When the science of midwifery undermines the art

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Self-hypnosis for pain relief in labour

Obstetrician and canoeist through the thick waters of controversy Jim Thornton drew my attention to this recent trial, published by the BJOG in February (Werner et al 2013, read it here), through his blog (read his post here, always though-provoking). Jim calls the trial ‘lovely,’ but I can’t agree. Rather, I think it illustrates how research, if not appropriately designed, can potentially cause more harm than good.

This study was well-conducted in randomised controlled trial (RCT) terms, so we can depend on the results: Take a group of women who are up for it and randomly allocate them to a short course on either self-hypnosis, relaxation, or standard antenatal care. They then give birth supported by a midwife who is not allowed to know how they prepared to self-manage pain in labour. You will find that no one education intervention results in more or less pain, more or less need for epidurals, nor any noticeable difference in satisfaction with their childbirth experience. I’m not surprised.

I was pleased to see the authors shared many of my concerns in retrospect and can only imagine it was over-confidence in a technique they had observed many women use with great satisfaction that led them to proceed with a trial design which featured some predictable flaws. One of my biggest concerns was that staff were blinded about the woman’s allocation. Effect: most of the time the midwives could not guess correctly which group the woman belonged to. This was a piece of midwifery research, but it effectively disabled midwives from practicing their art, sympathetically enhancing the woman’s coping techniques using knowledge gained about that woman through their relationship.

This debate was bugging me until I picked up the latest issue of The Practising Midwife and read midwifery lecturer Charlotte Kenyon’s very sensible piece on ‘Clinical hypnosis for labour and birth: a consideration.’ She discusses the difficulties with conducting research in this area (I refer you to her article for a fuller account; TPM is digitally lacking, so visit your library), but most importantly she points out, “No recent studies could be found which employed individualised hetero-hypnosis” (Kenyon 2013, p12).

‘Individualised hetero-hypnosis’ is what you get when you give midwives a set of tools (along with women) and enable them to use them to support women on an individualised basis, according to the woman’s needs and values, enhancing the woman’s own coping skills. Delivering individualised care, sympathetically combining experience- and evidence-based knowledge, is the art of midwifery. In contrast – “Where research is undertaken using formulaic scripts, results may be affected by the use of a one size fits all approach to a therapy which by its nature is individualised” (Kenyon 2013, p12). Yep.

Soo Downe is currently conducting an RCT (registered here) on the use of self-hypnosis with a mixed methods design that appropriately includes other strands of contextualising data collection such as interviews, focus groups, logs and questionnaires. Importantly, the midwives supporting women in labour will not be blinded; therefore, the conduct of the trial itself presents an opportunity to expand the practice of midwives providing individualised care. This sounds like a study which will pragmatically improve our understanding of how women use self-hypnosis and how midwives can enhance women’s own efforts, as well as whether or not there is a quantifiable difference in outcomes which would justify increased investment to integrate such services into the NHS. Can’t wait for the results.

So what harm can come from poorly designed research? Well, I wouldn’t have liked a positive outcome for the Werner trial to lead us down a path of advising all women they will have a better time if they use self-hypnosis (without a greater understanding of who it is most likely to help, how and why). But I also don’t like the idea that on the back of this large RCT some individual women’s use of self-hypnosis will inevitably be dismissed by some professionals as ‘not evidence-based,’ rather than respected and appropriately supported. This could undermine a woman’s confidence and feeling of being supported in her chosen coping strategies. For what? Because we know better?

Declaring my personal biases (because it’s my blog): I have never been drawn to using hypnosis (self-administered or otherwise) while giving birth, despite having four home births. If you told me I would never have to listen to a hypnosis CD throughout a night of someone else’s labour again, I wouldn’t complain; they make me feel like I’ve just had a lobotomy. My personal birth mix included Nina Simone, Herbie Hancock, and Madonna’s ‘Like a Virgin,’ just to lighten the mood while I swore like a trucker. But I trust women. Having listened to many women describe how hypnosis-related techniques and programmes helped them feel more confident and in control, and having watched them give birth, I am siding with those who insist their experience be properly accounted for before we close the book on the hypnosis for childbirth debates.

Reference

Kenyon C (2013) Clinical hypnosis for labour and birth: a consideration. The Practising Midwife. 16(5):10-13.

Update 2015 – You can read Downe et al 2015 by following the link.

BJOG. 2015 Aug;122(9):1226-34. doi: 10.1111/1471-0528.13433. Epub 2015 May 11. Self-hypnosis for intrapartum pain management in pregnant nulliparous women: a randomised controlled trial of clinical effectiveness. Downe S, Finlayson K, Melvin C, Spiby H, Ali S, Diggle P, Gyte G, Hinder S, Miller V, Slade P, Trepel D, Weeks A, Whorwell P, Williamson M.

Cord prolapse: what do midwives do?

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This post was originally written as a Letter to the Editor, but when I went to submit it, I discovered the on-line journal does not accept any unsolicited writing. All of the articles are ‘commissioned by the Editors from specialists in their field,’ so I guess we should read them as more of a pronouncement than the opening of a dialogue?

I have some concerns about an intervention for cord prolapse described in a recent article on Abnormal Labour (Obstetrics, Gynaecology and Reproductive Medicine, Volume 23, Issue 4, Pages 121-125, April 2013): “Filling the urinary bladder (with 500-750 ml normal saline) helps to elevate the presenting part off the cord – this technique is particularly more suitable to the homebirth or standalone midwifery unit setting where prolonged manual elevation during transfer to an obstetric unit is difficult to maintain. In the hospital setting, filling the urinary bladder offers no increase in survival or improvement in fetal umbilical cord gases over manual elevation alone, although may be a useful adjunct if there is no theatre immediately available.”

As I said, I have some concerns. The authors suggest filling the urinary bladder as a method of preventing cord compression following cord prolapse. They say this technique has not been shown to improve outcomes in a hospital setting, but is ‘particularly more suitable to the homebirth or standalone midwifery unit.’ There are no references provided for the evidence related to use of this technique in either setting. As a midwife who has worked in two countries and the complete range of midwifery-led settings, I have never encountered this technique, nor anyone carrying appropriate equipment to enact it. I am concerned that an unproven, potentially harmful intervention not in widespread use is being presented as best practice, for use by midwives.

I am also concerned that, although the case scenario ended in a vaginal birth, the discussion presents caesarean section as the preferred method of delivery when a cord prolapse is seen, without discussing the importance of determining whether or not delivery is imminent before intervening. Cord prolapse is a common occurrence preceding the birth of a second twin, and during the births of babies with complete (knees flexed) and footling breech presentations. A prolapsed cord at full dilatation may precede a healthy vaginal birth with a delivery interval significantly less than a caesarean section (Gannard-Pechin et al 2012, Huang et al 2012), and when accompanying non-frank breech and twin births is associated with fetal compromise less often than for cephalic singletons (Kouam & Miller 1980, Broche et al 2005). Therefore, giving the impression that the best course of action upon seeing a cord in every situation is to elevate the presenting part manually, effectively preventing descent and spontaneous delivery in preference of a crash section, in many instances will cause more harm than good. This may seem like a matter of course to experienced practitioners, but it won’t be for the inexperienced.

Judging which instances require such emergency measures, and which would benefit from cautious expectant management, is a matter of skill and experience (in theory and practice), to which articles like the one linked above could usefully contribute. Factors to consider include cervical dilatation, type of presentation, signs of fetal distress, and descent with expulsive effort. Additionally, management of breech deliveries with the woman in an all fours position may reduce cord compression (as the cord is above the fetal body rather than below), and can easily be converted to a knees-chest position for more active intervention if delivery does not progress as quickly as expected. This is a strategy midwives are actually using in the community.

Update (December 2014): Those of you who are interested in this topic should read this report from the Netherlands:

M Smit et al, Umbilical cord prolapse in primary care settings in the Netherlands; a case series, Part 2, The Practising Midwife 17 (7); 34-38.

When considering what is recommended and best practice for midwives working in primary care settings, evidence needs to come from those settings. In this study, 2/8 UCP’s were managed with retrograde bladder filling, and these two instances were associated with the poorest Apgars, and the only death reported. While the numbers are small, they suggest that bladder filling in primary care settings may not offer benefits over manual elevation of the presenting part. Additionally, because it is time consuming, especially for a single midwife on her own at home, it may lead to unnecessary delays, compared to outcomes which were conducted in settings where assistance from other staff was immediately available.

What do you think? Are you carrying equipment to inflate women’s bladders if you detect a cord prolapse at home?

Broche, D. E., Riethmuller, D., Vidal, C., Sautiere, J. L., Schaal, J. P., & Maillet, R. (2005). [Obstetric and perinatal outcomes of a disreputable presentation: the nonfrank breech]. J Gynecol Obstet Biol Reprod (Paris), 34(8), 781-788.

Gannard-Pechin, E., Ramanah, R., Cossa, S., Mulin, B., Maillet, R., & Riethmuller, D. (2012). [Umbilical cord prolapse: a case study over 23 years]. J Gynecol Obstet Biol Reprod (Paris), 41(6), 574-583. doi: 10.1016/j.jgyn.2012.06.001

Huang, J. P., Chen, C. P., Chen, C. P., Wang, K. G., & Wang, K. L. (2012). Term pregnancy with umbilical cord prolapse. Taiwan J Obstet Gynecol, 51(3), 375-380. doi: 10.1016/j.tjog.2012.07.010

Kouam, L., & Miller, E. C. (1980). [Prolapse of umbilical cord – new aspects]. Zentralbl Gynakol, 102(13), 724-733.

Heads Up! International Breech Conference

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Washington, DC – November 9-12, 2012

Conference report.

Driven by consumers, sponsored by the Society of Obstetricians and Gynecologists of Canada and attended by obstetricians and midwives from 15 different countries, the third International Breech Conference convened in Washington, DC, from November 9-11.

The highlight of the conference was soon-to-be-published data from observational studies in Frankfurt and Sydney, representing nearly 800 planned vaginal births, presented by obstetricians Andrew Bisits, FRANZCOG, and Anke Reitter, FRCOG, along with Frankfurt team researchers, midwife Betty-Anne Daviss and epidemiologist Ken Johnson. Fellow conference presenter Sophie Alexander (MD, PhD, and co-author of the PREMODA study )1 summarised by pointing out, “These results are consistent with all of the large studies done since the Term Breech Trial. Everyone except Hannah has observed a small increase in low Apgars and non-significant birth injuries for vaginally born breech babies, with no difference in mortality rates or long-term morbidity.”2

The current state of breech research was summarised by Prof Marek Glezerman, MD, Chairman of the team which contributed results from Israeli institutions to the Term Breech Trial, and author of the significant 2006 re-evaluation of the same study which concluded that due to serious flaws in the research and the simplications of standardising its recommendations, the results of the study should be withdrawn.3 Glezerman presented research from further studies, which demonstrate, as Dr Alexander pointed out, that where vaginal breech birth is well supported, it can be a safe option.4,5 Additionally, Glezerman pointed out that we need to be less precious in our initial evaluation of significant morbidity: “A low Apgar at 1 minute means nothing in 2 hours or 2 years; it only serves to make you alert to the baby.” Bisits also participated in the original TBT and shared Glezerman’s and others’ skepticism about whether the trial design was appropriate to measure what it intended to measure.6

Significantly, Anke Reitter, Andrew Bisits and Betty-Anne Daviss are experts in the use of upright techniques for breech delivery, along with Reitter’s Frankfurt colleague Professor Frank Louwen. A majority of the births in each location took place in upright positions, with the woman on hands/knees or a birthing stool. In both settings, they have observed an increased need for manoeuvres or forceps and an increase in birth injuries when the mothers have been in lithotomy position, and these obstetricians are now keen to share their data so that other clinicians can learn safer ways to facilitate vaginal breech births.

This stance was well-received by the many midwives in the audience, many of whom have been advocating upright delivery techniques for vaginal breech birth for some time. One of the foremost breech midwives is Jane Evans, SCM, SRN, a UK Independent Midwife, who presented her recently published descriptions of the mechanisms of a normal breech birth,7,8 the result of decades of close observation. Although one panel featured a lively debate about whether breech presentation should be viewed as an abnormality or an unusual variation of normal, all agreed that a thorough understanding of the parameters of normal specific to breech birth is a prerequisite for a safe service. Knowing the mechanisms allows a practitioner to understand when progress has deviated from normal and intervention is indicated, and when to refrain from potentially harmful manipulations when these are not required.

The varied conference contributions made two points very clear. Firstly, knowledge about breech birth is evolving far beyond what research done over a decade ago can address, with so much more to learn about how to make breech birth as safe as possible. Secondly, moving breech knowledge forward will require genuine multi-disciplinary openness and skill-sharing, exemplified by the humbleness of the expert obstetricians and midwives who acknowledged the many sources of their knowledge.

Following on from three days of intense discussion, a post-conference practical session on November 12 was dedicated to hands-on, practical learning with simulated breech births, guided by several of the experienced obstetric and midwife practitioners. This included two new manoeuvres, the Louwen Manoeuvre for assisting the birth of fetal arms in an upright delivery through rotation (a variation of Lovset’s), and Frank’s Nudge, used to promote flexion and birth of an extended fetal head. Detailed descriptions of these manoeuvres will be published alongside the Frankfurt data early next year, but they are already being taught in several UK hospitals which incorporate upright techniques into annual mandatory breech updates.

Throughout the three-day conference, we also heard from women who spoke very movingly about their experiences of breech pregnancy and attempts to secure support for their choice of a vaginal breech birth. Evident in these stories was the fear and resistance their providers felt, which prevented them from providing appropriate, woman-centred care, and the long-term effects this had on each woman’s wellbeing. A panel discussion dedicated to this topic included Benna Waites, a UK clinical psychologist whose own experience prompted her to gather the available evidence into her very thorough book, Breech Birth,9 essential reading for any breech practitioner. As Waites passionately summarised in her own story: “I was angry, not just scientifically disappointed. Providers need to know: your fear and your ignorance cannot be the reason for our lack of choice.”

The conference was designed to tackle this fear and resistance head-on with expert-led discussions of what is required to change the current situation, in which a caesarean section is either the most often only option when a baby presents breech, or is promoted as the best option due to providers’ lack of familiarity with current breech research since or lack of confidence in their own skills to safely deliver a breech baby. Glezerman argued that to reinstate breech skills, we must standardise assessments of competency with theoretical and practical tests, and while this must be combined with hands-on experience, standardisation cannot be based on numbers alone.10

This is partially because large numbers of breech births are simply not available to today’s trainee obstetricians and midwives. Recent research into the breech experience of obstetricians training in the UK show remarkably little experience, compared to what obstetric trainees would have experienced a few decades ago.11 The need to measure breech competency independent of birth numbers also results from the influence of personal skill sets on the ability of breech attendants, including confidence and motivation to develop expertise, which requires additional on-call commitments.12 Several speakers, obstetricians and midwives, spoke movingly of how breech birth attendance is an art, like many aspects of our professions, which some are simply more drawn to than others.

This viewpoint is consistent with the secondary analysis of the TBT results, which demonstrated that a clinician’s own evaluation of his/herself as “skilled and experienced,” when confirmed by their Head of Department, was more strongly associated with good outcomes than when the attendant was defined as a registered obstetrician or by number of years of experience.13 It also mirrors the Canadian recommendations that on-call specialist teams be established.14 In a move which reflects growing institutional support for practitioners who are willing to acquire the necessary experience to support breech birth safely, we heard how one hospital in Canada has recently abolished a mandatory transfer-of-care from midwives to obstetricians when women labouring with breech-presenting babies enter the hospital. It seems likely that, while universal training for doctors and midwives in emergency breech delivery remains required on safety grounds, planned breech births will increasingly be managed by breech specialists. In which case, more of us are needed.

Three days of presentations and discussions ended with a panel dedicated to exploring the legal and ethical dimensions of supporting a woman’s choice to birth her breech baby within today’s risk-adverse and minimally experienced services. As well as legal experts, the panel included obstetricians who facilitated planned breech births, as well as those who were prevented from doing so by their hospital’s policies, which made for an interesting discussion around the ethical dilemma resulting from the professional obligation to respect clients’ informed refusal (eg. of a caesarean section) amidst active obstruction from risk management policies. The discussion made clear that in order to provide the woman-centred service that clients want and many providers want to provide, there are many obstacles which need to be overcome, not all of these are apparent or clearly defined, so they remain difficult to tackle.

Although over the course of the conference we heard from a few American obstetricians who were preserving breech skills in isolated pockets (with positive outcomes, similar to their European counterparts), the medicolegal panel was the only portion of the conference attended by a representative of the ACOG (Dr Constance Bohon), despite repeated invitations. This was a great disappointment to the organisers from the Coalition for Breech Birth, who chose the Washington DC location for this international conference particularly to support the American chapters, who are struggling to open up lines of dialogue between consumers wanting more options and providers and their professional organisations. Listening closely to women’s concerns and extending an olive branch, Bohon suggested, “Perhaps it is time to set up a task force.”

While we in the UK are often not as circumscribed by actual legal constraints limiting woman-centred practice, a well-supported vaginal breech birth is still not easy to come by. The conference organisation team included a UK Coalition for Breech Birth user representative, student midwife Ruth Mace-Tessler, and was attended by several UK midwives and an obstetrician, but again no RCOG representative despite repeated invitations. Maybe the time has come for us to set up a similar task force in the UK?

Shawn

References

1. Goffinet F, Carayol M, Foidart J-M, Alexander S, Uzan S, Subtil D & Bréart G (for the PREMODA Study Group) 2006. Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium. American Journal of Obstetrics and Gynecology, 194: 1002-1011. 1. Daviss, B. A., Johnson, K. C. & Lalonde, A. B. 2010. Evolving evidence since the term breech trial: Canadian response, European dissent, and potential solutions. J Obstet Gynaecol Can, 32, 217-24.

2. Hannah, M. E., Hannah, W. J., Hewson, S. A., Hodnett, E. D., Saigal, S., Willan, A. R. & Term Breech Trial Collaborative, G. 2000. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Lancet, 356, 1375-1383.

3. Glezerman M. 2006. Five years to the term breech trial: the rise and fall of a randomized controlled trial. Am J Obstet Gynecol, 194, 20-5.

4. Toivonen, E., Palomäki, O., Huhtala, H. & Uotila, J. 2012. Selective vaginal breech delivery at term – still an option. Acta Obstetricia Et Gynecologica Scandinavica, 91, 1177-1183.

5. Hauth, J. C. & Cunningham, F. G. 2002. Vaginal breech delivery is still justified. Obstet Gynecol, 99, 1115-6.

6. Kotaska, A. 2004. Inappropriate use of randomised trials to evaluate complex phenomena: case study of vaginal breech delivery. BMJ, 329, 1039-42.

7. Evans, J. 2012a. Understanding physiological breech birth. Essentially MIDIRS, 3, 17-21.

8. Evans, J. 2012b. The final piece of the breech birth jigsaw? Essentially MIDIRS, 3, 46-49.

9. Waites B. 2003. Breech Birth, London, Free Association Books.

10. Glezerman M. 2012. Planned Vaginal Breech Delivery: Current Status and the Need to Reconsider. Expert Review of Obstetrics & Gynecology., 7, 159-166.

11. Dhingra, S. & Raffi, F. 2010. Obstetric trainees’ experience in VBD and ECV in the UK. Journal of Obstetrics and Gynaecology, 30, 10-12.

12. Kotaska, A. 2009. Breech birth can be safe, but is it worth the effort? J Obstet Gynaecol Can, 31, 553-554.

13. Su, M., Mcleod, L., Ross, S., Willan, A., Hannah, W. J., Hutton, E., Hewson, S., Hannah, M. E. & Term Breech Trial Collaborative, G. 2003. Factors associated with adverse perinatal outcome in the Term Breech Trial. American Journal of Obstetrics and Gynecology, 189, 740-745.

14. Daviss, B. A., Johnson, K. C. & Lalonde, A. B. 2010. Evolving evidence since the term breech trial: Canadian response, European dissent, and potential solutions. J Obstet Gynaecol Can, 32, 217-24.