NICE guidance – Preterm Labour and Birth updated

NICE have updated their Preterm labor and birth guidance which covers the care of women at increased risk of or with symptoms and signs of preterm labor. The guideline includes new and updated recommendations on:

• Prophylactic vaginal progesterone and prophylactic cervical cerclage
  • When to offer prophylactic vaginal progesterone and prophylactic cervical cerclage
  • Who to consider offering prophylactic vaginal progesterone to
• Magnesium sulfate for neuroprotection
  • For women between 23+0 and 23+6 weeks of pregnancy who are in established preterm labor or having a planned preterm birth within 24 hours, discuss with the woman (and her family members or carers as appropriate) the use of intravenous magnesium sulfate for neuroprotection of the baby, in the context of her individual circumstances
• Intrapartum antibiotics
  • For guidance on the use of intrapartum antibiotics in established preterm labor, see the NICE guideline on neonatal infection (early onset).

​The guidance in full is available here - https://www.nice.org.uk/guidance/ng25

Effectiveness of financial intervention strategies for reducing cesarean section rates

A systematic review has been conducted evaluating the effectiveness of financial interventions on reducing cesarean section rates. There were 9 studies included in the review with some focusing on provider interventions and some with provider and patient interventions.

Provider interventions

• Fee equalizing for facilities – no effect
• Risk adjusted payment – could be effective

Combined provider and patent intervention

• Co-payment for elective cesarean section – no significant effect

The study concludes that risk adjusted payments may be an effective method to reduce cesarean section rates and considering stakeholder characteristics may also be important.

https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-019-7265-4

Association between rates of second-stage Caesarean section and instrumental delivery

A study from Hong Kong has looked at the trends in cesarean section and instrumental delivery rates. Records for cesarean sections and instrumental deliveries between 1997 and 2016 were examined. Over the period there were 87413 deliveries, 17600 (20.1%) of which were CS and 6502 (7.4%) instrumental deliveries.

Over the study period the cesarean section rate increased whilst the instrumental delivery rate decreased. The decline in instrumental delivery was replaced by second stage cesarean section.

Lack of confidence with instrumental delivery, medicolegal concerns and failed instrumental delivery may trigger a reluctance to attempt.

Training programs that include teaching on instrumental delivery skills as an alternative to cesarean section and having experience obstetricians involved are described as important for optimizing outcomes.

Read the full study here - https://www.hkjgom.org/sites/default/files/pdf/v19n2-89-association.pdf

Tips to provide best practice care to help prevent stillbirth

Safe Care Victoria is aiming to reduce the rate of stillbirths across Victoria, Australia. They have shared 6 tips to aid in providing best practice care for pregnant women:

1. Talk to your patients about the risk factors for stillbirth
2. Offer a carbon monoxide breath test at booking and 28-week appointments
3. 'Ask, Advise, Help’ to support women to cease smoking while pregnant
4. Make sure you’re across current best practice approaches to measure fetal growth and detect any abnormalities
5. Share up-to-date information on decreased fetal movements and maternal sleep position
6. Discuss timing of birth and support shared decision-making when planning for birth.

They are also encouraging women to:

• get familiar with baby’s movements and contact the midwife or obstetrician if they notice a change
• sleep on side: from 28 weeks (3rd trimester), going to sleep on your side is safer for your baby.
• seek support to quit smoking during pregnancy.

They share other support resources on their website - https://www.bettersafercare.vic.gov.au/news-and-media/six-tips-to-provide-best-practice-care-for-pregnant-women

Women with increased BMI could be having unnecessary cesarean sections

A study of 526 patients in Canada has found that patients with a higher BMI took up to 2.67 hours longer to reach a dilation of 10cm compared to women with a normal weight. A high BMI was also associated with increased oxytocin use.

The study highlights that care providers should take into consideration the time it takes for labor to progress in women with high BMI to help avoid undertaking premature cesarean sections.

https://www.sciencedirect.com/science/article/abs/pii/S1701216319304682

Second victim experience is an underestimated problem

A study in the Netherlands has looked at the experiences of healthcare providers who have been involved in a patient safety incident during their careers.

4369 doctor and nurse respondents were involved, 462 of which had been involved in an incident in the last 6 months that caused permanent harm or death. Those who had experienced an incident were more likely to report symptoms including hyper-vigilance, they felt doubts about knowledge or skill, felt unable to provide quality care and felt uncomfortable within a team. Where the outcome of the incident was more severe these symptoms lasted longer.

The study concludes ‘Attention should be given to how to cope with these symptoms as they profoundly affect personal well-being, professional performance as well as teamwork-related efforts directly influencing patient safety and the provision of quality care.’

https://bmjopen.bmj.com/content/9/7/e029923

NHS Resolution – Maternity Litigation

NHS Resolution has published its latest annual reports which details the types and value of litigation claims. Again, the highest value of claims relate to obstetrics where claims account for 10% of the volume of claims but an estimated 50% of the total value. This is a slight increase on the estimated value from 2017/18 of 48%.

The reports outlines that in 2018/19 the cost of harm was approximately £9 billion of which around 60% (£5.4 billion) related to obstetrics. For every baby born in England hospitals pay out about £1100 in indemnity costs.

NHS Resolution has attempted to address the high rates of maternity claims through research, early notification and financial incentives for best practice. With attempts at identifying maternity incidents, sharing learning and providing earlier support to families.

The report provides more details - https://resolution.nhs.uk/wp-content/uploads/2019/07/NHS-Resolution-Annual-Report-2018-19.pdf

Conjoined twins separated
​
Pakistani conjoined twins Safa and Marwa have been separated during surgery at London Great Ormond Street hospital. The twins who were joined at the head were separated in a procedure that took 50 hours and involved a team of 100 staff. The separation process for the twins took place over 4 months and they have now returned home. 

Patient Safety Network – Maternal Safety

The patient safety network has produced a guide to maternal safety. The resource summarizes the key issues facing mothers in the US, Statistics around who is at most risk, factors contributing to maternity related deaths and education and resource guides available to support pregnant women.
​
https://psnet.ahrq.gov/primers/primer/50/Maternal-Safety

Organisational interventions to reduce cesarean sections

 A systematic review has been published looking at organisation interventions and the impact on rates of cesarean birth. The study identified several interventions that impacted the cesarean section rates:

• Midwife led models of care – where the midwife is the lead professional in planning, organisation and delivery of a woman's care
  • Women were less likely to have a cesarean section overall
  • Women were less likely to have a planned cesarean section
  • There were no significant different between groups of for emergency cesarean section, instrumental delivery, labour augmentation, epidural use, special care admission and induction of labour
• Continuous midwifery care
  • No significant difference on rates of cesarean sections
• Audit and feedback to promote implementation of evidence-based practice
  • Small but significant impact on cesarean section reduction
• Hospital policy of mandatory second opinion for cesarean section
  • Small but significant impact on cesarean section reduction

The study concludes that:
‘women allocated to midwife-led models of care implemented across pregnancy, labour, birth, and the postnatal period were, on average, less likely to experience CS (overall), planned CS, and episiotomy compared with women allocated to routine care.’

https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-019-2351-2

First live birth after deceased donor uterine transplant

A baby has been born at Cleveland clinic in the US after the mother received a uterus transplant from a deceased donor. The mother is part of a trial at the clinic where they are using wombs from donors who have recently died. This reduces the risk of harm a living donor would face if donating their uterus.

​https://health.clevelandclinic.org/for-the-first-time-in-north-america-woman-gives-birth-after-uterus-transplant-from-deceased-donor/

Australian Mother and Babies reports

The Australian institute of health and welfare has released reports on the outcomes for mums and babies - Australia's mothers and babies 2017 and Stillbirths and neonatal deaths in Australia 2015 and 2016. Both reports look at the outcomes and experiences for different factors of pregnancy and birth.

Key outcomes from the report are:

• The rate of women giving birth has decreased
• The average age of women giving birth was 30.6 years
• 99.9% of all mothers had at least 1 antenatal visit
• 1 in 10 mothers smoked during pregnancy
• Almost ½ of mothers were overweight or obese at their first antenatal visit
• Everyday 6 babies are stillborn
• In 2015-16 there were 1439 neonatal deaths
• Perinatal mortality rates were higher among indigenous women, those who liver in very remote areas and those living in disadvantaged areas
• Congenital abnormality was the most commonly classified cause of perinatal death, neonatal death and stillbirth

These reports can be read in full using the links below.

https://www.aihw.gov.au/reports/mothers-babies/australias-mothers-and-babies-2017-in-brief/contents/table-of-contents

https://www.aihw.gov.au/reports/mothers-babies/stillbirths-neonatal-deaths-australia-2015-2016/contents/overview-of-stillbirths-and-neonatal-deaths
 
Nigerian women refusing cesarean sections

The cesarean section rate in Nigeria is 2%, 58,000 women die in childbirth each year and there is one doctor for every 6000 people. There are many barriers and stigmas associated with cesarean birth in Nigeria:

• In rural areas 58% of deliveries take place with unskilled birth attendants
• In urban centers cost is prohibitive
• There is shame associate with cesarean section and the thought that vaginal birth is aligned with womanhood
• Many women don’t have control over their birth experience – many believing men should make the decisions

Work is being done across Nigeria to help educate women about their choices and some of the complications that can arise along with efforts to remove fees for hospital births.

​http://www.bbc.com/future/story/20190612-caesarean-sections-in-africa-stigma-and-maternal-mortality
​

Maternal positions during the second stage of labor

A study has looked at common maternal positions during the second stage of labor reviewing and comparing the risks and benefits of 6 common positions. The study reviewed research on each position looking at factors including accelerating progress of labor, alleviating maternal pain, reducing perineal trauma, decreasing blood loss, promoting fetal & newborn well-being and treating certain obstetric complications.

The study summarized that:

• Upright and lateral positions
  • More potential benefits in improving maternal and neonatal outcomes and dealing with certain obstetric complications
  • Upright position, especially in squatting and sitting position, may be associated with increased perineal trauma
  • Upright positions may correlate with blood loss of greater than 500 ml
• lithotomy and supine positions
  • Avoid unless women feel comfortable
  • Increased risk of severe perineal trauma, comparatively longer labor, greater pain, and more fetal heart rate patterns

The role of midwives in having the skills and knowledge to support women with their position can impact their birth experience.

https://www.sciencedirect.com/science/article/pii/S2352013219301309
​

This week the Royal College of Obstetricians and Gynaecologists 2019 conference was held in London. The event spanning 3 days covered sessions on maternal and fetal medicine, health policy, early pregnancy, training and abortion care.

A poster of Fetal Pillow was presented at the congress highlighting the impact of introduction of Fetal Pillow for management of a deeply impact head. Of the 131 deliveries included in the study there was use of Fetal Pillow in 61 Cases. Outcomes from cases where Fetal Pillow is used includes a reduction in postpartum haemorrhage, massive obstetric haemorrhage, and mean blood loss.

​The study highlights:
‘The fetal pillow can be a useful tool in reducing overall blood loss at full dilatation caesarean in preventing both postpartum and massive obstetric haemorrhage.’

https://obgyn.onlinelibrary.wiley.com/doi/10.1111/1471-0528.11_15703#

A Norwegian study has looked at womens’ perceptions of the care they receive in the maternity ward following an emergency cesarean section.

Interviews were conducted with women who had experienced an emergency cesarean section. Analysis of the interviews identified 4 key themes:

• Post-surgery experience
  • Need for pain relief
  • Importance of sleep and rest
  • Attention only on the baby not on the mothers well-being
• Importance of continuity and midwife presence
  • Confusion with changing staff
  • Need for greater staff presence
• Importance of knowledge and good information
  • Informed women felt more confident
• Value of a partners presence
  • Important to have partner staying over to support

The study concludes that the general feeling from women was that they didn’t always feel adequate help and support was available when needed. There were some instances of medication being forgotten or complications being overlooked.

https://sykepleien.no/en/forskning/2019/06/perceptions-postnatal-care-after-emergency-caesarean-sections

An article from cosmopolitan magazine ‘6 myths about caesarean sections too many women believe’ highlights some of the myths surrounding the delivery of a baby that may cause unnecessary anxiety for expectant mums.

The 6 myths covered:

• Cesarean section scars are big and visible
• If you have had a cesarean section, you will be unable to have a vaginal birth in future pregnancies
• There is a limit to the number of cesarean sections you can have
• You can't breastfeed babies delivered via cesarean section
• The recovery period for cesarean section and vaginal delivery is roughly the same
• You won’t feel anything at all during a cesarean section

In the article Dr Penelope Law, Consultant Obstetrician and Gynaecologist address these myths explaining the evidence and experience surrounding the topics.

https://www.cosmopolitan.com/uk/body/a28001821/c-section-scar-caesarean/

What is Diastasis-Recti?
​
Diastasis-Recti, common in pregnancy. is a condition in which the large abdominals (top abdominal layer- Rectus Abdominis) separate. It is commonly defined as a gap of roughly 2.7cm or greater between the two sides of the rectus abdominis muscles.
 
Who is likely to get Diastasis?

Anyone can end up with Diastasis-Recti, however, it is more common in:

• Women who carry larger babies
• Multiple births
• Multiple pregnancies
• Very tight abdominals
• Anyone can get it… babies, children, men, low and high BMI.

 
How to test if you have Diastasis?

1. Lie on your back with your knees bent, feet flat on the floor.
2. Place your fingers with the palm facing you on your belly button.
3. Lift your head and neck just slightly off the floor while you press down with your fingers. If you can feel a gap, that is the diastasis.
4. Conduct the same test just above your belly button and just below the belly button (as the gap can measure differently in these places).

 
What you can do to try avoid Diastasis?

For those carrying multiple babies or large babies it can be hard to avoid but there are things you can do or stay clear of to reduce the chance of getting separation of the abdominals. Try to avoid:

• Abdominal curls and planks

• Putting too much load on your abdominals (includes carrying heavy weight; especially above your hips).
• Lying on your back and leveraging legs away from your centre.
• Twists (especially closed rotations)
• Rolling up from lying on your back.
• Jumping out of bed

  
If you know you have Diastasis also stay clear of the above exercises until it has recovered or minimised and you feel strong and stable in your core and pelvic floor.
 
What can you do if you have Diastasis?

You can try the following exercises and tips to help strengthen your body and help heal your abdominal separation:

• Roll over to your side from a lying position
• Strengthen your pelvic floor and Transverse Abdominal muscles
• Improve your posture
• Breathing exercises – Controlled deep lateral diaphragm breaths, lower belly breathing.
• Strengthen your spine
• Seek a specialist in post-natal care and exercise (Physiotherapist, Pilates Instructor) to work with

 
Every individual is going to have a different situation so it is best to seek help and advice from a professional who specialises in pre and post-natal care. Enjoy the journey in getting to know your new body as a mother. 

Written by: Tenille Samuelson
www.awomanswellness.com



​​Tenille is a qualified Yoga and Pilates Instructor. Over the past 10 years Tenille has operated her own Pilates and Wellness studio with a passion for women’s health. Providing guidance to many women through fertility, pregnancy (pre and post-natal) and supporting women after traumatic birth experiences.

What is the pelvic floor?

The pelvic floor is a thick, sling shaped group of muscles located at the base of the pelvis that span from the tailbone (coccyx) to the pubic bone. It is a group of muscles that can be consciously controlled and exercised just like any other voluntary muscle in the body.

Why is it so important?
 
A balanced pelvic floor is one that you can control to switch on and off throughout movement and breath. A connected and strong pelvic floor helps to support your organs, control your breathing, increase your sex drive and correct your posture. 

Exercise and the pelvic floor

It is best to work with a specialist (Pilates or Physio) who can assist you in the correct exercises and movements for pelvic floor. It is highly recommended that you have good functioning pelvic floor before undergoing more intense exercise like long walks, running, weight and strength training. 
 
Pelvic Floor Exercise (Lift & Hold)
​
You can try this exercise to work on your pelvic floor: 

• Try this exercise kneeling, sitting (on an exercise ball would be best) or in a squat.
• Imagery: imagine your pelvic floor like a lift. When it’s off it is at ground level. As you lift a little it’s at level 1, lift a little more to level 2, gradually lifting your pelvic floor to its maximum at level 5. The aim is to control your pelvic floor muscles, gradually switching them on and off, like a lift going from level 1-5-1.
• Start by drawing your awareness toward your pelvic floor and completely relaxing all the muscles around your pelvic floor, abs, hips, glutes and bottom.
• Inhale: to prepare. Breathing deeply in to your lungs and keeping pelvic area relaxed.
• Exhale: gradually lift your pelvic floor muscles. Thinking about a lift gradually lifting from Ground level (nothing on) to level 5 (maximum strength)
  • Important that you keep the muscles in your bottom, hips and abdominals relaxed. Only engage pelvic floor
• Inhale: hold your pelvic floor at Level 5
• Exhale: to gradually (with control) release your pelvic floor from level 5-1 and back to ground level (switch off).
• Repeat this 5-10 times.
• Progression: Once you can control this see if you can hold your connection at level 5 for 3-5 breaths before gradually letting it go again.

​
Written by: Tenille Samuelson
www.awomanswellness.com


​​Tenille is a qualified Yoga and Pilates Instructor. Over the past 10 years Tenille has operated her own Pilates and Wellness studio with a passion for women’s health. Providing guidance to many women through fertility, pregnancy (pre and post-natal) and supporting women after traumatic birth experiences.

​We do so much research during our Pregnancy for our Birth and together with our support partner and specialists we plan for our Birth…However, it is just as important to have a Post-Natal Plan and be informed in how we can support our bodies as we transition in to Motherhood.
 
Every woman has her own unique birthing experience, from natural birth to cesarean section. First, it is important to acknowledge that there is no correct or one way to birth… we all have different views, customs, symptoms, bodies, growing babies and support. However, no matter what your pregnancy or birthing experience there are a few things you can do to help re-balance your hormones, strengthen your body and keep you sane post-birth.
 
Here are my 7 tips for after Birth:

1. Sleep as much as you can. Yes everyone says it but studies show that Sleep is the best way to re-balance your hormones. 
2. Put Together a Post Pregnancy Plan. This doesn’t have to be complex, it could be as simple as just writing down a few points to focus on over the next year or 2. This could include things like feeding times, or how long you’d like to feed for, when you’d like to go to bed by each night, meal times, when to prepare food, your partners roles, when you get to exercise, when you have to go back to work, when you want your child to start day-care or school or just a financial plan.
3. If breastfeeding do not over exercise or over-stimulate your body. You need that energy to feed and nurse. 
4. Feed your body to help re-balance your hormones and keep your energy up. Think warm, nourishing, easy to digest foods. Foods best for this are soups, broths, steamed veggies, fish, tea, poached or cooked fruit, good/healthy carbs and sugars.
5. Don’t be Afraid to Ask for Help. It really does take a village to raise a child. Use your support networks around you. Family, mums and babies classes, local council nurse, parenting support groups, a friend. We all have something different and unique to teach a child and help them grow. 
6. Strengthen your pelvic floor muscles. A balanced pelvic floor is one that you can control to switch on and off throughout movement and breath. A connected and strong pelvic floor helps to support your organs, control your breathing, increases your sex drive and corrects your posture. Best to work with a specialist (Pilates or Physio) who can assist you in the correct exercises and movements for pelvic floor. It is highly recommended that you have good functioning pelvic floor before undergoing more intense exercise like long walks, running, weight and strength training.
7. Do some relaxation, breathing or meditation exercises. This could be as simple as taking 10 conscious deep breathes before bed, going for a swim, lying over a Yoga Bolster and relaxing in to your body and breath, doing a restorative Yoga class, practising 5-10 minutes of mindfulness or meditation each day. The better you breathe, connect to your body and clear your mind the more relaxed and connected you will be as a parent. 

​Written by: Tenille Samuelson
www.awomanswellness.com
​

​​Tenille is a qualified Yoga and Pilates Instructor. Over the past 10 years Tenille has operated her own Pilates and Wellness studio with a passion for women’s health. Providing guidance to many women through fertility, pregnancy (pre and post-natal) and supporting women after traumatic birth experiences.

Genome sequencing can help with diagnosis and treatment of critically ill babies

A study is using advanced genome sequencing to help identify genetic conditions in neonatal and pediatric intensive care units. The study found that 1 in 4 babies had an underlying genetic condition and the identification of this in many cases altered the treatment plan. The findings of the study will allow doctors to intervene and manage conditions earlier with potential to improve outcomes and save lives. Within the UK there is potential to help more than 3000 patients through implementing this genome sequencing.

 https://www.elystandard.co.uk/news/cambridge-study-to-give-hope-for-sick-babies-1-6100326

PTSD - A maternal-fetal medicine specialists experience

Dr. Shivani Patel is a maternal-fetal medicine specialist and Assistant professor of obstetrics and gynecology in the US. She developed preeclampsia during her first pregnancy at 32 weeks and her baby was delivered via caesarean section within 24 hours of diagnosis which led to PTSD. Now having her blood pressure taken can trigger flashbacks and anxiety. Her experience has helped her awareness of the fears and anxieties parents may be experiencing.

She highlights ‘The onus is really on doctors to try to gauge whether a patient had a traumatic birth experience and may be experiencing PTSD. This is yet another instance in which a patient’s emotional well-being can play as big a role in care as her physical well-being.’

https://www.mysanantonio.com/opinion/commentary/article/PTSD-and-pregnancy-yes-it-s-real-13969325.php

Increased neonatal deaths from overseas IVF

Study finds that women who conceived a multiple pregnancy from IVF abroad had poorer obstetric and neonatal outcomes. In a large center in northwest London 65 women were referred to the fetal medicine center between 2012 and 2016. 38 of those women had IVF overseas and within that group 24% of live born babies died in the neonatal period compared to 0 in the UK group. The average cost  per overseas IVF baby was £20,600. It is suggested that providing IVF in the UK may improve obstetric and neonatal outcomes with lesser cost burden for families and service providers.
​​
https://www.ejog.org/article/S0301-2115(19)30194-0/fulltext

Three things to know about the state of maternal mortality research in the United States
​
A blog from Maternal Health Task Force presents 3 things to know about maternal mortality research in the US from a seminar by Dr Gene Declercq:

1. Maternal mortality is calculated differently in the US compared to other countries. Maternal mortality ratio is used by all other countries, but the government stopped reporting this in 2007.
2. The problem involves women not just dying in labor but also before and after birth. The US statistics may cover a large time frame than data reported from other countries so rate of maternal mortality may appear higher.
3. Maternal morbidity is also an important issue – listening to women is an integral part of improving outcomes.

https://www.mhtf.org/2019/06/07/redefining-the-challenge-of-maternal-mortality-in-contemporary-mch-a-seminar-with-dr-gene-declercq/?utm_source=MHTF+Subscribers&utm_campaign=22d1ff13cf-RSS_EMAIL_CAMPAIGN&utm_medium=email&utm_term=0_8ac9c53ad4-22d1ff13cf-183820305