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Normal birth - Is it possible in the 21st century?
This is a report of a meeting of the Forum on Maternity and the Newborn of the Royal Society of Medicine, held on Thursday 22nd April 2004.
The report is to be published in The Midwives Journal of the Royal College of Midwives. It is reproduced here with their consent and our thanks.
Chair, morning session: Professor Wendy Savage, Middlesex University, Retired Senior Lecturer in Obstetrics & Gynaecology, Royal London Hospital
Hands off - a new approach to labour
Professor Jim Thornton (JT), Professor of Obstetrics & Gynaecology, Nottingham University and City Hospital.
I am conducting research aimed at reducing interventions in labour such as those I mention here. It was probably in Africa that partograms first found a useful place; there too regular vaginal examinations (VE) seemed to be necessary to avoid the late diagnosis of obstructed labour. Rupturing the membranes gave people the opportunity to look at the liquor and exclude the presence of meconium, to test the fetal condition. Epidural analgesia, being the most effective means of pain relief, came into frequent use, and active management of labour has been widely employed. It was felt that the package of interventions which comprise active management (antenatal classes, amniotomy, oxytocin, constant support in labour) would reduce the caesarian section (CS) rate. Most observational studies have not confirmed this, and in some places, without the use of amniotomy or oxytocin (Semmelweis, Vienna; Wormeveer, Holland), quite low CS rates are being achieved.
Randomised controlled trials (RCT) have shown benefit in reducing interventions, including reduction in CS, from continuous support in labour; they have not confirmed any such benefit from amniotomy, nor from the early use of oxytocin in labour. The hugely expensive American RCT on active management (Frigoletto, 1995) concluded that active management of labour did not reduce the rate of CS in 2000 nulliparous women, but was associated with a somewhat shorter duration of labour and less maternal fever. Analysis of the results of active management are confounded by errors in the diagnosis of the time of onset of labour. When this is accurately diagnosed active management results in delivery whether vaginally or otherwise within 12 hours of the given time; when women are told they are not in labour 50 per cent nevertheless deliver within 24 hours, and there is a trial showing that these women have a lower CS rate, probably due to the few interventions which are used . Trials of epidurals, although not statistically significant, show a trend toward an increase in the CS rate.
Natural labour is only achieved by avoiding interventions, and CS should usually (but not invariably) be reserved for fetal distress. Natural labour needs clear guidelines similar to those given for active management of labour; so how long do we wait for the baby to be born?
The guidelines I propose are essentially indications for CS for dystocia in first labours. When there is "delay" before 4 centimetres (cms.) cervical dilatation it is ignored ; if the membranes are intact and there is no fetal distress, observe indefinitely. After 4 cms. and before 7 cms. perform CS if there is less than 2 cms. progress in 12 hours or less than 4cms. progress in 16 hours. After 7 cms. resort to CS if there is less than 2 cms. progress in 6 hours or less than 4 cms. progress in 10 hours, secondary arrest of labour being more significant.
The effect on cervical monitoring according to these guidelines is that a vaginal examination (VE) is only necessary when it might provoke delivery by CS. Diagnose full dilatation by inspection only; VE will never be done more frequently than 4-hourly, and never left for more than 12 hours; VE is deferred until the findings would prompt CS. The result is that very few vaginal examinations are needed.
The implications of these guidelines are that a woman admitted at 4 cms. might take 22 hours to reach full dilatation (16 hours to reach 8 cms. and 6 more hours to full dilatation). Assuming a 2 hour second stage this is equivalent to a maximum 24 hour labour.
The guidelines are at best consensus based, certainly not evidence based. My purpose is to help midwives and obstetricians who want to intervene less in labour, and to help mothers and babies to achieve natural birth.
Frigoletto et al., (1995) N Engl J Med 333 12: 745-750
A midwifery vision for the 21st century.
Professor Wendy Savage (WS).
The vision of a future written by young midwives in 1986 had 60% of midwives working in community-based practices of 2-5 midwives in 10 years' time. They would work in a variety of places depending on local need, for example shopfront, community centre, health centre (e.g. the South-East London King's College Hospital project now), house, and in hospital facilities. Midwives would be the recognized portal of entry into care for pregnant women and would care totally for the vast majority of women who fall within 'normal limits', making full use of their skills. All child-bearing women would receive continuity of care, with choice for all. The ethos would be that care should cause no harm to mother and baby, and the midwives would be accountable to the mothers themselves for their services. In a later edition of their vision a 10-year plan was envisaged in which the public's perception of the midwives' role as working uniquely with women would be changed, and the relationship between mother and midwife seen to be fundamental to good care, in which the pregnant have the central place.
The Winterton committee took evidence about the maternity services and reported in 1992; the government response was the Cumberlege report, Changing Childbirth, in 1993. Women had been heard, and it was agreed that home birth is a safe choice. Now women would be at the centre of care, and midwives the major providers, guided by the Four Cs: communication, choice, continuity, and control. Targets of success would be revisited in five years.
Why was the vision not realized? Women will never be at the centre of care while midwives are organized from within the hospital service, where managers and professionals are overly influenced by the fear of litigation and risk. The NHS has been in organizational turmoil since 1989, and the 1997 change of government meant a new agenda. Women are not a priority for National Service Frameworks (NSF) which focus on serious disease and only belatedly on children. Maternity care has been tacked on to the children's NSF recently only because of pressure from the All-party Parliamentary Group. The introduction of the proposed changes was to be cost neutral, with no new money, a known recipe for failure. Powerful professional interests, midwives as well as obstetricians, preferred the status quo. Midwives have become institutionalized; they fear the world of work away from the hospital, with its machinery and its expert backup. The Royal College of Midwives (RCM) is divided and so lacked a coherent strategy. Midwives who want to work effectively from a community base find their ambition frustrated, and leave the profession or work independently; this has its drawbacks of uncertain income, with clients who must be able to pay.
Some facts about the workforce. There are 50 schools of midwifery and 15 professors of midwifery; 3500 midwives are trained each year in England. Of 23,820 Full Time Equivalent midwives working in the UK about 600 would be managers. About 2000 are lecturers but they are not counted in NHS figures and some may do some practical work. Most midwives have family responsibilities. MiDIRS has improved communication between midwives and obstetricians; the British Journal of Midwifery has been published for the past 10 years. The respect for midwives which was eroded by the introduction of monitoring is now recovering. Of 92,000 midwives in 1998 36.7 per cent intended to practise. Of the midwives employed in England, an average 30.1 were responsible per 1000 maternities, or 32 deliveries per midwife. The figures for Scotland were 19 deliveries per midwife, for Wales 31, and Northern Ireland 23.
There are problems with the present structure:
Shortages of midwives in many parts of the country.
Team midwifery does not deliver the continuity of carer which is so important.
Caseload midwifery is unpopular with managers.
Conflict between ideals and work stresses leads to burnout (Sandall), with the loss of trained and dedicated staff.
Midwives are constrained by institution and workload and so are unable to give women the best care or time for informed choice (Kirkham & Stapleton).
Now we need a vision for the 21st century. Midwives are the experts in normal birth; most pregnancies are normal and most women are healthy. Midwives must organize themselves to practise in the way that Farr's mortality statistics in the 19th century , Holland to date, the 1958 Perinatal Mortality Statistics (PMS), the Farm data, Wormeveer, Nottingham, Flint, and Page have shown is safe. Midwives should be organized into primary and secondary care sectors, the basic training to include both, but with the first and third of the three years in the community. Primary care midwives will work in the community in groups of two to five with GPs and social services, regaining their place in the community as trusted professionals. It will be to them that women will go when they want to book for antenatal care. They will work in small group practices, either self-employed or with contracts with PCTs, who will provide premises and administrative support. Secondary care midwives will work in hospital in teams with obstetricians to give women continuity of care from antenatal clinic through delivery to postnatal care; they could come back to the community but would need refresher courses about how to manage normal childbirth. Superspecialist midwives may take on responsibility for renal or diabetic patients in tertiary units, making birth as normal as possible.
What needs to be done? The All-party Parliamentary Group must be asked to take on the co-ordination of an initiative to have primary and secondary care midwives as professional and government policy, an urgent priority. The RCM must urge government to move to ensure equity in numbers of employed midwives by region and country, allowing for geography, and needs to work together with women to get necessary changes into NHS plans. A primary care midwives agency to help with changes over next three years should be set up, aiming for 40% midwives as primary care midwives doing 60% of births, 20% at home in five years,and then......?
Apart from every thing else that is important to it, normal birth needs strengthening of the midwifery profession and a reorganisation of its working practices.
Durand AM (1992) The safety of home birth: the farm study. AmJPH 82:450-2
Butler NR & Bonham EG (1963) Perinatal mortality. E&S Livingstone Edinburgh
N H S centre for review and dissemination. Ed Kirkham & Stapleton (2001) Informed choice in maternity care: an evaluation of evidence based leaflets. University of York.
(JT) We need incentives to make it worthwhile for people to practise normal midwifery, for example an incentive to support a woman throughout her labour. Among many other specialists I advocate that the NHS goes over to a social insurance model such as is favoured on continental Europe. Under this system all insurance companies must provide the same level of service for young, old and ill whatever the level of premium. Thus everyone becomes a private patient, an expense which our public seems prepared to afford. Here could be the incentive for midwives to work in free-standing units or with home birth.
(JT) There are not a few difficulties in organising RCT to research natural birth, not least that women devoted to it are unlikely to want to be randomised to an amniotomy or oxytocin group. However, such evidence as there is points to non-intervention.
(Jill Demilew, midwife) I prefer to consider the individual woman and her progress in labour, certainly without a partogram. If it comes to transfer to hospital, that is for another review of an alternative line of management, a course which most women will realise is never impossible when natural birth is planned. Good clinical decision-making, a good relationship with the woman, and her making the choices are the keys.
(Beverley Beech, AIMS) An analysis of interventions at the National Maternity Hospital, Holles Street in Dublin showed that the more women delivered there, the shorter the period allowed before CS is advised - clearly a managerial decision.
(WS) A change of mind set is required to believing that birth is likely to be normal, from our present obstetrician-driven attitude that labour is only normal in retrospect. The 1958 PMS clearly showed that the non-interventive management of birth at that time was accompanied by the very low CS rate of 2.6%.
Information is power - finding your way round the web
Dr Trefor Roscoe (TR), GP, Sheffield and Honorary Lecturer, Sheffield University
Where is the life we have lost in living? Where is the wisdom we have lost in knowledge? Where is the knowledge we have lost in information?
T S Eliot. The Rock (1934)
I spent 1 1/2 years as a medical knowledge architect with an Internet company. There are over 4 billion web pages (as distinct from websites), and millions of new pages are added daily; there are over 200 million health related websites, and health related information is now the commonest thing that people admit to looking up on the Internet. Probably the amount of Internet information useful to a person has by now fallen to less than 0.01%.
People caring for patients need medical knowledge management, the knowhow and where to find what they want in order to avoid information overload. The integration of Internet information into care has led to the creation of the electronic patient record; by the end of next year all of our citizens will have a unique identifiable patient record, and it is intended that by the end of the year 2010 everyone will be able to access a summary of their GP and hospital records using secure Internet type links. By the end of 2005 there will be full NHS interconnectivity. The record will run from before the cradle to beyond the grave, containing information about the genetic predisposition of individuals, their antenatal influences, feeding into the health care of subsequent generations. Primary, secondary and social care records will be incorporated, and the record will become an important and familiar entity. Security and confidentiality can, as far as possible, be guaranteed. The UK is well ahead of Europe in medical informatics, and probably as far advanced as the USA .
Patients too are information finders: probably almost 50% of the UK population has access to the Internet in one way or another. Access is there for consumers and professionals; pharmaceutical company sites have recently approached ethical standards, but it is always important to find reliable sources. Search for UK sites, since specific information differs widely between nations, particularly at present between the UK and the USA. Any GP is likely to be approached about once a week by a patient bearing information sourced from the Internet ("Internet print-out syndrome"), and we also have cyberchondria - the inducement of illness or anxiety caused by finding information on the Internet.
How is this going to change health care? How will midwives face the challenges?
Medical workers in the community will eventually have full mobile access. The Palm Pilot in my hand linked to the mobile phone in my pocket is an example of the convenience of this. Help is already to hand, with information resources such as the search website Google; others, for example MiDIRS have assembled information relevant to their specialisation, in this case midwifery, and they have links to other medical and related databases. Other resources are the Association of Radical Midwives; the National Electronic Library for Health (NeLH); the RCM; the Nursing and Midwifery Council (NMC). See below for their website addresses and some others (URLs).
Are we prepared? Is there enough understanding of IT? Is there enough access? Is there enough training? Unfortunately not, as evidences the RCM Computers and Midwives survey of April 2003, which revealed that 10% of practising midwives had no computer access; 60% only had shared or difficult access, and 30% felt that computers hindered care delivery. 10 recommendations arose from the survey, including: all to have access, all to have email; more training was required (NHS Information Authority, Latchford 2003). Happily there are signs of rapid improvement in the situation.
The National Programme for IT (NPfIT) conducted a survey of 2000 nurses who have online access, asking "How much information have you had about IT developments?" Responses ranged from "Fully adequate information" 2%, to "Reasonably adequate" 22%, and "This is the first time I've heard of it" 26%. Three-quarters did not know enough. The responses to the question "Will electronic records improve health care?" were "Significant improvement" 51%; "Slight improvement" 19%; "No change" 3%, "Slight worsening" 1%, "Significant worsening" 1%, and "Unsure" 25%.
In summary, the volume of information is a problem; medical knowledge management is becoming a new and important speciality; patient found information will be influential; delivery of care will change; and midwives must make themselves IT literate.
The Nursing and Midwifery Council
The Royal College of Midwives
The Association for Improvement in the Maternity Services
The National Electronic Library for Health
The Forum on Maternity and the Newborn
Independent Midwives UK
Mind your language - exploring positive communication skills
Bernadette Matus, Chair, NCT Trading and Belinda Phipps (BP), Chief Executive NCT
When a woman talks about birth it ranks very high in importance, along with her wedding, or the death of a partner, and it marks the transition from one sense of her identity to another.
"The way a woman gives birth can affect the whole of the rest of her life" . "It was life-changing - more meaningful than all my other experiences". "Birth experiences strike at the very heart and soul of you; they touch emotions never before experienced".
Birth can be an empowering experience; it can confirm you as a person and as a woman. There is an identity change, to being a woman and a mother. It confers courage, and creates you as an advocate for your child. For some women who feel themselves to have been damaged formerly in their lives birth can be a healing.
The use and misuse of words in pregnancy and labour can change a woman's perception of the event for good or ill. Words such as "patient", which regards her as passive; "baby" can make her feel like a baby; women dislike being called "mum" or "mummy" by someone who is not their child; "delivery" suggests something done by somebody else, taking her out of the active role. "Section", while implying CS for a professional in a maternity unit, may have a double meaning, reminding a woman of the Mental Health Act. "Discharge" also has a double meaning, while "discharged" again makes a woman feel passive. "Normal birth" may mean something quite different to a professional than it does for a woman who hopes for it. Trial of labour (to be on trial, or to try but fail), incompetent cervix (how would a man feel to be told that he had an incompetent penis?), failure to progress and "not allowed" (reminders of past failures and restrictions). These and other phrases can be quite undermining: "You can't try for a vaginal delivery, as you have not proved that you can deliver." "It's your decision, but no, you can't have a home birth; it's too risky." "Your only X centimetres dilated" will be taken to mean "You're not trying hard enough" (and failing). To a second-time mother, struggling with breast-feeding: "I thought you said you'd done this before?"
Some expressions may thoughtlessly or intentionally cause fear in a mother. "Gosh, that's big for 11 weeks! Any twins in the family?" "If you don't agree to induction of labour your baby may get an infection and die." "The doctors will decide how your labour will be managed." "No woman of mine would refuse to get out of a pool when I tell her to." Positively damaging is "Get angry with this baby or you'll never get him out." "I'm not sure you'll be able to cope with the pain at home." (This woman decided not to have her baby at home, and blames this decision for the eventual CS). "You'll never get a baby to feed with those." (A joke? This woman couldn't and wouldn't breastfeed).
Asked what they would like to say to health care professionals on the subject of the use of language some women said:
Address a woman as an adult and accept that she has the right to make a choice.
Explain things properly, listen to questions before answering them, and be reassuring and positive.
You are talking to individuals with individual needs and not to baby delivery machines.
Think before you speak; words are very powerful and can make a bad experience bearable or spoil what might have been a good experience.
What is obvious and normal to you may be obscure and frightening for parents.
On the other hand we repeatedly hear examples of the good and positive use of language:
Is it all right for me to feel your stomach for your baby?
You are doing really well.
That's fine - trust your body.
We are going do this woman to woman (from a midwife holding the mother's hand and looking into her eyes during the second stage of labour).
She was the only person who actually listened to my fears. She actually said very little, but her whole presence spoke volumes; she was a true advocate for me.
To you it's a job; for them it's a life-changing event. Mind your language, make others mind theirs, and make a difference.
Discussion.(TR) A hand-held computerised version of the patient record of a pregnancy which can be updated at every visit by download from the main computer is a possibility for the future. It is for you the professionals to tell your technical division what you want.
(TR) The quality of health care must suffer in countries where practitioners are not able to access the evidence database. The depth and breadth of the structure of recording in the NHS explains why we are so far ahead of Europe in this field.
(TR) Under current data protection legislation patients are allowed to see and verify any information which has been recorded about them. The mother who asked "Is it normal for my blood group to change in every pregnancy?" may certainly identify and require any essential changes to the record. The coming electronic healthcare record is certain to make a difference. At present a charge can be made for access to medical records, to a maximum of £10.
(WS) We must remember that while labour and birth are routine for us they are never routine for the women who are going through the process.
(BP) When speaking to women around pregnancy we must use the language of women or not the medical jargon; this applies as much to us in the NCT as to health care professionals. The use or misuse of language is always likely to be remembered by women.
The sensitive use of language is coming into midwifery training and use. (WS) The training of medical students now includes communications skills, which are tested during their examinations. However a reversion to authoritarian mode is all too probable in the excessively busy and pressurised first year after qualification.
(MC) Please let us substitute "This labour needs help" for "Things are going wrong".
A midwife recalled how debriefing after a birth and her sense of humour served to defuse the effect of the derogatory meanings in some of the language she had used.
The language used in textbooks needs adjustment; and please let us remove the word "Patient" from the notice on the door "Patient toilet"!
A recently qualified midwife who had worked in advertising is very sensitive to the uses of a language, and makes every effort to avoid words such as failed, inadequate, trial, Mr. X's patient - he doesn't own her. But I feel isolated in this exercise; it is not unusual for my note on the labour ward progress board "Baby born" to be deleted very soon and replaced with "Del". The support of senior members of staff for juniors like myself with a mission to improve the language is badly needed.
The language of risk as used by professionals is very subjective; a risk may be exaggerated or played down, in either case to the confusion or harm of a woman. This is one of the many situations in which advice rather than information is given; a woman can then decide with the professional on the basis of information what course of action should be taken and should then be supported in her decision. Advice is usually inappropriate, and if it is taken against a woman's better instincts may lead to lifelong feelings of guilt or to shifting of blame. (TR) Online connection enables patients to share their experiences; as examples the research into and management of polycystic ovary syndrome and hepatitis-C in the USA is now largely driven by the online community.
At first meeting ask a woman/couple how they wish to be addressed. If possible interpreters working with immigrants should also be using appropriate and sensitive language.