settings. However, in reflecting on the information earlier, and on the anecdotal accounts from the workshops described earlier, we began to wonder how midwives (and MIDIRS Midwifery Digest 24:1 2014

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other professional groups involved in intrapartum care) in high-resource settings, where timely transfer is less critical than in low-resource countries, square the apparent disconnection between the formal evidence base in this area, what they observe in practice, and what the evidence indicates is best. We were also intrigued by the observation that there is a proliferation of new studies of technical methods of assessing labor progress, mechanically or through imaging (Molina & Nicolaides, 2010; Nizard et al., 2009), but with a few exceptions (Burville, 2002; Duff, 2005) very little published on behavioral assessment tools, which these anecdotal accounts report as being used commonly in practice. It appears that research efforts and paradigms that underpin these studies emphasize the importance of progressive dila¬tion of the cervix in determining labor progress but often at the expense of other ways of knowing. Table 2 Main points raised by midwives about use of vaginal examination following two questions being posed: (a) Is vaginal examination ever used without using a partogram? (b) Where a partogram is used, are all the elements used to decide whether to intervene? Is vaginal examination Where a partogram is used, ever used without using a are all elements used to partogram? decide whether to intervene? Only when labor is not Mainly based on dilation established Partogram is only used with Overall clinical picture primiparous women Always used in conjunction Action lines used with partogram Midwives do “quickie” vaginal Action lines not used examinations; they don’t record especially in second stage Partogram still not available No systematic way of in all hospital settings recording information Partograms are not used for all births in primary units Continuity of care influences the way a partogram is used Partogram is only used if labor is deviating from normal Partogram is less likely to be used in MLU and home birth Note. MLU = midwife-led unit; countries: United Kingdom, Denmark, Netherlands, Africa (country unknown), Palestine, Germany, Kenya, Tanzania, Cyprus, New Zealand, Ireland, United States, Papua New Guinea, Canada, and Australia (15 countries; 26 responses)

Ajzen’s theory of planned behavior offers a partial insight into this situation. Although it has been critiqued and amended since it was first proposed, the core elements of the theory are that specific behaviors become adopted (and embedded) if they are easy to carry out, if they fit with local social norms, and if they are under the control of the individual to MIDIRS Midwifery Digest 24:1 2014

enact (Ajzen, 1991). Moving from one intervention to another is fairly straightforward if these factors are stronger for the new intervention. So, in a world that values technical solutions and precise, linear measurement based on population norms, moving to new means of assessing progress that are increasingly independent of subjective human assessment, but still focused on cervical dilation (such as mechanical measurement or ultrasound imaging), is easily accommodated. Indeed, this is a logical next step from Friedman’s data, action and alert lines on the partogram, and active management of labor. However, moving to more nebulous methods—such as behavioral cues, expert option, and woman’s intuitive sense of how far their labor is progressing—does not fit with wider behavioral or social norms, in a risk averse to surveillant context where overt recording and mathematical measurement is the norm. In marginalized contexts, routine vaginal examinations still serve the purpose of triggering the move from distant settings to specialist settings (assuming the resources are there to do this). In settings where most women labor in specialist centers, routine vaginal examinations are now part of a clinical conversation and not about an absolute measure. As discussed earlier, there is some evidence that labor progress assessment is caught in a “perfect circle” where the norms that arise from the widespread use of oxytocin have reified the physiological norms of laboring women so that it is increasingly impossible to justify the continuation of spontaneous labor that is outside of these new artificial boundaries. Vaginal examinations also act as functional boundary objects that can be used to determine whether a woman should move from one place of birth to another, or from one type of lead caregiver to another, in settings where the continuous presence of a skilled practitioner is less and less of a norm despite rhetoric supporting this. If a woman is not attended continuously, complex dynamic behaviors cannot be observed and integrated into a picture. They are also hard to transmit to other carers in con¬texts where care is fragmented, and information must be transmitted rapidly and concisely. Systems of intrapartum care that are organized to see bodily processes as simple linear phenomenon act to reinforce cervical dilation as a gold standard for communication and action and to marginalize those practitioners who understand the process of labor as a complex and dynamic phenomenon. It is clear that a radical change in practice around the use of routine vaginal examination is unlikely to occur anytime soon, and evidence to support the safest way to do this is limited. Where midwives are working in continuity of care models and, in particular, where this model is located in nonhospital locations (freestanding midwife-led units, birth centers, and home birth), vaginal examination appears to be used less as a routine and more as an


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additional tool available to midwives when labor “appears” not to be going “normally.” More research is needed into how midwives make their assessments of labor progress when vaginal examination is not used. The effect of models of care, places of birth, women’s preferences, and institutional requirements on the use of vaginal examination as a routine method of assessment is also unknown. A randomized controlled trial of routine versus discretionary vaginal examination in different models of care and places of birth could reveal some useful evidence on which to base change in clinical practice and how to do this safely. In some parts of the world, such as in resourcepoor countries, routine vaginal examination can be an important tool in improving outcomes for women and babies.

Conclusion The information collected in this article suggests that in many contexts, vaginal examination has become a routine intervention, and it is not necessarily predictive of how labor will proceed. There is little doubt that vaginal examinations are a useful clinical tool to have when there are concerns about progress in labor, but the routine, frequent performance of the examination on all women needs to be challenged. As part of the international move to support normal labor and birth and reduce unnecessary interventions, less invasive methods of labor assessment are needed, that can recognize the complexity of physiological labor, that are easy to use in a range of contexts and settings, that are under the control of local practitioners, that fit with local norms (for women as well as for practitioners), and that can he easily translated across organizational and professional boundaries. Ultimately, however, it is women who should have the final say in this important issue. We suggest that this is a research question that now has some urgency. Hannah Dahlen, Professor of Midwifery, University of Western Sydney, Locked Bag 1797, Penrith South DC NSW 2751. Soo Downe, Professor of Midwifery, University of Central Lancashire, Preston PR3 2LE, Lancashire, United Kingdom. Margie Duff, Senior Lecturer in Midwifery, University of Western Sydney, Locked Bag 1797, Penrith South DC NSW 2751. Gill Gyte, Cochrane Pregnancy and Childbirth Group, Department of Women’s and Children’s Health, The University of Liverpool, Liverpool, United Kingdom. Correspondence regarding this article should be directed to Hannah Dahlen, University of Western Sydney, Locked Bag 1797, Penrith South DC, NSW 2751. E-mail: h.dahlen@ uws

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