Dear all

Apologies for cross-posting

Thank you for your e-mail, Belinda, and for generating such an interesting discussion.  As others have remarked, it is shocking that the Trust is considering the implementation of routine scans in labour for all nulliparous women.

I wanted to follow up on the discussions around midwifery practice, and the question of whether midwives falsely record a cephalic presentation in order to try to protect women from unnecessary intervention.  This 'fits' with one of the findings of my PhD, which explored midwives' experiences of vaginal examination in labour.  The midwives I interviewed all spoke about the practice of falsely recording a vaginal examination - this was something they had either done themselves and/or witnessed other midwives doing.  The most common example midwives described was a scenario where a vaginal examination indicated that the cervix was fully dilated but the midwife recorded that it was only 9 (or 8 ...) cms dilated.  Midwives did this in order, as they described it, to 'buy time' i.e. to try to avoid an instrumental birth for 'delay' in the second stage.

This practice of hiding/subverting midwifery knowledge is fascinating and hugely problematic.  The midwives I interviewed all believed, with great sincerity, that they were protecting the woman's best interests and that they were providing woman-centred care.  However, there are several points to consider:
1) Working in this way simply sustains dominant belief  systems.  In relation to vaginal examination, it upholds current beliefs about the length of labour, rather than challenging them. 
2) The midwives in my study did not involve women in the decision to falsely record vaginal examination and therefore I don't accept that this is woman-centred practice. 
3) This is a highly subversive way of working.  I believe passionately in the important of evidence based practice (by which I mean all types of evidence, qualitative and quantitative).  We, as midwives, need to have the courage and integrity to expose our own knowledge and practice to scrutiny, rather than hiding it away and practising in a way that is, ultimately, dishonest.

Sorry, this is rather a long e-mail but if, as others have suggested, midwives may be recording a cephalic presentation when they know this is untrue, I don't think this is 'doing good by stealth' - it's dishonest and unhelpful and, as Belinda's e-mail starkly illustrates, can lead to more rather than less intervention.

Very best wishes

Mary


Research Midwife
Birthplace Study
National Perinatal Epidemiology Unit
University of Oxford
Old Road Campus
Oxford
OX3 7LF
 
Tel: 01865 289732
 
http://www.npeu.ox.ac.uk/birthplace
 


>>> "Davenport, Claire" <[log in to unmask]> 5/12/2010 9:30 am >>>
Dear Belinda,

 

I always become somewhat dismayed when I hear about trusts adopting
"knee jerk" reactions to isolated incidents. Where is the evidence for
implementing the practice of scanning all nulliparous women in labour? I
would also question where they intend to obtain the resources for such a
policy, particularly out of office hours. Are they going to rely upon
the already over burdened junior doctors? Perhaps the consultant will be
called each time a woman is admitted in labour? If they intend to train
all the midwives in ultrasonography I would argue that the time and
resources required would be better spent developing their basic
midwifery skills and confidence in abdominal palpation in the antenatal
period.  

 

Perhaps you could suggest that an audit of all women admitted to your
unit in labour with an undiagnosed breech presentation be undertaken to
ascertain how many women this actually affects. Once you have obtained
the figures a clinical skills and education initiative could be
implemented which focuses on diagnosis and management of breech
presentation both antenatally and in the intrapartum periods followed by
another audit to assess whether this has been effective in reducing the
incidence.

 

I think developing midwives' skills seems rather more sensible than an
over reliance upon USS and a consequent decrease in basic midwifery. 

 

Claire

Claire Davenport

Research Midwife

Research Midwives' Office, Level 6, Leazes Wing, Royal Victoria
Infirmary, Newcastle Upon Tyne. NE1 4LP

Tel: 0191 2820436

 

________________________________

From: A forum for discussion on midwifery and reproductive health
research. [mailto:[log in to unmask]] On Behalf Of
Belinda Cox
Sent: 11 May 2010 14:27
To: [log in to unmask] 
Subject: Breech presentation

 

Dear all,

 

Apologies for cross posting this. 

 

I really need some advice and support here - I'm almost in tears!! 

 

The Trust I work for has identified that we're having an increased
number of women diagnosed with breech presentation in established
labour, and are exploring the implementation of scanning all nulliparous
women on admission in labour to confirm presentation!! 

 

My view is that we need to look at why the presentation isn't being
confirmed  PRIOR to labour if there's a query about it (e.g USS), and
then if breech presentation is confirmed offering appropriate
counselling and ECV. IF a woman chooses to have a CS for breech
presentation it's better that she gives true consent (not in labour) and
that it's done electively and calmly rather than her being 'encouraged'
to have an emergency CS in labour. 

 

Have any other Trusts identifed this as a problem? does anyone have any
teaching or assessment tools that they use which would support the
midwives and obstetricians to decrease the number of breech presntations
that are missed prior to labour?

 

Any other thoughts on this? 

 

Best wishes,

 

Belinda