Midwifery Digest
September 2016, volume 26, number 3
research & education midwifery pregnancy labour & birth postnatal infant nutrition neonatal & infancy worldwide maternity services news & reviews
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Contents Housekeeping............................................................................................................................ 273 Contents.................................................................................................................................... 274 Editorial..................................................................................................................................... 276
277 Hot Topic Resilience and stress management ............................................................................................. 277 Maggie Howell
283 Research & Education Patient and public involvement in designing an online survey about hyperemesis gravidarum ............................................................................................................ 283 Caitlin Dean, Sian Goddard Better Births: moving from ‘failure to progress’ to ‘rhetoric into reality’?................................... 290 Elizabeth Duff Workplace learning in midwifery education in Flanders (Belgium)............................................. 295 M Embo, M Valcke — Reviewed by Annabel Jay Clinical nursing and midwifery research: grey literature in African countries............................. 296 C Sun, J Dohrn, G Omoni et al
297 Midwifery Continuity within the NHS: it can and does happen, but why not for everyone? Part one — a macro level analysis.............................................................................................. 297 Bev Jervis A literature review to explore women’s lived experiences of pregnancy after sustaining a third- or fourth-degree perineal tear in a previous birth.......................................... 303 Ana Gomez-Thompson A qualitative study of how caseload midwifery is constituted and experienced by Danish midwives........................................................................................................................ 310 Ingrid Jepsen, Edith Mark, Ellen Aagaard Nøhr et al — Reviewed by Sara Borrelli Health care professionals’ knowledge, attitudes and practices relating to umbilical cord blood banking and donation: an integrative review.................................................................... 312 Lisa Peberdy, Jeanine Young, Lauren Kearney
313 Pregnancy Effects of spina bifida cystica on progression through pregnancy............................................... 313 Laura Hoskin Zika virus – what UK based midwives need to know................................................................. 317 Judy Bothamley Weight loss in pregnancy............................................................................................................ 321 Tisian Lynskey-Wilkie The additional cost burden of preexisting medical conditions during pregnancy and childbirth ........................................................................................................................... 326 Amy Law, Mark McCoy, Richard Lynen et al
327 Labour & Birth ‘Can you tell me about your perineal suturing career?’ Midwives’ experiences of perineal suturing accreditation: a descriptive study.................................................................... 327 Fiona Campbell Choosing an out-of-hospital birth centre: exploring women’s decision-making experiences...................................................................................................... 334 Rebecca J Wood, Javier Mignone, Maureen I Heaman et al
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Effect of mode of delivery on vertical human papillomavirus transmission — a meta-analysis ..................................................................................................................... 343 Kimon Chatzistamatiou, A Sotiriadis, Theodoros Agorastos Better perineal outcomes in sitting birthing position cannot be explained by changing from upright to supine position for performing an episiotomy........................................................... 344 Willemijn DB Warmink-Perdijk, Joke M Koelewijn, Ank de Jonge et al
345 Postnatal Postnatal experiences of women and midwives in the hospital setting........................................ 345 Kursoom Khan, Helen McIntyre Frequency, severity and persistence of postnatal dyspareunia to 18 months post partum: a cohort study............................................................................................................................ 353 Ellie A McDonald, Deirdre Gartland, Rhonda Small et al
361 Infant Nutrition Predictors of breastfeeding initiation and frequency for preterm infants in the NICU................ 361 Hannakaisa Niela-Vilén, Hanna-Leena Melender, Anna Axelin et al Changing societal and lifestyle factors and breastfeeding patterns over time.............................. 372 Chad Logan, Tatjana Zittel, Stefanie Striebel et al — Reviewed by Annie Rimmer Breastfeeding and infant hospitalisation: analysis of the UK 2010 Infant Feeding Survey........... 374 Sarah Payne, Maria A Quigley
375 Neonatal & Infancy Examination of the newborn...................................................................................................... 375 Paula Izod Family-integrated care in the neonatal unit................................................................................ 380 Liz McKechnie The transition to parenthood and early child development in families with same-sex parents.... 384 Rachel H Farr, Samantha L Tornello — Reviewed by Sarah Lewis-Tulett Neonatal outcomes of waterbirth: a systematic review and meta-analysis.................................. 385 Henry Taylor, Ira Kleine, Susan Bewley et al
387 Worldwide Maternity Services Empowering midwives in the United Arab Emirates................................................................... 387 Grace Edwards, Philidah Seda ELLY Appeal: twinning with India............................................................................................. 391 Inderjeet Kaur Perceptions of Hong Kong Chinese women toward influenza vaccination during pregnancy...... 394 Carol YS Yuen, Joan E Dodgson, Marie Tarrant Who’s that girl? A qualitative analysis of adolescent girls’ views on factors associated with teenage pregnancies in Bolgatanga, Ghana................................................................................. 403 JK Krugu, FEF Mevissen, A Prinsen et al — Reviewed by Mutinta Muleya
405 News & Reviews Did you miss it?......................................................................................................................... 405 Author index.............................................................................................................................. 407 Subject index.............................................................................................................................. 407
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From the Editor Many people think of a New Year beginning in January, however, for students and midwifery teachers the year begins now in September. Congratulations to all the students embarking upon a career in midwifery. For you this will be a very exciting, if a little daunting, New Year. There will be times when you cannot think of anything else you would rather do and there will be some days that are more challenging. Build yourself a network of strategies and contacts to help you get over the difficult times, talk to your personal tutor and mentors in practice — they have been there and know how you are feeling. Join your Midwifery Society; if you do not have one, consider forming one. On our website you will find a directory of Midwifery Societies with contact details, and their members will be pleased to help you in starting your own and be able to offer advice and ideas. We at MIDIRS are always keen to hear from students and you can contribute to our blog, letting us know how your new life as a student midwife is going. The blog is not limited to students; it would be interesting to hear from midwives too, particularly about how you are supporting students in practice. Tips for students and mentors are particularly useful in helping with getting the most out of a student/ mentor relationship. To get the most out of the practice placements you will need to understand the theory behind why things are done in a certain way, or indeed, challenge the status quo. We hope that MIDIRS can support you in your academic work through the journal and the Reference Database. In this edition we have some very interesting articles to read and I would draw your attention particularly to the Hot Topic, which I hope will be useful to you all in your daily lives. We increasingly hear of people being adversely affected by stress and this can have a profound impact upon both our personal and professional lives. Maggie Howell specialises in hypnotherapy during pregnancy, birth and beyond, and in the course of her work has talked to many midwives and discovered the high levels of stress they were experiencing. This article explores the understanding of stress and explores some useful ideas for managing it. An exciting review, chaired by Baroness Cumberlege, has recently been published following extensive work — Better births: improving outcomes of maternity services in England (NHS England 2016). Many of you will remember Baroness Cumberlege also produced the Changing childbirth document in 1993. Elizabeth Duff (p 290) reports on this and gives a brief history of the documents leading up to this review. It is hoped that the care we give to women and their families can be greatly improved through implementing the recommendations reported upon. 276
Bev Jervis (p 297) also alludes to the document when discussing the merits of providing a home birth team to give continuity and choice for women. Unfortunately this project came to a premature end, similar to midwifery-led units in other areas. It is hoped that through this new review, women and midwives will once again regain autonomy and choice in care during pregnancy, birth and the postnatal period. I hope these papers inspire you to read the review and begin to plan and implement the positive changes that can be made. The role of midwives is increasing and greater opportunities are open to us for further training and enhanced skills, all to ultimately be of benefit to the woman and baby. It also increases job satisfaction for midwives and helps you to move along the career pathway. Paula Izod (p 375) relates her experience and knowledge when undertaking the examination of the newborn training. In part one the author discusses the examinations undertaken. In the next edition paper two will explore the communication and counselling skills required and give a reflective account of the personal and professional learning gained through this experience. Through reading this it is hoped that more midwives will consider further training to also undertake such examinations. This is particularly of value when working in a midwiferyled setting as midwives are truly giving midwifery-led, woman-centred care. Wishing you all every success on your chosen pathway.
References Department of Health (1993). Changing childbirth. Part I: report of the Expert Maternity Group. London: HMSO. NHS England (2016). Better births. Improving outcomes of maternity services in England. A Five Year Forward view for maternity care. NHS England.
Cathy Ashwin, Principal Editor. Š MIDIRS 2016. MIDIRS Midwifery Digest 26:3 2016
Hot Topic
Resilience and stress management Maggie Howell
ORIGINAL Introduction The issue of stress is constantly hitting the headlines — from the increase of stress in the workplace to research highlighting the impact that stress can have on a physical, emotional and psychological level. This article will explore the stress-related issues faced by midwives and strategies to help them increase their resilience and ability to cope with the ever increasing levels of adversity. In the 2015 National Health Service (NHS) staff survey, almost half of the 5286 midwives who took part suffered from work-related stress (Picker Institute Europe 2015). In a survey of midwives I worked with in 2014, a shocking 78% had considered leaving the profession with a staggering 81% citing stress as the number one reason (Howell 2014).
This statement will resonate throughout the midwifery arena and wholly echoes my sentiments and those of many others. Considering almost every midwife enters the profession because they are
© Maggie Howell 2016
Royal College of Midwives (RCM) Director for Policy, Employment Relations and Communications, Jon Skewes says:
‘Midwives are the backbone of the NHS, they work tirelessly to deliver the highest quality care to women and their babies, often without fair overtime payments and to have almost 4000 midwives suffering work-related stress is deeply concerning’ (Griffiths 2016).
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Hot Topic
passionate about supporting women and their babies, there is something fundamentally wrong when such a high percentage find their job has taken a toll on their emotional, as well as physical, well-being.
Let us just briefly explore what stress actually is. We use the term prolifically as it has become interwoven with all areas of modern living. Nevertheless, the term ‘stress’, as we know it, is relatively new and continues to evolve in both meaning and context. The term originated from the Latin word stringere meaning to ‘draw tight’. The use of the term in relation to the ‘fight or flight’ response was attributed to Walter Cannon in 1932 and then later to Hans Selye in 1936 who used the term ‘stress’ as a psychological concept (Kennard 2008). In research terms today, stress embraces biochemical, behavioural, physiological and psychological effects. We have come to a common understanding that stress is what you experience when you are faced with a perceived difficult situation, which feels in some way threatening to you, and your instinctive reaction is that you cannot cope effectively. This perceived threat activates your parasympathetic nervous system, which triggers a series of biochemical, behavioural, physiological or psychological changes, which in turn can put significant strain on the body. Observing the biology and chemistry of stress, it is actually a phenomenal process that has helped to keep humans safe since man first walked the earth. The problem that we face today is that this system has not evolved quickly enough to cope with the new challenges of modern day living, and we are spending longer and longer in this parasympathetic state which is leading to an ever increasing strain on our bodies. It is now believed that 75–90% of doctors’ visits are due to stress-related problems or illnesses (The American Institute of Stress 2016).
And yet some people do not seem so affected by stress Why is it that some people seem to cope so well with stress or even thrive with adversity? Is this something that anyone can learn to do? Hunter & Warren (2013) argue that resilience in the workplace or ‘positive adaptation to adversity without residual significant psychological disruption’ is an area of increasing interest in the midwifery profession. This belief led to an absorbing study investigating resilience in midwifery. Furthermore, Hunter (2014) suggests it was of value to explore the concept in greater depth to discover what coping mechanisms midwives used to deal with the 278
challenges of midwifery, as not all succumb to stress and burnout. The study identified key times when resilience was low — being newly qualified, coping with a difficult case and being under investigation. However, one of the positive findings was that the research suggests that resilience is a learned process, developed over time.
Literature on stress management and resilience There is very little research or literature on solutions to increasing workplace stress or resilience. Deery (2005) determined that, although the existence of stress and burnout in midwifery was evident by the extensive published literature available, none of the research addressed ways of alleviating this situation. This situation is not unique to midwifery and is also evident within the wider medical field. Shapiro et al (2000) undertook a review of stress management in ‘medical education’ with the search yielding over 600 articles, highlighting its existence and the need to address the issue within medical education. Intervention programmes were only evident in 24 of the reported studies, and yet when participants did undertake some form of stress management or resilience training the results were impressive. Medical students demonstrated: • improved immunologic functioning • decreased depression and anxiety • increased spirituality and empathy • enhanced knowledge of alternative therapies for future referrals • improved knowledge of the effects of stress
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© Maggie Howell 2016
What exactly is stress?
Hot Topic
• greater use of positive coping skills
with what you have around you.
• the ability to resolve role conflicts.
Not all of these may appeal or be appropriate to you so pick and choose — even if you implement just one stress-busting tip a day you will begin to feel more relaxed, more in control and better able to deal with the daily stresses and strains of midwifery.
Resilience is both a natural but also a learnt skill From my experience with clients and through study days, I believe that everyone can learn strategies and skills to help increase their resilience and so reduce the effects and symptoms of stress. When you look back at my definition of stress it is all about ‘perceived’ threat; in other words there is a belief that the situation is threatening. There is a big difference between perceived threat and real danger — if you were in the jungle and confronted by a tiger then that is real danger and the parasympathetic system will kick in within a millisecond to try and keep you safe. However, dealing with a difficult colleague or filling in paper work is not real danger — it has become a perceived threat as you immediately associate it with challenges you have faced in the past. The key is that there is a belief, based on previous experiences, that you do not have the skills to effectively deal with a particular situation. The result is you continue to react in the way you have in the past and so the cycle goes on. So take a moment now to consider why you are getting stressed: What is the cause of your stress — workload, money, relationships, colleagues? Then think about what your response would be. How do you react when you get stressed? Why do you get more stressed on some days than others? The answers to these may be different for everyone; however, the solutions would be the same for many of us. Understanding your stress is the first step to knowing how to change your reaction. As Jack Sparrow says in the film Pirates of the Caribbean: ‘The problem is not the problem: the problem is your attitude to the problem’ (2003). By identifying your key triggers, you can begin to pre-plan responses so you learn to respond to a situation rather than just react instinctively.
My top 20 stress-busting tips So if your Trust does not yet offer a stress management programme or resilience training, then here are my top 20 stress-busting tips to help you cope with work-related stress. This is not about ‘toughening up’ but more about dealing effectively MIDIRS Midwifery Digest 26:3 2016
1. See things in their true perspective – stress can make you feel more sensitive, vulnerable and lacking in self-esteem. It is so important to keep things in perspective and not to take things personally. If you are not dealing with a potentially threatening situation, take a step back. Will this really matter next week? Is it really worth me getting stressed about? 2. Make a list of the things that cause you stress – again no matter how big or small. Go through each one and think of alternative responses. Think of things you can do to prevent the stress from building in the first place. One thought that always works for me is to remember ‘and this too shall pass’. No matter what you are going through, it will pass, it will be over and you will get through it. 3. Take the lid off the pot – talk about the stress you are going through rather than bottle it up. Get together with colleagues for a good natter and whinge – it is a great way to off-load and to realise that you are not alone. 4. Lower the worry rating – worry is such a wasted use of energy. If you can do something about it now then do it. If you cannot, then mentally park it or write it down. You can spend a few moments worrying about it later if you really need to, then move on so you can get on with your daily routine without the burden of worry. 5. Set up a mutual appreciation group with your colleagues – so that each day you have to say one nice thing to each other. Identify one good quality, one good action. Once you start saying them and hearing them it can really lift your mood and self-esteem. All too often stress leads to and is compounded by lowered confidence and lack of self-esteem (Seaward 2006). Everyone needs a boost now and again so start the ball rolling and tell your colleagues something positive about their skills or actions! 6. Focus on the positive – every day spend a few moments thinking about all the great things about your job, no matter how big or small – great muffins in the canteen, lovely colleagues, the women you care for, the smell of newborn 279
© Maggie Howell 2016
Hot Topic
babies or the sound of a breastfeeding baby. Being appreciative and thankful of even the tiniest things can help reduce stress. 7. Create a protective bubble – this is something I have found incredibly useful as a way of protecting yourself from negative or challenging experiences. Before going to work, imagine you have a protective bubble all around you and any negative experiences, words or actions just bounce off leaving you unaffected. 8. Ask for help – as women who care for others it is often very hard to ask for help. However, sometimes getting a little help from a colleague or manager is enough to take the lid off the bubbling stress pot. Speak up if you are experiencing a problem, talk to your manager to help find a win-win solution. Remember, it is part of their role to help you do this. 9. Take time out to RELAX – it is amazing how many people do not see this as a priority. Make a list of the ways you like to relax and put them on the fridge door so you are reminded every day to take time to relax. Even it is just for a few minutes – see the end of the article for a great free resource. 280
10. Coping with difficult colleagues – one of the most challenging areas for midwives is often other colleagues – especially senior colleagues. A very sad 32% of midwives had experienced bullying, abuse or harassment from NHS staff in the previous 12 months (Picker Institute Europe 2015).
One of the challenges that can cause stress at work is being in close proximity to difficult colleagues. In the recent study exploring resilience in midwives, Hunter & Warren (2013) note that one midwife felt that she was able to cope better by staying away from those who made her feel undermined or negative.
Whilst this is not always possible, one thing to always remember is that no matter how much you would like to, you cannot change the individual or their personality. The only thing you can change is your reactions. So the next time a person says or does something that makes you feel stressed, pause for a moment, take a deep breath and accept that you cannot change a person. Respond calmly and with empathy, you can stay in control, and you can defuse the situation.
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Hot Topic
11. Get some fresh air during your shift – not always easy but it is so good to help your blood flow, to breathe fresh air, to reoxygenate and to just ‘be’ for a bit. 12. Feed your body and soul – work toward filling your body with food that gives you energy, vitality and a sense of well-being. It is all too easy to reach for a Mars bar or biscuits as a quick fix, but when you can fill up on fruit, veg and protein, drink lots of water, drink smoothies, have bags of healthy snacks. Avoid processed carbs, especially sugar; they are a real stress inducer as your blood sugar levels go awry, they contribute to increasing your weight and are highly addictive – not great for beating stress! However cocoa, which is rich in antioxidants, has been shown to reduce stress, so go for a good quality high percentage chocolate bar if you need a chocolate fix. 13. Make a ‘to do’ list – sometimes the sheer volume of things that need to be done can cause a stress response. So chunk it down, make a list of what you have to do and then check back to the list so you can tick things off. This helps to increase your self-esteem and give you a boost as you can see that you really are getting things done. 14. Create mini spa moments in your day – this need only be for two minutes. Stop what you are doing, take three deep breaths. Focus on how your body feels. Notice if there is any tension and then just wriggle and relax that part of the body. Next massage the fleshy bit on your palm between your thumb and forefinger. This helps to relax and disseminate tension. Next, using both your thumbs, massage the top ridge of your eye socket at the top of your nose then work way around the eye socket. All the time keep taking deep breaths. You can also visualise being on a beautiful beach or in your favourite garden. Then circle your shoulders a few times one way and then the other. And finally end with three deep breaths. You can even do this whilst on the toilet! 15. Have a good laugh or even just a smile laughter is one of nature’s best cures. It lowers levels of cortisol, adrenaline, and epinephrine, which are stress-aggravating hormones; and it releases feel-good hormones, such as dopamine. Plus our brains are interconnected with our emotions and facial expressions. When people are stressed, they often hold a lot of the stress in their face. So laughs or smiles can help relieve
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some of that tension. Get a favourite comedy box set, find pictures that make you laugh, read a joke book that appeals to you, and watch funny videos on YouTube. Schedule in a smile/ laugh session at least once a week. 16. Plan ahead – if you have a stressful situation coming up then take some time BEFORE the event to run through it in your mind and visualise or imagine yourself coping brilliantly, staying calm, focused and positive. Just by imagining this a few times your mind will gravitate towards those actions when you go into the situation for real. 17. Learn to say no – once again many women who care for others find it hard to say NO. If you are feeling overwhelmed then do not take on any more shifts, committees, projects for the time being. As you may tell others, no one is perfect so remember to include yourself in that bucket. Saying no is OK. Saying no to yourself is also OK – you do not always need to fix things, go the extra mile, sort out other problems. 18. Identify your triggers – in your role as a midwife you come across many factors that cause stress which you cannot change; however, we all have buttons which get pressed and trigger stress whereas others may not be stressed. Take time to notice what has caused you to feel stressed. Identify those triggers and think about ways you could react differently, maybe watch how others react and copy them. There may also be more practical things you can do, for example, if stress is caused by hunger, dehydration, lack of fresh air. 19. Take time out to be kind to yourself – again a bit tricky if you are a working mum or work long hours and many shifts. However giving yourself little treats at regular intervals gives you something to look forward to, helps you nurture yourself and relax. Schedule in bubble baths, an hour to read a good book, coffee with friends, an hour to browse fun YouTube clips, a visit to a local garden centre. Actually put them in your diary and make them happen. 20. Learn quick, easy stress reduction techniques – one of the techniques I teach on all my hypnosis tracks is the ‘321 relax’ – it sets up the suggestions that every time you hear or say the words 321 relax, you take a deep breath, relax your shoulders and allow a growing sense of confidence to build.
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Hot Topic
As a hypnotherapist, Maggie Howell has developed and produced many hypnosis tracks, predominantly to help pregnant women with their birth preparation. Through her work training midwives she has developed a specific hypnosis track to help midwives cope more effectively with the most common stresses and challenges of midwifery.
Kennard J (2008). A brief history of the term stress. http://www.
This 30-minute hypnosis relaxation track will help to put in place many of her top 20 stress-busting tips to help you:
Directed by Gore Verbinski. California: Buena Vista.
healthcentral.com/anxiety/c/1950/30437/history-term-stress/ [Accessed 30 June 2016]. Picker Institute Europe (2015). NHS staff survey 2015. http://www. nhsstaffsurveys.com/Page/1010/Home/NHS-Staff-Survey-2015/ [Accessed 30 June 2016]. Pirates of the Caribbean: The curse of the black pearl (2003). Seaward BL (2006). Managing stress: principles and strategies for health and well-being. 5th ed. London: Jones and Bartlett.
• deal more effectively with daily stresses
Shapiro SL, Shapiro DE, Schwartz GE (2000). Stress management
• manage your emotional as well as physical wellbeing
in medical education: a review of the literature. Academic Medicine
• learn coping strategies to deal with difficult situations
The American Institute of Stress (2016). Workplace stress. http://
• see things in their true perspective • manage your own energy levels
Howell M. MIDIRS Midwifery Digest, vol 26, no 3, September 2016, pp 277–282.
• become better at being ‘with woman’
Original article. © MIDIRS 2016.
75(7):748-59. www.stress.org/workplace-stress/ [Accessed 30 June 2016].
• give your mind and body a chance to recuperate, repair and heal itself. You can download this free track from: https://maggiehowell.leadpages.co/ midwivescompanion/ For information on study days contact: maggie@natalhypnotherapy.co.uk Maggie Howell is a clinical hypnotherapist specialising in hypnotherapy for childbirth (Natal Hypnotherapy method) and stress management. She has trained over 1000 midwives on how they can support women using hypnosis for labour and has a group of over 100 practitioners delivering the two-day Natal hypnotherapy class.
References Deery R (2005). An action-research study exploring midwives’ support needs and the affect of group clinical supervision. Midwifery 21(2):161-76. Griffiths J (2016). Stress affects almost 50% of England’s midwives. 1st March. https://www.rcm.org.uk/news-views-andanalysis/news/stress-affects-almost-50-of-englands-midwives [Accessed 30 June 2016] Howell M (2014). [Unpublished survey on midwives]. Hunter B (2014). One-to-one: bouncing back. Midwives 17(2):21-23. Hunter B, Warren L (2013). Investigating resilience in midwifery: final report. Cardiff: Cardiff University.
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Research & Education extract
Patient and public involvement in designing an online survey about hyperemesis gravidarum Caitlin Dean, Sian Goddard ORIGINAL Introduction There can be little doubt that the drive in recent years to bring patient and public involvement (PPI) into the very heart of health care research is a positive development, adding strata of value and relevance to research. Within the NHS there is a legal expectation that PPI will be promoted in health care service development and specific guidelines for PPI in a number of clinical areas, including maternity care, have been introduced (Savory 2010). Background
distress trimester internet
social survey media support psychodynamic thyrotoxicosis stigmatisation Facebook public depression community pregnancy
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patient
HG is a severe and debilitating complication of pregnancy which affects around 1–1.5% of the pregnant population (Einarson et al 2013). The condition is characterised by extreme nausea and vomiting which can lead to a host of complications, from dehydration and weight loss to life-threatening
intravenous treatment
frustration isolation study
Yet in under-funded areas of health care research, PPI is still being overlooked, despite the very desire for research being pushed by patient groups. This article will address the gap between the growing body of research on hyperemesis gravidarum (HG) and the lack of PPI in the hyperemesis gravidarum research process.
sickness research traumatisation dehydration health care debilitating hypokalemia hypermesis gravidarum maternity innovation Severe vomiting misconceptions nausea 283
Midwifery extract
Continuity within the NHS: it can and does happen, but why not for everyone? Part one — a macro level analysis Bev Jervis ORIGINAL As a midwife, a PhD student, a midwifery educator, a feminist and an activist, I am passionate about midwifery, excellent maternity care for women, and the NHS. With experience of a continuity model within the NHS, I know it is achievable. The recent maternity review (NHS England 2016) is the driver for the implementation of continuity models of care across the NHS. However, as this ideal was first proposed with the Changing childbirth report (Department of Health (DH) 1993), barriers to implementation require addressing. This paper examines my personal experience of implementing a continuity model and explores the reasons it ended, within the wider socio-political context of contributing factors within the NHS. Living the continuity dream
Š Laura Dempsey 2016
In 2008 two colleagues and I implemented a continuity midwifery team for home births. We all had similar philosophies about maternity care and
were passionate about home birth. We met over several months to determine how home birth could be better facilitated, led by a compassionate labour ward manager. We were well supported by the
Mum, Laura Dempsey holding baby Rowan, with midwives Jan Millar and Racheal Dishley
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Pregnancy extract
Effects of spina bifida cystica on progression through pregnancy Laura Hoskin ORIGINAL Spina bifida (SB) occurs when there is a fault in the development of the spinal cord and the surrounding vertebrae (Shine 2011). There are two types, spina bifida occulta (SBO) and spina bifida cystica (SBC). SBO is characterised by either a dimple, indentation or a tuft of dark hair along the spine towards the sacrum (Bates 2012). It is estimated that between five and 10% of the United Kingdom population has SBO, with the majority suffering no other health concerns and sometimes only being diagnosed in adulthood (NHS Choices 2015). SBC can be further split into meningocele or myelomeningocele. Meningocele is the least common form of SB and occurs when there is a protrusion of the meninges but the surrounding vertebrae are formed correctly and it may or may not be covered in skin (Bates 2012). Myelomeningocele, the most severe and more common form, occurring in 1:1000 births, is when vertebrae fail to form around the spinal cord. It involves not only tissue and cerebral fluid but also nerves. The health of adults with myelomeningocele varies greatly depending on the amount of nerve tissue involved and the location of the lesion (Webb 2010). The lesion can occur anywhere along the spine from the head to the sacrum but is found most commonly within the sacro-lumbar region (Bates 2012). With the improvement of antenatal care and surgical techniques, more neonates affected with SB are reaching adulthood and therefore women are reaching childbearing age (Blasi et al 2012). This paper addresses the implications of living with SB whilst pregnant and how a midwife supports and coordinates a woman’s care along the childbirth continuum. Although sufferers of SBO and SBC meningocele can have health implications, this paper will focus on those with myelomeningocele during the preconception and antenatal period.
Š www.dreamstime.com
While SB can be caused by, amongst others, genetic and environmental factors (Visconti et al 2012), having one parent with SB increases the chance of the fetus having the condition to 1–5% and having two parents with the condition increases the risk to 15% (Visconti et al 2012). All women with SB who are of childbearing age should be given preconceptual advice and 5mg of folic acid should be taken every day before conception and until at least ten weeks, ideally 12, to reduce the risk of the fetus developing SB (Surico et al 2012). Using folate prophylaxis reduces the risk of inherited SB but it does not remove it and for parents to make a fully informed choice regarding pregnancy, genetic counselling should be offered (Webb 2010). MIDIRS Midwifery Digest 26:3 2016
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Labour & Birth extract
‘Can you tell me about your perineal suturing career?’ Midwives’ experiences of perineal suturing accreditation: a descriptive study Fiona Campbell ORIGINAL Background: Most midwives who attend perineal suturing workshops do not complete the accreditation process to become an actively suturing midwife. This completion rate was given as a reason not to offer further workshops to other midwives in a local health district (LHD). Perineal suturing is an expected competency of Australian midwives. Midwives value it as part of the continuity of care experience. There is a deficit in policy and guidelines around midwifery perineal suturing in legislative, professional and regulatory bodies in New South Wales, Australia. Research question: What are the enablers and barriers for midwives seeking to complete perineal suturing accreditation? Participants: Ten consenting midwives who had completed a perineal suturing workshop. Methods: One-to-one in-depth, semi-structured interviews assessed midwives’ experiences of becoming accredited. Thematic analysis and member checking used in-vivo coding. Results: The factors that enable accreditation were midwifery mentors and clinical leaders and experience in or aspiring to work in a midwifery continuity of care model. The barriers were lack of confidence, fear of causing long-term damage, lack of opportunity and a workplace culture that historically did not support this skill. Conclusion: The introduction of midwifery perineal suturing champions facilitates midwives to attain accreditation by providing supportive mentors who are skilled in clinical teaching and promote perineal suturing as a normal midwifery skill.
© Dreamstime.com
Keywords: midwifery, education, qualitative descriptive, obstetric surgical procedures.
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Postnatal extract
Postnatal experiences of women and midwives in the hospital setting Kursoom Khan, Helen McIntyre ORIGINAL Background: Postnatal care is an important aspect of maternity care and a time of great change for a woman as her body starts to return to a non-pregnant state and she makes the transition to motherhood, yet research shows that women and midwives identify poor satisfaction with postnatal care provision (Audit Commission 1997, Beake et al 2005). The natural focus is on the woman’s pregnancy and labour and, as staff want to ensure excellent health preparation for labour, this is when the woman spends the greatest time in contact with a health professional. This acute service is also risk-driven and is the period where the greatest number of deaths and injuries can occur. Less emphasis is placed on the postnatal period or on newborn issues and as a consequence, less time is dedicated to informing women of what they should expect. The maternity review (NHS England 2015) also stated that postnatal care needs to be resourced appropriately. Aim: To obtain a detailed local picture of the postnatal service in a tertiary referral unit and to understand the experiences of women and midwives. The information gained could support improved outcomes, satisfaction, effective use of resources and improve clinical practice. Design: A mixed methods (Bowling 2009) design was chosen using a self-completed questionnaire incorporating a variety of open and closed questions (Bowling 2009). Method: Recruitment took place over a three-month period within the acute setting of a local NHS Trust within the East Midlands. All postnatal women fulfilling the inclusion criteria were asked to participate in the study. Midwives on the postnatal wards were also given questionnaires during this time. Results: Data were analysed by descriptive statistical analysis (SPSS version 21) for the closed questions and thematic analysis for the open questions (Bowling 2009). Conclusion: This study highlights that postnatal care is still not meeting the needs of women in relation to feeding support, information giving and practical facilitation of baby care skills.
Introduction This study was undertaken to gain a detailed picture of the service given and to understand the experiences of women and midwives on the acute postnatal ward. The postnatal period begins with the birth of the baby and ends when the baby is six weeks’ old (Nursing & Midwifery Council (NMC) 2012). A great deal of emphasis is placed upon one-to-one care during labour (National Collaborating Centre for Mental Health (NCCMH) 2007) but benchmarks to support effective postnatal care are lacking.
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NICE (National Collaborating Centre for Primary Care (NCCPC) 2006) recommends that postnatal care is individualised and that the midwife is responsible for the physical, emotional and psychological wellbeing of both mother and baby. The current trend is for mothers to have a shorter stay in hospital, increasing pressure on hospital midwives to ensure all aspects of postnatal care are delivered and that women are discharged in a timely manner. A recent study also highlighted that across
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Infant Nutrition extract
Predictors of breastfeeding initiation and frequency for preterm infants in the NICU Hannakaisa Niela-Vilén, Hanna-Leena Melender, Anna Axelin, Eliisa Löyttyniemi, Sanna Salanterä REPRINT Objective: To determine factors that predict the initiation and frequency of breastfeeding, attitudes about breastfeeding, and the self-efficacy of mothers of preterm infants in a neonatal intensive care unit. Design: A structured survey using two measurement points. Setting: A university hospital in Finland. Participants: Mothers (N = 124) and their infants born at less than 35 weeks gestation. Methods: Structured questionnaires were used during the first week postpartum and at discharge of infants from the hospital. Neonatal and breastfeeding data were collected from patient records. Results: Preterm infants initiated breastfeeding at the median postnatal age of 4 days (range = 0–70 days). The factors that predicted earlier initiation of breastfeeding were greater gestational age, no ventilator treatment, early physical contact, and greater maternal education level. Greater gestational age, early physical contact, and a breastfeeding-favorable attitude also predicted the frequency of breastfeeding. The attitudes of the mothers regarding breastfeeding immediately after birth were generally positive but decreased during their infants’ hospital stays.
© © Fotolia.com
Conclusion: Gestational age and early physical contact seemed to be the strongest predictors of breastfeeding initiation and frequency in the NICU. In addition, the role of the mother’s attitude regarding breastfeeding was significant. Current care practices should be critically reviewed with emphasis on early physical contact at the time of birth.
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Neonatal & Infancy extract
Examination of the newborn Paula Izod
ORIGINAL Background
www.fotolia.com
Many midwives are now undertaking further study to enable them to qualify in the examination of the newborn. Working within a stand-alone midwifery-led unit I was keen, though apprehensive, to take on this role. Notwithstanding, I considered this was an important step not only for my own professional development but for the benefit of the women and families I support on their journey to parenthood. This paper is the first of two and the hope is that it will aid understanding and encourage others to study to become newborn midwife examiners. The first paper discusses the examinations undertaken, namely ophthalmic, chest, hips and limbs. Paper two will explore the communication and counselling skills required to undertake the newborn examination and finally will give a reflective account of the personal and professional learning gained through this experience.
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Worldwide Maternity Services extract
Empowering midwives in the United Arab Emirates Grace Edwards, Philidah Seda ORIGINAL Introduction Considerable efforts have been made to increase women’s access to quality midwifery care around the world. The World Health Organization (WHO) identifies midwives as ‘the most appropriate and cost effective healthcare professional to provide care in normal pregnancy and childbirth’ (WHO 2009). A growing body of evidence demonstrates that midwifery care is associated with more efficient use of resources and improved outcomes when provided by midwives who are educated, trained, licensed, and regulated. A recent Cochrane review revealed many benefits of midwifery care, including reduction in the use of regional analgesia, fewer episiotomies, fewer instrumental births, and women feeling more in control and involved in their birthing experience (Sandall et al 2016). However, previous research by one of the authors (GE) found that the role of the midwife in the United Arab Emirates (UAE) was poorly understood with many women feeling that they were safer with care from a doctor (Edwards 2014, Edwards et al 2014).
© Grace Edwards 2016
This paper describes an initiative to reestablish the midwife as the expert in normality and create a supportive environment whereby midwives can practise to the full extent of their education and license within the government hospitals in Abu Dhabi.
Grace Edwards (left), demonstrating emergency breech
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News & Reviews extract
Did you miss it? Thanks to the project, the number of women of reproductive age using long-acting family planning methods went from 5224 (34%) to 29,081 (70%) and women delivering in health centres and hospitals rose from 1326 (10%) to 14,024 (37%). SafeHands has also produced an illuminating book of photographs due to be released in the autumn. It will feature some of the key themes that have had a positive impact on the lives of women and children all around the world over the last ten years. Advance copies can be ordered now at: studio@safehands.org
PANDAS awareness week
©Nancy Durrell McKenna/SafeHands for Mothers 2016
Between 5th and 11th September 2016, PANDAS (UK’s leading pre and postnatal depression charity) will be launching and hosting the first ever Pre and Post Natal Depression Awareness and Support Week (#PNDAW16) in the UK. PANDAS would like to invite your organisation to sign up as a supporter of #PNDAW16. There is no cost involved in being a PND Awareness Week supporter. To sign up as a supporter:
Latest news from SafeHands for Mothers SafeHands for Mothers has just launched their new film entitled Leading Safe Choices: moving mountains commissioned by the Royal College of Obstetricians and Gynaecologists (RCOG). Leading safe choices is a programme being run by the RCOG in South Africa and Tanzania to address the shortage of health care professionals. In particular, training is being given in postpartum family planning and comprehensive abortion and post-abortion care. SafeHands has also achieved a further milestone, reaching the end of a three-year project funded by Comic Relief ‘Making pregnancy safer II’ in northwestern Ethiopia in partnership with the Family Guidance Association of Ethiopia.
• reply to the email telling Panda’s that you wish to sign up as a #PNDAW16 supporter • provide your logo (as high resolution as possible) for use on promotional materials and website • let them know your Twitter handle (if you have one) so that they can follow you and promote any posts you use (and vice versa if you so wish). Together we can launch #PNDAW16 in order to raise awareness to support those currently suffering, to reach those that have yet to become aware that the way they are feeling is an illness, and to urge them to get the necessary support. Contact details: Tillie Mabbutt, Media Officer and Support Group Leader, PANDAS Foundation (Pre and Postnatal Depression Advice and Support). Tel: 07861 377118, Email: mediateam@ pandasfoundation.org.uk, Website: www.pandas foundation.org.uk
Editor’s note: Julie Spencer and Tania McIntosh, authors of What are women’s lived experiences of weight management in pregnancy? (June Digest, pp 179–185) would like to thank the women in this study who willingly gave up their time, and shared their stories. Please also let it be known that this article presents independent research funded by the National Institute for Health Research (NIHR). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR, the Department of Health or MIDIRS.
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