Yes, you are right Laura – we only need to think about the ‘gentle’ belt because we introduced the ‘not gentle’ Kristaller manouver, that we never even needed in the first place! so now we are spending huge amounts of health service/service users money that should be spent on women and babies who really need it to fund a technology that is only being used because we did something in the first place that was not helpful, potentially damaging, and not needed… madness.

All the best

Soo

Very interesting Laura – and do you know that there is a Cochrane review on these kinds of labour belts that shows there is no evidence of effectiveness?:

 

http://www.cochrane.org/CD006067/PREG_fundal-pressure-during-the-second-stage-of-labour-for-improving-maternal-and-fetal-outcomes

 

There is only evidence of benefit for midwifery led out birth centre care – so if it aint broke, why (try to) fix it?! AND all these interventions are expensive – when all they are doing is trying to mimic physiological birth that, left to its own devices for healthy women and babies who want this approach, needs no tools, drugs, techniques or equipment – just careful loving support from a skilled practitioner with a good referral system!

 

 

All the best

 

Soo

 

From: Laura Iannuzzi [mailto:[log in to unmask]]
Sent: 12 June 2015 12:53
To: A forum for discussion on midwifery and reproductive health research.; Soo Downe
Subject: Re: Isnt the concept of low risk induction a category error?

 

Dear all,

I have been 'enchanted' by all this debate that starts from a particular to, as often when talking about childbirth, get deeper and wider.

The last point made by Soo Downe made me think about a little episode happened in Italy in the last days that I think well reflects the ambiguitiy that can be created around concepts of risks and 'normalisation of intervention' I would say in our culture. And I think that the problem starts often not from doctors' strenght but from our weaknesses as midwives, in having clear views on our profession at times. I agree with what previously stated and also with the fact that 'we are in danger of building up interventions to prevent other interventions . 

 

 this is for me an example: a young midwife has been recently awarded by a scientific association for having invented a special birthing pool.(actually after some days of polemic the association stated that the award was for the studyconducted behind this invention...) 

 

 This pool is equipped with an elevating basis/platform to be used in case of emergency (and so far I thought 'great') but also with other special components so that it can be transformed into this.....

 

 

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for me it was a bit of a shock....

 

the colleagues argued that the idea came from her investigation among midwives that outlined the poor used of water immersion and water birth in some hospitals due to the perception of risk (as far as I understood, unfortunately I report what I read and was not in contact with this midwife).

 

 Basically the rationale was 'given the safety discourses discouraging this practice in some areas, let's invent something that can make it waterbirth safer at the eyes of our culture so to make it more acceptable in Italy and enchance the possibilities for women'. debates were not lacking in Italy after that, and I read many comments on facebook between the midwife-inventor and many other colleagues and obstetricians as well that questioned her idea (I sense that this pool looks ideal to many others though).

 

I could even imagine the genuine attempt of this young colleague to contribute to increase the possibility of using water for women in Italy, but is equally evident the paradox we can embody. I could also mention another dangerous apparently little thing (because many episodes are totally unknown to the most)... 

 

I discovered that there is a proposal for a law in Italy made by an obstetrician in our parlament, to reduce CS and increase normal birth. I though 'wonderful maybe we are getting there, they will invest on evidence based midwifery models).... well actually not at all. the proposal was to introduce as way of enhancing 'natural birth' (parto naturale) [sic] another splendid invention, that is part of a current study in Tuscany and that already regardless the negative statements on this made by our college and many experts (obst included)-

 

basically is about a belt called 'baby guard' for 'a safe birth' that fundamentally is a soft high tech way of making fundal pressure in labour -Kristeller manouvers  (!!!!!) 

Again let's build (medical) interventions to reduce (medical) interventions. No protests done so far have been successfull in stopping this also because I don't think we really understood the danger behind this. Just yeterday I raise again these two episodes as something we don't have to ignore in our local college of midwives. 

 

 

 

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it's so painful for me to see that the future for normal birth in our parlament is to invest in these things, there is so much to change and I can see that problem is first of all among midwives to be sure that this cannot be the way. Certainly being aware is the necessary first step 

we cannot acknoledge the advantages of certain models and then letting them be altered in the name of 'contextualisation of care..' for example.  

 

 

sorry for the long mail and the aweful pictures but I found all this interesting, it makes me reflect a lot, question a lot.

I think we need to spread knowledge, to keep fighting to avoid alteration of truth but also I can see how we need confident, supportive and caring midwives in the everyday battles. I can never take for granted that we as midwives are sharing views and professional identity, we need probably to re-make clear points on basic things like what 'normality' is about, what 'midwife-led care is about'.. evidence is not missing so probably we are missing something in getting right messages right...don't know, I would love your view on this.

 

thanks to all for being such 'critical' inspirations

 

Laura Iannuzzi

 

 

 

2015-06-12 11:28 GMT+02:00 Soo Downe <[log in to unmask]>:

Very interesting observations Allision, and I agree with you we have been guilty of what Annendale calls ‘ironic interventions’ (what midwives do is normal, and we will do it to stop doctors doing all their interventions, which are abnormal) – and your analysis of the choice phenomenon is really insightful in my view. Indeed, the issue of ‘low risk induction’ brings this into sharp focus, as now we are introducing exogenous pharmaceutical agents into the induction process and calling it low risk. Just because we have made the mistake of doing interventions in the name of protecting women from other ‘bad’ interventions before doesn’t make it safe to be extending these ironic interventions into ever more pharmacologically or technologically intensive modes in the name of normalising birth, when the interventions we are trying to protect women from are unnecessary in the first place (acknowledging that the choice debate brings in another dimension here). I have been using  a house of cards metaphor to think about/discuss these kinds of issues recently – and I think we are in danger of building up interventions to prevent other interventions (rather than  to prevent pathology), when there may be better outcomes for women and babies overall if we backwards-engineer  the logic for each layer of the house of cards. I think we also may find that the opportunity costs of the resources we are using to do interventions to prevent other interventions are very large (now induction is being proposed for (? most) women as a general strategy to reduce ceasaren section, for instance).

 

all very interesting food for thought!

 

All the best

 

Soo

 

From: A forum for discussion on midwifery and reproductive health research. [mailto:[log in to unmask]] On Behalf Of Allison Farnworth
Sent: 12 June 2015 09:45

To: [log in to unmask]
Subject: Re: Isnt the concept of low risk induction a category error?

 

We’ve been doing some work with practitioners and pregnant women around this issue in Newcastle as part of an NIHR Knowledge Mobilisation fellowship, with the aim of increasing the use of high quality evidence in discussions about induction; we have chosen to focus on the issue of postdates induction as an issue of concern raised by service users and staff.  Note that we are trying to increase the use of this evidence, not suggest that it is the only form of knowledge used in individual decisions about IOL – we just want to make sure it’s somewhere in the discussion.

 

The qualitative work we did suggested that a major barrier to evidence use is the way in which postdates IOL is offered; not as a choice but as something that ‘happens’ (the phrase ‘what we allow’ and ‘what I’m allowed to do’  came up again and again, as it sadly does in many aspects of maternity, and indeed health care).  The set-up of services created an additional layer of influence in terms of what is viewed as a ‘good’ choice (i.e. go along with local guidelines, midwife will arrange the induction) and what is viewed as problematic (i.e. you want something different?  You need to see a consultant).  Where a choice is not presented as a choice (i.e. the alternatives are not described) then this decreases a woman’s motivations to seek information about her options, and where women don’t ask questions health care professionals assume that they’re happy and don’t want any more information (added to that the difficulties of accessing, interpreting and discussing the evidence base, particularly when it involves discussion of risks around difficult topics like stillbirth).  Additionally, the issue of who holds the power to decide was relevant, with midwives shying away from discussion of risks and benefits when they felt that they ultimately couldn’t sanction decisions (e.g. not wishing to provide information which could support the idea of going for care which is ‘off guidelines’ when that would mean involving a consultant).  So in terms of implementation it is far more complex that just providing the information, to either staff or women, there are cultural and institutional forces at play – the fact that induction is viewed as routine is a major barrier to increasing choices.

 

The issue was just as difficult for women who requested IOL without indication (similar issues to the elective CS debate which has been occurring on the mailing list recently) – it seemed as if evidence was given to them selectively, to support the position set out in the guidelines (or the position of the individual clinician).   Incidentally, many women I spoke to were more than happy to complete their pregnancy as soon as was possible and it’s important to note that many were engaging in all kinds of activities to try and induce labour ‘naturally’ – some of these activities were potentially dangerous (i.e. performing multiple cervical sweeps on themselves or getting their partner to do it, castor oil etc.).  I think in our wish to give good information about the benefits of physiological labour, we need to be very careful not to alienate women who don’t place a lot of value on that (for some women, labour is just a means to an end, and one they would happily accelerate or omit if they were able to). 

 

We’re currently working on a service development initiative, working with service users and frontline practitioners to see whether making choice explicit, providing good quality information, and then supporting choice makes a difference (in terms of knowledge, confidence and perceived involvement in decision making).  We’re also doing some work with a health economist to look at the way in which women prioritise different factors when making choices about induction at term.

 

Sorry, I have rambled on a little there!  To address the low risk/high risk issue of the original post – risk is on a continuum and informed by individual risks and population level risks.  Low risk postdates induction involves women with no pathology who just happen to fall into a category where we know that risks of stillbirth are raised at the population level (although this is rarely communicated well to women).  It’s a very blunt screening tool but, as we are not good at identifying which are the women most likely to experience an adverse outcome, we offer IOL to all. Induction itself is clearly an intervention, so not low risk, but if evidence supports it being an intervention which can be safely managed in an environment designed for low risk situations for women who are having the procedure in the absence of an additional individual pathology, then I think we should consider that – if that matches a woman’s preferences.   It’s worth remembering that we perform cervical sweeps at home/in clinics and consider it a  spontaneous onset if the woman subsequently labours – but it is an intervention and one which appears to be administered to ‘low risk’ women quite liberally and haphazardly in my experience, food for thought!

 

Thanks, Allison

 

From: A forum for discussion on midwifery and reproductive health research. [mailto:[log in to unmask]] On Behalf Of Yvonne McGrath
Sent: 12 June 2015 12:47 AM
To: [log in to unmask]
Subject: Re: Isnt the concept of low risk induction a category error?

 

Hi 

 

I also totally agree. The concept of a low-risk induction is slightly bonkers and comes back to the interpretation of risk...going beyond 42 weeks versus the risk of induction.  In many cases women who may opt ( as most actually labour spontaneously prior to 42 weeks) to decline induction are treated as though they are playing a game of Russian roulette rather than making an informed decision to wait for spontaneous labour.

 

As we go 'forward' and things like the RCOG position paper on maternal age and induction inform practice the more I feel like the importance of properly informed consent (as enshrined in recent case law- health care practitioners take note?) increases. To quote the adage- It's not an informed decision unless you have all the information and just as we train women to be 'compliant' midwives are often 'compliant' or even indeed  to 'believe' all of the 'information' that they give to women.  "We offer IOL as the risk of stillbirth increases" but without giving the actual figures...

 

Yvonne

 

 

On Thu, Jun 11, 2015 at 11:41 PM, Lucia Rocca <[log in to unmask]> wrote:

Hi,

I completely agree!

We are getting to the paradox. In many Trusts if women agree to be induced and start labour with 1 Propess they are considered low risk and have access to AMUs....

Why where those women induced in first place?

xx

Lucia

 

Lucia Rocca-Ihenacho

Consultant Midwife for Public Health

St George's NHS Trust
4^th Floor Lanesborough Wing
St Georges Hospital
Blackshaw Rd
SW17 0QT
London
UK

PhD Student

Centre for Maternal and Child Health Research

School of Health Sciences

City University London

1 Myddelton Street

London EC1R 1UW

 

07989 230313

Skype contact: luciainsky

 

 

 

On 11 June 2015 at 23:33, Soo Downe <[log in to unmask]> wrote:

This looks like an important initiative that is likely to improve care in many areas, but I have to say,  I just don’t get the concept of a low risk induction. If a woman/baby is low risk, why are they being induced? I was always taught that you never undertake induction of labour unless you are prepared to do an emergency caesarean for the reason that the induction is taking place. So all women who have their labours induced are high risk aren’t they, by definition?

 

Or am I missing something fundamental here?

 

All the best

 

Soo

 

From: A forum for discussion on midwifery and reproductive health research. [mailto:[log in to unmask]] On Behalf Of Sandall, Jane
Sent: 11 June 2015 17:05
To: [log in to unmask]
Subject: NHS England London Strategic clinical network for maternity toolkits to improve experience and outcomes across London

 

Dear all

 

The NHS England London Strategic clinical network for maternity had a launch event yesterday.

http://www.londonscn.nhs.uk/networks/maternity-childrens/maternity/

The Overarching aim is to reduce variation in outcomes and experience of care for women and their babies in London.

FOCUS AREAS are

§  Maternal mortality

§  Reducing stillbirth

§  Women’s experience

A range of briefings and implementation toolkits are available on the website along with a fantastic film about IMPROVING MATERNITY EXPERIENCE ACROSS NHS SERVICE. The Maternity toolkits cover two work streams on models of care and improving outcomes, and are evidence based and address implementation by providing examples from London.

§  You can see the Full suite of toolkits on the web page above.

§  Continuity of midwife care

§  Outpatient induction of labour in low risk women

§  Midwifery led units

§  Maternity experience workshop

§  Post partum haemmorhage

§  Reducing stillbirth through improved detection of fetal growth restriction

§  Fetal fibronectin testing

 

Regards

Jane

 

 

______________________________________________________________________________

Jane Sandall
Professor of Social Science and Women's Health

NIHR senior Investigator
Division of Women’s Health | Faculty of Life Sciences & Medicine | King’s College London |Women’s Health Academic Centre | St. Thomas' Hospital

London| SE1 7EH

Florence Nightingale Faculty of Nursing and Midwifery

http://www.kcl.ac.uk/lsm/research/divisions/wh/index.aspx

 

[log in to unmask] | 020 7188 8149 | Skype | jsandall
PA Fiona George | [log in to unmask] | 020 7188 3639
https://kclpure.kcl.ac.uk/portal/jane.sandall

Maternity and Women’s Health and  Capacity Building theme lead
NIHR CLAHRC South London | www.clahrc-southlondon.nihr.ac.uk
King's Improvement Science | www.kingsimprovementscience.org

 

“Birth in Europe in the 21^st Century" is now published in English and is available  http://www.euro.who.int/en/health-topics/Life-stages/sexual-and-reproductive-health/publications/entre-nous/entre-nous/birth-in-europe-in-the-21st-century.-entre-nous-no.-81,-2015

 

 

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