In the News
Is your hospital safe?
US Hospital safety grades have been released providing hospitals with a rating from A to F. Patients treated at hospitals graded D and F were at 92% greater risk of dying from safety problems compared to those with an A grade. In total it was found that 160,000 lives are lost annually in the US due to avoidable errors.
Patients may often have an option of what hospital they are treated at and therefore knowledge of hospitals with higher safety grades can be important. Across all states 32% of hospital graded received an A. Shockingly there were no A rated hospital in Wyoming, Alaska, Washington, D.C., Delaware or North Dakota. The states with the highest % of A graded hospital were Oregon, Virginia, Maine, Massachusetts and Utah.
Faecal incontinence from tears while giving birth
Up to 10% of mothers who give birth vaginally will develop some form of anal incontinence. An Irish barrister is working to raise awareness of the problem that affects a large number of women. She highlights the devastating impact that these injuries can have on women including the ending of careers and relationship breakdown. Noting that ‘For me, the major thing is information so people can make an informed choice’.
Tools and Resources
Assisted Vaginal Birth – Clinical Guideline - Society of Obstetricians and Gynaecologists of Canada
The Society of Obstetricians and Gynaecologists of Canada (SOGC) has released a clinical practice guideline ‘No 318 Assisted Vaginal Birth’. It provides recommendations for safe and effective assisted vaginal birth including:
Antibiotics for operative vaginal delivery – Randomized Controlled Trial
Use of prophylactic antibiotic after operative vaginal birth can reduce the risk of women developing an infection. A randomized study of women across 27 UK obstetric units was conducted. Women were either allocated to receive a single dose of intravenous amoxicillin and clavulanic acid or placebo following operative vaginal birth at 36 weeks gestation or later.
In total 3427 women were randomly assigned treatment, 1719 to antibiotics and 1708 to placebo. The women who received antibiotics had a 56% reduction in confirmed infection compared to the placebo. The study also estimates that there is potential for a 17% reduction in overall antibiotic use when administered prophylactically.
Pregnancy is a wonderful time filled with many expectations and bodily changes. For some women pregnancy can be a relatively easy time but for others it can present some challenges. We are all different but what can help are the preparations you take before falling pregnant. This alone can make a major difference to your pregnancy and growing baby. It is normal to experience a few minor or major changes and issues throughout your different stages of pregnancy and this is why choosing a specialist who works in this field is imperative.
Whilst working with your GP, Midwives, Obstetrician or Doula is imperative during your pregnancy, there are many other specialised professionals who can support you. Look for pregnancy specialist in areas of; Yoga, Pilates, Acupuncture, Naturopathy, Chiropractic and Massage. These holistic therapists can help support you throughout your pregnancy, prepare you for your labour and guide you through post-natal self-care and baby support.
Remember Pregnancy is a time to Nurture and Embrace! Whilst you want to look after you and your growing baby know you can use this time to also embrace some amazing pregnancy exercises and techniques which in turn will assist your labour.
Every woman’s body is different; therefore, the ability of exercise options will also be different from one woman to the next.
Having a healthy balanced diet will assist in your baby’s development, your growing body and how much energy you have throughout the day. Meditation is another practice that you and your partner can do together to keep a balanced mental and emotional state during this life changing experience. Meditation or mindfulness practice will also help you prepare for labour.
It is important for women to acknowledge that pregnancy and birth does not need to be feared or scary. Know your body, communicate with your specialists, research and ask questions about your pregnancy and labour. Be informed and know your options and choices, without over-whelming yourself. As you become more connected and informed you will make the right choices for you, your baby and your family.
Most importantly take time to slow down and connect with your growing baby. The more connection you both have the smoother your transition in to mother-hood will be.
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.
In the News
Keyhole surgery in the womb
Surgeons in the UK have performed keyhole surgery to repair a babies spine whilst in the womb. The baby was diagnosed with Spina bifida after a routine scan which showed the spine and spinal cord weren’t developing correctly. The mother underwent surgery at 27 weeks to correct the defect with doctors performing keyhole surgery to address the problems with the babies spine and spinal cord. Performing the surgery whilst the baby is still in the womb can reduce risk of complications for the baby later in life.
What happens to a baby during birth?
MRI showing the molding that occurs to a baby’s head during the second stage of labor has been examined in a recently published study. 7 women had an MRI before labor and during the second stage. All 7 showed fetal head molding in the MRI during the second stage of labor. Following delivery only 2 of the newborns showed deformed head contours.
The study highlights that the results suggest the fetus is subjected to greater stress than it was previously thought. It also highlights that a ‘normal birth’ where a mother gives birth by natural means with only a few maternal expulsive efforts may not lead to the optimal fetal outcome as it doesn’t take into consideration the amount of fetal head molding that may take place.
The study concludes that fetal head molding was observed in all 7 patients but was observed in only 2 following delivery. The ‘overlapping of the cranial sutures was most significant in the anterior-posterior direction, at the coronial and lambdoid suture’. The findings of the study are important for understanding the mechanism and risk of labor and birth.
Obesity status has no effect on VBAC
In this study 614 underwent trial of labor after cesarean section with 72.3% having a successful VBAC. The women were divided into 4 categories based on their pre-pregnancy and delivery weight. The study found that the success of VBAC was no different across the 4 groups and furthermore there were no difference in perinatal morbidity. The study highlights the importance in counselling women appropriately on TOLAC.
Model for likelihood of success of ECV
A study has looked into ECV with the aim to identify determinents of success. Women in the study underwent an ultrasound scan to provide a variety of information on the fetal position. An obstetrician attempted the ECV terminating the procedure if fetus was unsuccessfully turned, 30 minute of manipulation had elapsed, the woman asked to stop or the obstetrician determined there was no benefit of proceeding. Following the procedure another scan was performed.
A total of 250 women under the procedure during the study with a 64.8% success rate. Variables that impacted the success rate were determined to be BMI, size of fore-bag and parity. A large fore-bag, multiple parity and lower BMI were all found to be important determinants of ECV success.
Tools & Resources
A new website ‘Every week counts’ is highlighting the importance of the last few weeks of pregnancy. Research from the Clinical and Population Health Perinatal Research Centre of the Kolling Institute, based at Royal North Shore Hospital, Sydney Australia has shown the benefits for babies born close to their 40 weeks due date.
The website aimed at healthcare professionals highlights the short term and long term benefit of birth at 40 weeks including:
The website provides research papers and resource to support the conversations obstetrician are having with expectant mums.
WHO: Strengthening quality midwifery education
The WHO report in midwifery education has been published identifying 3 strategic priorities and a 7 step action plan.
The 3 strategic priorities:
The 7 step action plan to achieve this:
The full report goes into much greater detail on the importance of the strategic priorities and how they can be achieved.
In the News - Alabama passes law banning abortion
Legislation passed in Alabama is the most restrictive abortion bill in the US. It makes carrying out an abortion at any stage in pregnancy illegal even criminalizing abortion in cases of rape and incest. Doctors carrying out the procedure could face up to 99 years in jail.
Abortions would only be legal in cases where the mother’s life is in danger or if the fetus has a fatal condition. Many groups and organizations are planning to challenge the bill.
There are several countries around the world where there are also restrictions or bans on abortions including Northern Ireland, Malta, Philippines and Poland.
Safety culture can positively impact surgical outcomes
This study into the influence of hospital safety culture on surgical outcomes highlights the positive impact safety culture can have. Those hospitals that reported a positive safety culture were significantly associated with lower risk of postoperative morbidity. The study concludes:
‘Hospital safety culture can influence certain surgical patient outcomes. Improving the safety culture within a hospital can represent a previously unrecognized approach that can be leveraged to strengthen surgical quality improvement efforts at the hospital level.’
The study can be found here.
Translating Maternal Mortality Review into Quality Improvement Opportunities in Response to Pregnancy-Related Deaths in California
An article has been published looking at improvement opportunities from the maternal mortality review in California. The study looked at readiness, recognition and response allocating data from 203 pregnancy related deaths into one of the 3 categories. Opportunities for improvement relating to each category were identified:
Read the study here.
Pregnancy related deaths report
The Centers for Disease Control and Prevention has published a report into pregnancy related deaths. It highlights that around 700 women die each in the US from pregnancy related complications estimating that 3 in 5 of these could be prevented.
Figures in the study outline the statistics for the 2011 – 2015 period. The split is relatively even between deaths happening during pregnancy, at delivery or up to 1 week after and 1 week to 1 year postpartum. Heart disease and stroke were the cause of over 1/3 of the deaths and Black and American Indian/Alaska Native women were about 3 times as likely to die from a pregnancy-related cause.
Although heart disease was one of the main causes of death other causes differ depending on the stage of pregnancy or postpartum period. Most deaths during delivery are caused by obstetric emergencies for example excessive bleeding and in the week after delivery bleeding and infections are common. Some of the factors that play a part in deaths include women’s access to care, missed/delay diagnosis and failure to recognise warning signs.
The report provides some recommendations for what all stakeholders can do:
The full report and further resources are available here.
SMFM guidance - Immediate postpartum long-acting reversible contraception for women at high risk for medical complication
New guidance on Immediate postpartum long-acting reversible contraception (LARC) for women at high risk for medical complications has been published by the Society for Maternal Fetal Medicine. The document has been designed to educate all providers about the benefits of postpartum contraception, and to advocate for widespread implementation of immediate postpartum LARC placement programs.
Recommendations from SMFM are:
This Week in Maternity - Safer Care Victoria Report, Maternal Mental Health and International day of the Midwife
International Day of the Midwife
The 5th May marks the International Day of the Midwife, a day to recognise and celebrate the work done by midwives around the world. The theme this year is ‘Midwives: Defenders of Womens Rights'.
The Virtual International Day of the Midwife is an online conference celebrating the day. There are speakers from around the world discussing a range of topics and it is free to attend!
The full programme can be found here.
Safe Care Victoria – Mothers, Babies and children report 2017
Safer Care Victoria has published their latest report on data and trends in maternal and fetal mortality and morbidity. The report on data from 2017 provides recommendation for clinicians and health service providers.
The recommendations relating to pregnancy and childbirth are:
In 2017 there were 78226 women who gave birth in Victoria, the number of women giving birth by cesarean section increase to 34.9% and ¼ experienced a postpartum haemorrhage. Those women gave birth to 79407 babies, 8.5% of which were born preterm with 7% with a birth weight of under 2500g.
The report outlines that there were 7 maternal deaths with suicide being one of the main causes. The number of perinatal deaths across 2017 was 702 with the main causes of congenital abnormality, spontaneous preterm and other specific perinatal conditions. It is thought that sub-optimal factors likely contributed to 20 stillbirths and 12 neonatal death. The recommendation highlighted above are designed to address some of the factors found to be related to sub-optimal care.
The full report with all statistics and recommendations can be read here.
Maternal Mental Health Awareness
The 1st of May, World Maternal Mental Health Awareness day, marked the start of Maternal Mental Health Month. The initiative is aimed at highlighting and promoting the experiences of women and their families and providing information on the resources and support available.
To recognise and support the initiative we will be sharing information and resources across our social media platforms. You can follow along with the #MaternalMentalHealth.
This Week in Maternity - WHO digital intervention recommendations, Care provider wellness and maternal mental wellbeing
This video from perinatal positivity shares the stories and experiences of those men and women who have experience mental wellbeing difficulties around pregnancy and childbirth. It provides a useful insight into the different mental wellbeing experiences an individual may face and outlines the avenues for help.
Perinatal Positivity suggests some ways you can use the film including:
There is also further information and support resources on the perinatal positivity website.
Provider Wellness Mini-Series from the council on patient safety in women's healthcare
The council on patient safety in women's healthcare is hosting a series of teleconferences on the topic of provider wellness. In the first part of the series the speakers look at the current state of wellbeing and its effect on patient care.
There is discussion on compassion fatigue and burnout and the implications that has on the care provider. There are between 300-400 physician suicides per year. Burnout and fatigue can also have a negative impact on an individual’s performance leading to medical errors.
The speakers cover ways to enhance wellness both at an individual and a system level suggesting:
The next part of the series is on the topic of 'moving from surviving to thriving'.
You can catch up on the first part of the series and sign up for the next topics here.
WHO recommendations on digital interventions
The World Health Organisation has published a guideline: recommendations on digital interventions for health system strengthening.
The guide is designed to provide recommendations on digital health interventions that are emerging. Based on evaluation of evidence the guide outlines the impact digital interventions can have on health systems.
Some of the recommendation include:
The full document is available here.
This Week in Maternity - Screening for breech presentation study and South Dakotas high sleep related infant death rate
A study recently published has looked at the impact that screening for breech presentation at 36 weeks has on the birth. The study ‘Screening for breech presentation using universal late-pregnancy ultrasonography: A prospective cohort study and cost effectiveness analysis’ found that screening could lower the risk of breech delivery.
Researchers from Cambridge recruited 4000 women to the study. The women all received a scan at 36 weeks to help determine the position of the baby with 4.6% with a breech presentation. Those with a breech presentation were either given an ECV or counselled on their options – Cesarean section or vaginal birth.
Of the 179 women with a breech presentation more than half were previously undiagnosed. ECV was tried for 84 women but was only successful in 12. The types of delivery for the 179 women were:
The study also looked at the financial/economic implications of introducing the 36 week scan. The cost for adding the additional ultrasound would be £4.27 million annually however some of this would be offset by savings made from avoiding the complications associated with a breech delivery.
The study concludes:
‘This study shows that implementation of universal late-pregnancy ultrasound to assess foetal presentation would virtually eliminate undiagnosed intrapartum breech presentation in nulliparous women. If this procedure could be implemented into routine care, for example, by midwives conducting a routine 36-wkGA appointment and using a portable ultrasound system, it is likely to be cost effective. Such a programme would be expected to reduce the consequences to the child of undiagnosed breech presentation, including morbidity and mortality.’
The full study is available here.
Why are South Dakotas infant death rates so high?
Figures published on infant mortality rates due to sleep related disorders show that the rates in South Dakota are much higher than the national average.
The rate of 157.3 deaths per 100,000 births is 43% higher than the national average. Although the rate has been decreasing over the past 25 years the decrease has tapered off in the last few year. Sleep related cause include sudden infant death syndrome, accidental suffocation and strangulation. Between 2013 and 2017 95 babies in South Dakota died of sleep related causes following discharge from hospital.
Some of the possible risk factors contributing to sleep related deaths include:
To try and address the higher rate in South Dakota there are initiatives being implemented.
The America Academy of Paediatrics recommends a number of steps to support safe sleeping that includes placing the child on their back to sleep, keeping soft objects and bedding away from the sleeping area, avoiding smoking during pregnancy and after birth and avoid overheating.
This article details further information about the statistics and recommendations.
What does the NHS Long term plan say about maternity care?
The NHS Long term plan sets out how the NHS plans to provide care over the next 10 years addressing the changing nature of healthcare and the challenges being faced. Within the plan are provisions for maternity care. The plan outlines a number of goals including:
Saving babies live care bundle
The saving babies lives care bundle will be rolled out across all maternity units in England in 2019. The bundle has shown a 20% reduction in stillbirths across those units where it is already in place. There are also plans to expand the bundle to focus on prevention of pre-term birth.
Local maternity systems
All units will be part of local maternity systems which include a named maternity safety champion bringing together all aspects of maternity care.
Clinical negligence scheme
The clinical negligence scheme will continue to financially reward those units that deliver on 10 key safety actions.
Continuity of care
Work will continue on providing continuity of care with teams being set up across the country with a particular focus on care for BAME communities. Evidence suggests that for these community’s midwifery led continuity of care leads to improved clinical outcomes.
Learning from mistakes
The healthcare safety investigation branch will review all term stillbirths, early neonatal deaths and cases of severe brain injury in babies, as well as all maternal deaths reporting on lessons learned and how to avoid similar incidents.
Mental health services
There will be increased provision of mental health services both for mothers and fathers with care provided by specialist perinatal mental health services from preconception to 24 months after birth. Additionally, the types of therapies available will be expanded.
The plan also includes provision for neonatal care including better design of service to improve safety and effectiveness, development of the neonatal workforce and increased support for families.
The full plan and addition information can be found here. There is also a proposal for changes to legislation to help support the implementation of the long term plan that you can provide feedback on.
Pushing from below increases maternal complications
A study published in BMC Pregnancy and childbirth ‘Maternal and neonatal outcome of reverse breech extraction of an impacted fetal head during caesarean section in advanced stage of labor: a retrospective cohort study’ has found some significant differences in outcomes when comparing ‘pushing from below’ and reverse breech delivery of a baby with an impacted fetal head.
The retrospective study conducted in Switzerland analyzed the outcomes of 629 women whose baby was delivered via cesarean section in the later stages of labor. If difficulty was faced in disimpacting the fetal head either the reverse breech technique or head pushing was used. 82 women were in the head pushing group and 55 in the reverse breech.
The study found that outcomes were improved for women in the reverse breech group. They had lower uterine extension rates, a shorter operating time and less blood loss. There was no significant difference in the fetal outcomes however 2 babies in the head pushing group suffered skull fractures, one of which resulted in death.
The paper highlighted:
‘The deeply impacted fetal head is an obstetrical emergency situation, which requires a secure delivery technique to prevent undesirable maternal and neonatal consequences’
The full paper is available here.
Maternal and perinatal deaths dis-proportionally high following cesarean section in low- and middle-income countries.
The Lancet has published a study titled ‘Maternal and perinatal mortality and complications associated with caesarean section in low-income and middle-income countries: a systematic review and meta-analysis’.
The systematic review including 196 studies from 67 different countries looked at the risk of mortality in women who have had a cesarean section in low and middle income countries; estimating the cesarean deaths as a proportion of all deaths, the number of stillbirths and perinatal deaths along with risk of morbidity.
The review found that the cesarean section rate in most of the countries in the review was less than 10% with almost one quarter of cesareans being done for non-progress of labor. Findings for the rate of deaths per 1000 for those undergoing cesarean section were:
The review also found that women undergoing an emergency cesarean section were twice as likely to die than those undergoing an elective cesarean. A third of all the maternal deaths were attributed to post-partum haemorrhage and those cesareans performed in the second stage of labor were at higher risk of complications.
The study concludes:
‘The risk of maternal death following caesarean section is disproportionately high in LMICs, and women in sub-Saharan countries have the worst outcomes. The risks do not appear to have reduced over the past nearly 30 years, and are high in countries with a low rate of caesarean sections. Offspring outcomes are poor after a caesarean section, with high stillbirth and perinatal mortality. Emergency caesarean sections, particularly when undertaken in the second stage of labor, is a major risk factor for maternal and perinatal deaths, maternal near miss, and other major complications.’
The full study is available here.
Cesarean delivery associated with higher morbidity for women over 35
In a study titled ‘Risk of severe maternal morbidity associated with cesarean delivery and the role of maternal age: a population-based propensity score analysis’ researchers looked at 6 regions across France covering 119 maternity units. A total of 4908 women were part of the study.
In those women with maternal morbidity over 85% of women had a post-partum haemorrhage with an increased risk of severe maternal morbidity for women with cesarean deliveries during labor. The risk of maternal morbidity for women with cesarean section before labor was significantly higher only for women over 35.
The study highlights that cesarean section was associated with a significantly higher risk of severe morbidity when compared to vaginal delivery. The risk for women over 35 was particularly significant for those undergoing cesarean both before and during labor.
It is important to recognize and evaluate both the risks and benefits when performing a cesarean section.
The full study is available here.