zaterdag 16 mei 2015

Normal birth: a retrospective by Dr. Denis Walsh

Assessing the agenda around normal birth

Dit artikel is gepubliceerd in 2008. Het onderwerp is voor Nederland zeer actueel. De inhoud kan behulpzaam zijn bij discussies en stellingname over de nieuwe VIL in de maanden mei en juni 2015 .

It is three years now since the publication of Soo Downe’s (2004) important book Normal birth: evidence and debate. In that book, she fleshed out her concept of ‘salutogenesis’ in childbirth or well-being to correct decades of focus on the pathologies associated with birth. As she developed her critique of the biases to scientific knowledge in our knowing about birth, she coined the phrase ‘unique normality’ to capture the physiological variations between women in their labour experiences, though still under the umbrella of normality. This was validating what many women, midwives and some obstetricians had believed for a long time – that the textbooks on labour are too restrictive in representing physiology, based as they are on the ‘template’ paradigm. Seven years ago, I launched the first Course in Evidence-Based Care for Normal Labour and Birth to highlight the largely underutilised body of evidence supportive of physiological birth. Seventy courses and 3,000 delegates later, it is worth reflecting on what difference they have made and the impact of Soo Downe’s ideas on practice. I want to examine three issues: development in models of care, intrapartum practices and evidence and interdisciplinary collaboration.

Organisational models
As a midwife, it was heartening this year to see Maternity matters (DH 2007) launched in the UK with a blue print for maternity service that endorsed the centrality of normal birth and the role of the midwife in facilitating that. The policy paper supported choice regarding place of birth, stating unequivocally that home and birth centre care should be as available as hospital birth. It also supported continuity of carer models, local service provision and adequate staffing to provide one-to-one care in labour. These were not new ideas and largely echoed Changing childbirth (DH 1993) from a decade earlier.
Comparisons with the impact of that document are inevitable and some people responded with a pessimistic take, like the Senior Midwife who, when asked about a local response to, Maternity matters, stated it was all tried in the 1990s and didn’t work then. Or the Senior Midwife who took the opposite view, that now additional pressure could be applied so that the reforms of the 1990s could be properly implemented. I have deliberately used anecdotes from Senior Midwives because they have been instrumental in evolving high quality midwifery services in some parts of the United Kingdom (UK) while other places have stagnated or regressed. Guys & St Thomas’ are an outstanding example of success and are an encouragement for the rest of us. They have one of the largest caseload schemes in the UK and a very good alongside birth centre, right in the centre of London. These are impressive but it is at strategic level that some outstanding examples have been set for other midwifery leaders. Guys and St Thomas’ have one of the only Clinical Directors in the country who is a midwife. This important strategic post can positively influence priorities for the maternity service, and together with the Senior Midwife, the promotion of normal birth has been designated as a priority. While other services have been cutting back on training budgets, they have been extending theirs in a unique initiative to get as many midwives and obstetricians to attend normal birth evidence days as possible. Consultant midwife roles have been invested in which reap benefits at a number of levels, including practice development and research. Finally, all their midwifery management posts work in clinical practice weekly. This has a positive impact on their credibility as change leaders with other midwives and keeps them grounded in challenges of every day practice. Kings is another example of keeping the cycle of innovation, going with their various midwifery teams delivering hybrid caseload and continuity elements and the Albany Group subcontracted to them. Again, inspirational midwifery leadership exists in a number of posts at the top of their organisation. In the north west of England, Blackburn and Burnley are going through major reorganisation that will see the largest free-standing birth centre in the country open next year along with a large alongside birth centre together with an existing caseload scheme. The strategic importance of the Consultant Midwife role in pubic health has been pivotal to these changes, along with other visionary midwifery managers. The other settings that it has been a privilege to visit over the past seven years have been the numerous birth centres and midwifery-led units (both free-standing and alongside) that are flourishing, not just in the UK but in Australia, New Zealand, Germany, Switzerland and the USA. These facilities have a sense of integrity and purpose that is life enhancing to the visitor. You get to meet many contented, confident and assertive midwives in these settings and usually these attributes have been won at a cost in time and energy, fighting closure and a control agenda from external forces. If pride is a positive quality, then here is a place to find it. What strikes me more than anything else in birth centres is the staff’s confidence that comes with working autonomously. They are frequently the most up-to-date with evidence, very tuned into emergency drills and highly skilled at keeping births physiological, especially with nulliparous women. All of these examples should inspire us in the spirit of this quote from Robert Kennedy, spoken about his brother (JF Kennedy) at his funeral in 1963: ‘Some people see things and ask why. I dream dreams and ask, why not’. What is happening in all these settings is that individuals are matching their dreams to policy and are making things happen. They are the living embodiment that power does not just reside with institutions, bureaucracies, vested interests and chief executives but with committed people from lower ranks in an organisation.

Intrapartum practices and evidence
It was depressing to learn recently that 25% of women still gave birth in lithotomy in the UK (Guardian 2007). It serves to highlight that entrenched practices that are not evidence-based are still occurring. I would add to the list coached pushing, particularly with epidurals, under use of water and over use of syntocinon for labour.
Labour posture continues to be a problematic area for normal birth practice across the Western world. I am still looking for any evidence that says lithotomy bestows any benefits for women, even in the situation of assisted vaginal birth. Certainly, ventouse births should be exploring alternative postures like standing, supported squat, sitting and kneeling. As mandatory episiotomy has changed in recent years for assisted vaginal birth, so should the lithotomy position. I have heard stories from three different countries of obstetricians and midwives challenging this sacred cow with positive outcomes, especially in relation to maternal satisfaction. Regarding semi-recumbent normal birth, this should be very much a minority outcome. Labour ward should be setting targets of getting this figure under 20% because of what we know about the advantages of upright birth (Walsh 2007). Coached pushing still remains common, especially for epidural second stages and therein lies a glaring inconsistency with the evidence. If prolonged breath holding gradually leads to fetal hypoxia (Caldeyro-Barcia 1979), how can it be acceptable for women with epidurals, where posture could arguably make this worse? The approaches to addressing this are to wait longer for passive descent, at least two hours (NICE 2007), mimic spontaneous pushing behaviours in helping women with no bearing down reflex (breath-holding periods to be kept under 10 seconds) and utilise upright posture. In a little recognised evidence source, Soo Downe (2004) has already shown that women with epidural will have more normal births if they birth on their side. There are some maternity units where the advent of evidence has meant prescriptive guidelines that have become apparently mandatory to follow. This was never the intention of the evidence-base medicine movement. Famously, Sackett (1996) envisaged an evidence triad made from three elements: research underpinning a guideline, practitioner experience/expertise, patient choice or preference. Guidelines are made to be a guide only. It was always understood that the individual clinician would assess the individual and apply evidence-based decision-making taking into account the patient’s perspective. From this stand point, a decision that departs from the guideline because of clinician experience or patient choice, is still an evidence-based (my emphasis) intervention. The following story illustrates how risk management in practice can undermine this principle. A midwife delays a vaginal examination after doing an ARM for slow labour beyond two hours because the woman wanted to maximise her opportunity of getting to fully dilated. The repeated VE at four hours shows no change so transfer occurs out of a birth centre to the main delivery suite. Later, a staff member from the delivery suite puts in an incident form, stating that the guideline of repeating a vaginal examination two hours after an ARM had not been followed. The midwife is gently reprimanded by a phone call from the birth centre manager and asked to follow the guideline in future. Yet the midwife’s judgement was that the triad had been applied correctly and her decision was an evidence-based one. It is reasonable to state that in high risk obstetrics, a guideline can become more a protocol to be adhered to because, arguably, more could go wrong whereas in normal labour and birth the risks are lower and there can be greater flexibility. At that end of the spectrum, some birth centres do not use partograms because they believe they encourage ‘wrote’ compliance to time lines that do not represent the spread of physiology. They reason that it is far better to encourage midwives to individualise decision-making with women according to a holistic assessment of the dynamics of different labours. The other danger of the prescriptive interpretation of guidelines is that they encourage ‘doing good by stealth’ behaviours (Kirkham 1999). This is the age old trick of protecting the woman from intervention by telling ‘little white lies’. Regarding partograms, one way this is played out is by not commencing the partogram until labour is clearly well advanced, say beyond 5cms dilated. Most commonly, ‘doing good by stealth behaviours’ occur around the diagnosis of second stage. Sadly, the new NICE intrapartum guideline will still encourage this as it sticks to the inflexible one hour before referral should be made for delay, though this is two hours with an epidural (NICE 2007). Midwives know of course that some women have a latent element at the start of second stage but this will remain unrecognised if these guidelines are followed. Therein lies such a negative consequence for Soo Downe’s unique normality. We will never legitimise and capture the physiological variation in women’s labour rhythms when we continue to conceal it with ‘doing good by stealth’ behaviours. There is nothing more urgent in the normal birth research agenda than the observational work that needs to be done around labour rhythms, especially in out-of-hospital birth settings. Jane Fry (2007) wrote an important paper on intuition in MIDIRS Midwifery Digest in September 2007 that is required reading for all midwives. There she explores the territory of intuitive decision-making for midwives and the clear application is to ‘sussing labour rhythms’. But for that to happen, we have to let go of our reliance on vaginal examination. I look forward to the day that vaginal examination in normal labour is viewed as episiotomy is now, an occasionally necessary, if unpleasant, medical intervention. We have to become deeply circumspect and hesitant about its use in physiological labour and we may well be forced down the path of minimum examinations by the spectre of hospital-acquired infection risks.

Interdisciplinary collaboration
I highlight this area because it is still a space where we are oppressed by stereotypes of obstetric/midwife conflicts and perceived differences. Yes, we have to acknowledge historically inherited unequal power differentials, particularly in hospitals. And there is still evidence of gendered responses that we would prefer to leave behind, like the recent anecdote from a student midwife who, in the process of being orientated to a hospital antenatal clinic, was shown operational guidelines that included a description of how the consultant liked his tea and what his favourite cakes were at the mid morning break!
I have met too many thoughtful obstetricians in recent years to sustain a view that they are all signed up to the medicalisation of childbirth. Normal birth sometimes finds more resistance from midwives working in traditional labour wards. Birth centre midwives get negative vibes when they accompany intrapartum transfers more often from midwives than obstetricians. There are many examples of constructive interdisciplinary working between midwives and obstetricians often fleshed out in scenarios where women want great flexibility around VBAC, breech delivery, birth centre and home birth when they have significant risk factors. Thus you hear of diabetic mothers having home births, VBAC home waterbirths and active breech births in nulliparous women. The key ingredients in these collaborations are not deference and paternalism but mutual respect and trust. This is true power sharing across professional groups and women. It puts a lie to the idea that team working has to mean working in each other's pockets on one huge labour ward and that separate midwifery-led areas breed distrust. Positive relationships can and do exist across the primary/secondary care interface and across different geographical spaces in the one building. What we need more of is interdisciplinary working in training and educational environments like evidence forums, case reviews and in skills workshops like vaginal breech. These will only work if respective parties give up old patterns of relating which could mean for some dropping a control agenda and for others eschewing deference or passive-aggressive behaviours.

Midwives and obstetricians have much to be hopeful about regarding the future of normal birth. For local maternity services that are falling behind the agenda, then there are brilliant exemplars out there to learn from. We should not underestimate the power of transformational midwifery leaders to bring about change in local services, nor the power of committed midwives on the ground. Some of the challenges that lay ahead are:
  • Responding to the damaging policy of centralising all birth by exploring midwifery-led units, birth centres and home birth options
  • Investing in skills to maximise normal birth care
  • Researching physiological birth to ascertain its variability and complexity
  • Investing in interdisciplinary training
  • There are areas I have not commented on that equally important to the future of normal birth, like redressing the balance of the risk discourse in maternity care so all of us can rediscover our hope and faith in normal birth and, of particular interest to me, researching the empowerment and growth potential for individuals of the experience of physiological childbirth.
    As I finish this article, I have had another email from Australia about the recruitment of caseload midwives to a new birth centre opening in Townsville, Queensland, my home state. It serves to remind us that the best midwifery care is always mediated through compassionate, nurturing relationships with women. That remains our fundamental calling.   
  • References:
    Bosely S (2007). More than half of maternity units use outmoded practices, survey discovers. The Guardian. 27 November 2007.
    Caldeyro-Barcia R (1979). Influence of maternal bearing down efforts during second stage on fetal well-being. Birth and Family Journal 6(1):7-15
    Department of Health (1993). Changing childbirth: report of the Expert Committee on Maternity Care. London: HMSO.
    Department of Health (2007). Maternity matters: choice, access and continuity of care in a safe service. London: DH
    Downe S ed (2004). Normal childbirth: evidence and debate. Oxford: Churchill Livingstone.
    Fry J (2007). Are there other ways of knowing? An explanation of intuition as a source of authoritative knowledge in childbirth. MIDIRS Midwifery Digest 17(3):325-8.
    Kirkham M (1999). The culture of midwifery in the National Health Service in England. Journal of Advanced Nursing 30(3):732-9.
    National Institute for Health and Clinical Excellence (2007). Intrapartum care: care of healthy women and their babies during childbirth. London: NICE.
    Sackett D.1996. Evidence based medicine: what it is and what it is not. BMJ 312:71-72.
    Walsh D (2007). Evidence-based care for normal labour and birth: a guide for midwives. London: Routledge. | Denis Walsh | Reader in Normal Birth | University of Central Lancashire |


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