The Magazine of The Royal College of Midwives Midwives · THE OFFICIAL MAGAZINE OF THE RCM DECEMBER 2010 MIDWIVES +(THE OFFICIAL MAGAZINE OF THE RCM CommunitiesDiscussions from the

MidwivesDecember 2010

The Magazine of The Royal College of Midwives

LEARNING TO LESSEN RISK | CREATING MEMORIES | SOMEBODY TO LEAN ON | CONFERENCE ROUND-UP | CARE AFTER MISCARRIAGE | DISCUSSIONS FROM THE COMMUNITIES | RIGHT TO LIFE | KEEP CALM AND CARRY ON | OUT ON HER OWN

001_mid_cover.indd 1001_mid_cover.indd 1 18/11/10 16:05:5418/11/10 16:05:54

MIDWIVES 03 THE OFFICIAL MAGAZINE OF THE RCM DECEMBER 2010

editorialRCM director of employment relations and development Jon Skewes

Meeting RCM workplace representatives in Manchester at our conference earlier this month brought home to me why now, and for the year ahead, RCM membership is indispensable for anyone working in

maternity services. So it’s good news for all of us to see that RCM membership is at its highest in memory and is delivering even more value for midwives and maternity support workers.

Our time at conference inspired me and my colleagues to continue to work hard on your behalf, to lobby for your interests and those of the women you care for, and to be enterprising in developing the resources you need from your membership.

I left Manchester overwhelmed by the commitment, supportiveness and quality negotiation skills that make our frontline member services unrivalled. But I also heard stories from the workplace and examples of cases handled by our legal assistance service, which made me fear for anyone in today’s NHS maternity services who neglects to join us. The most frustrating situations for us involve maternity workers who turn to us too late having lapsed their membership, leaving them uncovered when an incident occurs.

While you may pay more for everything else next year, at least there is one essential that will give you more value for the same money you paid two years ago – your RCM subscription rate has been frozen for yet another year.

With new member services such as RCM Communities, RCM i-learn and the relaunched library information service, we are increasing our value to members and transforming our role as a professional hub for interaction and learning. In the diffi cult year ahead, we will work to protect your pay, pensions and terms and conditions. We will raise awareness of the midwife’s role and why it delivers value. We will speak up for your local service and stand by members facing challenges to their employment and registration with the in-depth professional knowledge, peer-to-peer support, and legal back-up you can depend on from the RCM.

Finally, conference reminded me that we are led by you. We are committed to listening to our members and welcome your feedback on all we do. That is why we will be conducting a survey in the New Year to fi nd out more about what you think of us. The new RCM Communities facility will also transform the way you get involved, talk to us and contribute your views to the consultations on policies that affect you.

Best wishes for the year ahead. And when you receive your new membership card this month, you will know that, whatever next year brings, you can count on representation from fully-trained stewards and regional or national offi cers, the cover and resources you need, and a strong voice to convey your professional perspective where it matters.

Regeneration and renewal

MIDWIVES THE OFFICIAL MAGAZINE OF THE RCM DECEMBER 2010


StewardsStewards

ILLUSTRATION BY: MYDEADPONY/COLAGENE.COM

While most midwives will never find themselves the subject of a disciplinary investigation, in the unlikely event of an

untoward incident at work, an RCM steward will be ready to offer guidance and support, writes Nicki Perry.

to lean on



Self-harm

Psychologist and managing director of a self-harm training organisation Jennifer McLeod looks at the reasons behind self-harming behaviour and what midwives can do to help pregnant women who deliberately injure themselves.

Coping mechanism

ILLUSTRATION BY: PETER CROWTHER

On the trigger



Discussions from the Communities It’s a brand new venture for the RCM, which has taken months to plan and structure, but it’s here… the RCM communities.

HTTP://COMMUNITIES.RCM.ORG.UKHTTP://COMMUNITIES.RCM.ORG.UK

RESPONSE

POSTED BY: A STUDENT MIDWIFE

RESPONSE

POSTED BY: A HEAD OF MIDWIFERY

DISCUSSION 2

The latent phase of labour

DISCUSSION 1

Your trust’s policy What’s it all about?

RESPONSE


RESPONSE

POSTED BY: A CONSULTANT MIDWIFE

LINKS& NOTES

YOUR TRUST'S POLICYFor more in-depth answers to the questions, please visit: http://communities.rcm.org.uk/groups/student-midwives/conversations/your-trusts-policy

THE LATENT PHASE OF LABOURFor more in-depth answers to the questions here, please visit: http://communities.rcm.org.uk/groups/midwives/conversations/latent-phase-labour

In every issue of Midwives, there will be space dedicated to the latest discussions taking place on the RCM Communities site. If you want to read more responses or add a discussion of your own, then please log on and get involved at: http://communities.rcm.org.uk. You will need your membership number to create your user profile. If you have any problems, then contact the RCM communities manager Emma Godfrey-Edwards at: [email protected]

RESPONSE


The default setting on the communities user account is to receive an email alert when a member leaves a thread/response within a group you are a member of. You do have the option to make this a combined alert or not to receive these alerts at all. Please go into your account, click on the 'alerts' tab, and then on one of the options in 'alerts settings' to change this.

ILLU

STR

ATIO

NS

BY: J

O H

AYM

AN

TOP PICKS: Articles on the work of an RCM steward, the reasons behind self-harm, and the latest from the new RCM Communities site

Somebody to lean on (p24) Scratching the surface (p26) Discussions from the Communities (p40)

003_mid_editorial.indd 3003_mid_editorial.indd 3 22/11/10 11:15:5422/11/10 11:15:54

NEWS

8 News Midwives ask minister, is

the government listening? PM questioned over midwives staffi ng pledge.

9 News Short distance makes for big

difference in care, elective caesarean makes for calm babies says China study.

10 News Home birth rate sees

slight drop, NHS pensions put billions back into public purse.

11 News Expectant mothers assume

GP is fi rst port of call, win a pair of Fitfl ops’ Gogh Pro workwear clogs.

12 RCM news HoMs survey, RCM launches

quartet of new publications, government could reverse commissioning policy, RCM library partners MIDIRS.

14 Board news RCM UK Boards for

Scotland and Wales.

15 InFocus New survey on obesity has

revealed critical gaps in the weight management and dietary advice available.

CONTENTSDecember 2010 | Volume 13 • №7

34 RCM workplacereps conference

Speakers offered advice on meeting the challenges facing maternity services.

36 Risk management Catherine Doherty offers

advice on managing risk in maternity services.

38 Stillbirth After a stillbirth, parents

should be given the choice of holding their baby.

40 RCM communities It’s a new RCM venture,

which has taken months to plan, but it’s here...

42 Amnesty RCM NI joins forces with

Amnesty International.

10 16

26

04 MIDWIVES THE OFFICIAL MAGAZINE OF THE RCM DECEMBER 2010

36

26 Self-harmJennifer McLeod looks at what midwives can do to

help pregnant women who injure themselves.

On the cover

ILLUSTRATED BY: Peter Crowther

dietary advice available.

21

FEATURES

24 Stewards Nicki Perry describes the

role of the RCM steward.

30 RCM annualconference

Midwives assembling in Manchester took the chance to speak up for principles and priorities.

32 RCM student conference

RCM SMWG members provide a snapshot of this year’s student conference.

004-005_mid_contents.indd 4004-005_mid_contents.indd 4 22/11/10 11:17:3022/11/10 11:17:30

REGULARS3 Editorial The RCM’s Jon Skewes

on why RCM membership is indispensable.

6 Feedback Letters on leaving midwifery

and hypnobirthing.

16 One-to-one Independent midwife Mary

Cronk talks to Gareth Price.

19 Upfront A midwife describes her

feelings after a miscarriage.

20 Cutting edge Jan Wallis reviews the latest

midwifery-related research.


MidwivesThe offi cial magazine of The Royal College of Midwives15 Mansfi eld StreetLondon W1G 9NHTel: 020 7312 3535

EDITORIALEditor and communities manager: Emma [email protected]: 020 7324 2751Deputy editor: Gareth [email protected]: 020 7324 2752Assistant editor: Sasha [email protected]: 020 7880 7604News and features reporter: Hollie [email protected]: 020 7880 6210Digital media executive: Rhea [email protected]: 020 7324 2773Professional editor: Professor Mary SteenPhD MCGI PGDipHE PGCRM BHSc CIMI RM RGN

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

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

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

DESIGNArt director: Mark ParryArt editor: Carrie Bremner

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

MEMBERSHIP DEPARTMENTTel: 020 7312 3500

MAGAZINE SUBSCRIPTION RATES(for non-members only, per annum) UK: £97.50; European Union: £132.20;Rest of the world: £138

MAGAZINE SUBSCRIPTION QUERIESMidwives, PO Box 2068, Bushey, Herts WD23 3ZFTel: 020 8950 9117 Fax: 020 8421 [email protected]

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

Midwives ISSN 1479-2915

21 How to... Adminster oral medication.

22 On politics Stuart Bonar gives members

an update on the RCM’s lobbying efforts.

43 On course Emma Edwards gives a few

words of wisdom to students as she looks back over her fi rst year as a newly qualifi ed midwife.

44 Bookmark Birthing positions: do midwives

know best? and The cutting tradition are up for review.

49 2010/11 Events 50 Close up A day in the life of a

professor of midwifery.

38

24

11 Win a pair of Fitfl ops

Why not enter to win a pair of Fitfl ops’ new Gogh Pro clogs?

Competition

ip

fery

40

004-005_mid_contents.indd 5004-005_mid_contents.indd 5 22/11/10 11:57:2622/11/10 11:57:26

FeedbackYour published views


AIR YOUR VIEWSby email to: emma@midwives.

co.uk or write to: Midwives at Redactive Media Group, 17-18 Britton Street, London EC1M 5TP (The editor reserves the right to edit letters).

subject: Leaving midwiferyfrom: Name and address supplied

subject: Hypnobirthing or natal hypnotherapy? from: Annie Robertson, independent midwifeemail: [email protected]

It is with a heavy heart that I am planning to retire next March, aged 55, having spent the last 28 years practising midwifery – working in the community and, later on, in postnatal care. I have loved my job and consider it a privilege caring for new parents and their babies at probably one of the most precious and vulnerable times in their lives. I was refl ecting poignantly the other day on the ironic state of affairs we fi nd ourselves in these days – obstetrics has advanced in so many admirable ways over the past three decades in terms of fetal and paediatric medicine. But one area where we’ve taken a backwards step is

the fundamental, grassroots day-to-day care of the people we’re supposed to be looking after. As postnatal midwives, we’re expected to mentor students and auxiliary staff, be ready to manage any midwifery emergency, advise and alert other medical staff, and reassure and support extended family members of inpatients, as well as oversee the day-to-day running of a very busy postnatal ward for periods of 12 hours at a time. I am proud to say I was trained to provide a very high standard of midwifery care and I have to confess that I can no longer deliver this. So I have made the extremely hard decision to leave. Am I the only midwife who feels like this?

rcm response:It is wonderful that you have enjoyed your career as a midwife so much, but very sad that you now feel compelled to leave. Many midwives share your concerns about the impact workload challenges and the staffi ng situation are having on care. In particular, there are concerns about where we are going with postnatal care and whether we are really supporting the women and their families. This was highlighted recently in an NCT survey on fi rst-time mothers. The RCM will continue to lobby politicians and health boards to ensure they fulfi l the commitments they have made under the banner of quality and in their manifestos.

I was interested in the Effective birth preparationCD review in the October/ November issue of Midwives. I recommend these CDs to couples who attend my NHS birth preparation classes, as well as to my independent clients. In my experience, they really help women overcome their fears and feel more positive and relaxed. To be effective, the woman is encouraged to listen to the CD three times a week from 32 weeks, leading up to every day in the last two weeks. It gives an opportunity to learn how to deeply relax, as well as absorbing the positive emotional and mental preparation. I think this is a

brilliant, accessible resource, and it only costs £11.99.

This CD is part of the natal hypnotherapy approach to self-hypnosis in childbirth, which is a registered trademarked name, as is hypnobirthing. The two names are not interchangeable, so I was surprised that natal hypnotherapy wasn’t mentioned in the review, but hypnobirthing was used as a generic name. Hypnobirthing is the Mongan method and involves a very informative course, which costs several hundred pounds, and a strong commitment from the woman and her birth partner to practise relaxation and visualisation. Most

hypnobirthing practitioners promote not using the word ‘pain’ and replacing ‘contraction’ with ‘surge’, which I have mixed feelings about. I totally endorse encouraging a positive mindset, but feel it’s honest to acknowledge women experience a wide spectrum of sensations in labour. Although I’ve been with some couples who found hypnobirthing very effective, I’ve also worked with couples who were disappointed that labour wasn’t totally pain free. I hope this clarifi es the differences between the two self-hypnosis approaches. More information can be found at: www natalhypnotherapy.com or www.hypnobirthing.co.uk

Inbox Junk E-mailDeleted itemsSent items

RCM COMMUNITIES‘Am I the only midwife

who feels like this?’. Join the discussion at: http://communities.rcm.org.uk

006_feedback.indd 6006_feedback.indd 6 22/11/10 11:18:5922/11/10 11:18:59


Essential advice, tips and miscellany for midwivesFRONTLINE

Health minister Anne Milton told midwives that the government was considering ways of improving recruitment and retention in the profession and will work with the RCM to make sure midwives were properly resourced and skilled.

But after her speech to the RCM annual conference in Manchester, the minister faced robust questioning by an impassioned audience.

Working environments with too few staff and pay freezes were keeping morale low, Ms Milton was told.

She responded: ‘If you don’t feel you are being listened to, I need to do more, and make sure your voice gets heard.’

In her speech, the minister spoke of her wish to see greater autonomy for midwives.

David Cameron denied RCM claims that the coalition government had reneged on a pre-election pledge and insisted he wanted to ‘see an increase in midwives’.

At Prime Minister’s Questions, Owen Smith, Labour MP for Pontypridd and a former BBC radio and television producer, asked Mr Cameron: ‘Th is morning you stand accused by the RCM of reneging on that promise - do you want to take this opportunity to diff erentiate yourself from your deputy’s attitude to such solemn promises and honour that pledge to midwives?’

Th e prime minister replied: ‘We do want to see an increase in midwives and unlike the party opposite we’re actually funding the health service in a way that makes that possible.’

Mr Cameron added: ‘Now I know you used to work on the Today programme so let me give you a thought for the day: the health service is better off with our government.’

But RCM general secretary Cathy Warwick told BBC Radio 5 live that ministers had gone back on their word: ‘Just before the election, both the prime minister and the deputy prime minister told us that they would commit to continuing the previous government’s promise to give us more midwives. We’ve just surveyed heads of midwifery and they’ve got vacant posts but they’re having diffi culty fi lling them.’

For details of the HoMs survery, see RCM news on pages 12-13.

PM questioned in parliament over midwivesstaffi ng pledge

‘I look forward to working with the RCM to consider the best ways to get the right workforce, in the right place.’

Ms Milton said apprenticeships will encourage more young

people into midwifery and free up time for midwives: ‘We’ve announced an extra £10m of investment into the apprenticeship programme.’

Delegates were concerned to fi nd out from the minister

£10m TO BE RECEIVED BY THE

NHS APPRENTICESHIP SCHEME TO CREATE 75,000 NEW PLACES

what the department’s plans on commissioning would be.

Recent media speculation had suggested the White Paper proposals for a national board might be dropped in favour of placing the task with GP consortia.

Ms Milton said an announcement on commissioning would be made shortly, but stressed that it will need ‘to preserve midwives’ unique ability to touch the lives of even the most hard-to-reach women’.

But she said the government had received a variety of views, many favouring community-based commissioning.

Midwives ask, is thegovernment listening?

008_009_mid_news.indd 8008_009_mid_news.indd 8 22/11/10 11:19:3622/11/10 11:19:36

MIDWIVES 09 THE OFFICIAL MAGAZINE OF THE RCM

DECEMBER 2010

Women’s experience of maternity care in England varies widely according to which hospital they use, shows a report from The NHS Information Centre’s Hospital Episodes Statistics maternity report 2009-10.

The greatest differences reported centred on fi rst antenatal assessments, where Royal Cornwall Hospitals NHS Trust recorded seeing 86% of women within the recommended fi rst 12 weeks – 11 times higher than Walsall Hospital NHS Trust’s 8.3%.

The caesarean rate at

Imperial College Healthcare NHS Trust in London was, at 31.4%, almost twice that of Shrewsbury and Telford Hospital NHS Trust in Shropshire (15.8%).

However, wide variations in care were also apparent in trusts either neighbouring each other or within the same region. For example, the percentage of women to have their fi rst antenatal appointment within the recommended fi rst 12 weeks of pregnancy at Rotherham NHS Foundation Trust (87.6%) was fi ve times the percentage in neighbouring

Barnsley Hospital NHS Trust (17.2%).

RCM general secretary Cathy Warwick said: ‘Superfi cially the huge variations revealed in this report are a concern and further analysis is needed to fi nd out why they are occurring. The variation on the fi rst antenatal booking is astonishing and those on caesarean section rates – already widely known – are worrying in their persistence at such a level.’

The full report is available at: www.ic.nhs.uk/pubs/maternity0910

SHORT DISTANCE MAKES FOR BIG DIFFERENCE IN CARE

Th e founder and chief executive of the Baby Lifeline charity has been named fundraiser of the year at the Daily Mirror’s Pride of Britain Awards.

Judy Ledger, accompanied by her family, attended the gala award ceremony at the Grosvenor House Hotel in London, where she was presented with her award by Sir Ben Kingsley, the patron of the charity.

Since founding Baby Lifeline nearly 30 years ago, Judy has raised £8m to pay for equipment ranging from digital weighing scales to technology such as incubators and scanners. Th e charity also supports training and education programmes.

Th e Pride of Britain award is the second honour Judy has received in 2010. In September, charity recruitment event forum3 selected Judy for an Alternative Rich List 2010, which recognises individuals who ‘enrich other’s lives in a way money can’t’.

Pride award for fundraiser

SINCE THE COALITION GOVERNMENTCAME TO POWER MORE THAN 30MATERNITY UNITS AND A&E DEPARTMENTSHAVE FACED CLOSURE OR RESTRUCTURINGTO ACCEPT LOW-RISK CASES ONLY

NEWS IN BRIEF

Children born by assisted vaginal delivery (AVD) are more likely to develop psychopathological problems than those born by elective caesarean or spontaneous vaginal delivery (SVD), according to a Chinese-based study published in BJOG.

The study involved 4190 pre-school children from south-east China and looked at the different modes of delivery and their relation to childhood psychopathology.

Caesarean section rates in the area have risen sharply

Elective caesarean delivers calmer babies, says study

since the 1990s, increasing from 22% in 1994 to 56% in 2006. Of the 4190 children who took part, 2.4% were delivered by caesarean delivery on maternal request (CDMR), 85% by SVD and 12.6% by AVD (210 forceps and 317 ventouse).

The report authors believe high levels of the stress hormone cortisol during birth could cause changes in the infant’s brain that affect his or her development. Professor Jianmeng Liu, deputy director of the Institute of Reproductive and Child Health in Beijing, one

of the authors on the paper said that this research was the fi rst to look at the effect of caesarean delivery on maternal request on childhood psychopathology: ‘The caesarean section rate is increasing and this study was a large population based study. Cortisol levels have been linked to childhood psychopathology, however, more studies are still needed to look at this in more detail.’

In the study the parents of selected children were asked to describe behaviour, assessed again the 1991 Child Behaviour Checklist (CBCL). These results were then matched with delivery method. The study

shows that CBCL problem scores were lowest in children born by CDMR and highest

in those born by AVD.

MIR

RO

R P

IX/G

ETTY

IMAG

ES



FRONTLINEFigures reveal drop in home birth rate The proportion of women giving birth at home has fallen slightly in England and Wales, according to new fi gures.

In its latest statistic bulletin Live births in England and Wales by characteristics of birth, the Offi ce for National Statistics (ONS) reports that the rate fell from 2.9% in 2008 to 2.7% in 2009.

Commenting on the decrease, RCM general secretary Cathy Warwick said: ‘Even though it is a small one, the drop in the home birth rate is a real disappointment, particularly because the UK already has a very low rate compared to many other countries.’

Cathy said the fi gures suggested that there is insuffi cient choice provided to women and that they deserve more from commissioners.

‘My worry is that increasing

pressures and demands being made on midwives and maternity services are driving out choice for women. There is a real need to look behind these fi gures to fi nd out why our rate is so low and why it is falling.’

Cathy noted that there were many great examples of midwifery teams who were bucking the trend and that had very good home birth

rates, often in areas of social deprivation where the option might be least expected.

She said: ‘We should be looking to their work and methods to reverse this trend, so that mothers really do have

a choice about where they give birth to their baby.’

The south west had the highest rate of women giving birth at home in 2009 (4.1%) while the north east returned the lowest numbers (1.3%).

The 2009 fi gures on the age groups of women giving birth at home showed that 35-39 year old women provided the largest proportion, 3.8%. In contrast, only 1% of women aged under 20 gave birth at home.

The ONS bulletin also showed an increase in the number of multiple births, with women aged 45 and over showing the highest rate. Overall, births fell in 2009, the fi rst annual decrease since 2001. There were 706,248 births in England and Wales in 2009, down from 708,711 in 2008, a 0.3% decrease.

Reference

Offi ce of National Statistics. (2010)Live births in England and Wales by characteristics of birth. ONS: Newport.

GET

TYIM

AGES

Money paid towards pensions by midwives is contributing to the Treasury, not burdening the taxpayer, the RCM has said.

Commenting on the release of NHS pension scheme statistics, RCM deputy general secretary Louise Silverton said: ‘There is a vast chasm between what some people say about the pensions that NHS professionals like midwives get and the truth.’

The fi gures show that as

more is paid in every year in contributions than is paid out to pensioners, the scheme produces a surplus worth billions of pounds to the government.

Louise said: ‘The NHS pension scheme handed over to the Treasury more than £11bn over the last fi ve years. It is time people heard the truth about the NHS pension scheme rather than the myths.’

Under the scheme, managers

collect employer and employee contributions and use these to fund payments to existing pensioners with the excess receipts being paid into the scheme’s Consolidated Fund. Pension accounts for 2009-10 alone showed contribution income was £8bn whereas pension payments totalled just £6bn, leaving a £2bn surplus for the government.

Louise said that both contributions represented ‘a massive windfall for the nation’.

‘In effect, the Treasury has had an interest-free loan from both the staff and the employer. If they tried to raise

that on the market, it would cost a fortune,’ she said.

The RCM had the backing of Conservative MP for Southend West David Amess, who led a recent Commons debate on the provision of maternity services.

Among the concerns he raised in parliament were the lack of midwives and the NHS pension scheme: ‘Midwives throughout the country are anxious about the outcome of the review of their pensions. The NHS pension scheme hands billions of pounds over to the taxpayer, thereby helping, not hurting, public funds.’

NHS pensions put billions back into public purse

4.1% OF BIRTHS IN THE SOUTH-WEST ARE

AT HOME



Mothers-to-be are unsure of which healthcare professional they should visit to confi rm their preg-nancy, according to a recent survey by the RCM and Pampers.

The survey found 85% of women thought they should visit their GP fi rst and 10% did not know who should confi rm their pregnancy.RCM deputy general secretary Louise Silverton said: ‘While most people think of their GP as the fi rst port of call for everything, it is a lesser known fact that women can actually refer themselves straight to a midwife once they know or suspect that they’re pregnant. They do not need to go via their

GP unless they wish to do so.’ To help support women through the early stages of pregnancy, the RCM and Pampers have produced a guide offering information to dispel common misconceptions. Guide to the First 12 Weeks is available to download from www.pampers.co.uk/en_GB/Pregnancy

INBRIEFExpectant mothers assume GP is fi rst port of call

NMC issues new guidanceon whistleblowing Guidance for midwives on speaking up about the safety or wellbeing of women or babies in their care has been launched by the NMC. Raising and escalating concerns: guidance for nurses and midwives sets out clear steps for raising and escalating concerns and is intended to establish best practice. ‘Th is new guidance will support nurses and midwives to eff ectively manage risk and empower them to speak out on behalf of the people and families in their care,’ said NMC chief executive and registrar, Professor Dickon Weir-Hughes. Th e guidance is available from: www.nmc-uk.org

Midwife among the winners at Mary Seacole awardsSpecialist midwife Sarah Bennett has been named as one of the recipients of this year’s Mary Seacole awards, announced at a ceremony at the RCN headquarters in London. Sarah (right), who is based at St James’s University Hospital in Leeds, will receive a bursary of £6250 for her project to explore midwives’ experiences of caring for women who are seeking asylum.

Foundation announces inaugural conferenceTh e chief executive of the Florence Nightingale Foundation Elizabeth Robb has announced details of the organisation’s fi rst conference, ‘Sharing Innovation, Delivering Solutions’, set to take place in London on 10-11 March 2011. Delegates can register for a place at: www.glasgows.co.uk/fl orencenightingale

Greatvine launches new service for parents onlineTh e parenting advice line Greatvine has launched its new website, Greatvine.com, to complement its established telephone service. Th e website off ers access to health and parenting experts including midwives, child psychologists, nutritionists and counsellors. Th e new website also features a library of expert-written articles and downloads.

IFA services partner rebrandsTh e number of advisors on personal fi nance planning available for consultation by midwives is to increase following internal reorganisation by the RCM’s independent fi nancial advice partners, Lighthouse. From December, the advisors will trade under the new name of Lighthouse Financial Advice. More information on the services available are at: www.rcm.org.uk/college/membership/benefi ts

y’ m

epmtfris

Ma

®

Pampers and the Royal College of Midwives – working together for the support and wellbeing of mothers and babies every step of the way

BySbi

Sogivyoupre

To ha mColleyou and t

y

es Competition

FitFlops are giving away two pairs of their new Gogh Pro clogs.

The leisure footwear company produce biomechanically engineered shoes for toning and tightening leg muscles. The new Gogh Pro brings the same technology to a work-friendly, lightweight, non-slip, non-marking regulation clog.

For a chance to win a pair, simply write and tell us an amusing story about a midwife on the move.

Send your anecdotes, in no more than 500 words, to

the editor Emma Godfrey-Edwards at: [email protected]

The competition is open to all Midwives readers aged 18 or over. Closing date for entries is 1 January 2011. Winners will be notifi ed within 14 days and names will appear in a future issue of Midwives.

One one entry per household will be accepted. The editor’s decision is fi nal.

Win a pair of Fitfl ops new Gogh Pro workwear clogs

s ut a



RCMNEWSRCM launches quartet of new publicationsThe socioeconomic value of the midwife, responding to reconfi gurations in maternity services, standards for lead midwives in diabetes, and running a successful birth centre are all covered in new RCM publications, launched at the recent RCM annual conference.

The Reconfi guration Guide has been published in response to a steady increase in restructuring proposals impacting on maternity services and is intended to assist RCM members affected by reconfi guration. It includes advice

on how to respond to different reconfi guration proposals and how to produce authoritative, evidence-based responses.

The Socioeconomic value of the midwife takes a fresh look at midwife-led models of care and analyses its socioeconomic benefi ts, emphasising the high quality of care delivered by midwives and the long-term cost savings associated with midwife-led care. The executive summary is now available, with the full report due for publication in the new year.

Falling budgets and midwifery staffi ng cuts are causing maternity services to struggle, according to an RCM survey of UK heads of midwifery (HoMs) – part of the RCM’s submission to the NHS Pay Review Body.

Nearly a third of maternity units have seen a fall in their budget and just under a third have been asked to cut their staffi ng levels in the past year. Two-thirds of HoMs surveyed also said that they do not have enough staff to cope with demand.

The fi ndings are supported by the views of midwives in the NHS Staff Survey, which revealed that over the past 12 years the birth rate in England has increased by 19%, with midwife numbers in England increasing by just 12.1% over the same period.

Half of the respondents

also said that the increasingly complex nature of birth was adding to the demands on midwives’ time. Among the main concerns were the increasing numbers of pregnant obese, older and younger or teenage women, many of whom need additional time and support from midwives.

RCM general secretary Cathy Warwick said: ‘I am deeply worried that we are seeing static or falling budgets, yet midwives and maternity services are faced with a continually rising demand. Whichever way you look at them, the fi gures are not adding up.’

The survey results can be found in the RCM’s evidence to the NHS Pay Review Body 2010 submission, which is available to download from the RCM website at: www.rcm.org.uk/college/support-at-work/pay-pensions-tax/pay

HoMs survey

Government could reverse commissioning policyThe RCM has described reported plans to hand maternity services commissioning to GP consortia instead of NHS Commissioning Boards as a complete reversal of the policy proposed in the recent White Paper Liberating the NHS.

The turnaround was reported in a story on the Health Service Journal’s website.

In response to the reports, the RCM said that it supported the original White Paper recommendation for maternity services to be commissioned by NHS Commissioning Boards.

The proposal was radical and, in the RCM’s view, was a very important indicator of how keen the coalition government was to make changes, which would signifi cantly improve the chance of all women having choice, and of

being able to access services of the highest standard.

The RCM said it fi nds it diffi cult to understand what has caused the change of heart.

The White Paper proposal was also supported by the RCOG, the Royal College of Paediatrics and Child Health, the National Childbirth Trust and BLISS.

RCM general secretary Cathy Warwick recently met with the secretary of state to seek more information on the issue.

While health minister Anne Milton, speaking at the RCM’s annual conference in Manchester, invited all midwives to let her know how commissioning can be made to work better.

For further information on this and how the RCM is responding, please visit the RCM Communities.

012_013_mid_RCM_news.indd 12012_013_mid_RCM_news.indd 12 22/11/10 11:21:2722/11/10 11:21:27


INBRIEFULRs off er help with workplace learningTh e union learning representatives (ULRs) project team is off ering assistance to RCM branches and members to organise workplace learning events on topics relevant to midwifery practice.

Th e team can arrange speakers and refreshments for branch meetings or provide a ULR project worker to speak to midwives, maternity

support workers and students on the benefi ts of lifelong learning.

ULRs can help to organise workplace learning events on anything from computer skills and languages to aromatherapy and stress. To read about some of the projects ULRs have been involved in, see the October/November issue of Midwives. For more information on ULRs,

see: www.rcm.org.uk/college/support-at-work/workplace-reps/ulr/contact-the-ulr-team

New contracts undermine Agenda for Change

A number of trusts – including the Norfolk and Norwich Trust – are attempting to undermine the existing Agenda for Change national terms and conditions agreement by introducing new contracts of employment that provide for: ✼ Statutory sick pay only ✼ Statutory annual leave only (22 days) ✼ Statutory maternity/adoption/paternity leave ✼ No enhancements for weekend, night shifts and

public holidays ✼ Overtime paid at time and half even on

public holidays ✼ Compulsory requirement to work extra hours

including on-call✼ A freeze on increments. Th e RCM will strongly resist these proposals and want to hear from you if your Trust is planning to do the same.

Contact George Georgiou of the RCM employment relations team at: [email protected] and report your concerns.

RCM membership renewal packIt’s time to renew your RCM membership so look out for this year’s membership renewal pack, which will be through your letterbox soon.

Th e RCM have not increased membership subscriptions for 2011.

Please check the RCM website for further details.

The RCM has launched two new services enabling members to study RCM-approved courses online and to join interactive communities.

RCM i-learn is a new online learning environment for members, which offers courses including ‘study skills’ and ‘the clinical midwife’, as well as modules for workplace representatives and a short course on bullying and

stress. The RCM plans to add more courses over the next few months.

RCM Communities is a new social media forum, which uses the latest tools to enable members to connect to each other. Members are encouraged to join up to discuss experiences and to exchange resources and skills.

To access both of these member benefi ts, please visit the RCM website.

The RCM is launching a new online library information service – in partnership with MIDIRS – to give full, student and MSW members a discounted subscription to the MIDIRS research database.

Available from 1 December 2010, it will allow members to make full use of the research tool, which has over 173,000 records constantly updated by qualifi ed professionals.

Members will have unlimited access

to literature searches, dynamic folders for storing articles, email updates and midwifery news and diary dates.

RCM general secretary Cathy Warwick said: ‘I am delighted to be offering this new and exciting development to our members, and to be joining in partnership with MIDIRS.’

Please see: www.rcm.org.uk/midirs to fi nd out more.

The RCM library collection will be moving to a new home during 2011.

New online member benefi ts

Th e teamrefreshmeproject w

suppoof lifelo

ULRseventslanguaabout involveMidwiv

see: wwat-work/the-ulr-

New Agen

REX

FEA

TUR

ES/I

STO

CK

Since many maternity services have introduced a lead midwife in diabetes (LMD) role, which has not been supported by overall planning, the RCM has published the Lead midwife in diabetes: standards, role and competenciesto help clarify the role and streamline levels of care. The document, developed in collaboration with NHS Diabetes, includes an agreed job specifi cation and competency framework.

The new Birth centre resource: a practical guide (2010) offers advice on developing a birth centre based on fi rst-hand experiences. It follows on from last year’s guidance in Standards for birth centres

in England. The guide promotes normality, women-centred care and autonomous decision-making, while prioritising safety in practice.

The new publications are available from the RCM website.

RCM library partners with MIDIRS

012_013_mid_RCM_news.indd 13012_013_mid_RCM_news.indd 13 22/11/10 11:23:0222/11/10 11:23:02

RCM UK BOARD FOR SCOTLAND

Iolanthe Midwifery awardsMidwives’ and students’ achievements were recognised at the Iolanthe Midwifery Trust Awards 2010, hosted by the RCM UK Board for Wales.

The awards, presented by RCM general secretary Cathy Warwick, included the 2010 Tricia Anderson Award recognising innovation in midwifery education and research.

The ceremony, held on 23 September at Cardiff’s Park Plaza Hotel, included the Sandy Fyfe Memorial Lecture given by Professor Billie Hunter, who talked about how she had explored the working conditions and practices

of a Welsh midwife during the last century. The award winners also gave short talks about their achievements.

Supporting women’s choiceIn collaboration with the Heads of Midwifery Advisory Group in Wales, the RCM UK Board for Wales has organised a conference on supporting women’s choice and making the Midwifery 2020 report a reality.

The conference will be held on St David’s Day next year (3 March) at the Mercure Holland House Hotel in Cardiff, and will focus on the importance of choice and how midwives can help women make decisions on the care they want. Speakers will also looking at the challenges and opportunities presented by Midwifery 2020.

For further information, please contact the RCM UK Board for Wales via email at: [email protected] or Tel: 02920 228111.

Bright futures

RCM UK BOARD FOR WALES

Helen Rogers, RCM UK Board for Wales board secretary

Reducing inequalities seminarThe RCM UK Board for Scotland held a very successful inequalities seminar on 21 October. This free event, held at the Beardmore Hotel in Clydebank, was chaired by director of nursing for acute services in Glasgow Rory Farrelly and included a variety of speakers covering subjects such as reducing inequalities in child health and the midwife’s role in supporting healthier families.

RCM sponsoring awardThe Scottish Board has

sponsored an award at the Scottish Health Awards to

recognise signifi cant contributions to women’s and children’s health.

Manifesto launchIn preparation for the Scottish parliamentary elections 2011, the RCM in Scotland has been working on a manifesto, which will be launched next month. The manifesto was developed following a focus group with members, so the fi nal document refl ects their views. It is hoped that members will use it during debates and discussions with their prospective parliamentary candidates. It will be available on the RCM website and each prospective candidate will receive a copy,

so remember to ask them about it on the doorstep.

Maternity Services FrameworkThe refreshed Maternity Services Framework is nearing completion and the government hopes to launch it early next year. There has been wide involvement from clinicians, service managers and users to make it fi t for future challenges.

Reproductive health forumNHS Quality Improvement Scotland held its Reproductive Health Forum on 9 November. Delegates attended from many disciplines, including midwifery, paediatrics and anaesthetics. Topics included patient safety and the challenges posed by the obesity epidemic.

Supporting healthier familiesGillian Smith, director of the RCM UK Board for Scotland

BOARDNEWS


L to r: Iolanthe midwives award winner Sarah Norris, RCM general secretary Cathy Warwick, chair of the trustees Professor Billie Hunter, Iolanthe student award winner Louise Randall, Tricia Anderson Award winner Jane Cross and Ann Stewart award winner Jude Davis.

014_mid_board_news.indd 12014_mid_board_news.indd 12 22/11/10 11:24:3822/11/10 11:24:38

For article references, please see the RCM website.

INFOCUS

More input for a growing problemA new survey on maternal obesity has revealed critical gaps in the weight

management and dietary advice available, reports Gareth Price.

The fi ndings of a study that canvassed the views of more than 6000 mothers as to the care

they received regarding weight and diet should act as a wake-up call to midwives. That’s according to Sally Russell, the co-founder of the parenting website that joined with the RCM in conducting the survey, Netmums.com.

The key fi ndings of the survey, the results of which were launched the RCM annual conference recently, touched upon the lack of advice for women and the uncertainty as to where they can access better information. Sally said: ‘The results from this survey are clear cut and shocking: you are more likely to have a caesarean if you are already overweight before you become pregnant. It’s important that mums-to-be don’t panic, as most women do have a normal vaginal delivery, but it is a wake-up call to midwives to

they could have a normal birth, only medicalised. However, 55% of women in this category, who were overweight, did go on to have a normal birth, suggesting an overestimation of risk for medical intervention for overweight women. Yet, only 12% of mothers identifi ed the correct BMI fi gure that defi ned a mother as overweight during pregnancy (25 or more).

RCM general secretary Cathy Warwick added: ‘As a result of the increase in obesity among pregnant women in the UK, midwives are dealing with more complex births – on top of the continuing baby boom. These women need to see a midwife as early as possible in their pregnancy, and midwives need more time to spend with them to help and advise them, as well as involving the wider healthcare team. NHS trusts should be making sure that they have the resources in place to do this.’

Anxiety about cultural expectations also surfaced, prompted by media portrayals of celebrity mothers.

Despite concerns expressed, the survey showed some positive developments and a ‘can-do’ attitude among mothers.

When asked to describe how they felt about their body and weight while they were pregnant, the women’s comments ranged from ‘disgusting’, ‘elephant-like’ and ‘fat ugly big, embarrassing and felt down’ to the more affi rming comments, such as ‘happy and proud’ and ‘I loved my bump’.

support women better throughout their pregnancy and inform them of their options.’

Almost nine out of ten women rated the overall care that they received from midwives regarding healthy eating and weight management as ‘neutral’, ‘poor’ or ‘very poor’. Nearly three-quarters of women said that the NHS should provide midwife-led antenatal classes to address issues of weight and diet, and two-thirds reported that their midwife did not have time for such a discussion.

Almost half of those surveyed admitted to anxieties about their weight during pregnancy, with 41% of the women describing themselves when they became pregnant as ‘over what they would like to have weighed’ and/or ‘overweight’. Of the women who described themselves as ‘overweight’ and were told that their BMI was high, more than one in four did not think that G

ETTY

IMAG

ES


015_mid_newsfocus.indd 15015_mid_newsfocus.indd 15 22/11/10 11:26:3022/11/10 11:26:30


Just over 40 years ago, a pregnant woman was admitted to a west London hospital after suffering a ruptured lumbar disc. She was 24 weeks but was placed in skeletal traction for the

rest of her pregnancy. An elective forceps delivery at full dilation was eventually carried out.

Then, to the mother’s dismay, her newborn son was taken away to be cot nursed for 48 hours, such was the hospital’s routine after forceps delivery. The infuriated woman ordered that her baby be returned immediately. A matron’s reprimand was rebuffed by the mother’s plain instructions: this baby was to be put alongside her, she would observe her own baby, he was not to be removed because – the staff were sternly reminded – she, the mother, was the baby’s legal guardian.

This story means a great deal to Mary Cronk, after all she was that mother in traction. Angry and upset, but ultimately motivated by doing what was right for a mother and her newborn child. The characteristics demonstrated by Mary the mother would also shape her as a midwife – conviction and tenacity, backed up with sound principles and sharp knowledge.

As a midwife for over half a century, attending the birth of more than 1600 babies, Mary has been a staunch advocate of woman-centred midwifery and, as such, is held in the highest regard by her peers and her clients. Her time with the former UKCC (now the NMC) earned her an MBE and she’s an honorary fellow of the RCM. Mary has run her own independent practice for nearly 20 years, but as she tells Midwives, her routine these days is relaxed one.

Her days begin by checking post and emails – her expertise is very much in demand.

‘A lot of women email me asking me, “Am I allowed

to do this?”, “Must I do that?” – I say, have you asked your midwife, but they reply, I don’t know my midwife or I haven’t got a midwife. It’s very sad.’

What Mary offers is information based on fi ve decades in practice – information, she is keen to stress, not advice.

‘I am very clear with the women, I don’t give advice. I’ll give information and discuss their options with them but I tell them I can’t give advice on the phone or by email,’ she says. Her clarifi cation typifi es her thoroughness and a respect for the profession that she’s applied herself to since 1957.

It’s a career that began in her native Glasgow, training as a nurse at the city’s Royal Infi rmary, before switching to midwifery: ‘I loved it. I liked the autonomy of midwifery and I was well trained – not educated – very well trained.’

Noting the distinction, Mary explains how she envies, in part, the education of today’s midwives but alerts them to the importance of gaining ‘the apprenticeship’, such as she received working with ‘very practical midwives’.

Once qualifi ed, her career thrived in domiciliary midwife roles in Twickenham and eventually the Isle of Wight: ‘I had my own district – and in Twickenham

As an independent midwife held in the highest regard by her peers and clients, Mary Cronk tells Gareth Price about what has motivated and inspired her through more than half a century of practice.

One-to-oneMary Cronk

Out on her own

Above: Mary in 1960, as a domiciliary midwife in East Twickenham

t

y email,’ shehe ssays.s

016-017_mid_one2one.indd 16016-017_mid_one2one.indd 16 22/11/10 11:27:0422/11/10 11:27:04

I did it on my bicycle. I ran my own clinics – every woman who was planning a home birth was sent to me. I was autonomous. I had a supervisor who was very good. I loved it.’

But the time would come when organisational changes would begin to change Mary’s attitude to her role and spark disillusionment that would eventually lead her to a signifi cant career move.

In 1970, the Peel report had recommended all women should give birth in hospital, resulting in a sharp fall in home births. Then new legislation shifted domiciliary midwifery management from the local authorities into the NHS. Mary recalls how the change was not as seamless as anticipated.

‘I was told that the only change would be that my salary would come from the area health authority, not the county council anymore. But there were enormous differences. District midwives became community midwives, employees of the area health authority. Home confi nements, as they were known, were phased out and I was encouraged to take women into hospital.’

Mary did her best to conform and moved to work at the hospital but soon became disillusioned: ‘I’d never worked with my practice managed by another professional. I’d worked with GPs but now I was to conform to protocols laid down by obstetricians. I found this very diffi cult.’

One example of Mary’s dismay involved a consultant obstetrician – ‘Mr High and Mighty’ as she calls him – and his insistence on routine episiotomies.

‘All woman had to have them and he would go around the postnatal ward to inspect, making sure the midwives had done it. Most midwives muttered but complied. And I did, to my shame. I assaulted these women with the scissors.’

On one occasion, Mary saw a colleague make an episiotomy after a baby’s head was born. She decided enough was enough. Mary told the consultant how, from now on, she would only make episiotomy if it was clinically justifi ed and that if he didn’t like it, ‘here’s the address of the Central Midwives Board to whom you should address any complaint about my practice’.

But no complaint was made – in fact her colleagues followed her example. It was a small victory, but Mary remained dissatisfi ed with the practice environment that she faced. In 1990, inspired by two colleagues who had made a similar break from the NHS, Mary left to start her own midwifery practice, helping women have their babies in the way they wanted.

‘I never regretted it. I went back to running my own clinics, as I had done in Twickenham, except the woman had a choice to come to me. Big difference.’

As well as running her own practice, Mary has shared her knowledge and expertise through articles and study days. She is renowned for her expertise on vaginal breech deliveries, twins, waterbirths and vaginal birth after caesarean and would run workshops with fellow independent midwife, Jane Evans.

‘I’ve attended quite a few breech births and breech labours. I’d like to do more study days on it. A breech is an unusual birth but it can still be a normal birth. There is more potential for needing help but it can be normal.’

Mary’s plan is to continue giving support and information to women but she expects that the moment is approaching when she will come off the register ‘and retire’, she says with a wry smile. Recuperation from a knee replacement operation and ‘galloping arthritis’ has prompted a slower pace in recent months but that has allowed her more time to pursue her another lifelong passion – sailing. Mary and her husband Joe still spend time on their 24ft sloop ‘Juno Lucina’ – fi ttingly named after the Roman goddess of childbirth.

But as she reaches the end of a long and fulfi lling career, her message to other midwives refl ect her own spirit of perseverance: ‘Never give up, keep in there. There’ll be challenges clinically and professionally. But never give up.’


o

italal.’.

hhs a dnd vaginalal

Above: Mary through the years, 1980 (top) and in 2000

To watch a video of the interview with Mary, please visit: www.rcm.org.uk/midwives/videos

016-017_mid_one2one.indd 17016-017_mid_one2one.indd 17 22/11/10 11:27:1322/11/10 11:27:13

Upfront

Care after miscarriage

ISTO

CK

I am a midwife and would like to share my experiences after I recently suffered a missed miscarriage at 16 weeks. At the particular hospital where I was ‘cared’ for,

I was told I would have to wait a week before I could have medical management, even though the baby had already been dead for six weeks.

Medical mismanagementThe procedure for medical management has changed to oral tablets, which are taken all at once so women can miscarry at home. I was told a nurse would ring me within 48 hours to see if the treatment was working. But this phone call never came, so after three days I phoned the ward, because I’d had pain for two days but passed nothing. I was told, unsympathetically, that I would have to wait three weeks for a scan and then a doctor would review my case.

This was unacceptable to me – I wanted to get on with my life, get back to work and get over my loss. Did they expect me to go back to work with a dead fetus inside me for three weeks while I waited for a scan? I was so upset that I started crying and pleading on the phone. In the end my mother phoned the ward sister and, after threatening to make a complaint, the hospital agreed to give me a scan within four days.

Uncaring careMy scan showed the whole pregnancy was still there so I was asked to consider another bout of medical management, but I requested surgical evacuation as I did not want to prolong the agony for my own mental health. The consultant told me ‘miscarriage was not a priority’ and I would be ‘done’ when they could fit me in. In terms of life risk, I could see their point, but it still hurt to feel that no-one cared.

After the evacuation, there was no aftercare and I didn’t see a surgeon or doctor so I can only assume

it went to plan. I like to think I’m a strong person with good family support, so I hate to think how people cope who do not have the same support network around them.

Cold comfortOn the ward, the girl in the bed next to me was miscarrying alone and cried all night with no support. Everything seemed so clinical and detached – are we really that inhumane in our treatment of people?

Was I left to get on with it because I’m a midwife or is this how women with fetal loss are treated under 16 weeks? It made me think these women should be cared for by midwives rather than gynaecologists. I know this would be too much pressure for an already overstretched service, but what about offering women a follow-up from a bereavement midwife?

RCM COMMUNITIESDo you think midwives should off er care to

women who suff er miscarriages under 16 weeks? Join the discussion at: http://communities.rcm.org.uk

After suffering a missed miscarriage, a midwife describes how she felt let down in her hour of need by the healthcare services she received.


019_mid_upfront.indd 19019_mid_upfront.indd 19 22/11/10 11:28:2922/11/10 11:28:29

The lower segment caesarean section (LSCS) rate in England has increased from 9% in 1980 to 24.6% in 2008-9, according to the authors of this study. The reasons

for this include the rising age of fi rst-time mothers, technological advances improving the procedure’s safety, changes in women’s preferences and a growing number who have previously had a caesarean delivery. But there is concern about how these rates are justifi ed, since the procedure is not without the risk of complications such as haemorrhage, infection, and thrombosis, together with increased risk of complications in subsequent pregnancies, such as uterine rupture and placenta previa. There may also be neonatal complications. There is evidence of considerable variation in rates of LSCS; in England and Wales in 2000, the rates ranged from 10% to 43% and recent fi gures during 2008-9 show substantial variation, revealing a north/south divide.

This cross-sectional analysis, using routinely collected hospital episode statistics gathered from 146 NHS trusts, used a multiple logistic regression model to estimate the likelihood of women having an LSCS, given maternal characteristics such as age, ethnicity, parity, and socio-economic deprivation and clinical risk factors such as previous caesarean section, breech presentation, and fetal distress.

In 2008, there were 620,604 singleton births in NHS Trusts in England. Of these, 397,573 (64.1%) were normal vaginal deliveries, 75,305 (12.1%) were assisted vaginal deliveries, and 147,726 were caesarean deliveries (23.8%). Of the caesarean deliveries, 57,892 (9.3%) were elective and 89,834 (14.5%) were emergencies.

A quarter of nulliparous women had a caesarean, compared with only 9% of multiparous women.

Women were more likely to have a LSCS if they had had one previously (71%), they had a breech presentation (90%) or they had placenta previa or placental abruption (85%). Among the women with a previous LSCS who delivered by caesarean, 70% had an elective procedure, and 57% of women who delivered a breech baby had an elective caesarean. Overall, 72% were performed for previous LSCS or breech presentation.

The likelihood of an LSCS was higher in older women, independent of other risks, and in Afro-Caribbean women. The odds ratio of LSCS was greatest for women who had placenta previa or placental abruption, previous LSCS or breech presentation. Other obstetrical complications, such as dystocia and fetal distress were signifi cant, but less marked. The unadjusted LSCS rates varied substantially between NHS trusts, ranging from 13.6% to 31.9%. Patient populations varied, but adjusted rates still ranged from 14.9% to 32.1%.

The researchers concluded that studies should avoid comparing unadjusted LSCS rates. Adjusted rates still vary considerably and attempts to reduce this variation should examine issues linked to emergency LSCS.

Jan wallis is a retired midwife and senior lecturer

What does this study add?

✻ Rates of LSCS still varied considerably between NHS trusts after adjustment

✻ Th ere was little variation between trusts in rates of elective caesareans✻ Most variations were associated with rates of emergency LSCS, probably

refl ecting lack of precise criteria for fetal distress and dystocia.

OVERVIEW

Cutting Edge

Caesarean section rates across English trusts

THE SOUTH OFENGLAND HAS HIGHERRATES OF LSCS THANTHE NORTH


Paper | Variation in rates of caesarean section among English NHS trusts after accounting for maternal and clinical risk: cross-sectional study.

Authors | Bragg F, Cromwell D, Edozien L, Gurol-Urganci, Mahmood T, Templeton A, van der Meulen J.

Publication | British Medical Journal 2010: 341; c5065.

020_mid_cuttingedge.indd 20020_mid_cuttingedge.indd 20 22/11/10 11:28:5022/11/10 11:28:50

How to…

they will need to be dispensed into a medicine pot. Medication for a baby should be administered using a syringe inserted into the mouth towards the cheek (Johnson and Taylor, 2010) 0.1ml at a time to enable the baby to suck, swallow the medication and breathe.

The baby and mother will need to be observed for drug interactions and compatibility. These may not occur initially, but can manifest orally as xerostomia (dry mouth) or candidiasis (BNF, 2009a).

If there is any incompatibility or reaction, it should be reported to the prescriber immediately and the medication should be stopped.

ConclusionThe National Patient Safety Agency continues to report on medication errors. But integrating Essential Skills Clusters (NMC, 2009) for medicine management into midwifery education may reduce this type of error in future and improve the treatment of women and babies in our care.

How to… administer oral medicationSenior midwifery lecturer at Middlesex University Anna Lyons outlines the principles of administering oral medication.


to calculate the dosage: what you want divided by what you have multiplied by what it is in. The calculation needs to be completed and then checked with a calculator.

Local policy will also advise and support your practice. Calculations for controlled drugs require two people to complete the procedure (NMC, 2007).

For a baby, the drug calculation will also need to be calculated in relation to the baby’s weight (BNF, 2009b).

Administering the drugBefore administering oral medication, an assessment needs to be completed to address if the woman or baby are able to receive it. Midwives also need to obtain consent and ensure the prescription is understood. All prescribed medication needs to be documented and signed for by the registrant (NMC, 2007).

If administering drugs from a bottle or blister pack to a woman,

Oral drug therapy for a woman or baby is commonly recorded on a drug prescription

chart. Medication is prescribed in this format to provide a specific treatment that is absorbed by the gastrointestinal tract.

Treatment specificOral medication can be prescribed for an infection, to reduce an inflammatory response, as a prophylaxis and for its analgesic effect. Administering it to a woman or baby will have a known safety rating (British National Formulary (BNF), 2009a).

When to administer?To ensure full absorption, the drug may be prescribed on an empty stomach or before, with or after food. Ferrous sulphate is more effectively absorbed on an empty stomach, for example, but due to its corrosive qualities, it is best taken with food (BNF, 2009a).

PreparationCrushing tablets or opening capsules may affect the concentration of the drug rendering the medication inert (Taylor and Johnson, 2010). This could affect the recovery of the woman or baby.

What dosage?The following formula can be used

How to…Howw tHHooww ttoo

Oral presentationsTypes of oral medications Examples of the presentation of oral medication

Tablets Plain/regular tablets, lozenges and buccal tablets

Granules Bulk or divided granules that are dissolved in a liquid

Capsules Plain/regular capsules or modifi ed-release capsules that need to be swallowed whole

Liquids (solutions and suspensions)

Linctuses, mouthwashes, supplied ready prepared or needing to be mixed before dispensing

Oral sprays/powders Sprays/bulk powders, powders for oral liquids

✼ For article references, please see the RCM website.

SCIE

NC

EPH

OTO

LIB

RA

RY

021_mid_how_to.indd 21021_mid_how_to.indd 21 22/11/10 12:50:2222/11/10 12:50:22

future of the Health in Pregnancy Grant. Louise made the case for the grant, which is threatened with abolition to help cut the deficit. The decision to scrap the grant is still working its way through the

Commons, before being considered by the Lords. The RCM will continue to make the case for extra help for women during pregnancy.

The RCM also met with members of the Northern Ireland Assembly’s health committee over soup at Stormont to discuss a range of issues, from the effects of the cuts to the forthcoming maternity service strategy. The committee members were open, friendly and above all wanted to hear from the RCM about the issues of most concern to midwives.

In Scotland, the RCM attended the annual conference of the governing Scottish Nationalist Party. As a non-party political organisation, the RCM maintains good relations with all parties, but attending the SNP event enabled us to hear directly from deputy fi rst minister and cabinet secretary for health and wellbeing Nicola Sturgeon MSP.

Scotland, Wales and Northern Ireland go to the polls next May to elect new governments, and the RCM will be speaking with all parties, including the SNP, to find new friends in the new administrations elected.

Stuart bonar is the RCM public affairs offi cer

On PoliticsStuart Bonar

In the corridors of power

Stuart Bonar gives members an update on the RCM’s lobbying efforts over the past month.

IT’S GREAT FOR MIDWIVESTHAT MPS SUCH ASAMESS ARE STANDING UPFOR THEM IN THE NEWPARLIAMENT

Lobbying for midwives in the new House of Commons is beginning to hit its stride. Meetings with MPs and peers are continuing, with new parliamentarians

signing up to support midwives all the time.Of particular importance was a debate on

maternity services secured by Southend West’s Conservative MP David Amess, who is also an RCM parliamentary panel member. Amess was full of praise for midwives and the job they do, calling on all sides to do more to value and support them.

He called for more consultant midwives, as the number dropped last year in England. He also pointed out that the NHS pension scheme produces an annual surplus of around £2bn, which goes back to the government as income.

Amess highlighted the fact that the last decade witnessed a baby boom, with the number of midwives not keeping up with the rise in the number of babies being delivered. More complex pregnancies have also added to the need for more midwives, he told fellow MPs.

The MP also spoke about the need for women to have greater choice on where to give birth, with more capital needed to increase the number of midwife-led units. Finally, he drew attention to the high cost of litigation in obstetrics, which means that cutbacks made in maternity care are often very false economies, carrying fi nancial and human costs that far outstrip any short-term savings.

The RCM is extremely grateful to Amess for taking so many of our concerns directly to the minister on the floor of the House of Commons. With the loss at the last election of MPs such as Sir Nicholas Winterton, who were willing to champion maternity services, it is great for midwives that MPs such as Amess are standing up for them in the new parliament.

Away from the main chamber, RCM deputy general secretary Louise Silverton appeared before a committee of MPs who were deciding on the


022_mid_politics.indd 22022_mid_politics.indd 22 22/11/10 11:31:0122/11/10 11:31:01


Stewards

Midwifery is a vocation, not a job. We hear that statement all the

time, but what does it mean to you in your daily working life? I believe it means that every single day of our career, midwives endeavour to provide the best possible care and support to the women and families they work with, and to always be a safe and competent team member.

None of us ever starts a shift without believing we will be the best practitioners we can possibly be. So it follows that we all pay our monthly RCM subscriptions never really believing we will be the midwife that needs steward representation or support in the workplace.

Of course, for many of you, your years as a midwife will pass happily and safely, and you will never fi nd yourself the subject of a disciplinary investigation. But, though you may not be

aware of it, your steward is still quietly working on your behalf, attending joint consultative negotiating committee meetings, terms and conditions groups, and working parties to develop the HR policies that will directly affect you at work.

These groups discuss and come to agreements between staff and employers on grievance, disciplinary and sickness absence policy, and even policies on work breaks. Your steward will be working to infl uence the very policies that you may be examined against in your career. Without realising it, you are already benefi ting from your monthly subscriptions.

What can you expect from your steward when faced with an untoward incident? And what will happen in the supervisory and management investigation that will follow? All stewards will take a slightly different approach to supporting you, but the bottom

ILLUSTRATION BY: MYDEADPONY/COLAGENE.COM

While most midwives will never fi nd themselves the subject of a disciplinary investigation, in the unlikely event of an

untoward incident at work, an RCM steward will be ready to off er guidance and support, writes Nicki Perry.

to lean on

line is they will be working with your best interests at heart, providing you with strength and reassurance at a time when you will undoubtedly be stressed and upset, and may be feeling vulnerable and afraid.

If a situation arises where your actions and practice come under scrutiny, you will have the support of your supervisor of midwives through any supervisory investigation. You will be asked to give a statement about what happened, and hopefully this will be the only action that follows. But it is wise to seek your RCM steward’s advice before submitting any statements, so they will already know the facts should the matter progress.

Alongside the supervisory

024-025_mid_Stewards.indd 24024-025_mid_Stewards.indd 24 22/11/10 11:31:5022/11/10 11:31:50


Stewards

progress to a disciplinary hearing. In the vast majority of cases, the investigation is not taken any further, but if a full hearing is planned then your steward’s support will continue. Whether you carry on working or are temporarily put on leave until the process concludes, your steward will maintain close contact with you and will endeavour to keep you calm, reassured and focused.

At the same time, your steward will carry out her own investigation into events to provide you with the best possible representation. This may involve looking at rotas, workloads, leadership, other clinicians’ actions at the time of the incident, and examining work policies and procedures to ensure they detail best practice. Your steward will also plan questions to ask you and other witnesses, gather character references and look into any mitigating circumstances. The way a case is compiled to support you at your disciplinary will vary depending on the circumstances, but it will always be prepared comprehensively.

With your permission, a steward can speak on your behalf at the hearing itself and will lay out the details of her investigation and your response to the allegations. She will also make sure proceedings are fair and consistent with process. Your steward will be working towards the best possible outcome for you at the hearing, regardless of the event that took you there.

Hopefully you will have a trouble-free career and never need RCM representation through a workplace disciplinary process but, should you require it, you can be assured your steward will provide the best possible support, advice, friendship and representation.

investigation, your employers will conduct their own investigation to make sure you are working safely and competently in your role. If the supervisory investigation concludes that your practice was sound, it doesn’t necessarily mean that you won’t be taken through the disciplinary process by your employers.

In the fi rst instance, you will receive a letter inviting you to an investigatory meeting, and advising that you can bring a friend, colleague or union representative with you. Many midwives would elect to take a friend because they believe

their practice was sound. But some may be embarrassed by the whole situation and want to keep the matter as private as possible, worried that to be investigated at all may somehow imply guilt to others.

I would always advise you contact your RCM steward. Absolute confi dentiality is assured, and she will not be making any judgements about your guilt or otherwise. Unlike a friend, in her recognised capacity as a union rep, your steward can speak on your behalf, and will have a greater understanding of the HR policies being used. It is your steward’s role to ensure due

process is followed and the interview is conducted without bias or the use of leading

questions.By their

nature, midwives are

usually fantastic communicators and

strong individuals, but being investigated

at work can often feel daunting and your usual

eloquence may desert you. At any investigatory meetings,

your steward will be there to offer the help and support you need. She will work with you to ensure you verbalise your actions clearly and concisely, and give the best possible account of yourself. If breaks are required to maintain composure, your steward will make sure these happen, and she will also ensure all questioning is open and fair.

Sometimes other individuals are interviewed before you hear the result of the investigation and whether or not the matter will

024-025_mid_Stewards.indd 25024-025_mid_Stewards.indd 25 22/11/10 11:31:5922/11/10 11:31:59


Psychologist and managing director of a self-harm training organisation Jennifer McLeod looks at the reasons behind self-harming behaviour and what midwives can do to help pregnant women who deliberately injure themselves.

Most people who self-harm hide their injuries in fear that society

will judge them for it, though some famous names, such as Princess Diana and UK athlete Kelly Holmes, have had the courage to publicly admit cutting themselves in times of extreme emotional distress.

The secrecy and stigma surrounding self-harm means it can be diffi cult to spot and even more diffi cult to estimate how common it is. According to the Royal College of Psychiatrists (RCPsych), self-harm in the UK has continued to rise over the

past 20 years and around four in 1000 people have intentionally injured themselves (RCPsych, 2010). Types of self-harm vary from hitting, cutting, scratching and burning to pulling hair, overdosing or self-strangulation, but the most common form involves lacerating arms and legs with sharp implements such as scissors or razor blades (BBC, 2004).

The RCPsych recently criticised the NHS for not providing enough training to healthcare professionals on how to treat people who self-harm, and midwives, while familiar with antenatal and postnatal

ILLUSTRATION BY: PETER CROWTHER

026-029_mid_Self-harm.indd 26026-029_mid_Self-harm.indd 26 22/11/10 11:32:3022/11/10 11:32:30


Self-harm

depression, may know very little about the issue. So, what drives people to self-harm and what should you do if you come across an expectant mother you suspect of deliberately injuring herself?

Coping mechanismSelf-harm is generally used as a coping mechanism for managing overwhelming emotional states and feelings. The behaviour is focused on injuring the self rather than anyone else (Sutton, 2007), so midwives should be aware that the baby is not generally the target of the harm.

As a means of externalising emotional pain, self-harm can

serve the function of helping the expectant mother prevent committing suicide; bring herself back to reality or conscious awareness; nurture herself, especially if she was not nurtured as a child (Miller, 1994); or regain an element of self-control.

For midwives, it is not as easy as telling an expectant mother to stop self-harming for the sake of her baby. If the mother-to-be is going to stop successfully, other more positive coping strategies will need to replace the self-harm, which is often addictive. It is similar to telling someone who is alcohol or drug dependent to kick the habit instantly.

On the triggerSelf-harming behaviour in pregnant women could be triggered by a fear that they will not be able to cope with the responsibility of caring for another person. Childbirth or pregnancy itself may also be a trigger as it could raise suppressed memories and images of traumatic child-hood experiences.

An enlarging body, differing in proportion and size at different stages in pregnancy, could present another challenge to expectant mothers with a tendency to self-harm. They may feel they have no power over their own bodies and could be tempted to hurt themselves in an effort to regain a feeling of self-control (Babiker, 1997).

Self-harming mothers-to-be may feel vulnerable and reluctant to talk for fear of child protection issues being raised. So, as a midwife, it’s important not to judge women on the basis of self-harming behaviour and to make sure you are aware of any messages you could be projecting inadvertently. To help women in this situation, trust needs to be built, as any negative judgements could lead to a feeling of rejection.

Given that pregnant women sometimes suffer emotional

AROUND FOUR IN

1000PEOPLE HAVE INTENTIONALLY

INJURED THEMSELVES



PHOTOGRAPH BY: LEON NEAL

Self-harm

swings due to hormonal imbalances, those with a history of self-harm could be at a heightened risk of injuring themselves during pregnancy. The temptation to cope with emotional distress by infl icting self-harm is an extra pressure that the mother-to-be will have to deal with. Midwives can play a major support role by being understanding and sensitive to the woman’s needs.

Another factor that may set off insecurities is the stigma attached to self-harming activities. Other forms of self-harm, such as drug and alcohol abuse and eating disorders, are better understood and accepted by society, but self-injury can still be a taboo subject.

Terms of engagementTo date, professionals have not yet agreed a term to describe self-harming behaviour, so several different names and labels are used such as self-harm, deliberate self-harm, self-injury, self-mutilation, self-infl icted violence, self-injurious behaviours, para-suicide, self-abuse, cutting, and self-wounding (Sutton, 2007). In terms of cultural differences, ‘self-harm’ and ‘deliberate self-

harm’ are largely used in the UK (Sutton, 2007), while many of the other terminologies are used predominantly in the US.

It is important to ask expectant mothers which term they prefer to use to describe their behaviour. It’s also important to make the distinction between the person and their self-harming behaviour. So referring to the mother-to-be as someone ‘who self-harms’ as opposed to a ‘self-harmer’ is one way of helping her to keep her identity intact (Sutton, 2007), and to show appreciation that a person is not defi ned by one aspect of their behaviour.

At the rootSelf-harm affects all age groups and its causes are attributed to social and economic issues, as well as health-related situations. People can be driven to self-harm by issues around powerlessness, alienation and exclusion (Warner, 2010). There are also high-risk groups who are least likely to have access to good health care, which begs the question of whether the issues should be addressed by government health policy and public health strategies, as was recommended in the recent RCPsych report

Self-harm, suicide and risk: helping people who self-harm.

According to the NICE clinical guideline on the subject: ‘Self-harm is an expression of personal distress, not an illness, and there are many varied reasons for a person to harm him or herself ’ (NICE, 2004). The most helpful way of looking at self-harm is that it is only a symptom and physical manifestation of what is really going on underneath. Identifying the root cause of the self-harm is the key to alleviating it or stopping it altogether, and this is normally achieved through therapy.

Handle with careIf you suspect that an expectant mother is self-harming, broach the subject with sensitivity and provide some element of reassurance. To help develop a healthy relationship it might be useful to arrange to see her more frequently than you would

‘Self-harm is only a symptom and physical manifestation of what

is really going on underneath’

For further information, go to: www.stepup-international.co.ukFor article references, please see the RCM website.



Self-harm

other women. You could also check she has the additional support she needs or refer her to a counsellor, therapist or support organisation. Supporting the woman to find the most appropriate remedies for her self-harm will also help to develop trust.

It’s also worth bearing in mind that women with a history of self-harm could be more susceptible to antenatal or postnatal depression, especially as their emotional problems could be exacerbated by hormonal imbalances in pregnancy.

Research shows that talking to a therapist has been beneficial for treating depression and self-harm. Cognitive behavioural therapy, which focuses on altering negative

behaviour, is one of the main treatments suggested to have a significant effect on depression (Greenberger and Padesky, 1995) and it can also be effective in identifying the root cause of self-harming activity. Cognitive analytic therapy, which is a combination of cognitive therapy and psychotherapy, can also be effective in encouraging individuals to change destructive patterns of behaviour, and group or family therapy could also help pregnant women struggling with self-harm.

By offering support and understanding, midwives can play an important role in helping pregnant women who self-harm to see their behaviour as a problem to be solved rather than as a shameful secret.

One midwife described her experience of caring for a pregnant women exhibiting self-harming behaviour as ‘very very challenging’. When the midwife booked the client, she had no idea of her medical history and fear of hospitals, but it later emerged that the women was having diffi culty coping with her pregnancy and was deliberately harming herself.

Th e midwife was fi rst alerted to this when she visited the woman at home: ‘I went in and she had bruising on her abdomen and my notes had been torn,’ she said. Th e woman admitted she had torn the notes, and explained she had injured herself because she hated being pregnant.

Th en the client requested to be induced: ‘She said to me, “You’re to rupture my membranes. I want to have this baby. I want to have

this out”.’ But the midwife calmly explained that this would be unprofessional, but she still respected the woman for sharing her feelings.

After leaving her client, the midwife immediately called her supervisor for advice and contacted the woman’s GP, who told her the woman had nearly died from an appendicitis because she had refused to go to hospital. Th e midwife discussed calling in mental health professionals with the client’s GP, but the doctor saw no reason to engage them and so it was decided the midwife would continue care, with the assistance of a colleague, and take careful notes.

Th rough reassurance and slowly building trust, the midwife tried to get the woman to open up about her feelings and discussed what they would do if the circumstances in the pregnancy changed. Th e

woman would sometimes refuse to see her, but the midwife persevered and asked the client to call her when she was ready. Th e client even threatened to rupture her own membranes, but the midwife calmly informed her that this was a dangerous thing to do and made sure the incident was documented.

Th e woman went into labour at about 37 weeks, and the baby was born safely. Th e midwife said: ‘I was very careful postnatally because I was looking out for postnatal depression and postnatal psychosis. But she made a full recovery.’

Th e midwife said she couldn’t have cared for the woman without her ‘very supportive’ supervisor. She said the most vital, but diffi cult aspect of caring for her client was ‘maintaining the relationship and maintaining the friendship’.

CASE STUDY

Treading carefully



RCM annual conference

Praise and encouragement was in great supply at the RCM annual conference in Manchester. The news that membership numbers for midwives and student

midwives were at record levels demonstrated that the profession has strength in numbers. With fi nancial and organisational problems mounting, such reinforcement among the ranks brings a confi dence to speak up – to managers and ministers.

RCM general secretary Cathy Warwick began her opening address with an admission: ‘I must confess to being a bit nervous. It’s because it really matters to me that you are all here and that you have a really good two days. I really, really care about midwifery and midwives and I really, really care about the RCM doing its best for all of you.’

Despite her confession, the nervousness was not as apparent as the determination that inspired it. Delegates heard that the conference’s strapline ‘a changing world’ couldn’t be more fi tting. The profession was meeting at a time of great anxiety, with the state of the economy and the impact of public sector cuts leading to uncertainty in the future direction of the NHS.

Earlier, conference chair Jenni Murray had opened proceedings speaking about her own appreciation of midwives, saying ‘there is nothing more important for the relationship between mother and child than the manner of that child’s birth.’

The Woman’s Hour presenter urged the profession to carry on in its efforts to get across the importance of the midwife’s role, before, during and after birth. She said: ‘A great midwife is the best start in life.’

High praise for the profession also came from Health minister Anne Milton, who ended her address telling the audience how she still

Midwives assembling in Manchester took the chance to speak up for principles and priorities.

remembered well the midwives who delivered her four children. She said: ‘Thank you for all you do and the difference that you make.’

But as welcome as the tributes are, midwives at the conference were looking for change. One told the minister that staffi ng issues meant that they could not offer home births, and that the unit was ‘close to breaking point.’ A student asked: ‘What’s the point of training, where are the jobs at the end of it?’ As others spoke out against freezing recruitment and pay, changes to pension arrangements and trusts beginning to renege on Agenda for Change – each drawing enthusiastic applause. The audience was keen to send a clear message to a minister who had said she was listening. Her hearing test will come when the Department of Health fi nally announces where the role of commissioning maternity services will lie. Delegates made it plain to the minister that it is the midwife, not the GP, who acts as lead carer for pregnant women.

In his presentation, associate professor of midwifery at the University of Nottingham Denis Walsh encouraged midwives to reconnect with philosophical ideals. He spoke of the oneness between mother and baby, the rites of passage experience and the symbolism of love over fear.

Professor Hannah Dahlen, president of the Australian College of Midwives, also addressed issues of fear in her address ‘Perspectives on risk’. She said that the focus was on death and damage and forget ‘the real contributors to maternal and perinatal safety – emotional, psychological and spiritual safety’. She likened it to looking at the tip of an iceberg and forgetting that 9/10s is below the surface: ‘A lethal 9/10s. The leading cause of maternal death in Australia is suicide.’

Show of strength

Pictured clockwise from top: panellists including Professor Hannah Dahlen and Professor James Walker discuss delivering excellence for mothers and babies; Professor Soo Downe speaks on normal birth alongside RCM council chair Debby Gould

If you missed out on Manchester, then why not head to Brighton (15-16 November) next year? Keep an eye out on the RCM website for further details.

030-031_Conference.indd 30030-031_Conference.indd 30 22/11/10 11:54:5622/11/10 11:54:56


RCM annual conference

Earlier, CMACE chairman Professor James Walker had called upon obstetrics and midwifery teams to show greater trust and cooperation. He said an obstetrician should have faith in the knowledge and judgement of the midwife, while the midwife should trust that they can raise an issue with an obstetrician who won’t automatically opt for intervention. There was consensus at that notion but Hannah added a further element, which was to trust in women and birth. She said: ‘Don’t let risk rule the day. Remember it is about women, not us.’

It was a lively conference that featured a rich and diverse agenda. Yet improving matters for midwives and the women to whom they deliver care remained at the forefront. Viewpoints aired by the speakers and issues raised by the delegates make it a valuable platform to move discussion forward. Assembling for the event will have confi rmed the anxieties of many that the changing world is a challenging one. Yet, importantly, it will also have strengthened feelings of unity and inspired a determination to ensure those changes for the better.

In the fi rst of two big debates at the conference, discussion on 'Who do midwives really work for?' turned to the industrial action taken by Danish midwives. Debate chair Jenni Murray posed the question, what is an acceptable way of expressing disapproval? Lillian Bondo, president of the Danish midwives association, spoke about action her colleagues had taken, including withdrawal of antenatal classes and ultrasound scans. Th ese were measures, she said, that made an impact without aff ecting care. Kings’ Fund senior associate Paul Corrigan stressed that any action will stand or fall on public opinion and that the need to engage the population was vital. He urged midwives to raise their grievances with the press and tell the public of their anxieties. NCT chief

executive Belinda Phipps suggested engaging with women, asking them to write to NHS managers and MPs demanding better services. Independent midwife Annie Francis called upon NHS staff to escalate issues. She said midwives are good at coping, continuing to care despite enormous diffi culties. It was time to start passing problems upwards.

Th e second debate posed the question, why is normal birth regarded as abnormal? RCM council chair Debby Gould described how despite campaigning for a better birthing environment since the 1980s not much has changed (except for caesarean section rates doubling) and that midwives must shoulder part of the blame. Maureen Treadwell of the Birth Trauma Association spoke of the

physical and psychological problems that women have been left with, having opted for normal birth. James Drife, emeritus professor of obstetrics at the University of Leeds, considered the defi nition of normal birth, asking whether midwives consider an epidural would render a birth abnormal – when put to the audience, a show of hands revealed a split response. Professor of midwifery studies at the University of Lancashire and chair of the RCM’s Campaign for Normal Birth Soo Downe said that it seems like the majority of women, midwives, obstetricians and politicians think that this ‘thing called normal is a good thing’. A positive normal birth or a birth that is as normalised as far as possible, she said, is the best starting for parenting.

Matters for debate

030-031_Conference.indd 31030-031_Conference.indd 31 22/11/10 11:55:3122/11/10 11:55:31


RCM student conference

he theme of the 20th RCM student conference this year was ‘Rising to the challenge: the

changing face of midwifery’. Chaired by members of the RCM’s Student Midwives Working Group (SMWG), the day was kicked off by a rousing speech by RCM Council chair Debby Gould. Debby reminded us that the future is ours and we must take responsibility in forming future practice. We must learn how to talk and take charge, valuing our autonomy and respecting our accountability.

The fi rst main session aimed to address the infl uence of the media. Issues surrounding celebrity adoration and emulation, the rise of the ‘instant update generation’ and the speed of technological advances were all introduced by the session chairs. Communication expert and author, Julia Hobsbawm sparked some heated debate with her insight into the media. She

RCM SMWG members NNNaaatttaaalieee FFoouuubbbissttteeerr, a newly qualifi ed midwife and RRaamoonaa RRoodddderr, a second year student provide a snapshot of this year’s 20th RCM student conference in Manchester.

questioned whether problems in the profession’s reputation lay in the media, or in the perceptions we allow women to form of us. She reinforced that we are the media and that we need to learn how to use technology for our own interests. One comment in particular seemed to offend – Julia offered her personal opinion that you need to have had children to be a good midwife.

Following the outrage that ensued, Princess Anne Hospital’s head of midwifery Maria Doré discussed the reasons behind, and processes of, the fi lming of Channel 4’s One born every minute within her unit. She conveyed that the project was not only one of entertainment, but a means of telling real birth stories and a method of improving their services. The series achieved high viewing fi gures and is an example of sensitive yet realistic portrayal of childbirth in the media.

The infl uence of the media was further scrutinised by research

fellow at Aberdeen University Tracey Humphrey. Through her research, she demonstrated that 29% of inductions could not be explained by clinical risk and that often beliefs about the induction process had been skewed by the media.

Questioning whether we are meeting the needs of the diverse population, teaching fellow at Queen’s University Belfast Shirley Stronge acknowledged that we face challenging times, but that these can be overcome with kindness, respect and compassion for the women we care for. Ros Davies went on to discuss the work that Women and Children First UK are doing in developing countries such as Nepal to reduce perinatal mortality. Consultant midwife Yana Richens shocked the audience by announcing that UK maternal mortality rates have not improved in the past 20 years! Those most at risk include the socially excluded, teens and ethnic minorities. Yana believes that access, information and communication are the keys to improvements and left the students with a poignant message: we never know when we save a life, we will always know when we haven’t.

The third session of the day revolved around student issues and involvement, opened by the

032-033_Student.indd 34032-033_Student.indd 34 22/11/10 11:38:1422/11/10 11:38:14


RCM student conference

RCM’s John Skewes and Frances Day-Stirk. They were keen to establish how students felt they should be represented within the RCM, whether through online communities, physical and virtual networks and the SMWG. Concerns were raised from the audience over the possible obstacles of integrating RCM reps into universities, and onto the RCM Board. The theme of networking was continued with the introduction of the new RCM Communities by communities manager Emma Godfrey-Edwards. She guided the students through the interactive member-only hub and encouraged us all to use it to open and partake in discussions, blogs and consultations.

Findings from a joint RCM and RCOG survey were also shared with the group, which highlighted a need for students to crank up their collective voice, as well as the disappointing statistics relating to workplace bullying. This theme was then picked up on by Imperial College NHS Trusts’ director of midwifery Maggie O’Brien. Maggie touched upon its existence in many forms within clinical and university settings, alongside ways of identifying it and possible causes.

Finding the balance between normality, risk and safety was the topic of discussion next. Associate professor of midwifery in Sydney Hannah Dahlen raised the question of whether the term ‘normal’ has become too constricted, and if risk management is forgetting about

aspects of wellbeing out with ‘death’ and ‘damage’. She reminded us to form relationships with women and that there are 136 million reasons (births per year) to get this right. Hannah’s inspirational speech reminded us that we need to change the births, to change the birth stories, in order to change the births.

Perhaps a lone voice in the sea of ‘normality experts’ was consultant obstetrician Melissa Whitworth, who challenged whether intervention is bad. She highlighted that it may be impossible to reduce rates any further in the UK without affecting mortality rates.

The fi nal speaker of this session was midwife coordinator Lindsay Durkin, who shared with the audience a model of care used within her hospital to protect normality for high-risk women. This package ensures there will be no regrets over what ‘could have’ been done to improve outcomes. Lindsay ended her presentation with an inspirational fi lm, which had many of us shedding a tear.

The fi nal panel of the day were tasked with discussing alternative funding models for maternity services and was opened with an insight into Danish midwifery. President of the Danish Association of Midwives Lillian Bondo described the evolution of the Danish system and the work of the association now, in trying to design a fairer and more successful way of funding and organising services.

Private midwifery care was also represented by Joyce Woolford,

a supervisor of midwives at The Portland Hospital. Joyce explained what the private system can offer and received a mixture of laughs and gasps when she revealed a vaginal birth costs £5400, and a standard room from £1050 per night – you can imagine the shocked faces around the room. However, this does serve to remind us that the services we provide in the NHS do come at a cost and we need to be mindful of this.

The independent midwifery perspective was provided by Independent Midwives UK (IMUK) Annie Francis. Annie presented a model of care, which would allow independent midwives to work safely within the UK and involved caseloading midwives working in neighbourhood practices, overseen by IMUK. With regards to the ongoing struggle surrounding indemnity insurance, Annie felt that this would be solved – it’s simply a matter of when.

The conference was closed by general secretary Cathy Warwick, who presented fi ndings on the benefi ts of midwifery-led care. It was estimated that around £1.16m could be saved per year by providing this type of care, which in this economic climate should be music to our ears!

Throughout the conference, there was an overriding sense of a ‘calling to arms’, for students to take ownership of their profession, its reputation and its future. Each speaker demonstrated a belief that student midwives have the power to affect change and to improve maternity services.

Th e RCM student conference is a fantastic opportunity to meet student colleagues from across the UK. If you weren’t able to attend this year in Manchester, perhaps you would fancy heading to Brighton next year on 15 November? Keep an eye out on the RCM website for further details.

of inductions could not be explained by

clinical risk

Pictured l to r: chief executive of Women and Children First UK Ros Davies, RCM general secretary Cathy Warwick, Student Midwives Working Group members Alexandra Birch and Charlotte Elliott

032-033_Student.indd 35032-033_Student.indd 35 22/11/10 12:53:1922/11/10 12:53:19


RCM workplace reps conference

Maternity services are getting to breaking point,’ said RCM general secretary

Cathy Warwick in her opening address to the RCM workplace representatives annual conference on 17 November. And indeed there was an all-pervading air throughout the conference that maternity services are under siege and midwives are attempting to hold the fort in the face of cuts to staffi ng, pay and benefi ts, a rise in birth rate and the number of women requiring more complex care.

Speakers at the Manchester conference, including other trade unionists and legal experts, offered guidance on the way forward and how workplace reps can stand up for midwifery services and staff.

Emphasising the message that ‘the contract is sacrosanct’, Bernie Wentworth from Thompsons Solicitors said that if an organisation is attempting to change the terms and conditions of a worker’s contract, they cannot do it without the collective agreement

Sasha Wood gives a round-up of the RCM workplace representatives conference, where speakers off ered advice on meeting the biggest challenges maternity services have faced in many years.

of the union or the individual. He urged RCM workplace reps to raise a grievance if their employer attempts to change conditions of employment, and on a show of hands, it appeared that quite a few employers are already breaching agreed terms and conditions.

He said that other than by agreement with the individual staff member, the only way an organisation can alter an employment contract is by dismissing everybody and re-engaging them, something the Fire Brigades Union has been fi ghting recently. According to Wentworth, unions can claim for a protective award of 90 days full pay for staff members if an employer attempts to sack and re-hire more than 20 people without negotiating with the union. But, in a workshop on the subject, some speakers warned that employers will try other tactics to change workers’ terms and conditions and workplace reps need to circulate information to others on what’s happening in their local area, so

everyone is well prepared. The new professional networking hub RCM Communities could be the ideal forum for members to share this kind of information.

Kevin Callinan, deputy general secretary of Ireland’s largest public sector union, Impact, shared his experiences fi ghting Irish health service cuts. He said the union tried to counter media attempts to vilify the public sector by running an advertising campaign about the government attack on public services. Callinan advised that: ‘The most effective action we have taken is withholding key fi nancial and statistical data.’ This sentiment was echoed by other speakers at the conference, who said that withholding key data makes managers sit up and listen, because it leaves them unable to do their jobs properly.

Speaking on managing maternity services in times of austerity, chief midwife at South London NHS Trust Donna Ockenden pointed out that, despite government assurances that the NHS budget is protected,

Knowledge is power

034-035_Workplace.indd 34034-035_Workplace.indd 34 22/11/10 13:03:3922/11/10 13:03:39


RCM workplace reps conference

the next few years will see the lowest growth in NHS spending since 1951-52, meaning the health service is facing its biggest challenge for more than half a century.

Ockenden said that now, more than ever, midwifery leaders need to look at services pragmatically. She advised workplace reps to make sure they understand the fi nancing and costs of their service, adding: ‘There is nothing more powerful than workplace reps who are well-informed.’

Budget cuts in the NHS are having a knock-on effect on employment rights enshrined in Agenda for Change (AfC) too, with a raft of trusts attempting to undermine AfC and introduce employment contracts with only statutory terms and conditions, such as the minimum allowance for annual leave, sick pay and maternity leave, and containing a compulsory requirement to work extra hours including on-call with no pay. ‘We’re now seeing a green light given by the government to renegade trusts who are cutting

a swathe through Agenda for Change,’ said RCM director of employment relations and development Jon Skewes.

In a workshop focusing on how best to defend AfC, RCM employment relations advisor George Georgiou explained that the government’s NHS White Paper suggested individual trusts should be able to determine their own rates of pay, ‘opening the door to attacks on AfC’. Georgiou said Norfolk and Norwich NHS Trust is currently at the centre of the fi ght to protect AfC, with the RCM battling attempts by the trust to introduce new base contracts for midwives that contain ‘all conditions of service outside Agenda for Change’. He warned ‘if they get away with it in Norwich, it will be rolled out everywhere else’.

According to Bernie Wentworth, there is nothing legally that can be done to stop trusts introducing new contracts with statutory minimum conditions outside AfC, which will not only impact on anyone moving jobs or being offered a promotion, but will also lead to midwives

receiving different pay and benefi ts throughout the NHS.

The panel suggested that workplace reps resisting these changes could adopt a ‘work to rule’ policy, where midwives only work their allotted hours and refuse to carry out duties beyond their remit. This is a particularly effective tool for midwives who have had their employment band downgraded from a band seven to a band six. One workplace rep said this tactic had led to her trust reinstating all their band seven midwives.

Drawing the conference to a close with a presentation on the way forward, TUC assistant general secretary Kay Carberry welcomed the prospect of a close relationship with the RCM. She pointed out that the policies contained in the government’s White Paper on the NHS were not signalled in either the Liberal Democrats or the Conservative parties pre-election manifestos. The RCM will be joining the TUC for a march and rally to defend public services in March next year.

Closing the conference, Jon Skewes told delegates: ‘I don’t ever remember a time when there was more of a threat to the public sector and the NHS.’ He said the RCM employment relations and development committee is currently undertaking a review around possible action the RCM can take to counter this threat, including the need to build alliances, raise the RCM profi le and step up campaigning efforts.

Calling on all workplace reps and members to take action and raise awareness in their communities, chair of the RCM employment relations committee Corina Casey-Hardman said: ‘We’ve got the opportunity to motivate the women in our country and there’s never been a better time.’

If you weren’t able to attend this year in Manchester, what about heading to Brighton next year on 16 November? Keep an eye out on the RCM website for further details.

Pictured l to r:RCM employment relations advisor George Georgiou and RCM director of employment relations and development Jon Skewes

034-035_Workplace.indd 35034-035_Workplace.indd 35 22/11/10 12:52:2822/11/10 12:52:28


Risk management

Earlier this year, an NHS trust was ordered to pay £100,000 after its failure to manage the risk of

drug errors led to the death of a new mother, when a midwife mistakenly administered an epidural anaesthetic via an intravenous drip rather than saline solution. The case illustrated the vital importance of avoiding mistakes by controlling risk effectively. The substances had been mixed up as they were in similar packaging, in the same cupboard, and the trial concluded that avoiding ‘any one’ of a number of errors would ‘probably have averted’ the woman’s death (Health and Safety Executive, 2010).

Prosecutions and claims for medical negligence have escalated and are still on the increase (CNST,

Clinical risk facilitator and midwife Catherine Doherty off ers advice on managing risk in maternity services and achieving accreditation for the Clinical Negligence Scheme for Trusts (CNST).

2009), which has a knock-on effect on services because resources that could have been used for client care are diverted to settle claims.

Risk management is the lynch pin that pulls together all the different sections of clinical governance. It is a systematic process of identifying incidents and near misses, so when things go wrong, lessons can be learnt to improve clinical practice and provide explanations and answers. Safety is the top priority in clinical care (National Patient Safety Agency, 2004).

Over the last 20 years, there has been an improvement in care quality and standards, dramatic advances in technology, and a noticeable rise in public expectations. The public expect pregnancy and labour to be straightforward and so, when complications occur, their initial reaction is to assume health

professionals have made a mistake and to demand an explanation.

There is pressure on the NHS to perform, which partly comes from a user’s right to complain with the possibility of it leading to litigation. But risk management is not only concerned with a reduction in lawsuits, it should be seen as a proactive way to prevent and reduce poor outcomes.

National confi dential enquiries have highlighted areas of sub-optimal practice and made lots of recommendations. Many of the poor outcomes identifi ed could have been avoided if only lessons were appropriately learnt.

Risk is everyone’s responsibility and risk assessments should be part of everyday practice. It is not a new concept; clinicians have always assessed risk. But in today’s climate, it is essential to have a robust system in place, which addresses risk management and supports the multidisciplinary team.

With government initiatives and the need to meet targets, it’s important practitioners are

Learning to lessen risk

036-037_mid_Risk.indd 34036-037_mid_Risk.indd 34 22/11/10 11:40:2022/11/10 11:40:20


Risk management

aware of the need to report all accidents and incidents, and are seen to be proactive rather than reactive. Most staff are aware of the relevance of risk management to their work, but may feel accountability and responsibility for risk fall solely to the risk manager. One major lesson for clinicians is that risk management is a process, not a position.

Supervisors of midwives (SoMs) and the clinical governance lead play an important role in risk management, by not only working within the clinical governance framework, but also with the maternity risk manager, supporting all staff and ensuring the service maintains good practice.

An organisation needs to have a clear review mechanism for it to adopt an open and fair blame culture. It was previously named a ‘no blame’ culture to encourage staff to report incidents without fear of reprisals, but this didn’t always work so a ‘fair blame’ culture was developed, enabling staff to share their experiences, learn lessons on improving client care and create a positive safety culture.

When there has been an incident or near miss, it is essential to analyse root causes across all services to identify areas for improvement and prevent unnecessary changes in practice. If incident analysis identifi es training or practice issues, then prompt action should be taken.

It is important staff receive feedback to ensure lessons are learnt.

Trigger lists are an essential part of incident reporting because there is no guarantee information will be cascaded. It is diffi cult to think of incident reporting in the middle of a short-staffed and busy ward, but it is important the team detects under-performance and resolves it at an early stage by escalating issues to senior management and SoMs.

Supervision plays an important role in incident investigation, as a supervisor can advise staff and employers and promote good clinical practice. If there is a serious untoward incident (SUI), it is imperative an identifi ed SoM and all senior staff are available to give support and actively listen to those who were directly involved.

The service should arrange an open discussion meeting so personnel involved in the case can clarify issues, and identify good and bad practice. The team should devise an action plan with time scales to implement lessons learned from the incident. Any changes to clinical practice should be audited to make sure it’s improved and has not introduced any unforeseen risks.

The RCOG Maternity Dashboard, developed in 2008 to help maternity units plan and improve services, is a useful tool for clinical governance, as it allows the team to identify trends, shortfalls and plan action. Also referred to as a clinical performance and governance scorecard, the dashboard monitors

the implementation of local targets and principles of clinical governance on the ground, helping identify patient safety issues in advance so that appropriate action can be taken.

To promote risk management standards and manage litigation claims against the NHS, CNST maternity standards replaced previous standards in April 2009. The standards can be adapted to specifi c services, and a CNST assessment is used to audit them.

When priming a maternity unit for a CNST assessment, preparation is paramount. The process should include:✼ Planning and team work to

gather appropriate evidence✼ An informal visit from the

assessor to gain guidance✼ Reviewing the standards,

ensuring all evidence is relevant✼ Regular communication with the

assessor and other units✼ Identifying and cross-referencing

relevant case notes✼ Correlating evidence and putting

it into the CNST template, which will form the foundation for the assessment.With continuous education

and promotion, risk management will eventually become part of everyday practice. By working together to break down barriers to effective risk management, and committing to a culture of openness and honesty, maternity services can improve care by assessing and reducing risk.

For article references, please see the RCM website.

036-037_mid_Risk.indd 35036-037_mid_Risk.indd 35 22/11/10 11:40:3722/11/10 11:40:37

Stillbirth

Parents whose baby has just died are often deeply traumatised. Their immediate

response to suggestions about seeing and holding their baby is often ‘no’. But that refusal could indicate fear of the unknown or of what the baby might look like, rather than a genuinely informed choice. They are unlikely to know, for example, that many parents treasure the memories of the time they had with their baby. So staff need to gently hand-hold to fi nd out what may lie beneath their initial refusal.

Nice advice NICE published Clinical Guideline 45 – Antenatal and Postnatal Mental Health in 2007, which consisted of four different documents, each with a slightly different statement about parents seeing and holding their stillborn baby. These inconsistencies created a great deal of anxiety and confusion. Many midwives and others were concerned that parents might no

After a stillbirth or neonatal death, midwives need to off er sensitive support and give parents the choice of holding their baby, says Sands member and

practising midwife Michelle Dimery.


Creating memories

longer be offered a choice about seeing and holding their baby.

In 2009, bereavement charity Sands launched a campaign asking NICE to review these statements, eliminate the inconsistencies, and make it clear that parental choice was the most important consideration.

After several months of careful negotiation between NICE and Sands, NICE issued a clarifi cation statement in June 2010: ‘This recommendation is not intended to suggest that women should not be given the choice of seeing and holding their baby, but rather that they should not be routinely encouraged to take up this choice if they do not wish to. In line with patient-centred care, it is expected that treatment and care should take into account the woman’s individual needs and preferences. Sensitive support will be required in offering this choice or other choices such as seeing or holding the baby with other family members present. Current evidence suggests that seeing and holding the baby is not benefi cial for everyone and if women do not

wish to see or hold their baby they should not be encouraged to do so.’

Free choiceIt is now clear the parents’ wishes should be the chief factor when helping them to cope with the aftermath of a stillbirth. Individual needs and preferences must be taken into account, and staff should offer sensitive support to help parents make their own choices.

This is not an easy task. Staff have their own anxieties and fears – they may lack experience, be under pressure when the ward is busy, or not understand the value of creating memories for parents. One midwife commented: ‘Looking after parents when you are about to deliver their stillborn baby is frightening, it’s scary. The condition of the baby is unknown. You don’t know how the parents are going to react; you don’t know how you are going to react.’

A mother whose baby was stillborn recalled not holding him with regret: ‘I turned down

038_039_mid_stillbirth.indd 26038_039_mid_stillbirth.indd 26 22/11/10 11:41:4322/11/10 11:41:43


the opportunity to hold my baby because I was so scared. I was asked if I wanted to go and see him in the mortuary and at the time visualised several dead bodies on a mortuary slab and I was too scared to go. Nobody sat down and just spent fi ve minutes with me to inform me that one day I could regret not holding him. None of the staff offered to come with me. The agony and the pain never go away. I will always regret never having held Christopher.’

Research has shown that parents often look to healthcare professionals for support when their baby dies (Lovell, 2001; Dyson et al, 1998). So midwives need to ensure they are offering informed choices, rather than making parents who don’t want to see and hold their baby feel they ought to. To reach an informed decision, parents need to know what their choices are. They could see their baby straight away or after he or she has been washed, wrapped or dressed, for example. Their baby could be placed in their arms or in a crib, and depending on the baby’s condition, they could bathe and dress him or her themselves.

Healthcare professionals should allow parents to have as much or as little contact with their baby as they want. For some parents a few moments will be enough, while others will need a couple of days to say goodbye and may take their baby home with them (Trulsson, 2004; Lundqvist, 2002; Radestad, 2001; Dyson, 1998; Lemmer, 1991).

Gentle remindersMany parents treasure photos of their baby, so it is essential that these are high quality. The pressure to provide some positive memories from the birth is huge, and this is more diffi cult if the baby has a visible abnormality or is

macerated. Careful positioning and wrapping can help, as can taking pictures from a variety of angles, or focusing mainly on the baby’s hands and feet. It is also important to position the baby so he or she looks natural and comfortable.

Staff should ask parents what they want and, where appropriate, make suggestions. The baby could be wrapped or dressed for the photograph, for instance, or undressed with a cuddly toy. Parents may also want pictures of themselves, and of other relatives with the baby. ‘I always take a lot of photos and I never put the camera away until the parents have seen all the photos and are satisfi ed that they have enough,’ said one midwife.

It is always important to ask parents if they want photos to be taken of the baby. And it is worth considering that not all hospitals store photos in the mother’s notes, so it is essential that parents who prefer not to take the photos straight away are told whether or not the hospital can store them.

Memory boxWith the help of their midwife, parents can collect other mementos to store in a memory box. Items should be as personal as possible. The baby’s identity bracelet should have the baby’s given names on it rather than just the mother’s name, for example. Hand and footprints should show all digits clearly as some parents have the images of their baby’s hands or footprints made into jewellery.

Research has shown that in retrospect many women wished they had more reminders of their baby, and that not having reminders increased anxiety and stress (Radestat, 2001; Trulsson, 2004). Midwives and other healthcare staff can make a crucial difference to parents’ long-term wellbeing if they take time to explore any fears, offer choices and ideas, and support parents to reach decisions that could impact on the rest of their lives.

Th is article is adapted from a presentation for the second annual conference Uncertainty and loss in maternity and neonatal care run jointly by the RCM, Sands and Bliss.

For article references, please see the RCM website. D

REA

MST

IME/

ISTO

CK

038_039_mid_stillbirth.indd 27038_039_mid_stillbirth.indd 27 22/11/10 11:41:5322/11/10 11:41:53


Discussions from the Communities

HTTP://COMMUNITIES.RCM.ORG.UK

1RESPONSE

“In our trust, they can change position, but are bed bound. Many women recognise the benefi ts of mobilisation during labour. However, there is a distinct lack of practitioners in our trust, who can offer a mobile epidural. I believe such epidurals would change the statistics linking them with assisted deliveries and give women a sense of empowerment. Those with epidurals are not automatically catheterised. They are given the opportunity to pass urine naturally, but this is often not achieved. A mobile epidural may avoid the need for catheterisation and reduce the risk of infection.”


2

DISCUSSION 1

>>Your trust’s policy What is the policy at your trust on women with epidurals? Can they change position? Can they mobilise?

What’s it all about?The simple answer is engagement. The ever-changing world of technology has transformed the way people communicate and engage with each other. And the RCM wants to keep abreast of these developments.

Feedback from members revealed that a communities section of the RCM website was what was needed to engage and encourage members to talk to each other – a potential benefi t and a vehicle of support. The RCM saw the idea as another way it could interact with its membership. And so the beginnings of an online member-only professional networking hub took shape – the RCM Communities. It is a virtual meeting place for members to share ideas and advice, post the latest resource, and infl uence the profession’s standards and practice by contributing to the most recent consultations.

It’s building e-communities with a special interest or common theme, where issues and concerns can be discussed and debated, questions can be posed to fellow members, and new groups can be formed. There’s blogs and polls too.

It is hoped that the RCM Communities will see the overall member-to-member channels of communication improve, and in turn re-ignite the passion for midwifery throughout the profession.

There are only fi ve member groups at the moment – students, maternity support workers, consultant midwives, professors of midwifery and a general midwives group. But this is just for starters – we had to start somewhere. If you’ve colleagues who would like to start a new group, then hit the ‘Suggest a group’ button on the groups landing page.

RESPONSE

“I also think that with the client controlled epidurals, there seems to be some confusion over the best way to manage their use. Some evidence-based guidelines need to be introduced and enforced so that women are getting consistent and relevant advice from midwives.”


n r,

they mobilise?

040-041_Communities.indd 40040-041_Communities.indd 40 22/11/10 11:58:1922/11/10 11:58:19


It’s a brand new venture for the RCM, which has taken months to plan and structure, but it’s here… the RCM communities.

HTTP://COMMUNITIES.RCM.ORG.UK

1RESPONSE

“One idea I really liked was in a midwifery-led unit. When a woman rang up who, on questioning, seemed to be in the latent phase, they advised her to stay at home, but told her that her name was going on the ‘board’. In other words, when she next rang, the midwife would already be aware of her and the details of her last phone call. This seemed like a simple, but good way of helping a woman feel she was in touch with the unit and that they cared about her.”

POSTED BY: A HEAD OF MIDWIFERY

DISCUSSION 2

>>The latent phase of labour What are the various practices and coping mechanisms that midwives are offering to women in the latent phase of labour? Is there a particular combination of analgesia being used in some units, which is

more benefi cial to women? This is a stressful time for all involved when women may be in pain, but are told ‘you are not in labour yet’, and will no doubt impact on physical and psychological wellbeing.

2RESPONSE

“We have a couple of ways of helping women – we invite them in for a chat on how to cope, we offer them a TENS unit and also give them a leafl et, which we go through, and fi nally put their name and phone number on the board and agree to phone them after an agreed time.”


LINKS& NOTES

YOUR TRUST'S POLICYFor more in-depth answers to the questions, please visit: http://communities.rcm.org.uk/groups/student-midwives/conversations/your-trusts-policy

THE LATENT PHASE OF LABOURFor more in-depth answers to the questions here, please visit: http://communities.rcm.org.uk/groups/midwives/conversations/latent-phase-labour

In every issue of Midwives, there will be space dedicated to the latest discussions taking place on the RCM Communities site. If you want to read more responses or add a discussion of your own, then please log on and get involved at: http://communities.rcm.org.uk. You will need your membership number to create your user profi le. If you have any problems, then contact the RCM communities manager Emma Godfrey-Edwards at: [email protected]

3RESPONSE

“We have developed a DVD about our maternity services. Included in this is education about the normal physiological birth process and coping strategies to use at home in early labour. It has ipod downloads, so women can also use this information when they come into hospital.”


Th e default setting on the communities user account is to receive an email alert when a member leaves a thread/response within a group you are a member of. You do have the option to make this a combined alert or not to receive these alerts at all. Please go into your account, click on the 'alerts' tab, and then on one of the options in 'alerts settings' to change this.

ILLU

STR

ATIO

NS

BY: J

O H

AYM

AN

040-041_Communities.indd 41040-041_Communities.indd 41 22/11/10 11:58:4822/11/10 11:58:48

Amnesty International

Chair of the RCM UK Board for Northern Ireland Shoona Hammilton and Northern Ireland campaigner for Amnesty International GGrainnne Tegggart discuss collaborative eff orts to recognise

maternal health as a human right’s issue.

Each year, millions of women face death, serious illness and permanent disability because of complications relating to pregnancy and birth, while many more must

cope with an unplanned pregnancy because family planning is not available.

The RCM and Amnesty International in Northern Ireland have joined forces to campaign for preventable maternal death to be recognised as a human right’s issue through Amnesty’s Demand Dignity campaign.

In 2000, the UN set eight Millennium Development Goals (MDGs), which included MDG5 to improve maternal health by cutting maternal mortality by three quarters from 546,000 in 1990 and prevent the deaths of 740,000 women from complications in pregnancy and childbirth by 2015. But so far progress has been slow. Deaths in pregnancy fell to 358,000 in 2008 – a reduction of more than a third – but one woman still dies every minute from pregnancy-related factors and it is the poorest and most excluded women in society who face the greatest threat (WHO, 2005).

According to Amnesty International, 74% of maternal deaths could be averted if these women had access to antenatal healthcare services (Amnesty International, 2009b).

Adequate healthcare is not a privilege afforded only to the rich, it is a basic human right. We should not accept that a poor pregnant African-American woman is four times more likely to die from complications in childbirth than her Western counterpart (WHO, 2005).

Poverty, violence and lack of education lead to the avoidable deaths of women in childbirth, with a host of knock-on effects on children and communities. But it’s not all doom and gloom, in many countries such as Nepal, Sri Lanka and Honduras, government action has reduced maternal mortality rates.

In September 2010, just days before a crucial UN summit to review progress on the MDGs, chair of the RCM board for Northern Ireland Shona Hamilton participated in Amnesty International’s conference on poverty, health and human rights, held at Stormont. She provided great personal insight into the daily

lives of women in some of the world’s poorest regions and the role midwives can play in addressing the disproportionate impact of poverty on women. She was accompanied by midwifery teaching fellow at Queen’s University Shirley Stronge who has experience of working in Malawi and Ethiopia.

The UN special rapporteur on health Anand Grover was keynote speaker and addressed politicians and experts from the health sector on the links between global poverty and poor health. He explained that Northern Ireland could help to achieve the MDGs through a combination of political collaboration, support and action by local and international development and health agencies, including the RCM.

The MDGs provide a real opportunity for the world to combat extreme poverty and inequality. But the goals can only succeed if they are closely aligned with basic rights. Unless human rights are placed at the core of poverty reduction efforts, little will change for those who need the assistance most. Falling short of these targets will mean failure to uphold basic human rights.

As we mark Human Rights Day on the 10 December, it’s time to renew our determination to meet the challenges ahead.

Pictured l to r: Th e UN’s Anand Grover, chair of the Coalition of Aid and Development Agencies NI Karen Gallagher, Queen’s University’s midwifery teaching fellow Shirley Stronge, Shona Hamilton, Conall McDevitt MLA and Grainne Teggart


To fi nd out more, visit: http://tinyurl.com/maternalmortality For full references, visit the RCM website.

042_mid_Amnesty.indd 40042_mid_Amnesty.indd 40 22/11/10 11:44:0022/11/10 11:44:00

ONCOURSE

Over the past year, I have embarked upon a journey that has seen me evolve

from student to professional. I feel fortunate that I started this journey at Barnsley District General Hospital, where a renowned reputation for excellence in maternity care, together with some fabulous colleagues, have helped to make the diffi cult transition an achievable one.

It has truly been an incredible year that has seen me stretched to my limits, out of my comfort zone and facing the steepest learning curve to date. I believe it’s called being a newly qualifi ed midwife. The very nature of the job is demanding and challenging, no more so than when you are trying to negotiate your newly found status, with new responsibilities, new paperwork, new people, places and protocols!

Fortunately, a year’s comprehensive induction programme provided a fantastic opportunity to rotate onto labour suite, postnatal ward and antenatal clinic, allowing me to establish myself and consolidate my skills in each clinical area. With great

Emma Edwards gives a few words of wisdom to students everywhere as she looks back over her fi rst year as a newly qualifi ed midwife.

support from colleagues and fi nding I could now focus on clinical practice (opposed to my studies), I soon found myself rising to the demands of the job and growing in confi dence. Some memorable words, which empowered me to feel more capable, came from my manager: ‘The only stupid questions are the ones that you don’t ask.’ This underpinned my thinking, together with the words inscribed on a large poster on labour suite... ‘Keep calm and carry on!’ A sense of humour is defi nitely a requirement in this job!

Of course the gratitude you get from families and the valuable role we endeavour to play in women’s childbearing experiences makes all the hard work worthwhile. Whether it’s making that fi rst antenatal booking, sharing the miracle of birth or helping a baby to breastfeed, I am constantly reminded of my privileged position and why I became a midwife. Evidently, our role goes far beyond the realms of midwifery and I never fail to be surprised by the sheer diversity of the job, from the social challenges posed, to the ethical and legal issues we encounter on a regular basis. I have already gained a wealth of experience in such a short space of time, yet somehow I know I have barely touched the surface.

Fortunately, there has been a tremendous amount of learning

and development opportunities to support me in my new role. Mandatory training, practice updates and skills workshops ensure I continue my personal and professional development. A supervisory review formed a sound basis for refl ection; to consider my progress and achievement to date, to tackle pertinent issues and derive an action plan for the future. I feel a good supervisory experience is fundamental to feeling supported in practice, to encourage professional growth and ultimately enhance the quality of care provided. Career progression opportunities are also there in the not too distant future.

For now though, I’ll focus on striving for excellence in all things midwifery. Every day brings something new and no two days are the same, therefore I know I have my work cut out! Being a student was good, but taking real ownership of your work is better. When shifts are long and I feel overwhelmed, I remember what I have come through to get here. To newly qualifi ed midwives who face the same challenges, rest assured that you will make the necessary transition and learn an immense amount along the way. If I had to summarise the past three years, I guess it feels a little like I climbed a mountain only to fi nd, when I reached the top, that it was the foothill of a much larger peak.


IT FEELS LIKE I CLIMBED A MOUNTAIN ONLY TO FIND IT WAS THE FOOTHILL OF A LARGER PEAK

Keep calm and carry on!

043_mid_student.indd 43043_mid_student.indd 43 22/11/10 11:44:2522/11/10 11:44:25

BookmarkThis month's books and DVDs reviewed by Midwives' team of experts

Review by Carol Hindley Th is book is well written and includes some of the contemporary evidence surrounding positions for birth. In spite of a range of positions being available, it would seem that the supine position still dominates practice in maternity units. Th e author maintains that this is because women are not aware of the choices available to them or that some midwives might not facilitate this choice.

Chapters in the book include discourses on the medical philosophy of birth and how this has aff ected the traditional, naturalistic approach to labour and

delivery in conjunction with a comprehensive history of birthing positions across the ages. A comprehensive and well-researched text, it highlights the evidence of the advantages and disadvantages of various birthing positions.

A further strength of the book is in the review of several studies, which originate from diverse perspectives and include historical as well as anthropological outlooks. Th e book also includes research, which reports midwives' views of alternative birthing positions along with quantitative data that examines women’s

decision processes on their choice of birthing positions.

Midwives will undoubtedly fi nd this a very useful resource, which will allow them to appraise the best evidence surrounding birth positions and enable them to incorporate this into their practice. Th e evidence provided in the book is focused on woman-centred care and informed choice with respect to positions for labour and birth. Th is is very important because midwives are already aware that women trust midwives’ knowledge and tend to regard their advice as crucial in helping to attain the benefi ts of an appropriate birth.

BOOK

Birthing positions: do midwives know best? Author: Regina CoppenPublisher: Quay BooksISBN: 1856422569

Review by Comfort MomohTh is is a fantastic educational tool and I felt the fi lm was very informative and gave some balance to the view of what female genital mutilation (FGM) is about. Extremely thought-provoking, it was excellent to see both sides of the argument from the people actually involved. I hope however, that this does not evoke stereotypes.

Revealing and factual, the DVD provides quite a graphic but necessary and realistic approach to the subject, making the audience more aware of the horrifi c aspect of FGM. I believe the fi lm should be

shown nationally so that the general public can be made truly aware of FGM, its problems and the history behind the practice. I believe there is a great need to infl uence all sectors of society about it, especially men.

Th ere are balanced views shown of men and women and it also involves religious leaders. It tells us how important education is and that awareness should be included in schools, colleges, churches, mosques, anywhere, so that it can eradicate the ignorance surrounding the practice.

Th is really is an excellent DVD, which should be shared with all health

professionals and medical staff especially midwives and obstetricians, as well as teachers and other agencies to highlight the issues of FGM, and the diversity of thought, belief and sentiments within those populations who practise it. Th e expert fi lming provides an enlightening insight into the topic and it was very professional yet still emotive at highlighting where FGM is happening and how. However, there is a lot of information included so maybe a diff erent version could be made for health professionals and the fi lm could be condensed into 30 minutes.

DVD

The cutting traditionWritten, fi lmed and edited by John Howarth Producer: Nancy Durrell McKennaDirectors: Nancy Durrell McKenna and John HowarthWeb: www.fi go.org and www.safehands.org

n

tgrsatI


044_mid_resources.indd 44044_mid_resources.indd 44 22/11/10 12:55:0722/11/10 12:55:07


Principles and practiceof perineal repair module

Date Th ree-day module: next scheduled for October 2011Location University of SurreyCost £1028 Details A self-directed work-based module incorporating face-to-face and ULearn. Off ered to midwives at degree and masters levels. For more information see: www2.surrey.ac.uk/healthandsocialcare/study/CPD/degreeContact 01483 684620; [email protected]

OCTOBER

Perinatal Medicine2011

Date 15-17 JuneLocation HarrogateCost Early bird rates apply before 28 February 2011. Details A joint meeting of the British Maternal and Fetal Medicine Society, the British Association of Perinatal Medicine, the Neonatal Society and the Neonatal Nurses Association. See: www.perinatalmedicine2011.ukevents.orgContact 020 8979 8300; [email protected]

JUNE

15-17

MARCH

Introduction to reikiin pregnancy

Date 16-17 FebruaryLocation LondonCost £285 (places limited to eight)Details Reiki is a method of facilitating universal energy to aid relaxation. Th is two-day course constitutes levels 1 and 2 of approved reiki training and will focus specifi cally on the practical application of reiki within maternity care. See: www.expectancy.co.ukContact 08452 301 323; [email protected]

16-17

Masterclassin CTG -deeper undersanding

Dates 25-26 JanuaryLocation LondonCost £155 for one day and £295 for both daysDetails Th e CTG masterclass course is aimed at all midwives, obstetricians and clinical negligence lawyers who are involved in interpreting CTG traces. See: www.babylifelinetraining.org.ukContact 024 7642 2135; [email protected]

25-26

CMACE conferenceseries: saving mothers’lives

Dates 1, 2, 3, 4 MarchLocations London, Manchester, Glasgow and DublinCost Early bird fees from £94 until 31 December. Standard fees from £96.Details Th ese conferences mark the launch of the eighth report of the Confi dential Enquiries into Maternal Deaths in the UK.Contact 020 7467 3220; [email protected]

1-4 In the footstepsof Florence:sharing innovation,delivering solutions

Dates 10-11 March Location London Cost Early bird fee of £175+17.5%VAT before 3 January. £225+20%VAT after 3 January. Details Florence Nightingale Foundation will present on the issues facing healthcare today. Contact 01772 767782; fl [email protected]

10-11

Aquanatalcourses

Dates Aquanatal fi tness instructor (22 January), Aquanatal stage 1: introduction to teaching (12-13 February), Aquanatal stage 2: advanced teaching skills (6 March). Location Leeds Details Aquafusion is a leading provider of aquatic training. We run a programme of aquanatal courses for qualifi ed midwives. Plus pilates in pregnancy courses.Contact 01943 879816; www.aquafusion.co.uk

22 Promoting normal birthstudy day

Date 14 FebruaryLocation St Helier Hospital, SurreyCost £90 for midwives and £50 for student midwivesDetails St Helier Hospital study day for midwives and student midwives to promote normal birth using evidence-based midwifery practice. Expert midwifery speakers include RCM president Liz Stephens. Contact 020 8296 3375; [email protected]

14

RCM annualmidwifery awards2011

Dates 19 January Location Th e Royal Garden Hotel, Kensington, LondonCost Purchasing single tickets is £85+VAT, a full table of ten guests will cost £825+VAT. Shortlisted midwives will receive one complimentary place.Details Th ese awards are organised by the RCM and are designed to celebrate achievements in midwifery.Contact See: www.rcmawards.com

JANUARY 2011

19Breastfeeding specialiststudy days

Dates 4 December, 8 January, 5 February, 5 MarchLocation Rochester, KentCost £70Details Another chance to catch one or more of the oversubscribed study days without waiting for the new series to start in London in May. Full details are on the website: www.breastfeedingspecialist.comContact Deborah 01634 814275; [email protected]

DECEMBER

4 The events page

aims to inform readers

of courses relevant

to midwifery.

Only those marked ‘RCM

approved’ are accredited

by the RCM.

2010/11 EVENTS

If you would like to advertise on this page, please contact sales executive Giorgio Romano on 020 7880 7556 or email: [email protected]

RCMAPPROVED

FEBRUARY

RCMAPPROVED

RCMAPPROVED

RCMAPPROVED

RCMAPPROVED

049_mid-events.indd 53049_mid-events.indd 53 22/11/10 11:45:3822/11/10 11:45:38

CLOSEUP


9.00

am After quickly reading my emails, I meet with Lucie, one

of my PhD students, to discuss her fieldwork. These supervision sessions are always rewarding – I love seeing how students develop in confidence and ability. Lucie, a Swansea University midwifery graduate, is doing a full-time, funded PhD studentship. She is keen to combine a research career with clinical practice, a pioneering stance we’ll see more of in future.

10.00

I go over to the local hospital for a steering group meeting with

midwives, doctors and service users. This study grew out of the local midwives’ desire to investigate how women decide on mode of birth after a previous caesarean section, with the ultimate aim of increasing their VBAC (vaginal birth after caesarean) rate. It’s a lively meeting, as we discuss the fi ndings and what they might mean for practice.

12.00

pm Back to the office. I spend the next hour reviewing a midwifery

journal article. It’s interesting, but needs a few alterations before it’s ready for publication. The challenge is to give constructive feedback, so that the author feels encouraged rather than demotivated – I know how easily a negative review can knock you back.

1.00

I have a quick sandwich at the computer while I tackle my growing

email inbox, and accept an invitation to do a research presentation at Manchester University – an exciting prospect as I was a student there many years ago.

2. 00

I meet with university colleagues to discuss ideas for a research

study. We may respond to a call for proposals from one of the main UK funding bodies, but the deadline is tight. There’s no shortage of creative ideas – we just need to

mould these into a feasible and coherent study.

3.30

The meeting ends and I start my job list – contacting potential

co-applicants from across the UK, and downloading and reading a long list of research articles. The study has great potential, as it could give some important insights into UK maternity care, but competition for research funding is high and the probability of success is relatively low.

4.30

I read through my lecture notes for a research methods

session with midwifery students tomorrow. I look forward to my undergraduate teaching –the students’ interest and enthusiasm is infectious.

5.30

Time to go home, then to a yoga class, followed by some

Iolanthe Trust work and bedtime research reading!

AAAAAAAAAAAAAAAAAAAAA ttttttttttttttttyyyyyyyyyyyyyyyypppppppppppppppppiiiiiiiiiiiiiccccccccccccaaaaaaaaaaaallllllllllllll dddddddddddddddaaaaaaaaaaaaaayyyyyyyyyyyyyyyy

A day in the life of… a professor of midwifery

I became the professor of midwifery at Swansea University on 1 March 2006 – a fitting date as it was St David’s day and I’m the first midwifery professor in Wales. The main aim of my post is promoting midwifery research by conducting my own

studies and disseminating the findings, and also by supporting others to undertake research. My varied role includes teaching student midwives, supervising PhD students, and supporting clinical midwives to investigate their practice. I’m keen to make

research accessible and exciting to as many midwives as possible. I sit on many Welsh and UK committees, including the Iolanthe Midwifery Trust and the All Wales Midwifery and Reproductive Health Research Forum.

name: Billie Hunteroccupation: Professor of midwifery,

Swansea Universitylives: Swansea, Wales

050_mid_dayinlife.indd 50050_mid_dayinlife.indd 50 22/11/10 11:46:3222/11/10 11:46:32

Documents

The Magazine of The Royal College of Midwives Midwives · THE OFFICIAL MAGAZINE OF THE RCM DECEMBER 2010 MIDWIVES +(THE OFFICIAL MAGAZINE OF THE RCM CommunitiesDiscussions from the