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Access to water immersion for labour and birth during the pandemic: an opinion piece

During the final year of the Bachelor of Midwifery at Griffith University, midwifery students are asked to write an opinion piece focussed on normal birth that could be published. Dr Jyai Allen convenes this course and supported the students to complete this work. Several of these were of such good quality that we offered students the option of having them published here. This is the first of four articles in a series. The author of this article preferred to publish anonymously. 

Access to water immersion for labour and birth during the pandemic: an opinion piece

There is no denying that COVID-19 has completely changed the world (United Nations Children’s Fund, 2020). Many populations have been unequally disadvantaged by the global pandemic, including childbearing women (Gausman & Langer, 2020). It has been a period of heightened anxiety as new policies aimed at flattening the curve have limited women’s birth preferences and choices (Australian College of Midwives [ACM], 2020a). This includes the Royal Australian and New Zealand College of Obstetrics and Gynecology (RANZCOG) recommendation to suspend the use of water immersion for all labouring women within COVID-19 hotspots (ACM, 2020a). Whilst staunchly opposed by ACM (2020a), this position statement has been adopted by health services across the nation including the Department of Health and Human Services [DHHS] in Victoria (2020). The topic is controversial as the suspension of access to water immersion is not supported by evidence (Centres for Disease Control [CDC], 2020a) and devalues a woman’s autonomy and right to self-determination.

Midwives have a professional obligation to advocate for evidence-based practices that empower women and promote normal birth. Water immersion during labour is associated with positive outcomes and should be available to all low-risk women who are presumed or confirmed COVID-19 negative.

Arguments for the suspension

Let us consider the evidence for suspending water immersion in the context of a woman with a confirmed positive COVID-19 test result. The rationale behind RANZCOGs recommendation was the protection of healthcare workers (ACM, 2020a; 2020b). Concerns have been raised regarding the level of protection provided by personal protective equipment when immersed in water (DHHS, 2020; Royal College of Midwives [RCM], 2020). It was also believed the moist atmosphere of the birth pool room could increase the risk of droplet transmission (RCM, 2020).

Some evidence contradicts this viewpoint, however, finding the virus is less likely to be transmitted in humid environments (Qi et al., 2020). Given that COVID-19 is not a waterborne virus, it is believed that liquid may dilute contamination and therefore reduce the potential risk of transmission (ACM, 2020a). Another potential benefit from water immersion is that the birth pool aids in physical distancing by providing a barrier between women and care providers (Burns et al., 2020; Ulfsdottir et al., 2018).

Another concern that was raised was faecal-oral transmission of COVID-19 within a birth pool. While some studies suggest the virus can be transmitted through faeces (Wang et al., 2020; Zhang et al., 2020a), there has been no evidence of faecal-oral transmission to date (World Health Organization, 2020). Some argued that if faeces were highly contagious for COVID-19, healthcare workers would be at greater risk during land birth as the particles are not diluted (ACM, 2020a). So while water immersion has been framed as posing a risk to clinical staff, women and babies; there is limited evidence to suggest it is easily spread to humans through birth pools (CDC, 2020a).

Benefits of water immersion

It is important to recognise the known benefits of water immersion during labour and for birth. Water immersion facilitates positive birth experiences (Cooper & Warland, 2019; Lathrop et al., 2018; Neiman et al., 2019). When immersed in water during labour, women have increased feelings of empowerment and experience a greater sense of privacy, safety, control and focus (Fair et al., 2020; Ulfsdottir et al., 2018). It is also an effective pain management method which can help to avoid a cascade of intervention and therefore promotes normal birth practices (Cluett et al., 2018). Women who were prevented from accessing water immersion as a consequence of their COVID-19 status would not access these benefits. The arbitrary decision to suspend water immersion for all labouring women is consistent with historical practices in maternity care that value subjectivity over evidence-based recommendations (Cooper et al., 2017).

What the suspension really represents

It can be assumed that broader socio-cultural factors have influenced RANZCOGs recommendation. RANZCOG is an obstetric organisation that aligns itself with the technocratic model of care and values surveillance, intervention, and hierarchy (Davis-Floyd, 2001). This is demonstrated by their staunch and public opposition to practices such as homebirth – which is discussed in the context of obstetric outcomes and perinatal mortality (Licqurish & Evans, 2015).

RANZCOGs position statement on water immersion is similar. By standardising institutional practices and banning all women from using water immersion, the individual needs of women are deemed unimportant. Consequently, these clinicians retain their position at the top of the organisation’s hierarchy (Davis-Floyd, 2001). The recommendation represents authority and responsibility inherent in the healthcare provider, not the woman –  as the woman’s personal preferences are disregarded by the institution (Davis-Floyd, 2001).

Loss of choice and failing to make decisions in partnership with women may also add to women’s feelings of stress and anxiety (Jago et al., 2020). This further impacts normal birth outcomes as women are passive in decision-making and do not challenge recommended practices (Carolan- Olah et al., 2015). The prohibition of water immersion also fails to demonstrate a holistic approach to care as the social and emotional needs of women are neglected (Jago et al., 2020) during a period in history that has elevated anxiety and depression amongst pregnant women (Lebel et al., 2020).

Medicalisation of childbirth also likely influenced the decision to suspend water immersion. An obstetric approach views water immersion as inherently risky and therefore requires medical management (Licqurish & Evans, 2016; Milosevic et al., 2019). This is demonstrated by RANZCOGs recommendations for water immersion statement (2017) which focuses on rigorous protocols, exclusion criteria, and obstetric emergency drills. Their value of a medicalised approach is also apparent when considering that they have not recommended suspending the use of nitrous oxide for all labouring women (RANZCOG, 2020c), despite posing a higher risk of contracting COVID-19 through droplet or aerosol transmission (ACM, 2020a; CDC, 2020b).

The influence of medicalisation is even more obvious in the recommendation to site an epidural early in labour, in case an emergency caesarean section becomes ‘indicated’ (DHHS, 2020). This practice has been adopted by Barwon Health, along with the recommendation of continuous fetal heart rate monitoring, should a woman be suspected of COVID-19 (2020). Normal birth outcomes then become even more difficult to achieve as interventions such as instrumental birth are increased (Alfirevic et al., 2017).

To affect any sort of change, it is important for midwives to gain confidence in water immersion (Plint & Davis, 2016). Lack of training creates a workplace culture where water immersion is feared (Klein et al., 2011). Consequently, medicalised approaches are promoted as midwives do not feel confident advocating for normal birth practices.

The media also plays a pivotal role in the depiction of childbirth, often shaping public opinion irrespective of evidence (Petrovska et al., 2017). Normal birth practices are vastly underrepresented, with childbirth often portrayed as medicalised and risky (Luce et al., 2016). Commonly associated with fear, pain and intervention, high-impact dramatic stories are more often depicted in the media rather than calm, normal births (Maclean, 2014). Media portrayals will influence women’s perceptions of water immersion given that two out of three women source information from the media instead of their healthcare provider (Carlsson & Ulfsdottir, 2020). Combined with media coverage on COVID-19, it is no wonder water immersion is scarcely supported. As women become fearful of childbirth, they are disempowered to advocate for normal birth practices (Plint & Davis, 2020). It is imperative for midwives to support women in making informed choices to ensure their decisions are not influenced by fear perpetuated by the media
(Jago et al., 2020).

How do we move forward?

Maintaining the health and safety of women, babies, and healthcare workers is paramount.

Measures can be taken to minimise the potential risk of COVID-19 transmission whilst still promoting normal birth practices. Screening women for COVID-19 and fast-track testing will inform care management more accurately (RCM, 2020). Individualised risk assessments should be undertaken and midwives should demonstrate effective clinical decision making (RCM, 2020). Being up-to-date with infection control practices would be supportive (Liang & Archarya, 2020; Public Health England, 2020) along with access to appropriate personal protective equipment (RCM, 2020). Burns et al. (2020) found wearing long gauntlet gloves that are one size too small can improve the seal when immersed in water. Maintaining proper cleaning and hygiene practices reduces the risk of transmission (ACM, 2020a) as well as removing faecal matter should it contaminate the water (Gu et al., 2020).

Empowering women to guide their babies into the world while immersed in water facilitates physical distancing practices (RCM, 2020). This would be supported by antenatal education as it  instills confidence and allows women to engage in their care (ACM, 2020a; Milosevic et al., 2019; Plint & Davis, 2016). Arguably the most important factor, is that midwives must be trained in water immersion. This will ensure competence and develop a workplace culture that supports normal birth practices (Nicholls et al., 2016). Midwives should also engage in respectful conversations that promote midwifery care by challenging practices that are deemed unnecessary or not based on evidence.

In summary

Midwives have a professional obligation to protect choices for women and promote normal birth practices (ACM, 2020b). Water immersion should be available to all women. RANZCOGs recommendation is not based on evidence and has been influenced by technocratic ideologies. As gatekeepers to normal birth, midwives are in a powerful position to influence maternity reform and must continually advocate for evidence-based practices to ensure women are supported throughout their childbearing journey (McIntyre et al., 2012).

References

Alfirevic, Z., Gyte, G., Cuthbert, A., & Devane, D. (2017). Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database of Systematic Reviews, (5), 1-141. https://dx.doi.org/10.1002/14651858.CD006066.pub3

Australian College of Midwives. (2020a). ACM’s updated position on use of water in labour. https://www.midwives.org.au/news/acm-s-updated-position-use-water-labour

Australian College of Midwives. (2020b). Midwifery philosophy and values. https://www.midwives.org.au/midwifery-philosophy-values

Barwon Health. (2020). COVID-19 (coronavirus) and pregnancy.
https://www.barwonhealth.org.au/maternity-services/component/zoo/item/covid-19- coronavirus-and-pregnancy

Burns, E., Cooper, M., Feeley, C., Hall, P., Roehr, C., & Venderlaan. (2020). Coronavirus COVID-19: Supporting healthy pregnant women to safely give birth. https://www.brookes.ac.uk/WorkArea/DownloadAsset.aspx?id=2147622699

Carlsson, T., & Ulfsdottir, H. (2020). Waterbirth in low‐risk pregnancy: An exploration of women’s experiences. Journal of Advanced Nursing, 76(5), 1221-1231. https://dx.doi.org/10.1111/jan.14336

Carolan-Olah, M., Kruger, G., & Garvey-Graham, A. (2015). Midwives׳ experiences of the factors that facilitate normal birth among low risk women at a public hospital in Australia. Midwifery, 31(1), 112-121. https://dx.doi.org/10.1016/j.midw.2014.07.003

Center for Disease Control. (2020a). Coronavirus Disease 2019 (COVID-19) [Topic: Pools, Hot Tubs, and Water Playgrounds]. https://www.cdc.gov/coronavirus/2019- ncov/faq.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2 019-ncov%2Fphp%2Fwater.html#COVID-19-and-Water

Center for Disease Control. (2020b). How COVID-19 Spreads. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/how-covid- spreads.html

Cluett, E., Burns, E., & Cuthbert, A. (2018). Immersion in water during labour and birth. Cochrane Database of Systematic Reviews, (6), 1-171. https://dx.doi.org/10.1002/14651858.cd000111.pub4

Cooper, M., McCutcheon, H., & Warland, J. (2017). A critical analysis of Australian policies and guidelines for water immersion during labour and birth. Women and Birth, 30(5), 431-441. https://dx.doi.org/10.1016/j.wombi.2017.04.001

Cooper, M., & Warland, J. (2019). What are the benefits? Are they concerned? Women’s experiences of water immersion for labor and birth. Midwifery, 79, 102541-102551. https://dx.doi.org/10.1016/j.midw.2019.102541

Davis-Floyd, R. (2001). The technocratic, humanistic, and holistic paradigms of childbirth. International Journal of Gynecology and Obstetrics, 75(1), 5-23. https://dx.doi.org/10.1016/S0020-7292(01)00510-0

Department of Health and Human Services. (2020). Maternity and neonatal care during coronavirus (COVID-19). https://www.dhhs.vic.gov.au/covid-19-maternity-and-neonatal- care-during-coronavirus

Fair, C., Crawford, A., Houpt, B., & Latham, V. (2020). “After having a waterbirth, I feel like it’s the only way people should deliver babies”: The decision-making process of women who plan a waterbirth. Midwifery, 82, 102622-102628. https://dx.doi.org/10.1016/j.midw.2019.102622

Gausman, J., & Langer, A. (2020). Sex and gender disparities in the COVID-19 pandemic. Journal of Women’s Health, 29(4), 465–466. https://dx.doi.org/10.1089/jwh.2020.8472

Gu, J., Han, B., & Wang, J. (2020). COVID-19: Gastrointestinal manifestations and potential fecal-oral transmission. Gastroenterology, 158(6), 518-519. https://dx.doi.org/10.1053/j.gastro.2020.02.054

Jago, C., Singh, S., & Moretti, F. (2020). Coronavirus disease 2019 (COVID-19) and pregnancy: Combating isolation to improve outcomes. Obstetrics and Gynecology, 136(1), 33-36. https://dx.doi.org/10.1097/AOG.0000000000003946

Klein, M., Liston, R., Fraser, W., Baradaran, N., Hearps, S., Tomkinson, J., Kaczorowski, J., & Brant, R. (2011). Attitudes of the new generation of Canadian obstetricians: How do they differ from their predecessors? Birth, 38(2), 129-139. https://dx.doi.org/10.1111/j.1523- 536x.2010.00462.x

Lathrop, A., Bonsack, C., & Haas, D. (2018). Women’s experiences with water birth: A matched groups prospective study. Birth, 45(4), 416-423. https://dx.doi.org/10.1111/birt.12362

Lebel, C., MacKinnon, A., Bagshawe, M., Tomfohr-Madsen, L., & Giesbrecht, G. (2020). Elevated depression and anxiety symptoms among pregnant individuals during the COVID-19 pandemic. Journal of Affective Disorders, 277, 5-13. https://dx.doi.org/10.1016/j.jad.2020.07.126

Liang, H., & Acharya, G. (2020). Novel coronavirus disease (COVID‐19) in pregnancy: What clinical recommendations to follow? Acta Obstetricia et Gynecologica Scandinavica, 99(4), 439-442. https://dx.doi.org/10.1111/aogs.13836

Licqurish, S., & Evans, A. (2016). ‘Risk or Right’: A discourse analysis of midwifery and obstetric colleges’ homebirth position statements. Nursing Inquiry, 23(1), 86-94. https://dx.doi.org/10.1111/nin.12111

Luce, A., Cash, M., Hundley, V., Cheyne, H., van Teijlingen, E., & Angell, C. (2016). “Is it realistic?” the portrayal of pregnancy and childbirth in the media. BMC Pregnancy and Childbirth, 16(1), 40. https://dx.doi.org/10.1186/s12884-016-0827-x

Maclean, E. (2014). What to expect when you’re expecting? Representations of birth in British newspapers. British Journal of Midwifery, 22(8), 580-588. https://dx.doi.org/10.12968/bjom.2014.22.8.580

McIntyre, M., Francis, K., & Chapsman, Y. (2012). Primary maternity care reform: Whose influence is driving the change?. Midwifery, 28(5), 705-711. https://dx.doi.org/10.1016/j.midw.2011.08.004

Milosevic, S., Channon, S., Hunter, B., Nolan, M., Hughes, J., Barlow, C., Milton, R., & Sanders, J. (2019). Factors influencing the use of birth pools in the United Kingdom: Perspectives of women, midwives and medical staff. Midwifery, 79, 102554-102561. https://dx.doi.org/10.1016/j.midw.2019.102554

Neiman, E., Austin, E., Tan, A., Anderson, C., & Chipps, E. (2019). Outcomes of waterbirth in a US hospital‐based midwifery practice: A retrospective cohort study of water immersion during labor and birth. Journal of Midwifery & Women’s Health, 65(2), 216-223. https://dx.doi.org/10.1111/jmwh.13033

Nicholls, S., Hauck, Y., Bayes, S., & Butt, J. (2016). Exploring midwives’ perception of confidence around facilitating water birth in Western Australia: A qualitative descriptive study. Midwifery, 33, 73-81. https://dx.doi.org/10.1016/j.midw.2015.10.010

Petrovska, K., Sheehan, A., & Homer, C. (2017). Media representations of breech birth: A prospective analysis of web‐based news reports. Journal of Midwifery & Women’s Health, 62(4), 434-441. https://dx.doi.org/10.1111/jmwh.12609

Plint, E., & Davis, D. (2016). Sink or Swim: Water immersion for labor and birth in a tertiary maternity unit in Australia. International Journal of Childbirth, 6(4), 206-222. https://dx.doi.org/10.1891/2156-5287.6.4.206

Public Health England. (2020). COVID-19: infection prevention control guidance. https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection- prevention-and-control

Qi, H., Xiao, S., Shi, R., Ward, M., Chen, Y., Tu, W., Su, Q., Wang, W., Wang, X., & Zhang, Z. (2020). COVID-19 transmission in Mainland China is associated with temperature and humidity: A time-series analysis. Science of the Total Environment, 728, 138778. https://dx.doi.org/10.1016/j.scitotenv.2020.138778

Royal Australian and New Zealand College of Obstetricians and Gynaecologists. (2017). Warm water immersion during labour and birth. https://ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG- MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical- Obstetrics/Warm-water-immersion-during-labour-and-birth-(C-Obs-24)-Review-July- 2017.pdf?ext=.pdf

Royal Australian and New Zealand College of Obstetricians and Gynaecologists. (2020a). COVID-19: Protection of midwives and doctors in the birth unit. https://ranzcog.edu.au/news/covid-19-protection-of-midwives-and-doctors-in-th

Royal Australian and New Zealand College of Obstetricians and Gynaecologists. (2020b). RANZCOG statement. https://ranzcog.edu.au/news/ranzcog-statement

Royal Australian and New Zealand College of Obstetricians and Gynaecologists. (2020c). A message for pregnant women and their families. https://ranzcog.edu.au/statements- guidelines/covid-19-statement/information-for-pregnant-women

Royal College of Midwives. (2020). RCM Professional briefing on waterbirths for women without symptoms during the COVID-19 pandemic. https://www.rcm.org.uk/media/4034/rcm-professional-briefing-on-waterbirth-in-the- time-of-covid-v-3-7-may-2020.pdf

Ulfsdottir, H., Saltvedt, S., Ekborn, M., & Georgsson, S. (2018). Like an empowering micro- home: A qualitative study of women’s experience of giving birth in water. Midwifery, 67, 26-31. https://dx.doi.org/10.1016/j.midw.2018.09.004

United Nations Children’s Fund. (2020). How COVID-19 is changing the world. https://data.unicef.org/resources/how-covid-19-is-changing-the-world-a-statistical-perspective/#

Wang, J., Tang, K., Feng, K.,; Li, X., Lv, W., Chen, K., & Wang, F. (2020). High temperature and high humidity reduce the transmission of COVID-19. Centre for Evidence- Based Medicine. https://www.cebm.net/study/covid-19-high-temperature-and-high- humidity-reduce-the-transmission-of-covid-19/

World Health Organization. (2020). Modes of transmission of virus causing COVID-19: Implications for IPC precautions and recommendations. https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus- causing-covid-19-implications-for-ipc-precaution-recommendations

Zhang, Y., Chen,C., Zhu, S., Shu, C., Wang, D., Song, J., Song, Y., Zhen, W., Feng, Z., Wu, G., Xu, J., & Xu, W. (2020). Isolation of 2019-nCoV from a stool specimen of a laboratory- confirmed case of the coronavirus disease 2019 (COVID-19). China CDC Weekly, 2(8), 123-124. http://weekly.chinacdc.cn/en/article/doi/10.46234/ccdcw2020.033

Does intrapartum CTG monitoring save lives?

Dr Kirsten Small is a project lead with the Transforming Maternity Care Collaborative. Yesterday she delivered the closing keynote address at the GOLD Obstetric Conference, speaking about why it is so difficult to align clinical practice with the research evidence. Kirsten hosts the Birth Small Talk blog and her post today reviews the research evidence she summarised in her address. She has kindly shared it here as well. 

If you are interested in pursuing research relating to the use of fetal heart rate monitoring in labour please connect with us via our contact form

 

Today’s post examines the research evidence about CTG monitoring with regards to stillbirth and neonatal death. This is a deep dive for my fellow data geeks who like to read the fine print, not the executive summary. The short version is – no. Using a CTG to monitor a woman in labour doesn’t prevent the death of her baby. If you are keen to know the details, read on!

Intrapartum CTG monitoring in low risk populations

This is the least controversial area of evidence, and the one most maternity clinicians are familiar with. Of the eleven randomised controlled trials that have compared CTG monitoring with intermittent auscultation (IA) during labour, three were done in low risk populations, five in high risk populations and the remaining three in mixed risk populations or where risk was not specified (Alfirevic et al., 2017).

The three low risk trials were Kelso et al., 1978, Leveno et al., 1986 and Wood et al., 1981. A total of 16,049 births were included in this analysis, which showed no statistically significant difference in the perinatal mortality rate (RR 0.87, 95% CI 0.29 – 2.58).

It has been almost 40 years since the last of these trials was performed. It could be argued that CTG technology has improved, or that we are better at CTG interpretation now. Heelan-Fancher et al. (2019) examined a large population data set from two states in the United States, specifically looking at birth outcomes for low risk women. This was not a randomised controlled trial – rather it was a non-experimental analysis of what happens in practice when women are monitored by CTG or by IA, with a very large sample size (1.5 million births). They didn’t report on intrapartum stillbirth. They found no significant difference in the neonatal mortality rate when CTG monitoring was used.

On the basis of available evidence, there is nothing that suggests that use of CTG monitoring rather than IA reduces the perinatal mortality rate in women considered to be at low risk. That’s not all that controversial. Most people in maternity care know this particular bit of information.

Intrapartum CTG monitoring in mixed, unknown, and high-risk populations

There is a widespread assumption that the absence of mortality benefit derived from CTG monitoring in labour ONLY applies to women considered to be low risk. We wouldn’t be using CTGs so widely if they didn’t save lives, right? But what does the evidence actually say regarding the use of intrapartum CTG monitoring in women who are not at low risk?

The randomised controlled trial evidence regarding high risk populations consists of five studies published over 6 papers, over a thirty-year period, starting in 1976 and continuing to 2006 (Haverkamp et al., 1979; Haverkamp et al., 1976; Luthy et al., 1987; Madaan and Trivedi, 2006; Renou et al., 1976; Shy et al., 1987). In addition, there are four studies published over five papers which were conducted in populations with both women considered to be at lower and higher risk or where the risk profile of the population was not described (Grant et al., 1989; Kelso et al., 1978; MacDonald et al., 1985; Neldam et al., 1986; Vintzileos et al., 1993). With my co-authors Associate Professor Mary Sidebotham, Professor Jenny Gamble, and Professor Jennifer Fenwick, we have synthesised the findings from these populations (Small et al., 2020).

In the high-risk population (n = 1,975), perinatal mortality was not significantly different when CTG was compared with IA (RR 1.17, 95% CI 0.62 – 2.22). There was also no statistically significant difference in mortality in the mixed-risk population (n = 15,994, RR 0.67, 95% CI 0.36 – 1.23). The mortality rate was higher in the mixed risk population than it was for the low risk population, and higher again for the high-risk population, indicating that researchers have correctly identified populations of women with higher risk.

Note that the number of women in the high-risk population is small. It has been argued that with a larger sample size a difference would be detected but that it would be unethical to recruit women considered to be a high-risk to further RCTs because the non-experimental evidence supporting the use of intrapartum CTG monitoring is so compelling. We set out to examine this assertion and examined the nonexperimental evidence (Small et al., 2020).

Non-experimental research

Our searches located 27 papers published between 1972 and 2018 which provided evidence about the use of intrapartum CTG monitoring in high-risk populations. We then used a tool (ROBINS-I) to assess the degree to which the findings of the research might be affected by bias – that is that the findings were due to something other than CTG use. 22 papers were at critical risk of bias and another was a serious risk. Most of these papers compared a time period prior to the introduction of CTG monitoring with a period after it was introduced, without controlling for any of the other changes to practice which might improve outcomes over time. Given the high risk of bias, the findings from these papers should not be relied on to guide practice as a consequence. The remaining five studies were assessed to be at moderate risk of bias. According to the ROBINS-I tool, studies at moderate risk of bias can be relied upon to inform clinical practice.

Starting with the studies at critical or serious risk of bias, only five of these studies showed a statistically significant reduction in perinatal mortality out of fourteen where this could be calculated. In the studies at moderate risk of bias (which ranged in size from 235 to 1.2 million women), no significant differences in perinatal mortality rates were reported. The argument that the non-experimental evidence presents a compelling argument for intrapartum CTG monitoring can’t be sustained on the basis of the available evidence.

Where to next?

Where does that leave us as clinicians and what recommendations can we make on the basis of these findings? We have an ethical obligation to include information regarding the lack of effectiveness of CTG monitoring in our discussions about intrapartum fetal monitoring with birthing women, regardless of their risk profile (Sartwelle et al., 2020) and to support their informed decision making. However, doing currently places clinicians at odds with professional guidelines. Professional guidelines are meant to be evidence informed, yet this is clearly not the case for intrapartum fetal monitoring. In order to support clinicians to provide evidence-informed care, there needs to be stronger recognition in professional guidelines that the evidence in favour of intrapartum CTG monitoring is far from compelling and that using IA instead is not proof of unprofessional practice.

The full reference list is available on the post on Birth Small Talk. 

 

New research from the Transforming Maternity Care Collaborative Team

Collectively, the Transforming Maternity Care Collaborative generate a large volume of high quality, impactful research. This week has seen the publication of five new papers from our team members in the Women and Birth journal. You can access the full text of each of these via the links below. Settle in with a cuppa and enjoy getting up to date.

Intrapartum CTG monitoring does not improve perinatal outcomes.

Authors: Dr Kirsten Small, Associate Professor Mary Sidebotham, Professor Jennifer Fenwick, Professor Jenny Gamble.

This systematic literature review identified all randomised controlled trials and non-experimental evidence which has examined whether the use of CTG monitoring during labour rather than intermittent auscultation reduces perinatal mortality or cerebral palsy rates in babies born to women considered to be at high risk. No improvement in mortality was found, while an increase in the cerebral palsy rate was noted when CTG monitoring was used during preterm labour.

“High-quality research is urgently required to identify which women, if any, obtain a perinatal benefit from intrapartum CTG monitoring.”

Access this paper here.

Measuring midwifery students’ experiences of learning in clinical practice environments.

Authors: Ms Marnie Griffiths, Professor Jennifer Fenwick, Professor Jenny Gamble, Professor Debra Creedy.

Learning in a clinical environment is a key component of a comprehensive midwifery education program. Being able to measure how well specific learning environments support midwifery students as they develop the knowledge and skills required for professional practice is important. This paper reports on the development and testing of the MidSTEP tool which offers a robust way to capture students’ perceptions of the clinical practice component of their degree. Students indicated high level support for the statements that the clinical environment supported their learning, enabled them to work across the full scope of practice, and fostered a self-directed approach to learning.

Access this paper here.

Placing students in the driver’s seat.

Authors: Ms Valerie Hamilton, Professor Kathleen Baird, Professor Jennifer Fenwick

This research reports on students’ experiences of learning to provide midwifery care in a student-led midwifery clinic providing antenatal and postnatal care. Students who were on-call for individual women were supported to provide antenatal and postnatal care under the supervision and guidance of their university practice lecturer. “Being in the driver’s seat” was the major theme of the findings, with students reporting a sense of being in control and feeling like “a real midwife”. Students described growing in confidence over time and feeling competent to step into practice.

Access this paper here.

Stepping from student to employment through simulated employment interviews.