Valerie Gommon Midwife’s Blog

Archive for the ‘WHO’ Category

This is a guest blog written by Sarah Ward.

 Homebirth & PPH

Women often worry about what would happen if a woman bled heavily after a home birth. Throughout history, severe blood loss has been one of the main causes of women dying in childbirth, and it remains the most common cause of maternal death in the world [WHO, 1994].

Efficient management of postpartum haemorrhage is one of the wonders of modern obstetrics. The key is the availability of oxytocic drugs, which make the uterus contract down and normally stop bleeding.

You can choose to have either a ‘managed’ or a ‘physiological’ third stage, at home or in hospital. A ‘managed’ third stage means you have an injection of syntometrine as a precautionary measure. A ‘physiological’ third stage means you take a ‘wait and see’ approach to the delivery of the placenta, and only have drugs if you are worried about bleeding or if the placenta is taking longer than you want to wait for it to turn up

Sometimes one hears of doctors trying to dissuade women from home birth because of the risk of postpartum haemorrhage yet in fact severe bleeding after a home birth in the UK is rare, and postpartum haemorrhage is usually managed at home or by transfer to hospital. Despite the fears of some doctors, you would be very unlikely to bleed to death after a planned home birth in a developed country.

A famous review of quality studies of home birth (Olsen, 1997) looked at outcomes for over 24,000 women and found no maternal deaths. The National Birthday Trust Fund study looked at around 6,000 planned home births in the UK, and found no maternal deaths.

Where treatment for postpartum haemorrhage is needed, there are two elements. Emergency treatment focuses on stopping the bleeding, and in severe cases, keeping blood volume up while the bleeding is stopped. The other element of treatment is helping you to recover from blood loss, by administering a blood transfusion or iron supplements, this usually occurs several days after the bleed after blood tests have been performed.

What can a midwife do about heavy bleeding at a home birth?

Your midwife would follow exactly the same steps that she would take in hospital. Oxytocic drugs to manage blood loss are part of the basic kit that midwives take to every home birth.

If these did not bring the situation under control quickly then an ambulance would be called, and the midwife would take other steps if necessary, such as manually compressing your womb to stop bleeding.

In the UK most midwives can put an intravenous drip in at home while they are waiting for an ambulance to arrive.

What if the midwife isn’t there?

In the rare circumstances that a baby is born so quickly the midwife has not arrived yet, or the bleed has occurred after the midwife has left (also extremely rare), then you can do the following:-

  • ·       Call 999 if you can’t get hold of your midwife immediately
  • ·       Massage the uterus firmly – this often stops the bleeding immediately
  • ·       Pass urine
  • ·       Bi-manual compression – only if bleeding is extreme – involves someone continually massaging uterus externally and internally until help arrives

When the midwife arrives…

  • ·       She considers what we call the 4 T’s: Tone, Trauma, Tissue and Thrombin (clotting) factors.
  • ·       She can make sure the woman has passed urine and does not have a full bladder.
  • ·       She can use massage of the uterus, syntometrine or ergometrine medication to try stem bleeding. These medications induce a sustained uterine contraction. The massage of the uterus will sometimes expel any tissue obstructing good uterine clamp-down.
  • ·       The midwife can check for a tear, sometimes we can tear internally and it be less obvious
  • ·       Bi-manual compression will be used and transfer to hospital will happen as soon as an ambulance arrives if bleeding is not slowing.
  • ·       If bleeding has been easily stopped and woman feels fine then she may end up declining transfer to hospital. However in hospital they can offer a number of extra helpful interventions for anyone who has experienced or is experiencing a life-threatening PPH.

Placental Problems

  • ·       Occasionally the placenta doesn’t separate properly and obstructs, the midwife can manually remove it allowing the uterus to contract down and stem the bleeding

Can more be done in hospital than at home?

  • ·       The answer is yes, but only because there are more staff on hand, however the chances of having a life threatening PPH are far far greater in a hospital than at home in the first place.
  • ·       The most common reason for PPH is to do with atonic uterus, where the womb fails to contract down properly. At home, this is dealt with in the same way and with mostly the same drugs that would be used in hospital.
  • ·       It’s important to mention that PPH at home is reasonably rare, by the very nature of the fact that the major risk factors for PPH are things which only happen in hospital (instrumental deliveries, long hours on syntocinon drips, caesarean section etc).
  • ·       The last confidential enquiry into maternal deaths listed approx 5 deaths from PPH, all of which were in hospital, four of them were following instrumental deliveries and one following caesarean.

 How likely is post-partum haemorrhage after a home birth?

  • ·       PPH is significantly less likely to happen after a home birth than after a hospital birth.. This is probably because home birth reduces the risk of interventions which can contribute to PPH
  • ·       For more info, see the National Birthday Trust Fund study in the first instance, but numerous other studies have also found a reduced PPH rate in planned home births.
  • ·       Part of the reason for higher rates of blood loss after hospital birth is that PPH is statistically more likely to occur after intervention such as caesarean section, assisted delivery (forceps or ventouse), or medical induction or augmentation of labour (having a drip to speed labour up). None of these things will be happening at home. If you were to have any of these interventions, you would already be in hospital.
  • ·       There are some ways in which planning a home birth actually reduces your chances of having a PPH. Simply planning a home birth significantly reduces your chances of ending up with a caesarean or an assisted delivery – labour just seems to progress more smoothly at home, leading to less call for intervention. As these interventions increase the risk of PPH, by reducing the risk of the intervention, you are reducing the risk of PPH.

Can you have a home birth after having had a PPH with a previous baby?

  • ·       To try to work out the chances of a PPH recurring, and whether this is ‘safe’ for a home birth, you’d need to know why the PPH occurred, and if the same circumstances were likely to recur.
  • ·       Much depends on how you felt after the PPH.  Some women feel great even after losing a considerable amount of blood whereas others may feel terrible only losing 300ml.
  • ·       Its often hard to accurately measure the amount of blood loss. In the UK we call a loss of 500ml a PPH, but Europe don’t record a PPH unless over 1000ml.
  • ·       What were the circumstances the PPH occurred in? Were there known risk factors for PPH which would not apply this time? For instance, PPH is more common after assisted deliveries, first babies, large babies, induction or augmentation of labour.

o      If she needed an assisted delivery this time she would transfer to hospital, so that shouldn’t affect her status as regards home birth.

o      Likewise, her labour is not going to be induced with prostaglandins or augmented with syntocinon.

  • ·       Was the PPH a ‘true’ PPH in terms of being blood loss from her uterus, or was it associated with perineal tearing or episiotomy? Blood from both sources ends up in the same measuring jug, but the difference is significant.
  • ·       Did she have a retained placenta, or did the bleeding occur after the placenta was delivered – some ‘uterine atony’ involved?

Conclusion

All in all the risks of a PPH are lower in a planned homebirth than in a planned hospital birth.

However if one should occur, there are many ways it can be treated successfully at home, or by transfer to hospital.

It’s also important to realise that a negative outcome from a PPH can also occur in a hospital situation as well as at home.

Having experienced a PPH following a birth is not an automatic barrier to home birth in the future, it would depend on the reasons why it occurred. In fact planning a home birth may significantly reduce the chances of having a PPH in the future.

 

The idea that the umbilical cord should not be cut immediately after the birth but left to pulsate giving the baby extra blood, oxygen and stem cells is not a new idea to myself or many of my colleagues.  I have long believed that the baby should remain “attached” via the umbilical cord to his/her mother and my usual practice is to await “delivery” of the placenta before asking the mother or father to cut the umbilical cord.  I believe that early cord clamping interferes with the normal physiology of birth.

Recently Dr David Hutchon, a retired consultant obstetrician from Darlington, wrote in the British Medical Journal that maternity staff should wait for several minutes before cutting the cord and has also called for further research into leaving the cord intact.  http://topnews.co.uk/216535-expert-calls-hospitals-change-practice-clamping-newborns

The National Institute for Health and Clinical Excellence (NICE) still advocates active management, which includes early clamping and cutting off the cord. These guidelines mean that doctors and midwives are sometimes reluctant to change their practice.  This is despite the fact that both the World Health Organisation and the International Federation of Gynaecology and Obstetrics advise doctors to refrain from early cord clamping.

In summary, it is definitely worth thinking about whether you would prefer your baby’s umbilical cord to be left to pulsate and indeed possibly left intact until you have delivered your placenta.

Midwife Gloria Lemay also comments on this issue on her website.

www.gentlebirth.org/archives/lateClamping.html

ICM Statement International Day of the Midwife 2010

The World Needs Midwives Now More Than Ever!

www.internationalmidwives.org

Many midwives around the world celebrate the ‘International Day of the Midwife’ o­n May 5th each year. The International Confederation of Midwives (ICM) established the idea of the ‘International Day of the Midwife’ following suggestions and discussion among member associations in the late 1980s, then launched the initiative formally in 1992. The aim of the day is to celebrate midwifery and to bring awareness of the importance of midwives’ work to as many people as possible. This is done in many different ways according to what works best in each country.

The International Day of the Midwife is an occasion for every individual midwife to think about the many others in the profession, to make new contacts within and outside midwifery, and to widen the knowledge of what midwives do for the world. In the years leading up to 2015, ICM will use the overarching theme “The World Needs Midwives Today More Than Ever” as part of an ongoing campaign to highlight the need for midwives. This reflects the World Health Organisation (WHO) call for midwives and the need to accelerate progress towards Millennium Development Goals (MDGs) 4 and 5.

Midwife numbers must be expanded to achieve Millennium Development Goals 4, 5 and 6 by 2015 350,000 more midwives are needed!1

The UN Millennium Development Goals Report 2008 states: The high risk of dying in pregnancy or childbirth continues unabated in sub-Saharan Africa and Southern Asia … little progress has been made in saving mothers’ lives. Over 60% of women in these areas of the world still do not have skilled care during childbirth.
This report notes better progress for all of the MDG goals, apart from MDG5!2 Yet all the goals are linked: until poverty and hunger are reduced, until diseases such as HIV and malaria are controlled, until there is more equality between men and women, until every child completes primary education, until all women have access to reproductive healthcare – then mothers and babies will continue to die.

Midwives are key healthcare providers in achieving MDG 5: Improving Maternal Health3
That is the clear message coming from the WHO, UNFPA, UNICEF and the World Bank: the four UN agencies that have recently united to pledge increased support to countries with the highest maternal mortality rates.
They identified mortality in pregnancy and childbirth as the “highest health inequity in the world with over 99% of deaths occurring in the developing world”. They committed to work with governments and civil society organizations to address the “urgent need for skilled health workers, particularly midwives”.4

Midwives provide skilled newborn care to achieve MDG 4: Reduce Child Mortality5
Every year in sub-Saharan Africa and South Asia more than 1 million infants die within their first 24 hours of life due to lack of adequate health services, including midwifery care. The midwives of the world understand that every childbearing woman deserves to give birth within a safe and supported environment for herself and her baby. Skilled midwifery care includes emergency care for both mothers and their newborns.

Midwives are essential to achieve MDG 6: Combat HIV/AIDS, Malaria and Other Diseases
Thousands of pregnant women and hundreds of thousands of newborns die each year due to preventable disease. Throughout sub-Saharan Africa governments have recognized the primary role of midwives in reducing these devastating deaths. As essential frontline workers, midwives provide vaccines to newborns and children; they identify, counsel and treat pregnant women with HIV and AIDS, thus preventing mother-to-child transmission of HIV; they also provide anti-malarial drugs and bed nets to vulnerable pregnant women and their children, saving lives and promoting health.

The achievement of MDGs 4, 5 and 6 requires a global commitment to grow a strong, well educated midwifery workforce within functioning health service delivery systems.

The sense of urgency to achieve MDGs 4, 5 and 6 in the next six years is increasing daily. The ICM and the midwives of the world are committed to working with global partners to achieve these goals. The Confederation has grown to 91 member associations with 250,000 midwives in over 80 countries and has recently partnered with the UNFPA to strengthen midwifery education, regulation and associations in 40 low income countries. The ICM has also joined the White Ribbon Alliance (WRA) and Sarah Brown’s Maternal Mortality Campaign to increase public awareness and apply political pressure on the G8 and G20 to make maternal and newborn health a global priority. The ICM recognizes that health delivery systems must be strengthened and the midwifery workforce must be increased to stop the needless deaths of millions of women and their newborns who will die in the next six years if immediate action is not taken now.

The world needs midwives now more than ever!

For more information contact ICM President Bridget Lynch or ICM Secretary General Agneta Bridges at +31 70 3060520 or e-mail a.bridges@internationalmidwives.org.
1. The World Health Report: Make every mother and child count. World Health Organization, 2005.
2. The Millennium Development Goals Report 2008. New York, USA: UN, 2008
3. MDG 5 Target: Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio. UN, 2000.
4. Accelerating efforts to save the lives of women and newborns. WHO/UNFPA/UNICEF/World Bank. Joint statement: Sept. 2008.
5. MDG 4 Target: Reduce by two thirds, between 1990 and 2015, the under-five mortality rate. UN.

What is the definition of Natural Childbirth?  A hospital might say that a woman whose labour was induced and who had an epidural was a normal birth; others might say that induction, augmentation, analgesia, episiotomies etc do not constitute a normal birth!

A more radical definition of a natural birth might be a labour that starts spontaneously between 37 and 42 weeks gestation, and progresses to a vaginal birth without any intervention or pharmacological drugs.

Natural childbirth has been given a bad press – women choosing natural childbirth have been described as “hippy types” and indeed there has been an item in the press this week about a midwife who suggested that women would do better to avoid epidurals that has caused considerable outrage!

Pregnancy and childbirth are normal life events, not medical condition; a woman’s body is perfectly designed to give birth.

Of course some pregnancies and labours will need medical help – but the vast majority of women will go through their pregnancy and birth without problems and this process works best when interference is kept to a minimum.

For example anything we do to interfere with this natural processes has consequences – if mother and baby are well I am suggesting that we (the medical profession) should not interfere!

One example of this is the huge number of women whose labours are induced – why?  In some areas women are induced at 41 weeks (interestingly in France a normal pregnancy is defined as 41 weeks!).

Induction is not an easy option.  It is usually quite a lengthy process which makes the mother tired.  It is also usually more painful and the mother is therefore more likely to need pain relief, possibly an epidural … the mother is then less mobile … making it harder for the baby to find a way through the pelvis and consequently she is more likely to need the help of a ventouse or forceps, or even a caesarean section.

We all know that although caesareans are very safe in this country, it is still far safer for both mother and baby if the baby is born vaginally.  A caesarean section is major abdominal surgery which will take weeks and months to fully recover from – and the mother will have a demanding baby to care for too!  Babies born by caesarean also have many more problems, and are far more likely to need to receive Special Care.  There are also implications for future pregnancies – so, although fantastic if needed, caesarean sections are far from ideal.  The World Health Organisation recommends a 5 – 10% caesarean section rate, but our rate is approaching 30%, and I believe 90% at The Portland private maternity hospital!

This interference in birth has been called a “cascade of intervention”, because we do a) we have to do b) and because we do c) d) is also necessary this is also described as “iatrogenic” or hospital induced.  Whatever we do has consequences, for example a woman with an epidural will need more careful monitoring, she will need an IV drip and also a catheter – so you can see this spiral effect, because we do this, we have to do that and so on …

I believe there are several factors that lead to this escalation of intervention in childbirth:

Our cultural conditioning, fear, poor health habits and medical intervention in normal birth (perhaps because of fear of litigation) that make birth difficult often requiring more intervention, including surgery.

With good preparation, much intervention can be avoided – women who have a midwife they know and trust are less likely to need analgesia.  With good preparation they should be in optimal health for the birth – complementary therapies they may have experienced acupuncture, homoepathy, osteopathy or any number of helpful treatments during their pregnancy which will help align their body and prepare them for birth.  They may also have practised relaxation or hypnosis techniques all of which can be hugely beneficial.  There is also much a woman can do to help herself: mobilization, relaxation, support, the use of water …

The satisfaction that a woman feels when she has successfully given birth is amazing – it is empowering and is a fantastic start to the parenting journey, and of course breastfeeding is so much easier when you haven’t got a caesarean section wound on your abdomen.

If things didn’t work out this way for you, remember that you did the very best you could at the time.  Some labours do need help and some mothers and babies wouldn’t survive without the help of our medical colleagues.  If this has raised questions or distress for you I am more than happy to speak to you please do feel free to email me info@3shiresmidwife.co.uk

A difficult or traumatic birth experience has long-lasting implications for both the mother and sometimes her child.  We don’t have many babies in our lifetime and it is important to get things as right as we possibly can!

Just in time for National Breastfeeding Awareness Week (next week) www.breastfeeding.nhs.uk/en/fe/page.asp?n1=5&n2=13 the Department of Health has announced that baby growth charts – against which all babies physical growth is measured and compared – are to be redrawn.

The figures used until now have been based mainly on formula-fed babies. This has meant that some breastfeeding mothers have been incorrectly advised that their babies are gaining insufficient weight.  The new tables, drawn up by the World Health Organisation (WHO), are based entirely on the rate of growth of breastfed babies, which tend to put on weight more slowly than those given formula milk in their first year.

It is generally accepted that babies fed on formula put on weight more quickly than those on breastmilk, which can make breastfed babies look like they are not thriving.  Consequently, there might have been pressure to wean early on to solid foods or formula milk.  In fact it is a WHO recommendation that babies receive only breastmilk for the first six months of their life, www.who.int/topics/breastfeeding/en/, it is then recommended that breastmilk be supplemented with solid food, but that breastfeeding continue for at least 12 months.

Breastfed babies are leaner during the time when a lifetime supply of fat cells are laid down, which helps explain why breastfed babies may tend to be leaner throughout their lifetimes, thus helping to prevent obesity.  This said, many breastfed babies appear quite “chubby” – this is normal and healthy.

Fewer than one in two mothers still breastfeed at six weeks and this falls to 25% at six months. Fewer than 1% of mothers follow official advice to breastfeed exclusively for the first six months of an infant’s life.

I’ve been thinking for a while that I should write about breastfeeding … I’m sure you are very familiar with the benefits of breastfeeding:

Benefits for the baby
Reduced risk of gastro-enteritis, diarrhoea, urinary tract, chest and ear infections, obesity and diabetes.  Latest evidence suggests reduced risk of Sudden Infant Death Syndrome and childhood leukaemia

Benefits for the mother
Reduced risk of breast cancer, ovarian cancer and osteoporosis (www.babyfriendly.org.uk)

This is apart from the benefits of the convenience of breastfeeding: having an ever-ready continuous supply of breastmilk, no need for sterilization, warming up of milk etc

However despite all the positive work and advances in making breastfeeding more acceptable and normative:

– in November 2004 an Act of the Scottish Parliament made it an offence to prevent or stop a person breastfeeding in a public place www.opsi.gov.uk/legislation/scotland/acts2005/asp_20050001_en_1).

– throughout the UK it is government policy to increase the number of babies who are breastfed (the Government is fully committed to the promotion of breastfeeding, which is accepted as the best form of nutrition for infants to ensure a good start in life. Breastmilk provides all the nutrients a baby needs. Exclusive breastfeeding is recommended for the first six months of an infant’s life www.dh.gov.uk/en/Healthcare/Maternity/Maternalandinfantnutrition/index.htm).

– this is also supported by the World Health Organisation who state Breastfeeding is the ideal way of providing young infants with the nutrients they need for healthy growth and development. Virtually all mothers can breastfeed, provided they have accurate information, and the support of their family and the health care system. should be  Exclusive breastfeeding is recommended up to 6 months of age and supplemented breastfeeding up until the age of two or beyond www.who.int/nutrition/topics/exclusive_breastfeeding/en/.

it is therefore disappointing to note that the social networking website Facebook has been removing breastfeeding photographs and and banning users on the grounds that they’d uploaded “obscene content” to their profiles.  In response an on-line protest group “Hey Facebook, breastfeeding is not obscene! Official petition to Facebook” has been launched at www.facebook.com/group.php?gid=2517126532 and a virtual “nurse-in” event was held on 27th December 2008 at www.facebook.com/event.php?eid=39521488436.

Lots of good free information and support about breastfeeding is available:

“From Bump to Breastfeeding” is a great new FREE DVD available to all pregnant women at www.orderline.dh.gov.uk or call 0300 123 1002.

www.breastfeeding.nhs.uk

National Breastfeeding Helpline
Operated by the Association of Breastfeeding Mothers and The Breastfeeding Network
Tel. 0844 20 909 20

La Leche League
Tel. 0845 120 2918

National Childbirth Trust
Tel. 0870 444 8708

The Breastfeeding Network – breastfeeding support in Bengali and Sylhetti
Tel. 07944 879 759



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