Andrea’s Diary

It is time to pack up and get ready to return home to Sydney. This trip has offered the usual diverse experiences, including travelling to Scotland and Ireland and meeting midwives from a large variety of maternity units.

My final program was a Teaching Skills workshop in Bristol. Many of the group had been to an Active Birth workshop in the past and it was good to see them again. We had a lot of fun exploring all kinds of interesting and involving ways to get information across to parents and many new ideas were explored and discussed over the two days.

The topic of stillbirth and handicap came up too. This is a topic that many educators avoid, because it is always an emotional issue, tapping into fears for the unborn baby that many/most women harbour during their pregnancies. We looked at ways of bringing the topic up, such as bolting it onto other issues, such as pregnancy tests, signs of premature labour, fetal developments, nutrition, and newborn care. Almost any topic in a prenatal program could provide an opportunity for raising this area of concern, and although it can be hard to facilitate, a discussion around the basic needs of parents when one of these tragic events occurs is vital - it must be acknowledged as a genuine and common fear or concern.

I have written up some ideas for presenting this topic in prenatal programs. The paper is called “Unexpected outcomes - mention the unmentionable” and it offers some suggestions for those responsible for facilitating parent education. It might be worth a look, if this is your field……

I won’t be back tomy Diary for a few days. There are a number of issues that have popped up in the last 24 hours and I will be exploring these in entries early next week. See you then!

Tonight’s news on the BBC had a great story about women and midwives marching on Westminster to demand that the proposed closure of two small maternity units in the west of the country be cancelled. The units, at Malmsbury and Devizes are typical of those lovely smaller units that provide care close to home for many families. The local Area Health Service is claiming that they are “too costly” but after today’s publicity, they have said they will consider the community’s concern (and the 8,000 petition signatures) in May when they make their final decision.

Many smaller units have faced these kinds of cuts and a number have been “re-invented” as midwifery units. There are some great examples in the UK, where not only are women and midwives experiencing normal births, but where the local health authorities are actually saving money.

It will be the economic argument that finally saves midwifery, I am convinced. Community action is also an important ingredient in forcing home this argument and the news item on the news tonight was a beauty. Women, babies, prams, balloons, banners and voices all combined to create a colourful and powerful message.

Midwives and women, working together, can achieve amazing results, and it is to be hoped that those politicians in Westminster were taking note of the strength of feeling on this particular issue.

More meetings with midwives this weekend, this time a group that has representatives of 6 hospitals around Birmingham. The contrast in maternity services (that exists in every country) was very apparent, with some midwives telling excited stories of their new midwifery unit opened six weeks ago and others bemoaning the rigid obstetric policies being applied in another unit.

We talked about the usual topics including the effects of drugs given for pain on both mothers and babies. I am always surprised that many midwives have not considered the consequences of giving these drugs on the babies. Many consider that Entonox is “harmless” when it clearly has an anaesthetic effect on women and will therefore be having some impact on the unborn baby. Opiate drugs are still widely used even though they are not pain killers but sedatives and the depression on the baby’s respiratory system and sucking reflex should be well known.

We talked yesterday about the continuum between pregnancy, labour, birth and the immediate post natal period, which includes breastfeeding. Putting the baby to the breast is part of the birth process, triggering the flow of oxytocin that causes placental separation and birth. When babies are drugged and drowsy, or irritable and unsettled, these precious moments are likely to be disturbed and this first breastfeed unsuccessful. Fortunately, any stimulation of the nipple, such as licking, nuzzling or even touching, will initiate the release of oxytocin, an important safety mechanism provided by nature in case the baby is unable to nurse normally.

The effects of drugs on newborns is well set out in an important new book “Impact of Birthing Practices on Breastfeeding” which is the first to collect the evidence into one convenient reference. All of the obstetric practices and drugs offered to labouring women are included. This books should be required reading for midwives and doctors, so that they are clear about the implications and consequences of the treatments they offer women during labour and birth. In the UK, where much effort and money is being expended on attempts to boost breastfeeding rates, the link between labour ward practises and post natal problems is one area that needs close attention. Reviewing the evidence included in this book would be a good place to start.

I finished the week with an interesting group of childbirth educators in Manchester. We had fun exploring a number of different ways of presenting information about some of the more difficult topics that are included in prenatal programs, including labour pain and epidurals.

Enabling expectant parents to explore basic concepts around labour pain is a tricky exercise. I took the group through a practical exercise that enables parents to experience some of the basics: dealing with stretching muscle; the benefits of yielding, not fighting it; the impact that experience has on confidence; the uncontrollable nature of contractions and the role of supporters during labour. It is a very effective exercise that enables a number of aspects to be explored and assimilated and I have had a lot of success with it in parents groups.

One of the most effective ways of informing parents about epidurals is to use a simple role play that shows them what will be involved when an epidural has been chosen in labour. Most parents have no idea that siting an epidural will also mean intravenous drips, continuous electronic fetal monitoring (probably with an internal fetal scalp clip), intermittent blood pressure readings and probably a catheter.

For women to have a straightforward, efficient and relatively comfortable labour they need to have 100% mobility at all times. The loss of mobility that results from the epidural itself and these trappings is the most negative aspect of an epidural. Instead of liberating women from the pain of labour, an epidural enslaves them to the medical system, quite literally tying them down and making them entirely dependent on others. The risk of requiring forceps or vacuum to extract the baby rises dramatically (to around 50%, according to the research) placing the baby at increased of complications as well.

The activity I demonstrated to these educators highlights these effects and is a powerful way of getting the message across to parents. This role play can be presented simply and factually - there is no need for comment or personal views. The picture it creates is better than a thousand words.

These workshops are fun and informative. I have another one early next week with a group in Bristol. But first, another Active Birth program in Birmingham.

At one point today, during the Teaching Skills workshop I am currently presenting in Manchester, the comment was made that many people find some activities and topics a “bit embarrassing” and are reluctant to participate. Later, an educator said that she sometimes gives the group permission to feel embarrassed, suggesting that “if they are unhappy practising these positions in front of the group, then they can practice at outside the room”. This was in the context of preparing them for having to make themselves comfortable in labour, perhaps under the watchful eyes of a midwife.

It seems to me that this is a good example of the “learned helplessness” that afflicts many English women. If someone suggests that “they might feel embarrassed” doing something it encourages women to feel this way. No wonder that people don’t participate easily in group work, or feel comfortable exploring some issues - if the facilitator gives out these kinds of messages it is hardly likely to help people see themselves differently.

It is the same in the labour wards. When midwives say to women “you’re doing well now, but don’t forget that of you need something for the pain later, just let me know” it sends a message that women are poor creatures that will need help, that this is not a matter of “if” but “when”.

This is one aspect of the birth culture that needs changing. Instead of telling women that they are strong and resilient and capable of looking after themselves, they receive various messages that they are weak, need looking after, rescuing from uncomfortable situations and shielding from difficult issues in life. Imagine the difference if they were told they were strong, had ideas that were worthwhile, could develop any skills they needed to further their own personal goals and had the internal fortitude (guts!) to make tackling any task possible!

Pregnancy and birth offer unique opportunities for self discovery and we must find ways of enabling it to happen. The way we communicate with women throughout this life experience will shape their views and colour their interpretations of not only of this momentous event but of themselves.

As educators we must carefully weigh the words we use in our classes. Honesty is an important ingredient and confidence building activities and exercises that promote self discovery are important elements in our programs. I don’t see any place for giving women permission to feel “embarrassed” or for “sitting out if you are not happy to participate”, except in exceptional circumstances, which would be best dealt with individually.

Learned helplessness is an issue that I will be raising in the group tomorrow. It will be interesting to get their views!

Another catch-up day in the UK office today. Next week we are having a trade display at a big breastfeeding conference in London, so I have been packing up stocks of books, videos and models for sale and display at that event.

I am also monitoring the situation in Israel, as I am due to travel there in a few weeks to present two Active Birth workshops. My main concern is being stranded if the airport is closed - I have a number of workshop commitments in Australia both before and after this trip, so cannot afford to experience travel delays.

Tonight I am off to Manchester, for the first of three workshops that will conclude my trip to the UK. Two of these programs are on Teaching Skills for childbirth educators and the other is an Active Birth program. It will be good to be covering some different topics with these groups, although each workshop is always unique because the groups, their needs and personalities are so different every time.

I will report from Manchester in the next day or two.

The three Spanish midwives I had in my workshop last weekend were discussing the need for more information on natural birth to be available in Spanish. It is hard for both midwives and women to consider alternatives to the highly medicalised birth in Spain if they are not aware of other possibilities.

One web site that might be a useful starting point is www.obstare.com - Ob Stare is a professional journal for midwives, produced in Spain by a team dedicated to promoting natural birth. I have just given permission for one of my articles to be translated for inclusion on this site and I know there are many others there that will be prove helpful to women.

I am hopeful that a translation of my book “The Midwife Companion” into Spanish will be completed soon and that a publisher will undertake to have it printed and distributed in all Spanish speaking countries. Midwives will need textbooks to help them learn the necessary skills for supporting natural births and this text is used widely in English speaking countries for this purpose. It is a best seller in the Italian version, and their struggle to normalise birth is well underway. It would be wonderful is Spanish women could have a humanised birth - they are certainly suffering at the present time under a very obstetric model that would be completely unacceptable elsewhere.

There was an interesting discussion on the ozmidwifery list a few months ago regarding the use of the Epi-No vaginal dilator as a preparation for birth. Several contributors thought that it was a useful tool and quoted anecdotal evidence of good outcomes. Others thought it was a bit strange, and using a gadget to stretch perineal tissues was seen as mildly distasteful.

A study undertaken in Israel has now been published that compared perineal outcomes for women who used the Epi-No and women who did not, in a culture where episiotomy a is routine part of birth management. In this climate, many women have tried the Epi-No as a means of avoiding this routine procedure and many hundreds have used it over the past 4 years.

Using a descriptive, retrospective approach, all women who had bought the device before April 2002 were contacted and surveyed. The results were compared with published episiotomy rates for the same period. When analysed, the results showed that users of the vaginal dilator had lower episiotomy rates than women generally, and there was an increased confidence in giving birth amongst users, who felt better prepared for pushing and the sensations of birth. There was also a reduced need for episiotomies when vacuum was being used.

It seems that this device may have its uses, particularly for women who fear second stage and face birth in a climate of routine episiotomy. It is expensive and takes time and commitment to use. It may not be attractive to all women but for some, it seems to provide a useful alternative to routine perineal surgery.

Reference:
Siome Cohain J. MIDIRS Midwifery Digest. vol 14, no 1, March 2004, pp 37-41.

It is encouraging that midwives in Britain are starting to write their own midwifery guidelines for the provision of maternity care. What usually happens in a hospital is that a Committee is formed, mainly composed of obstetricians, with perhaps a few token midwives, to draw policies up for the management of labour and birth in the unit. In the past, these were often a formal documentation of the doctor’s personal practise habits and preferences rather than evidence based guidelines. The midwives were told they had to follow them religiously, often with the threat of being censured if they deviated from them in any way.

Hospital administrations also felt they were covering themselves legally if the unit had documented procedures for the management of labour and stated that if everyone “followed the rules” then the risk of legal action was reduced (perhaps even eliminated). Senior midwifery managers backed up t he doctors and kept their staff in line. Midwives joining the staff were quickly inculcated into the policies of the unit, which were very likely different to those encountered elsewhere.

The availability of the Cochrane Library, the explosion in obstetric and midwifery research, the rapid increase in litigation, and the legal ramifications of “informed consent” have all had a huge impact, and “policies” are now becoming “guidelines” rather than rigid rules for practice. The importance of basing guidelines on clear evidence has been recognised, even though there are huge areas yet to be formally investigated and truly informed consent is rarely obtained from women undergoing any aspect maternity care.

Many of the policies are still being drawn up by the doctors in the expectation that midwives will follow them closely. Apart from being completely inappropriate for one professional group to be dictating the practises of another, few doctors will ever follow the hospital’s policies, even if they have been instrumental in drawing them up. Obstetricians have traditionally “done their own thing” and many birth suites maintain a book where specific practise habits of the various consultants are recorded, to avoid having to disturb them frequently about care plans. Thus one doctor may leave blanket instructions that “all of his women” are to have their membranes ruptured routinely at a certain point, or that they can be given a specified dose of pethidine if required without further consultation. It is a handy system, especially in the private hospitals (where doctors must be consulted about every aspect of the woman’s labour management), and it saves disturbing the doctor at inconvenient times.

It is high time that midwives stopped colluding with this charade of “informed choice” and took steps to individualise care to specific women’s needs. Midwives work differently from doctors, and this must be reflected in the guidelines that they follow. Where clear evidence exists is can be used to under pin these guidelines, where it does not a degree of flexibility should be acknowledged in their wording.

When I was in Norwich I was told about the new midwifery guidelines that the midwives were developing. It was exciting to hear of this development and to see midwives taking positive action to clarify their professional status and skills. It is time that all midwives began this process of exploring and writing up appropriate guidelines for their units - there is a lot of evidence available and the exercise of working on this important issue as a collective would be a useful step in encouraging co-operative teamwork within the unit.

I have just obtained the information on Entonox supplied by its manufacturer (BOC Medical). It makes very interesting reading. Following details about its product name, dosage and method of administration, contraindications, interaction with other medications and its effects on the ability to drive or operate machinery, it lists the following:

Undesirable effects

The nitrous oxide constituent of Entonox causes inactivation of vitamin B12, which is a co-factor of methionine synthase. Folate metabolism is consequently interfered with and DNA synthesis is impaired following prolonged nitrous oxide administration. These disturbances result in megablastic bone marrow changes. Exceptionally heavy occupational exposure and addiction have resulted in myeloneuropathy and subacute combined degeneration. Theoretically similar adverse results could occur from heavy and prolonged Entonox exposure. All these effects are well documented, are extremely rare and may follow prolonged exposure to levels of nitrous oxide over 5000ppm or to frequent (more than once every 2 days) exposure to analgesic concentrations. It has been suggested that prolonged occupational exposure to high levels of nitrous oxide may affects a woman’s ability to become pregnant.

Use in pregnancy and lactation

Mild skeletal teratogenic changes have been observed in pregnant rat embryos when the dam has been exposed to high concentrations of nitrous oxide during the period of organogenesis. However no increased incidence of fetal malformation has been discovered in 8 epidemiological studies and case reports in human beings. There is no published material which shows that nitrous oxide is toxic to the human fetus. Therefore there is no absolute contra-indication to its use in the first 16 weeks of pregnancy.

Special warnings and precautions for use:

Administration of Entonox more frequently that every 4 days should be accompanied by routine blood cell counts for evidence of megoblastic change in red cells and hypersegmentation of neutrophils. Thorough ventilation or scavenging of waste gases should reduce operating theatre and equivalent treatment room levels of ambient nitrous oxide to a level below 200ppm. Entonox is non flammable but strongly supports combustion. It is highly dangerous when in contact with oils, greases, tarry substances and many plastics.

These comments have many implications for midwives, who regularly, even routinely, offer women Entonox during labour and birth. Apart from the potential impact on the labouring woman and her baby, for midwives there are risks as well, and it is clear that pregnant midwives should be considering their exposure to Entonox carefully. Scavenger units are being installed in some maternity wards, but most have no such protection for their staff. The recommendation for regular blood testing is also noteworthy.

The final comment about the danger of contact with oils, greases and plastics is also of concern. These dangers are not spelled out in these notes. Many women use massage oils during labour and plastics of various kinds can be found in labour rooms. I will try and discover the nature of these “dangers” and report further if I can.

The statement that there is no published material regarding the risks to the unborn baby and the conclusion that therefore there is no absolute contraindication to its use during labour, once again demonstrates the assumption that no evidence means no problems. Until research is undertaken to test this hypothesis, it may be wise to err on the side of caution.

Entonox is being sold rather heavily at the moment, it would seem, from the advertising being undertaken. It is very freely used in UK hospitals and elsewhere, including Australia. Perhaps it is time to reconsider its use in maternity care, where frequent and prolonged exposure of the mother, midwife and the un born baby is a common occurrence.