Question: Sarah, Consultant O&G, Australia
I have used the pillow once and it was great. The case was an emergency Caesarean at full dilatation after failed instrumental. The Caesar was actually very straight forward and blood loss only 300ml. I was very impressed. My only question is...
"Can we perform a caesar with the woman in lithotomy if we are also using a Fetal Pillow?"
Reply: Peter Dawes, Director of Sales AUS/NZ
Our guideline / information for use (IFU) directs users of Fetal Pillow to place patients legs flat on operating table. This is once you have positioned the Fetal Pillow in the posterior position toward coccyx / posterior Fornix (Balloon under engaged part of fetal head… past any caput & moulding / any position of fetal head – station zero and below).
Still, there are some O&G MOs that perform E-CS in stirrups and/or position the legs in mid- lithotomy position… however we feel that this reduces the ability for the balloon to elevate the Fetal Head to its capacity and if over lubricate it could move due to addition space available.
Laying patients legs flat on operating table prior to inflation will assist to entrap the device between Fetal head and pelvic floor and gain best uplift, lesson the ability for the device to move during inflation process.
For further information on the 'Steps and Instructions for Use' of the Fetal Pillow please visit: https://www.safeob.com/fetalpillow.html#use
This week in Maternity… How to reduce Maternal Mortality rates and Patient Impact on Obstetric Training
How to Reduce Maternal Mortality Rates in the United States
This interview provides useful information of addressing maternal mortality rates with improved management of obstetric emergencies.
In the podcast Professor Elizabeth Howell is interviewed and explains the relatively simple ways to address this problem.Dr Howell states that, “Maternal Mortality is a real issue in the United States compared to other high-income countries. Their major causes are cardiovascular disease, haemorrhage, high blood pressure, blood clots and infection. Sadly, statistics do show that 60-63% of these deaths are shown to be preventable.”
The podcast also discusses the ‘The safety bundles’ by the ‘Alliance for Innovation and Maternal Health’ which looks at the most preventable causes of maternal deaths. The safety bundles are a format that is published and then help hospitals in implementing the bundles and resources they need when faced with this maternal mortality causes.
Listen to the full Podcast here: https://edhub.ama-assn.org/jn-learning/audio-player/17455228?resultClick=1&bypassSolrId=M_17455228
Obstetric Multi-Professional Training and its impact on patient outcomes in Australia
The aim of this study is to evaluate the implementation of the Practical Obstetric Multi-Professional Training (PROMPT) simulation using the Kirkpatrick’s framework. It explores participants’ acquisition of knowledge and skills, its impact on clinical outcomes and organisational change to integrate the PROMPT programme as a credentialing tool.
Participants reported an improvement of both clinical and non-technical skills highlighting principles of teamwork, communication, leadership and prioritisation in an emergency situation.
Do cesarean sections cause autism?
There have been a number of articles published about some new research that looks at the link between cesarean sections and autism. An article by ‘The Conversation’ highlights that whilst the study shows an association between cesarean section and autism and ADHD the study does not indicate there is a causal relationship.
Cesarean sections are more common in women who are obese, older or have history of immune conditions all of which have been linked with a child having increased risk of autism. These factors may therefore be also contributing to the study findings.
National Centre for Maternity Improvement
In the UK charity Tommys, The Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists have joined together to launch ‘The Tommys National Centre for Maternity improvement’.
The alliance will work on 5 work streams:
There will be involvement from parents, midwives, doctors, the NHS and academic experts with the aim of preventing 600 stillbirths and 12,000 preterm births nationally.
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:
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.
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.
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
This Week in Maternity - Tips to prevent stillbirth, Cesarean sections in women with high BMI and Second victim experience
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:
They are also encouraging women to:
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.
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.’
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.
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:
‘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.’
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.
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:
These reports can be read in full using the links below.
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:
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.
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:
The role of midwives in having the skills and knowledge to support women with their position can impact their birth experience.
Events - RCOG World Congress 2019
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.’
New Studies - Perceptions of postnatal care after emergency cesarean sections
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:
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.
News - Myths women believe about cesarean section
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:
In the article Dr Penelope Law, Consultant Obstetrician and Gynaecologist address these myths explaining the evidence and experience surrounding the topics.
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:
How to test if you have Diastasis?
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:
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:
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
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.