Articles by Month: January 2006

A question of necessity

The debate going on in Ireland about sweeping and stretching the cervix to avoid induction, and the necessity of doing vaginal examinations offers a wake up call about the many procedures that are done to women (and babies) during pregnancy that are really just habit. Sure, some people have tried to justify the habit by doing research (long after the habit has become established practice) but this avoids the findamental question of why we are performing these invasive procedures in the first place.

One basic question, asked whenever a procedure or treatment is suggested, may help to stop some of these ubiquitous routines:

IS THIS REALLY NECESSARY?

Once time is taken for consideration, often the answer will be “No, not really”. Almost all inductions (except the 5 - 6% of babies with a real medical need), almost all episiotomies (except for the less than 5% of babies who need a rapid birth at the end of second stage), the majority of vaginal examinations, all the routine CGT traces on admission to hospital, all the artificial rupture of membranes, all the “push, push, push” instructions in second stage and the routine oxytocics for third stage would cease. Many more “management strategies” would also be reduced.

What a difference this would make for labouring women! Sure, some women might feel anxious if they are not subjected to all this interference because they associate it with “good care”. However, if their midwife said, cheerfully and firmly, that these routines were not necessary and could be harmful, women will quickly accept this, and discover the benefits of a more physiological labour.

If this question was then extended to the drugs routinely given to women in labour (pethidine, nitrous oxide, epidurals) we would have a revolution in our labour wards and healthier babies to boot. Women would discover their own innate power and midwives could practise their skills in a satisfying and enriching way.

It seems so simple....... I must be dreaming!

Posted by andrea at 11:31 AM

A question of necessity

The debate going on in Ireland about sweeping and stretching the cervix to avoid induction, and the necessity of doing vaginal examinations offers a wake up call about the many procedures that are done to women (and babies) during pregnancy that are really just habit. Sure, some people have tried to justify the habit by doing research (long after the habit has become established practice) but this avoids the findamental question of why we are performing these invasive procedures in the first place.

One basic question, asked whenever a procedure or treatment is suggested, may help to stop some of these ubiquitous routines:

IS THIS REALLY NECESSARY ?

Once time is taken for consideration, often the answer will be “No, not really”. Almost all inductions (except the 5 - 6% of babies with a real medical need), almost all episiotomies (except for the less than 5% of babies who need a rapid birth at the end of second stage), the majority of vaginal examinations, all the routine CGT traces on admission to hospital, all the artificial rupture of membranes, all the “push, push, push” instructions in second stage and the routine oxytocics for third stage would cease. Many more “management strategies” would also be reduced.

What a difference this would make for labouring women! Sure, some women might feel anxious if they are not subjected to all this interference because they associate it with “good care”. However, if their midwife said, cheerfully and firmly, that these routines were not necessary and could be harmful, women will quickly accept this, and discover the benefits of a more physiological labour.

If this question was then extended to the drugs routinely given to women in labour (pethidine, nitrous oxide, epidurals) we would have a revolution in our labour wards and healthier babies to boot. Women would discover their own innate power and midwives could practise their skills in a satisfying and enriching way.

It seems so simple....... I must be dreaming!

Posted by andrea at 07:32 AM

Sweeping the membranes

A technique for avoiding an induction of labour is being discussed amongst midwives in Ireland. Stretching the cervix and sweeping the membranes is sometimes seen as a way of avoiding an induction and has been recently resurrected in Ireland and some parts of the UK. I first learned of this technique on my first visit to Darwin about 25 years ago. One of the local obstetricians (now thankfully long retired) was very proud of his low induction rate. He credited these figures to his habit of doing a “strip and stretch” on every one of his patients at every visit from 36 weeks of pregnancy. He didn’t tell them what he was doing, but just said he would do an internal check. Many women went home bleeding and in pain from strong contractions or cramping. They would ring the hospital to ask if this was normal, and sadly, the midwives knew that it was normal for this particular obstetricians clients. In those days, the concept of “informed choice” or even “consent” was unknown and the midwives also tended to side with the doctors rather than the women. That didn’t make it right. These women has been physically assaulted without their permission - it could be described as a form of rape.

These days we ask women first if they want this aggressive and invasive procedure performed. They may be told that the evidence says that this “simple” technique performed “gently” by a midwife may reduce the chance of going overdue and the resultant induction for post-maturity. Even if this was the case, it still begs the question of why we feel we need to induce so often and why we feel that physical assaults on women can be sanctioned if someone does a study that suggests there might be some small benefit.

Have people gone mad? Are we losing the plot? If the baby’s health is being compromised by its intrauterine environment (which happens rarely) then surely a caesarean section is a better approach, as this will avoid the added stress of a labour for the sick baby.

My suspicion is that this procedure, largely forgotten until the last few years, has been resurrected by midwives who are distressed by the impact of induction on women and babies and who are looking for ways of helping women avoid this intervention. However, to substitute the risks of a “strip-and-stretch”(infection, ruptured membranes, bleeding, heavy cramping) for another set of risks of induction (the well-known cascade of interventions) seems to me to be questionable. There are many other ways that midwives could help women avoid an induction, and none of them involve a physical assault on women.

It’s time for some common sense to enter the debate. Research evidence is not always the answer.

Posted by andrea at 04:16 PM

Postnatal recovery Japanese style

There was one other interesting discovery that I made in Japan that I want to share with you.

Have you noticed how neat and trim Japanese women are, even after they have given birth several times? I am sure you have! I wonder if it has anything to do with their traditional practise of binding the woman’s pelvis for a few weeks after the birth? This technique was shown to me by Hatsue at the oldest Midwife House.

She took a long strip of soft cotton and wound it very firmly around my hips, trying it neatly in the front and tucking in the ends. It felt terrific - very supportive and comfortable. Hatsue explained that it was designed to hold the pelvic bones together but it would also help bring the stomach muscles together at the front. Lifting and carrying a baby would be a lot easier with this pelvic support too.

Women bind themselves each day for around the first three weeks after the birth. I think it is a wonderful idea. Judging from the photo, you can see that I could probably do with the binding a little higher up - all those delicious Japanese meals were taking their toll!

Posted by andrea at 02:34 PM

Term Breech Trial discredited

There was a post on the Irish Midwifery Mailing list that caught my eye last week. Declan Devane, a midwife researcher who keep a close eye on the professional journals, posted this brief abstract about the famous Term Breech Trial, that has resulted in routine caesarean births for all breech babies around the “developed” world. The date the item appeared in the AJOG wasn’t given.

Five years to the term breech trial: the rise and fall of a randomized controlled trial.

OBJECTIVE: On the basis of the end points of neonatal morbidity and death, the authors of the term breech trial concluded unequivocally that cesarean delivery was safer for breech babies.

STUDY DESIGN: Analysis of the original and new data gives rise to serious concerns as far as study design, methods, and conclusions are concerned. In a substantial number of cases, there was a lack of adherence to the inclusion criteria. There was a large inter-institutional variation of standard of care; inadequate methods of antepartum and intrapartum fetal assessment were used, and a large proportion of women were recruited during active labor. In many instances of planned vaginal delivery, there was no attendance of a clinician with adequate expertise.

RESULTS: Most cases of neonatal death and morbidity in the term breech trial cannot be attributed to the mode of delivery. Moreover, analysis of outcome after 2 years has shown no difference between vaginal and abdominal deliveries of breech babies.

CONCLUSION: The original term breech trial recommendations should be withdrawn.

Glezerman, Marek, Department of Obstetrics and Gynecology, Wolfson Medical Center, The Helen Schneider Hospital for Women, Holon, Israel.

American Journal of Obstetrics and Gynecology.

Of course, the flaws in this trial were known at the time, and there were calls for it to be abandoned before it was finished. There was much discussion amongst the researchers in the various countries and you can read more about this on Maggie Banks’ website.

In March there will be an important international meeting in Canada to discuss Breech Birth. It will be interesting to see what recommendations emerge from this gathering, in light of the results of the trial, its aftermath and the lack of evidence to support current routine caesarean for breech babies. Even if the results of the Term Breech Trial are discredited, changing practice habits of practitioners, who have lost their skills and confidence around facilitating vaginal breech births, will be the tough ask.

For women with breech babies, getting their baby to turn will still be the best step. The article on how to do this can be found here.

Posted by andrea at 03:11 PM

Some Midwives to be given Medicare numbers

It’s been a while since I posted to My Diary – holidays and writing a huge project (more of this later) have kept me busy. There is a lot happening, and a number of things to tell you about, so I will start with the latest news about midwifery in Australia.

There has been a campaign running for many years to have midwifery included as part of our free health care system.

All our maternity hospitals are staffed by midwives, and women giving birth in the public system will have midwifery care for free. However, midwives don’t have “provider numbers” as do the doctors, which means that women can’t engage a midwife privately and be reimbursed through our public health system (Medicare). Women who do pursue this option will have to pay from their own pocket for independent midwifery care, and this has been a major disincentive for some to seek a homebirth. It also means that midwives have no official recognition as health care practitioners in their own right, as they do in many other countries.

The inequities in this situation have been trumpeted for years by Aussie midwives. There have been almost 40 Government reports and enquiries over the years that have concluded that midwifery care is safe, affordable and practical. Finally, we are seeing s glimmer of hope – the current Federal Government is being forced to act, due to a shortage of doctors, midwives and nurses especially in our rural and remote areas (which is most of the landmass of this huge place!).

Last week, the Minister for Health announced that he will give midwives in some rural areas Medicare Provider Numbers so that they can provide pregnancy care for women who might otherwise have to travel long distances to see a doctor, or worse, have no care at all. It’s a start. The upside is that it is a foot in the door, and the downside is that nurses have also been given the green light to perform pregnancy checks. There will be much debate about whether a nurse is qualified for this role, but I suspect that in the end common sense will prevail and midwives will be the primary care givers for country women.

One problem that will need to be overcome is that the new arrangement will only be available when a doctor has made the referral to the midwife, which in effect means that a doctor will be supervising the professional practice of the midwives – this is clearly unacceptable. However, once the system is in place, it can grow from there and changes can be made.

The Shadow Minister for Health (a woman) has already publicly supported the call for Medicare numbers for midwives and is fully supportive of the widespread use of midwives as primary care givers. If we get a change of Government (fingers crossed) we should see a rapid expansion of the system which will have been in place for some while by the time the next election is due.

One interesting side light has been the indication that this new use of midwives as primary care givers will add $5 million to the annual cost of Medicare. Given that there have been widespread reports in the press this week about the rorting of Medibank by the doctors to the tune of tens of millions of dollars, introducing this simple measure has the potential to save money, as midwives traditionally prescribe fewer medicines and services than doctors (especially private obstetricians). We could have had this system in place years ago……

Posted by andrea at 01:32 PM