Top 10 things I learnt at the Essence of Midwifery Conference
It was great to be invited to several events over this week in support of all the wonderful midwives who work so hard to support women during their journey to pregnancy birth and beyond in Ireland. The big day was the Essence of Midwifery conference at The Coombe. As usual they put on a great show and there were some great speakers and posters with the focus being on caesarean section and choice within it.
Maternity Strategy 2016
1. That the maternity strategy has been launched a 100 days and nothing has yet been implemented. With a government now voted in, when is the action going to start in ensuring that women have access to along side midwifery led units? The overview of the Strategy was given by Deputy Chief Nurse and Midwife Susan Kent
Caesarean Section Rate
2. That the c section rate in the North of Ireland was 36% but investment in evidenced based research, support, care pathways, informing women of their choices and in trusting women was able to reduce it to 25%. (Dr Niamh McCabe and Margaret Rogan Consultant Midwife.) There are four main reasons for c section (1) compromised baby, (2) “failure to progress”, (3) breech presentation and (4) previous caesarean section. Niamh and Margaret highlighted this last issue and the lack of informed choice surrounding VBAC in Northern Ireland that was a major factor in maintaining the high caesarean rate.
Risks of Elective Repeat Caesareans
3. .Women are rarely told the risks of Elective Repeat Caesarean Section (ERCS), instead the risks of VBAC are the primary focus of discussion. Niamh discussed some of the risks including placenta acretia and hysterectomy. Niamh pointed out that she hardly ever used to see placenta acretia when she started out in her practise and now she sees about one a month.
4. Women hoping for a VBAC are absolutely encouraged to use the water pool for labour and birth and also CTG as Niamh argued that it is almost impossible to have a uterine rupture without an abnormal CTG . However, if its a woman’s choice then she doesn’t have to have it and there are other signs that can be looked for. Niamh said that the rate of uterine rupture has increased over the years as more and more women are having c-births.
5. The increased risk of a fetal death with a VBAC is about the same risk as when you had the caesarean birth the first time round. The increased risk is perceived because in general if you had a normal birth the first time round then the chances of your second baby dying is much less than your first.
6. You are three times more likely to die with a ERCS than with a VBAC
7. The risk of a VBAC is about the same as of an IOL
8.Birth is a series of involuntary processes hindered by the interference of the neocortex
9. Melatonin and oxytocin work together to promote surges and birth. Light in the blue spectrum inhibits the production of melatonin. The most common spectrum used in delivery suite lights is blue spectrum. The light emanating from mobile phones is also in the blue end of the spectrum. Mobiles and apps are not good for connecting with your inner self and increasing oxytocin levels. Michel Odent.
Decision Making in Midwifery and Obstetrics
10. When we make decisions around pregnancy labour and birth we tend to believe that the more information we have the better decisions we will make, however what we need is sufficient information to reduce our uncertainty enough to make a decision.
Also decisions are often based on heuristic pattern recognition. Once we see a pattern it is difficult to erase it from our minds so even though what we are seeing is marginally different from the pattern we know, we will recognise it as the same. Situations that are similar to ones we recognise can fool us into making quick decisions based on faulty recognition. On the other hand we like using patterns to make decisions because it enables us to make decisions more quickly. Until we recognise a pattern we have to work things out from first principles, and that takes time which most HCPs dont have. Prof Maskery.
Top 5 things I enjoyed
1. The company of being with midwives and women
2. The Japanese water blessing offered in honour of the day
3. The student midwife discourse “keep it going keep it going keep it going keep it going keep it going . . . keep it going keep it going” “Exactly how long is a breath?”
4. The poster presentations. My favourite was the poster looking at caring for same sex couples
Today, January 27th 2016, the Minister for Health Mr Leo Varadkar launched Ireland’s first Maternity Strategy. This is a big first for the country, as until now maternity service have developed in an ad hoc basis without any overall direction or unified goals. This has resulted in a “geographic lottery” in terms of women’s choices and developments with some parts of the country offering midwifery led care, birth pools, home birth services, open doula policies, anomaly scans, early transfer home, DOMINO care and other parts of the country offering nothing beyond an obstetric led service.
The Maternity Strategy was prompted by a variety of reports including those by HIQA into the baby deaths in Port Laoise hospital and Savita Halappanavar, and Roisin Molloy and Shauma Keyes whose babies both died in Port Laoise sat on the Maternity Strategy Committee, as did I representing AIMSI and the generic women’s voice.
The Chair’s preview summarises the input of Roisin and Shauna
“Finally, and most particularly, I would like to acknowledge the considerable input to this Strategy of Roisin Molloy and Shauna Keyes, two mothers who have experienced both joy and heartache within our maternity services. Their presence on the Group served to ground us in reality, and I thank them for that. Savita Halappanavar was also ever present with us in our thoughts and we hope that the outcome of our work will be of some comfort to her husband and family.” Sylda Langford Chair
The committee also consisted of many midwives, HSE managers, representatives from the Department of Health and Children, obstetricians and paediatricians. Furthermore the committee sought guidance from maternity strategies in Northern Ireland and Wales and also carried out a public consultation which many of you will have taken part in.
What are the key terms of reference of the strategy?
Women and babies have access to safe, high quality care in a setting that is most appropriate to their needs;
Women and families are placed at the centre of all services, and are treated with dignity, respect and compassion;
Parents are supported before, during and after pregnancy to allow them give their child the best possible start in life.
What are the four strategic priorities that the strategy addresses?
Health and Wellbeing approach is adopted to ensure that babies get the best start in life. Mothers and families are supported and empowered to improve their own health and wellbeing;
Women have access to safe, high quality, nationally consistent, woman-centred maternity care;
Pregnancy and birth is recognised as a normal physiological process, and insofar as it is safe to do so, a woman’s choice is facilitated;
Maternity services are appropriately resourced, underpinned by strong and effective leadership, management and governance arrangements, and delivered by a skilled and competent workforce, in partnership with women.
How will safety and risk be addressed?
The Strategy classifies pregnant women/babies into three risk groups; normal-risk, medium-risk (requiring a higher level of oversight), and high-risk (requiring a more intensive level of care, either throughout or at particular stage of care). Across all risk levels there is the potential need for an increased level of care and the importance of smooth transfer between pathways of care is recognised.
What pathways of care will be available to the three groups?
A choice of pathway of maternity care will be available based on this risk profile. A woman will be supported to make an informed choice with regard to her care pathway and will have her care delivered by a particular team. All care pathways should support the normalisation of pregnancy and birth. The pathways are:
1. Supported Care: This care pathway is intended for normal-risk mothers and babies, with midwives leading and delivering care within a multi-disciplinary framework.
2. Assisted Care: This care pathway is intended for mothers and babies considered to be at medium risk, and for normal risk women who choose an obstetric service. Care will be led by a named obstetrician and delivered by obstetricians and midwives, as part of a multidisciplinary team.
3. Specialised Care This care pathway is intended for high-risk mothers and babies and will be led by a named obstetrician, and will be delivered by obstetricians and midwives, as part of a multi-disciplinary team.
Where will women give birth?
Women in the Supported Care pathway will give birth in an Alongside Birth Centre; women in this care pathway may also choose a homebirth.
Women in the Assisted Care or Specialised Care pathways will give birth in a Specialised Birth Centre.
What are along side birth centres and specialised birth centres?
“An Alongside Birth Centre should ideally be situated immediately alongside and contiguous to a Specialised Birth Centre (current labour ward). These will provide comfortable, low tech birth rooms; labour aids such as birthing balls and pools and complementary therapy will be welcome alongside natural coping strategies. If epidural analgesia, electronic foetal monitoring or syntocinon is required, transfer to the Specialised Birth Centre will be organised and where possible the same midwife will continue the women’s care. In an emergency, the necessary critical services will be brought to the woman in the Alongside Birth Centre. ” National Maternity Strategy 2016
“For all care pathways, the physical infrastructure should be of a high standard, providing a homely environment and respecting the woman’s dignity and need for privacy during childbirth. While it is recognised that more medical equipment is required in a Specialised Birth Centre, as far as possible, all birth centres should be conducive to providing a calm and relaxing environment, such that it can best support a physiological process. Modern facilities including, where appropriate, birthing aids and birthing pools should be available.” National Maternity Strategy 2016
When will these setting be provided?
Obviously this document is just a Strategy and will need to be implemented. An implementation committee will be set up and some changes will take longer to put in place than others. Here is what the Strategy has to say on the lead in period: It is recommended that the The National Women & Infants Health Programme will, “within six months of the date of publication of this Strategy, develop a detailed implementation plan and timetable for the delivery of this Strategy, including the assignment of responsibility for required actions.” National Maternity Strategy 2016.
“Each maternity network will be required to prepare a plan to provide Alongside Birth Centres across their network. In determining the priority for implementation, each maternity network will have regard to the need to ensure a reasonable geographic spread of such birth centres across the network. Pending the development of Alongside Birth Centres, or where it is determined that, given the small size of a maternity unit, a discrete Alongside Birth Centre cannot be justified, it is recommended that a designated space is established within a Specialised Birth Centre, with an appropriate environment and processes to ensure that, as far as possible, the normal risk woman will be provided with a natural childbirth experience.” National Maternity Strategy 2016.
So in other word in small units or until alongside birth centres can be built a DOMINO style situation is expected to exist, not too dissimilar to the DOMINO service in the NMH at present.
What else that we do not have now will the strategy provide?
The Strategy recommends more resources for perinatal mental health. The strategy recommends that to perinatal psychiatry and psychology services will be standardised, and as a minimum provided on a maternity network basis.
The Strategy recommends more resources to support breastfeeding including that all maternity service adhere to the Baby Friendly Hospital Initiative.
The Strategy recommends improved appointment scheduling
The Strategy recommends the development and implementation of National Clinical Guidelines and National Clinical Audit. The NCEC will prioritise and quality assure National Clinical Audit and a set of National Clinical Guidelines for maternity services; guidelines on Intrapartum Care are a priority.
The Strategy recommends improved clinical audit of the maternity services. An annual survey of womens’ experience in maternity services will be undertaken by HIQA in partnership with the HSE.
The Strategy recommends geographic uniformity in terms of choice and care settings and other services
The Strategy recommends a new community midwifery service available to all women for antenatal and post natal care
The Strategy recommends home births be made available in all hospital groups. “Women in the Supported Care pathway should, where feasible, have the option to birth at home, with care provided by the community midwifery team and the lead healthcare professional. Thus, homebirth services will be integrated with the community midwifery and the wider maternity service as part of the maternity network. Care will be provided in line with agreed national standards, with clear care pathways identified for any change in the woman’s risk profile.” 184.108.40.206
The Strategy recommends the development of an on-line resource for maternity services, to act as a one-stop shop for all maternity-related information.
The Strategy recommends that mother-baby bonding will be facilitated and supported at all times, and as such, every effort will be made to keep the mother and baby together, if clinically appropriate.
The Strategy recommends that additional support will be available for women who have experienced traumatic birth or the loss of a baby.
What is not in the strategy?
The Strategy makes no provision for free standing birth centres, despite the public consultation being overwhelmingly in favour of this and despite the evidence for the safety of free standing birth centres being stronger than for homebirths.
The woman’s choice of care provider and setting overriding her risk status. The Strategy makes no clear provision for a woman to choose a model of care that is not deemed suitable for her risk status. The Strategy makes reference to the National Consent Policy and the 8th amendment to the Constitution of Ireland as being a barrier to following through on this.