the magazine of the royal college of midwives midwives · contents infront 5 editorial the next...

The Magazine of The Royal College of Midwives

MidwivesFebruary/March 2010

AVOIDING TROUBLED WATERS | WHY DID THIS HAPPEN? | IT’S MORE THAN JUST TALKING | RCM MIDWIFERY AWARDS 2010 | BRIDGING THE GAP? | WHICH BAND AM I? | RCM CONFERENCES: THE ISSUES UNEARTHED | A GROWING PROBLEM

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contents

Infront5Editorial The next general election is almost upon us, Stuart Bonar outlines the RCM’s ‘maternity manifesto’.

22How to... A refresher page on measuring a mother’s pulse/heart rate.

51On courseA newly-qualifi ed midwife refl ects on her elective placement with the stillbirth and neonatal death charity Sands.

25On boardThe RCM is preparing to consult members about its governance review.

26Midwifery2020What kind of midwifery services do we want to see by 2020?

6NewsVBAC, oral hygiene, DVD on FGM, ‘baby brain’ debunked... stories relevant to the maternity care team.

30BleedingdisordersThe fi rst of three articles on the most common disorders.

17UpfrontIs it fear that is preventing women from experiencing pain-free labour? Yes, according to Ann Higson.

29LegalWhat does it take to be a midwife expert witness? Mark Solon explains.

62Close upA day in the life of a midwifesonographer.

18FeedbackImproved care for Polish women... Uniforms for community midwives...members air their views.

61DiaryBreastfeeding mothers, pregnancy sickness, MDG4 and 5... some of the study day topics.

February/March 2010 | Volume 13 • №1

27MSWsThe role of the MSW and concerns around correct pay banding.

23On politicsStuart Bonar highlights the main parties’ plans to improve maternity services.

20CuttingedgeJan Wallis reviews the latest midwifery-related research.

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Indepth32RCMawardsThe winners of this year’s annual midwifery awards.

7

COVER ILLUSTRATION ilovedust IMAGE Photolibrary

36TalkingComunication skills can be enhanced by using simple counselling techniques.

16AlbanyMidwives’ explores King’s decision to terminate its contract with Albany.

How to...A refresher page on measuring a mother’s pulse/heart rate.

On courseA newly-qualifi edmidwife refl ects on her electiveplacement with the stillbirth andneonatal death charity Sands.

On boardThe RCM is preparing to consult members about its governancereview.

Midwifery2020What kind of midwifery services dowe want to see by 2020?

30BleedingdisordersThe fi rst of threearticles on the most common disorders.

29LegalWhat does it take to be a midwife expert witness?Mark Solon explains.

DiaryBreastfeeding mothers,pregnancy sickness, MDG4 and 5... some of the studyday topics.

27MSWsThe role of theMSW and concerns around correct paybanding.

On politicsStuart Bonar highlights the main parties’plans to improve maternityservices.

32RCMawardsThe winners of this year’sannual midwiferyawards.

11111111666666AlAlbab nyMidMidMidMMidMMiMidwivwww es’expxxppplorlorlorll es King’sdeecision to teeerminate its cocoontract withAlAlAlbany.

50SmokingNHS Tower Hamlets’ approach to smoking cessation for pregnant women.

38AnnualconferenceA snapshot of the RCM’s annual, student and workplace reps conferences.

42WaterbirthJane Pidgeon describes a risk assessment tool for supporting women and midwives at a home waterbirth.

44ChildpovertyAn outline of government initiatives to eradicate child poverty.

46StillbirthThorough investigation is key to the reduction of unexplained stillbirths.

48FGRresearchTracey Mills looks into the causes of fetal growth restriction.

49Start4LifeA new government campaign has been launched to tackle obesity.

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MIDWIVES 05 THE OFFICIAL MAGAZINE OF THE RCM FEBRUARY/MARCH 2010

editorialRCM public aff airs offi cer Stuart Bonar

MidwivesThe offi cial magazine of The Royal College of Midwives15 Mansfi eld StreetLondon W1G 9NHTel: 020 7312 3500

MEMBERSHIP DEPARTMENTTel: 020 7312 3500

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EDITORIALEditor: Emma [email protected]: 020 7324 2751Deputy editor: Maura O’Malleymaura.o’[email protected]: 020 7324 2752

Professional editor: Dr Mary Steen-Greaves PhD MCGI PGDipHE PGCRM BHSc CIMI RM RGN

EDITORIAL BOARDLouise Silverton, Sue Macdonald, Barbara Thorpe-Tracey, Margaret Rogan, Sarah Jamieson and Shirley Andrews

PUBLISHERSRedactive Publishing Ltd17-18 Britton StreetLondon EC1M 5TP Tel: 020 7880 6200Publisher: Jason Grant

ADVERTISINGAdvertising manager: Steve [email protected]: 020 7880 6220Sales executive: Giorgio [email protected]: 020 7880 7556

DESIGNArt director: Mark ParryArt editor: Carrie Bremner

PRODUCTIONSenior production executive: Kat [email protected]: 020 7880 6239

Printed by St Ives (Peterborough) Ltd Mailed by Packmail Ltd, Milton KeynesAll members and associates of the RCM receive the magazine free.The views expressed do not necessarilyrepresent those of the editor or of The Royal College of Midwives.All content is reviewed by midwives.Midwives ISSN 1479-2915

As I write this, there are less than 100 days to go until the most likely general election date of 6 May. With politics so fl uid, it may well come around even sooner. The RCM will be lobbying the parties and their

candidates direct from our London headquarters, but elections offer an additional opportunity for you to help us do that.

Elections are a time when power rests, not in the hands of the politicians, but in your hands. They need your votes to keep power, or to win it. And even in this era of facebook, twitter and all those other whiz-bang internet tools, candidates will still be out on the doorstep, speaking face-to-face with voters. We should all use those opportunities to challenge them on how they and their parties will improve maternity care.

So, if one or more of your local parliamentary candidates comes knocking, let me suggest a few questions and issues. Why not ask them if their party will recruit more NHS midwives? Tell them about your experience of working as a midwife, and any of the pressures and strains you operate under. Ask them about what their party plans to do with public sector pay and the NHS pension. Will their party support student midwives, offering them better fi nancial support? Will they work to give women choice and control over their care, and maternity services that

are better than they are now? They may not know the answer off the top of their heads as they will be asked about 101 things by voters, so ask them to write to you with the answers – don’t let them get away with niceties and platitudes.

With health a devolved issue, the House of Commons only controls the NHS in England. That said, if you live in other countries, you might still want to ask about your local situation. Whatever the constitutional position, politicians will want to respond to what you say.

From headquarters, we will be contacting all candidates from the mainstream parties with our own ‘maternity manifesto’. This will challenge candidates to work to ensure that frontline NHS services, like maternity care, are protected from the pressures that will be put on fi nances elsewhere. We will be asking them to make reducing inequalities the heart of their work. We will be pushing them to pledge to protect the pay and pension entitlement of NHS staff. We will also be asking them to act to cut obesity levels, to improve public health. They will also be asked to work to include fathers and families more. Finally, we will be pushing hard for better postnatal care – we asked the users of the netmums website to choose their priority for us, and that was their choice, by a country mile.

The power rests with you...

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News

Essential advice, tips and m

Women who have three or more prior caesarean sections (CS) are just as successful at attempting a vaginal birth as those that have had one previous CS.

This is the fi nding from a study that reviewed data from 25,005 women who

had at least one previous caesarean delivery in the US. The study not only looked at success rates for vaginal birth after caesarean section (VBAC) but the risk of maternal morbidity.

In total, 860 had three or more previous caesarean

deliveries and, of these, 89 attempted VBAC. The study found they were as likely to have a successful VBAC as women with one or two prior CS – 79.8% compared to 75.5% for one CS and 74.6% for two previous CSs.

Furthermore, none of

A new DVD has been launched to inform midwives and healthcare professionals on better working practices for sufferers of female genital mutilation (FGM).

Produced by the charity FGM National Clinical Group (FGM NCG), the DVD aims to inform midwives, doctors and nurses about better working practices when dealing with sufferers of FGM and their families.

Along with interviews and advice from senior health professionals, the DVD features instructions on how to perform a deinfi bulation with a live operation conducted by consultant gynaecologist at University College Hospital London, Sarah Creighton.

Patron of the charity, novelist Baroness Ruth Rendell, who features in the DVD, was

at the launch during the FGM NCG conference recently, highlighting

the need to safeguard women. Baroness Rendell has campaigned against FGM since she was informed of the subject around ten years ago. She told Midwives: ‘Before I was invited to the African women’s clinic at Middlesex Hospital years ago, I knew nothing about FGM, I knew it existed but that’s about it. After I saw photographs and heard stories from people

at the clinic, it simply grabbed me and I thought I’ve got to do something about this, and ever since then I’ve been writing about it, talking about it, asking questions in the House of Lords about it, writing articles for magazines and so on.’

Further information can be found at: www.fgmnationalgroup.org

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THREE PRIOR CS NO BARRIER TO VBAC

DVD highlights healthier future without FGM

06 MIDWIVES THE OFFICIAL MAGAZINE OF THE RCM FEBRUARY/MARCH 2010

Th ere is no evidence to support the idea that pregnancy causes lapses in memory, a new study has concluded.

It is a popular belief that pregnancy and motherhood aff ects a woman’s memory causing her to become more forgetful and absentminded, a phenomenon commonly referred to as ‘baby brain’.

Th e team recruited 1241 women aged between 20 and 24 and tested their cognitive function. Th e women were followed up at four-year intervals in 2003 and 2007, and given the same cognitive tests. In total, 76 women were pregnant at the follow-up assessment, 188 became pregnant between assessments and 542 remained childless.

Th e researchers found no signifi cant diff erence in cognitive function between women who were pregnant at the time of assessment and those that were not. Th is contradicts fi ndings from previous studies.

Lead author Helen Christensen said: ‘Obstetricians, family doctors and midwives may need to use the fi ndings from this study to promote the fact that ‘placenta brain’ is not inevitable.’

ReferenceChristensen H, Leach LS, Mackinnon A. (2010) Cognition in pregnancy and motherhood prospective cohort study. British Journal of Psychiatry 196: 126-32.

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MIDWIVES 07 THE OFFICIAL MAGAZINE OF THE RCM

FEBRUARY/MARCH 2010

d miscellany for midwives

them experienced signifi cant maternal morbidity, such as uterine rupture, uterine artery laceration and bladder or bowel injury.

The authors note that neither the RCOG nor the American College of Obstetricians and Gynecologists recommend planned VBAC attempts in women with three or more previous CS.

BJOG editor-in-chief

Professor Philip Steer said: ‘Although confi dence in the fi ndings of the study is limited by the relatively small sample size of women who have had three previous caesareans, these fi ndings provide additional information for women, and contribute to the available evidence on VBAC success and safety in women with more than one prior CS.’

The RCM’s general secretary Cathy Warwick

said: ‘This is a welcome study challenging the status quo in childbirth practice, providing signifi cant new information for women choosing VBAC.’ She added that the decision to have a VBAC can be hard to make.

ReferenceCahill AG, Tuuli M, Odibo AO, Stamilio DM, Macones GA. (2010) Vaginal birth after caesarean for women with three or more prior caesareans: assessing safety and success. BJOG: An International Journal of Obstetrics and Gynaecology doi: 10.1111/j.1471-0528.2010.02498.x.

NTLINERCM50

Do you think Maternity matters has made a real difference to women and their babies?

Off the Record is a bimonthly poll in which we ask 50 midwives a question refl ecting current professional concerns. It aims to be a forum and stimulus for discussion on issues of importance to midwifery. To join the panel, please contact Midwives’ deputy editor Maura O’Malley via email: maura.o’[email protected]

POLL

New blood spot screening card for EnglandNew blood spot screening cards are being introduced in England.

One of the main changes is that from 1 April, if the baby’s NHS number is not recorded on the card, laboratories will request a repeat sample. Any omission could prevent timely treatment of babies.

All fi elds must be completed and a bar-coded NHS number label should be applied to all sheets of the card.

Further information can be found at: http://newbornbloodspot.screening.nhs.uk

Th e vast majority of the panel voted ‘no’ to whether the government’s Maternity matters policy has made a real diff erence to women and their babies. Th e policy has promised women more choice when accessing maternity services.

Many in the ‘no’ camp believed that the resources to make the aims a reality were just not there and that it had given women unrealistic expectations of the service and resulted in an increase in dissatisfaction among women.

Another bemoaned the slow rate of change in the NHS, but said that

what it had done was raise awareness among users about what choices were available to them.

Another said midwives were dealing with more women, often with more complex needs and insuffi cient numbers of skilled midwives. Th e worsening fi nancial landscape had proved detrimental.

Among the ‘yes’ voters, one said it provided a framework for change and encouraged improvements in institutional policy.

Maternity matters

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FRONTLINENews

Improvements have been made to the maternity services of Milton Keynes NHS Foundation Trust, but planning to meet long-term demand remains a concern.

This is the conclusion reached in a review by the independent watchdog the Care Quality Commission (CQC).

The CQC says that temporary measures are in place to ensure that there are enough midwives to provide safe and effective care for mothers and babies.

However, these are not sustainable and the CQC said the Trust must concentrate on establishing permanent midwifery roles and opening more long-term beds.

It also said that the Trust must plan better for emergency situations, such as complicated births or staff shortages, and ensure that staff know what to do in these circumstances.

The CQC checked progress in implementing recommendations made in 2008 by the previous regulator the Healthcare Commission. The reviews were

prompted by concerns raised by a coroner following the death of two babies at the hospital. The CQC review refers to the babies’ deaths – one in June 2007, the other in May last year. While the circumstances

in each case were different, the CQC says the Trust must improve how it plans for periods of high demand.

More midwivesThe watchdog says it has not made ‘suffi cient progress’ in recruiting more permanent midwives. The Trust estimates that it will need about 150 midwives by 2013/14, in order to meet rising demand.

The key improvements that have been made include the appointment of more supervisors of midwives, the

fi lling of posts of risk midwife and head of midwifery, there are also plans to recruit a consultant midwife. Furthermore, policies and guidelines for maternity services are now regularly updated and cascaded to relevant staff.

The RCM’s general secretary Cathy Warwick said: ‘The actions and improvements made by Milton Keynes are welcome. The continuing increase in the number of births has made it diffi cult to ensure that midwife numbers keep pace, and this is the case for many English Trusts.’

Capacity remains a concern at Milton Keynes hospital


Government launches green paper on supporting familiesTh e government has announced a set of measures that includes plans by the RCM to produce new guidance for midwives on how to better engage with fathers.

Support for all – the families and relationships green paperdetails, among other things, how the government can support and recognise fathers, improve fl exible working for

families and provide targeted support for families in need.

Th e government has also published a booklet Guide for new dads, which will be included in Bounty packs. Th e guide gives tailored advice and tips for fathers ahead of their child’s birth.

Th e RCM’s general secretary Cathy Warwick said the RCM welcomed the green paper.

ensure that midwife numbers keep pace,and this is the case for many English Trusts.’

She added: ‘We particularly welcome the section of the green paper that supports plans by the RCM to produce professional guidance for our members on how best to engage fathers around the birth of their child and highlighting the benefi ts of this for the child and mother.’

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Training module for Down’s syndrome A new education module on screening for Down’s syndrome has been produced by the NHS Fetal Anomaly Screening Programme.

It aims to help health professionals deliver the frontline service to women and their families and to share a common framework of best practice.

Th e new resource, CEM T21, constitutes around 60 to 90 minutes of web-based learning time. It includes an overview of screening, choice and consent, screening times for Trisomy 21, how to perform fi rst and second trimester screening and the management of screen-negative and screen-positive women.

Th e modules can be accessed by visiting: www.fetalanomaly.screening.nhs.uk

PTSD in childbirthTh e second part of a study that focuses on post-traumatic stress disorder (PTSD) following traumatic childbirth in Eritrea is now available in the in-depth papers section of the Midwives website at: www.rcm.org.uk/midwives/in-depth-papers

Written by Eritrean midwife Ghebremicael Andemicael and University of Dundee’s Lorna Numbers and Linda Martindale, Eff ects on clinicians and lessons for practice focuses on the impact that obstetrical complications have on clinicians. It analyses critical incidents and the analysis is used to develop positive recommendations, such as the need for holistic assessment and correct documentation.

Win a BP monitorTwo blood pressure monitors, with proven and clinically validated accuracy during pregnancy and pre-eclampsia are available to win.

Th e Microlife 3BTO-A2 is designed to be used at the clinic or at home, with medium and large cuff s supplied to fi t all arm sizes. Th e monitor also comes with a three-year guarantee.

To enter the competition, write 200 words on eff ective blood pressure monitoring at home. Applications should be sent to the editor Emma Godfrey at: [email protected]

Th e competition is open to all Midwives’ readers aged 18 or over. Closing date for entries is 19 March. Winners will be notifi ed within 14 days of the decision being made and names will appear in a future issue of Midwives. Only one entry per household will be accepted. Th e judge’s decision is fi nal.

INBRIEF


A case of stillbirth caused by bacteria originating in the mother’s mouth has been reported in the journal Obstetrics and Gynecology.

The woman had pregnancy-associated gingivitis and experienced an upper respiratory tract infection at term, followed by stillbirth a few days later.

The bacterium Fusobacterium nucleatum was isolated from the placenta and the fetus. It was also isolated from the mother’s subgingival plaque, but not in the supragingival plaque, vagina, or rectum.

The authors conclude that the bacterium may have translocated from the mother’s mouth to the uterus where the immune system was weakened during the

Call to monitor future of maternity services

Poor dental hygiene associated with stillbirth

The shortfall between the number of midwives and rising birth rates across the UK is the main concern highlighted in the NMC’s Support, supervision and safety report.

Of the 26 local supervising authorities (LSAs) that reported to the NMC for the practice year 2008/09, only one LSA did not state an increase in birth rate. While most areas reported rate increases of 1% to 2%, some areas reported up to 5%.

Other concerns highlighted were an increasing number of complex births along with the challenges of obesity, substance abuse and the fact that in some areas, many experienced midwives are set to retire shortly.

Reported birth trends showed that caesarean section rates remained high, while home birth rates remained low and variable.

Analysis of all the individual reports did reveal good practice regarding service development for vulnerable families, with some LSAs having well-established specialist midwifery services available and increased midwifery ratios. Concerns were noted about the amount of midwives recommended to undertake a period of supervised practice.

The annual report helps to monitor the LSAs and make sure they are meeting requirements.

The report can be found at: www.nmc-uk.org

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recognised as a cause of stillbirth, but the source of the infection often remains unknown.

The RCM’s Mervi Jokinen says that this case highlights the importance of maintaining good oral hygiene during pregnancy, and to visit the dentist regularly, which is free for expectant mothers in the UK.

ReferenceYiping HW, Fardini Y, Casey C, Iacampo KG, Peraino VA, Shamonki JM, Redline RW. (2010) Term stillbirth caused by oral Fusobacterium nucleatum.Obstetrics and Gynecology 115(2): 442-5.

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RCMNews

CMMINBRIEF

Newly-qualifi ed membership subscription rateThe RCM has introduced a special discounted subscription rate for newly-qualifi ed midwives.

From 1 January 2010, RCM members who qualifi ed as a midwife after 1 September 2009 can benefi t from the discounted subscription.

The discounted rate of £9.99 per calendar month is 52% of the full membership subscription of £19.18.

Student members currently benefi t from a three-month extension period after the end of their training, during which their student subscription rate continues.

At the end of this period, qualifi ed midwives will be eligible to benefi t from the rate for 12 months. After this fi rst year, the full member

subscription rate will then apply.The offer is open exclusively to

qualifi ed midwives who transfer to full membership having previously been student members of the RCM.

The RCM’s deputy general secretary Louise Silverton said: ‘The RCM appreciates that our new midwives need our help as they make the transition to their fi rst job. We want to celebrate and reward the new joiners to our profession. We need to make sure midwives can rely on the RCM to provide the service they need at a cost they can afford throughout their professional lives.’

This discount has been introduced initially for a one-year pilot period.

Support for the millennium development goals (MDG) 4 and 5, and the need for midwifery-skilled professionals worldwide are the key RCM campaigns around this year’s International Day of the Midwife (IDM) on 5 May.

The International Confederation of Midwives’ continuing IDM theme ‘The world needs midwives now more than ever’ is set to see the RCM urging politicians to take action towards achieving MDG5 to improve maternal health and reduce

maternal mortality by three quarters and

MDG4 to reduce child mortality.

For IDM 2010, the RCM is also highlighting

obstetric fi stula and the work of the

UK charity Freedom for Fistula Foundation,

which funds projects preventing and repairing fi stulas in Africa and ensuring all pregnant women have access to health care.

If members would like to get involved in any fundrasing for IDM, check the RCM website or email: marketingoffi [email protected]


Th ere are no guaranteesTh e National Maternity Support Foundation (NMSF) and the RCM have launched a leafl et aimed at helping parents plan for the birth of their baby.

Th ere are no guarantees provides tips for discussing options for place of birth, as well as other important considerations, such as use of birthing pools and getting to know midwives in the team.

Th e leafl et is available from the RCM website at: www.rcm.org.uk/college/standards-and-practice/national-maternity-support-foundation

Birth centre opens

Th e RCM’s president Liz Stephens opened a new £180,000 birth centre at St Helier Hospital in January. She said: ‘Th is is a fantastic new facility and I’m proud to be here today.’ Pictured from left are chief executive Samantha Jones, RCM president Liz Stephens, MP Tom Brake, head of midwifery Sally Sivas and MP Paul Burstow.

RCM helps HaitiTh e RCM has donated a £500 start-up contribution to support medical relief charity Merlin and their work in earthquake-stricken Haiti.

Donations will be collected at the St David’s Day conference on 25 February in Wales and at events throughout England, such as the mothers and midwives collaborative conference on 15 April.

Members can make further donations for Haiti relief at: www.merlin.org.uk/donate.aspx/Haiti-Earthquake-Emergency-Appeal.aspx

Competition winnersCongratulations to our two competition winners – Elizabeth Wynn from Gloucester and a midwife from East Midlands – who were the winners of the ULR postcard competition from the recent RCM conference. Both have won an Apple iPod® Nano.

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RCM UK BOARD FOR SCOTLAND

HIV/AIDS DISCRIMINATIONThe RCM was invited to provide written and oral evidence to the Equality Committee of the Welsh Assembly Government on discrimination against pregnant women who have HIV or AIDS. We were pleased to report that there is no evidence of discrimination.

PARKING FOR PREGNANT WOMENThe RCM was delighted to support Assembly Member Darren Millar’s initiative to allow women in the latter stages of pregnancy to use parking spaces designated specifi cally for

them. This initiative was launched at the Senedd on the 1 December.

SNOWY CONGRATULATIONSJanuary has been particularly challenging because of adverse weather conditions. I have been heartened by stories of midwives putting in that bit extra to ensure women receive the care they need. Congratulations to all for maintaining a safe service in these diffi cult times.

ST DAVID’S DAY CONFERENCEThis year, our conference will be held on 25 February at the SWALEC

stadium. The theme is perinatal mental health. Women affected often face a postcode lottery when trying to access care. The new All Wales hand-held maternity records ensures that questions are asked regarding risk factors, which could help to identify women who may develop mental illness in the postnatal period. The day, which promises to be thought-provoking and informative, will highlight some of the excellent work being undertaken. Speakers will provide an insight into their own mental health issues. I look forward to welcoming midwives, students and other professionals from the fi eld of mental health. For further information, please contact the RCM Welsh Board offi ce on Tel: 02920 228111 or email: [email protected]

St David’s Day Conference 2010

RCM UK BOARD FOR WALES

Helen Rogers, RCM UK Board for Wales board secretary

FIRST MEETING OF NEW BOARDThe new board had their fi rst meeting in November followed by a reception for the retiring board. It is really encouraging to see that there are 11 new members with only one remaining vacancy in the South East. They are joined by two student attendees. The new board chair is Annette Lobo, consultant midwife for NHS Fife and ward manager from Tayside Vanessa Shand is deputy chair.

BOARD CONFERENCEThe Scottish board held

a very successful one-day conference on 12 November. The morning focused on the

international aspect of midwifery care, with the International Confederation of Midwives (ICM) vice-president and RCM director Frances Day-Stirk setting out the ICM vision and the work involved. The afternoon saw the normality agenda take centre stage. One of the most thought-provoking presentations was delivered by Ann Glaog, who established the charity Freedom from Fistula Foundation. This organisation works to tackle the problems around obstetric fi stula and to provide training for health professionals in the developing world. This year on International Day of the Midwife (5 May), the RCM will work with the foundation to raise UK awareness.

NEW CNO FOR SCOTLANDThe new chief nursing offi cer, Mrs Ros Moore started in January. Mrs Moore has occupied a number of posts in England, most recently as NHS Connecting for Health’s nursing director. I will be meeting with her shortly.

SERVICE POLICY REVIEWThe Maternity Services Action Group have been considering the service’s future and believe it is now time to review and update A framework for maternity services in Scotland, which was the cornerstone of maternity services policy when it was published. You will hear more about this shortly and a one-day conference will be held in May to bring together key stakeholders to infl uence this process.

Board conference successGillian Smith, director of the RCM UK Board for Scotland

BOARDNews

ARDARD


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INFOCUS

Are midwives becoming too specialised?Could an overemphasis on specialist skills be to the detriment of the core

midwifery role? Midwives’ Maura O’Malley reports.

NewsFOCUFOCU

Acquiring additional specialist knowledge and skills is usually viewed as an

unequivocally positive thing. But a motion for debate at this year’s RCM annual conference considered whether the emphasis on gaining specialist knowledge could come at the expense of key midwifery skills.

Speaking at the debate, North Wales community midwife Kath Jones said that midwives should be encouraged and enabled to take on extended roles, such as prescribing, performing neonatal examinations and facilitating more normality for high-risk women – all of this enhanced the continuity of care for them and their families.

She acknowledged, however, that by encouraging midwives to take on these specialist roles and specialist knowledge, there is the risk that the

core aspect of the role of the midwife is being ‘diluted’.

She, therefore, supported the meeting’s motion that called for higher education institutes to ensure newly-qualifi ed midwives had the opportunity to experience the ‘full spectrum of midwifery practice’, be that in midwifery-led units (MLUs) or high-risk labour wards.

The motion also appealed for ongoing learning opportunities as part of a structured approach to continuing professional development. Kath said it was imperative that midwives were able to develop their expertise and skills, whether these were developing technical skills, such as undertaking

does not necessarily ensure that midwifery retention rates are as healthy as they could be.’

Mary added that there was a view that care could be improved by midwives fi rst consolidating their labour ward practice before working in a community setting, ‘we are not aware of any evidence to support this position’. This tended to alienate midwives and made them less inclined to remain in practice. A more proactive approach would be to support young midwives ‘in the area of their choice, irrespective of whether it is the labour ward or the community’.

Kath said that there were not enough practising midwives to cope with the rising birth rate. ‘This capacity defi cit will make it diffi cult to facilitate more diverse models of care or cater for an expansion in the number of specialist midwives.

‘Any increase in the number of midwives with additional and specialist skills had to be planned in accordance with the overriding imperative to signifi cantly expand the existing core workforce.’

A Blackpool midwife said: ‘We have so many specialist midwives now who seem to have forgotten how to do basic midwifery.’ They have lost the ability to multitask like other midwives had to.

Kath concluded: ‘We have got a fi ght on our hands, to say to our employers, to say to our commissioners that we need more funding to enable midwives to be able to do the job we love, to provide fantastic services for women and their families.’

MIDWIVES SHOULD BE ENCOURAGED AND ENABLED TO TAKE ON EXTENDED ROLES SUCH AS NEONATAL EXAMINATIONS

forceps delivery or ventouse extraction, or skills involved in facilitating normality and ‘we must remember that is a skill’.

Kath and second speaker Dr Mary Steen-Greaves, a reader in midwifery and reproductive health at the University of Chester, said that by allowing midwives the choice of how they want to work could help the profession’s attrition rates.

Mary said: ‘An expectation that midwives rotate and maintain their skills in all areas may conform to an ideal of midwifery practice, but

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Th e RCM has expressed its disappointment at King’s College Hospital’s decision to terminate its contract with Albany Midwifery Practice. Midwives’ explores the issues around the decision.

Established in 1997, the Albany Midwifery Practice championed women-centred,

midwifery-led care and had been an inspiration to other midwives in the UK and internationally. The RCM believes that the model of maternity care offered by Albany, which specialised in home births, can and should be replicated and adopted by other maternity services.

The RCM has expressed its disappointment at the termination of the contract between Albany and King’s College Hospital. The contract was discontinued following the publication of a review by the Centre for Maternal and Child Enquiries (CMACE) into a number of babies delivered by Albany midwives that had been born in an unexpectedly poor condition.

The report pointed to a number of lessons that needed to be learned and addressed. It said that risk factors for a poor outcome in

pregnancy were being overlooked and called for improvements in teamwork, workload, midwife-client relationships, risk assessment, governance, leadership, training, supervision and audit.

The RCM is disappointed that the contract was terminated because the report did not call for this. It recommended changes to the service, not its closure. It believes that conclusions about safety cannot be drawn without further evaluation. Previous evaluations had shown the Albany practice to have exceptionally good outcomes.

It was legitimate that King’s investigated the cluster of cases causing concern, says the RCM. The specifi c methodology used for the report by CMACE had limitations that were acknowledged. The report itself notes that the confi dential enquiry methodology employed was ‘not intended to provide answers or information about individual cases’,

Albany

or does it demonstrate statistical signifi cance. The data generated by the review confi rms that the Albany group practice provides care for some women in the most deprived population quintiles.

Despite this, the obstetric and medical attributes of their clientele at booking and the problems encountered in the antenatal period did not appear, to the authors of the report, to be unusually challenging. As a result, the report said that similar outcome data should be anticipated for women cared for by the Albany group practice compared with women cared for in neighbouring midwifery practices serving King’s College Hospital.

The RCM believes that while this is true, the data cannot be drawn upon to support the notion that this model of care (and home birth) is intrinsically unsafe. It does, however suggest, as have other reports, that the planned assessment of appropriate care and place of birth and, hence the advice provided to women, should be of the highest standard.

The RCM’s general secretary Cathy Warwick said she was concerned that the closure was being used to ‘colour the debate’ on giving birth at home. Professor Warwick added: ‘Albany was a very innovative model and helped to accelerate the provision of women-centred services. There is no doubt that there are lessons to be learned from this report. With the right structures and processes in place, the model of service offered by Albany can and should be replicated and adopted by other maternity services.’

The RCM has been supporting Albany midwives throughout the process and will continue to represent them and promote their best interests.

End of the road


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Upfront

The fear of childbirth

Reference

Dick-Read G. (2005) Childbirth without fear: the principles and practice of natural childbirth (fourth edi-tion). Pinter and Martin Ltd: London.

A new read for modern midwives is an old book entitled Childbirth without fear. First published in 1942, this ground-breaking text-book put forward a

realistic and understandable hypothesis for the pain felt by most women when experiencing labour. The author, Dr Grantly Dick-Read was a GP, who attended home births and noticed vast differences in how women dealt with contractions. Women who were not afraid of childbirth appeared to have easier labours.

Dr Dick-Read assumed that there must be a physiological reason for this and on investigation into the anatomy and physiology of smooth muscle, he discovered why fear causes pain in childbirth.

The human body has a considerable amount of smooth muscle in it, the uterus being just a small fraction of our total count. The alimentary canal or guts are a prime example of smooth muscle. It takes our food and guides it through a series of tunnels to its fi nal destination, the toilet. It would be highly inconvenient, if every time we ate, we rolled around in agony shouting for an epidural while our gastric smooth muscle was contracting.

The uterus is basically an inverted bag of smooth muscle. There is no reason why this smooth muscle should hurt any more than non-uterine smooth muscle when contracting during normal use. The culprit for causing the pain of contractions is the hormone adrenalin, which is secreted whenever we are under physical or mental stress.

The secret to pain-free contractions is simply to teach women relaxation techniques in pregnancy, which can be practised before labour begins. A relaxed person does not secrete adrenalin.

So why are women secreting adrenalin during labour? Women believe that labour will hurt, so they are afraid of it and as soon as they start to labour, they begin to secrete adrenalin, which causes the pain and so justifi es their belief. The media in general love tales of woe regarding pregnancy and by far the most infl uential aspect of modern day living has to be television. When was the last time a birth was shown on one of the soap operas that did not present the

labouring woman as being in acute agony?

The best way to explain the concept of a pain-free labour to pregnant

women is to describe the way adrenalin attaches itself to the uterine cervix and prevents dilatation. An injection of adrenalin is often used in cervical surgery to minimise blood loss by causing the cervix to tighten. Women then understand that by being afraid they are tightening their cervix so it is harder to open, relaxation can then be introduced as a way to stop adrenalin secretion, thus releasing the cervix from its grip.

I know it is diffi cult to accept, especially if a painful labour has been experienced personally. As a mother of four, I had two very painful labours and then, after discovering what was causing the pain, two pain free. The fear of childbirth is so deeply entrenched into our belief system that it will be diffi cult to erase. Introducing the thought of using relaxation and explaining the effects of adrenalin on labour may just plant the seed that will fl ower into confi dent women, who can experience childbirth with calm enthusiasm instead of naked fear.

Is it fear that is preventing women from experiencing pain-free labour? Midwife Ann Higson explains her answer.

✻ Sit fairly upright in a chair or on a birthing ball✻ Th ink about parts of the body becoming heavy such as the feet then legs✻ Work up the body spending extra time on the shoulders and neck✻ When a contraction comes, don’t tense up – carry on going back to parts

of the body and relaxing them.

HOW TO RELAX IN LABOUR


ISTO

CK

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Feedback

Your published views

FROM: Aldona Morrison, midwifeSUBJECT: Improved care for Polish womenEMAIL: [email protected]

Dear editorIn Midwives October/November 2008, I wrote about my project to help Polish women, who have problems communicating in English. The project is going from strength to strength. The number of women attending Polish antenatal clinics is increasing and the feedback from clients and colleagues has been extremely positive.

Antenatal care in Poland is managed very differently and involves obstetricians on a daily basis. This is why it is so important to inform Polish women of the antenatal care pathway in the UK. The women have the ability to discuss their fears in their mother language; the medical and obstetric history is taken in Polish, thus ensuring appropriate individual care and allowing informed choice. To help my colleagues in all areas of practice, I have now developed a ‘Helping hand’ folder, which consists of leafl ets, information in Polish and English, key terms in both languages to ease communication and promote informed consent, especially in emergency situations and when an interpreter is not available. This has proved to be very successful and the folder has now been implemented in other Trusts, where the Polish community has signifi cant impact on their workload. Please contact me, if you are interested in further information about the folder.

FROM: Gwyneth Sanders, community midwifeSUBJECT: Specialised versus generalisedEMAIL: [email protected]

Dear editorI wonder what other midwives think of the idea that specialisation versus generalised midwifery skills are of benefi t to our profession. Specialisation has led to the development of antenatal screening midwives, drug and alcohol midwives, midwives with risk management knowledge, and midwife sonographers – all with midwife at the core of their job description, but with an added specialist role.

If we were to take that further, would we consider the community midwife has her own specialist skills relating to that role, in contrast to that of her colleague working within the hospital setting. After all, there are hospital-based nurses and community nurses, all


who operate within their particular area, requiring further training to undertake that role, which are not required to work in each other’s area of practice.

While most midwives might welcome the fl exibility that working in both settings gives, will the demands of what is a highly specialised area of practice – the hospital – lead to community midwives feeling underskilled in that setting?

The hospital midwife is a highly skilled practitioner. Many of the skills she exhibits are used regularly and in practising them frequently, she becomes more skilled. Equally, community midwives’ skills lie more in the care of the pregnant woman in relation to her social and emotional background, bringing into play issues such as social welfare and domestic abuse.

Is it possible that all this depth of practice can continue to be incorporated into one single midwife role or is there a place for further specialisation?

THE MEDICAL AND OBSTETRIC HISTORY IS TAKEN IN POLISH, THUS ENSURING APPROPRIATE CARE AND ALLOWING INFORMED CHOICE

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this PCT’s backward-looking view, we are to be colour coded according to our grade. Can you imagine teachers, health visitors or doctors agreeing to this? If the PCT want a corporate image, then all staff should be wearing a uniform. I have been told that ‘knowing one’s grade is useful for recognition of skill’, but this does not apply to community midwifery, where a certain amount of experience is required before leaving the hospital environment.

Wearing a uniform undermines a number of fundamental principles: a woman’s right to confi dentiality – we book in family centres, GP surgeries, clinics and homes; ease of communication and the avoidance of barriers in the community setting; of a woman’s right to see childbirth as normal physiology and not a pathological state.

For the midwife, there are other issues: the compromise of our safety as lone female workers when on-call. The uniform highlights our presence and our status as possibly carrying drugs, such as pethidine. By implication, the wearer is perceived

ILLU

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O H

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AIR YOUR VIEWSby email to: [email protected] or write to: Midwives at Redactive Media Group, 17-18 Britton Street, London EC1M 5TP (The editor reserves the right to edit letters).

as cleaner, the reality is solely dependent on individual cleanliness. Research shows no correlation between clothing and infection if basic principles are adhered to. In our case, the fi nal point is counter-intuitive – this perception is the reason for hospital staff not wearing their uniform outside the hospital.

We have tried hard to compromise, initially suggesting a blouse and trousers from an established uniform supplier. This was rejected.

We know an adjacent, more enlightened PCT rejected the uniform policy for community midwives on the grounds of lone worker safety. Are there any other community midwives out there taking the great step backward?

You may see this as petty in these diffi cult times, but our appearance is crucial to projecting an image of normality. I have nothing against uniform in a nursing job; I just don’t think community midwifery is that job.

So what is this about? Control of the workforce, keeping us in our place? Egos with the power to insist? We can’t feel less valued. With the threat of disciplinary action, where do we go from here? What is the union’s position on this?

ResourceJacob G. (2007) Uniforms and workwear: an evidence base for developing local policy. HMSO: London.

FROM: Name and address suppliedSUBJECT: Uniformed?

Dear editorI work within a community team. Most of us have been working as midwives for at least fi ve years, some with more than 20 years’ experience.

We have worked hard to remain autonomous, despite working for a large NHS Trust. We are proud of keeping midwifery normal and, as far as possible, outside of the medical model of care.

Unfortunately, without any consultation, we have been told to wear a nursing style uniform – dress or tunic and trousers, or risk disciplinary action. The reason for this as explained by our employers (the PCT) is corporate image. What does this mean? That the public will think we are more professional, effi cient and clean if we are dressed as nurses. There is no evidence to suggest this. If our aim is to keep birth normal, why are we being forced to wear a medical uniform? Furthermore, to reinforce

Want more views? Th en please visit: www.rcm.org.uk/midwives/your-views for more letters and opinions. Topics include:✲ Should fathers be present at the birth?✲ Are you Margaret Batch?✲ Another response to June/July’s Disillusioned and disgruntled too.

THERE’S MORE...

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This retrospective review, performed in University Hospital, Galway, identifi ed 12 pregnant women with pregnancy-associated

breast cancer (PABC), which is defi ned as cancer diagnosed either during pregnancy or in the fi rst postpartum year, with 24 age-matched controls. The aim of the study was to evaluate the experience of a specialist symptomatic breast cancer unit in the management of PABC. The women who were pregnant at time of diagnosis had a breast ultrasound, but no mammogram. The mean age of the women with PABC was 36 years and that of the controls was 38 years.

One woman presented with a bloody nipple discharge, while the remainder presented with a palpable lump. There was no statistically signifi cant difference in the mean time to presentation between the two groups, being 15.5 weeks. All the women underwent surgery, having mastectomy and axillary clearance during the second or third trimester; anaesthesia was avoided during the fi rst trimester due to the risk of low birthweight, prematurity, intrauterine growth retardation and neonatal death. All the pregnant women had a fetal ultrasound scan in the obstetric department and then received antenatal care following local protocol for high-risk pregnancy. There was no signifi cant difference in the grade of disease between the two groups. All the women, with one exception, were delivered at 32 weeks’ gestation. The neonates did not have any adverse outcome and no congenital malformations were recorded. All the children born to the women were healthy with no deformity or learning diffi culties. Adjuvant chemotherapy was given to seven (58.3%) of the PABC women, compared to 20 women (83.3%) in the control group. Chemotherapy doses were similar to those given in non-PABC women.

The risk of spontaneous abortion or congenital malformations often results in a delay to initiate

treatment, which compromises overall maternal outcome. Breast cancer is the most common malignancy that can occur during pregnancy, but the combination is rare, therefore there is limited data regarding the safety of chemotherapy at this time. The estimated incidence of PABC ranges from 0.2%

to 3.8%. During pregnancy, levels of oestrogen, progesterone, prolactin and chorionic

gonadotrophin rise and mammary blood fl ow increases by 180%, which may

predispose to tumour growth and the development of metastases.

The challenge with PABC, say the authors, is to identify the disease as early as possible and to treat it effectively without

compromising the health of the mother or the fetus. Neither surgical

intervention nor chemotherapy is advocated in the fi rst trimester of

pregnancy, but both have been shown to be relatively safe in the second or third

trimester. The authors assert that breast cancer associated with pregnancy can be treated effectively and safely for both the mother and fetus when coordinated in a multidisciplinary team.

Jan wallis is a retired midwife and senior lecturer

Cutting EdgePregnancy-associated breast cancer

BREAST CANCER ASSOCIATED WITH PREGNANCY CAN BE TREATED EFFECTIVELY AND SAFELY

✻ During the second and third trimesters of pregnancy, breast cancer can be treated with surgery and chemotherapy

✻ No adverse neonatal outcomes or congenital abnormalities were recorded following chemotherapy treatment.

OVERVIEW


Paper | Pregnancy-associated breast cancer

Authors | Makgasa M, Prichard R, Kerin M.

Publication | Irish Medical Journal 2009; 102: 10.

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How to…

Awoman’s heart rate is a vital sign that can provide information about her general

wellbeing. It may refl ect both her physical and emotional health. It is part of the Modifi ed Early Warning Score (MEWS) in use in many maternity units, which can alert the midwife that a woman’s condition is deteriorating (Lewis, 2007).

Term Defi nition

Heart rate/pulse Number of beats of the heart over a one-minute period

Stroke volume Amount of blood pumped out of the ventricle by each contraction of the heart

Cardiac output Amount of blood pumped out of the heart in one minute (stroke volume x heart rate)

At rest, the heart normally beats about 70 times a minute (Coad, 2006) and tends to be higher in women than in men. The rate increases in pregnancy by ten to 20 beats per minute, particularly in the second trimester. The heart rate fl uctuates depending on the requirements of the body for oxygen.

Increased sympathetic nerve stimulation leads to an increase in heart rate, whereas increased parasympathetic nerve stimulation leads to a decrease in heart rate.

‘Tachycardia’ is the term used to describe an elevated resting heart rate. In adults, this is over 100 beats per minute. Tachycardia may be noted when there is an increased body temperature, for example, in response to a postpartum infection.

‘Bradycardia’ is the term used to describe a resting heart rate of less than 60 beats per minute. Bradycardia may be noted when the body temperature is low, as a result of some drugs or if the parasympathetic nervous system is stimulated.

When the uterus contracts during labour, an additional 300mls to 500mls of blood enters the circulation. The heart rate may

also be increased by pain, anxiety and fear. The NICE intrapartum guidelines (NICE, 2007) recommend that a woman’s pulse should be taken as an observation when labour is suspected and should be observed when listening to the fetal heart to ensure there is differentiation between the two. The pulse should be taken hourly in the fi rst and second stages of labour and recorded again after the birth. There are no requirements to take the maternal pulse again unless clinically indicated.

Measuring pulse/heart rateThe site most commonly used to measure an adult’s pulse/heart rate is the radial artery, which is located in the inner aspect of the wrist at

the base of the thumb. Where this is diffi cult to palpate, it may also be heard by placing a stethoscope directly over the heart. When measuring a mother’s pulse/heart rate, you should:✲ Explain what you are going to do✲ Obtain consent✲ If possible, sit at the same level as

the woman✲ Locate the radial pulse by gently

pressing the artery against the bone, using the pads of the fi ngers

✲ Count for one minute✲ Inform the woman of the result and

record it in her notes.

ConclusionFailure to monitor or act on abnormal fi ndings can compromise the health of the mother or her unborn baby. It is therefore important that the midwife understands the importance of undertaking this simple observation and recognises when to refer her care to a medical practitioner.

How to… measure a mother’spulse/heart rateSheffi eld’s consultant midwife in public health Helen Baston provides an overview of calculating a mother’s pulse/heart rate.


o too t

B t

References

Coad J, Dunstall M. (2006) Anatomy and physiology for midwives (second edition). Mosby: Edinburgh.

Lewis G. (Ed.). (2007) Th e confi dential enquiry into maternal and child health (CEMACH). Saving mothers’ lives: reviewing maternal deaths to make motherhood safer – 2003 to 2005. Th e seventh report on confi dential enquiries into maternal deaths in the United Kingdom. CEMACH: London.

NICE. (2007) Intrapartum care. Care of healthy women and their babies during childbirth. NICE clinical guideline 55. NICE: London.

iryd

Comingnext issue:How to measure a baby’s pulse/

heart rate

ALA

MY

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As the general election draws closer, the three main parties have begun to sketch out how they want to improve maternity care.

LabourLabour’s policy is the same as it has been for the last three years. Their blueprint, Maternity matters, published in 2007, sets out what NHS maternity care in England should look like. It involves national choice guarantees. Women should be able to make choices about their antenatal care, their postnatal care, and of course where they have their baby. The option of a home birth is guaranteed.

All this should be happening now, and according to what strategic health authorities have to say, it is happening almost everywhere.

Labour committed to recruiting an extra 1000 midwives by 2009, and achieved that a year early. They have also promised an extra 4000 by 2012, provided the number of births continues to rise.

ConservativesThe Conservatives published the health chapter of their election manifesto, or at least a draft of it, in January. They also stress the choice they want to offer women. This will include a home birth, a midwife-led unit, as well as the local district general hospital. The party also wants to see new maternity networks, linking up all maternity care providers in a given area. This, they hope, will deliver clinical benefits.

On the recruitment front, they want an extra 3000 midwives, and also acknowledge the need to build up midwifery education to deliver this.

Liberal DemocratsThe Liberal Democrats also wish to see women given choice over their care, and would recruit an

extra 3000 midwives to help deliver that.

Th ere are similaritiesAs you can see there is some similarity in what the three parties are offering. All three want to see greater choice, and are willing to commit

to additional midwives to make that happen. Given where we are, all three are offering about an extra 3000 midwives (Labour promises an extra 4000 by 2012, but around 1000 of those are already in post).

What do we want?Yes, we would want more midwives. Yes, much is far from perfect in maternity care. But in the current fi nancial climate, with the government likely to need to borrow in excess of £100bn every year for the next few years at least, just to balance the books, it is no mean feat to have all three main parties committed to extra resources for maternity care.

Please do raise maternity services with your local parliamentary candidates. Even if you live outside England, your candidate may be willing to speak about local health services. We must keep up the pressure.

Stuart bonar is the RCM public affairs offi cer

On PoliticsStuart Bonar

In the spotlight

It’s almost election time... A potential change in government looms... Stuart Bonar shines a spotlight on the three main parties’ plans to improve maternity services.

IN THE CURRENT FINANCIAL CLIMATE, IT IS NO MEAN FEAT TO HAVE ALL THREE MAIN PARTIES COMMITTED TO EXTRA RESOURCES FOR MATERNITY CARE


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the response page from the consultation paper and send it by post.

You will be asked to indicate whether or not you agree with each of the Council’s proposals and if, in

addition to doing that, you have other comments that you would like the Council to consider, you will be able to do so.

Except for any member who is also responding on behalf of a group (see below), only one response will be accepted from each RCM member. Responses must include a valid RCM membership number. If more than one response is made bearing the same membership number, none of the responses bearing that number will be accepted.

Closing date The closing date for responses will be 30 April. You will not be able to respond through the RCM website after that date, and responses received by post after that date will also not be considered.

Group responsesResponses may also be made by groups of RCM members such as branches, country boards, heads of midwifery services, the RCM’s student midwives group, and consultant midwives. Such groups are encouraged to arrange meetings during the consultation period to consider the consultation paper.

After the consultationThe Council will meet to consider the responses received and, as necessary, modify its proposals. A meeting of RCM members will then be held to make any changes to the RCM’s constitution.

Your RCM – your views matterRCM members deserve the very best governance and opportunities for constitutional change are essentially infrequent. So, please consider and respond to the consultation paper. The Council wants to know what you think about its proposals for reform.

In the last issue of Midwives, the Governance Committee introduced the likely areas of governance where change might be proposed and explained that you, the RCM membership,

will be consulted before the Council fi nalises its proposals. The Council wants to know what you think about its proposals for reform and this article is to give you notice of the consultation process. First, here’s a reminder of the likely areas of governance where change might be proposed.

Th e probable key areas are:✲ Changing the Council into a smaller board✲ The competencies, knowledge, experience and

personal qualities to be demonstrated by those seeking election to the board

✲ Addressing diversity among the membership of the board

✲ Arrangements for elections to the board✲ Arrangements for informing and advising ✲ Transitional arrangements.

Consultation arrangementsThe Governance Committee is presently working on the consultation paper, which will be posted on the RCM’s website on or around 19 March. If the RCM has your email address, electronic notifi cation will be sent to you at this time. You will be asked to go to the RCM website to read the paper and respond online to the consultation questions.

If the RCM does not have your email address, a copy of the consultation paper will be sent to you by post asking you to do the same and visit the RCM website to respond online to the questions. Do please make every effort to respond via the website. It is by far the more effi cient and economical method and will save the RCM money, which can instead be used for services to RCM members. If you really cannot respond via this method, you may, of course, use

On BoardGovernance CommitteeGovernance review: transforming the RCM

The RCM is preparing to consult you about its governance review. Please make a note of the consultation period so you will be ready to respond.


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What kind of midwifery services do we want to see by 2020? UK programme director Noreen Kent outlines the progress of a project, which is set to fi nd answers to this.

Midwifery 2020 started out with the intention of maximising

the mid wifery contribution to maternity care. It recognised that enabling midwives to lead and deliver care would help maternity services meet changing health and social care needs and improve user experiences and maternity outcomes. The programme of work has now been in place for just over a year and the fi ve key work streams (see box) have undertaken a signifi cant amount of work during this period.

As we move into 2010 and enter phase two of the project, each of the work streams are due to submit interim reports outlining the progress made to date and their work plan for the next few months. These reports will be circulated to the UK Programme Board in advance of their meeting shortly. The key stakeholders involved will then have the opportunity to consider the progress made against the agreed aims and principle objectives of the programme.

In the spring, a fi nal report will be produced based on the recommendations and principles emerging from the work streams. This will be used as the basis of focus groups, which are being planned across the UK in the

summer to further engage with midwives and other stakeholders in maternity services. The fi nal document is then due to be launched in the autumn.

Interest in the Midwifery 2020 programme has been very encouraging with an average of 1000 hits per month on the project website with the most visited page being on the core role of the midwife. While the majority of interest has been shown from the UK, there has also been interest from the US, Eire, Australia, Canada,

Midwifery 2020

New Zealand, the Philippines and India. At the recent RCM

annual conference in Manchester, a large number of delegates visited the Midwifery

2020 exhibition stand for information. A brief presentation outlining the programme was also given at the

morning plenary session on day two.

Further information

For further information and to follow progress across the work streams, please visit: www.midwifery2020.org

The future of the profession

Each country is leading on or contributing to the following work streams:

✲ Core role of the midwife: Th is covers all aspects of care, including models of care, service delivery, elements of skill mix and social enterprise. Wales, supported by Northern Ireland, will lead this work.

✲ Workforce and workload: Th is includes demographics, education commissioning, attrition and workforce planning. Scotland will lead this work.

✲ Education and career progression: Th is includes clinical and academic careers, mobility and fl exibility, newly-qualifi ed midwives, levels of practice, research, midwife managers and teachers, as well as the image of midwifery as a career choice. England will lead this work.

✲ Measuring quality: Th is will consider metrics work, clinical quality and outcome indicators and valuing midwifery care. England will lead this work.

✲ Public health: Th is will consider the public health role of the midwife taking account of inequalities, parenting education, work that relates to a child’s early years and multi-agency working. Scotland, in partnership with Northern Ireland, will lead this work.

MIDWIFERY 2020: THE FIVE KEY WORK STREAMS


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MSWs

It is nearly a year since the RCM welcomed maternity support workers (MSWs) into its membership, during

which time the RCM has enjoyed a steady increase in its MSW members, while at the same time meeting the challenges that this new membership category brings. These include ensuring that the training and development of MSWs is consistent and transferable across organisations, the midwife/MSW ratio correctly refl ects the needs of the service and that MSW members are correctly banded for the role that they are undertaking.

The maternity service has always been reliant on support workers to ensure that midwives can deliver high-quality care to mothers, but these have often

focused on general housekeeping or clerical/administrative functions. Increasingly, however, these roles have developed to support midwives at a higher level in directly assisting, for example, women with personal hygiene, demonstrating infant bathing techniques, acting as a runner in theatre and supporting mothers with infant-feeding.

Since 2006, the RCM has sought to capture the number of NHS Trusts/health boards that employ MSWs (maternity care assistants in Scotland) and how they are utilised in the RCM staffi ng survey. In 2009, it was noted that the composition of the maternity workforce was changing, with 90% of heads of midwifery (HOMs)

reporting that they employ MSWs compared to 77.4% in 2007, representing on average 17.5% of the maternity workforce. It should, however, be noted that as there is no recognised universal defi nition of an MSW, some HOMs could be including all support workers in their data, while others are not.

MSWs can be banded at Agenda for Change (AfC) bands 2, 3 and 4.

The AfC national job profi les that an MSW role will normally be matched against are:✲ Clinical support worker nursing

(hospital): band 2 ✲ Clinical support worker nursing

higher level (hospital): band 3 ✲ Maternity care assistant: Band 4.

The rationale behind using the generic job profi les for bands 2 and 3, but developing an MSW profi le at band 4 was in order to recognise the specifi c nature of the maternity support role undertaken at band 4 compared to the more generic nature of band 2 and 3 posts, where job demands can often be transferable between support worker roles.

One of the main concerns raised by our MSW members is the banding of their post. Anecdotal evidence indicates that MSWs are undertaking roles that are not refl ected in their banding. This led the RCM to issue a statement, which affi rmed that job evaluation principles must be adhered to when banding MSW posts and that employers would be challenged by the RCM where MSWs were placed on ‘a lower band when they are performing duties commensurate with a higher banded job profi le’ (RCM, 2009).

MSWs should seek advice and support from their RCM steward if they are concerned that they are not correctly banded.

In the fi rst of a series of three articles, RCM advisor Denise Linay explores the role of the maternity support worker and the concerns around correct pay banding.

Which band am I ?

mothers, but these have often

Furtherinformation

Additional information can be obtained from RCM advisor Denise Linay via email: [email protected]

Reference

RCM. (2009) RCM position on the AfC banding of maternity support worker posts. See: www.rcm.org.uk/college/MSWs (accessed 25 January 2010).


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Legal

Many midwives can earn a substantial secondary source of income by

becoming an expert witness, but they need to know exactly what this entails, as the work requires a new set of skills. Courts and lawyers must know that expert witnesses understand their role, responsibilities and the basics of law and procedure. It is essential that such witnesses also have the necessary competencies to produce an expert report that complies with court rules and that they are able to communicate their evidence effectively while withstanding the rigours of cross-examination.

So what is an expert witness? An expert witness is an independent person who assists in the legal system on issues that require specialist knowledge. A midwife can help in legal claims resulting from incidents that happened around a birth and will give evidence of both facts and opinion. Facts fall into two different categories. There are those facts that the expert midwife has observed herself such as found on a visit to a hospital. Then there are those facts observed from documents or real evidence or from what the expert has been told.

Expert opinion evidence deals with matters not within the common knowledge of the court. The reason for an expert witness being asked to give evidence is because the court does not know or understand matters within certain fi elds. They need the help of an expert to understand the

case. Experts are entitled to give opinion evidence, because of their qualifi cations and experience in their particular fi eld of expertise.

Experts will generally compile a report. This report is a written document in a particular format, which sets out the facts and what the expert’s opinion is. It is possible for the court to read an expert’s written report even though they do not attend the trial, if the other party agrees this oral evidence is not necessary or the court gives leave for the report to be used without the expert’s attendance.

If you want to be an expert witness, you need to be trained. Most lawyers prefer to instruct experts who have been formally trained to be experts. Training can make the difference in their choice between two experts with similar experience and expertise. Training means the lawyers need to do less ‘hand holding’ to ensure reports are

in the correct legal format and that experts know what to expect from the legal system. Most solicitors expect expert witnesses to be trained in writing expert reports and in giving oral evidence, as this saves them time and gives them comfort that the expert can produce court-compliant evidence.

Solicitor and director of medico-legal training company Bond Solon Mark Solon outlines the role of the midwife expert witness.

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Please give details of your qualifi cations and experience.You need to be able to give a full and accurate list of your professional qualifi cations and your length of experience. Th e court has to accept that you are the right person to give the opinion. If the barrister can confuse or belittle you at this stage, you may not be able to give further evidence! Th is is not a time to be reticent.

Please explain the term ‘abruption’, ‘amneocentesis’, ‘anaemia’ (for example).You will need to be able to explain clearly technical terms and should prepare for this before going to court.

In your professional opinion, would you expect a competent midwife to have conducted the procedure in this way?You should have evidence of what is good practice at a particular time. Th e main thing to remember is that the questions will be about your area of knowledge and you should have done the necessary research to prepare your report anyway. Th e lawyer is not a midwife and so will not have your depth of knowledge.

EXAMPLES OF QUESTIONS YOU MAY BE ASKED:

So you want to be an expert witness…

Furtherinformation

For further information, please visit: www.bondsolon.com

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Bleeding disorders

Bleeding disorders are uncommon, but not rare. Although often regarded as a male issue, they are

known to affect women themselves or as carriers of a disorder.

Von Willebrand’s disease Von Willebrand’s disease (vWD) is the most common bleeding disorder and affects up to 1% of the population. It is inherited, mainly affecting the quantity and/or quality of von Willebrand factor (vWF). vWF is a protein that is produced in

endothelial cells lining the walls of blood vessels. It is released by these cells, when injury to the vessel wall occurs. It helps to bind platelets to form a platelet plug. This plug is the initial response to arrest bleeding – primary haemostasis. vWF is also a carrier protein for factor VIII. Factor VIII is one of the clotting factors involved in the clotting processes that occur after primary haemostasis to stabilise the platelet plug and ensure bleeding is arrested – secondary haemostasis. In some types of vWD, there is very

little or no vWF, so the amount of factor VIII available is signifi cantly reduced as it has a very short half life without its carrier protein. The most common clinical features of vWD illustrate the part vWF plays in primary haemostasis, such as prolonged bleeding with dental extraction, easy bruising, epistaxis (nosebleed) and diffi culty stopping bleeding from superfi cial wounds.

Classifi cation and inheritance vWD varies enormously in severity, although most cases are mild and may not be diagnosed until a ‘challenge’ to the haemostatic system, such as surgery occurs. The disease is divided into three types:TYPE 1 – This is the mildest and most common form, accounting for up to 75% of all cases. To be affected by this type, a child would only have to inherit one defective vWF gene from either parent. The vWF in this type is normal in structure and function, but reduced in

Th is is the fi rst in a series of three articles by Liz Hay, Saint Mary’s Hospital’s haematology specialist midwife in Manchester, which aim to give an overview of the most common bleeding disorders, their management in pregnancy and around delivery. Th is issue is von Willebrand’s disease.

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quantity. This type of the disorder usually normalises in pregnancy and then does not need treatment.TYPE 2 – This accounts for around 25% of cases. Type 2 is made up of inherited, qualitative abnormalities of the structure and function of the von Willebrand molecule. It is subdivided into types 2A, 2B, 2N and 2M. The treatment of these is broadly similar. Type 2 is inherited from one or other parent and each child has a 50% chance of inheriting it. It does not normalise during pregnancy and does not respond to desmopressin (trade name DDAVP), prescribed to promote the release of vWF. Type 2B is particularly signifi cant in pregnancy as it is associated with progressive thrombocytopaenia (fall in platelet count), which needs corrective management for labour and delivery.TYPE 3 – This is the rarest form and it accounts for around 1% of cases. Both vWF genes a child inherits are defective. There is almost complete absence of vWF making it the most severe form, occasionally causing spontaneous joint and muscle bleeds.

Antenatal and intrapartum managementLevels of factor VIII and vWF normalise under the infl uence of oestrogen. Most women with type 1 vWD have normalised and generally have no bleeding problems in pregnancy.

Monitoring of vWF and factor VIII should take place at booking, prior to any invasive testing, for example, amniocentesis and between 32 and 34 weeks’ gestation. In women with type 2B, the platelet count should be monitored at least four weekly, but precise frequency depends on the level of the platelets and any haemorrhagic symptoms displayed. Treatment should be introduced appropriately based on these symptoms (such as petichiae and/or spontaneous bruising) rather than absolute

ReferencesBritish Committee for Standards in Haema-tology, General Hae-matology Task Force. (2003) Guidelines for the investigation and management of idiopathic thrombo-cytopenic purpura in adults, children and in pregnancy. British Journal of Haematol-ogy 120(4): 574-96.

Kadir RA, et al. (1998) Frequency of bleeding disorders in women with menorrhagia. Th e Lancet 351: 485-9.

Lee CA, et al. (2006) Th e obstetric and gynaecological man-agement of women with inherited bleeding disorders: review with guidelines produced by a task force of UK Haemophilia Centre Doctors’ Organisa-tion. Haemophilia 12: 301-36.

from women with type 2 and 3 to assess vWF. Mild cases may be missed, as the stress of labour can falsely elevate vWF levels so as to appear in the normal range. Levels of vWF are repeated again within 12 months. All babies of women with vWD should be referred to a paediatric haematologist for further screening and follow up. Vitamin K must be given orally and immunisations intradermally. Care should be taken with heel pricks and pressure applied for fi ve minutes afterwards. Breastfeeding is safe with all treatments.

ConclusionMild bleeding disorders frequently go undiagnosed or unrecognised (Kadir et al, 1998), yet they can have a marked effect on a woman’s health and quality of life. As well as menorrhagia, women may have a history of postpartum haemorrhage and/or prolonged or heavy postpartum loss. Midwives are particularly well placed to affect and improve women’s health during their reproductive years and beyond. By careful questioning during history-taking, a midwife may elicit information suggestive of a bleeding disorder (see check-list).

Bleeding disorders check-list

Easy bruising (from childhood in inherited disorders)

Nosebleeds (from childhood in inherited disorders)

Menorrhagia (from menarche in inherited disorders)

Bleeding after dental extraction

Prolonged bleeding following trauma or surgery

Postpartum haemorrhage or prolonged heavy lochial loss

Appropriate referral and testing will affect the care she (and her unborn child) receives during pregnancy, labour and delivery. This in turn will not only affect her future health and wellbeing, but that of her children and perhaps her children’s children.

counts. It is recommended that women are reviewed at 36 weeks’ gestation and a delivery care plan is formed, outlining any particular treatments required depending on type and degree of correction. DDAVP may be used for type 1 as it increases both factor VIII and vWF. A virally inactivated plasma concentrate containing vWF may be used for those who do not respond to DDAVP, that is, severe type 1 and types 2 and 3. Treatment is usually started at the onset of labour or when the membranes are artifi cially ruptured. Tranexamic acid (a fi brinolytic inhibitor) is used in most cases at the beginning of labour and continued for fi ve days following delivery. Spontaneous labour is the aim.

Regional anesthetic may be offered for type 1 depending on the degree of correction of factor VIII and vWF following consultation between anaesthetist and haematologist. It is contraindicated in type 2 and 3 vWD, a fentanyl patient-controlled analgesia affords alternative means of pain relief.

Fetal scalp electrodes and fetal blood sampling should probably not be used in labour for women with severe types of vWD. Also a prolonged second stage should be avoided, with early recourse to syntocinon augmentation in primigravida. While non-rotational forceps delivery can be undertaken, rotational forceps and/or ventouse extraction are contraindicated. The third stage of labour should be managed actively.

There is an increased risk of secondary postpartum haemorrhage as both factor VIII and vWF levels fall to pre-pregnancy levels within a couple of days of delivery. This may be treated with DDAVP or tranexamic acid depending on the severity and type of disease. Obstetric causes must however be excluded.

Neonatal careCord blood samples should be sent

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Midwives gathered in London recently to attend the eighth RCM Midwifery Awards.

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WinnersResponding to government policy and reducing failure to recogniseKathryn Murphy and Helen Hindle, Salford Royal Hospital, Salford University, Pennine Acute Hospitals NHS Trust

The winners developed a post-registration training module aimed at improving midwives’ ability to recognise and respond appropriately to early signs of deterioration and collapse during childbirth. The module has proved popular among clinicians and the judges felt that it gives midwives the opportunity to enhance their skills in risk management, focusing on the needs of women and the delivery of high-quality and safe maternity services.

here was an air of excitement and anticipation as midwives gathered at London’s Royal Garden Hotel in Kensington on 27 January for the eighth RCM Midwifery Awards. This year, there was a record

number of 13 categories, with a new category voted solely by mothers for their favourite midwife of the year.

Award-winning projects on topics ranging from modules on enhancing basic midwifery skills to developing maternity services for young people were recognised.

The RCM’s royal patron HRH the Princess Royal presented the awards. She said: ‘Midwives are a very central part of health care, their profi le is high. And I hope these awards help to maintain that and increase their profi le within the whole of the health service.’

She added that midwives’ special relationship with pregnant women under their care was really the ‘key to your success’.

‘The midwife is still the very human face of care’ and she said that in many instances midwives would become more than just an advisor to expectant mothers, ‘for many, it will be an important friendship and relationship as the pregnancy develops’.

The RCM’s general secretary Cathy Warwick said: ‘I think you will all be impressed by the range of projects represented here that benefi t mothers, babies and families throughout the UK.’

She thanked all the nominees for entering the awards, ‘I know award ceremonies are about winners, but honestly just to reach the shortlisted stage makes you a winner’.

She thanked the sponsors Pampers, Johnson’s Baby, The Children’s Mutual, Philips AVENT, Bounty, Pregnacare, National Maternity Support Foundation, Thompsons Solicitors, the NCT, NHS Employers and the Department of Health for all their support.

At the awards, over £600 was collected for the victims of the devastating earthquake that struck Haiti in January.

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Care of the bereaved familyJayne Welch and Barbara Hanson, Newcastle upon Tyne Hospitals NHS Foundation Trust

This award went to two initiatives that complement each other at Newcastle's Royal Victoria Infi rmary. Barbara Hanson established a bereavement counselling service for parents suffering pregnancy loss, complications with an ongoing pregnancy, anticipatory grief and fertility issues. Jayne Welch created the Halcyon suite for the sole use of parents suffering the loss of a pregnancy.

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ALERT: Adverse Labour Event Review Team Margaret Rogan and Nuala Sherry, Belfast Health and Social Care Trust

The adverse labour event review team (ALERT) meets every week to review intrapartum incidents, a decision is made on each report as to whether an investigation or follow-up is required. The judges said this project demonstrated collaboration and team-working in its truest sense and celebrates best practice. When things go wrong, the team actively identifi es where care could have been better and lessons are learned.

Feeding matters – educating for informed choice, nurturing and inclusionMichelle Davidson and Carolyn Worlock, NHS Lothian

The winners developed an infant-feeding teaching manual and toolkit. The programme is designed to replace breastfeeding workshops that had often been delivered inconsistently and with limited resources. The judges felt it was well researched, innovative and could be rolled out to other areas. They saw the project as very inclusive from boththe parents’ and other professionals’ perspective.

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Getting it right at the very beginning – Care bundle for the latent phase of labourMaggie Davies and Elizabeth Rees, Abertawe Bro Morgannwg University Health Board

The winners developed a care bundle for the latent phase of labour. This involved looking and listening, assessing maternal observations and using non-pharmacological pain relief. Results have been very favourable with women seeming to be more satisfi ed with their care.

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Back to basicsClaire Allan and Alison Talbot, NHS West Midlands

The project involved developing a training package to enhance basic midwifery skills to maintain normality in maternity care. An interactive DVD was also created to support and compliment training. It aims to be fun, practical and interactive, promoting debate and discussion around basic midwifery skills. The judges saw evidence of good partnership working and noted the multidisciplinary approach, as it is now being rolled out to include obstetric staff. The DVD is fl exible for use to improve care in hospital and at home.

Reaching the seldom heard women of NewhamTracy Beeching and Fiona Laird, NHS Newham

The project helped revitalise maternity services in the London borough of Newham, which face particularly challenging circumstances. More than 70% of the local residents belong to a minority ethnic group and the number of languages in the community is set at around 120. Community midwives were based in each of the four quadrants of the borough, making sure the local midwife was just a ‘pram-ride away’. The early signs of success include a big increase in antenatal clinic attendance and a 40% reduction in stillbirths.

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The BOAT (Better outcomes achieved together) at TamesideLesley Tones and Emma McDonough, Tameside NHS Foundation Trust

The BOAT project developed an interdisciplinary team approach to the care of expectant and teenage parents. They aimed to develop a service for young parents that was accessible, reliable, responsive and excellent. The judges liked the way the team had identifi ed the needs of the local teenage community, demonstrating true partnership with the multi-agency and voluntary services.

Interactive puzzles for clinical midwifery educationLyndsay Durkin, Royal Wolverhampton Hospitals NHS Trust

Two interactive puzzles on waterbirth and postpartum haemorrhage have been developed for use in the clinical area and the classroom. Both can be used by a multidisciplinary team and aim to be fun, tactile and generate debate among the players. The two puzzles have been used in a number of teaching situations and evaluations have been very positive. The organisers are now looking to develop them for breastfeeding and vaginal birth after caesarean section.

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What we do best – an innovative approach to recruitment and retention in midwiferyHilary Thomas, Maidstone and Tunbridge Wells NHS Trust

The winner designed a recruitment brochure to help fi ll the increasing number of midwifery vacancies at the Trust. Hilary felt that the Trust's staff were the greatest ‘selling point’ and therefore invited key midwives, both junior and senior, from all over the Trust to write a short piece about their work. The end result gives an excellent picture of positive midwives who love midwifery. By September last year, eight months after they started the campaign, all the midwifery vacancies had been fi lled.

WinnerBarbara Curtis, Hull and East Yorkshire NHS TrustNominated by Susan Beevers, Hull and East Yorkshire Hospitals NHS Trust

Barbara has been a member and steward of the RCM for 20 years, she is a highly respected and proactive member and staff side secretary for the Trust.

Winner Hayley Darby, Russells Hall Hospital, Dudley, Midlands and the south west of England.

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Midwifery study tour to south IndiaDebra Flynn and Gemma Slator, Thames Valley UniversityThese students have been awarded fi nancial support to join a two-week study tour of maternity services in southern India.

Observing midwives at the Carmen suiteShelley Lacey and Sarah Powell, University of LeedsThis award will enable them to spend some time at the Carmen Suite in Tooting to build on their skills and passion for normal birth.

Elective placement to Ketchene clinic, Addis Ababa, EthiopiaCharlotte Monnelly, University of GlamorganThe award will help to fund an elective placement to gain greater understanding of caring for women in a developing country, seeing at fi rst hand the midwifery and obstetric diffi culties in Ethiopia.

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Communication

ommunication skills are critical to the delivery of high-quality maternity services. It is

impossible to ensure the provision of the best possible care, using available resources to their fullest, without accurate and complete communication with women, their families and multi-professionals.

This need for communication skills has always been a fundamental part of delivering maternity care. The quantity of information to be shared (Department of Health, 2007) and regulatory requirements that mandate communication are increasing (NMC, 2008). The booking interview, for example, will now typically cover information on baseline screening tests, informed choices around patterns of care and where to access it, and whether to opt for maternal or fetal screening for a range of possible anomalies.

Clearly the intention is that this information helps support the provision of care. The communication challenge is to go beyond imparting information. Midwives must also check and facilitate women’s understanding of facts, elicit structured information, and help women to match their want and needs with

It’s more than just talking

the realities of childbirth and service provision. Flowing from all of this must be support for informed consent – a key theme from such national drivers as the National Service Framework for children, young people and maternity services (2004) and Maternity matters (2007). This requires midwives to be skilled in giving information in a non-biased, logical, constructive manner that can be retained by women and their partners, so they can draw upon this data as and when they need it.

To develop and improve communication skills, there are some basic counselling techniques that midwives can use. These approaches will help whether the situation is normal or high risk, to communicate information, to elicit information, to engage in a dialogue, to listen, to check women’s and their partners’ understanding of information they are given. They can allow the midwife to provide women with the opportunity to check complexities or uncertainties they may have in comprehending information and making important choices throughout all stages of pregnancy and childbirth.

Communication skills begin by creating, as far as possible, the

right environment for women and their partners ensuring privacy and comfort so that nothing inhibits dialogue.

Listening must be active – it includes non-verbal components of communication, such as body language, maintenance of eye contact and looking for incongruence between the verbal and non-verbal behaviour (Rogers, 1980).

Active listening should include frequently giving women the space to clarify their understanding of what has been said. This means midwives need to reduce their own contribution and not make judgements.

It is the midwife’s responsibility to guide, direct and structure communication. Midwives build trusting positive relationships with women and their partners – this consists of three core elements of congruence (genuineness and honesty), unconditional positive regard (non-judgemental acceptance and respect) and empathy (the ability to feel what the woman feels). Without these elements, women will not trust and communicate openly (Rogers, 1957) with midwives.

Beyond environment, active listening and trust, there are a number of basic techniques:

Head of midwifery at the Liverpool Women’s NHS Foundation Trust Kim Gibbon explores how communication skills can be enhanced by using simple counselling techniques.

ReffereennccesssBordin ES. (1979) Th e generalisability of the psychoanalytic concept of working alliance. Psychotherapy: theory, research and practice 16: 252-60.

Confi dential Enquiry into Maternal and Child Health. (2007) Saving mothers’ lives: reviewing maternal deaths to make motherhood safer – 2003 to 2005. Confi dential Enquiry into Maternal and Child Health: London.

Department of Health (Department of Education and Skills). (2004) National Service Framework for children, young people and maternity services. HMSO: London.

Department of Health. (2007) Maternity matters: choice, access and continuity of care in a safe service. HMSO: London.

Egan G. (1998) Skilled helper: a problem-management approach to helping (sixth edition). Brooks/Cole: Pacifi c Grove, California.

Ivey AE, Galvin M. (1984) Microcounselling: a metamodel for counselling, therapy, business and medical interviews: In: Larson D. (Ed.). Teaching psychological skills: models for giving psychology away. Brooks/Cole: Monterey, California.

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✲ Refl ecting (Bordin, 1979) – this is using the same words back to women. Th is reassures women that you have understood and heard what they have said and also accepted what they have said without judgement

✲ Summarising (Ivey and Galvin, 1984) – this is articulating the story back to the woman in a shortened version. Th is gives her a chance to hear what they have said, check whether the information is correct and segments the information into manageable portions

✲ Paraphrasing (Ivey and Galvin, 1984) – this is putting what the woman has said into your own words, which can help reassure women that you have heard the most signifi cant aspects of what they have said

✲ Hunching and checking (McLeod, (1998) – this is used to check incongruity. If you think what is said is not what is meant, then formulate a hypothesis as to what you think the woman really means. Th ere are no rights or wrongs – the woman will correct you

✲ Questions (Egan, 1998) – do

not use closed questions, which can be answered with a ‘yes’ or ‘no’, unless you want to close the dialogue down. Open questions will allow women to express their own understandings and feelings, rather than being forced into the midwife’s conceptual framework where the only answer can be ‘yes’ or ‘no’

✲ Silences (Egan, 1998) – never be embarrassed by silence. Th is gives women time and space to think and fi nd ways of expressing themselves.

The use of these techniques is made more diffi cult for midwives by the complex and changing environment in which communication must take place. Some key considerations are:

✲ As pregnancy progresses, there is a requirement to give diff erent information and make a range of choices at diff erent points. Th is change continues from pre-conceptual and antenatal care to intrapartum and postnatal care. Th roughout this journey, the way in which women engage in communication will also change

✲ Th e very nature of childbirth may

place some women into high-risk and

high stress situations. Th e approach to and

pace of communication will change in a high-risk

situation or where there is bad news to work through

✲ Communication will not just be with women, but their families and with multi-professionals involved in care. Th e approach to communication will change depending on the combination of people present

✲ Women and their families will come to pregnancy with a whole range of ideas, pre-conceptions and cultural fi lters. As part of this, another focus of government drivers is to reach groups of vulnerable women, who may be socially excluded and tend not to access care as robustly as women from less vulnerable groups (Confi dential Enquiry into Maternal and Child Health, 2007; Department of Health, 2007; NICE, 2008). Th is requires midwives to have sophisticated communication skills to engage and persuade women to access maternity services and sustain this access.

Despite this multi-dimensional complex of infl uences on communication, the basic techniques outlined above can be applied sensitively to improve communication. This in turn will allow midwives to facilitate delivery of the best possible care matched to the needs and wants of women.

ReffereennccesssMcLeod J. (1998) An introduction to counselling. Open University Press: Buckingham.

NICE. (2008) Antenatal care: routine care for the healthy pregnant woman. NICE: London. See: www.nice.org.uk/CG62 (accessed 12 January 2010).

NMC. (2008) Th e code: standards of conduct, performance and ethics for nurses and midwives. NMC: London. See: www.nmc-uk.org/aArticle.aspx?ArticleID=3056 (accessed 12 January 2010).

Rogers CR. (1957) Th e necessary and suffi cient conditions of therapeutic personality change. Journal of Consulting Psychology 21: 95-103.

Rogers CR. (1980) A way of being. Houghton Miffl in: Boston.

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RCM annual conference

Manchester Central was the destination for the 126th RCM annual conference.

Over 600 midwives attended the RCM’s two-day event – ‘Pioneering the mother and baby pathway’.

With promise of an eclectic mix of thought-provoking speakers and discussions on all things midwifery, the tone of day one was set with the authoritative voice of Woman’s Hour’s Jenni Murray as she summed up the heart of the problem facing the profession – midwife shortages. She called for this to be ‘put right’, saying: ‘Politicians need to be made aware of the situation.’ Her rallying opening aptly fi tted with RCM president Liz Stephens’ warm welcome. She said: ‘Whoever you are, enjoy today and tomorrow, make it a conference to remember.’

Consultant for service redesign and transformation Dr Peter

Lachman provided the fi rst presentation exploring the reasons for changing a service and the way in which to do it, calling it a ‘quality and productivity challenge’.

Patient safety was the subject of consultant in obstetrics and gynaecology Tim Draycott’s presentation. He emphasised the need for better training, saying: ‘Make the right way, the easiest way.’

Niall Dickson’s presentation on the King’s Fund’s Safer births rounded off the fi rst section. In it, despite concluding that ‘most births are safe’, he explored the importance of improving safety by creating safe teams with clear objectives, leadership and agreed procedures for communication.

Shadow health secretary Andrew Lansley provided the fi rst of fi ve keynote addresses, where NHS budget increases topped the bill. Budgets will see a rise of up to 3%

over the next few years if suffi cient effi ciency cuts are made in NHS administration, according to Mr Lansley, but he assured delegates that his party was opposed to cuts to frontline maternity services, though it was going to be a ‘tough call’. He also announced the release of the Conservatives’ Rebirth of NHS maternity care document.

After concurrent sessions on a host of practice, education and research issues, a chance to network with friends old and new at lunch and take in some 85 stands in the free-to-attend exhibition (with not an infant formula milk company in sight for the fi rst time), the conference reconvened with Jenni Murray again at the helm. She was joined by the likes of NHS Education Scotland’s programme director Monica Thompson, who prompted ripples of animated discussion as she described the role and training of maternity care assistants (MCAs)in Scotland and outlined a proposed midwife to MCA ratio of 60:40 – a fi gure some found slightly alarming.

The fi rst day ended with a drinks’ reception, and gala dinner at the Hilton Manchester Deansgate, where midwives threw some memorable shapes on the dance fl oor!

The second day got off to a great

A radio 4 broadcaster, key politicians, and the prime minister’s wife were just a few of the speakers at last year’s RCM annual conference. Midwives editor Emma Godfrey provides a snapshot of the proceedings.

The issues unearthed

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start with the profession’s future under the microscope and Noreen Kent’s presentation on Midwifery 2020. Equality and Human Rights Commission chair Trevor Phillips provided the conference’s second keynote address with charismatic fl are as he outlined the Equalities Bill – ‘the most far-reaching equality law for a generation’ – and its impact on the equality for expectant mothers and their families.

Next it was the turn of the Department of Health’s Gary Belfi eld. He highlighted the gap between service provision and user experience, and what the future of service provision should look like. His answer? ‘Better customer care.’

The future of maternity services, the need for investment and resources, and a review of service provision were the topics up for panel discussion – a panel, which included England’s chief nursing offi cer Dame Christine Beasley, who asked: ‘Are we using resources to the best of our ability?’ She said: ‘We need more investment and we’ve got to use what we’ve got better.’

The penultimate keynote address was reserved for White Ribbon Alliance’s global patron and prime minister’s wife Sarah Brown, who highlighted the international maternal mortality and morbidity rates, while emphasising the role of the midwife in addressing these. She said: ‘A health system that works for mothers, works for every member of the community… Girls and women

unlock the key to everything.’ Mrs Brown delivered a hard-hitting message with obvious passion.

After further concurrent sessions and refreshments, the National Childbirth Trust’s Mary Newburn and Jay Francis took to the stage with their fi ndings on what women want from maternity services and their childbirth experience: ‘An environment that is safe, clean and comfortable, a baby that gets a good start and a woman who is well.’

With the director of Maternity Action outlining the charity’s efforts to end inequality for disadvantaged women, it was then the turn of RCM general secretary Cathy Warwick to provide her fi nal thoughts. After thanking delegates for attending and those involved in the conference’s organisation, Cathy went on to highlight the profession’s positive achievements: ‘It is thanks to you that things are getting better… We’re now seeing gradual improvements – money is increasing and so are midwife numbers.’

Health secretaryAndy Burnham provided the closing address, where he announced the launch of

a new campaign to tackle obesity – Start4Life. The main thrust of his presentation was on how ‘to get everyone up to the standard of providing good services, and go on to provide great preventative, people-centred services’. He said he recognised there are problems with the current service, fi nancial challenges and that the government needs to support midwives further. He assured the audience that he expected 4000 more midwives to be recruited by 2012. He called on more maternity support workers as a ‘complement, not a substitute to midwives’. He also thanked delegates: ‘You are a role model – you are the reason England is one of the safest places to have a baby.’

Asked about their thoughts on the new style conference, delegates were very positive: ‘An inspiring experience – I want to go home and change the world, one woman at a time.’ Another said: ‘It was a good opportunity for motivating me to reaffi rm my own vision for midwifery.’ And another: ‘I feel it has rejuvenated me for 2010 to support women and midwives.’

Further informationTh is year’s RCM annual, student and workplace representatives conference will be held on 16 to 17 November in Manchester Central. Further information will be available via the RCM website and Midwives during the year.

IT IS THANKS TO YOU THATTHINGS ARE GETTING BETTER...MONEY IS INCREASING AND SOARE MIDWIFE NUMBERS

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Th e RCM’s fi rst ever workplace representatives conference was held during its annual conference in Manchester recently, Midwives Maura O’Malley reports on the day.

The day’s conference was aimed at RCM stewards, health and safety and union

learning representatives to support them in their work for members. Thus, much of the agenda was devoted to question-and-answer sessions and interactive workshops.

There were workshops on topics such as lone working, policy and campaigning and bullying in the workplace. There was also ample opportunity for delegates’ queries to be addressed, where representatives from the NHS, Thompsons Solicitors, and the RCM fi elded questions on long-term sick leave, NHS pensions, Transfer of Undertakings (Protection of Employment Regulations) 1981 (TUPE) contracts and on-call agreements.

MSWsA session was dedicated to maternity support workers (MSWs) or maternity care assistants (MCAs) as they are known in Scotland. Scottish MCA Cherylene Dougan described how training to become an MCA had allowed her to progress in a career that she loved, which she said, was pretty much ‘dead ended as an auxiliary’ and increased her academic confi dence.

She assuaged fears that MSWs

could encroach on the role of the midwife, saying: ‘Midwives are midwives and support workers are there to do just that – support.’

In Scotland, a ‘skills passport’ that aims to provide clarity and consistency on what MCAs can and cannot do had been developed to clarify the boundaries between the two roles. Cherylene said: ‘Midwives very quickly saw us as an asset and not as something to fear because the boundaries were more clearly defi ned.’

Discussing her role, she gave a lot of time to supporting women breastfeeding on the wards, and had received very positive feedback.

New agenda for NHSPublic sector net debt of around £870bn meant that the NHS now had to work in a very different environment compared to recent years. Unison’s Karen Jennings’ assertion that the NHS was still in a better place now than in 1997 when Labour came into power was met with much scepticism from the audience. She argued that the debt did not have to be paid off quickly, pointing out that the amount accrued by the UK following the Second World War had only recently been paid back.

The newly-appointed director of NHS Employers Sian Thomas said that the best organisations were responding to the diffi cult

Workplace rep conference

fi nancial landscape by listening to customers, being innovative and having good fi scal control.

‘The bank crisis showed how precarious and connected the world now is and no organisation lives in isolation of its neighbour.’

Responding to a question from the fl oor about Payment by Results (PbR), she said: ‘We don’t seem to have got to a place where the way organisations are run in the health system is motivated to improve in delivering the results we want.’

‘I don’t think PbR has delivered any change,’ adding that she did not think choice and competition are the levers to deliver improvement: ‘They deliver some improvement, but not where it’s really needed.’

The RCM’s general secretary Cathy Warwick thanked workplace representatives for all their work, saying they were the ‘lifeblood of the college’.

‘Although funding is provided for training and courses, you do the work very much in your own time because you are committed to looking after your fellow members.’

She added: ‘We could not do our work of supporting and championing members without you. This conference is a thank you to you.’

Supporting representatives to support members

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The RCM’s student conference offered up a varied programme ranging from a

controversial debate on whether fathers should be present in childbirth, to how to support the new generation both fi nancially and in the workplace through mentoring and maintaining a healthy work-life balance.

Achieving normal birth in practice today was also discussed. Head of midwifery at University College London Hospital Debby Gould said that natural and normal should be interchangeable, but people had very different perspectives on what constituted ‘normal’ birth.

University of Manchester’s Professor Tina Lavender argued that normality had to be placed in a cultural context. She had just returned from Mexico where the caesarean section (CS) rate was between 40% and 80% – what was normal for women there, she asked.And, what about the high rates of maternal mortality in sub-Saharan Africa where CS was viewed as something of a luxury?

She said that health professionals should not assume that their views were shared and wondered whether normality was the best context in which to explore women’s views. Medical intervention did not have to mean a poor birth experience, as she had come across many women who

had obstetrical interventions, but still had a positive experience.

One of the pioneers of birth plans, Sheila Kitzinger considered the impact of choice. She said that it was now time to deconstruct the meaning of the word. Taken from the world of advertising, the concept had turned pregnant women into consumers, but there was no discussion of the side-effects of those ‘goods’ on offer.

She argued that lip service was paid to the notion of choice. Some believed women had the right to choose CS if they wanted it. She knew of one obstetrician who described women who chose vaginal births as ‘irresponsible as drink drivers!’. But she believed this concept of choice was not extended to home birth, with many women being told they could not have a home birth because of

RCM student conference

midwifery shortages.She said that women were also

denied choice ‘when midwives are rushed off their feet trying to care for three or four women in labour at the same time, when there are no opportunities to explore their options, and when emotional blackmail is used as a weapon for ensuring compliance.’

Fathers at birthThe debate ‘Birth is no place for a father’ between French obstetrician Michel Odent and chief executive of the parenting website www.dad.info Duncan Fisher had already attracted a number of headlines in the media. On one side, Michel Odent believed the expectation that fathers should be at the birth was simply social conditioning and could cause the father

psychological harm and actually delay the birthing process.

However, the rise in the number of fathers present at birth was simply a natural progression after birth was taken out of the home and the creation of smaller family units in the 1950s and 60s, said Duncan.

He added: ‘Following the instinct to have someone who loves them at the birth, it was absolutely inevitable that many mothers would want to take the fathers with them.’

After the debate, a show of hands revealed that most delegates believed that fathers should be present at the birth.

As the conference drew to a close, student Jennifer Hey from Suffolk found the day ‘informative and controversial’, fellow Suffolk student Rebecca Scott also thought it was ‘fantastic’, and ‘would recommend it to any student’.

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Stepping stones to the future

Over 400 students gathered at Manchester Central to attend the RCM’s 19th student midwives annual conference Midwives Maura O’Malley reports.

Th e panel debates whether fathers should be present at childbirth. From left: student midwife Joanna Oliver, Michel Odent, Aneurin Bevan Health Board’s consultant midwife Grace Th omas and Duncan Fisher

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Although the RCM and RCOG support labouring in water for healthy women with

uncomplicated pregnancies, the evidence to support underwater birth is less clear. Complications are rare, but from my personal investigation, there is limited research to enable fi rm conclusions about the safety and effectiveness

Avoiding troubled waters

of labouring and birthing in water. Both the RCM and RCOG

state that attendants need the appropriate skills and confi dence, but this is where the clarity ends. There appears to be a lack of quality safety data (Woodward et al, 2004; Geissbeuhler et al, 2004) and no mention about the risks involved if the mother feels unwell in the pool or what actions to take.

As a clinical risk supervisor, I felt a supervisory approach to address potential risks to mother, baby and midwife was required. With fewer individuals present and a need to await assistance, emergency evacuation from a pool at home carries a greater risk than from a pool at hospital, but this risk needs to be balanced with the mother’s choice of delivery. Also, the midwife cannot readily climb into the pool to lift the woman out, as she could sustain injury in doing so.

After searching for guidelines, it became apparent that no one had developed a specifi c guide for home births. Most adapted their hospital guidelines – these do not cover all the associated issues. Due to the potential risk for the primary care Trust, the Trust provided funding to undertake a risk assessment. It was then that a risk assessment

NHS Nottingham City's Jane Pidgeon describes a risk assessment tool for supporting and protecting women and midwives at a home waterbirth.

As aclinicalrisksupervisor, I felt asupervisory approach to address potential risks tomother, baby and midwifewas required. With fewerindividuals present and a needto await assistance, emergency

sessment tool forome waterbirth.

Procedures for emergency evacuation of mother/mother and baby from birthing pool in the home

Mother alert and compliant

Mother alert with limited compliance

Mother unconscious/ unable to comply

1) Baby not delivered

2) Baby’s head delivered

Talk mother through rolling onto side, onto all fours and onto feet to step over side of pool

Collar fl oat fi tted to mother and asked to sit forward for the lifting net. Roll/lean to one side and fi t net. Four people minimum to lift mother from pool

Collar and/or body fl oat, and net fi tted. Four people minimum to lift mother from pool

3) Baby delivered and still attached to mother

4) Th ird stage of labour

Someone hold baby, talk mother through rolling onto side, onto all fours and onto to feet to step over side of pool

Someone hold baby, collar fl oat fi tted to mother and asked to sit forward for the lifting net. Roll/lean to one side and fi t net. Four people minimum to lift mother from pool

Someone hold baby, collar and/or body fl oat, and net fi tted. Four people minimum to lift mother from pool

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Waterbirth

ReferencesAlfi revic Z, Gould D. (2006) Immersion in water during labour and birth. RCM and RCOG: joint statement no 1. See: www.rcog.org.uk/fi les/rcog-corp/uploaded-fi les/JointStatmentBirth-InWater2006.pdf (accessed 18 January 2010).

Brown S, Rogers R. (2008) Home water-birth report: emergen-cy evacuation during home waterbirth. Handling, Movement and Ergonomics Ltd: Ilkeston.

Geissbuehler V, et al. (2004) Waterbirths compared with land births: an observa-tional study of nine years. Journal of Perinatal Medicine 32: 308-14.

Gilbert RE, Tookey PA. (1999) Perinatal mortality and morbid-ity among babies delivered in water: surveillance study and postal survey. BMJ 319: 483-7.

McCormick C. (1992) Cross-town guideline for use of the birthing pool for labour and/or birth. Nottingham Primary Care Trust Nottingham University Hospitals NHS Trust, reviewed August 2006.

RCM. (2000) Th e use of water in labour and birth. Position Paper No 1a. RCM: London

RCOG. (2001) Birth in water. RCOG state-ment. RCOG: London.

Woodward J, Kelly SM. (2004) A pilot study for a randomised controlled trial of waterbirth versus land birth. BJOG 111: 537-45.

tool was devised to take into account the identifi ed issues.The issues addressed:✲ Current guidelines ✲ Filling the pool and maintaining

water temperature ✲ Home environment ✲ Staffi ng and training ✲ Equipment ✲ Legal issues regarding

emergency evacuation.

Recommendations Several recommendations arose from the risk assessment:✲ Continue to use Trust and RCM

waterbirth guidelines (Alfi revic et al, 2006)

✲ Awareness and hands-on

training for midwives to be ‘familiar with the

locally agreed procedure for getting a mother out of the pool should she become compromised’ (Brown and Rogers, 2008)

✲ Ensure that the associated risks of fi lling and maintaining water temperature, such as slips, burns and scalds are discussed in the antenatal period in order to reduce them

✲ The position of the pool should ensure:

1| Access to all sides 2| Space for the mother to lie on

the fl oor to allow the midwife to attend to her needs, such as delivery or other medical input

3| Minimal clutter and obstacles✲ Pregnant midwives must have a

risk assessment undertaken and midwives with a medical reason why they should not attend must

be assessed by occupational health

✲ Essential equipment for an emergency situation:

1| Net for lifting the mother from the pool – it should be big enough for midwives to hold its corners close to their body to reduce risks associated with lifting

2| Waterproof sonicaids (already available for home births)

3| Infl atable swim collar to support the mother’s head if needed

4| Foam ‘fun noodles’ to support the mother’s trunk

5| Collapsible step for the mother to exit the pool. This doubles as a seat for the midwife to reduce prolonged periods of kneeling

6| Waterproof torch for easier assessment

7| Gauntlet gloves (due to blood products present at delivery).

✲ Written procedure for emergency evacuation from the pool.

This covered the use of new equipment, the minimum number of people required to lift the mother from the pool, her degree of compliance and the stage of labour or delivery. This clarifi es the midwife’s role and must be discussed in the antenatal period, so the woman and birthing partner know what to expect in the unlikely event of her collapsing in the pool. It is good practice to get her to sign the risk assessment to confi rm she understands the procedure.

IT BECAME APPARENT THAT NO ONE HAD DEVELOPED A SPECIFIC GUIDE FOR HOME BIRTHS

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Child poverty

Twelve years ago, the Acheson Report (1998) recommended that ‘a high priority is given to

policies aimed at improving health and reducing inequalities in women of childbearing age, expectant mothers and young children’. The recommendations from the report formed the basis of the government’s action plan to tackle health inequalities over the next decade. The strategy aimed to address the underlying determinants of health, and as a consequence to support families, mothers and children and to reduce inequalities in infant mortality and life expectancy at birth (Acheson, 1998; Department of Health (DH), 2003). A key objective of the inequality Public Service Agreement (PSA) target has been to reduce, by at least 10%, the gap in infant mortality in England and Wales between the routine and manual socio-economic groups and the population as a whole. Although the infant mortality rate among this group has fallen from 19% in 2002-04 to 16% in 2006-08, it is still higher than in the total population, compared to the baseline fi gure when it was 13% higher in the period 1997-99 (DH, 2007).

It is acknowledged that what happens to individuals in their early years, such as the circumstances in which they are born and brought up in, is a strong determinant of their future – poverty and deprivation

Bridging the gap?

have serious impacts on children’s life chances. Poor childhood development and experiences can lead to lower educational attainment, poor health and poor non-cognitive skills. These outcomes can increase the likelihood that children who grew up in poverty are likely to face poverty in later life, submitting to the consequences of intergenerational cycles of deprivation (Acheson, 1998; Horgan, 2007; DH, 2009; Marmot, 2004, 2009).

The impact of income inequality and social background cannot be underestimated. For example, every extra £100 per month in income when a child is small is associated with a difference, equivalent to a month’s development in the child. More alarming is the fact that even when children from a lower social class are initially assessed as having a high cognitive ability, they are eventually overtaken by children

from a higher social background who had started off with relatively low cognitive ability (Government Equalities Offi ce, 2010).

The gap between rich and poor is more marked in the UK than in the majority of similar countries, with people on very low incomes or benefi ts being worse off than the rest of the population (Palmer et al, 2008).

The UK government set out to eradicate child poverty within a generation with a target of halving it by 2010 and eradicating it by 2020. Although over half a million children have been lifted out of relative poverty since 1997 through the tax and benefi t system and other policy measures (HM Treasury, 2004, 2008; Department for Children, Schools and Families, 2007), there remain however, a signifi cant number still experiencing relative poverty. There are regional variations among those 2.8 million UK children still affected. For example, 28% of children in north-east England live in poverty compared to 13% in the South East. Children from ethnic minorities are at higher risk of growing up in

Th e RCM’s professional policy advisor Janet Fyle describes government initiatives to eradicate child poverty, including tax credits and the Child Trust Fund.

FurtherinformationFor this article's full references, resources and footnotes, please visit: www.rcm.org.uk/midwives/features/bridging-the-gap

THE UK GOVERNMENT SET OUT TO ERADICATE CHILD POVERTY WITHIN A GENERATION WITH A TARGET OF HALVING IT BY 2010 AND ERADICATING IT BY 2020

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poverty – for example, the fi gure is 58% for children of Pakistani or Bangladeshi origin compared to 19% for white children (Harker, 2006).

As part of the government’s poverty reduction strategy, it increased the universal child benefi t to £20 a week for the fi rst child and the Child Tax Credit by £50 a year. It also established a Social Fund aimed at assisting families most in need or those in fi nancial crisis with emergency interest-free loans enabling them to avoid costly debt.

Nine out of ten families with children get tax credits and some working families on low wages may also qualify for Working Tax Credit. Other benefi ts include: the Healthy Start vouchers, which replaced the previous Welfare Food Scheme, aimed at improving the nutrition of pregnant women and babies and may include free vitamins. The Health in Pregnancy Grant is a one-off payment of £190, which is given to pregnant women from 25 weeks onwards regardless of income or any other benefi ts. To help women on low incomes with the cost of a new baby, there is an additional payment, the Sure Start Maternity Grant, which is a means-tested benefi t.

The government has also initiated the Child Trust Fund (CTF), in order to spread asset ownership and encourage future generations to gain an understanding of fi nance and savings. All children born from September 2002 are eligible for the CTF payment and a voucher for £250 is sent to the parent who claims child benefi t, to open a CTF

account on behalf of the child. Since 2006, a child with a CTF account will receive an additional payment of £250 at age seven and children from lower-income families will receive £500. Only the child can access the account on their 18th birthday. There are now almost four million children with CTF accounts valued at approximately £2bn (HMRC, 2009).

The recent economic downturn has had an impact on many families. In a survey conducted by the RCM in 2009, midwives reported a rise in the number of women seeking advice on fi nancial hardship and benefi ts. Anecdotal evidence from some Sure Start children’s centres also suggests an increase in enquiries about benefi ts.

It is worth noting that all of these benefi ts are restricted to those who are ordinarily resident in the UK, and excludes asylum-seekers, foreign students and those who have no recourse to public funds. Nevertheless, the government sees its measures as a moral and social imperative at least to alleviate, if not eradicate child poverty.

In his review, Marmot (2009) raises the question that despite a decade of government measures, pursuing various policies to narrow the gap over the last ten years, there still remain marked social, economic and health inequalities in our society. It is important to note, though, that a reason for disparity between ethnic groups and, more generally, the continuation of child poverty despite the government’s efforts at tackling it, may be that many people do not know what they are entitled to or how to access the appropriate benefi t schemes. Midwives can play an important

role here, by obtaining relevant factual knowledge on what benefi ts women and their families are entitled to. This enables them to give correct information to parents who need it, or at least be able to direct them to relevant sources of information or refer them as appropriate when they are at their most vulnerable.

2010 brings the fi fth anniversary of the launch of the CTF and will also see the fi ve millionth CTF account opening1. Before the CTF was introduced, just one in fi ve families2 were saving over the long-term for their children – now 31% of CTFs3 receive some form of additional saving. What’s more, calculations by leading CTF provider and RCM alliance partner, Th e Children’s Mutual (TCM) suggest 50% of the government CTF investment so far is going to 1.5m families with the lowest household incomes (under £15,000)4, with families in the lowest income bracket saving a higher proportion of their household income for their children than those in more affl uent groupings5.

Children whose friends and families save £24 per month into their CTF (the average amount among TCM customers), could have a fund worth £97506 when they reach age 18 and those with the maximum £1200 into their CTF each year could have a fund worth an estimated £37,1007 upon maturity. Currently 1.4m parents, family and friends are contributing to their children’s accounts with an excess of £22m being added every month8. TCM estimates £2.74bn9 will be collectively available to young adults each year as they turn 18 – money set to help towards the cost of higher education, fi rst homes and beyond for young adults from all backgrounds.

Open your child’s CTF with TCM and they will contribute £40 into your CTF account if you set up a direct debit for more than £10 at the same time. Th ey will also make a donation to the Safe Motherhood Initiative. For a full information pack, Tel: 0808 145 2578, quoting reference HCF4478 or visit: www.thechildrensmutual.co.uk

CHILD TRUST FUNDS

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Stillbirth

References

Alderliesten ME, et al. (2003) Perinatal mortality: clinical value of postmortem magnetic resonance imaging compared with autopsy in routine obstetric practice. BJOG 110(4): 378-82.

American College of Obstetricians and Gynecologists. (2009) ACOG Practice Bulletin No. 102: management of stillbirth. Obstet Gynecol 113(3): 748-61.

Cohen MC, et al. (2008) Less invasive autopsy: benefi ts and limitations of the use of magnetic resonance imaging in the perinatal postmortem. Pediatr Dev Pathol 11(1): 1-9.

Confi dential Enquiry into Maternal and Child Health. (2009) Perinatal mortality 2007: England, Wales and Northern Ireland. Confi dential Enquiry into Maternal and Child Health: London.

Department of Health. (2008) Mortality statistics: childhood, infant and perinatal series DH3. No: 39. HMSO: London.

Heazell AE, Martindale EA. (2009) Can post-mortem examination of the placenta help determine the cause of stillbirth? J Obstet Gynaecol 29(3): 225-8.

Heinonen S, Kirkinen P. (2000) Pregnancy outcome after previous stillbirth

With just over three-quarters of stillbirths ‘unexplained’, University of Manchester’s clinical lecturer Dr Alexander Heazell and medical student Mary-Jo McLaughlin emphasise the importance of clinical investigations into these deaths.

Despite signifi cant advances in maternity care, stillbirth is still an all-too-

common occurrence. In the UK, approximately one in 200 babies are stillborn – a baby born without signs of life after 24 weeks’ gestation. Surprisingly, this rate has not changed signifi cantly since the mid-1990s (Department of Health, 2008), and 76.2% of those classifi ed remain ‘unexplained’ (Confi dential Enquiry into Maternal and Child Health (CEMACH), 2009). Despite its frequency, public awareness of stillbirth is less widespread than other neonatal complications – 75% of the public were surprised by the number of stillbirths and were more concerned about cot death and Down’s syndrome, even though these are ten-fold less common than stillbirth (Scott and Bevan, 2009).

The ‘Why17?’ campaign launched in 2009 by Sands asks why 17 babies die every day in the UK as a result of stillbirth or neonatal death (Sands, 2009). Through this campaign, Sands hopes to dispel the notion that these deaths are unavoidable. It is anticipated that improved research into the causes and consequent enhanced management and support for women and their families will reduce the impact of stillbirth and neonatal death in the UK.

For each woman and her partner, stillbirth is a devastating event with far-reaching consequences, not only physically, psychologically and emotionally, but it may also impact on the outcome of future pregnancies. In such pregnancies, a woman is at increased risk of preterm labour, low birthweight infants, placental abruption and the risk of having another stillbirth is increased by two to ten times (Heinonen and Kirkinen, 2000; Reddy, 2007). Therefore, care should include counselling about investigations into their stillbirth. This requires a multidisciplinary approach with roles for midwives, specialist bereavement midwives, bereavement support, obstetricians and perinatal pathologists. As members of this team, individuals have a responsibility to support parents, enabling them to make fully informed decisions. Discovering a reason for the stillbirth may not only aid care of a future pregnancy, but may help parents’ grief response (Teigen, 2008).

Investigation of stillbirth can take various forms. Non-invasive tests include clinical examination or imaging (x-ray or magnetic resonance imaging (MRI) scans) of the baby. Minimally invasive tests include maternal and paternal blood tests and placental

Why did this happen?

histological examination. The most invasive investigation is a postmortem examination, which is still considered to be the gold standard, revealing important new information in 20% to 86% of cases (Porter and Keeling, 1987; Stewart et al, 1998; Thornton and O’Hara, 1998) in comparison to 47% for placental histology (Heazell and Martindale, 2009) and a much lower proportion of blood tests such as chromosomal analysis, which detects abnormalities in 4.6% of structurally normal infants (Korteweg et al, 2008). Although less invasive tests may be more acceptable to parents, studies have shown that while they can contribute additional valuable information (Alderliesten et al, 2003; Cohen et al, 2008), essential information would have been missed if these were not combined with a postmortem (American College of Obstetricians and Gynecologists, 2009).

Despite its effi cacy, the uptake of postmortem in the UK is between 29% and 54% (CEMACH, 2009). Potential barriers to such an examination include parental religious beliefs, a lack of perinatal pathologists, the need to transfer babies to another unit and the length of time taken for results to be given (see table). Many of these factors are not simple to modify, others such as religious

resulting from causes other than maternal conditions and fetal abnormalities. Birth 27(1): 33-7.

Hunter B, Deery D. (2008) Emotions in midwifery and reproduction. Palgrave Macmillan: Basingstoke.

Korteweg FJ, et al. (2008) Cytogenetic analysis after evaluation of 750 fetal deaths: proposal for

diagnostic workup. Obstet Gynecol 111(4): 865-74.

Porter HJ, Keeling JW. (1987) Value of perinatal necropsy examination. J Clin Pathol 40(2): 180-4.

Reddy UM. (2007) Prediction and prevention of recurrent stillbirth. Obstet Gynecol 110(5): 1151-64.

Sands. (2009) What is

046_047_mid_Stillbirth.indd 44046_047_mid_Stillbirth.indd 44 4/2/10 10:09:494/2/10 10:09:49


beliefs should not be questioned by health professionals. Some factors amenable to modifi cation are the communication between parents and professionals, in particular: who gives counselling and takes consent, whether they have been trained and have suffi cient knowledge to answer the questions asked. In addition, the time when the subject is approached, how sensitively this is done and whether any written resources are used may also impact on the parents’ decision.

As well as practical and personal considerations, the organ retention scandals at Alder Hey and Birmingham Children’s Hospitals brought to public attention in 2000 affected public confi dence in post-mortem examination of children. Parents may fear the possibility of tissue retained without consent, despite the introduction of the Human Tissue Act in 2004. The issues surrounding organ retention may have also affected healthcare professionals’ attitudes, changing the way and affecting confi dence with which they approach the subject of gaining consent.

As the central component of the maternity multidisciplinary team, the midwife often has the strongest clinician-patient relationship with a woman and her partner, and parents may fi nd their midwife more approachable than medical staff to ask questions about subsequent investigations. Midwives require suffi cient training in dealing with bereaved parents, but also on the causes and investigation of stillbirth. It must also be acknowledged that caring for a mother who has

Potential factors aff ecting parents’ decision to choose investigations after stillbirth

PARENTAL FACTORS

Religious and ethical considerations

Past and personal experience of postmortem

Knowledge and media perception

COUNSELLING AND CONSENT PROCESS

Who performs counselling and obtains consent

When and how many times option of postmortem is raised

Knowledge and training of staff

Time given

How sensitively it is dealt with

Availability of specialist trained bereavement midwife

Paperwork

PRACTICALITIES OF POSTMORTEM

Availability of perinatal pathologist

Need to transfer baby to another hospital for procedure

Cost of postmortem

Time taken for body to be returned to parents

Time taken for results and report to be communicated to parents

Why17? See: www.why17.org (accessed 15 January 2010).

Scott J, Bevan C. (2009) Saving babies’ lives 2009. Sands: London.

Stewart JH, et al. (1998) Numbers of deaths related to intrapartum asphyxia and timing of birth in all Wales perinatal survey, 1993-5. BMJ 316(7132): 657-60.

Teigen J. (2008) Parents’ needs for care and support when a child dies in stillbirth. International Stillbirth Conference, Oslo, Norway: International Stillbirth Alliance: Baltimore.

Th ornton CM, O’Hara MD. (1998) A regional audit of perinatal and infant autopsies in Northern Ireland. Br J Obstet Gynaecol 105(1): 18-23.

experienced a stillbirth takes extra time and can have emotional consequences for the midwife, so adequate support is vital for staff involved as well as parents (Hunter and Deery, 2008).

Although stillbirth affects a signifi cant number of women, there are few large-

scale studies of the knowledge and practice of the multidisciplinary maternity team members. Such a study is being carried out in the UK, US and Australasia. In the UK, the RCM has distributed a link to an online questionnaire to 10,000 practising midwives. The survey has questions relating to midwives’ knowledge, views and attitudes on the management of stillbirth, with a focus on counselling and potential barriers to consent for postmortem examination. Over 3000 responses have been received so far. If you would like to participate, please visit: www.surveymonkey.com/s/TCPX9LQ.

A similar questionnaire has also been sent to UK perinatal pathologists and consultant obstetricians. This research will enable us to describe how women are cared for and identify whether clinicians involved feel they have suffi cient knowledge and training and how useful they view postmortem as an investigation. We hope that the fi ndings will enable us to improve care, as well as reduce the number of unexplained

stillbirths by achieving thorough appropriate investigation.

MIDWIVES MID WIVES 47 THTHTHE OFFICIAL MAGAZGAZINE OF THE RCM

FEB EBRRUARY/MARCH 2010

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Furtherinformation

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046_047_mid_Stillbirth.indd 45046_047_mid_Stillbirth.indd 45 4/2/10 10:10:094/2/10 10:10:09

Midwife researcher and Action Medical Research training fellow Tracey Mills is looking into the causes of fetal growth restriction. Here she provides the background to her research.

Effective monitoring of fetal growth is vital in antenatal care. Problems can develop

unexpectedly and fetal growth restriction (FGR) is a signifi cant cause of perinatal mortality and morbidity, underlying a signifi cant percentage of unexplained stillbirths.

FGR and stillbirthIn the UK, FGR affects between 5% and 8% of pregnancies (Neerhof, 1995) and around one in every 200 babies are stillborn (Smith, 2007).

Measurement of symphysis fundal height is recommended from 24 weeks’ gestation, but this has limited effectiveness in identifying FGR, with only around 25% of affected pregnancies detected antenatally (NHS Perinatal Institute for Maternal and Child Health, 2009; Ross et al, 2008). Even if FGR is detected, there are no effective treatments – all we can do is monitor until the benefi ts of continuing the pregnancy are outweighed by the risk of fetal death, at which time an early delivery may be needed. If we are to impact on the rates of stillbirth, we need to signifi cantly improve the detection and

management of FGR.Growth restricted babies are

more likely to have problems with development and may be at increased risk of developing illnesses, such as heart disease and diabetes later in life (Barker and Osmond, 1986).

Boosting research A lack of understanding of the mechanisms underlying FGR, coupled with diffi culties in developing treatments for pregnancy complications has resulted in limited research and drug development in this area. Research is crucial in midwifery, but it is important to carry out research that is clinically relevant.

Boosting understandingI am involved in a new clinic for women at increased risk of FGR. Using Doppler ultrasound scans and laboratory studies of their placentas after birth, I am investigating why blood fl ow to the baby can be reduced in FGR.

In normal pregnancy, Doppler ultrasound indicates that placental blood fl ow steadily increases over the course of pregnancy to meet the fetus’ demands for oxygen and nutrients. In contrast, in FGR,

FGR research

placental blood fl ow is reduced.The cause of this reduced fl ow

is unknown, but previous studies indicate that abnormal blood vessel function is a factor (Challis et al, 2000). This is important as it may be possible to reverse abnormal function by developing drugs to improve fl ow and possibly increase fetal growth in utero.

In addition, potassium channels are important in controlling the diameter of blood vessels and blood fl ow. Preliminary studies suggest that they contribute to determining blood vessel function in the placenta in normal pregnancy (Wareing et al, 2006). The aim now is to fi nd out how placental blood vessel function relates to the reduced blood fl ow in FGR, and to examine the role of potassium channels in controlling blood vessel function in pregnancy.

A growing problem

ReferencesBarker DJ, Osmond C. (1986) Diet and coronary heart disease in England and Wales during and after the second world war. J Epidemiol Community Health 40: 37-44.

Challis DE, et al. (2000) Glucose metabolism is elevated and vascular resistance and maternofetal transfer is normal in perfused placental cotyledons from severely growth-restricted fetuses. Pediatr Res 47: 309-15.

Neerhof MG. (1995) Causes of intrauterine growth restriction. Clin Perinatol 22(2): 375-85.

NHS Perinatal Institute for Maternal and Child Health. (2009) Detection of fetal growth restriction. See: www.perinatal.nhs.uk/growth/Detection_of_fetal_growth_restriction.pdf (accessed 9 November 2009).

Ross MG, et al. (2008) Fetal growth restriction. eMedicine: obstetrics and gynaecology. See: http://emedicine.medscape.com/article/261226-overview (accessed 9 November 2009).

Smith GCS, Fretts RC. (2007) Stillbirth. Th e Lancet 370(9600): 1715-25.

Wareing M, et al. (2006) Expression and function of potassium channels in the human placental vasculature. Am J Physiol Regul Integr Comp Physiol 291: R437-46.

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Children’s charity Action Medical Research awards research training fellowships annually. For further information, please visit: www.action.org.uk

FURTHER INFORMATION


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R ecent fi gures have shown that, if trends remain unchecked, one in ten children

will be obese by the time they are primary school age. Data collected by the National Child Measurement Programme (2009) highlighted the contrast in obesity rates between UK regions, and exposed a clear relationship between deprivation and obesity prevalence. These statistics join the mounting evidence that risk of obesity can start early, even within the fi rst year, and can contribute to increasing rates of heart disease, type 2 diabetes and cancer in later life (Department of Health, 2008).

Following the success of Change4Life, the government campaign launched in January 2009 to tackle the rising tide of obesity, the Department of Health (DH) has introduced a sister campaign, Start4Life. Focusing on starting life with good eating and activity habits, Start4Life supports pregnant women and parents of babies in helping reduce the proportion of overweight and obese children in England. It aims to improve exclusive breastfeeding continuation rates, increase the average age of introducing solid foods to 26 weeks and, for the fi rst time, encourage active play. Start4Life also supports the Healthy Child Programme, the

universal early intervention and preventative programme that begins in pregnancy.

For both parents and the healthcare professionals working with them, Start4Life provides accessible, concise and authoritative information, which, at the same time, echoes the informality and colourful style already familiar from Change4Life. A leafl et and poster focus on six recommended behaviours for parents to follow and adopt, covering the three strands of the campaign: breastfeeding, introducing solid foods and active play. The behaviours comprise:✲ Mum’s milk… Why breastfeeding is better for both mother and baby, detailing the health benefi ts breastmilk provides. ✲ Every day counts… How each day of breastmilk makes a difference to the baby’s health, and why exclusive breastfeeding is recommended for the fi rst six months of life.

Start4Life

✲ No rush to mush… Three signs to help recognise when the baby is ready to move onto solids. 1. Stay in a sitting position and hold their head. 2. Co-ordinate their eyes, hands and mouth and look at food, grab it and put it in their mouth by themselves. 3. Swallow food. ✲ Taste for life… Giving the baby a variety of food to develop their taste buds and help prevent them becoming a fussy eater.✲ Sweet as they are… How to avoid giving the baby a sweet tooth by limiting sugary foods.✲ Baby moves… The importance of active play for babies.

The Start4Life poster and leafl et made their fi rst appearance at the RCM annual conference last November and are now available for midwives to give to pregnant women and parents. The campaign website (www.nhs.uk/start4life) also provides a set of frequently asked questions and answers for download and the campaign’s marketing activity is well

underway – you may already have been seen advertising in

women’s magazines. The involvement of

midwives is important to the success of the campaign: midwives are in a unique position to engage with pregnant women and new parents to help them make

positive changes to their diet and physical activity

levels. With the help of the midwifery community, Start4Life will contribute to making a reduction in the proportion of overweight and obese children in England and help address

health inequalities.

References

Department of Health. (2008) Healthy weight, healthy lives: a cross-government strategy for England. HMSO: London. See: www.dh.gov.uk/en/Publica-tionsandstatistics/Publications/Publica-tionsPolicyAndGuid-ance/DH_082378 (accessed 1 February 2010).

Th e NHS Informa-tion Centre. (2009) National Child Meas-urement Programme: England, 2008/09 school year. Th e Health and Social Care Information Centre: London. See: www.ic.nhs.uk/ncmp (accessed 4 February 2010).


A healthier Start4Life

Th e Department of Health launched a new campaign at the RCM annual conference to encourage healthy eating and increased activity at an early age. University of York’s Professor Mary Renfrew outlines the essence of the campaign.

049_mid_start4life.indd 49049_mid_start4life.indd 49 4/2/10 14:13:164/2/10 14:13:16

NHS Tower Hamlets’ communications and marketing offi cer Anna Wilson outlines the borough’s attempt to help pregnant women quit smoking.

Since running the fi rst NHS Tower Hamlets stop smoking in pregnancy group in May 2009,

facilitator and pregnancy and early years stop smoking advisor Farah Desai has had a steady fl ow of pregnant women looking to quit. The 90-minute Friday sessions at John Smith Children’s Centre are open to any female living in the borough of Tower Hamlets in east London, irrespective of their stage of pregnancy. Topics each week cover smoking cessation options, managing cravings and withdrawal symptoms and common triggers such as daily stresses that women can relate to.

Tower Hamlets has the highest prevalence of tobacco use in London. It is estimated that 22% of deaths in the borough are due to smoking, compared to 18% in the rest of the capital. One in three of the adult population smoke, compared to one in four nationally (NHS Tower Hamlets, 2009).

Smoking in pregnancy is still a major concern as it increases rates of complications in pregnancy during and after birth and triples the risk of sudden infant death syndrome (British Medical Association, 2004). Smoking in pregnancy also increases low birthweight by around 40% (Health Inequalities Unit, 2007).

Two focus groups were conducted with pregnant smokers to discover why pregnant women fi nd it so diffi cult to quit and

what would make it easier. The participants said they wanted sessions in a non-clinical setting with other pregnant smokers, who understood their diffi culties in quitting.

Before joining a group session, each new member has a personal induction to discuss their motivation to quit, their individual smoking patterns and to set a date to stop smoking. Each group member has a carbon monoxide reading taken, which helps to motivate and monitor progress. The full range of nicotine replacement therapy is then explained in detail to the group. Farah describes the process: ‘I normally help women set their quit dates about a week in advance, as it gives them enough time to plan and prepare for stopping smoking. I encourage women to attend six sessions as a minimum, but they can access support as long as they need to.’

Nineteen-year-old Cindy Barton joined the pregnancy and smoking cessation group when she was six months pregnant, after a friend recommended it. Having smoked from the age of nine, Cindy felt she had nothing to lose. Once discovering she was pregnant, she cut down, but was never able to fully quit. She quickly realised that pregnancy wasn’t the only thing all of the women had in common.

Cindy said: ‘I fi gured it was worth a try and thought why not? We related to ways that our

Smoking

partners stress us out and how to cope while quitting smoking.’

Cindy started with the inhalator, followed by lozenges to fi nd that ultimately, the gum and patch best curbed her cravings. She banned smoking in her home as her partner and family members smoked around her regularly. The option to quit together with partners and family members is also available if required, however Cindy’s partner didn’t feel ready to quit at the time.

The group sessions enable a relaxing and de-stressing environment that make sharing and relating to one another easy. Cindy began looking forward to the weekly discussions to learn of her fellow members’ progress. Even though she quit during her fourth week, she continued attending to support new and existing members.

Cindy says she doesn’t know where she’d be without the group sessions and that quitting smoking has made her ‘more relaxed and more focused on my future’.

Cindy, who gave birth to a healthy baby girl last year, is adamant that she won’t go back to smoking as it has become easier for her to be a non-smoker. She will also continue to ban smoking in her home, as she is desperate to protect her baby from the effects of other people’s cigarette smoke.

Craving to quit

ReferencesBritish Medical As-sociation. (2004) Smoking and repro-ductive life: the impact of smoking on sexual, reproductive and child health. British Medical Association: London.

Health Inequali-ties Unit. (2007) Implementation plan for reducing health inequalities in infant mortality: a good practice guide. HMSO: London. See: http://www.dh.gov.uk/dr_consum_dh/groups/dh_digitalas-sets/@dh/@en/documents/digitalas-set/dh_081336.pdf (accessed 4 February 2010).

NHS Tower Hamlets. (2009) Realising world-class ambition. Annual report 08/09. NHS Tower Hamlets: London. See: www.towerhamlets.nhs.uk/about-us/our-performance/annual-report-2008-2009 (accessed 3 February 2010).

egnant


Cindy is pictured here with her fi ve-month-old daughter Cali


ONCOURSE

It is vital for midwives to provide women and their families who experience a stillbirth or neonatal death

with evidence-based and sensitive care, thus contributing to maternal postnatal wellbeing (NMC, 2008). As a third-year student at the University of Northampton, I recognised a defi cit in my clinical experience and knowledge base within this area. I therefore saw it was vital for my professional development to approach Sands. So when I met a representative at a conference, I arranged a week’s placement in London.

I was well aware of Sands, having read their bereavement care guidelines Pregnancy loss and the death of a baby: guidelines for professionals (Schott et al, 2007). However, when I read the Saving babies’ lives report 2009 (Scott and Bevan, 2009), I realised that the charity had far more to offer than bereavement support. Sands wanted answers and change, and it was this that I was eager to fi nd out about.

I began my week on a really positive note. Everyone welcomed me with a warm smile, and it was

Newly-qualifi ed midwife Charlotte Clayton refl ects on her elective placement with the stillbirth and neonatal death charity Sands during her last year of training at Kettering General Hospital.

brilliant to sit in on a meeting with Judith Schott (co-author of the guidelines) and Sands’ group services manager Sue Hale regarding healthcare professionals’ training of the bereavement guidelines. I was also able to gain insight into the functioning and importance of the nationwide support groups. Over the next few days, I attended several meetings. Perhaps the most fruitful was one that focused upon Sands’ prevention message and the work it is doing to promote and fund the much-needed research into stillbirths (Scott and Bevan, 2009).

I was also able to speak with different members of the Sands team, from those who run the telephone support service, to the fundraising team and the chief executive. This gave me an invaluable insight into the services the charity provides.

I also attended the British Association of Perinatal Medicine conference with Charlotte Bevan and Janet Scott, who lead the prevention and research area of the charity. This enabled me to interact with members of the multidisciplinary team.

As a now newly-qualifi ed midwife, I fi nd myself refl ecting upon my experiences with much optimism and thanks. I am astonished at how pioneering the

charity is and how passionate Sands is in promoting awareness of stillbirth and neonatal death, in order to evoke change. Ultimately women and their families who experience such a devastating loss deserve honest answers, care that is both sensitive and fl exible to meet individual need, and support that is tailored to promote long-term wellbeing whether that be from a healthcare professional or from charities such as Sands.

The way in which I will practise has been infl uenced greatly. I feel far more equipped to care for women, recognising antenatal risk factors and referring appropriately in order to reduce perinatal mortality (Lewis, 2006; King’s Fund, 2008; RCOG, 2008).

I would recommend to student and practising midwives alike to work with Sands, as it is always important to enhance your knowledge and experience life from a different perspective.

Th e author would like to thank Milton Keynes Sands, who made the placement possible by funding travel expenses, to Chris Wildsmith and Charlotte Bevan who helped organise the placement, and friend Kelly Sharman for her support.

THANK YOU


IT IS IMPORTANT TO ENHANCE YOUR KNOWLEDGE AND EXPERIENCE LIFE FROM A DIFFERENT PERSPECTIVE

A momentto refl ect

References

King’s Fund. (2008) Safe births: everybody’s business. An independent inquiry into the safety of maternity services in England. King’s Fund: London.

Lewis G. (Ed.). (2007) Th e Confi dential Enquiry into Maternal and Child Health (CEMACH). Saving mothers’ lives: reviewing maternal deaths to make motherhood safer – 2003 to 2005. Th e seventh report on Confi dential Enquiries into Maternal Deaths in the United Kingdom. CEMACH: London.

NMC. (2008) Th e code of professional conduct. Standards of conduct, performance and ethics for nurses and midwives. NMC: London.

RCOG. (2008) Standards for maternity care. Report of a working party. RCOG Press: London.

Scott J, Bevan C. (2009) Saving babies’ lives report 2009. Sands: London.

Schott J, Henley A, Kohner N. (2007) Pregnancy loss and the death of a baby: guidelines for professionals (third edition). Sands: London.

051_mid_student.indd 51051_mid_student.indd 51 4/2/10 14:13:494/2/10 14:13:49

2010 DIARY


BabyFit UK

Location Various Cost From £5000 Details We have established a completely safe, structured ante- and postnatal exercise programme, business and marketing package. We have an ongoing audit proven to help with labour and postnatal recovery. We are looking for committed professionals to run BabyFit in other areas, with ongoing support. Fitness qualifi cation can be arranged.Contact www.babyfi tuk.co.uk

6-7

High dependency unit

Date 16 MarchLocation Northwick Park Hospital, HarrowCost £100Details Topics: Management of the par-turient with low saturations and low urine output, MEWS scoring, hypotension and tachycardia in the parturient, small group teaching-clinical cases. Practi-cal session-invasive monitoring. Contact 020 8869 2254/2251; [email protected]

16

March

June

MSWs, mothers and midwives- a collaborative conference

Date 15 April Location Bradford Cost £50 (midwives); £25 (MSWs); £10 (service users/students) Details MSWs, mothers and midwives can join to share experiences. Keynote speeches: RCM general secretary Cathy Warwick and president Liz Stephens. Contact Alison Brown 01274 383595; [email protected]

15

Aquanatal courses

Dates 22-23 April, 22-23 JulyLocation BirminghamCost £250 (£230 early booking)Details Two-day course includes: anatomy and physiology, legal and professional aspects, practical skills in planning, implementing and evaluating aquanatal classes, land and pool sessions. Contact Natasha Carr/Maggie Prain 0121 331 6085/7182; [email protected]

22-23

AprilHow to be a relaxed midwife

Dates and locations 13 May (Oxford), 3 July (Somerset) Cost £95 (lunch included)Details Midwives and students - do you want to manage stress better, increase confi dence and decision-making skills? Facilitated by two midwife hypnotherapists and leading providers for staff and couples support.Contact Eleanor Copp/Naomi Morton 07929 857608; www.relaxedparenting.co.uk

13

Pregnancy sickness and hyperemesis gravidarum

Date 1 July Location University of Warwick Cost £80; £42 (students)Details First national conference. Lectures from national speakers and opportunity to contribute to ‘national thinking’ on this under-appreciated and under-researched condition during workshops.Contact Terry Salter, [email protected]; 07811 593319

1

Reducing maternal and newborn deaths- MDG4 and 5

Date 1 July Location RCOG, LondonCost £220 +VATDetails MDG4 and 5 are unlikely to be met by 2015. Th is meeting will discuss the need for advocacy, appropriate resource allocation, training and the need to consider maternal and neonatal deaths as inter-related problems.Contact 020 7772 6245; www.rcog.org.uk/events

NEW premises available for use by midwives to run

antenatal/postnatal classes in West Drayton area.

If interested contact MAJELLA ON

020 8863 8796

July

Th e study day listings page exists to inform readers of courses relevant to midwifery. Only those marked ‘RCM approved’ are accredited by the College. If you would like to advertise on this page, please contact sales executive Giorgio Romano on Tel: 020 7880 7556 or email: [email protected]

Association of breastfeeding mothers: cultural challenge and the breastfeeding mother

Date 19 June Location Lancaster Hall Hotel, London Cost £70 (non-members); £48 (members) Details How breastfeeding develops in premature infants, supporting younger mothers to breastfeed, breastfeeding in public spaces, parenting through touch.Contact 0844 412 2948; www.abm.me.uk

19

RCM approved • RCM approved

•

Aquanatal courses

Dates and locations Aquanatal stage 1: introduction to teaching courses 6-7 March (London), 8-9 May (Bristol), 24-25 July (Birmingham), 11-12 September (Leeds). Introduction to pilates and abdominals in pregnancy 25 April (Leeds). Details We run courses for qualifi ed midwives. Aquafusion is a leading provider of aquatic training. Contact 01943 879816; www.aquafusion.co.uk

Becoming a lactation consultant

Date 5 June Location London Cost £70Details Consider building on your breastfeeding support skills and enthusiasm to achieve the professional qualifi cation in lactation. Learn about new exam eligibility rules and what the study involves.Contact Deborah Robertson 01634 814275; www.breastfeedingspecialist.com

5

1

May


•


•

UNI

VERSITY ACCRED

ITATION PENDING

061_mid_events.indd 61061_mid_events.indd 61 4/2/10 14:15:194/2/10 14:15:19

CLOSEUP


7.00

am Arrive at offi ce, and check my diary and emails. Consider the

skill mix and allocate accordingly to cover the various clinics. For example, routine 20-week scans, early pregnancy assessment and the ‘high risk’ clinic for pregnancies complicated with fetal anomalies.

7.30

Review guidelines for early pregnancy loss, which are being updated.

As a member of the bereavement committee, I provide educational sessions on ‘communication and breaking bad news’.

8.00

Attend weekly multidisciplinary meeting, where we

discuss current cases and review ultrasound examinations. This forum is also educational and involves delivering presentations that are relevant to case studies.

9.00

As clinical supervisor for the MSc in diagnostic imaging, I interview a

midwife undertaking the course. We identify aims and objectives for the forthcoming semester and complete

the necessary forms.

9.30

I am required to give a second opinion on a twin pregnancy, as there is

uncertainty about the chorionicity.

10.30

Attend a monthly department head meeting with the director of

midwifery and nursing. Discuss organisational issues and feed back to my staff any relevant issues.

11.30

Continue to perform ultrasound examinations and be available for

colleagues should they require a second opinion or advice.

12.15

pm As the unit is considering purchasing a new ultrasound machine,

I meet briefl y with a rep to organise for a machine to come to the unit for demonstration. Return to scanning.

1.30

Informed of the arrival of a couple whose baby has a fetal anomaly, they return

to see the consultant for confi rmation and a diagnostic test. We answer their questions and offer the various support services available to them. I assist the consultant and ensure arrangements

are in place for further follow-up. They are informed of the potential diagnosis and prognosis.

2.15

A group of midwifery students attend the department for a brief

overview of our work. This is followed by a trip to the local university to give a presentation on antenatal ultrasound to medical students.

3.30

Return to the department to scan, as a number of in-patients require

ultrasound prior to possible discharge.

4.15

A call from the antenatal clinic requests a departmental scan, as

they are unable to auscultate a fetal heart. Unfortunately an intrauterine death is confi rmed at 38 weeks’ gestation. The appropriate steps are undertaken to ensure adequate care and support for the couple, including contacting the bereavement midwife.

5.00

I head for home with a number of research proposals, which I need

to read and comment on before the next meeting of the ethics committee of which I am a member.

name: Valerie Kinsellaoccupation: Clinical midwife manager: fetal assessment unitlives: Dublin, Ireland

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A day in the life of… A midwife sonographer

After completing my general nursing and midwifery training, I was fortunate to work in a leading fetal medicine unit in London and my interest in antenatal ultrasound began. I completed a higher diploma

in diagnostic imaging (obstetrics and gynaecology). I now work in the fetal assessment unit in the National Maternity Hospital in Dublin. It is midwifery led and referrals are made to consultants specialising in

feto-maternal medicine. It provides a comprehensive ultrasound and national fetal medicine service. A total of 8983 women delivered 9142 babies in 2008. We had over 23,000 attendances to the unit.

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