Issue 43 • July 2019
Birth doesn’t need a
How to
• Implement skinto-skin care in the C-section theatre • Get KMC up & running where you work
Natural birth in South Africa – a retrospective
Breast anatomy is unchanged It was imperfect information!
push start!
Looming controversies • Commercialisation of ultrasound • Implications of the ‘ARRIVE trial’ • Harmful chemicals passing through the placenta
Too little emotional support for
Mental health during pregnancy
CONTENTS Issue 43 • July 2019
Anterior
21. First Steps
3. Editor Margreet Wibbelink welcomes readers
»» Advising mothers on otitis media
4. Guest voice – Evashnee Naidoo champions skin-to-skin care in the C-section theatre
6. The importance of mental health during pregnancy There’s too little emotional support
»» Singing sessions alleviate PND symptoms
Breast assurance 24. No mammary mutation
10. Belly Talk
'Just improving imperfect information
»» Dry, itching or flaking skin
27. Milky Ways
»» Be aware of the commercialisation of ultrasound! »» Harmful PFAS chemicals pass through the placenta »» Morning sickness linked to better mental development »» Vitamin B6’s role while expecting
»» Another reason to delay newborn bathing »» Ditch the dummy for breastfeeding »» Better birth, better breastfeeding
Dimensions 28. Where women gather
Birth
18
»» Medical breakthrough for NICU babies »» The dangers of baby wipes
Pregnancy
6
»» Canny colic cures
Sister MorningStar’s message
12. The history of natural birth in South Africa
29. Be calm and master the menopause 31. Reflections
15. Birth review
»» SANC Fraud Hotline
»» Women-centred care linked to fewer second-degree tears
»» Antihistamines affecting male fertility
»» Safer home births with standardised bags »» Don’t go with the ‘ARRIVE trial’
Posterior 32. Sensitive Midwifery Symposium 2019 Programme
16. Push-started Is that how birth is supposed to be?
34. Research references for key articles in this edition
Mom & Baby 18. The Kangaroo Care story Dr Elise van Rooyen shares KMC’s history and value
21 eSensitive Midwifery Magazine
»» Partner violence during pregnancy
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Issue 43
35. Last word – The revival of the birth chair
Anterior
Midwife Margreet
Editor's Letter
Hi there beautiful midwives, We are halfway through the year already! Time flies, doesn’t it? Midwives are often very busy people, juggling many balls. I don’t know about you, but I have become pretty good at juggling! Unfortunately, at times, when life happens, I find myself dropping balls, which leaves me feeling defeated. This forces me to take stock, to assess whether there are too many balls and if I should leave some on the floor where they fell. That doesn’t always feel good but I have learned that it is better
to be ‘on the ball’ than ‘juggling balls’; to rather be proactive instead of reactive. We hope you are keeping warm and healthy during this winter season. To be the sensitive midwives we all want to be, it is so important to look after ourselves and our health. So here a gentle reminder to do just that … and, of course, to stay on the ball! .
Blog
www.sensitivemidwifery.co.za
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Managing editor Sister Lilian Editor Margreet Wibbelink Sub-editor Kelly Norwood-Young, Hello Hello Contributors Evashnee Naidoo, Sally Field, Simone Honikman, Dr Elise van Rooyen, Hettie Grove, Sister MorningStar, Margreet Wibbelink, Kelly Norwood-Young Snippet research Margreet Wibbelink, Kelly NowoodYoung, Sister Lilian Business manager Alan Paramor Advertising sales Gillian Richards, Diana Twala Design Lise-Mari Coetzee, JBay Studios E: magazines@sisterlilian.co.za T: +27 12 809 3342 C: +27 71 447 3321 Fax2email +27 86 691 2485 Snailmail PO Box 11156, Silver Lakes, Pretoria, 0054
Published by Sister Lilian Centre® No part of Sensitive Midwifery Magazine may be reproduced in any format without written consent of the publisher. All rights reserved. Every precaution has been taken to ensure correctness of information and references, but opinions expressed in the digital, print or any other version of Sensitive Midwifery Magazine do not necessarily reflect standard obstetric practice, though the publishers and editorial team set great store by ethical, responsible maternity care. While we firmly believe that the content found here will help improve midwifery and birthing, responsibility cannot be taken for the application in practice of Sensitive Midwifery Magazine’s information, tips, suggestions and guidelines. The publication is intended for the interest of midwives and related maternity professionals only. Copyright : Sister Lilian Centre® eSensitive Midwifery Magazine
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Issue 43
Anterior
Guest voice Skin-to-skin care after C-section
I wanted to be that midwife who persevered to promote skin-to-skin care at caesarean births, shares Evashnee Naidoo.
W
orking in a busy level-one public hospital in the Ethekwini District of KwaZulu-Natal comes with many practice challenges, not least of all pertaining to birth and neonatal care. After reading evidenced-based literature on the benefits of skin-to-skin care (SSC), I understood that it was more than just the opportunity for a mother and her newborn to bond. My greatest desire was to extend the many benefits to babies who were born without complications by C-section. That’s why I set out to achieve this and my experience goes to prove that it can be done, even in a busy level-one public hospital!
Serendipity at work Fortunately, because of a quality improvement initiative in our hospital’s neonatal nursery, aimed at reducing their occupancy rates, all neonates born via C-section were no longer admitted to the nursery for observations. Besides reducing the nursery occupancy rate, it ensured that mother-neonate separation time was done away with and, thankfully for my goal, offered a perfect opportunity to practise routine SSC intra-operatively and in the recovery room. Initially, I had to convince the anaesthetic and scrub teams that I would not pose a hindrance to them while they performed their duties. Soon, it became accepted as part of my routine practice, without much discussion or reservation from those who had initially been concerned.
Care and considerations Preoperatively, I inform the expectant mother of the protocol to implement SSC in the operating room, and request her to bring along a nappy and baby hat. Intraoperatively, as soon as the neonate has been examined and noted to be well, and we have donned the nappy and hat, Baby is taken to the mother and SSC begins on the operation table.
Prior consultation with the anaesthetist and the surgeon about my intention to initiate perioperative SSC usually gains the cooperation, and even the assistance, of the team. It gives me great satisfaction to see how many neonates in SSC with their mothers initiate breastfeeding in the operating room itself. The star of the show has to be the neonate who so naturally roots towards the nipple, showing readiness to feed. This is the cause of much giggling and amazement among the team, and only strengthens our efforts to advocate for early SSC in the operating room.
Celebrating skin-to-skin It makes me so happy that now, more midwives in our hospital are advocates of SSC at caesarean-section births, and there have been no reported adverse events. I am convinced that if we provide the opportunity, these smart little beings naturally do what is best for them! Why not join me and do this in your hospital?
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Issue 43
Complete Vacuum Delivery System
91%
92%
98%
93%
99%
96%
OA***
Position of Foetal Head
Pelvic Outlet
OP**
Pelvic Floor
OT*
Mid-Pelvis
76%
(0 to+1)
(+2 to+3)
(+4 to+5)
Station of Foetal Head
Overall Successful Completion of Birth
Pregnancy
The importance of mental health
during pregnancy
Maternal mental health during pregnancy is crucial to the wellbeing of both mother and child, and yet very little emotional and psychological support is offered, say Sally Field and Simone Honikman of the Perinatal Mental Health Project.
About the Perinatal Mental Health Project The Perinatal Mental Health Project (PMHP) is based at the Alan J Flisher Centre for Public Mental Health, in the Department of Psychiatry and Mental Health, University of Cape Town. They envision mental health support for all mothers to promote their wellbeing, and that of their children and communities. Their mission is to develop and advocate for accessible maternal mental health care that can be delivered effectively at scale, in lowresource settings. To achieve this, they collaborate with government, and the academic and NGO sectors. Read more about PMHP and its resources at https://pmhp.za.org/.
T
he first 1000 days of a child’s life, from conception until age two, is a period that has the potential to shape lifelong health and development. Mothers have increased contact with health professionals during this time, providing ample opportunity for timely intervention. However, health care for both mother and child tends to focus mainly on physical health. The prevalence of common mental disorders (CMDs), including depression and anxiety, in the perinatal period is extremely high in South Africa. Studies have shown approximately one in four mothers suffer from depression and/or anxiety during pregnancy or after birth. This is far higher than the rates found in high-income countries. The risk factors for CMDs in South Africa include poverty, food insecurity, HIV+ status, domestic violence, being an adolescent, and having inadequate social support. A past history of mental health problems places women at much higher risk of experiencing these in the perinatal period.
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Pregnancy
When is it CMD and when not? Depression
Symptoms need to be present for at least two weeks and negatively affect functioning
Anxiety disorders
Symptoms must be present for several months; functioning also affected
Baby blues
Presents in the first few days after birth; linked to hormonal change with sudden mood swings: crying for no apparent reason, and feeling overwhelmed, inadequate, lonely or sad; usually resolves with compassionate support
Postnatal psychosis
Occurs in 0.02% of births; is a severe psychiatric disorder; can develop rapidly; the mother is out of touch with reality; may experience delusions and hallucinations; urgent same-day referral to specialist mental health care is needed
CMD
Not CMD
Outcomes of pregnancy CMDs CMDs can put the pregnant mother at greater risk for preterm delivery and a low-birth-weight baby, substance and alcohol abuse, and suicide. She is more likely to experience domestic violence and is less able to generate income. Untreated, CMDs may negatively impact the developing baby, physically, cognitively, psychologically and socially. If a mother receives appropriate care and if there are additional caregivers who are able to provide nurturing care, these impacts may be avoided.
How to recognise CMDs A pregnant woman suffering from CMDs may present as a ‘difficult’ client, be more likely to miss appointments, or not adhere to medication or treatment protocols. She could be withdrawn, aggressive or experience a range of different physical complaints such as vague aches and pains. While changes in sleep, appetite or tiredness are common symptoms during pregnancy, they may also be indications of mental distress. A woman’s body language and behaviour can often
show that she is sad or worried, so take note if she cares for her appearance and if she makes eye contact. After birth, the interaction between a mother and baby can provide clues as to her mental state. A distressed mother could show hostility towards her child or describe the baby as ‘fussy’ or ‘difficult’. She may not play or communicate with the infant. Breastfeeding could be difficult, particularly if the mother has low self-esteem or is worrying excessively.
Detection of CMDs Screening with a questionnaire can help identify symptoms. Further assessment from a qualified professional may be needed for a diagnosis. Screening should only be undertaken if there are referral options in place. SADAG (South African Depression and Anxiety Group) have a 24-hour helpline on 0800 12 13 14, as does Lifeline on 0861 322 322. The PMHP developed a brief mental health screen that is validated for use in the South African setting (see panel on next page for details).
Continued on page 8
7
Pregnancy
Perinatal Mental Health Project screen This screen should only be conducted if resources are available for referral, e.g. mental health nurse, social worker, NGO or a medical officer. Before screening, use words like: ‘We would like to know about all the women who come here; how they are doing physically and emotionally. This helps us to understand the best sort of care we can offer. Please may I ask you three questions about how you are emotionally? Please answer ‘yes’ or ‘no’ to each question.’ In the last 2 weeks, have you on some or most days felt unable to stop worrying or thinking too much?
Yes
[1]
No
[0]
In the last 2 weeks, have you on some or most days felt down, depressed or hopeless?
Yes
[1]
No
[0]
Yes Refer
[1]
No
[0]
In the last 2 weeks, have you on some or most days had thoughts or plans to harm yourself or commit suicide?* TOTAL SCORE
1 >>>>>>>>>>> no referral 2 >>>>>>>>>>> refer 3 >>>>>>>>>>> refer
Offered counselling
Yes
No
Accepted counselling
Yes
No
* The self-harm question will require urgent referral if there are both thoughts AND plans. If there is a history of previous attempt, referral is required even if there are thoughts alone.
Midwives can play a vital role Women suffering from CMDs need someone who can listen, guide them gently and provide information. They may feel isolated and vulnerable, and need to be encouraged to make social connections and form support systems. Once detected, the management of CMDs should be based on these five principles: 1. Empathic care All women benefit from empathic care. Empathic engagement includes creating a safe, caring environment, actively listening, being respectful and non-judgemental, providing the opportunity to explore possible solutions. Pregnant women suffering from emotional distress should hear: • You are not alone • You are not to blame for how you feel • There is help available 2. Psycho-education Psycho-education involves providing information about mental health and mental illness in an understandable way, and providing options for how she can manage her situation. 3. Early treatment Early treatment reduces the risks for both mother and child. The first line of treatment for mild to moderate CMDs would be one of the talking therapies, such as problem-solving therapy, cognitive behavioural therapy and interpersonal therapy. For women who do not
respond to talking therapy or those with moderate to severe CMDs, more specialised care, including medication, may be needed. Antidepressants (particularly the selective serotonin reuptake inhibitors, or SSRIs) may be prescribed for pregnant and breastfeeding mothers. They have been considered relatively safe compared to the risk for both mother and child of untreated CMDs. 4. Holistic management Holistic management includes assessing the underlying causes or factors that may increase the risk of CMDs. This may include referrals to social or community-based services that offer specific interventions for issues such as food insecurity and domestic violence. Helping a mother to link to supportive social networks could be of great benefit. In making referrals, it is useful to explore with the mother whether she is able and willing to attend. A successful referral does not stop at making a recommendation, but rather needs to be followed up to see if the referral was useful. 5. Suicide risk assessment This calls for immediate referral.
What about the health providers? Health providers who are involved with women around the time of pregnancy and birth play a vital role in the physical and psychological health of these women and their children. The work may be very rewarding but can also be stressful and lead to burn-out. Caring for your own physical and emotional wellbeing is extremely important! See references on page 34
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Pregnancy
Be aware of the commercialisation of ultrasound! Pregnant women need to know that ultrasound screening has been commercialised and is not needed in most instances. We also don’t know about all potential harmful effects long-term. Even though thoroughly tested and retested, prenatal ultrasound screening does not improve outcomes, except for slight improvements shown in questionable studies of Doppler velocity among preterm pregnancies suffering from severe preeclampsia.
Dry, itching or flaking skin To help pregnant women get rid of dry, flaky or itchy skin during pregnancy, a midwife first needs to know what’s causing it. It never goes amiss to enquire what changes took place at the time the symptoms first manifested, because the root cause can then often be more easily tracked. Common triggers of dry, itchy or flaking skin in pregnancy are use of a new skin product, an increase in dairy and processed grain product intake, or sometimes even a pregnancy supplement. Advising mothers-to-be to eliminate these progressively will soon indicate if the cause has been found and corrective steps can be taken.
Pregnant women should distance themselves from prenatal testing and focus on lifestyle improvements. Prenatal care can focus on the 80% of controllable factors: diet, exercise, not smoking, limiting drug and alcohol use, education, being employed with adequate income, lifestyle, family and social support, community safety, environmental safety, housing, water supply and energy supply. Cohain, JS, ‘Prenatal Ultrasound does not improve perinatal outcomes’, 2012. Available: https://midwiferytoday.com/mt-articles/ prenatal-ultrasound-does-not-improve-perinatal-outcomes/
These self-help tips will also assist women with this troublesome symptom: • Use omega-3 plant oils and eat foods that are high in omega-3, like dates, avo, nuts and seeds • Add a pot of rooibos tea to your bathwater and dab cooled rooibos directly onto the area • Apply vitamin E cream or oil that is in a hypoallergenic base • Supplement with zinc, which helps treat rashes and itching Rarely, itching may be linked to the more serious condition obstetric cholestasis, which can be suspected if a woman experiences severe itching on her hands, soles of her feet and abdomen, and later the rest of her body; if she feels very nauseous; her urine is dark and her stools are light; she has pronounced oedema; or if her skin seems jaundiced.
Harmful PFAS chemicals pass through the placenta PFAS (perfluoroalkyl substances) chemicals are widely used in consumer products – in clothing, cleaning agents, frying pans, food packaging, and more. Focusing on six of these PFAS substances, Swedish researchers discovered all six in fetal tissue and the placenta. ‘So, when the baby is born, it already has a build-up of these chemicals in the lungs, liver, brain, and elsewhere in the body,’ said Richelle Duque Björvang, doctoral student at Karolinska Institutet’s department of clinical science, intervention and technology. More research on the long-term health effects of everyday chemicals is sorely needed. Mamsen, LS, ‘PFAS chemicals passing through the placenta into the foetus’, 13 February 2019. Available: https://www.medicalbrief.co.za/ archives/pfas-chemicals-passing-placenta-foetus/
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Issue 43
Pregnancy
From your first moments together, South Africa’s leading baby hyper is with you every step of the way.
Morning sickness linked to better mental development Moms suffering from severe morning sickness, and perhaps worrying if Baby is getting sufficient nutrients, will be reassured to know that a small Canadian study has tied pregnancy nausea to better mental development. Testing 121 children, researchers discovered that those whose mothers had suffered morning sickness scored higher on IQ, memory and language tests. Hartnett, J, ‘Study finds mums who suffer from pregnancy sickness tend to have kids with higher IQs’. Available: https://www.healthymummy.com/mums-sickness-tend-kids-higher-iqs/
Vitamin B6’s role while expecting The advice to supplement vitamin B6 to help relieve mild pregnancy nausea is still supported by research, but the World Health Organization clearly revokes any suggestion that it can assist in the prevention of preeclampsia and premature birth, stating that there are no substantiated claims that vitamin B6 can improve either maternal or infant outcomes. However, folic acid belongs to the vitamin B group too, and its importance in pregnancy is well-established. The water-soluble vitamin B6 (or pyridoxine) cannot be seen in isolation from the other B vitamins, and is also unlikely to have exclusive deficiency. Fortunately, many plant foods are vitamin B6-rich: sweet potato, bananas, avocado, potato, tofu, spinach, peas, mango and pineapple, as well as various lean meats and fish. The WHO always urges that dietary intake of nutrients should be the first-line approach. Whitbread, D, ‘Top 10 Foods Highest in Vitamin B6’, 9 April 2019. Available: 'https://www.myfooddata.com/articles/foods-high-invitamin-B6.php
•
World Health Organization, ‘Vitamin B6 supplementation during pregnancy’, e-Library of Evidence for Nutrition Actions (eLENA). Available: 'https://www.who.int/elena/titles/vitaminb6-pregnancy/ en/
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www.babycity.co.za 52098 Fire Tree e&oe
•
Birth
Looking back at
natural birth in South Africa In Part 1 of this topic, Sensitive Midwifery writer Kelly Norwood-Young considers South Africa’s unique history and how this impacted natural birth.
T
he history of natural birth in South Africa is intrinsically tied to the history of midwifery and as such, the history of the country itself. It’s a tale of hugely discrepant worlds, parallel but antagonistic systems, and vastly different approaches to birth. While there is little documentation regarding the way that births were conducted prior to the arrival of the Dutch in 1652, we know via oral history that women of the tribe, mothers and grandmothers, acted as midwives to labouring women. Midwifery skills were developed with experience, and knowledge of herbs was passed on through the generations. Official historical records of midwifery in South Africa begin with Henrietta Stockdale who arrived as a missionary in 1874 and worked to legalise nurse/midwifery training. By then, medical missionaries had set up numerous missionary hospitals in the country, and towards the end of that century, South Africa was the first country
in the world to register a nurse-midwife (Sister Louisa Jane Barrett) and officially recognise the legitimacy of the profession. Importantly, we must acknowledge the colonial and medical bias of much of midwifery’s documented history, and the consequent loss of knowledge about truly natural birth customs and practices.
That 20th century trend In her online blog article ‘Midwifery and apartheid in South Africa’, midwife Marianne Littlejohn also reflects on the cost of colonialism, and reminds us that Western medicine should not automatically, and sometimes erroneously, be considered superior, nor confused with evidence or scientific research. She implores midwives to ‘be the guardians of a birthing woman’s inner wisdom’. Broadly, South Africa’s documented history of natural birthing, particularly in the 20th century, mirrors that of the Western world. The decline of home births in favour of the hospital setting, Continued on page 13
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Birth
where the obstetric doctor took charge, was a trend that emerged in many developed and developing countries. By the 1960s, most South African women gave birth in hospitals (according to the history books anyway), as this was viewed by the medical world as the safest place for birth. Since independent midwives were not permitted to practise in either the private or public sector hospitals, midwives in hospitals were soon regarded as obstetric nurses who worked under the obstetricians.
Home and hospital births during apartheid By the 1970s, South Africa’s racial segregation and escalating economic stratification continued to influence health care, extending to care providers’ approach towards natural birth. Interestingly, it was the white population who seem to have been at a natural birth disadvantage as the business and medical models increasingly took over in predominantly white-used private hospitals; whereas in the state hospitals (increasingly patronised by all other racial groups), midwives played a more prominent role, ensuring that more vaginal births took place. Home birth was also still common in townships. Mona McAlpine, a midwife who lived and worked in South Africa for 50 years, remembers her early experiences of natural birth in the country, having arrived from the UK in 1969. Less than a month after she arrived, she was employed at Noordgesig Clinic, a coloured clinic on the border of Soweto. For women in the townships, most births happened at home with very little need for intervention, says Mona. Mona was on maternity leave after having her own baby when the Soweto Uprisings took place in 1976, and in 1977, she began working at the Marymount – a private ‘white’ hospital. Mona, having witnessed births in Soweto, where the majority were natural, was shocked – the difference between the two settings was stark. At the Marymount, she says, a truly natural birth was rare: ‘If a normal, natural
birth did take place, it was because the mom couldn't hold back the urge to push her baby out.’
Economic birth disempowerment ‘Inductions were the order of the day. I remember one Saturday having 11 women sitting in the waiting room of the labour ward, all with Syntocinon drips … To be fair, some women did need induction, but many inductions were done for the doctor’s convenience. Then, of course, many of these inductions did not do the trick because the cervix was not ready, or they were done far too early – sometimes routinely at 38 weeks – and a premature baby would be delivered, or the failed induction would end up as a caesarean section,’ shares Mona. Other, often unnecessary or otherwise harmful interventions were common too: ‘Shaving of the vulva, enema and episiotomy were routine procedures. IM pethidine was the preferred pain relief in labour. Mothers were delivered on their backs, often with their legs in stirrups.’ She notes that ‘the Marymount was no different from the rest of the private maternity sector in South Africa’. For private patients, it was ‘the doctor’s responsibility to deliver the baby. Doctors were fed up if we called them too soon or too late,’ says Mona. This was very different to state hospitals where, as midwife Marilyn Sher remembers, ‘midwives did all the births’. Now an independent midwife with her own practice, Marilyn qualified in 1973 and worked in the state hospitals during her early days of midwifery. Here, ‘mothers were given one-on-one care by midwives’, who only called a doctor if there were problems. Vaginal birth without intervention was still considered normal in state hospitals and Midwife Obstetric Units (MOUs), and tearing seldom happened as ‘midwives were trained on how to guard the perineum and allow slow delivery of baby’. Still, Marilyn recalls that ‘mothers were not allowed to get off the bed and move around’ and ‘were always on their backs’. Continued on page 14
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Birth
Making an active change Marilyn remembers how, in the early 1980s, one doctor working at the then Johannesburg General Hospital (nicknamed Joburg Gen) and then Coronation Hospital ‘started to think out the box and look at what was happening in the rest of the world’. He opened the first active birth unit at the Joburg Gen: in a calm, low-light environment, women could move around and were even given the option of a water birth. At the Marymount, Mona, who by then had become Assistant Matron, set up one of the first private active birth units in the country in the early 1990s. She recalls: ‘Midwives in private practice made use of this unit with its birthing pool. In no time, women got to know and love it. This unit was next door to the labour ward, and we had a few doctors we could call on if intervention was necessary. There was little in the way of objection, though I recall one doctor storming into my office: “You are taking away my bread and butter,” he roared at me.’
Variable conditions continue In the 1990s, healthy women in private care were generally still ‘subjected to routine procedures, such as enemas, restricted oral intake, intravenous therapy and episiotomies, with no evidence of effectiveness’, according to one 1998 journal article. In private hospitals, many labouring women had epidural or spinal analgesia, and C-section rates were between 45–80%. However, those who chose to deliver with the support of a private midwife, mostly had active labour and births. Water baths, upright positioning and mobilisation were used for pain relief, although some midwives did offer pethidine or nitrous oxide and oxygen (‘Entonox’). In state hospitals throughout South Africa, midwives continued to provide primary care for all low-risk pregnancies, and many of these did sterling work. Epidural or spinal analgesia were not usually available. Though C-section rates
were incredibly low (6.8% in some hospitals), overcrowding meant that women could have to wait as long as three hours for the emergency procedure. Unfortunately, diminishing midwifery education standards and resources, and increasing medicalisation of birth, gradually eroded the quality of birth care provided in state facilities. As the author of the 1998 journal article insightfully noted, ‘As varied as the Rainbow Nation of South Africa is, so variable are the conditions under which midwifery is practised.’
The more things change … Looking back at South Africa’s birth practices, the trajectory towards increased intervention and higher C-section rates is clear. Today, C-sections appear to have become the norm for most private patients, with one recent 2019 report revealing that 74% of babies born to members of Discovery medical scheme are delivered via C-section. This is almost three times the 26% national average for public hospitals, where elective C-sections are not offered, but where C-section rates are still high, particularly when compared to the World Health Organization’s recommended 10–15%. And yet, while these figures may cause natural birth advocates to feel despondent, there is also much to celebrate. Not only are there more active birth units around the country than ever before, but as more and more women (encouraged by birth stories and evidence available to them online) seek out birth practitioners who support and trust their innate ability to birth, the culture of birthing in South Africa is beginning to change. As Marilyn Sher reflects, ‘In the new millennium, support for midwives has increased many-fold and there are a lot more midwives working independently now.’ Part 2 of this topic, in the October 2019 edition of Sensitive Midwifery Magazine, will take stock of the various natural birth trends in South Africa, and factors that might influence the future of birth in the country. See references on page 34
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Birth
Birth
review Safer home births with standardised bags
A UK mother and baby charity, Baby Lifeline, has worked to develop a standardised equipment bag for community midwives attending home births. The rucksack-style bag contains everything they may need, including emergency equipment. Follow the link to find out more.
Woman-centred care linked to fewer second-degree tears A study from Sweden looked at strategies care providers can use in the second stage of labour to improve health outcomes. Midwives treated 296 first-time mothers with a three-part protocol called ‘woman-centred care’ and 301 first-time mothers with standard care. The group that received womancentred care used spontaneous pushing (pushing efforts were not coached or directed); flexible sacrum birthing positions (kneeling, standing, hands-andknees, side-lying, birth seat); and birth of the baby’s head and shoulders in two separate contractions. The midwives who practised standard care didn’t receive any special instructions. The researchers determined that the odds of seconddegree tears were less likely in the people who received woman-centred care compared to those who received standard care. However, since this was a three-part protocol, it’s not known which part of the protocol contributed to the fewer second-degree tears. Sensitive Midwifery imagines that any and all woman-centred care will improve birth outcomes, including the incidence of perineal tearing! Edqvist, M, et al, ‘Birth. Midwives’ management during the second stage of labor in relation to second-degree tears – an experimental study’, Birth, 2017, 44(1), 86-94
Betteley, C, ‘Home births: Community midwives trial “delivery bags”. Available: https://www.bbc.com/news/uk-wales-47452372
Don’t go with the ‘ARRIVE trial’ A 2018 article about ‘A Randomized Trial of Induction Versus Expectant Management’, also referred to as the ‘ARRIVE trial’, claims that induction of labour at 39 weeks has better outcomes for mother and baby compared to going into labour naturally. This is despite findings and recommendations to the contrary by none less than the University of Copenhagen (specifically about timing of induction) and the American College of Obstetricians and Gynaecologists (regarding updated classification of gestational full term). Low-risk births have better outcomes when they are allowed to proceed with minimal medical intervention. Take care not to fall into the trap of medicalising the birth process and changing protocols based on one-sided research. •
Cohain, JS, ‘More evidence to avoid hospital birth: a critique on the results of the arrive study’. Available: https://midwiferytoday. com/mt-articles/more-evidence-to-avoid-hospital-birth/
•
The American College of Obstetricians and Gynaecologists Committee on Obstetric Practice & Society, ‘Definition of Term Pregnancy’, 2013 (reaffirmed 2017). Available: https://www.acog. org/Clinical-Guidance-and-Publications/Committee-Opinions/ Committee-on-Obstetric-Practice/Definition-of-Term-Pregnancy
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Birth
Push-started Sensitive Midwifery Magazine asks, is this how birth is supposed to be?
T
he most common form of pushing in labour is directed pushing. Women are instructed to start pushing as soon as they are fully dilated and hold their breath when a contraction begins, pushing as hard as possible while the midwife sets a particular rhythm. After a quick breath, they do it again, aiming for at least three pushes per contraction. However, this approach is outdated and potentially harmful to women, infants, and natural birth itself.
Dangers of directed pushing Directed pushing started in an attempt to speed up the second stage of labour, because a prolonged second stage was deemed dangerous. Studies have since found that directed pushing does not shorten labour; instead, it: • Increases chances of perineal tears, episiotomies, post-birth urinary problems, and forceps or vacuumassisted birth
Because a woman who feels rushed, and directed against her instincts, often panics and tenses up, labour progresses less well.
Spontaneous pushing Once fully dilated, women wait until they feel the urge to push; resting and relying on contractions to keep Baby moving down the birth canal. Instead of midwives timing pushes, women push whenever and however they like, based on their bodies’ natural urges. They are also encouraged to keep breathing while pushing. Spontaneous pushing enables better labour progress, despite a potentially slower process. Mom and Baby recover between contractions. Midwives can work with moms’ bodies by: • Helping women change into upright positions while pushing
• Decreases oxygen for Mother and Baby due to breath holding
• Advising women to push using their abdominal muscles and pelvic floor instead of their upper bodies
• Limits blood flow to the placenta
• Reassuring women that it is normal for Baby’s head to crown and then disappear again
• Fatigues women because pushing starts before Baby is low enough • Disregards women’s instincts and sabotages a gentle birth
• Encouraging women to breathe during contractions and not hold their breath for longer than six seconds at a time • Letting women feel Baby’s head or see it using a mirror if they need some encouragement Continued on page 17
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Issue 43
Birth
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Understanding the transition stage
The transition phase of labour – where the rim of the cervix moves away – may overwhelm women. It either takes the form of a few intense contractions at the end of the first stage, or a brief rest period before the second stage begins. It is the shortest but hardest stage of labour, and many women grow agitated, tremble, and become nauseous.
NASG Saving Mothers Lives
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During transition, women need you to be their champion, encouraging them and reassuring them that this phase only lasts a few minutes, and that their body now does everything automatically. To assist women during this stage, advise them to: • Squat, crouch, or kneel on all fours while rocking to support the womb’s activity
What is the NASG? The NASG, a Non-Pneumatic Anti Shock Garment, is used to manage shock and postpartum haemorrhage (PPH) in birthing mothers.
• Grunt and focus on breathing to ease the urgeEC0F746G9&?C6G&@=-9H&A4.70C6&F10/&6-&74C4I0&1=-9H&4C/&3-1634.6F7&=407-..=4I0& to push This first aid compression device can stabilise the patient for up to 72 hours until receipt of definitive medical and surgical interventions.
<=G1&NG.16&4G/&9-73.011G-C&/0OG90&94C&164MG5G10&6=0&346G0C6&N-.&F3&6-&*%=-F.1&FC6G5&.090G36&-N&/0NGC • Vomit if nauseous – this often provides relief The garment is lightweight, washable and reusable up to 144 times. It is
1F.IG945&GC60.O0C6G-C18&<=0&I4.70C6&G1&5GI=6;0GI=6B&;41=4M50&4C/&.0F14M50&F3&6-&P##&6G7018&Q6&G1&N50R flexible and comfortable and need not be removed to conduct patient 9-7N-.64M50&4C/&C00/&&C-6&M0&.07-O0/&6-&9-C/F96&346G0C6&0R47GC46G-C1B&3.-90/F.01&-.&4M/-7GC45&1F.I0.S8
If contractions cease during transition, encourage moms to lie down and rest until the second stage starts spontaneously.
examinations, procedures or abdominal surgery.
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How does the NASG work? The NASG is put in place by a trained medical professional by strapping the device on to the patient. Once on, the NASG applies sufficient <=0&>?@A&G1&3F6&GC&35490&MS&4&6.4GC0/&70/G945&3.-N011G-C45&MS&16.433GCI&6=0&/0OG90&-C&6-&6=0&346G0 circumferential counter pressure onto the lower body and uterus. This /0OG90&4335G01&1FNNG9G0C6&9G.9F7N0.0C6G45&9-FC60.&3.011F.0&-C6-&6=0&5-;0.&M-/S&4C/&F60.F18&<=G1&GC9.0410 increases circulating blood and blood pressure to the heart, lungs and M5--/&4C/&M5--/&3.011F.0&6-&6=0&=04.6B&5FCI1&4C/&M.4GCB&GC&0NN096&/09.041GCI&M5--/&5-11&4C/&.0O0.1GCI&=S brain, in effect decreasing blood loss and reversing hypovolemic shock.
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and low resource settings in ;;;8304.5160789-8:4 Asia, South America and Africa (Nigeria, Kenya, Zambia, Zimbabwe) where PPH is the leading cause of maternal mortality. The NASG has been piloted in South Africa, in 2018, with great success.
FAQ ’s
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How do you clean the NASG? - In .01% chlorine bleach solution. How long does it take to put the NASG on? - Approximately 2 minutes. How long does the NASG last? - At least 144 uses.
084 524 3994 / 074 604 0656 0864350027 eSensitive Midwifery Magazine
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www.pearlstem.com Issue 43
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Mom & Baby
The Kangaroo Care story Internationally renowned Head of the KMC Unit at Kalafong Hospital in Pretoria, Dr Elise van Rooyen, shares KMC’s history and value.
M
aternal-infant skin-to-skin contact and Kangaroo Mother Care (KMC) for low-birth-weight (LBW) infants was initiated by doctors Rey and Martinez, in Bogotá, Colombia in 1979. This was prompted by shortages of staff and equipment, an unacceptable high mortality and infection rate in their neonatal unit and the burden of a large number of infants who were abandoned by their mothers. Infants who were considered for this regime were LBW infants in stable condition. This decreased overcrowding in the incubators as well as in the neonatal unit, and the infection and mortality rate decreased dramatically. It also improved mother-to-infant bonding with a reduction in abandoned infants. KMC consists of kangaroo position, kangaroo nutrition and kangaroo discharge, which is underpinned by a supportive environment in the healthcare facility and at home: • Kangaroo position refers to the nursing of a LBW infant skin-to-skin on the mother’s chest. • Kangaroo nutrition aims at establishing exclusive breastfeeding. • Kangaroo discharge is possible once the infant is feeding satisfactorily and weight gain is maintained, much sooner than current practice. In the words of the Bogotá Declaration of 4 December 1998: ‘KangarooMother Care should be a basic right of the newborn, it should be an integral part of the management of low birth weight and full term newborns, in all settings and levels of care in all countries.’
KMC benefits everyone While the benefits to the hospital include significant cost-savings, improved staff morale, better survival and improved quality care, the benefits to Mom and Baby are especially heartening. Benefits to the baby: • Maintenance of adequate body temperature • More quiet sleep periods • Fewer energy-consuming movements, resulting in satisfactory weight gain • Increased initiation and duration of breastfeeding with more infants receiving exclusive breastfeeding • No additional risk of infection and reduction of the occurrence and severity of nosocomial infections Continued on page 19
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Mom & Baby
Benefits to the mother: • Increased sense of bonding with her infant • Increased confidence in caring for her infant • Continuation of her interrupted nurturing role as a mother and the empowerment to become the primary caregiver again
KMC’s South African story
The rollout of KMC at Kalafong The ward space that was allocated used to be a paediatric ward and the bathroom facility was not adequate for a large number of mothers. Still, while waiting for the structural changes that were necessary to practise KMC, the implementation process continued with educational and information sessions about KMC and its benefits.
The first KMC unit in South Africa was opened in 1997 at Grootte Schuur Hospital, Cape Town after a clinical trial conducted in 1996 convinced the hospital management of the advantage of opening such a unit. Kalafong Hospital, a Pretoria provincial tertiary teaching hospital serving a mainly black urban indigent population, is now synonymous with KMC in South Africa. It is a referral hospital and manages high-risk pregnancies, and a large number of high-risk preterm and LBW infants are delivered annually. In the late 1990s, due to limited number of step-down beds, increased numbers of high-risk preterm and LBW infants, outbreaks of severe nosocomial infections in the HCU and the general lack of resources and equipment, it became necessary to consider an alternative method of caring for the infants at Kalafong Hospital. Much research on the best way to implement KMC was done with the assistance of the Medical Research unit situated at Kalafong Hospital under the guidance of Professor Bob Pattinson.
KMC requires a paradigm shift from conventional nursing practices of washing, cleaning and feeding to a supportive role where the mother is assisted and supported to become the primary caregiver of her infant. The campaign for KMC implementation and establishment of a unit at Kalafong Hospital was launched in January 1999. After role-players (hospital management, medical, nursing, general administrative and supportive staff) attended a general information session about KMC and its benefits, everyone was enthusiastic about the change. A multidisciplinary KMC implementation workgroup was established. Needs and resources for a KMC unit were identified and hospital managers gave their full co-operation in providing facilities for the establishment of a unit. The hospital managers allocated ward space in a ward that also housed the existing low-care stepdown unit for stable preterm infants. The existing nursing staff took over the responsibility for the running of the KMC unit.
The KMC ward at Kalafong Hospital Successful implementation could not take place before all the medical and nursing staff involved had received a thorough grounding in the new intervention. The nursing management’s full commitment to the cause and support of the nursing staff was also of vital importance. The implementation process was open and transparent, which enabled the nursing staff to take part in the decisionmaking process and take ownership of the KMC concept. A philosophy was developed, noting that: • KMC should be conducted in a caring environment • The staff of the unit should be empowered by continual education and skills development to help mothers become the primary caregivers of their infants • The rights of the mothers, which include respect, honesty, openness, transparency and informed decisions, should be considered at all times and be an essential part of the patient care in the unit After opening the unit on 6 July 1999, formal written guidelines and policies were developed by consensus for each role-player to enable a uniformity of care in the unit. These policies ensured consistent, standardised methods of assessment, progression of care, and management of the unit so that the full benefit of KMC could be experienced. Since the implementation of KMC at Kalafong Hospital, the flow of patients between the High Care (HCU) and KMC units improved. This relieved the pressure for beds in the HCU, allowing for more infants to be accommodated in the HCU since 1999.
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Issue 43
Mom & Baby
Soothe, Heal & Protect Dr Elise van Rooyen with a KMC mother and baby
Spreading the love Kalafong Hospital very quickly became a centre of excellence for the training and implementation of KMC. • Improves concentration • Relieves stress • Releases energy
Essential vitamins for mom • It’s used by almost every cell in the body and helps to regulate muscle contractions, hormonal release, heartbeat, and blood clotting • With added vitamin D3
For your little one • Boosting the immune system • The treatment of acute and
chronic broncial disorders • Supporting and improving respiratory function in patients with chronic bronchitis
All hospitals in Gauteng have received training at Kalafong Hospital by Dr Van Rooyen and Dr Anne-Marie Bergh, senior researcher at the Medical Research Unit, to enable them to implement KMC in their individual hospitals. Health workers in hospitals from Mpumalanga, KwaZulu-Natal, Limpopo, North West and the Free State have also all received training either on site or off site, and Kalafong KMC unit has had and trained many international visitors over the 20 years of the unit’s existence. Dr Van Rooyen developed a special wrap to tie the babies securely skin-to-skin to the mothers’ chests. This wrap became known as thari, and is being used nationally as well as internationally.
It’s official policy! Over the years, more and more research has found that KMC is a low-tech, high-impact intervention that can save premature infants’ lives. The World Health Organization, UNICEF and other NGO’s promoting neonatal care, such as Save the Children, have committed themselves to the implementation of KMC worldwide. It is now national and provincial policy that all South African hospitals with maternity facilities should provide a room or space for the practice of KMC. Over the past couple of years, Dr Van Rooyen has been contracted by UNICEF New York’s office to provide training for many countries. Some of the training has taken place in the individual country, such as The Gambia in West Africa, Kenya and Iran, while other training of international health workers has been held at Kalafong Hospital. Most health workers have gone home, inspired to attain the same standard of KMC as seen at Kalafong Hospital. eSensitive Midwifery Magazine
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Mom & Baby
steps Advising mothers on otitis media While not strictly respiratory conditions, earache and ear infections are characterised by inflammation and fluid accumulation frequently associated with other upper respiratory conditions. They often follow a persistent cold or other upper respiratory affliction; Baby may have a high temperature; be irritable, with a poor appetite; and night waking will likely increase because congestion and pain are always worse when in the horizontal position. While otitis media is not to be taken lightly, there is much that nursing professionals can assist with to overcome repeated incidents. Advise parents to: • If not breastfeeding, change to an allergy formula or a formula previously found less problematic to address the common trigger of excess mucus. Although special formula milks are expensive, parents save a lot on medical bills. • Take note that grain products like baby cereals are common mucus triggers, as are dairy products like yoghurt and cheese. • Place a covered hot water bottle (not too hot; avoid burns) against the affected side for pain relief. • Let Baby sleep on a lift wedge, or prop yourself up (against pillows or in a rocking chair) with Baby sleeping on you, to ensure better fluid drainage and less pain.
Canny colic cures Not every constant bout of newborn crying is colic. To give mothers insights and tips that result in real solutions, you, their midwife or postnatal advisor must let go of stubborn, outdated ideas, and you need to respect a baby’s individuality! What seems like colic could be a reaction to Baby’s milk formula, or excessive dairy, grains and sugary foods in a breastfeeding mom's diet. Additional symptoms, like skin rashes or mucus, can indicate that digestive discomfort is part of an allergy or intolerance. The answer: get babies breastfeeding, and get nursing mothers to reduce or cut out the food triggers! Also, avoid scheduling feeds – breast and formula babies should feed when hungry! Crying can also have emotional triggers, like a traumatic birth or C-section; being handled by too many strangers – discourage this in the early weeks; and an anxious mother whose baby will pick up on this. Sensitive Midwifery advocates five other tried and trusted strategies to help moms relieve ‘colic’ too: 1. Rock Baby 2. Bath with Baby 3. Walk or dance with Baby 4. Bond with Baby through talking and lots of skin-toskin contact 5. Let Baby co-sleep with you
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Mom & Baby
steps Medical breakthrough for NICU babies
The dangers of baby wipes
Researchers in Chicago have now found a way to monitor vital signs in NICU babies – without all the wires that make care cumbersome and stressful. Dr Amy Paller, who co-led the study, explains: ‘… when you have wires everywhere and the baby is tethered to a bed, it's really hard to make skin-to-skin contact’.
A chemical preservative called methylisothiazolinone (MI), found in baby wipes, can cause an allergic reaction in some cases. The red, itchy, scaly rash is often mistaken for other conditions like eczema, impetigo, and psoriasis – but one study, published in Pediatrics, has found that the allergy is more common than previously realised. Parents can limit exposure by using cotton wool and water, or a damp cloth when at home, and saving the wipes for travel times.
Now, the biosensor stickers – two of which are used, one on the chest or back and another on a foot – allow for more skin-to-skin contact, and more efficient, family-integrated care. The stickers monitor temperature, heart rate, respiration, and blood pressure. The stickers themselves have also been designed for a premature baby’s delicate skin, and are more gentle than traditional tape, sensors and blood pressure cuffs. ‘The strength of the adhesive required to keep our lightweight device on the skin is much lower than that of the kinds of adhesives needed to maintain an interface between a hardwired sensor and an external box,’ says John Rogers, PhD, a bioelectronics expert and the study's co-author. ‘We have seen no adverse side effects in our study, not even a hint of skin injury even in the most frail babies.’
Byrd, C, ‘Doctors warn parents about the dangers of using baby wipes’. Available: https://edrugsearch.com/baby-wipes-doctorwarning/
Singing sessions alleviate PND symptoms
John Rogers has said that American hospitals will likely be using the wireless sensors within two to three years. Hopefully this technology makes it to South Africa speedily!
A recent British study examined 134 mothers with postnatal depression and found that those who engaged in singing sessions with their babies tended to show quicker improvement in symptoms, compared to those who didn’t. These findings are especially encouraging, as singing is a simple, no-cost, no-risk activity that all mothers can try, regardless of location or socio-economic status.
Marcoux, H, ‘New technology could see NICU babies go wireless within two years’, 4 March 2019. Available: https://www.mother.ly/ news/wireless-sensors-for-nicu-babies-coming-in-two-years
BBC, ‘Singing “speeds up” recovery from post-natal depression’, 9 January 2018. Available: https://www.bbc.com/news/ health-42607141
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Breast assurance
No mammary mutation Just improving imperfect information Sensitive Midwifery has long advocated that instinct and intuition are accredited more respect, precisely because ‘evidence’ so often has to be revoked after causing untold harm. We asked Hettie Grove to explain some ‘new’ basics about breast anatomy.
H
ettie Grove is a Specialist Midwife who has been in private practice for 22 years. She is an International Board Certified Lactation Consultant and developer of the South African certified lactation course for students from all the medical fraternities. Hettie is also a wife, mother of two and grandmother of three who believes that she is living her passion and calling.
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Breast assurance
We know that human beings are mammals, and that mammals feed their young with their own milk and yet, nowadays, it has become ‘normal’ to feed our babies with another species’ milk. We are the only mammals to do so. The reasons for this are complex, but I personally believe that the increased normalisation of formula and cow’s milk for human babies, particularly in the past century, has been indirectly influenced by the medicalisation of birth, and with this, poor feeding advice and ‘rules’ that mothers follow from early on. These rules and regulations by institutions interfere with the intuitive process of breastfeeding. While breastfeeding can come with challenges, babies are hardwired to breastfeed and moms are hardwired to respond to their babies’ cries. I do believe that if we did fewer interventions, we would have more breastfeeding mothers.
Surprise! No lactiferous sinus It is a human trait to believe what we believe, to accept what we’ve been taught. At times, it can be difficult to change our minds – even with new evidence that what we thought we knew is wrong. According to Merriam Webster dictionary, a lactiferous sinus is ‘an expansion in a lactiferous duct at the base of the nipple in which milk accumulates’. The Dictionary.com definition is ‘a circumscribed spindle-shaped dilation of the lactiferous duct just before it enters the nipple of the breast’. In the past, many healthcare professions being taught about the anatomy and the physiology of breastfeeding were told that the milk is stored in the lactiferous sinuses under the areola. Anatomy of the normal breast did not receive a lot of attention since Sir Astley Cooper performed dissections of the breast about 180 years ago. These anatomical drawings only changed slightly over the years as more publications were printed, and so we continued to believe that lactiferous sinuses do exist. But with technology comes change and though surprising, we need to acknowledge now that not only are there are no lactiferous sinuses, but that this must have an impact on how we advise mothers about breastfeeding. The long and short of it is simple: our breasts have not mutated; rather, it is our knowledge that has changed.
New research means re-learning In the late 1990s and early 2000s, more research on the anatomy of the breasts emerged as technology developed. In 2005, researchers viewed new dimensions using ultrasound – a non-
invasive, relatively cheap approach to re-examine the anatomy of the breast. This led to groundbreaking discoveries and changed our whole outlook on the anatomy of the lactating breast. Some of the findings from this research were mind blowing: • No lactiferous sinuses exist • The ductal system is comprised of fewer numbers of main ducts than previously thought – the actual number of openings is between four and 18 (previously, we believed it was 15 to 20) • The ducts branch much closer to the nipple than what we thought • Some ducts are very close to the skin surface and therefore they are easily compressible • Compressible ducts do not contain large amounts of milk • The amount of fatty tissue in the breast is variable; a proportion is situated within the glandular tissue • Most of the glandular tissue is within 3cm of the nipple Since medical professionals need to know the normal to be able to depict the abnormal, these findings not only add to our understanding of the physiology but also the pathology of the lactating breast. As a breastfeeding consultant, this research changed my whole outlook on breastfeeding. You think you know it all and then realise you’ve only seen the tip of the iceberg. Now, 14 years later, I continue to be amazed by the world of breastfeeding and how little we know.
Updating our advice With any new information, we, as midwives and healthcare workers, need to really look at our practices. If, as the evidence now shows, there are no lactiferous sinuses, we need to revisit our understanding of a good latch and where the nipple should be in the baby’s mouth to ensure a rapid first milk ejection for optimal drainage of milk. We now know that very little milk is removed before the first milk ejection reflex as the breast doesn’t store milk. Rather, rapid initial sucking action from the baby stimulates milk ejection, which will lead to subsequent milk ejections. The implication of this is that a sleepy baby may not have this rapid sucking action, and the healthcare worker needs to help the mom to establish a good, effective latch as soon as possible to stimulate milk ejection. Continued on page 26
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Breast assurance
When helping the mom to position her hand, knowing that the glandular tissue is 3cm from the nipple and the ducts are superficial, care should be taken so that pressure on the ducts is avoided. This is not only to prevent blocked ducts, but also to make sure the milk can flow freely, decreasing the risks of engorgement and milk stasis, as well as reduction in supply. After all, we also know that fuller breasts make milk slower and conversely, emptying the breast boosts and maintains supply according to Baby’s needs.
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Breastfeeding benefits with accurate information We don’t need any new research to tell us that many women want to breastfeed but very few of them reach their breastfeeding goals, leading to early cessation of breastfeeding. Undoubtedly, anatomy doesn’t change over the course of a century or two. However, human perception can – and the emergence of technology gives us a clearer picture of how the breast works. With this information, we have a duty to help mothers to get the correct information to fulfil their goals.
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It’s so liberating to come to new insights, but never forget to run every bit of ‘knowledge’ or ‘evidence’ past your common sense and intuition too. Chances are we would never have subjected mothers and babies to such harm if we’d believed that Mother Nature had an infallible breastfeeding blueprint. Hettie’s article again underlines the importance of prevention being better than cure!
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Breast assurance
Milky
ways
Ditch the dummy for breastfeeding In 2008 in Brazil, 41.3% of infants up to six months of age were exclusively breastfed (EBF). Over the previous decade, EBF rates had increased by 15.2%, whereas pacifier use had decreased by approximately 17%. A new study has found that the reduction of pacifier use contributed towards approximately one-third of the increase observed in EBF prevalence, suggesting that discouraging dummies may be an effective intervention to promote EBF. Buccini, G, et al, ‘Exclusive breastfeeding changes in Brazil attributable to pacifier use’, PLoS One, 2018; 13(12): e0208261. Available: https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC6300199/
Better birth, better breastfeeding Another reason to delay newborn bathing There are many reasons not to bath a newborn immediately after birth, including improved temperature control, reduced risk of infection, and keeping stress hormones low. A new Cleveland Clinic study from Hillcrest Hospital in Ohio, USA has now also found that delaying a newborn’s bath benefits breastfeeding.
With medicalised birth (which includes interventions like intravenous fluid administration, routine separation of Mom and Baby after delivery, and advice to breastfeed according to a schedule), painful, swollen, breasts are often thought of as ‘normal’. In days gone by, mothers were mostly advised to limit their fluid intake and bind their breasts for postnatal breast pain from engorgement. Nowadays, they are seldom given advice that is of any more constructive help, even if binding isn’t advocated!
Babies whose baths were delayed by at least 12 hours after birth saw an increase in in-hospital exclusive breastfeeding rates, from 59.8% before the intervention, to 68.2% after the intervention. Study author and nursing professional development specialist Heather DiCioccio noted that there are many reasons delayed bathing would benefit breastfeeding, including more time for skin-to-skin.
The normal postpartum fullness of the breasts may be exacerbated by or confused with oedema associated with excessive intravenous fluids during medicalised labour, birth and the immediate postnatal period. While breast oedema and pain will gradually resolve as these excessive fluids drain from the body, the effect on breastfeeding can be very negative, and prevention through enshrining natural birth is really the best option.
Zeltner, B, ‘Breastfeeding rates rise if newborn’s bath delayed, Cleveland Clinic study finds’, 21 January 2019. Available: https://www. cleveland.com/metro/2019/01/breastfeeding-rates-rise-if-newbornsbath-delayed-cleveland-clinic-study-finds.html
Kujawa-Myles, S, et al, ‘Maternal intravenous fluids and postpartum breast changes: a pilot observational study’, International Breastfeeding Journal, 2 June 2015, 10 (18). Available: https://www. ncbi.nlm.nih.gov/pmc/articles/PMC4480510/
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Issue 43
Dimensions
Where
women gather
Margreet Wibbelink contacted well-known North American midwife, Sister MorningStar, to discover the essence of her instinctual birth message.
S
ister MorningStar describes herself as ‘a keeper of a story, a woodland mystic and a preserver of the sacred feminine’. She was only 12 years old when she started her first ‘wimyn’s study group’. She had never read or heard of such gatherings but was just following her heart and soul, so was thrilled to find other girls wanted to gather with her. ‘Womyn’ (plural ‘wimyn’) is the feminist spelling of ‘woman/women’, with the purpose of objecting to its man-derivative. Sister MorningStar would spend lots of time in silence and solitude in the woods and walking the creeks, daydreaming as teenagers do. She describes those times as a fundamental part of her unfolding life, realising even at that young age that women’s issues are important; how closely the body, mind and soul are interconnected; and that healing, peace and happiness come first to the spirit and leave from there first as well. ‘We often die spiritually, long before our bodies die,’ explains Sister MorningStar. Five decades later, she still meets once a week with a circle of women, talking about what is relevant in their lives. In 1993, together with her three daughters, Sister MorningStar moved to a little cottage in the woods of Missouri surrounded by hundreds of acres of Ozark Mountains. This is where the initial circles grew into the well-known community, called ‘MorningStar Community’; in 2018, the community celebrated their 25th anniversary. The women’s circles are still the heartbeat of the community life.
Straight from Sister MorningStar’s heart ‘Please tell South African midwives that the wimyn gather. That the babies are birthed in power and passion and under the moon. That mothers feed them that power through milk from their own bodies and that they can look at the moon and hear the voice of their pack across the big waters. That instinct can be grown and sisterhood can too. May they have strong bodies, lucid minds and clean spirits. ‘To the birth keepers, break the silence, tell the stories, ask the questions, learn from nature, trust instinct, be a believer in what you believe. Thoughts are things. You are queens on your pelvic thrones. What you say, you decree. Think about what you are thinking about. From first to last breaths and all in-between, simple and sacred will preserve the ancient wisdom ways of the sacred feminine. You are the birth keepers. The story tellers.’
Three main MorningStar messages 1. Women need to get together to talk about what is going on in their lives and in their hearts. 2. Women in isolation are trapped, scared, sad, depressed and hopeless – not so much in their circumstances but within. All that changes when they can be with other women and begin to talk openly. 3. What one ‘womyn’ can do, all ‘wimyn’ can do. What one village can do, all villages can do. What I can do, you can do.
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Issue 43
Be calm and
Dimensions
master the menopause Menopause must rank as one of a mid-life midwife’s least favourite things; remember, help is at hand and the symptoms will pass one day, reminds Sister Lilian.
O
estrogen does not totally disappear from a woman’s system at menopause. Though the prime manufacturer of oestrogen, the ovaries, may cease functioning then, about 40% of previous levels are produced by the adrenal glands and fat cells. Menopausal symptoms may also be linked to synthetic oestrogen dominance, rather than falling natural levels. No matter the cause, they’re not very nice when you’re in the middle of a work shift, helping a heavy-breathing woman through a contraction! What’s more, symptoms often disturb a midwife’s much-needed sleep, leading to the infamous irritability of menopause. This may just be
the straw that breaks the camel’s back in a busy, stressful work environment.
In the heat of the night Despite much research, hot flushes (or flashes) and night sweats are poorly understood. Women who experienced more adolescent menstrual challenges and premenstrual syndrome, or have a rather tense nature, have a greater tendency. Hot flushes seemingly come from nowhere, although women often feel intensely cold just before a flush. The hottest sensations are over the breast bone, the back and the head. They mostly last no longer than two or three minutes, and are more frequent at night, with clusters of flushes in the early evening and morning.
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Palpitations, memory loss and vaginal dryness
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A racing heartbeat felt in the chest is common in the menopausal years too. Anxious women may become rather frightened, though menopausal palpitations are seldom of any significance. Breathe deeply and slowly through them, and rest for a while if you were exercising. If they don’t pass soon or if they make you feel ill, you may need to be checked to see if there is another cause. Decreased oestrogen may be linked to memory loss, but then general ageing is too! Research shows that the link between menopause and memory loss is in fact very tenuous. Use techniques like lists, memory games and actively concentrating, and you’ll likely have far less menopausal memory loss! When you’re feeling down, think of how much you do remember! Vaginal dryness is one of the most common and troubling menopause symptoms, affecting as many as 80% of women. Supplement essential fatty acids to help alleviate this and apply Vitamin E cream. Regular sexual activity may in fact also decrease vaginal dryness, research now shows – which is comforting for those who thought that a satisfying love life is over after the menopause. There are also very effective lubricants available to ease intercourse.
Self-help tips VITAMIN B’S
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Hormone replacement therapy (HRT) may seem to be the surest way of stopping menopause symptoms in their tracks, but there are so many potential adverse effects, and times when HRT is not suitable, that many women are keen to try alternatives. These nine may well help you: • Add antioxidants and soy (a natural plant oestrogen) to your diet – make sure the soy is as unprocessed as possible and stick to dosage advice. • Regular cardiovascular exercise is linked to fewer or less severe symptoms and will help to improve sleep too – walk, jog, swim or dance. • Having a fulfilling relationship that includes satisfying lovemaking releases hormonal responses that can curb imbalances. • Actively decrease animal produce in your diet, especially if it has been hormone-treated. • Minimise the use of environmental, medicinal and dietary exposure to substances that affect the endocrine system, like some detergents, cosmetics, contraceptives and foods treated with hormone preparations. • Play the flushes down in your mind, calling them ‘warmings’ rather than flushes – the power of the mind is amazing. • Wear light cotton or no nightwear; use bedding that is easy to throw off; place a towel on your pillow at night; keep a thermos of ice-cold water at hand to sip from; and hold a small ice pack against your sternum when a flush strikes. • Stop smoking and decrease alcohol intake as both of these contribute to greater incidence of symptoms. • Relaxation therapies have been shown to decrease the severity and frequency of symptoms – such as yoga, meditation and breathing classes. eSensitive Midwifery Magazine
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Reflections SANC Fraud Hotline Did you know that the South African Nursing Council (SANC) has a hotline to report any unethical or fraudulent practices? SANC is asking all midwives and nurses not be silent observers of practices that erode the values SANC wants to uphold. If you come across any fraud, theft, corruption, financial mismanagement, or examination and registration fraud, do not remain silent. Callers to 0800 201216 are guaranteed anonymity and the Call Centre is manned on a 24-hour basis.
Partner violence during pregnancy Rates of violence against women are reported to be highest in Africa compared to other continents. A recent study, done among pregnant women in a low-resource setting in Cape Town, focused on determining associations between mental illness, demographic, psychosocial and economic factors with experience of intimate partner violence (IPV), and exploring the contextual elements pertaining to domestic violence. Results show that adversity, including food insecurity and mental ill-health are closely associated with IPV during the antenatal period. The study also points out that advocates against violence against pregnant women should consider that violence in the home may be perpetrated by non-intimate partners too, possibly enabled by a pervasive belief in the acceptability of the violence. Field, S, et al, 2018, ‘Domestic and intimate partner violence among pregnant women in a low resource setting in South Africa: a facilitybased, mixed methods study’, BMC Women’s Health, 18:119-132
Antihistamines affecting male fertility While antihistamine use has been on the rise, correlating with the rise of allergies in the industrialised world, scientists warn that histamines (which are released in response to an allergy) also have other important roles to play in the body – from healthy sleep to sexual behaviour and fertility – and the drugs should be taken only when truly necessary. Reviewing several antihistamine drug studies in animals, Argentinian researchers at the Instituto de Biologia y Medicina Experimental in Buenos Aires have noted that the drugs could affect male fertility negatively in the long term by influencing testicular production of male sexual hormones. This, in turn, could cause altered morphology and decreased motility of sperm, as well as a lower sperm count. At this stage, doctors and researchers have cautioned against overuse, but note that it’s still too soon to know to what extent the medication impacts male sexual health. Study author Dr Carolina Mondillo said: ‘More large-scale trials are needed … This can then lead to developing novel treatments to relieve allergy symptoms without compromising fertility.’ Prof Darren Griffin, professor of genetics at the University of Kent, said: ‘Any medicine that has the potential to do good also has the potential to do harm and side effects of over-the-counter drugs constantly warrant further investigation,’ going on to note, tongue-in-cheek, that ‘persistent sneezing is not a particularly good reproductive strategy either …’ Guardian, ‘Antihistamines linked to fertility problems in men’, 9 March 2018. Available: https://www.theguardian.com/society/2018/mar/09/ antihistamines-linked-to-fertility-problems-in-men
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Johannesburg May 2019
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KEY RESEARCH REFERENCES IN ISSUE 43 The importance of mental health during pregnancy – page 6 • Field, S, et al, ‘Maternal Mental Health: a guide for health and social workers’, Bettercare, 2018. Available: http://bettercare.co.za/learningprogrammes/maternal-mental-health/ • Turner, RE, et al, ‘Maternal mental health and the first 1 000 days’, South African Medical Journal, 2016, 106(12):1164-1167. Available: http://www.samj.org.za/index.php/samj/article/ view/11610/7758 Looking back at natural birth in South Africa – page 12 • Grant, L, ‘This map tells you which districts have the highest c-section rates’, 9 January 2019. Available: https://bhekisisa.org/article/2019-0109-00-which-south-african-health-districts-havethe-highest-rate-of-caesarean-sections/ • Littlejohn, M, ‘Midwifery and apartheid in South Africa’, 17 September 2014. Available: http:// www.spiritualbirth.net/midwifery-and-apartheidin-south-africa • Nikodem, C, ‘Midwifery in the Rainbow Nation of South Africa’, Midwifery Journal, 1998, 14(1), 1–3. Available: https://www.midwiferyjournal.com/ article/S0266-6138(98)90107-3/pdf • Wasserman, H, ‘The C-section rate among Discovery members is now up to three times higher than at American celebrity hospitals – here’s why’, 20 April 2019. Available: https:// www.businessinsider.co.za/discovery-c-sectionsnatural-births-2019-4 • Wikipedia, ‘Midwives in South Africa’. Available: https://en.wikipedia.org/wiki/Midwives_in_ South_Africa
Book now for Bloemfontein: 25 July 2019 Cape Town: 17 October 2019
No mammary mutation – page 24 • Geddes, D, et al, ‘Anatomy of the lactating human breast redefined with ultrasound imaging’, J Anat, 200, 206(6): 525–534 • Nickell, WB, et al, ‘Breast Fat and Fallacies: More Than 100 Years of Anatomical Fantasy’, Journal of Human Lactation, 2005, 21(2), 126–130. Available: https://doi. org/10.1177/0890334405276471 • Ramsay DT, et al, ‘Anatomy of the lactating human breast redefined with ultrasound imaging’, J Anat, 2005, 206(6), 525–534. doi:10.1 111/j.1469-7580.2005.00417 • Riodan, J, et al, Breastfeeding and human lactation (5th ed.), Jones and Bartlett Learning, 2016 • Sakalidis, VS, et al, ‘Suck-swallow-breathe dynamics in breastfed infants’, Journal of human lactation, 2016, 32(2): 201–211 • Walker, M, ‘Influence of the infant’s anatomy and physiology’ in Breastfeeding Management for the Clinician: Using the Evidence, Jones and Bartlett Learning, 2014. Available: http://samples. jbpub.com/9781449694654/9781449694654_ CH03_131.pdf
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Last word:
The revival of the birth chair
Order Sensitive Midwifery’s birth stool online
Birthing aids have been used throughout midwifery history to support the mother, and one famous one was the birthing chair or stool, explains Margreet Wibbelink.
A
study of the history of birth shows that women gave birth in many different ways over the eons, and that upright birthing positions such as standing, squatting and kneeling were by far the norm for most of those years, rather than a fringe behaviour. A birthing stool helps women to maintain a squatting position more easily, and so facilitates upright birthing while still offering the birth benefits from the force of gravity. Studies have shown that use of the birthing chair allows for a satisfactory birthing method and does not increase any risk for the mother or the baby, unlike recumbent birthing positions. Furthermore, it has also been found that there is less cord compression, as well as significantly lower rates of episiotomy in all upright positions.
Pull up a chair – are you birth-stool-ready? Most South African midwives and birth workers will never have seen a birthing stool, let alone helped a mother to birth using one. But Sensitive Midwifery believes that there is new awareness among women and birth workers about the value of birthing upright and naturally, and that they would be keen to use a birth stool! One mother wrote to us about her experience of birthing her baby on a stool:
‘When my body started bearing down by itself it was an incredibly intense feeling, and was something I couldn’t control. I was very tired by then and lay on my side to rest, but I was very uncomfortable in that position and I remember thinking that I couldn’t do this anymore … I had read in another woman’s story that she knew that when she felt she couldn’t go on, that meant that her child was close to being with her. This gave me strength and I moved onto the birthing stool. I didn’t want to be on my back or side, but lacked the strength to stay in a squatting position. The stool held me up and took the pressure off my legs. I could also push down on the stool to help me hold my contractions for longer. I loved that from the stool I could reach down to receive my baby and bring her to my chest myself.’ Sensitive Midwifery has commissioned the design of a beautiful birth stool that can be used in any setting, whether state or private, hospital or home. Excitingly, it can be used on a bed as well – no more excuses about visualisation or backache, colleagues! Order it online at www.sensitivemidwifery.co.za or send an email to info@sensitivemidwifery.co.za. Scholz, HS, et al, ‘Spontaneous Vaginal Delivery in the Birth-Chair versus in the Conventional Dorsal Position: A Matched Controlled Comparison’, PubMed, 2001. Available: http://www.ncbi.nlm.nih.gov/pubmed/11603105
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