Balancing  the  interests  of  your  clients  and  mi4ga4ng  li4ga4on  opportuni4es  

Dr  Danielle  Wilkins  

Working  with  a  birth  plan  

Declara4ons  •  Consultant  Obstetrician  in  private  prac5ce  •  2  children,  planned  pregnancies,  births  both  completely  not  to  plan  

•  Trained  and  worked  in  a  ter5ary  ins5tu5on  with  a  midwifery  model  of  care  for  15  years  

Birth  plan  •  WriBen  birth  plan  introduced  in  the  1980’s  •  Communica5on  tool  •  Encourage  women  to  think  about  what  is  important  to  them  

•  Realis5c  plan  •  Make  informed  decisions  

Birth  Plans:The  good,  the  Bad,  and  the  future.    Journal  of  Obstetric,  Gynaecologic  and  Neonatal  Nursing.  Vol  35  March  2006  

Birth  plan  •  Bubhub    •  “extremely  important  part  of  your  pregnancy  planning”  

•  “tremendous  significance”  •  “you  are  your  health  care  providers  are  in  agreement  on  all  issues  regarding  the  birth  of  your  child”  

Issues  •  “cynics  argue  that  wri5ng  a  birth  plan  is  fu5le  as  it  is  hard  to  predict  a  birth”  

•  A  detailed  proposal  for  doing  or  achieving  something  •  Conflic5ng  beliefs  about  what  cons5tutes  safe,  effec5ve  care  

•  Asked  to  prac5ce  against  our  training  and  professional  judgment,  “Clash  of  world  views”,  prac5ce  against  the  best  available  evidence  

Birth  Plans  Tickets  to  the  OR?  •  Percep5ons  of  obstetricians,  midwives  and  pregnant  women  regarding  outcomes  in  women  with  birth  plans  •  65%  of  health  care  providers  thought  that  women  with  a  birth  plan  were  more  likely  to  have  a  caesarean  sec5on  

•  2.4%  of  pa5ents  believed  that  women  with  birth  plans  had  an  overall  worse  obstetric  outcome  

White-­‐Corey,  Shelley.  MCN,  The  American  Journal  of  Maternal/Child  Nursing  Vol  38  

Oct  2013  

Dr  Google  •  “Men5on  clearly  how  oaen  you  want  your  cervix  checks  and  monitoring”  

Dr  Google  •  “Do  you  consider  aBached  fetal  monitors  to  be  something  invasive,  uncomfortable  and  restric5ve  to  your  mobility  and  only  to  be  used  for  short  periods  of  5me?”  

Dr  Google  •  “If  you  require  help  to  deliver  your  baby,  what  would  your  preference  be  –  forceps  or  ventouse?”  

Dr  Google  •  “Do  you  prefer  a  rou5ne  episiotomy  or  to  avoid  an  episiotomy  altogether?”  

Dr  Google  •  “Do  you  prefer  to  have  a  natural  third  stage  without  the  use  of  drugs  to  speed  up  the  delivery  of  the  placenta?”  

Some  real  life  examples  •  “We  want  the  lights  dimmed.    We  don’t  want  anyone  to  talk  unless  it  is  an  emergency.    The  only  sound  we  want  to  hear  is  the  music  we  have  prepared  for  the  birth”  

Some  real  life  examples  •  “We  are  happy  to  have  the  baby  monitored  with  Doppler  only.    CTG  will  only  be  consented  to  if  there  are  clear  and  dis5nct  signs  of  distress  in  the  baby  or  clear  and  dis5nct  concerns  for  the  baby”  

Induc4on  of  labour  •  Reluctance  =  medicaliza5on  •  Strong  belief  that  induc5on  increases  CS  •  Cascade  of  interven5on  •  More  common  with  prolonged  pregnancy  •  There  is  a  significant  increase  in  the  risk  of  s5ll  birth,  neonatal  and  post-­‐neonatal  mortality  in  prolonged  pregnancy  

Hilder  L.  Prolonged  pregnancy:evalua5ng  gesta5on-­‐specific  risks  of  fetal  and  infant  mortality.  Br  J  Obstet  Gynaecol  1998  

Induc4on  of  labour  •  A  policy  of  induc5on  compared  with  expectant  management  is  associated  with  fewer  perinatal  deaths  and  fewer  caesarean  sec5ons  

•  Expectant  management  monitoring    

Gulmezoglu  AM.  Induc5on  of  labour  for  improving  birth  outcomes  for  women  at  or  beyond  term.  Cochrane  Database  Syst  Rev  

2012  

Monitoring  in  labour  •  IntermiBent  doppler  ausculta5on  vs  CTG  monitoring  

Monitoring  in  labour  -­‐  CTG  •  Intrapartum  risk  factors  

•  Induc5on  of  labour  with  prostaglandin  or  oxytocin  

•  Abnormal  ausculta5on  or  CTG  

•  Oxytocin  augmenta5on  •  Regional  anaesthesia  •  Abnormal  vaginal  bleeding  •  Maternal  pyrexia  >37.9  •  Meconium  or  blood  stained  liquor  

•  Absent  liquor  following  amniotomy  

•  Prolonged  first  stage  •  Prolonged  second  stage  •  Pre-­‐term  labour  less  than  37  

completed  weeks  •  Tachysystole  •  Uterine  hypertonus  •  Uterine  hypers5mula5on  

Monitoring  in  labour  •  “clear  and  dis5nct  signs  of  distress  “  •  Blood  stained  liquor  •  Absent  liquor  following  amniotomy  •  Prolonged  first  or  second  stage  •  Tachysystole  •  Uterine  hypertonus    

Monitoring  in  labour  -­‐  IA    •  RANZCOG  guidelines  for  intermiBent  ausculta5on  •  Every  15-­‐30  minutes  during  the  first  stage  of  labour  •  Aaer  each  contrac5on  or  at  least  every  5  minutes  in  the  ac5ve  stage  of  labour  

•  Each  ausculta5on  episode  should  commence  toward  the  end  of  a  contrac5on  and  be  con5nued  for  at  least  30-­‐60  seconds  aaer  the  contrac5on  has  finished  

Rou4ne  vaginal  examina4ons  •  Uncomfortable  •  Invasive  •  Flat  on  bed  •  Risk  of  ascending  infec5on  

•  Confirm  presen5ng  part  •  Assess  posi5on  •  Assess  progress  •  Assist  with  progress  •  Assess  well-­‐being  

Presenta5on  and  posi5on  can  be  assessed  by  ultrasound  scan  but  this  is  less  common  

once  labour  has  commenced.      

Ac4ve  management  of  labour  •  Kieran  O’Driscoll  BMJ  1973  •  Main  emphasis  was  on  care  and  managing  pain  •  Examina5ons  for  progress  every  1-­‐2  hours  •  Decreased  CS  rate  •  “Rectal  examina5on  has  a  decided  advantage  over  vaginal  examina5on  in  assessing  progress  because  it  can  be  performed  at  regular  intervals  with  much  less  formality.    An  important  prac5cal  considera5on  in  a  busy  unit.”  

NICE  guidelines  2014  •  When  conduc5ng  a  VE  •  Necessity  •  Aware  of  distress  •  Explana5on  before  •  Ensure  

•  Consent  •  Dignity  •  Privacy  •  Comfort    

•  Explain  aaerwards  

•  Avoid  “rou5ne”  interven5ons  

World  Health  Organisa4on  •  4  hour  ac5on  line  

I  won’t  have  an  epidural  Pro’s  •  Most  cases  v  effec5ve  pain  

relief  •  Relaxa5on  of  perineal  m  •  Rest    •  High  blood  pressure  •  Less  discomfort  with  

assisted  birth  •  Awake  for  CS  

Con’s  •  5-­‐10%  patchy  pain  relief  •  Effect  is  too  high  •  Limited  mobility  •  IV,  monitor,  catheter  •  Less  effec5ve  labour  •  Less  effec5ve  pushing  with  

increased  risk  of  forceps  •  Can  double  the  odds  of  CS  •  Drop  in  blood  pressure  •  Spinal  headache  

todaysparent.com  

Storknet.com  •  Undesired  effects  on  newborn  •  Neurobehavioural  effects  –  irritability,  inconsolability,  decreased  ability  to  track  an  object  visually  or  to  shut  out  noise  

54  infants….  •  Possible  less  efficient  or  less  organized  roo5ng  •  Short  term  decreased  infant  responsiveness  

Denise  M.  Risks  and  Benefits  of  Epidural  Analgesia  

NICE  guidelines  •  Only  form  of  full  pain  relief  •  Not  associated  with  a  longer  first  stage  of  labour  •  Not  associated  with  an  increased  risk  of  CS  •  It  is  associated  with  a  longer  second  stage  (wait)  •  There  is  an  increased  risk  of  instrumental  birth  •  Will  be  accompanied  by  more  intensive  monitoring  

Ventouse  or  forceps  •  “an  episiotomy  is  cut  to  make  space  for  the  forceps  in  the  vagina”  

Episiotomy  •  Not  rou5ne  •  Does  not  prevent  all  third  degree  tears  •  Nega5ve  impact  on  birth  sa5sfac5on  

Physiological  third  stage  •  Oxytocin  for  third  stage  •  Less  blood  loss  at  delivery  •  Less  likely  to  have  a  blood  transfusion  •  More  likely  to  have  aaerpains  

Making  it  work    •  Communica5on  tool  

•  Ask    •  Con5nuity  of  carer  

•  Encourage  women  to  think  about  what  is  important  to  them  •  Nature  

•  Realis5c  plan  •  No  epidural/episiotomy  

•  Make  informed  decisions  •  Accurate  informa5on  

PND  •  Sa5sfac5on  with  birth  experience  is  closely  linked  with  postpartum  depression  

•  Women  who  felt  in  control  of  their  birth  plans,  and  who  had  support  when  things  didn’t  go  as  planned,  were  very  sa5sfied  with  their  birth  experience  and  experienced  less  postpartum  depression  

Benoit  et  al  2007