 | P1 - Support in labour
W1 - Support in labour
It has become increasingly recognised that an important aspect of a woman’s birth experience is the impact of feeling supported, listened to and involved. The extent to which this is achieved will impact on their perception of how much control they had over the labour events and their participation in them. In contrast, some of the most negative and traumatic reports from women relate to their feelings of fear and isolation where such support has not been forthcoming. This section looks at the meaning of support in labour as part of the statutory care given by midwives within United Kingdom maternity services. It also considers the option of, and access to, additional forms of support which can help a woman to cope both physically and psychologically during labour and birth. |
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 | P2 - Fetal heart rate monitoring in labour
W2 - Listening to your baby`s heartbeat during labour
This section covers approaches to the assessment of fetal well-being in labour through the monitoring of the rate and activity of the fetal heart. The methods of listening to, and observing the rate and pattern of the fetal heart range from use of a direct aural route – ‘listening in’, usually with a Pinard stethoscope – to the use of more complex electronic and sonic devices. This section aims to explore the use of various approaches to fetal heart rate monitoring in labour and their relationship to maternal and fetal outcomes. |
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 | P3 - Routine ultrasound scans in the first half of pregnancy
W3 - Ultrasound scans - what you need to know
Most women in the UK enter pregnancy expecting to receive at least one ultrasound scan and welcome this as an opportunity to ‘see’ their baby. They do not generally view it as threatening or, indeed, as a screening test to detect possible fetal abnormalities. When ultrasound is offered to an unselected population, it is being used to ‘screen’, and because screening tests are only concerned with likelihoods, they inevitably have ‘false positives’ and ‘false negatives’. Some women will be told that there may be a problem when there is not, and some will be falsely reassured that all is well, because although a problem exists, it has not been recognised. It is in this context that health professionals should help women make an informed choice about whether or not to have a scan by ensuring they understand the purpose and limitations of scans. |
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 | P4 - Alcohol and pregnancy
W4 - Alcohol and pregnancy
There has been increasing concern over the last decade of the impact of alcohol on maternal and fetal health and well-being. This is a complex area as it involves social as well as physical and psychological issues, and therefore undertaking research can be complicated by a number of confounding factors. In addition, although there might be some immediate outcomes identified at the point of birth, the impact of exposure to inappropriate levels of alcohol are now considered to affect longer-term health and developmental outcomes. In recent years younger women and more women in general in the UK, are consuming higher quantities of alcohol. This, in combination with the traditional UK drinking pattern that is seen within both males and females, particularly high dose weekend drinking, is a cause for concern. Midwives are in a prime position to offer health care advice and support to women about alcohol intake both pre-conceptually and in pregnancy, as well as ensuring their increased awareness of its potentially harmful effects. |
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 | P5 - Positions in labour
W5 - Positions for labour and birth
Any human being when faced with pain, discomfort and unfamiliar experiences, will instinctively adopt the position from which they derive the most comfort and relief. In the context of childbirth, it could be argued that there is a primeval urge to adopt a position which relieves the pain of labour contractions; this can be in any location and involve a range of positions. This section is about facilitating choice for women where they may wish to adopt a variety of positions during their labour and birth. In this section the research evidence is presented where it informs the current knowledge base. This means that some papers are cited which are now over 20 years old. These studies were undertaken at a time when the idea of not lying down on a bed during labour was considered to be a significantly new concept, but within the context of practice at that time, still have much to offer. |
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 | P6 - The use of epidural analgesia for women in labour
W6 - Epidural pain relief in labour
The degree to which individuals can tolerate pain varies considerably and is affected by a number of diverse physiological and psychological factors. This section is about the use of epidural analgesia, a method of blocking the painful stimuli from the contracting uterus, enabling a labouring woman to be pain-free. While an epidural is the most effective technique for relieving pain in labour, it is also one of the most invasive methods. Given the technical nature of the procedure, those supporting her need to be able to explain the advantages and disadvantages of having an epidural and what the procedure entails, in language that will be understandable to the woman and her partner. It is only where this can be achieved that the woman can give her informed consent to proceed. |
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 | P7 - Breastfeeding or bottle feeding
W7 - Feeding your baby - breast or bottle?
The World Health Organization (WHO) recommends that mothers’ exclusively breastfeed for the first six months of their baby’s life, and continue breastfeeding for two years or more. However, in practice, many women decide not to; instead, choosing to replace breast milk with commercial or other substitutes commonly using formula milks. Formula milks and bottle feeding equipment are not only an added expense but are known to carry increased risk for infections and other illnesses, and in rare cases, even mortality. This section is written in a context that respects and supports a mother’s choice in how she wishes to feed her baby, while being supportive of babies receiving breast milk wherever this is possible. It outlines the advantages and disadvantages of breast and bottle feeding so that health professionals can access summarised reliable information that will enable them to support women to make the right choices for themselves and their babies. |
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 | P8 - Antenatal screening for congenital abnormalities: helping women to choose
W8 - Is my baby alright?
Between 2-3% of babies are born in England and Wales with a major congenital anomaly as defined by the International Code of Diseases. These include simple structural defects, errors of metabolism, hereditary diseases and chromosomal abnormalities. Antenatal screening for congenital abnormalities is an integral component of routine antenatal care, and screening tests should be offered to all pregnant women in the UK. The range and format of these tests are continually changing as advances in medical technology strive to improve reliability and increase the capacity to determine new tests for conditions not yet screened for. Screening tests during pregnancy help to identify those women at an increased chance of having an affected pregnancy using biochemical or ultrasound markers, or a combination of both methods. The screening tests themselves do not put the pregnancy at any risk; however, they can impact significantly on the emotional and psychosocial aspects of pregnancy and should not be viewed in isolation but as part of a holistic screening, diagnostic and treatment programme. Choosing whether to embark on the screening journey is an important decision for women and their families and health professionals need to be adequately informed and knowledgeable about all aspects of the screening process in order to facilitate informed choice and support the decisions made. |
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 | P9 - Breech presentation
W9 - If your baby is in the breech position, what are your choices?
Breech presentation is common before 37 weeks’ gestation with a suggested incidence of 15% at 29-32 weeks’ gestation, reducing to between 3-4% at term. Identification of a breech presentation has different implications depending on the gestation of the pregnancy and whether onset of labour is spontaneous. The care and support of women with a breech presentation is one of the more complex areas for midwifery input. This section aims to explore the existing evidence base, the care options for women with a diagnosed breech presentation, and their choices for the birth. The main focus of this information is the options for women with regard to the management of breech presentation at term; however, a short section about preterm management is included at the end. |
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 | P10 - Place of birth
W10 - Where will you have your baby?
Birth is generally very safe for both women and babies, with perinatal mortality rates of 7.9 per 1000 births in 2006. According to recent National Institute for Health and Clinical Excellence (NICE) guidelines, women should be offered the choice of planning birth at home, in a midwifery unit or in an obstetric unit, although the available research information on planning place of birth is generally not of good quality. This section describes the choices women are able to make about where to have their baby. It sets out national policies about choices that should be offered to women and includes evidence about safety, levels of intervention and how women feel about different birth settings. |
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 | P11 - The use of water during childbirth
W11 - Do you want a waterbirth?
Since the early 1980s use of immersion in water during labour and birth has been increasingly promoted to enable women to relax, help them cope with the pain from uterine contractions, and maximise their feelings of control and satisfaction throughout the birth process. Water use ranges from informal, for example, when a woman in early labour decides to get into her bath at home before going to hospital, to formal use in a specially designed birthing pool. Informal use in a domestic bath or shower is often initiated by a woman herself to help her cope at home before labour is well established. Formal use implies either that a woman has actively chosen to use water as part of her plan for labour and/or childbirth or that a health professional, usually a midwife, has raised this option |
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 | P12 - Prolonged pregnancy
W12 - When your baby is overdue
The estimated due date (EDD) of a woman’s pregnancy has considerable social and emotional significance where it enables the woman, her partner and family to prepare for the birth of the baby. It also has significance for midwives, obstetricians and neonatologists who use the EDD to estimate key stages of fetal development and to assess fetal well-being. Where a pregnancy continues beyond term; the risk of perinatal morbidity and mortality increases slightly, although the overall risk remains low. Given the risks associated with prolonged pregnancies, which are considered to be avoidable, there has been increased attention to their management with the use of interventions to stimulate the onset of labour or to expedite the birth. Therefore, in order to be able to make an informed choice, women need to receive information about the possible risks to their own health and that of the baby where the pregnancy is prolonged. They also need information about what approaches can be used to induce labour and the risks associated with these methods as well as the risks associated with continuing the pregnancy in the expectation that labour will start spontaneously. This section explores the current situation with regard to the management of pregnancy where it extends beyond the 42nd week and includes aspects of monitoring maternal and fetal health and well-being and the approaches to induction of labour. |
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 | P13 - Diet and nutrition during pregnancy
W13 - Eating well - for your baby and for you
A healthy diet during pregnancy has been an important aspect of antenatal health promotion for many years. Advice initially centred more on maternal energy intake and weight gain, but recent interest has focused on improving the quality of the maternal diet, and advice and health policies that address increasing concerns about obesity. This shift arises out of a growing body of research into the effects of maternal nutritional status, before and during pregnancy, on the development and growth of the fetus and upon subsequent morbidity and mortality in childhood and adult life. This section looks at the research evidence around diet and nutrition in pregnancy, and the general principles of a healthy diet and its relevance to favourable pregnancy outcome. It considers how pregnancy increases a woman’s nutritional requirements and how certain nutrients may have an impact on pregnancy outcome and on longer-term health. The dietary requirements of specific population groups who may be more vulnerable to inadequate nutritional intake are considered, as well as the effectiveness of intervention strategies to improve nutritional status. There is also guidance on general food safety; this should be read in conjunction with the section Screening and management of infectious diseases. |
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 | P14 - Non-epidural strategies for pain relief during labour
W14 - Non-epidural pain relief
The element that best predicts a woman’s experience of labour pain is her level of self-confidence in her ability to cope with labour. Where the labouring woman copes well, even when her contractions are at their most intense, self-satisfaction, fulfilment, and a sense of accomplishment are most often reported, and the negative effects of ‘suffering’ with pain, are often felt to have been reduced. Women’s expectations of labour as a whole (eg their involvement in decision making and care given) appear to be of more importance to their overall satisfaction with their labour experience than the perceived effectiveness of pain management. Therefore, introducing effective strategies for coping with the pain of labour is a key component of intrapartum care. It is, however, very clear that no single method for coping with the pain of labour and childbirth will meet the needs of every labouring woman. This section presents the available scientific evidence on the effectiveness, advantages and disadvantages associated with various forms of non-epidural pain relief. |
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 | P15 - Health and care after childbirth
W15 - Caring for yourself and feeling well after you have had your baby
Although pregnancy is described as a normal health event for a woman, various outcomes associated with the pregnancy, the birth and health of the newborn child influence the short and longer-term health outcomes of women after pregnancy. While ‘recovery’ may have connotations of ill health, in this context, the birth event and the challenges of the first few weeks of motherhood, suggest that this is a period where many adjustments need to be made in order to return to what each woman considers was their normal, pre-pregnant level of physical and mental health. This section looks at the major obstacles facing women after childbirth with regard to physical recovery and social adaptation to motherhood and the role of the midwife and other health carers who offer support and advice over this period, in order to reduce morbidity and achieve the best possible physical and psychological health outcomes. The more specific psychological health aspects are covered in the Informed Choice section on Postnatal depression. |
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 | P16 - Mode of delivery and events around the second stage of labour
W16 - How will your baby be born?
For most women, pregnancy, labour and birth are normal physiological events in their life cycle. Where labour is allowed to occur naturally it will usually be followed by a spontaneous vaginal birth. However, with the increasing use of interventions and rising caesarean section rates in many units, there is evidence of a downward trend in the number of women realising this. Whether a baby is born vaginally (spontaneously or as an assisted birth), or by lower segment caesarean section (LSCS) will depend on a number of factors. This section provides practitioners with an introduction to some of these factors, and the research and evidence to support discussions with women when exploring the most appropriate mode of delivery for their baby’s birth. Additionally, it will explore the implications for midwifery practice where there is a renewed focus on normality, but also recognition of the changing profile of the midwife in supporting the underlying medical and social needs of pregnant women and their families. |
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 | P17 - Caesarean section and VBAC (Vaginal birth after caesarean)
W17 - Caesarean section and subsequent births
Caesarean section is the commonest major operation performed on women worldwide. Women are over four times more likely to have a caesarean birth now than they were thirty years ago. In 1973 the estimated caesarean rate for England and Wales was 5.3% and latest data show a rate for Britain in 2005/6 of almost 25%. Sixty years ago, mortality following caesarean section was much higher than following vaginal delivery, because of infection, thrombosis and anaemia. The improved safety of surgery with modern anaesthetic techniques, the availability of antibiotics and of blood transfusion has meant that caesareans are safer than they were. Thus, obstetricians, when balancing the risks, have a stronger case for undertaking surgery, even though there is still a significant maternal mortality and morbidity rate following caesarean section. Women who receive adequate information about caesarean birth prior to experiencing it are better prepared and have a more rewarding experience overall. Therefore women need to be appropriately informed and prepared during their pregnancy for the possibility of caesarean birth within the context of potential risk versus normality. |
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 | P18 - Vitamin K – the debate and the evidence
W18 - Vitamin K for your baby
The development of the condition haemorrhagic disease of the newborn (HDN) was first recognised over 100 years ago when it was noted to be associated with a high mortality rate. The relationship between this condition and low levels of vitamin K was then identified in the late 1920s and the use of prophylactic administration of vitamin K was seen to effectively reduce the numbers of deaths from HDN. However, from that point, administration of vitamin K to neonates has had a rather chequered history and although there has been interest in, and concern over, the role of vitamin K and the health of young babies for over 30 years, there remains considerable debate about its use, and particularly the route of administration. The information presented in this section is a synthesis of that debate and how it links to the recommendations for practice based on current government policy. As such, it should be seen as a framework for health care professionals to help parents in their understanding of this complex area so that they can make choices about their baby’s health based on the best information currently available. |
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 | P19 - Prophylactic anti-D for Rhesus negative women
W19 - Information for women who are Rhesus negative
Within the general population, 84% of people are Rhesus positive, leaving around 16% of people as Rhesus negative. As a baby inherits its blood type from both parents, the RhD negative mother can be carrying a baby who is RhD positive - approximately 10% of all births per year are estimated to be Rhesus positive babies born to Rhesus negative mothers. The main concern in pregnancy is where there is contact between the blood of the Rhesus negative mother and the blood of the Rhesus positive fetus (an event called feto-maternal haemorrhage or FMH). The presence of fetal RhD positive cells in the maternal circulation can initiate an immune response when there is future contact with the Rhesus antigen. This sensitisation or isoimmunisation then results in the production of antibodies against the RhD antigen (anti-D antibodies). This section gives information about the Rhesus factor, its relevance to pregnancy, fetal well-being and childbirth and the current strategies available to reduce potential fetal and neonatal morbidity and mortality. |
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 | P20 - Postnatal depression
W20 - Mood changes after childbirth
The transition to parenthood is a time when familiar and routine patterns of life style can become disrupted by the arrival of a new baby. For women in particular, the fundamental changes and responsibilities that motherhood brings can challenge their self concept, and have the potential to be detrimental to both emotional and psychological well-being. A woman’s pregnancy and puerperium are critical times of psychological adjustment and there is growing evidence that a woman’s mental health state during these periods influences obstetric outcomes, as well as the future development of her infant. It is therefore important to accurately identify women who are at risk of developing mental illness, as well as, those already suffering from mental health disorders This section focuses on postnatal depression (PND) and the current screening tools, signs, symptoms and management of PND are presented alongside the latest research evidence into the effectiveness of a range of treatments. |
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 | P21 - Sickle cell and thalassaemia disorders: screening offered to mothers and babies
W21 - Sickle cell and thalassaemia disorders: screening offered to mothers and babies
Haemoglobinopathies are genetically inherited disorders of the haemoglobin. They mainly affect individuals who have originated from Africa, Asia, the Caribbean, the Middle East, and the Mediterranean, but because of migration and subsequent integration may now affect any ethnic group. The pattern of inheritance for haemoglobin disorders is autosomal recessive; therefore, if both parents are carriers (inheritance of one abnormal haemoglobin gene; heterozygous) there is a 1:4 (25%) risk in each pregnancy of the child inheriting a major haemoglobin disorder. There are two types of haemoglobin disorders categorised as qualitative or quantitative mutations (alterations) of the globin chains in the haemoglobin molecule. Quantitative disorders, thalassaemias, affect the quantity of haemoglobin produced. Qualitative disorders affect the quality of haemoglobin produced and there are a large number of clinically insignificant haemoglobin variants (types). The significant haemoglobin variants are haemoglobin S (sickle), C, D (Punjab), E and O (Arab). Screening for sickle cell and thalassaemia, like other antenatal screening tests, should provide women and their partners with sufficient information regarding the screening test to make an informed choice. |
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 | P22 - Sexual health and contraception
W22 - Sexual health and contraception before and after childbirth
It could be suggested that society in general is uncomfortable about sex and sexuality and health professionals too can find this a difficult area of their practice. Sexual health is of lifelong relevance, especially with regard to the ability to conceive and sustain a pregnancy, as well as the avoidance of adverse health outcomes for the fetus. Rising rates of sexually transmitted infections (STIs) and new cases of HIV have significant implications for those being diagnosed and for onward transmission, particularly so where these are women in the reproductive age group.
Traditionally, contraceptive advice within the UK has been offered in the initial first few days following the birth, but it is questionable whether this is appropriate timing, both from the perspective of the health care professional, as well as the woman herself. The specific suitability of any contraceptive method will depend on whether or not a woman is breastfeeding and whether there are any concerns relating to her previous medical history, family medical history and inherited disorders, as well as any ongoing health problems. |
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 | P23 - Anaemia in pregnancy, birth and afterwards
W23 - Anaemia - preventing, detecting and treatment in pregnancy and beyond
Globally, estimates of the prevalence of anaemia in pregnancy range from an average of 56 per cent in developing countries, to 18-25 per cent in industrialised countries, however, the actual prevalence is difficult to ascertain. The WHO defines anaemia in pregnancy as an Hb value below 11 g/dl, which is the level used in the UK, however there is considerable controversy around this value and it often depends on where the women started at the beginning of pregnancy. After excluding genetic factors, chronic blood loss, underlying malignancies and parasitic infestation, iron deficiency is the most common cause of anaemia worldwide, with women in the reproductive years of their life being the most susceptible group due to menstrual blood loss. In the UK, the current recommendation for the management of anaemia in pregnancy is to offer all pregnant women screening to assess their Hb level. If iron deficiency anaemia is diagnosed, this approach enables health professionals to discuss any implications with the woman within a sufficient timeframe to help her consider the available options and, where necessary, offer appropriate treatment ahead of her baby’s birth. This section discusses the appropriate screening tests for anaemia as part of routine care, and the management of iron deficiency anaemia in pregnancy and afterwards. |
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 | P24 - Screening for infectious diseases in pregnancy
W24 - Infections in pregnancy - prevention, detection and treatment
The range of infectious diseases that can occur during pregnancy, as throughout life, is very diverse. Most pregnant women are generally healthy and therefore they may be relatively unaffected systemically and be unaware that they have contracted an infection. The outcomes for infectious disease range from fairly minor and short-lived discomfort to serious complications for the mother in pregnancy and postpartum as well as to the developing fetus or neonate. Therefore, it is the detection and management of infectious diseases, especially during the early stages of pregnancy, which may prevent or minimise the occurrence of adverse consequences for fetal development and well-being in the presence of intrauterine or neonatal infection. The UK National Screening Committee (UK NSC) sets out guidance on policies to detect the most common and important infections which can seriously affect mainly fetal well-being. However, alongside the national screening programmes, it is important that both health care professionals and women are aware of a range of other infections that have an impact on neonatal outcomes but which are not covered by any form of routine screening. This section aims to raise awareness of the initial information needed to recognise the importance of certain signs of infection in order to refer appropriately and at the earliest opportunity. |
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 | P25 - Achieving optimal health for parenthood
W25 - Health for parenthood - practical advice on how to maintain a healthy lifestyle for you and your baby
The National Service Framework for Maternity Services (NSF) identifies that all prospective parents need easy access to information that will help them to prepare for a healthy pregnancy and birth. However, optimum health for parenthood depends on a number of factors. Pre-conceptual awareness may help women to choose when to become pregnant and how best to achieve a healthy pregnancy, including recognition of the adjustments they might need to make to their lifestyle. Pregnancy has been recognised as a ‘window of opportunity’ with regard to health promotion and education and it has been identified that prospective parents are often more willing to make health behaviour and lifestyle changes to ensure the health and well-being of their developing baby. Pre-pregnancy counselling, which may include specialist genetic services, can also be useful for women and their partners who might consider themselves to be at higher risk for fetal abnormalities. This section reviews aspects of physical and psychological health and social and environmental factors, which may have some impact on male and female fertility and ability to conceive, fetal development, maintenance of the pregnancy, and ultimately, the longer-term health of the nation’s children. |