UNITED WE STAND
MERAS ROLLING STRIKE ACTION P.16 PERINATAL MENTAL HEALTH
SEARCHING FOR CLUES
NAUSEA AND VOMITING IN PREGNANCY
PART II: MEDICATIONS P.18
DR KELLY WAIANA TIKAO P.22
PRACTICE UPDATE P.28
ISSUE 102 SEPTEMBER 2021 I THE MAGAZINE OF THE NEW ZEALAND COLLEGE OF MIDWIVES
W IP ES
BIOD
RADABLE G E
YOUR COLLEGE
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ISSUE 102 SEPTEMBER 2021
FORUM FROM THE PRESIDENT 4. STANDING IN SOLIDARITY FROM THE CHIEF EXECUTIVE 5. A PROFESSION AT A CROSSROADS 7. COVID-19: THE RIPPLE EFFECT
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8. BULLETIN 10. YOUR COLLEGE 12. YOUR UNION 14. YOUR MIDWIFERY BUSINESS FEATURES 16. MERAS STRIKE ACTION
22
18. PERINATAL MENTAL HEALTH PART II 22. SEARCHING FOR CLUES: DR KELLY WAIANA TIKAO 26. SLEEP FOR MIDWIVES
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28. PRACTICE UPDATE: NAUSEA AND VOMITING 32. PASIFIKA 33. NGĀ MAIA 34. BREASTFEEDING CONNECTION 37. CHARLOTTE JEAN MATERNITY UNIT 38. SECTION 88 CHANGES 40. NAVIGATING UNEXPECTED PRACTICE OUTCOMES 41. MY MIDWIFERY / MY MIDWIFE DIRECTORY
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EDITOR Amellia Kapa, P: (03) 377 2732 E: communications@nzcom.org.nz
ADVERTISING POLICY AND DISCLAIMER: The New Zealand College of Midwives maintains a schedule of guidelines to exclude advertisements for products or services that are not aligned with its principles and ethics. Every effort is made to ensure that advertising in the magazine falls within those guidelines.
ADVERTISING ENQUIRIES Hayley McMurtrie, P: (03) 372 9741 E: Hayley.m@nzcom.org.nz
Where advertising is accepted, this does not imply endorsement by the College of the product or service being promoted.
MATERIAL & BOOKING Deadlines for December 2021 Advertising Booking: 8 November 2021 Advertising Copy: 15 November 2021
Aotearoa New Zealand Midwife is published quarterly for the New Zealand College of Midwives. The articles and reports printed in this newsletter are the views of the authors and not necessarily those of the New Zealand College of Midwives, its publishers or printers. This publication is provided on the basis that New Zealand College of Midwives is not responsible for the results of any actions taken on the basis of information in these articles and reports, nor for any error or omission from these articles and reports and that the College is not hereby engaged in rendering advice or services. New Zealand College of Midwives expressly disclaims all and any liability and responsibility to any person in respect of anything and of the consequences of anything done, or omitted to be done, by any such a person in reliance, whether wholly or partially upon the whole or any part of the contents of this publication. All advertising content is subject to the Advertising Standards Authority Codes of Practice and is the responsibility of the advertiser. Contents Copyright 2020 by New Zealand College of Midwives. All rights reserved. No article or advertisement may be reproduced without written permission. ISSN: 2703-4546 .
ISSUE 102 SEPTEMBER 2021 | 3
FROM THE EDITOR
FROM THE PRESIDENT
from the president, new zealand college of midwives, nicole pihema Nau mai haere mai ki Aotearoa New Zealand Midwife As we find ourselves back in Level 4 lockdown, it’s hard to imagine what our new ‘normal’ will eventually look like, or at what point we'll know we've arrived. The future of our profession feels equally uncertain, with plenty of changes afoot; College president Nicole Pihema touches on this on p.4. CEO Alison Eddy further elaborates on p.5, with an announcement about the College taking further legal action against the Ministry of Health for breach of settlement agreement.
Kaua e rangiruatia te hoe o te waka e kore e tae ki uta
(If we are out of sync in our paddling, we are destined to circle the bay)
Amellia Kapa, Editor/Communications Advisor Email: communications@nzcom.org.nz square
Recent national health reforms have encouraged reflection at an organisational level, including the review of structure, governance, and te Tiriti obligations. This has been the reality for most institutions throughout Aotearoa and the College is no exception. It is timely, therefore, that we reassess our national board structure to ensure it is fulfilling its purpose and aligns with our values and future direction. Historically, due to the politically challenging and ever-changing landscape within which the midwifery profession has operated, the environment has necessitated a ‘strength in numbers’ approach. However, given the rapid evolution we have experienced in more recent times as we have adapted to an unforeseen pandemic, the question of how we can work smarter, utilise technology more widely, and innovate, in order to keep costs down and productivity up, must be asked. Close and honest inspection of whether we are meeting te Tiriti obligations is also necessary if we are to call ourselves a true te Tiriti partner, starting with review of national board representation, including consumer groups. Gone are the days of ticking boxes for ticking’s sake. Now is the time for true accountability. Accountability, as we know, means fulfilling our obligations as a professional organisation; to our members, to the wāhine and whānau we care for, and let’s not forget, this includes accountability to each other as midwives. The human mind is expert in compartmentalisation; separating this from that in order to minimise discomfort and pain. It’s an unconscious safety mechanism we fall back on time and again in order to keep moving through our most traumatic experiences. As a profession, however, this approach can lead to our demise.
4 | NEW ZEALAND COLLEGE OF MIDWIVES MAGAZINE
4 | AOTEAROA NEW ZEALAND MIDWIFE
Strike action from around the country can be seen on p.16-17 and the most recent updates to the Primary Maternity Services Notice are detailed on p.38-39, including details on which modules have been updated and how. Traditional Māori birthing practices and the establishment of a kaupapa Māori birthing unit are explored through a Ngāi Tahu lens on p.23, and the mental health series is continued on p.18, with a focus on psychotropic medications and their implications for wāhine, pēpi and midwives. Tips for improving sleep quality and switching off after a stressful shift or complicated birth are shared by sleep specialist Dr Alex Bartle on p.26 and a practice update on nausea and vomiting in pregnancy is provided on p.28, with clear guidance surrounding midwifery prescription of ondansetron. Important changes to the newborn resuscitation guideline are highlighted on p.9 and messages from the Newborn Screening Unit can be found in the Bulletin on p.8. This issue’s Breastfeeding Connection discusses supplementary feeding, whilst a successful antenatal education programme is explored in Pasifika (p.32) and the first Ngā Maia national student hui is celebrated on p.33. In these uncertain times, we hope midwives throughout Aotearoa recognise the importance of prioritising self-care and whānau wellbeing above all. Kia kaha, kia māia, kia manawanui. Mā te wā,
In reality, there is no division between LMC midwives and employed midwives. We are all midwives who embarked on our education with a common goal: to empower our communities through the profound experiences of hapūtanga, birth and parenthood. It was heartwarming, and encouraging, therefore, to see midwives from all employment settings unite through the recent rolling strikes. Make no mistake: this was not an exclusive fight for employed midwives. The struggle for employed midwives to attain satisfactory pay and working conditions is the responsibility of the entire profession to ease, and the more we view each challenge through this lens, the stronger our voice will be. It was uplifting therefore, to see midwives who aren’t currently practicing, standing in solidarity with fellow practicing midwives to further bolster the movement. It is this unity and connection that we must continue to foster within our profession, and whilst talk of te Tiriti obligations may appear separatist on the surface, the truth is that by uplifting those who have been downtrodden; by acknowledging inequities and reducing them, our entire profession is also uplifted. And the knock-on effect for wāhine, pēpi and whānau is immeasurable. square
In reality, there is no division between LMC midwives and employed midwives. We are all midwives who embarked on our education with a common goal.
MIDWIFERY: A PROFESSION AT A CROSSROADS Many midwives I speak to around Aotearoa agree, it feels as though the profession is at an evolutionary crossroads. There are numerous challenges and changes afoot: workforce shortages; generational shifts within the profession; dissatisfaction with pay and conditions; a health system reform on the horizon; and increasing development in ensuring te Tiriti responsibilities are being met by individual practitioners, and the sector as a whole. Midwifery is a single profession, and at the same time, there are multiple workforces operating within it. These workforces are bound by what attracted us all to the role in the first place; a common recognition of the potential inherent in the processes of pregnancy, labour, birth and motherhood, to become transformational events for women and whānau. Our workforces are in fact not separate, demonstrated by their symbiotic relationship; they rely on each other at the interface to provide care to women, and we need sufficient numbers and the right balance of midwives working in facility and community-based settings, for our service to function. Our maternity system enables midwives to change their work setting throughout their careers to support different stages of their lives, and it is not uncommon to
hear of experienced senior DHB employed midwives moving into LMC practice, and vice versa. Although changing work setting may alter our day-to-day responsibilities, it doesn’t change our scope of practice, our accountability to the women we provide care to, nor our accountability to each other. Midwifery is a demanding but incredibly rewarding profession. Not a job for the faint-hearted, it takes courage and tenacity - attributes which require nurturing. In order to sustain and retain midwives in the workforce, some key elements must be present: • A workload which affords midwives the professional satisfaction of providing quality care within the relational model in which we are educated to practice • Sufficient financial recompense (relative to the responsibility and demands of the role)
Midwifery is a single profession, and at the same time, there are multiple workforces operating within it. These workforces are bound by what attracted us all to the role in the first place; a common recognition of the potential inherent in the processes of pregnancy, labour, birth and motherhood, to become transformational events for women and whānau.
• Satisfactory work-life balance • Supportive work environments where midwifery expertise is respected, midwifery leadership is visible, and collegial relationships with peers and members of the medical team are the norm.
ALISON EDDY CHIEF EXECUTIVE
Unfortunately, for many midwives these elements are not present, thus their professional practice and personal wellbeing
ISSUE 102 SEPTEMBER 2021 | 5
FROM THE CEO
are suffering. This deeply concerns the College, from both the perspective of the sustainability of the workforce, and the quality of care that women receive. Appropriate remuneration and reasonable working conditions are among the most vital elements required by all midwives, and the College has been working closely with MERAS to support its pay equity claim. The College has also involved Jill Ovens in its formal mediation meetings with the Ministry of Health. By working collaboratively, we can better ensure that any benefits achieved for one group of midwives will also be realised for the other. MERAS’s pay equity process has been fraught with the same bias and discrimination that the LMC process has faced. MERAS has struggled to have their perspective understood, resulting in formal mediation with the Employment Relations Authority (ERA). MERAS invited me to attend the ERA meeting, where I spoke about the work undertaken to date comparing LMC midwives to GPs, and the specific professional responsibilities and challenges faced by employed midwives. As a result of the ERA mediation process, I was appointed to the Pay Equity Quality Review Panel, and thus had further input into how midwifery roles were assessed as part of the claim. The health reforms offer an opportunity to reconsider the way both LMC contracting and employed midwife MECA arrangements are negotiated with Health NZ in the future. This could be a win-win situation; by
reiterating the connection between employed and LMC midwives’ working conditions and pay, MERAS could distinctly and overtly uncouple their negotiations from nursing, and LMCs could potentially benefit from some of the working conditions that employed midwives can access. However, such change would take time, and there are pressing issues for LMC contract conditions, which cannot wait. Whilst there have been significant gains in the improvement of Section 88, which would not have occurred to the same degree without a legal process (the mediation agreement) running in the background, they alone are not enough. The national board has determined that it will pursue further legal action against the Ministry of Health for breach of the second settlement agreement. There are two main reasons why the College’s board has taken this decision: 1 / The current Section 88 is a legislative document, and although the College has a level of influence on its terms and conditions, we do not ‘sign off’ on the final version; this right is reserved for the Ministry of Health and Minister. Simply increasing payments in Section 88 does not address the core issue. The settlement agreement promised a new contract model by July 2020, which would ensure sustainable practice models for LMC midwives, and this has not materialised. 2 / As a result of the health system reforms, there is uncertainty about future arrangements for community LMC midwives. In order to have any influence over our future, we need to use all of the tools in our kete, and enforcing the terms of the legally binding settlement
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is one of these.
The College has sought extensive legal advice to inform the best approach. Enforcing the contractual promises made by the Ministry in the settlement agreement with the College is legally straightforward. The terms of the settlement agreement are clear; the Ministry committed to delivering a new national midwifery contract by July 2020, reflecting a blended payment model, alongside determining ‘fair and reasonable’ pay for LMC midwives. Holding the Ministry to those contractual promises is the most expedient route, which the College will be pursuing. Sadly, many midwives I speak with comment that the necessary focus on our inadequate pay and working conditions
over the past few years has had a profoundly negative effect on the profession’s morale; leading to a sense of dissatisfaction, an inward focus, and a loss of joy related to our work. It’s disheartening that DHB negotiators and Ministry officials are dismissive of our concerns and midwives are leaving the profession because their cries for help have fallen on deaf ears. Despite this, there are positive examples of midwives taking their power back. I recently had the pleasure of attending the 30-year celebration of Midwifery Associates - an LMC practice I was briefly a member of. This practice has had 26 midwife members throughout its history, with one original midwife remaining. There are some key ingredients which have made this practice and its model so successful: it has always had roughly six to eight members; there is an agreed system of regular time off; caseload sizes are mutually agreed; regular practice meetings are held; a system exists to manage contact from women seeking to book; cross-practice financial arrangements have been agreed upon, and most importantly, members share a philosophy of care and practice standard, including a commitment to provide cover throughout the enitre year. This, and many other similar examples are highly sustainable and successful; the midwives themselves have defined the arrangements that work for them. They have not been imposed upon them, and selfemployment has enabled midwives to come and go from the practice over the years on the terms that suit their needs. The health system reform provides an opportunity to support these successful models by developing contract arrangements that further strengthen them, such that resourcing is provided for structural support to enable group practice models (and midwives) to flourish and integrate with wider maternity and other health services. When I ask midwives what they want to change - what would bring back the joy to their work, what would make their work more sustainable and improve retention invariably their responses reflect their desire to have job satisfaction; making a positive difference for the women, whānau and people they care for, and feeling valued and respected for doing so. That is not too much to ask and is exactly what we should be aiming to achieve for all midwives, regardless of where they work or who pays them. square
CONFERENCE
Covid-19: the ripple effect As this issue of Midwife goes to print, we find ourselves back in alert level 4 lockdown, with parts of the country expected to move down to alert level 3 over the coming week. Once again, we are in a position of uncertainty, bound by constraints, which - whilst enforced for our own protection and wellbeing - have undoubtedly added pressure to our work and home lives. We are all making concessions over this time,
level 4 lockdown, the venue would not be
ultimately, the decision was made in a bid to
to varying degrees, on both personal and
completed in time for the conference.
keep each other and our whānau safe.
professional levels, and are at the mercy of Covid-19. For our LMC workforce, this means
• The ongoing uncertainty around alert levels,
All those who registered will receive a full
particularly for Auckland midwives, who
refund and details regarding this should have
conducting clinics over the phone and in
have been carrying a significant burden of
been communicated by the time this issue of
driveways, reassuring women whose maternity
lockdown restrictions, means we may not
Midwife arrives in mailboxes. However, if you are
journeys have veered significantly off-course.
be at an appropriate alert level to convene
For our employed workforce, staff shortages
a conference that will fairly enable all of our
are being felt even more acutely, particularly in
members to attend.
places like Auckland, where the usual back-up pools of staff can no longer be called upon, due to redeployment while multiple DHB staff members self-isolate at home. The logistical nightmare that is our current reality affects all facets of life - from the mundane and now extraordinarily long trip to the supermarket, to the less frequent, highly anticipated events that only roll around once every couple of years. Unfortunately, the upcoming College 16th Biennial National Conference is the latest to be scooped up in Covid-19’s net of collateral damage, and it was with considerable
• This uncertainty means that even with an alternative venue, the potential for a later cancellation would not provide midwives with adequate time to modify or cancel travel, accommodation and leave arrangements.
any communication, please contact the College. Finally, the College wishes to acknowledge the exhaustive efforts of our members at this time, whose midwifery hearts continue to be the driving force behind providing compassionate care of the highest standard, to wāhine, pepi and whānau through our most challenging times. square
The College did consider converting the conference to an on-line format, but our national board was also very conscious of the extra pressure our workforce has been experiencing due to the recent resurgence of Covid-19, and the additional stress this causes for midwives. With this in mind, we considered the best course of action was to cancel the event entirely, and plan the next biennial conference for a time
disappointment that the College national board
when we can all be assured of more certainty
made the difficult decision to cancel the event.
than the current climate can provide.
A combination of concerns led to this decision:
entitled to a refund and have not yet received
We know this will be incredibly disappointing
• We were notified in late August by Te Pae
for our delegates, speakers and exhibitors,
(conference venue), that due to a halt in
who were looking forward to reconnecting
construction work during the current alert
and sharing their work with colleagues, but
We are all making concessions over this time, to varying degrees, on both personal and professional levels, and are at the mercy of Covid-19.
NOMINATIONS FOR PRESIDENT: College President Nicole Pihema has put herself forward for a second term as president (as is her right under the College’s constitution). Nominations are now called for any candidates who wish to stand against Nicole. The closing date for nominations is 11 October 2021. If there are any opposing candidates, an election will be held by online ballot. If there are no opposing candidates, Nicole will be re-elected unopposed. Please contact Lynda Overton Lynda.o@nzcom.org.nz for further information.
ISSUE 102 SEPTEMBER 2021 | 7
BULLETIN
BULLETIN newborn metabolic screening (nbms) programme The following messages are from the National Screening Unit: • Sample test cards will be accepted for processing from 24 hours, although the recommended time is still 48-72 hours, and as close to 48 hours as is feasible. • There will be a change of card colour from buff to white as new cards are printed. Continue to use the older buff cards until the stock is used up. • New information will be required on the cards related to the location where the sample was taken (home/birth unit/hospital). • The courier tracking number should be
much detail as possible, including a note that
resource, including: manaakitanga, kaitiakitanga
screening was declined, and courier it to the
and whānaungatanga.
laboratory.
The application of these guiding principles within the context of infant feeding are explained in the resource, which can be found on the Canterbury/West Coast College region’s website and an adapted version will also be added to the national College website in due course.
• Resources: lancets, cards and courier bags can be ordered via newbornscreening resources@adhb.govt.nz or phoning (09) 307 4949 ext 23806. • Reminder that results are no longer being sent by fax so if you answer ‘yes’ to either of the following questions, please contact the NSU as soon as possible to update your preferred contact details. • Do you receive screening results from the lab by fax? • Do you receive results via paper (mail) but would prefer to receive these via email or HL7
Please email Elaine at education@nzcom.org.nz if you have any professional queries relating to
are sent to the lab. Take one of the number
any of these changes. square
labels from the courier pack and attach it to • Ensure you are receiving all test results
developments within infant feeding emerge. square
message?
recorded before blood spot sample test cards
the baby’s health care record.
Aimed at bringing together a vast array of relevant feeding resources into one centralised location, it’s hoped the resource will assist midwives in easily and quickly accessing appropriate breastfeeding education, advice and support services for wāhine and whānau under their care. As a living resource, it will be updated regularly as new evidence or
WAITAHA INFANT FEEDING RESOURCE The Waitaha Infant Feeding Resource was
ONLINE TEACHING PACKAGE: WORKING WITH PASIFIKA WOMEN Moana Research have developed an online teaching package, Pacific women and pregnancy, for health professionals. Focused on the significance of Pacific knowledge systems and cultural perspectives during the perinatal period, the online module is aimed at improving outcomes for Pacific women and their families.
within 7-10 days of the sample being taken
launched on 3 August 2021, in conjunction with
and sent. If results are not received in this
World Breastfeeding Week. The online resource
timeframe, check that the lab has received
was developed by Canterbury/West Coast
the sample. Call 0800 LABLINK to enquire
Regional College Breastfeeding Representative
about the sample/result, quoting the courier
Catherine Rietveld, in collaboration with the
tracking number.
There will be two other learning modules available in the coming months: Working with Pacific families experiencing unconscious bias
Canterbury/West Coast Regional College
and Pacific infant health. square
• When parents/guardians/whānau decline
Breastfeeding Focus Group.
NBMS for the baby, please ask them if they
The focus group included representatives
agree to a blood spot card being filled out
from a wide variety of organisations, including
with their demographic information, to
Māori, Pasifika and LGBTQIA+ members involved
induction of labour guideline published
monitor participation in the programme. With
in breastfeeding support. Three key principles
The Ministry of Health has published the
their approval, fill the sample card with as
were identified in the development of the
Induction of Labour in Aotearoa New Zealand: A Clinical Practice Guideline. The guideline has gone through the Ministry’s external maternity clinical guideline appraisal process and has been ratified by the National Maternity Monitoring Group (NMMG). The guideline covers: • Indication and timing of induction of labour, neonatal risk factors and non-pharmacological methods • Methods of cervical ripening and induction of
Canterbury/West Coast Regional College Breastfeeding Focus Group.
8 | AOTEAROA NEW ZEALAND MIDWIFE
labour and the appropriate clinical setting. square
BULLETIN
updated newborn resuscitation guidelines In 2020 the International Liaison Committee on Resuscitation (ILCOR) undertook an extensive review of new evidence from the last five years, and updated its recommendations.
covid-19 vaccination during pregnancy
Evidence review topics included:
Just as the June 2021 issue of Midwife went
• sustained inflations for initiation of positive-pressure ventilation
to print, the Ministry’s updated advice
• initial oxygen concentrations for initiation of resuscitation in both pre-term and term infants
regarding Covid-19 vaccination during pregnancy was released.
The Ministry’s messages are: • If you’re pregnant, we encourage you to get a COVID-19 vaccine as part of Group 3 at any stage of your
• use of suction in the presence of both clear and meconium-stained amniotic fluid
• use of epinephrine (adrenaline) when ventilation and compressions fail to stabilise the newborn infant • appropriate routes of drug delivery during resuscitation • consideration of when it is appropriate to redirect resuscitation efforts after significant efforts have failed (Wyckoff el al, 2020).
pregnancy. This is because people who
As a result of ILCOR updating its recommendations, the Australian and New Zealand Committee on
are pregnant can become very sick if
Resuscitation (ANZCOR) has subsequently published changes to its guidelines. The following table
they get COVID-19 infection.
summarises significant changes to the ANZCOR guidelines, with an emphasis on those that are of
• Evidence from the large number of
particular importance to midwifery practice.
pregnant people who have already been vaccinated globally, indicates that there are no safety concerns with administering COVID-19 vaccines at any stage of pregnancy. • Vaccinating during pregnancy may also be helpful for the baby, as there is
TOPIC IN GUIDELINE
2021 CHANGES
Introduction to resuscitation of the newborn
For infants born at less than 34 weeks’ gestation who do not require immediate resuscitation after birth, defer clamping the cord for at least 30 seconds.
evidence of antibody transfer in cord blood and breast milk, which may offer
For term and late pre-term infants born at ≥34 weeks’ gestation who are vigorous or deemed not to require immediate resuscitation at birth, later (delayed or deferred) clamping of the cord at ≥ 60 seconds.
protection to infants through passive immunity. • If you have any questions or concerns, discuss them with your healthcare
Intact cord milking for infants born at less than 28+0 weeks’ gestation is not supported.
professional. The College worked with Dr Nikki Turner and Dr Mary Nowlan from the Immunisation Advisory Centre (IMAC) to run a second webinar for midwives about the science behind the recommendations, and to
Airway management and mask ventilation of the newborn
For all newborns exposed to meconium-stained amniotic fluid, ANZCOR suggests against routine direct laryngoscopy immediately after birth, with or without tracheal suctioning.
The resuscitation of the newborn in special circumstances
For pre-term infants born at less than 35 weeks’ gestation commence resuscitation either using room air or blended air and oxygen up to an oxygen concentration of 30% rather than higher initial oxygen concentration (60%–100%).
Ethical issues in resuscitation of the newborn
If, despite provision of all the recommended steps of resuscitation and excluding reversible causes, a newborn requires ongoing cardiopulmonary resuscitation (CPR) after birth, ANZCOR suggest discussion of discontinuing resuscitative efforts with the clinical team and family. A reasonable timeframe to consider this change in goals of care is around 20 minutes after birth.
update the IMAC information sheet for health professionals. You can find these useful resources on the College website under News & Events/Covid-19 Vaccination, Pregnancy & Lactation: June 2021 Update. square Correction: In the bulletin of Issue 101 of Midwife (p.8), Pauline Dawson was mistakenly reported to have completed her doctoral degree through Otago Polytechnic. In fact, Pauline attained her doctorate through the University of Otago.
ISSUE 102 SEPTEMBER 2021 | 9
YOUR COLLEGE
new e-learning modules available: free for midwives The College was invited to participate in the development of two e-learning modules: Alcohol in Pregnancy and FASD with the Health Promotion Agency, and Newborn Metabolic Screening with the National Screening Unit. Both courses have been designed to support and update midwives in practice. Midwives have been instrumental in the design of both courses, which are free and can be accessed via LearnOnline. square
will support midwives in their practice. These can
The content of the keteparaha is based on
be accessed through the Professional Practice
the experiences of midwives voiced at the
page on the College website. square
workshops, as well as consultation with College members and the national board.
A KETEPARAHA/TOOLKIT: SUPPORTING AND ENHANCING EFFECTIVE MIDWIFERY RECORD KEEPING IN AOTEAROA
its format enables a collection of adaptable
In 2005 the College designed a workshop
addressing it. Toolkits can help translate theory
titled Dotting the I’s and Crossing the T’s:
into practice and are effective resources for one
Midwives and record keeping. This has proved
main audience or issue. They are designed to
to be a popular workshop and over the years has
offer practical guidance and not intended to be
developed further, as midwives have
definitive, but rather, to exist as living documents
sought greater clarification on maintaining health
that reflect practice.
care records.
The concept of a toolkit was chosen because resources that support people to learn about a particular topic and identify strategies for
The keteparaha will be reviewed regularly
NEW PRACTICE GUIDANCE DOCUMENTS LIVE ON COLLEGE WEBSITE
health care records have evolved from nursing
in particular, the issue of electronic record
The College is pleased to announce the
and medicine, and it has become evident
keeping will become more prominent. The first
ratification of two new practice guidance
through the workshops that the recording
review is set for December 2021 and if there
documents at the SGM: Anti-D prophylaxis
of midwifery care is becoming increasingly
are any modifications, these will be presented
administration during pregnancy and early
complex. Therefore, the College has created a keteparaha in order to share professional
to the national board for ratification, to enable
postpartum and Assessment and promotion of fetal wellbeing during pregnancy, both of which
expectations of record keeping more broadly.
Most of the expected aspects of midwifery
and updated as new evidence emerges and
changes to occur readily. College members will be consulted about any significant changes and informed of updates, to effectively support record keeping in practice. The keteparaha is explored in depth with all midwives who attend Dotting the I’s and Crossing the T’s and can also be found on the College website under Professional practice/ practice guidance. Its interactive PDF format enables midwives to search for relevant questions or sections. Thank you to all midwives who have provided feedback thus far; any future comments or suggestions are greatly welcomed. square RURAL MIDWIFERY STUDENT GRANT Congratulations to Emily Sancha, third year student from Otago Polytechnic, who was the recipient of the final year rural midwifery student grant. This grant is open to applicants from any midwifery institution in their final year of study, intending to live and work rurally upon
New practice guidance and the keteparaha can be accessed through the Professional Practice page on our website.
10 | AOTEAROA NEW ZEALAND MIDWIFE
graduation. square
CV CHECK
to ensure continuous practice and payment
The College’s national office continues to receive a number of calls and emails from midwives experiencing difficulties with the CV check renewal process, which has resulted in claims being rejected when a CV check expires before renewal is confirmed. College staff have been successfully advocating for midwives to be paid on an individual basis, but this has only been possible in retrospect, as the Ministry has advised us they are not legally able to pay anyone without a valid CV check, until it is renewed. This year, the College and MMPO have written three extensive letters to the Ministry,
without impediment. The College considers it is unreasonable for LMC midwives to have payment withheld due to delays that are beyond their control. We will keep members updated with any developments on this issue. square
college midwifery student grants 2021 The College’s Midwifery Student Advisory Committee is pleased to announce the recipients
College Annual General Meeting (AGM)
of the College student grants for 2021. We are in the process of adapting the grants
outlining the significant issues with the
to include students undertaking the four-
application process and problems with claims/
year programmes and at all five institutions.
payments. We have had formal meetings with
Applicants are required to be members of
members of the Ministry maternity team and
the College and intending to practise in New
DATE: 3 NOVEMBER 2021 VENUE: NOVOTEL HOTEL, CATHEDRAL SQUARE, CHRISTCHURCH TIME: 6.00PM
set up a direct line of communication about
Zealand after graduation. Occasionally, there are no applicants from a particular institution,
Remits for consideration:
midwives who have extenuating circumstances for long delays in renewal.
and if this occurs, the grants allocated to that
The College has written an open letter to the Associate Minister of Health and Minister for
institution are shared between students from the others.
• Consensus statement on climate change, midwifery and environmental sustainability to be ratified • Increase of membership fees
Maternity, Hon. Dr Ayesha Verrall expressing
The College would like to wish all students
our concerns about the current process. As
nationally a successful and fulfilling year in their
Members will be notified of any further
providers of essential health care, the College
studies and midwifery practice. We look forward
AGM remits via email, prior to the meeting.
expects that any mandatory processes required
to welcoming all current third/fourth year
of midwives are streamlined and straightforward,
students to the profession next year. square
COLLEGE MIDWIFERY STUDENT GRANTS 2021 STUDENT MIDWIFE
MIDWIFERY EDUCATIONAL INSTITUTION
GRANT AWARDED
Tasmin Jury
Otago
2nd year
Nitya Lakshmanan
Wintec
2nd year
Otago
3rd year
Tania Webb
AUT
3rd year
Sophie Nation
Wintec
3rd year
Chontelle Eyre
Ara
3rd year
AUT
4th year
Vicky Henry Melisssa Musso Wanaka Noanoa
Candice Milner
Gemma Ray
YOUR UNION
CAROLINE CONROY MERAS CO-LEADER (MIDWIFERY)
midwifery clinical coaches and return to practice programme:
exciting opportunities from the midwifery accord In July, Associate Minister of Health Hon. Dr Ayesha Verrall announced funding for midwifery clinical coach roles and the Return to Practice (RTP) programme. These are the latest initiatives to emerge from the work of the Midwifery Accord Group. Funding from the Ministry of Health is available for each DHB to have at least one midwifery clinical coach position. A national position description has been developed and the role will be included in the senior midwife pay scale. The midwifery clinical coach
role was identified in the Midwifery Career Pathway (another Midwifery Accord project). The role will be clinical facing (i.e. in the ward) and the focus will be on providing clinical coaching support to new graduate midwives, return to practice midwives, those new to the service and any midwives wanting to enhance their clinical skills. As well as supporting new midwives, this role will also assist in retaining experienced midwives within the DHBs by creating a new career opportunity. This is a role for
experienced midwives who enjoy clinical teaching and also meets Midwifery Council of New Zealand’s criteria for supervisors within the RTP programme. In conjunction with the midwifery clinical coach announcement, Associate Minister Verrall also revealed funding of $1600 per midwife in the RTP programme, towards recertification costs for up to 40 midwives in the first year, and 60 midwives in subsequent years. Midwives in the RTP programme will have an APC, and can therefore be employed by DHBs. With around 600 midwives in New Zealand currently on the register but without current APCs, the funding and support for midwifery clinical coaches and those midwives in the RTP programme provides a great opportunity to attract midwives back into midwifery roles within the DHBs. Since the announcement, there has been significant interest in the RTP programme and DHBs are starting to employ more midwives on this basis. WHAT IS THE MIDWIFERY ACCORD? The Midwifery Accord was signed in April 2019 as an outcome of the negotiations for the last MERAS MECA. The Midwifery Accord signatories were MERAS, DHBs, Ministry of Health and NZNO.
Counties Manukau DHB Clinical Coach Lesley Maclennan (right), works alongside graduate midwives like Shekinah Gafa (left) and says she is excited about the new opportunities the clinical coach role will provide.
12 | AOTEAROA NEW ZEALAND MIDWIFE
Since its establishment, the group has focused on actions and strategies that will support midwifery workforce development,
MIDWIVES! as well as recruitment and retention for midwives employed by DHBs. Whilst the focus has been on the DHB midwifery workforce, the benefits of the initiatives will be felt across the entire midwifery profession. The Midwifery Accord has provided an opportunity to really focus on what is needed to create a sustainable DHB midwifery workforce. The initiatives already signed off and those in the pipeline will hopefully make a real difference to positively promoting a career in midwifery, improving our ability to grow our own local midwifery workforce and to retain those midwives once qualified. Not all the initiatives from the Midwifery Accord Group are new; the group identified projects that had been started by individual universities, workplaces or organisations that were making a positive difference and could be developed into national initiatives. One such project was support for Māori and Pasifika midwifery students.
REGISTERED MIDWIVES Birthcare Auckland is the primary birthing unit for Auckland DHB. We pride ourselves on providing
TE ARA Ō HINE – TAPU ORA
the best possible outcomes for
Announced in March, this initiative is something that many within the midwifery sector have long been advocating for. The initiative emerged from a project that AUT had already started as well as the Pasifika midwives ‘Aunties’ programme, both of which were yielding positive results in supporting student midwives.
women, babies and their whānau.
Te Ara Ō Hine – Tapu Ora will be implemented at the five midwifery education institutions and will fund financial, cultural, academic and pastoral support for Māori and Pasifika midwifery students. The support includes tutoring and guidance, a national network of Māori and Pasifika students, and at least one lead support provider at each school of midwifery. Hardship grants will also be available for midwifery students who need it.
This is an exciting time to work for Birthcare. We support our staff by providing: • Flexible roster • In house and external education
MIDWIFERY CAREER PATHWAY
• Free secure parking for our staff
The pathway has been described in the previous edition of Midwife and is intended to support the retention of midwives within DHBs, by providing a nationally consistent, clearly defined career pathway for midwives. Square
• Good remuneration • Career pathway support • Modern, homely environment • Centrally located in Auckland
SIGNATORY
MIDWIFERY ACCORD GROUP MEMBERS
MERAS
Caroline Conroy
MERAS Co-Leader (Midwifery)
Jill Ovens
MERAS Co-Leader (Industrial)
Julie Arthur
DoM Hawkes Bay
Deb Pittam
DoM Auckland
Carolyn Coles
DoM Capital & Coast
Joyce Croft
Māori Midwife Northland
Gillian Campbell
COO Taranaki
Trish Casey
GMHR Nelson-Marlborough
We have vacancies at this time for
Fionnagh Dougan
CEO Capital & Coast
permanent and casual midwives
Alison Plumridge
TAS
and are negotiable around what
Rebecca Kay
TAS
Abbey Hewitt
Senior Advisor, Maternity team
Please contact Angela Wilson
Laura O’Sullivan
Health workforce directorate
(Clinical Midwife Manager)
Kamini Panther
Health workforce directorate
Kate Weston
Professional nurse advisor
DHB
MOH
NZNO
• Collegial support across all disciplines • Up to date Primary Birthing facility which provides a superior birthing experience for our clients, LMC’s and working environment for staff.
hours you wish to work.
For MERAS Membership Email: merasmembership.co.nz www.meras.midwife.org.nz 03 372 9738
ISSUE 102 SEPTEMBER 2021 | 13
angelaw@birthcare.co.nz or 027 271 3566.
YOUR MIDWIFERY BUSINESS
managing your self-employed business – time for a spring clean? MICHAEL STIRLING FINANCE MANAGER, MMPO
Now that spring is upon us, it’s an ideal time to take stock and reevaluate areas of your business that have potentially been neglected, and could be costing you unnecessary money, time or energy. We suggest examining your business and personal situations by attending to the following obligations. INSURANCE NEEDS When was the last time you reviewed, in earnest, both your business (including ACC) and personal insurance cover policies? As part of managing your day-to-day risk, you should ideally engage with your broker on an annual basis, ensuring both you and your whānau are covered appropriately given your age, debt profile and stage of work. Further, your broker will also be able to confirm whether you may in fact be overinsured, and consequently paying too much. Ideally, you should have a broad range of insurance that meets your needs, with a relevant mix of life cover, income and mortgage protection, personal trauma, and ACC Cover Plus Extra. Your broker will be able to assist in recommending a balanced package, considering all known factors, including affordability. Schedule a meeting today - the broker’s time and service is free of charge, so you have nothing to lose and plenty to gain.
HOME UTILITY BILLS
KIWISAVER & OTHER INVESTMENTS
When did you last deep-dive into the present cost of your phone, broadband and energy plans? Have you considered signing up for a bundled package instead, as they are often cheaper? Utility companies are continually marketing deals to attract new customers. Even if you don’t want to change vendors, you can still obtain a superior deal with your existing provider by leveraging those competitor offers. You may well be pleasantly surprised at the potential savings.
Similar to insurance, review your KiwiSaver scheme, confirming you’re in the correct portfolio, considering your respective age and stage of life profile, as well as your overall risk appetite.
EXPIRY DATES Take a moment to check on expiry dates that can often creep up, including: • CV check • Vehicle registration and WOF • If you own a diesel vehicle, ensure your Road User Charges (RUC) are up to date. • Driver’s licence and passport • Vehicle logbook* * A vehicle logbook is used to determine the correct proportion of business versus personal usage, for the purposes of claiming vehicle related expenses. Inland Revenue rules state a logbook must be maintained for 90 consecutive days; the calculation based on those 90 days may then be used for up to three years. After three years you need to keep a logbook for another 90 consecutive days.
LEGAL & TRUST CONSIDERATIONS
HIRE PURCHASES/LEASES/LOANS
Update your last will and testament, including memorandum of wishes. If you don’t have a will, contact your solicitor or Public Trust Office, and arrange to have one prepared. In turn, this will allow your whānau to relax somewhat, providing peace of mind. If you utilise a family trust, familiarise yourself with the new Trusts Act 2019, ensuring compliance and an assessment as to whether it remains a suitable structure going forward.
In relation to credit contracts, operating leases and business loans, it’s very easy to lose track of where you are within the repayment plan cycle, which can often run over a series of months or years. Thus, review the original documentation, or contact the loan provider to confirm your current balance, including when your instalments are actually due to expire. Avoid late payment penalties and additional interest costs by paying on time, every time.
14 | AOTEAROA NEW ZEALAND MIDWIFE
Place a note in your diary to confirm by 30 June each year that you have managed to contribute the minimum amount of $1,042.86 over the preceding 12-month period, in order to receive the maximum Government subsidy of $521.43 per annum. Further, if you want to keep it simple and not have to think about it, we recommend you set up an automatic payment of $90 per month, in order to secure this ‘free’ money each and every year. The same principle applies to any other investments you may hold, whether it be term deposits or shares. It isn’t a ‘set and forget’ process; you need to review periodically for appropriateness, based on current level of interest rates, inflation, etc. If you hold a residential mortgage for the home you personally reside in, remember the key to future prosperity is endeavouring to pay it off as quickly as possible. HOME OFFICE CLAIM For tax purposes, you are entitled to claim a percentage of certain household expenses; namely broadband, energy bills, landline, rates, rent and/or mortgage interest, repairs/ maintenance, and consumables, such as lightbulbs and toilet rolls.The home office percentage allowable is based on the proportion of the total floor area of the house and garage that is utilised for running your business, which typically ranges from 10% to 40%, depending on the size of space used. It’s a good idea to revisit this number each year, in case you have relocated to a new dwelling, moved office rooms within your
house, or recently renovated. Your accountant will be able to assist you in this regard, ensuring your tax claim is maximised. YOUR BUSINESS FINANCES AND TAX POSITION If you are using online, cloud-based accounting software such as Xero, you can readily access reports, including profit and loss, statements of cashflow and balance sheets. These reports will assist you in tracking your financial performance for year-todate, versus both budget and the previous year’s actuals. Your decision-making will be enhanced once you understand the underlying variances, allowing potential cost savings to be made where appropriate. Cash is king, so get into the habit of processing your Section 88 claims in a timely manner, in order to receive the pending funds more promptly - in turn boosting your cash coffers. Understand your tax position, by logging into your myIR account and reviewing your balances for all tax types, including future payment dates; thus, no surprises when these commitments fall due. BANK ACCOUNTS We strongly recommend keeping your personal and business transactions flowing through separate bank accounts. This will make coding within your accounting software much simpler, as well as giving you a better handle on where your hard-earned cash is being expended. We continually advocate for midwives to operate a dedicated ‘tax’ savings account, in order to have ACC, GST, student loan and income tax obligations safely tucked away, until such time as they fall due. Again, no surprises, given you’ll possess clear funds in order to pay both ACC and Inland Revenue in full, and on time. Review the bank fees you are currently being charged, and if warranted, chat to your bank to obtain a better deal, including rewards schemes associated with your credit card. BE PREPARED AND STAY AHEAD OF THE GAME In summary, to maintain a stronghold on your business, undertake a spring clean and lean on your team to support you along the journey. Don’t be afraid to utilise the services of professional advisors to assist you with all key aspects of your profession, whether it be accounting, banking, insurance, legal, or personal-related advice. Further, it’s imperative you embrace digital technology, given such an investment will save you both valuable time and money going forward, enhancing your life/ work balance in the process. Lastly, both the College and MMPO are right behind you every step of the way, so feel free to reach out as the need arises; we are more than happy to guide you in the right direction, as best we can. Square
MMPO, the Midwifery and Maternity Providers Organisation provides self employed community midwives with a supportive practice management system. www.mmpo.org.nz mmpo@mmpo.org.nz 03 377 2485
FREE Iron in Pregnancy booklet includes:
Evidence-based information Key iron facts Iron deficiency signs & symptoms Top dietary iron tips Iron-rich recipes
Order your copies at beeflambnz.co.nz/pregnancy OR contact heather@beeflambnz.co.nz
We’re looking for an experienced midwife to join our team Are you an experienced midwife keen to join an outstanding team of committed rural midwives and health care professionals? We want to hear from you! We have a 12-month, fixed-term, full-time position available due to maternity leave. You will work alongside another midwife on a 24-hour roster — four days on, four days off providing continuity of care for antenatal, labour and birth and rural/remote rural postnatal care. We are looking for: + An experienced midwife seeking a move to a rural environment + Flexibility around working hours + Current Practicing Certificate + Start date is ASAP If you live outside the Tararua area, a midwife house is available on your rostered days. There may also be an opportunity to apply for a relocation grant from MMPO if you plan on moving to the region. Please contact: Robyn McDougal, Tararua Health Group, (06) 374 5691, Email: corporate@thg.org.nz
ISSUE 102 SEPTEMBER 2021 | 15
FEATURE
MERAS rolling strike action After mediation between MERAS and DHBs failed to reach agreement, MERAS organised rolling strikes for employed midwives to make their voices heard in August 2021. Midwives from all employment settings stood side-by-side with midwifery students and members of other unions, presenting a united front. Images of strike action received by the College from midwives throughout Aotearoa are shared here.
16 | AOTEAROA NEW ZEALAND MIDWIFE
FEATURE
ISSUE 102 SEPTEMBER 2021 | 17
FEATURE
AMELLIA KAPA COMMUNICATIONS ADVISOR
perinatal mental health in aotearoa part II: medications and implications Part I of the perinatal mental health series provided an overview of the current landscape in Aotearoa, discussing the midwife’s role, including screening. Part II focuses on commonly prescribed psychotropic medications and considerations for midwives when discussing their potential implications with wāhine/whānau. BACKGROUND He Ara Oranga, the 2018 report on the Government inquiry into Mental Health and Addiction Services in New Zealand, states that the number of general prescriptions for mental health-related medications increased by 50% over the previous 10 years, and was continuing to rise at a rate of around 5% each year at the time of the report’s publication (Government Inquiry into Mental Health and Addiction, 2018). In the same vein, a University of Otago study published this year which aimed to describe and compare antidepressant dispensing patterns before, during and after pregnancy in New Zealand between 20052014, reveals an antidepressant was dispensed in 3.1% of pregnancies in 2005, rising to 4.9% by 2014 (Donald et al., 2021). The study, which linked antidepressant dispensing records with 805,990 pregnancies over the nine-year period, also demonstrated a clear pattern; dispensing during the first trimester dropped to below pre-pregnancy and post-pregnancy levels, and the number
18 | AOTEAROA NEW ZEALAND MIDWIFE
fell even further in the second and third trimesters. This data would indicate women in Aotearoa who have been taking antidepressants prior to pregnancy are stopping, or significantly reducing their use of the medication during pregnancy. This finding is consistent with international data, including a Danish retrospective cohort study which showed that despite an overall increase of exposure to antidepressants in pregnancy in Denmark from 0.2% in 1997 to 3.2% in 2010, rate of exposure halved during the first trimester (Jimenez-Solem et al., 2013). A UK study mirrored these findings, revealing 79.57% of 19,774 women who were taking a psychiatric medication pre-conception, discontinued it in pregnancy (Margulis, Kang & Hammad, 2014). It is thought that hesitancy from both the practitioner to prescribe, and the woman to accept psychotropic medications in pregnancy, may be responsible for the sharp drop off, but both the Danish and New Zealand studies acknowledged the need for further research into the possible contributing factors (Jimenez-Solem et al., 2013).
Donald et al.’s (2021) analysis also showed that younger women, and those of Māori, Pacific, or Asian ethnicity were less likely to continue therapy during pregnancy if they were taking an antidepressant preconception. In their discussion, it was noted that whilst the prevalence of depression and anxiety in European and Māori women is similar, Māori women in the study were only dispensed an antidepressant around half as often as their European counterparts. Furthermore, Pacific and Asian women were only one-fifth as likely as European women to be dispensed an antidepressant, despite the fact that a longitudinal study has found that depressive symptoms during pregnancy were twice as likely to be experienced by the same group when compared with European women (Waldie et al., 2015). Donald et al. (2021) acknowledge that one possible explanation for the disparity in figures could be the potential for use of non-pharmacological therapies being higher in non-European ethnic groups, but do not discount the well-documented disparities in health service accessibility as possible contributing factors, nor the differences in cultural values regarding mental illness. Ethnicity aside, given that evidence has shown fetal antidepressant exposure may carry a small increased risk of preterm birth, congenital cardiac abnormalities, and persistent pulmonary hypertension of the newborn, hesitancy from a woman’s perspective is hardly surprising, and midwives may find themselves facing this situation in practice (Donald et al., 2021). COMMONLY PRESCRIBED MEDICATIONS Around 80% of dispensings in the Otago University study were for selective serotonin reuptake inhibitors (SSRIs) (Donald et al., 2021). Consultant psychiatrist and Clinical Head of the Mother and Babies Service at Canterbury District Health Board, Dr Liz MacDonald, has been working in the field of perinatal psychiatry for 20 years and corroborates this, naming SSRIs as the most commonly prescribed class in her experience. She cites sertraline and escitalopram as two well-known examples midwives will be familiar with.
FEATURE
Less commonly, she explains, antidepressants from other groups such as serotonin noradrenaline reuptake inhibitors (SNRIs) may be prescribed, such as venlafaxine. And at times, older tricyclics such as nortriptyline might be used. The choice of medication will depend on the individual and their overall clinical picture. “Antidepressants can be prescribed for use in anxiety, as well as depression. When choosing an antidepressant, we consider things such as previous response to medication and the properties of the medication. For example, a woman that is having difficulty sleeping might benefit from being on an antidepressant with sedative effects.” For severe anxiety, Liz says additional short-term medications like benzodiazepines may be used, such as lorazepam. And rarely, a woman suffering from severe depression or bipolar disorder might be prescribed lithium, used to treat depression and stabilise mood. Similar to the choice of medication, dosage will fluctuate throughout the population and over the course of a pregnancy, but caution is exercised to ensure minimal exposure for maximum therapeutic effect. “Dosage varies a lot depending on the severity and nature of the illness, and the woman’s own individual response and tolerance of the medication. However, in general the minimum dose to manage the symptoms should be used, with the goal of effective treatment for the woman, and avoiding unnecessary exposure for the unborn baby. Sometimes in the third trimester of pregnancy, the dosage may need to be increased, due to metabolic changes of pregnancy which ‘dilute’ the effective dose available,” Liz explains. The same approach of prescribing minimum doses to manage symptoms is used with breastfeeding mothers, but Liz advises newborns are generally less exposed than a fetus in utero, due to the fact that many of the antidepressants used postnatally are secreted in breastmilk in relatively small quantities. Continued next page >
In general the minimum dose to manage the symptoms should be used, with the goal of effective treatment for the woman, and avoiding unnecessary exposure for the unborn baby.
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FEATURE
IMPLICATIONS FOR NEWBORNS Exposure to SSRIs, SNRIs and tricyclics in utero may increase the risk of the newborn experiencing transient issues adapting to extrauterine life (CDHB 2017; Gentile, 2014). Whilst Liz maintains the need to balance these risks with the potential consequences of not managing depression and anxiety successfully, she details the most common concerns for newborns. “The main issue that people need to be aware of for the antidepressants is neonatal adaptation difficulties in the newborn period. This is a collection of symptoms seen in some neonates exposed to psychotropic medicines in utero, particularly with antidepressants and antipsychotics. Whether the symptoms relate to adverse effects of the medicine, or a withdrawal phenomenon, is often not clear.” Symptoms of Neonatal Adaptation Syndrome (NAS) may include: • poor feeding/suckling diffculties, vomiting or diarrhoea • restlessness, irritability or lethargy/drowsiness • tremors, hyper/hypotonia, hyperreflexia • nasal congestion, tachypnoea • body temperature instability • hypoglycaemia.
“These are usually mild and self-limiting, lasting just a few days, and no specific interventions other than reassurance are required,” Liz continues. “Very occasionally, babies may need additional support in NICU.” The symptoms of NAS are not specific to that syndrome, but may instead be signs of other conditions or issues. The effects of maternal medicines is a diagnosis of exclusion. IMPLICATIONS FOR PLACE OF BIRTH As midwives will be aware, women affected by mild mental health concerns are not excluded from birthing in primary settings, and allowing labour and birth to unfold physiologically is just as vital, if not more so, for women experiencing depression or anxiety during their pregnancy. Liz is explicit in her recommendations surrounding place of birth. “Women with mild mental illness, on single antidepressants within usual dosages, and with an uncomplicated pregnancy, can birth at a primary birthing unit or at home, providing there is someone present who is trained in newborn life support and that oxygen and resuscitation equipment are available.” “However, the LMC and the family need to be aware of the possibility of neonatal
20 | AOTEAROA NEW ZEALAND MIDWIFE
adaptation syndrome, which is usually mild and self-limiting. They should also be aware of the small risk of more rare and severe complications, such as persistent pulmonary hypertension of the newborn (PPHN), where the fetal circulation persists at birth.” Identifiable by the presentation of cyanosis in the newborn, Liz states there is a small increased risk of PPHN with maternal antidepressants. Although observation of the newborn’s transition to extra-uterine life including the establishment of respirations - is standard practice for midwives, Liz advises a higher level of vigilance in monitoring of the infant’s colour and respirations is warranted. If any concern, newborn resuscitation should be commenced, including use of pulse oximetry, and the neonatal team called. And for those on a combination of medications or high doses, the message is clear. “If a woman is on a high SSRI dose and/or multiple medications or lithium/ mood stabilisers for her mental health, we would recommend that the mother gives birth in a maternity hospital facility that has paediatric support. The neonatal team should be involved, as there is a likelihood infant resuscitation will be required.” Of note for midwives, both SSRIs and SNRIs may also increase the likelihood of postpartum haemorrhage (PPH), as shown by a systematic review and meta-analysis comprising eight studies and more than 40,000 PPH cases by Jiang et al. (2016). This may be worth factoring in to plans when discussing place of birth with women. A summary table including commonly prescribed medications, their potential associated teratogenic risks, potential risks for exposed neonates and recommendations surrounding place of birth can be found in Table 1. POSTPARTUM CONSIDERATIONS Liz advises that for the most part, women on antidepressants can continue on the same dose unchanged in the postpartum period, or if the dose has been increased in the third trimester, it may be possible to revert to the previous smaller dose. “Mental health in the postpartum period can be very variable,” she warns, adding, “some women are likely to need more care and will struggle, particularly if they are isolated or have few supports.” She goes on to explain those with the highest risk are women with a diagnosis of bipolar disorder, particularly in the postpartum period, where they have up to a 50% risk of having a severe mood or psychotic episode.
BREASTFEEDING Liz states nearly all of the commonly prescribed antidepressants are considered compatible with breastfeeding and transfer into breastmilk in low amounts. She explains some antidepressants, like fluoxetine, are worth being more cautious about, as they are secreted in breastmilk in higher amounts, and explains one group in particular - rarely prescribed now - called the monoamine oxidase inhibitors (MAOIs), are contraindicated due to a severe reaction people can have to particular foods whilst taking them. Liz also highlights more vulnerable babies as a group to be aware of when considering implications for breastfeeding women taking antidepressants. “The other group that we have more concern for are very premature or unwell babies, who may have increased difficulty metabolising antidepressants or other medications, and may show adverse effects such as sedation or other signs of maladaptation, requiring extra monitoring.” MIDWIFE’S ROLE So what should midwives do when a recommendation has been made for their client to continue or commence a medication for mental health needs, but the woman declines treatment? And at what point should a midwife refer a woman to her GP? Liz empathises with women’s trepidations about taking medications in pregnancy. “This is always a difficult and understandable concern,” she says. “However, the evidence for adverse effects in the developing baby shows the risks are very low. This must be balanced against our increasing awareness of the potential impact that untreated depression/anxiety can have on the woman’s wellbeing and on the developing child in utero, or the adverse effect severe depression in the postpartum can have on the early mother-infant relationship and the developing child.” Discussing all possible outcomes is paramount, as Liz reiterates. “Often, mothers tend to focus on their concerns regarding medications and can find it helpful to understand that untreated moderate to severe anxiety and depression can have risks as well.” Naturally, the risks vary, depending on the severity of the mental health concern, and Liz acknowledges pharmacological management is not the only option. “Generally, antidepressants should only be prescribed for moderate to severe illness. Mild depression is better managed by general supportive measures or counselling.”
FEATURE
The onus is not on a midwife to make these decisions, but if a history of recent or current mental health medications is disclosed at booking, Liz recommends referring the woman for further advice. “Any woman on antidepressants who is planning to, or becomes pregnant, should be advised to have a consultation with her GP to discuss whether she should stay on medication and/or alter her dosage. Any woman with moderate to severe depression is likely to be advised to stay on medication during pregnancy, and it’s important that antidepressants are not stopped suddenly without this review, as it can lead to relapse of depression,” she cautions. Good communication between midwives and general practitioners around women’s mental health care during pregnancy will support the best possible outcomes. Of course, a woman should definitely be referred to her GP if she thinks her depression and/or anxiety is worsening. “Urgent assessment (i.e. same day) is required if a woman has
suicidal thoughts or thoughts of harm to her baby,” Liz states. “This could be at the GP or the local crisis mental health service.” Triggers for relapse of mental illness or deterioration of mood will be well known to midwives, but Liz reiterates risk factors: • History of mental health problems
Nearly all of the commonly prescribed antidepressants are considered compatible with breastfeeding and transfer into
• History of trauma • Family history of postpartum mental illness (particularly in the pregnant woman’s mother) • Lack of social support at any time during the perinatal period • Having an unwell baby (either antenatally or postnatally) • Sleep deprivation • Overwhelm/exhaustion from over-exertion (particularly in postpartum - balancing visitors with rest/down time.
USEFUL RESOURCES FOR WOMEN For women seeking further information about the safety of medications in pregnancy,
breastmilk in low amounts.
Liz advises referring women to the UK Teratology Information Service’s website medicinesinpregnancy.org which contains comprehensive but easy to understand information leaflets for consumers. Alternatively, she suggests encouraging women to call their local perinatal mental health service for phone advice. Square
References available on request.
TABLE 1 DRUG CLASS
MEDICATION
Selective serotonin reuptake inhibitor (SSRI)
Sertraline
Citalopram
Escitalopram
Fluoxetine
POTENTIAL TERATOGENIC RISK: 1ST TRIMESTER USE
Very small increased risk (<1% of exposed infants) of cardiac malformations such as atrial sept defects and ventricular outflow tract obstruction with SRRIs, but most studies focus on paroxetine, so further research is needed. Anencephaly, craniosynostosis, omphalocele and gastroschisis reported with SSRIs, but data is conflicting. Sertraline appears to cause the least placental exposure. (CDHB, 2017A)
RECOMMENDATION FOR PLACE OF BIRTH*
Safe to birth in primary setting if dose ≤100mg/day and no other psychotropic**
Safe to birth in primary setting if dose ≤20mg/day and no other psychotropic
Safe to birth in primary setting if dose ≤10mg/day and no other psychotropic
Safe to birth in primary setting if dose ≤20mg/day and no other psychotropic
POTENTIAL RISKS FOR NEONATES
SECRETED INTO BREAST MILK (JONES, 2020)
Evidence strongly suggests SSRI and/or venlafaxine use in late pregnancy can cause delayed neonatal adaptation syndrome (DNAS) in 15-30% of exposed neonates. Most commonly linked to fluoxetine, paroxetine and venlafaxine.
Very low levels – preferred SSRI for breastfeeding
SSRI and/or venlafaxine use in late pregnancy have been shown to double risk of persistent pulmonary hypertension of the newborn (PPHN). Absolute risk appears small: two to three neonates per 1000. (CHDB, 2017A, 2017B)
Dose of up to 20mg/day produces low levels in breast milk (not expected to cause adverse effects).
Slightly higher transfer than sertraline, but widely used
Secreted in breast milk in higher amounts (symptoms: colic, fussiness and drowsiness).
Serotonin noradrenaline reuptake inhibitor (SNRI)
Venlafaxine
No known teratogenic effects, however an effect similar to SSRIs cannot be excluded. (CDHB, 2017A)
Safe to birth in primary setting if dose ≤150mg/day and no other psychotropic
Detectable in breast milk: observe for symptoms of neonatal abstinence syndrome (NAS).
Tricyclic (TCA)
Nortriptyline
No known teratogenic effects, however very few studies completed on TCAs. (UK Teratology Information Service [UKTIS], 2019).SSRIs cannot be excluded. (CDHB, 2017A)
Safe to birth in primary setting if dose ≤150mg/day and no other psychotropic
Low levels detected in breast milk
*Standard doses of antidepressants have been provided by Dr Liz MacDonald, but no absolute guidelines exist. Higher doses could still be considered for primary birthing, however consultation with obstetric services in these situations is recommended. **Polypharmacy is a contraindication for birthing in a primary setting, as the risk of a newborn requiring resuscitation increases with exposure to more than one psychotropic medication in utero.
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Dr Kelly Waiana Tikao (Ngāi Tahu)
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AMELLIA KAPA COMMUNICATIONS ADVISOR
searching for the clues our tūpuna left behind Taonga pūoro, oriori, karanga, karakia, rongoā; kupu that are ever so slowly weaving their way back into the discourse of maternity care in Aotearoa, but are still far from commonplace. Dr Kelly Waiana Tikao, of Ngāi Tahu descent, is dedicated to restoring these traditions, among others, to their rightful place within her iwi’s birthscape and shares her vision with Amellia Kapa. Dr Kelly Waiana Tikao: registered nurse, māmā of five, documentary maker and researcher, plays many roles in her ultra-busy life and career. Midwife isn’t one of them, yet last year saw the completion of her doctoral thesis Raro Timu, Raro Take: Ngāi Tahu Birthing Traditions. She attributes her interest, in part, to attending her cousin Ariana’s homebirth as a young and impressionable student nurse at her whānau papakāinga. Little did she know, the experience would spark questions in her mind that would ultimately become the focus of her academic career. “She [Ariana] was incredibly placid and internalising a lot, so she birthed really gracefully. And that’s who she is as a person,” Kelly explains. “This baby came into the world with karakia, at home, so gently. I wondered, could it always be as powerful, placid and graceful as I’ve just witnessed? And what makes it like this?” Even at this early stage, Kelly’s observations extended beyond the recognition that what she was witnessing was instinctive maternal behaviour. Unwittingly, she was already forging connections between empowered birth and self-determination; the kākano (seeds) were implanting. “What I saw was an example of a whānau’s desire being activated. I saw that it was a possibility - to have a birth with cultural elements and have non-Māori support it. And it was a very beautiful experience for both.”
After birthing two of her own pēpi at home and subsequently twins at the hospital, Kelly embarked on a Master of Science Communication with lived experience under her belt. Knowing she wanted to explore a Māori research topic, she decided to formally delve into the world of customary Māori birthing traditions, exploring not only what they were, but why Māori moved away from them. A short documentary, Iho – a cord between two worlds, was born and when the time came to embark on her PhD, Kelly’s pragmatic nature guided her to continue researching the topic she had become familiar with, despite its obvious challenges. The gap in literature pertaining to wāhine Māori forced Kelly to broaden her approach to resources along the way. “I had to put on my Māori lens and ask, how did we store knowledge? They [tūpuna] must have put it somewhere, so where did they put it? And whether I was pondering this at my marae, or looking at art in my room, I suddenly realised it was right in front of me, and that the task was to find people who could help me understand what it was saying.” And so began Kelly’s explorative journey into the creation symbolism, sequestered away in toi Māori (artworks). She describes the process as complex, but illuminating. “You’re trying to interpret the symbolism with your ‘now’ brain and trying to think of it in the context of when it was developed
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but the vibrations they emitted through the membranes, which were of particular spiritual significance.
Perhaps one of the most surprising sections to be found in Kelly’s thesis explores whe (sound) and its role in customary practices, both as a medium for the transfer of intergenerational mātauranga and a method of relaxation and pain relief for labouring wāhine.
or designed. Why did they place that there? What was it about the creation symbolism that they needed to impart? I constantly came back to survival and identity. Acknowledging the importance of starting well.” This theme - of ensuring the best start to life - emerges time and again throughout Raro Timu, Raro Take, which is comprised of a literature review, interpretations of Māori art in its various forms, and qualitative interviews of Māori midwives, student midwives, artists and kaumātua. Perhaps one of the most surprising sections to be found in Kelly’s thesis explores whe (sound) and its role in customary practices, both as a medium for the transfer of intergenerational mātauranga and a method of relaxation and pain relief for labouring wāhine. She shares the views of taonga pūoro (traditional Māori instrument) artist Richard Nunns, who iterated the importance of playing instruments such as the kōauau or pūmotomoto (two types of flute) to a growing fetus as their sense of hearing developed in utero. According to Nunns, Kelly explains, it was not only the sound these ancient instruments produced,
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Diving deeper still, she includes the work of Ngāi Tahu karanga and oriori specialist Raina Sciascia, whose teachings reveal that ihirangaranga (vibrations or sound waves) were thought to be able to access stored information encoded within a child’s mind. This provides a possible explanation regarding the significance of singing oriori (lullabies) or playing taonga pūoro during a woman’s hapūtanga, labour, at the point of a pēpi’s birth, and beyond. Reciting whakapapa in this form was believed to simultaneously connect the child to both its history and future. Even closer to home, Kelly interviewed kaumātua from her own hapū and explains the challenges were numerous, but worth the yield. “I was asking a lot of my interviewees, to think way back for any snippet, and it only came after lengthy conversations, and often after the microphone had been turned off.” She relays one interview in particular, where her uncles initially claimed to know nothing of traditional birthing customs, but went on to recall childhood memories of their parents discussing wāhine hapū and their attendants returning to the pā with newborn babies - with no hospitals in sight. “It validated for me that similar to other hapū, we did go away to designated birthing spaces. We had birthing rocks, or birthing creeks, and that’s the evidence I was searching for, but they were so vague. It was just a whisper of a memory.” Interpreting these whispers was all part of the process for Kelly, and what she has managed to portray quite clearly in the final product is the overarching intention behind every ritual; from pre-conception through to postpartum, every act was a conscious effort to protect the next generation and ensure the holistic wellbeing of the wahine-pēpi dyad. Armed with a new depth of understanding, Kelly’s vision for the future is to build up the capacity within Ngāi Tahu to rejuvenate these customs through collaboration; a dream that was partly realised at a wānanga she facilitated in April. “I wanted to combine artisans with practitioners and excite both of them,” she explains. “What I realised through my thesis is that artists have similar whakaaro to health practitioners, but they use different tools to do it. By bringing the two
together, you can provide a really dynamic approach to customary birthing practices that I think was always there. We can bring it back.” Dani Gibbs, Ngāi Tahu LMC midwife, attended the wānanga and found the experience invigorating. “It was an exciting connection to make - not just with other midwives, but with artists, and seeing this amazing web of how we could actually integrate and create meaningful change.” Jay Beaumont (Ngāti Rangi, Ngāti Uenuku, Ngāti Apa), a Māori LMC midwife working in the Kaikoura area also attended the wānanga, and found the experience invaluable. “Instead of just reading that Māori have taonga pūoro artists who play instruments to relieve pain and calm women down in labour, we actually talked to the taonga pūoro artists themselves, who could then share their skills with us, and come over to provide that service for us. I think that was the beauty of it.” The nature of wānanga encourages open discussion and naturally, the topic of an end-goal was raised, with kōrero surrounding the possibility of a kaupapa Māori birthing unit featuring. Both Kelly and Dani are in agreement that the process should unfold organically. “Do we wait until we’ve got all our ducks in a row and we’ve worked it all out?” Kelly asks. “I don’t think we’ll ever get to that point, because it’s unfurling whakaaro and knowledge, influenced by our tūpuna.” The intention at this stage is simply to keep building capacity, she explains. “What I really want to focus on now is working with midwives and whānau out there by running these wānanga, by building up the interest first. I’m not worried about getting it done immediately, I believe we just need to build the capability by providing opportunities for expansion and learning, and when we reach a point - which we’ll recognise as a collective we’ll know when to take the next step.” She’s also aware that midwives are a small workforce who are already time and energy poor. “What we’d love to do is facilitate karakia wānanga, oriori wānanga. Midwives don’t need to be the instigators of these things, they just need an awareness, and if they have a particular interest in one aspect, then that might become their specialty, but they don’t need to know all of it. The tohunga of old had their specialties, and there were other tohunga in different areas, and that’s how I see we can build more of an integrated team that have shared skills.”
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Dani agrees, and believes it’s not up to midwives to dictate how such a unit would be developed. “I don’t think any of us have all the answers. We’re all at different levels of understanding and confidence in te ao Māori and our birthing traditions. I think everybody will contribute to it in different ways and whānau will own it. Whānau will bring what feels right for them.” Dani also points out that assuming whānau Māori all have the same needs is a potential pitfall. “Whānau are on their own journey, and some may not feel comfortable with all of these things at once, because it can be really confronting when you don’t understand them. It can be upsetting for some people to know these things exist, but to not have a true grasp of them,” she explains. While the specific details of what a kaupapa Māori birthing unit might look like are unclear at this stage, Kelly explains the importance of ensuring any unit of this kind is iwi-centric in design. “It’s very hard to try and create a kaupapa Māori birthing unit that has no foundational or mana whenua attachment. It needs to be - and proudly so -
attached to the rohe it’s in, with core cultural values of that iwi and hapū. However, as most urban marae work, when a whānau comes in with Ngāpuhi, Ngāti Porou, or other affiliations, there is a process to acknowledge that they’re coming in with their tikanga, and just like on a marae, there’ll be a pōwhiri process, so that they can be in that space expressing their whakapapa, under the ahuru mōwai of Ngāi Tahu,” she says. And in line with the ethos underpinning midwifery, she reiterates that the ultimate goal in this mahi is to empower those receiving care. “The most important thing is you’re validating them as a Māori person, as a whānau giving birth, and validating that pēpi. With our midwives at varying levels of confidence and our whānau at varying levels too, the most important thing is to create a space that’s welcoming of all levels of ability and readiness, and to keep it as supportive as possible.” As trying as her doctoral journey may have been at times, Kelly is a firm believer that the true gifts lie in the process, saying the real value was never in how much evidence she could collate, but in the humbling experience
of searching for the clues her tūpuna left behind. “Just because it doesn’t appear as though there’s much there, it doesn’t mean it’s not worthy of research, particularly regarding our wāhine. The effort of trying to find the information on those who have little written about them is worth the process. At the end of it, with limited material, what you feel you’ve done is honoured their lives.” Square
"With our midwives at varying levels of confidence and our whānau at varying levels too, the most important thing is to create a space that’s welcoming of all levels of ability and readiness, and to keep it as supportive as possible.”
ISSUE 102 SEPTEMBER 2021 | 25
FEATURE
DR ALEX BARTLE MB, BS, FRNZCGP, DIP OBST, MM (SLEEP MEDICINE)
SHUT-EYE AND GETTING OFF THE LOOP: IMPROVING SLEEP QUALITY FOR MIDWIVES At one time or another, midwives are bound to have experienced trouble sleeping, whether as an isolated event, or a more pathological pattern. The intensity of midwifery, combined with unrelenting shift or on-call work can lead to sleep disturbances and/or cyclic thought patterns whereby midwives replay events from their day, questioning their decisions and/or worrying something has been missed. Dr Alex Bartle, Director of Sleep Well Clinic, generously shares his insights into the world of sleep for midwives and offers practical tips for those instances when the land of nod remains elusive. Being a midwife is one of the most rewarding professions, but with it comes responsibility and stress. The ability to be able to switch off after a birth or shift, whether it has been straightforward or complicated, is not always possible, with one potential consequence being difficulty sleeping. Sleep is one of the essential pillars of health and is such an active process that denying sleep will negatively impact on all aspects of our physical, cognitive and emotional health. Whether on shifts or on call, nighttime work is inevitable for midwives. In the literature, the definition of shift work varies, but is generally considered to be working any hours after 7pm and before 6am, not just overnight. Up to 20% of the adult workforce can therefore be considered shift workers. For LMC midwives, being on call for extended periods of time means night work is less predictable - in timing, frequency and duration. Consequently, managing workload is vital, although not always possible.
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Approximately 20% of those working shift work will suffer from ‘shift work sleep disorder’ implying that they struggle with changes to their circadian rhythm. Therefore, there will be some who struggle with this unnatural sleep/wake cycle. Working as an employed midwife, shift work is often more structured, when compared to the unpredictable nature of working as an LMC midwife, although a number of core midwives also have on-call responsibilities to staff maternity facilities if required. Shift work schedules can vary widely depending on potential workload, but generally a rotating shift work pattern is the least helpful for sleep, and indeed for family and social life. Short periods of night work can be tolerated more easily than working five to seven consecutive nights, and eight to ten hours are preferred to 12-hour shifts in a profession that requires periods of intense concentration. LMC midwives may be on call 24 hours a day, for lengthy periods of
time, depending on how they have set up their practice arrangements. Most people will need seven to eight hours sleep per night, which can be achieved in one, two and occasionally three episodes. However, consistently less than six hours sleep will undoubtedly impact on cognitive function including concentration, memory, mental agility, motivation and mood - all vitally important when involved in a potentially life-challenging activity. We have all suffered nights of little or no sleep, either with work or with young families, and cope well as long as we are eventually able to return to adequate sleep. The key is to ensure that you are well rested when needed for work, or an important personal situation or event. There is now irrefutable evidence that sleep is vital to functioning at our best. How then to cope with this challenge to sleep? There are a number of strategies that can be used to ensure healthy sleep for night workers. Maintaining wakefulness at
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work during the night may be helped with consideration of a few ideas: • If you are supporting a labouring woman in a dimly lit room, intermittently popping out into a brightly lit space may be helpful. • Keeping physically active is also important, as is being engaged and chatting with others in the environment, if at all possible. • Soothing music that may help a mother relax is also likely to increase sleepiness, so again, taking short breaks from the birthing room will aid in maintaining alertness – even if it is only possible to step out into a corridor for a few minutes. • As the night progresses, between 3-5am, sleepiness is greatest, and keeping active at that time will be even more helpful. However, when needed, your adrenaline will help, in addition to being well rested beforehand.
Travel home following births in the early hours of the morning can be challenging and driving accidents are common at this time. A 15-20 minute nap before driving home can be very restorative, especially if there is a long drive home; however, it may impact on the ability to sleep once home. Keep your home dimly lit, and ensure that you are sufficiently relaxed before going to bed, especially after a stressful shift or birth. Write down any worries that you may have in a journal, and consider using meditation techniques rather than medication. Going to bed soon after getting home is also better than staying up. That may not always be possible with children, but wearing sunglasses if you are out in the morning will help. Other activities should be postponed if possible. A quiet, cool and dark room is also important, without cellphone or TV. Blue light emitted from screens and LED lights has been demonstrated to suppress melatonin, which can lead to difficulty falling asleep, so avoid using your phone for any length of time before sleep. Two phones might be helpful: one for family and social life which should be switched off; the other for women who may need to contact you at any time. Supportive practice arrangements can mitigate the need to remain on call whilst sleeping following a night-time birth. For example, diverting calls to a practice partner will facilitate a period of uninterrupted sleep. Using automated systems/methods to postpone or cancel planned clinics or appointments (such as the caseload text messaging function through MMPO’s Tiaki app) before going to bed, will also support
LMC midwives to have a longer period of restorative sleep following a night-time birth. Negotiating with practice partners regarding agreed timeframes and parameters around when to call in back-up/second midwife to avoid prolonged periods of work without sufficient sleep or rest, will also support LMC midwives to avoid fatigue. Reciprocity within practices is key. Avoid alcohol and caffeine for at least six hours before considering sleep, including coffee, tea and chocolate. If still unable to sleep, a warm bath with soothing music is likely to be helpful. It is not common to achieve more than four or five hours sleep in the morning following a night shift, so a nap in the afternoon can be very helpful. Spending time outside whenever possible during the day will always help with sleep on a normal night. Light supresses melatonin and stimulates the production of serotonin, making us more relaxed and refreshed during the day. Serotonin then chemically converts to melatonin with darkness and helps sleep. Outdoor light is hugely more intense than indoors, even on a cloudy day, and therefore helps night-time sleep. A frequent concern relates to waking in the night with thoughts racing, and being unable to quell the anxieties that these typically evoke. This is particularly common with those taking responsibility for critical, lifechanging events. When awake in the night, molehills often become mountains and we tend to catastrophise. If this sounds familiar, the following strategies may help: 1 / Consider debriefing with a colleague, manager, mentor or College advisor following any particularly stressful or traumatic event, before attempting to sleep.
making us unaware that we have woken and rapidly returned to sleep. 5 / Avoid clock-watching. Have an alarm clock that you can neither see, nor touch, as this only serves to heighten anxiety levels. Do set an alarm however, as this will reduce anxiety about waking up on time.
If you are starting to worry and find returning to sleep difficult, engage learned relaxation strategies to try to calm your mind. If this is proving unsuccessful however, the next step is to get out of bed and follow this procedure: A / Before retiring to bed, set up a place in the house to go in preparation for a possible night of ‘worried wakefulness’. Make sure it is somewhere that is warm, dimly lit, has writing and/or reading material available. NO computers, cellphones or other screens. The idea is to calm the anxious, worrying brain. B / After 15 minutes, return to bed. If you again become anxious, get up and repeat the process until you go to bed and fall asleep. This procedure is designed for the brain to associate bed with sleep, and not anxiety. A study on this process showed over 70% of participants only needed to get up once.
Finally, one of the most challenging times for families is with children during the school holidays, and this highlights the fact that shift work impacts on the whole family. In such situations, communication with partners and children is vital so that they understand the importance of your sleep, and that you may not be available while prioritising your own sleep. While there is much emphasis on good nutrition and adequate exercise, sleep is equally important to function well, both in our daily lives and especially in our work, therefore it should be treated as a necessity, rather than a luxury. Square
2 / Ensure you go to bed in as relaxed a state as possible. Meditation techniques (mindfulness, prayer, self-hypnosis, transcendental meditation) and/or journaling (writing down worries) as previously mentioned, can help some people before retiring to bed. 3 / Two helpful sites are: www.calm.auckland. ac.nz and www.headspace.com. Learn the techniques so that you can use them in the night or whenever the mind starts to take over. 4 / Understand and be reassured that everyone wakes in the night; few however are aware that they do. Just before we fall asleep,
Consistently less than six hours sleep will undoubtedly impact on cognitive function including concentration, memory, mental agility, motivation and mood - all vitally important when involved in a potentially life-challenging activity.
there is a 2-3 minute period of amnesia, which happens again when we wake in the night,
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PRACTICE UPDATE
JACQUI ANDERSON MIDWIFERY ADVISOR
nausea and vomiting in pregnancy: it’s enough to make you sick Nausea and vomiting during pregnancy (NVP)
women and requires referral for a management
and Nausea) scoring index
is one of the most common pregnancy-related
plan, including ascertaining physiological
(Ebrahimi et al., 2009)
conditions that midwives support women
and psychological wellbeing and the need
(see p.28). This tool can
through. NVP has been shown to greatly impact
for rehydration and antiemetics. Signs of
be used to assist the
a woman’s life, negatively affecting daily
dehydration include: decreased skin turgor; dry
diagnosis of HG, but
activities, relationship with partner, parenting,
mucous membranes; decreased urine output;
can also help midwives
occupation and social functioning. Women have
concentrated urine and postural drop in blood
and women gauge
also identified feeling isolated, deeply tired,
pressure. The most commonly cited criteria for
the degree of their
depressed, and a sense of helplessness due to
diagnosis of HG include: persistent vomiting with
particular experience.
nausea (Heitmann et al., 2015; Lowe et al., 2020;
weight loss not related to other causes, along
Tan, Lowe & Henry, 2017).
with an objective measure of acute starvation
a mild score may
While women with
such as carbohydrate depletion, electrolyte
not require medical
experience nausea during pregnancy and 50%
abnormalities and/or acid-base disturbance
management, they
experience both nausea and vomiting (Heitmann
(London, Grube & Sherer, 2017).
still need support and
Approximately seven out of 10 women
et al., 2015). NVP is generally defined as
Women with diabetes or other pre-existing
symptoms of nausea, vomiting and/or
conditions (e.g. epilepsy, thyroid disease) who
dry-retching, commencing in the first trimester
may be adversely affected by nausea
of pregnancy without any pathophysiological cause (Lowe et al., 2020). For most women, symptoms appear around
and vomiting, especially in relation to timing and absorption of medications, need early support to manage NVP. Women with diabetes
affirmation that this will eventually improve, and to be given strategies to try and manage their symptoms. Acknowledgement that NVP is wearying and very
the sixth week of pregnancy, often peaking
need to be monitored carefully, as dehydration
around 8–12 weeks and gradually resolving
increases the risk of diabetic ketoacidosis, along
by about 16-20 weeks. Approximately 10% of
with the usual effects of early pregnancy on
women will still experience symptoms after
blood sugar stability.
MANAGING NVP
ASSESSMENT OF THE DEGREE OF NVP
A 2015 Cochrane systematic review
20–22 weeks of pregnancy (London, Grube & Sherer, 2017). While persistent nausea and vomiting in early pregnancy can be particularly
Asking women to keep a diary of when they
debilitating for some women, it is not usually
are affected by nausea and/or vomiting can
associated with any adverse pregnancy
help to identify the degree to which they are
outcomes. However, because NVP is viewed as
affected and the potential for dehydration. This
a normal and expected part of pregnancy, some
can also help women to identify triggers and
women tolerate significant symptoms, both
therefore consider ways to avoid or mitigate
physical and psychological (Lowe et al., 2020;
these where possible.
Tan, Lowe & Henry, 2017). The most severe form of NVP, hyperemesis gravidarum (HG), affects about 1% of pregnant
28 | AOTEAROA NEW ZEALAND MIDWIFE
One validated assessment tool used to try
unpleasant can be supportive for women and their families.
identified that there is insufficient strong evidence to support any one treatment or management regime (Matthews et al., 2015). There is limited evidence from clinical trials about the effectiveness of dietary and lifestyle interventions, but it is generally agreed that making adjustments in these areas should be the initial approach to managing NVP.
to determine the severity of NVP is the PUQE (Pregnancy Unique Quantification of Emesis
Continued next page >
PRACTICE UPDATE
NVP symptoms and management
• NVP symptoms are very common in early pregnancy and usually resolve between 12–20 weeks gestation. • In most cases these symptoms can be managed with diet and lifestyle advice. • NVP does not usually have any adverse effects on the wellbeing of the fetus. • NVP can significantly negatively affect women’s daily lives, physical and psychological wellbeing, and general functioning. • Women with more severe symptoms may require treatment with medication, and in severe cases, referral to hospital for IV fluids and antiemetics.
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PRACTICE UPDATE
PUQE-24 SCORING SYSTEM
Mild = 4-6 Moderate = 7-12 Severe = ≥ 13
1. IN THE LAST 24 HOURS, FOR HOW LONG HAVE YOU FELT NAUSEATED OR SICK TO YOUR STOMACH? Not at all (1)
1 hour or less (2)
2-3 hours (3)
4-6 hours (4)
More than 6 hours (5)
5-6 times (4)
7 or more times (5)
2. IN THE LAST 24 HOURS, HAVE YOU VOMITED OR THROWN UP? I did not throw up (1)
1-2 times (2)
3-4 times (3)
3. IN THE LAST 24 HOURS, HOW MANY TIMES HAVE YOU HAD RETCHING OR DRY HEAVES WITHOUT THROWING UP? None (1)
1-2 times (2)
Midwives have a variety of suggestions to offer
3-4 times (3)
5-6 times (4)
• Tiredness in early pregnancy is usual, but
7 or more times (5)
• Heartburn/gastro-oesophageal reflux (GORD/
women regarding lifestyle and diet, including:
it can increase NVP – try to rest as much as
GERD) has been associated with increased
1 / Drink small amounts often - dehydration
possible. Consider reducing work hours if at
severity of nausea and vomiting in pregnancy.
all possible.
Managing GORD/GERD by making dietary
can exacerbate nausea so it is important to maintain hydration by drinking adequate fluids. Try a variety of fluids. 2 / Avoid having an empty stomach, as this
• Take pregnancy vitamins (including folic acid) at a good time of the day when feeling well. • Avoid iron-containing supplements on an
changes or using medications may improve symptoms. As midwives, you will also have a variety of
can increase nausea – eat a light snack every one
empty stomach in early pregnancy, as they
suggestions from your own practice to add to
to two hours between meals.
can exacerbate nausea.
the above list. It is common for a combination
3 / Avoid very large meals – small amounts of food more often are usually better tolerated.
• Ginger has been shown in some studies to improve nausea and vomiting compared to
of suggestions to be needed to help women manage NVP to the point where it naturally
4 / Early morning nausea may be helped by
placebo (Matthews et al., 2015). Products
reduces and/or subsides.
eating a dry biscuit, or cracker, before getting
containing ginger such as tea, biscuits or confectionery, may help. Ginger can cause
PHARMACOLOGICAL TREATMENT OF NVP
out of bed. 5 / Frequent, small, carbohydrate-rich meals with a low fat content may be helpful. Consider flavours, temperature and textures that appeal:
reflux and heartburn in some people, so peppermint may be more helpful for some women. • Pyridoxine (vitamin B6) is also used as a low level support. Studies have shown that
1 / Sweet, salty, bitter, or sour
pyridoxine improves mild to moderate nausea
2 / Hot, warm, or cold
but does not significantly reduce vomiting
3 / Crunchy, dry or soft 4 / Thin, wafer-like slices or small cubes 5 / If the smell of hot food worsens nausea, try
(Matthews et al., 2015). The recommended dose in pregnant women is 25mg, up to three times per day. There are some products combining B6 and ginger on the market, but
cold food instead. Avoid cooking if possible, or
there is no strong evidence to support the
cook in well ventilated areas so that odours do
efficacy of these products in reducing NVP.
not accumulate. Other suggestions that may help: • Eat well when feeling the best, or whenever feeling hungry. • Delay brushing your teeth in the morning if you find it makes you sick. Instead, wait to brush until your stomach feels more settled. • Lie down when nauseated.
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• Acu-stimulation, such as acupressure and acupuncture, is safe during pregnancy and
Many women and their health practitioners are cautious about the use of medications due to concerns about teratogenicity, especially in early pregnancy. This can lead to women feeling that they have to manage regardless, and therefore they don’t seek the support that is available. This does not mean that we should ignore the teratogenic potential in the use of medications, especially in the first trimester when organogenesis is in process. In general, antiemetic medication use in pregnancy is considered to be off-label, as there is little or no specific data relating to safety in pregnancy. However, the Christchurch Medicines Information Service NVP bulletin (2016) identifies that first-line
may have some benefit for NVP. There is
treatments are usually well tolerated and
some evidence to suggest beneficial effects
have a large body of data to support their
of the use of motion sickness bands on NVP;
use. These medications include the sedating
they should be used to apply pressure to the
antihistamine cyclizine, and the dopamine
pericardium 6 point on the inside of the wrist,
antagonists: metoclopramide, promethazine
or alternatively apply pressure for at least a
and prochlorperazine (Christchurch Medicines
minute at a time.
Information Service, 2016).
PRACTICE UPDATE
First-line pharmacological treatment for mild to
defects with first trimester use of ondansetron,
moderate NVP is recommended as follows:
amounting to an additional three cases per
at the maximum recommended dose, the
10,000 exposed pregnancies (Huybrechts et
advice is to discontinue that medication before
al., 2018; Zambelli-Weiner, 2019). Even though
commencing an alternate agent. When NVP does
the research findings lack consistency and in
not improve with initial medication, investigation
some cases are conflicting, it appears that
of other causes should be considered and
Second-line treatment is usually reserved
ondansetron exposure may also be associated
would require a medical assessment. This is also
for women with severe NVP who have not
with a small increased risk of heart defects, as
important when nausea and/or vomiting begin
responded to other therapies. If this level of
well as orofacial defects (Zambelli-Weiner, 2019).
after the first trimester, as the cause is less likely
• Start with ginger +/- B6 • Add oral antihistamine or dopamine antagonist if needed.
treatment is needed, then this would require a
Some guidelines recommend that ondansetron
medical assessment. Ondansetron is generally
should be limited to second-line treatment
considered a second-line therapy, even though
and preferably used after the first trimester of
it is increasingly being used as a first-line
pregnancy (Lowe et al., 2020; Christchurch
treatment. The approved indications for the use
Medicines Information Service, 2016). Although
of ondansetron are the management of nausea
the absolute increased risk of oral cleft and heart
and vomiting caused by cytotoxic chemotherapy
defects is small, essentially it is recommended
and radiotherapy, and for the prevention of post-
that ondansetron should only be prescribed in
operative nausea and vomiting. However, it is also prescribed off-label for nausea and vomiting due to other causes, including for women in the early stages of pregnancy (BPACNZ, 2020). There is concern at the increasing use of ondansetron as a first-line treatment for
severe cases (i.e. HG) during the first trimester if the benefits of use clearly outweigh the risks of harm to the woman and fetus, and other non-pharmacological and pharmacological methods have not worked (Medsafe, 2020; Christchurch Medicines Information Service, 2016). Due to the fact that there is growing
NVP (Lowe et al., 2020; Huybrechts et al.,
concern surrounding the use of ondansetron
2018; Zambelli-Weiner, 2019; Medsafe, 2020;
and given its use is only recommended as a
Christchurch Medicines Information Service,
second-line treatment, together with its off-label
2016). This concern relates to findings of
use in pregnancy, midwives are advised to refer
the most recent studies, which suggest an
for medical assessment rather than prescribe
approximate 25% increase in the risk of oral cleft
this medication themselves.
Generally, where an antiemetic is not effective
to be related to normal NVP. Intravenous (IV) fluids have been shown to reduce vomiting and are therefore valuable for management of the symptoms of HG and severe NVP, as well as associated dehydration and electrolyte disorders. The prescription of IV fluids needs to take into account the degree of dehydration and any electrolyte and/or acid-base disturbances. Depending on how the woman is affected, IV therapy may be administered as an inpatient, or as an outpatient in GP and after-hour clinics, primary and/or rural units, depending on the DHB pathway for management of this condition. Some women with HG require multidisciplinary support in addition to midwifery care including obstetric, dietetic and social work input. Square
References available on request.
TABLE: MEDICATIONS FOR TREATMENT OF NVP
First-line treatments
MEDICATION
DOSE
SIDE EFFECTS
Cyclizine (Nausene)
25-50mg orally up to
Sedation/dry mouth
(oral histamine)
three times daily
Prochlorperazine (Stemetil, Nausafix) (dopamine antagonist)
5-10mg orally two to
Sedation/skin sunlight sensitive/
three times daily
dry mouth/dizziness
Promethazine (Phenergan)
10-25mg at bedtime or 4-6 hrly
Sedation/dry mouth
(dopamine antagonist)
orally (max 100mg daily)
Metaclopramide (Maxalon)
10mg three times daily
(dopamine antagonist)
Restlessness/drowsiness/extra pyramidal symptoms (abnormal motor function), drug-induced movement disorders especially if longer than 12 weeks. Do not use for women with epilepsy.
Second-line treatments
Ondansetron (Zofran) (selective serotonin receptor antagonist)
4-8mg twice daily
Headache, constipation, fatigue (see discussion on concerns re: oral cleft and heart defects)
ISSUE 102 SEPTEMBER 2021 | 31
PASIFIKA
NGATEPAERU MARSTERS COLLEGE PASIFIKA REPRESENTATIVE
Tapuaki: a blessing For the past two years, Pasifika Midwives Aotearoa has provided pregnancy and parenting education services, as defined by the Ministry of Health (MOH) service provision. The curriculum is Pacific focused and called Tapuaki – a Tongan word that encompasses the feeling of being blessed when expecting a pēpi into the whānau. Auckland University’s Pacific Health Section is located within the School of Population Health at its Tāmaki campus. It was here that Tapuaki was conceived over a decade ago, following a MOH Pacific Grant. Tapuaki had broad stakeholder involvement of Pasifika health professionals: midwives, student midwives, Well Child services, nurses, social workers, obstetricians, paediatricians; the service became known as Taha – Well Pacific Mother and Infant Service. It was an acknowledgement of the fact that within the Pacific, midwives hold dual registration as nurse/midwives and healthcare generally fits within a medical model. This is appropriate, given their context of often working in extremely remote areas and in sole charge. Tapuaki was designed with a strength-based focus on prevention within Pacific maternal and infant health. It aimed to change attitudes, systems, and behaviours, through social innovation. The curriculum was evidence-based and included the use of engaging tools and resources, improving Pacific families’ access to effective pregnancy education and support services by providing multiple community entry points. The purpose of the classes was to empower Pacific pregnant women of all ages, and their families, to talk about pregnancy and parenting. It allowed them to ask questions, seek advice, and make more informed choices about their care. Tapuaki was both inspirational and aspirational for Pacific peoples. As is often the case with such innovations, they are largely dependant on funds, which either stop abruptly or are phased out slowly,
32 | AOTEAROA NEW ZEALAND MIDWIFE
so much so that only a skeletal image of the original intention is left behind, as political priorities change. Midwifery was seen as one small part of the programme, yet today it is the sole surviving component of Tapuaki. It continues to be a vehicle for advancement of wellbeing, via which pregnant Pacific peoples of all ages continue to gather information and become inspired to actively participate in decision-making regarding their care.
This statistic challenges the belief that Pasifika
The current facilitators, midwives Lisa Nathan (Te Aupouri/Te Rarawa/Ngāpuhi/ Cook Island Māori) and Fa’anape (Nape) Tafiti (Samoa) periodically refresh the content and discuss ideas to improve engagement. Over the years, Tapuaki classes have predominantly been held in South Auckland, specifically in Manurewa, Otara and Mangere. More recently, Te Puke Otara Community Centre and Ngā Hau Mangere Birthing Centre (NHMBC) have been utilised, with NHMBC proving to be the most successful venue. Classes at NHMBC have reinforced the notion of primary birthing and enabled a deeper discussion about the most appropriate place to birth, in alignment with each woman’s individual health status.
Manukau Health, PHO South Seas Healthcare
women predominantly require secondary care. The myth of healthy Pasifika birthing women is in fact, a reality, and contrary to popular belief, these same women reside in South Auckland. The wero for midwives, therefore, is to ensure that these women are informed correctly, and that as a profession, we maintain the belief in primary birthing, utilising platforms such as Tapuaki to promote this. With Counties and Pasifika Midwives Aotearoa collaborating for the betterment of the community, what seems like a drop in the ocean makes the world of difference for each birthing wahine we serve, and her experience contains within it the power to become a catalystic event for the transformation of her wider whānau. square
Lisa and Nape utilise the NHMBC birthing rooms as part of their kōrero. They demystify the space by simply introducing ways whānau can make it their own for the precious time they occupy it. Their knowledge of the community as South Auckland-raised residents is invaluable in establishing connections. NHMBC’s data from 2020 showed 52.4% of wāhine using this facility identified as Pasifika.
L-R: Lisa Nathan and Fa’anape (Nape) Tafiti.
NGĀ MAIA
LISA KELLY NGĀ MAIA BOARD MEMBER (NGAI TAI)
Ngā Maia:
Popoia te kākano kia puāwai (Nurture the seed and it will bloom) On 11 June 2021, Ngā Maia held its first ever national Māori midwifery student hui. 148 participants, including 65 midwifery students from across the five midwifery education providers attended our three-day hui at Houghtons bush camp, Muriwai Beach, Kumeu. Nestled amongst the ngahere, our tauira,
time with the launch of the joint project Te Ara
dynamic and powerfully authentic midwives
midwives and tautoko whānau were treated
Ō Hine – Tapu Ora between the Ministry and
who will push the boundaries, demanding
to a range of guest speakers and workshops,
the midwifery education providers, aimed at
te Tiriti is honoured across the spectrum,
including taonga pūoro artist Hira Moewaka
addressing the issues and many barriers that
ensuring equitable health outcomes for Māori
Latimer, who blessed us with the reverberating
tauira face while studying. One such issue is
and Pasifika whānau. This hui will be the first
hum of the pūrerehua and lulling tones of the
the lack of cultural sensitivity and knowledge
of many, to allow students to articulate their
hue puruhau. Rongoā, harakeke harvest and
of whānau Māori dynamics that impact on
needs and ensure they reach the end goal that
prep for pito ties, Wahine Marohirohi and Hine
students’ ability to complete their degree.
is their tohu, so they can then provide the care
ora hine tu, to name some of the matauranga,
We heard of single income māmā travelling
that whānau need and want and only we can
were all eagerley soaked up by those present,
long distances to attend school without the
give to our own: true tino rangatiratanga.
desperately needing to fill their half-empty
support of whānau, limited accommodation
cups with tūpuna knowledge. Facilitated
and no funds to support this hardship, while
group workshops allowed tauira to express
up regional roopu, with our latest addition
dealing with culturally insensitive marking of
their views on what’s working and what’s not
being Ngā Maia ki Waiariki. This rohe includes
papers and lack of tikanga processes within
within their midwifery schools, and it became
Tauranga moana, Whakatāne, Opōtiki and
the institutions. One could argue, why give
even more apparent the mamae felt due to the
the coast, Rotorua and Taupo, with 30 new
$6 million to the very source of failure for
disconnect between tauira and their respective
members. The roopu adds to our collective
our Māori and Pasifika students? You can rest
midwifery education providers.
of Māori midwives and student midwives
assured that these current midwifery tauira,
servicing our high Māori population with a
if nurtured, will bloom into some fierce,
booming birth rate. Now more than ever,
Our hui could not have come at a better
Ngā Maia have also been busy setting
as our whānau are facing more challenges forced by Covid-19, the presence of a Māori health provider goes a long way in making healthcare more equitable, in a system that continues to fail Māori at every turn. The day a woman can choose a midwife who shares her values, principles and hails from the same iwi, will be a day to celebrate, and at this rate we are not far off. Wouldn’t you want to choose this for your sister, daughter, Ngā Maia national Māori midwifery student hui.
niece and mokopuna? square
ISSUE 102 SEPTEMBER 2021 | 33
BREASTFEEDING CONNECTION
BREASTFEEDING CHALLENGES IN THE EARLY POSTNATAL PERIOD: BREASTFEEDING SUPPLEMENTS AND INFANT WEIGHT LOSS Breastfeeding problems are solved by fixing breastfeeding, not by replacing it. But during the early newborn period, there may be challenges that require interventions, including alternative ways to give breastmilk other than via the breast, and/or the use of some infant formula. The first ‘rule’ when it comes to any form of infant feeding is to feed the baby, and feeding plans need to first of all act on this, while taking into account how to cause the least disruption to continued breastfeeding for the mother and infant.
CAROL BARTLE POLICY ANALYST
Ideally, exclusive breastfeeding/breastmilk feeding is an important objective, but parental wishes are paramount and all feeding plans and interventions should be planned by midwives with parental involvement. Giving additional fluids to the infant can interfere with breastfeeding physiology, and supplements may cause reductions in breastfeeding frequency, breast stimulation, breastmilk production and breastmilk removal. All of these issues need to be taken into account as part of the feeding plan. As well as considering how a supplement can be given in a way that preserves breastfeeding, the volumes of milk given should also be considered. This involves limiting the amounts to what is necessary for newborn physiology, and ensuring support for the infant to continue practising at the breast (Kellams et al., 2017). The optimal supplement when required is expressed milk from the mother, followed by screened donor milk, with formula being the last option. If neither sufficient breastfeeding nor expressed milk from the mother or donor milk are available, then formula milk is obviously essential.
34 | AOTEAROA NEW ZEALAND MIDWIFE
INFANT WEIGHT The size of the newborn stomach indicates that small quantities of colostrum are perfectly appropriate to prevent hypoglycaemia in a well, full-term baby (Kellams et al., 2017). Newborn infants lose weight because of a physiologic diuresis and well, full-term breastfed infants regain their birthweight at an average between 8.3 and 21 days (97.5% by 21 days) (Kellams et al., 2017).
As well as considering how a supplement can be given in a way that preserves breast feeding, the volumes of milk given should also be considered. This involves limiting the amounts to what is necessary for newborn physiology, and ensuring support for the infant to continue practising at the breast.
Neonatal weight loss needs to be interpreted in a context which looks not just at the weight, but at the infant in general; the infant’s output, the birth process and good assessments of breastfeeding. Excess newborn weight loss is also correlated with positive maternal intrapartum fluid balance received via intravenous fluids, which needs to be taken into account (Kellams et al., 2017; Noel-Weiss et al., 2011). Difficult beginnings to breastfeeding may resolve relatively quickly despite an initial larger than expected weight loss. Taking into account the context in which a weight loss occurs and the many variables that can influence weight loss supports informed decision-making about when intervention is required, and when it is not. Reliance on weight assessments alone may lead to red flags being missed, so weight assessment needs to be viewed as one strategy within a holistic breastfeeding evaluation, that includes the experience of breast fullness, observing infant breastfeeding behaviour, observing milk transfer, and other indications of adequate infant hydration (Noonan, 2011). The UK National Institute for Health and Care Excellence (NICE) Faltering Growth Guidelines (2017) discuss concerns about excessive infant weight loss of 10% or more. Recommended actions include clinical assessment looking for evidence of dehydration, illnesses that might account for weight loss, taking a detailed history to assess feeding, direct observation of feeding, and provision of feeding interventions that support the mother to continue breastfeeding alongside supplementation where necessary. SUPPORTIVE STRATEGIES Women at risk of delayed lactation require additional early breastfeeding support to reduce the risk of excessive infant weight loss. Delayed lactogenesis II is associated with mother-infant separation, maternal obesity and other factors such as primiparity, breast surgery, maternal age over 30, labour/birth factors, and stress (Wambach & Watson Genna, 2021). Close monitoring of infants where there are any known maternal risk factors for delayed lactation and/or if the infant is having difficulties with latching or effective suckling, is essential. The NICE Postnatal Care Guidelines (2021) emphasise what is necessary for a breastfeeding assessment: frequency and length of feeds; audible swallowing and rhythmic sucking
BREASTFEEDING CONNECTION
(audible swallowing will be limited initially); infant waking for feeds; weight gain/loss and output. Prolonged skin-to-skin contact with the mother can be useful for infants who are disinterested in breastfeeding. Mother contact can rouse and stimulate sleepy infants to feed (Couread et al., 2006; Doucet et al., 2007). Skin-to-skin contact is initiated at birth, but continuing this at any time in the post-birth period can support breastfeeding and calm an anxious mother or a distressed infant. Continuing skin-to-skin contact in the home environment if there are still breastfeeding issues is recommended. Because breastmilk is the ideal source of energy during postnatal metabolic adaptation, support to establish effective breastfeeding is critical (British Association of Perinatal Medicine [BAPM], 2017). The Academy of Breastfeeding Medicine (ABM, 2021) also emphasise maximising breastmilk provision to early full-term and full-term infants in an updated clinical protocol about glucose monitoring and treatment of hypoglycaemia. ABM also noted that after the initial infant awake period of around two hours, some infants have a sleep/rest period of six to eight hours, with very brief periods of semi-wakefulness. It is recommended that infants with any risk for hypoglycaemia are offered breastfeeding opportunities during these six to eight hours (ABM, 2021). In one study, support and information from health professionals enabled women to identify signs that their infant was receiving sufficient breastmilk, which included waking for feeds, alertness when awake, the number of wet nappies, attachment and sucking patterns, and changes in firmness of the breast before and after feeding (Kent et al., 2021). SUPPLEMENTATION Prevention of the need for supplementation is the first aim and this is supported by the Ten Steps to Breastfeeding (World Health Organisation/UNICEF, 2018). • Step 4 (skin-to-skin) • Step 5 (support for the initiation and maintenance of breastfeeding & management of common difficulties) • Step 6 (no food or fluids to breastfed infants unless medically indicated) • Step 7 (rooming-in) • Step 8 (responsive feeding/feeding cues) • Step 9 (counsel mothers on the risks of feeding bottles, teats and pacifiers)
ISSUE 102 SEPTEMBER 2021 | 35
BREASTFEEDING CONNECTION
These steps support exclusive breastfeeding and recognise the importance of decisions made about why, what, how much, and when supplementary feeds are given and how they are given. As previously noted, when supplementary feeds are medically necessary the primary goals are feeding the infant, and optimising maternal milk supply. In terms of methods of giving supplements, no method is really without potential risk or benefit (Kellams et al., 2017). Breastfeeding policy documents in Aotearoa New Zealand outline indications for supplementation and some include guidance on methods of supplementary feeding which may include cups, finger feeding and supplementary nursing systems. Initially, small amounts of colostrum are often given to a non-latching baby via a syringe, dropper or spoon. There has been limited research evidence to support the syringe feeding of infants despite this evolving into common practice in maternity facilities. Taking care to keep any intervention as gentle as possible is recommended to avoid causing any infant distress or generating feeding aversion. Putting a hard syringe into an infant’s mouth is likely to be experienced as unpleasant by the infant, particularly if a bolus of milk is ejected rapidly, and if a syringe is used it
36 | AOTEAROA NEW ZEALAND MIDWIFE
is better to place it on the infant’s lips and not directly into the mouth. Buldur et al., (2020) compared finger feeding and syringe feeding methods in supporting sucking skills of pre-term infants, and found that the finger feeding method was an effective way of increasing sucking abilities, accelerating transition to breastfeeding, and shortening the duration of hospitalisation in pre-term infants. Buldur et al., provide a useful technique for finger feeding in their article and although their work is based on pre-term infants, it is applicable to full-term infants also. A study of International Board Certified Lactation Consultants (IBCLC) (n= 2,308) and supplemental feeding methods for breastfed infants, found that they had no preferred method of supplementary feeding although supplementary feeding systems, cup feeding and finger feeding were reported as being used very often and bottles were always offered as a last resort (Penny et al., 2019). Because supplementation is also associated with a reduction of maternal breastfeeding self-efficacy, it is also important to consider the effects that feeding issues are having on the mother’s emotional health (Blyth et al., 2002). Blyth et al., (2002) suggest taking note of whether the mother experiences discomfort, anxiety, frustration or a sense of failure and recommend explicitly
acknowledging these feelings as normal experiences during breastfeeding challenges, while also ensuring tailored support for all breastfeeding ‘attempts’ to avoid undermining breastfeeding self-efficacy. Again, it is always necessary to acknowledge the challenges this presents for midwives in providing care for breastfeeding complexities in understaffed areas with increased rates of birth interventions. A salutogenic framework for midwifery practice, in terms of the promotion of maternal wellbeing, is useful (Mathias, et al., 2021). The use of alternative feeding methods may overwhelm mothers to different degrees (Penny et al., 2019) and manageability, comprehensibility and meaningfulness, as well as sustainability of method need consideration. Once the infant has managed to latch, supplementary breastfeeding systems are useful if more milk needs to be given, particularly for the shortterm, because infants learn to breastfeed by breastfeeding, and respond well to a milkflow, and because mothers learn to breastfeed by breastfeeding. The Academy of Breastfeeding Medicine (Kellams et al., 2017) provides a list of criteria to be considered when selecting a supplementation method: • Cost and availability • Ease of use and cleaning
FEATURE
• Stress to the infant • Whether adequate volume can be fed in 20-30 minutes • Whether anticipated use is short or long-term • Maternal preference • Expertise of staff available • Whether the method enhances development of breastfeeding skills
Depending on the cause of low supply, supplementation may be a temporary or a permanent solution. If an intervention - to bridge the journey to restoration of full breastfeeding - is likely to be long-term, then it is critical that whatever method is employed is sustainable and manageable for parents. As described by Kellams et al., (2017) the need for long-term use and maternal preference, alongside practical aspects of home-management, are factors to take into consideration if the infant is going home from the maternity facility still needing supplemental feeds. KEY POINTS • Keeping mother and baby in close proximity/
charlotte jean maternity hospital: the end of an era In 1997, Jenny O’Brien, a Central Otago midwife who had been working in the area for some time, turned a vision into a reality when she and husband Robin opened the Charlotte Jean Maternity Hospital. Named after Jenny’s mother Jean and mother-in-law Charlotte, the maternity hospital was the physical manifestation of Jenny’s desire to create a homely environment where women’s partners were encouraged to stay overnight, and be part of the first few days postpartum. After purchasing a house in Alexandra on Ventry Street, the pair got to work converting the building into a purposefit maternity hospital and it has remained in the caring hands of the O’Brien family ever since. Around 14 years ago, Jenny’s son Roger O’Brien and his wife Sue took over the helm at Charlotte Jean, but July of this year marked the end of an era, when Southern DHB started leasing the premises, in order to keep this vital facility operational 24 hours a day, 365 days of the year for the women and babies of Central Otago. Although the numbers have varied over the years, Sue estimates Charlotte Jean is the place of
facilitating skin-to-skin care supports
birth for around 75 babies per year, and says it has been an honour to play their part in its history.
instinctive maternal behaviours, feeding
“It’s been a huge privilege to provide care for the families of Central Otago over the years, and
responses and anxiety regulation in both
for Roger and I personally, to have carried on the ethos that Jenny created. We’d also like to
infants and their mothers.
acknowledge all of our staff, whose wonderful skill, dedication and care have given so many
• Breastfeeding problems are solved by fixing breastfeeding, not by replacing it. • Infants learn to breastfeed by breastfeeding, and respond well to milk flow, and mothers learn to breastfeed by breastfeeding. • All feeding plans are developed with parental input and require full explanation and consent.
families the best possible start.” Renamed as the Central Otago Maternity Unit, the facility will at some point relocate to new premises, but for now, women and babies of Central Otago will continue to be cared for at the original site where Jenny O’Brien welcomed the first baby to be born at Charlotte Jean. The Southland regional branch of the College plans to commission a plaque in recognition of the O’Brien family’s significant contribution to maternity services within the region and would like to thank the O’Brien family for their tireless work over the years, serving women and babies of the Central Otago communities. Square
• Consider the effects that breastfeeding issues are having on the mother’s emotional health. • If supplements are necessary consider what is given, when it is given, the volume given and how it is given. • Weight assessment needs to be viewed as one strategy within a holistic breastfeeding evaluation. • Cause the least disruption to continued breastfeeding for the mother and infant. • Supplementation may be a temporary or a permanent solution – decisions about short or long-term use of supplementation and devices need to take the timeframe into account, as well as the practicalities of home management. Square
References available on request.
Jenny O’Brien holding Melissa Klok, the first baby born at Charlotte Jean on 28 December 1997, to parents Margaret-Ann and Ronald Klok.
ISSUE 102 SEPTEMBER 2021 | 37
FEATURE
PRIMARY MATERNITY SERVICES NOTICE UPDATED: WHAT DOES IT MEAN IN REAL TERMS? Pursuant to Section 88 of the New Zealand Public Health and Disability Act 2000, the Primary Maternity Services Notice 2007 has been updated by the Government to implement the $85 million that was allocated to primary maternity services in the 2020 Budget. Following a public consultation period from September to November 2020 and considerable input from the College, the notice has now been gazetted and is a substantial improvement on the previous consulted version, indicating the Ministry has taken the College’s feedback on board and responded accordingly. The updated Primary Maternity Services Notice 2021 replaces the 2007 notice in its entirety, and will be implemented on 29 November 2021, once IT systems have
been adapted to enable claiming under the new notice. The most significant changes to the notice are as follows: • A single-service payment for consultation during pregnancy - where the midwife is not the woman’s LMC - has been introduced (e.g. early pregnancy advice and care, but woman does not register). • A payment for registration with an LMC is now claimable. • Fees for each trimester of antenatal care will now be claimable and paid at the conclusion
Whilst the revisions to the notice don’t provide the ultimate solution to the overarching issues currently facing the midwifery profession, the improvements do acknowledge aspects of primary maternity care that have long been undervalued and overlooked.
38 | AOTEAROA NEW ZEALAND MIDWIFE
of each trimester, rather than paid as lump sums at the end of the second trimester and/ or with the labour and birth fee. • The second midwife fee will become a permanent fixture under the updated notice. • Payments for care provided to women who have experienced a miscarriage will now be easier to access. • A missed birth fee for rural midwives will be claimable.
TRAVEL PAYMENTS Although this section of the notice has not yet been gazetted, the revisions at time of writing are explained here. Final details will be published on the Ministry’s website in due course. Payments in recognition of travel costs will be structured differently under the new notice and will be claimable for each period of care: antenatal, labour/birth and postnatal. Payments will be graduated according to degree of rurality and level of urban accessibility (UA) in line with the Government’s recent review of its previous classification system (which dated back to 1992). The six new classifications apply across all modules of the notice and payment will be determined by the woman’s address: • Major, large or medium urban area • High urban accessibility • Medium urban accessibility • Low urban accessibility • Remote
• A transfer fee for all midwives (urban or rural)
• Very remote
for ambulance transfers will be claimable.
(Stats NZ, 2020)
Due to urban sprawl, the introduction of these new categories may mean some areas, which were previously deemed rural or semi-rural, may now attract a lesser fee, thus affecting the payments midwives receive following the implementation of the new notice. ADDITIONAL CARE SUPPLEMENT This section of the notice - a new module - is also yet to be finalised and will be published on the Ministry’s website along with associated fees when completed, so that it can be adapted readily as required.
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The original proposed changes to the notice suggested midwives could only claim payment for additional care if the midwife completed a greater number of antenatal and/or postnatal visits. The College submitted extensive feedback stating this alone would not be a fair measure of extra work. The revised notice will therefore contain a module called the Additional care supplement, which will be claimable per period of care (antenatal, labour/birth and postnatal), according to a list of criteria, which will be graded as low, moderate or high. At time of writing, criteria for claiming through this module will include: • Acute call-out • Māori, Pasifika or Indian ethnicity • Refugee status • Conditions requiring consultation and/or attendance at multidisciplinary meetings • Home visits • Early labour assessments
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The business contribution payment will continue this year and the College has actively advocated for it to continue every year, until there is a new contract model in place for LMC midwives, however this is a budget-by-budget decision, with no guarantee that it will continue to be paid annually at this stage. Whilst the revisions to the notice don’t provide the ultimate solution to the overarching issues currently facing the midwifery profession, the improvements do acknowledge aspects of primary maternity care that have long been undervalued and overlooked. Celebrating each step toward midwives receiving fair and equal pay for work done is vital, and the College hopes members can appreciate every development as a victory for midwives and the whānau we all serve. The Ministry is currently hosting maternity stakeholder information sessions throughout the country and encourages midwives to attend. A pre-recorded webinar will also be made available for those unable to attend the meetings. Square
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FEATURE
navigating unexpected practice outcomes In 2019, the College launched a new workshop.
During the design phase we worked with Anna
After a break last year due to Covid, we are
Francis, a woman who has gifted her own story
pleased to announce it will be back in the
and suggests ways midwives can work with
2021-22 education calendar.
wāhine/whānau during such unexpected events.
This workshop has been designed to provide midwives with the opportunity to consider one’s
Anna’s story is woven throughout the workshop. We also worked with Carla Humphrey, the
for the workshop is to support midwives to be better prepared for these situations, should they occur. We look forward to seeing you at this and other College workshops, in the near future. To find out more, please visit the College’s education section on the website.
UPCOMING WORKSHOPS 23 SEPTEMBER 2021 Kirikiriroa / Hamilton 21 OCTOBER 2021 Rotorua-nui-a-Kahu Matamōmoe / Rotorua 30 NOVEMBER 2021 Tāmaki-makau-rau / Auckland
sustainability and how we look after ourselves
College’s legal advisor, to demystify some of the
and each other, should unexpected practice
processes that midwives need to work through
1 MARCH 2022
outcomes occur.
following an unexpected outcome. One key goal
Whakatū / Nelson square
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September - November Courses Certificate Courses (15 Credits) 20 September to 5 November Applied Anatomy and Physiology for Midwives, Diabetes in Pregnancy, Global midwifery: Practical Steps If you wish to complete the Complex Care Certificate in 2022, or would like further information about any of our postgraduate courses, please contact: suzanne.miller@op.ac.nz
40 | AOTEAROA NEW ZEALAND MIDWIFE
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FROM BOTH SIDES
my midwifery my midwife Anna Barley is a Clinical Midwife Specialist in ADHB’s Maternal Medicine team
Carrie Weaver, a registered nurse currently pregnant with her third baby,
and is dedicated to ensuring women experiencing high-risk pregnancies in
is under the care of Anna Barley for the second time around and describes
Aotearoa don’t miss out on the enjoyment of expecting a baby.
her as one in a million.
“My real passion within high-risk midwifery is to create normal, joyous,
Following the birth of her first child Kyle nearly 18 years ago, Carrie
positive birth experiences with women, who deal with really hard stuff in
became unwell, and after years of investigation and multitudes of tests, she
their pregnancies,” Anna begins.
was eventually diagnosed with McArdle disease, a rare muscle condition
“Some of them can be very unwell, with a lot of hospital admissions and medications, and a lot of stress surrounding their pregnancy. But just like
characterised by an inability to break down and utilise glycogen. McArdle disease can result in transient episodes of acute kidney failure,
low-risk women, they’re having a baby, and it’s the most exciting time of
which Carrie had the misfortune of experiencing,
their life. I think it’s important to remember that and
requiring extensive testing, including a kidney biopsy.
make it easy for them as they navigate a really tricky
The impact of the disease on her ability to engage in
pathway.”
physical exercise meant a career change for Carrie, who stopped working as a personal trainer and embarked on
Over the course of her nearly 20-year midwifery career, Anna has worked as an employed midwife in
study to become a registered nurse in 2010.
both hospital and community settings. Her caseload
Also affected by anti-phospholipid syndrome, Carrie
comprises women with complex health conditions
developed pulmonary embolisms both during and after
who may be coping with multiple diagnoses. She’s
her second pregnancy, as well as preeclampsia at 35
clearly tuned in to their unique needs but says the
weeks gestation.
social issues impacting whānau wellbeing are the
Now in the last trimester of her third pregnancy,
most challenging aspect of her job.
a year after birthing her second son David, Carrie
“Their illness is usually a life-long condition,” she
couldn’t be happier that it’s Anna guiding her through
says. “The absolute barriers some women face - to
another high-risk pregnancy. “She just treats you like
health, dry homes, food; it’s heartbreaking that in a
a real person,” she explains. “Like you’re a friend and a
country like New Zealand, as midwives, we still have
human, and she genuinely cares. She’s very authentic
to facilitate the most basic access for women and
and nurturing.”
their whānau, especially to medical services and social
“I find her very safe and thorough, and easy to
assistance. It’s all about health literacy and a lot of
contact,” she adds. “I don’t feel like there are any
women don’t have this.”
barriers whatsoever with Anna. She always goes the
On a day-to-day basis, Anna’s work is much like that
extra mile and she never looks burdened by it.”
of a community midwife. “We do clinics a couple of times a week along with the doctors, and then on the
Looking burdened is something Carrie would know
other three days we visit women in the community, or
about, having worked as an emergency care nurse for
in NICU. We also do a lot of investigative work, trying
years. “I’ve worked in hospitals myself and I know how
to find women and figure out what’s going on with
hectic they are. She is one in a million, because I know
them. It’s very organic. Stuff crops up and we deal
how difficult it is to keep caring when the hospital is so
with it as it happens.”
slammed,” she says.
As a side project, Anna is hoping to develop a
Anna’s neutral approach to providing information is
webpage resource for LMCs to use when caring for women with complex conditions. The webpage would list common diagnoses such as autoimmune diseases and cardiac conditions, which LMCs could refer to for a list of which blood tests to order, which referrals to make, and which scans to arrange and when. Anna emphasises that the focus would be on supporting LMC midwives to be able to continue providing as much care as possible to high-risk women in the community. “LMCs can look after those women on the whole, and work in conjunction with teams like ours,” she says. Anna is keen to hear from midwives who think they would benefit from the development of this web-based resource and is happy to receive suggestions regarding content. To get involved, email
also something Carrie appreciates. “She always makes me feel like anything I ask for is fine and she gives me plenty of options. She gives them all in a non-biased way, so she makes me feel like I’m in charge of my pregnancy, birth, and baby. And she’s like that all the time,” she emphasises. Feeling like she is still in charge amongst the complexity is important to Carrie. “I am quite complicated, but also quite well,” she explains. “Last time I had a lot of input from a lot of people and I was quite overwhelmed.” This time, Carrie is pleased to report she remains well despite her risk profile and is in the process of planning an empowered birth in conjunction with Anna and her team. square
anna.barley@adhb.govt.nz square
ISSUE 102 SEPTEMBER 2021 | 41
DIRECTORY
New Zealand College of Midwives Directory President Nicole Pihema Ph 021 609 011 nicolepihema@gmail.com National Office PO Box 21-106, Edgeware, Christchurch 8143 Ph 03 377 2732 Fax 03 377 5662 nzcom@nzcom.org.nz www.midwife.org.nz College Membership Enquiries Contact Lisa Donkin membership@nzcom.org.nz 03 372 9738 Chief Executive Alison Eddy Auckland Office and Resource Centre Delia Sang, Administrator Yarnton House, 14 Erson Avenue PO Box 24487, Royal Oak, Auckland 1345 Ph 09 625 9764 Fax 09 625 0187 auckadmin@nzcom.org.nz National Board Advisors Elder: Sue Bree Kuia: Crete Cherrington Education Advisor: Mary Kensington
Regional Chairpersons
Consumer Representatives
Auckland Sarah Ballard, Linda Burke auckchair@nzcom.org.nz
Royal New Zealand Plunket Society Carla Kamo carla.kamo@plunket.org.nz
Bay of Plenty/Tairawhiti Kelly Pidgeon chairnzcomboptairawhiti@gmail.com Canterbury/West Coast Bex Tidball chairnzcom.cantwest@gmail.com
Parents Centre New Zealand Ltd Liz Pearce Ph 04 233 2022 extn: 8801 e.pearce@parentscentre.org.nz
Central Julie Kinloch Ph 06 835 7170 julie.kinloch.nz@gmail.com
La Leche League Trudy Hart Ph 07 549 5644 hartyhealth@live.com
Nelson/Marlborough Rose O’Connor roseocon@gmail.com
Student Representatives
Northland Chris Byrne (Interim) tetaitokerauchair@nzcom.org.nz Otago Jan Scherp, Charlie Ferris otagochair@nzcom.org.nz Southland Natasha Baillie Ph 021 258 2701 merakimidwifery@gmail.com Waikato/Taranaki Tracey Williams chairwaikatonzcom@gmail.com
prepares the perineum
EPI-NO is clinically proven to significantly increase the chances of an intact perineum, reduce episiotomy, and is safe to use.
Wellington Sarah Gilbertson nzcomwellington@gmail.com
EPI-NO is a dual purpose CE approved medical device designed to strengthen the pelvic floor muscles from early in pregnancy, and again postpartum. The perineal stretching exercises commence concurrently after Week 36.
Regional Sub-Committees
EPI-NO Childbirth Training has been accepted in Australia & New Zealand for over 15 years as an effective preparation for women choosing a natural vaginal birth.
Manawatu Sub-Committee
EPI-NO Patient Brochures can be requested for New Zealand via info@starnbergmed.co.nz
Isabel Bedford
Over 50,000 EPI-NO births in Australia and New Zealand. Available in over 20 countries worldwide.
Wanganui Sub-Committee
Hawkes Bay Sub-Committee Sarah Nation sarahnation.midwife@gmail.com
Jayne Waite j.waite70@gmail.com Taranaki Sub-Committee nzcom.taranaki@gmail.com
Jo Watson Ph 021 158 6874
www.starnbergmed.co.nz Available online with shipment from Auckland and at selected pharmacies. ‘The human body performs to maximum efficiency in any physical activity when correctly trained and prepared. Childbirth is no exception.’ Dr Wilhelm Horkel, Starnberg (EPI-NO inventor)
42 | AOTEAROA NEW ZEALAND MIDWIFE
Home Birth Aotearoa Eva Neely evaneely@live.com
jothemidwife@gmail.com Made in Germany
Horowhenua Jennie Ferguson Ph 021 232 1980 thejensterrocks@gmail.com
Wanaka Noanoa Ph 021 139 6496 wanakahr@gmail.com Seraya Turnbull Ph 022 6852383 serayaalucas@icloud.com Nga Maia Representatives www.ngamaia.co.nz Sarah Wills Ph 021 02551963 sarahandcale@hotmail.com Colleen Brown colleenbrownlmc@gmail.com Pasifika Representatives Talei Jackson Ph 021 907 588 taleivejackson@gmail.com Nga Marsters Ph 021 0269 3460 lesngararo@hotmail.com MERAS PO Box 21-106, Edgeware Christchurch 8143 www.meras.co.nz General Enquiries & Membership Ph 03 372 9738 meras@meras.co.nz MMPO mmpo@mmpo.org.nz Ph 03 377 2485 PO Box 21-106, Edgeware, Christchurch 8143 Rural Recruitment & Retention Services Rural contact: 0800 Midwife/643 9433 rural@mmpo.co.nz Resources for midwives and women The College has a range of midwifery-related books, leaflets, merchandise and other resources available through our website: www.midwife.org.nz/shop
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Call 03 377 2485 or visit www.mmpo.org.nz to find out more and receive a demo
Research supports what you learn. We support everything you do.
Study Midwifery at Te Herenga Waka— Victoria University of Wellington Discover more at wgtn.ac.nz/bmid
