Statement re: The Irish Pregnancy Book, by Dr Peter Boylan, as reviewed by Beverley Lawrence Beech, AIMS UK The Association for Improvements in the Maternity Services (AIMS) Ireland would like the opportunity to respond to comments made by Dr. Peter Boylan in response to the review of his book by Beverley Lawrence Beech of AIMS UK.
further discussion. In the article, Peter Boylan states "that childbirth is a emotive issue and that experts can be at odds about what constitutes best practice." He then adds that, " Beech does not know how the Irish Health system works" and "she clearly does not understand what goes on here." These statements clearly illustrate Dr. Boylan's short-sightedness of the true issues at hand and sadly appears to hold no regard for utilising international guidelines for Normal Birth in the Irish maternity system. The research and information present in Beech's review are based on International Normal Birth guidelines as per the World Health Organisation. Evidence based research has concluded that Normal Birth practices are best practice for the majority of women worldwide; to suggest that the Irish system is somehow excluded from these guidelines is extremely concerning. WHO guidelines exclude practices such as routine use of episiotomy (when all women's perineum are cut regardless of medical need), routine ARM, with holding food and drinks to labouring women, recommendations for women to give birth on their backs on a bed, etc - all of which are recommended in The Irish Pregnancy Book. AIMS Ireland appreciates the opportunity to highlight these issues regarding the Irish Maternity System. Regards, Jene Kelly Chair of AIMS Ireland
"The Irish Pregnancy Book –A Guide for Expectant Mothers Reviewed by Beverley Lawrence Beech, AIMS UK
higher esteem and trust than a common or garden lay person. When the professional is an obstetrician the majority of women that they are the best people to approach when they are pregnant and are confident that the information they give is accurate and that they are the best people to approach when they are pregnant and are confident that the information they give is accurate and without bias. A book written by an obstetrician, therefore, would have a certain cachet. accurate and without bias. A book written by an obstetrician, therefore, would have a certain cachet. bias. A book written by an obstetrician, therefore, would have a certain cachet. On my visit to Ireland to help launch the AIMS Ireland group I was given a copy of The Irish Pregnancy Book with the suggestion that I might review it. Obstetricians in Ireland have closed down small, free standing maternity units, as did obstetricians in most of Britain. In Ireland, two midwifery units have just opened, in Britain they are still always under threat of closure as we described in our Journal on Birth Centres. As I was intrigued to see what was on offer, I began reading. The book is written by Dr Peter Boylan who was ‘The Master’ of the National Maternity Hospital, at Hollis Street, in Dublin – a hospital that delivers (and I use that word advisedly) over 8,000 babies a year. The fact that the head of obstetrics in the hospital is called the Master speaks volumes and is a reflection of the presumption that the women are there to do as they are told. The book began well enough (it does have a pretty cover) but it did not take long for my blood pressure to climb. Not only because of the amount of misinformation but also in the way it is delivered. Patronising is, perhaps, an understatement: ‘Is there such a thing as a stupid question? There is, of course, but that shouldn’t stop you asking’ ‘Nobody expects you to know anything or to take responsibility for anything so don’t be scared!’ ‘If you have already had a child, and are used to being pregnant, it can be difficult to assimilate the fact that each pregnancy is different and needs to be treated individually’ ‘The key to coping with your disappointment is to have realistic expectations about birth and keep an open mind as labour unfolds.’ ‘The choice is yours, but remember you are not making it just for yourself ’. The National Maternity Hospital was the home of Keiran O’Driscoll, the promoter of Active Management of Labour. The obstetricians in Ireland closed down small, free standing, maternity units so that there were four large centralised ones left. Their campaign resulted in a huge increase in the numbers of women being processed through the deliver y rooms and in order to do so Active Management was introduced and promoted on the grounds ‘that effective uterine action is the key to normal delivery’. As the numbers increased so the ‘advice’ about the length of a normal labour decreased, but women were not told the reasons for that. In 1963 women were told that a ‘normal labour’ lasted 36 hours. As the numbers of women going to the large centralised obstetric units increased so the length of labour decreased (O’Regan, 1998) so that now, in this book, women are told that ‘if your labour had started twelve hours ago there is a better than 90% chance that you would be sitting in bed holding your newborn baby! In fact the average length of time a first labour takes from arrival in the labour ward to delivery, is less than seven hours in the National Maternity Hospital.’ Instead of informing women that their labours are being induced and accelerated in order to get them through the labour wards as quickly as possible (in Dublin there are over 20,000 births for 30 deliver y beds) active management of labour is referred to as ‘A sensitive approach to the care of women in their birth labours.’ It is clear, throughout the book, that Dr Boylan has little understanding of normal birth. ‘Birth can only be defined as perfectly normal in retrospect.’ This is still the basis for obstetric care in Britain and Ireland, and it is still said in all sorts of different ways. Active Management is alive and well in both countries. All births are potentially normal until the labours (or during pregnancy) show signs that they are deviating from normal. To assume that you cannot define normality until the labour is over is ridiculous, but it does allow obstetricians the opportunity to portray birth as a dangerous, uncertain, event. Peter Boylan’s failure to understand normal birth colours the whole book and the advice given. ‘There is no advantage to keeping the waters intact, indeed not having the waters broken could slow your labour significantly.’ The research does not support Peter Boylan’s claim. Amniotomy (breaking the waters) results in significant disadvantages: • fetal heart abnormalities are more likely in a healthy, term baby when the waters are broken (Kariniemi 19983, Barrett et al 1992, Fraser et al 1993, Garite et all 1993) • it can precipitate umbilical cord prolapse (Levy et al 1984); • it has little effect on the length of labour (Seitchik et al 1985, Rosen and Peisner 1987, Barrett et al 1992); • it does not reduce the caesarean section rate (Barrett et al 1992, Fraser et al 1993 and Garite et al 1993). And where is the evidence that a slow labour needs speeding up? ‘During labour the stomach does not empty, so eating during labour is discouraged.’ The first high quality study of eating and drinking in labour was carried out in Canada. The study concluded that ‘women enjoyed being able to control their own oral intake; no other benefits or harmful effects were found’. It has been stated that withholding food and drink from women in labour is unlikely to be beneficial. ‘Some women prefer to let the baby’s cord stop pulsating and to attempt to breastfeed in an effort to make the third stage as physiologically normal as possible. There are no great advantages to be had however, and it is probably simpler not to delay.’ Professor Peter Dunn’s research (Dunn, 1984 and Dunn PM, 1993) revealed that early cord clamping ‘traps around 100ml more blood in the placenta than could be the case if cord-clamping were deferred until cord pulsation had ceased. As 100ml of blood in the term fetus is equivalent to 2.5 pints of blood in an adult, it is not surprising to observe that, following immediate cord occlusion, the newborn infant typically exhibits signs of hypovolaemia [too low blood volume due to excess fluid loss] and hypotension [an excessively low blood pressure]’ (Dunn, 2004/5). ‘Squatting or kneeling on all fours confers no advantage, gravitational or otherwise. In fact these positions make it more difficult for medical staff to see what’s going on and to help accordingly.’ A randomised controlled study reported that for primiparas (mothers undergoing first deliver y), the duration of the expulsion period was significantly shorter in the group of mothers who remained seated in a birthing chair than in the group opting for the lithotomy position [on their backs]. The efficiency of uterine contraction for dilating the cervix is also greater in a vertical position than in a horizontal position … It has been shown that appropriate position [squatting] of the mother increases the capacity of the pelvis’ (Caldeyro-Barcia,1985). Interestingly, at a World Health Organisation conference in For taleza, Brazil, Professor Caldeyro-Barcia remarked that ‘there was only one position worse than lying on one’s back for birth and that was hanging by one’s heels from a chandelier’. ‘Many interventions are designed to assist you achieve a normal birth in a reasonable period of time’ A ‘reasonable period of time’ is defined by doctors not by women. When doctors fail to understand that the standard interventions in labour pervert the course of a normal labour, and suggest that it is ‘assisting’ women those women then fail to realise that the, often traumatic, experience they have had was not ‘normal’ but caused by that ‘assistance’. As a result of this lack of knowledge they then stoically accept what happened, and some go on to book a caesarean or an epidural for the next birth because of the trauma they suffered. ‘There is no reason why you shouldn’t have a normal birth in hospital.’ The book omits to point out that fewer than one in ten women will succeed in having a normal birth in hospital. As the National is extremely coy about revealing its statistics one can only speculate how many women actually have a normal birth in that hospital. A normal birth does not include artificial rupture of membranes, induction or acceleration of labour, epidurals or episiotomy. But according to this book it does. ‘If you are having your first baby, you will have an approximately 50% chance of requiring stitches either from an episiotomy or perineal tear ; as the rate of episiotomy goes down, the rate of tear goes up! Look on the bright side though – you have a 50% chance of not having stitches, too!’ Not with a 20% caesarean section rate you won’t. This suggests that episiotomy prevents tears – it does not. A randomised controlled trial in Canada concluded that ‘there is no evidence that liberal or routine use of episiotomy prevents perineal trauma or pelvic floor relaxation’. (Klein MC et al, 1993). ‘The slower recovery may be because your labour was long and you are exhausted or because you have a larger episiotomy than you would have had with a normal birth.’ If a woman has an episiotomy at all, no matter how small or big she will not have had a normal birth, it is notmnormal to perform genital mutilation during birth. ‘Of course, induction can often be very successful and result in a normal labour and a normal delivery.’ In a normal labour a woman’s uterus increases the strength of contractions as the labour progresses, an induction of labour drives the uterus at the highest levels immediately, the labour is no longer normal. Space prevents me from highlighting all the misinformation in this book, but here are a few: ‘There is no evidence that ultrasound harms the fetus in any way’ ... ‘There is no risk whatsoever associated with having a scan.’ A randomised controlled trial from Helsinki of over 9,000 women found 20 miscarriages after 16 to 20 weeks in the group that had routine early ultrasound scans and none in the controls (Saari-Kemppainen, 1990). Another randomised study of 2,475 women in London (Davies, 1992) of babies exposed to routine Doppler ultrasound examination of umbilical and uterine arteries at 19-22 weeks and 32 weeks reported 16 perinatal deaths of normally formed infants in the ultrasound group, and none in the controls. Despite being asked to explain these findings the researchers have not responded. ‘The position of the baby’s head before labour is of no consequence whatsoever.’ In that case why are women told that they have to have external cephalic version, or a caesarean section, when the baby is presenting by the breech? ‘The midwives will perform an internal vaginal exam to see if you are in labour, and if so, how dilated you are. This procedure is the only way to assess your progress in labour.’ Skilled midwives are very competent at assessing progress in labour without performing internal vaginal examinations, obstetric nurses, however, rarely have this skill. Midwives will be concerned about the following statements as they casually dismiss potentially important warning symptoms: ‘You may get visual disturbances in pregnancy such as flashing lights before the eyes or blurred vision. These are of virtually no consequence but mention them to your doctor if they bother you.’ Visual disturbances often accompany pre-eclamptic toxaemia and skilled midwives will be concerned, and would be seen to be negligent should they fail to investigate should a woman mention that she has this experience. ‘Sometimes the mother gets leverage by holding her own knees, or the two midwives let the mother push her feet against them to brace herself.’ Research clearly shows that lying on one’s back for birth restricts the birth outlet. ‘Good, good, take a deep breath – no talk or sound. Put your chin on your chest and push that breath into your bottom as long as you can hold it, then quickly two more times within this contraction.’ ‘... you should push as if you are severely constipated …your midwife and doctor will help coach you.’ ‘Working right up until labour is fine from a physical point of view and doesn’t harm the baby but is probably unnecessary.’ Finally, the message in this book is that the doctor knows best and you will do as you are told: ‘Vitamin K will be given to your baby soon after birth’ No question here then of the woman being asked whether or not she wishes her fit and healthy baby to be overdosed with Vitamin K. ‘…you can decide who you want to be with you. You can even have a relay of a few people with you if you wish – but only one at a time.’ So, you can choose who to have with you, but if you choose to have two people you will not be allowed to do so. Some choice! The following is a question posed in the book: ‘How can I get the most out of my antenatal visits? Be informed – read this book!’ On the contrary, by reading this book you will be misinformed and my advice is save your money, there are better books on the market. Beverley A Lawrence Beech
Davies, JA, Gullivan, S, Spencer, JAD (1992) Randomised controlled Doppler ultrasound screening of placental perfusion during pregnancy. The Lancet; ii: p1299-1303 Dunn, PM (1984) The third stage and fetal adaptation. In Clinch J, Matthews T (eds). Perinatal Medicine. Proc IX Europ Congr Perinat Med, Dublin, Ireland, September 3–5, 1984. Lancaster : MTP Press, 1985: 47–54 Dunn, PM (1993) Stress failure of pulmonary capillaries at birth. Lancet, 1993; 341: 120 Dunn, PM (2004) Clamping the umbilical cord, AIMS Journal, Vol 16, No4 Klein, MC, Gauthier, RJ, Jorgensen, SH et al. (1992) Does episiotomy prevent perineal trauma and pelvic floor relaxation? Online J Curr Cliin Trials, 1992:1. O’Regan, M (1998) Active Management of Labour – The Irish Way of Birth, AIMS Journal, Vol 10, No2, Summer 1998, p1-8. Saari-Kemppainen, A, Karjalainen, O, Ylostalo, P and Heinonen, OP (1990) Ultrasound screening and prenatal mortality; controlled trial of systematic one-stage screening in pregnancy. The Lancet, Vol 339; p387-391. The Irish Pregnancy Book By Dr Peter Boylan Published by A & A Farmer Ltd ISBN 1-899047-88-3"
It seems that overcrowding is once again causing problems in Dublin hospitals. One Dublin hospital is in the media again this week as it emerged that they are keeping pregnant women who are in need of monitoring in nearby hotel rooms. I was confused to hear that the women, although told that they / their baby is in need of medical monitoring, are being deemed as “low-risk” enough not to be kept in a hospital setting. So, how are they defining "low-risk"? Surely a woman who is “low risk” has no need to be under the care of a hospital? Therefore, surely a woman in need of medical monitoring cannot be considered "low-risk"? So, why are our maternity hospitals stretched to breaking point? There are lots of factors here. It is not simply a case of population growth + rising numbers of births per year = overcrowding. If you are going to cram a hospital full of healthy women, eventually there will be nowhere for women with complications to go. It has to end somewhere. So, what is the solution? It depends who you ask. The most popular line you will hear from the hospitals bodies themselves will be: We need more / bigger hospitals and we need more consultants. How true is that when applied to Maternity care? Considering the vast majority of women have normal, healthy pregnancies and give birth to normal, healthy babies, is hospital really the appropriate place for these women? More importantly, is a hospital really where the majority of these women want to be? What we are hearing is that Ireland needs is more options. More domino schemes, nationwide support for women who would prefer a home birth, more community midwifery, more MLUs, the setting up of Birth Centres. All of these things would quickly, cheaply and effectively take the pressure off our maternity hospitals and free up the beds and consultants that are badly needed by women with pregnancy complications. It is about time the hospital management and the HSE took responsibility and took appropriate action. What women want in terms of Maternity Care and what can be safely and cost-effectively provided is actually the same thing. So it's time to ask ourselves: Why is it not happening? (It also poses another question: Just where is our money being spent!?) September 19th 2007 Do Irish Maternity Hospitals support ‘Rooming In’? ‘Rooming in’ involves the care of a newborn infant in a cot near the mother’s bed instead of in a nursery during their hospital stay. This has very many positive advantages for the mother and baby in terms of bonding and getting to know the new baby’s routine in the early days of its life and also the instant availability of the mother for feeding, a recognised bonding time be it bottle or breast. Rooming in also has many advantages for maternity hospitals in terms reduction in requirements for nursery spaces in hospitals and therefore, reduction in numbers of staff required to supervise the nurseries and take care of the infants. Most Irish maternity hospitals operate a full rooming in policy but the question is - Do Irish Maternity Hospitals support rooming in? AIMs Ireland conducted an online poll to find out what matters to Irish women in terms of maternity care. 15% of women listed lack of postnatal support as their main concern in the Irish maternity services. In their replies, women with traumatic deliveries and C sections, who were physically restricted by complications following the birth and often under the influence of morphine and other drugs administered post surgery described how they were left alone to look after their own and their infant’s needs. These women spoke of their distress at being physically incapable of taking care of their infant and how this lack of post-natal support affected them mentally; increasing anxiety, and promoting feelings of loneliness and failure that often had a lasting impact on them. Women in wards mentioned how they and neighbouring patients would often take care of each others infants in order to use the toilet or take a shower. Restrictive visiting policies put in place in maternity hospitals for security reasons mean that even family support is unavailable to these women outside of visiting hours. However, to expect new mothers to rely on the character of absolute strangers in the bed next to them in the absence of sufficient staff coverage hardly represents a comprehensive security policy. There are potentially serious health and safety implications from lack of support for rooming in mothers in maternity hospitals and currently these are not being addressed. Putting in place a rooming in policy in a hospital without providing the necessary support to women does not achieve the benefits of successful rooming in. Bonding is not enhanced between a stressed out mother, who is in physical pain, and her child. Maternity hospitals need to look at whether they are putting in place a rooming in policy for its mother-baby benefits, or for benefits to the balance sheet, it is not the same thing and it certainly does not represent the mother friendly-women centred care that Irish hospitals wish to achieve. August 2007 The Great Birthing Partner Debate… Irish Hospital's refusal of Additional Birth Partners and Doulas “Every woman deserves to have her mother in the delivery room with her” I remember reading these words on rollercoaster.ie years ago from a young scared Irish woman due with her first baby. Her heartfelt plea for help…her desperation for ANY suggestion ….of ANY possible way that she could persuade her maternity hospital to make the exception to the rule and allow her mother and husband in with her for the labour and birth. Likewise, I remember the replies of other women, women who have gone through it before, women dripped with cynicism because they too would have liked this choice but knew what her outcome would be. The pain, confusion and fear of that sad, sad post have stayed with me over the years. Unfortunately it looks like very little has changed for women in some areas of Ireland. While many maternity units around the country are receptive of additional birthing partners and Doulas, the Dublin hospitals remain unresponsive. AIMS Ireland has decided to look deeper into this issue. Background information Female birthing partners The desire to have our mothers, sisters or female friends with us in labour is a primal and instinctual example of women’s abilities to act on intuition. For centuries women have given birth with the support and understanding of elder women who have the life experience to guide the labouring woman through her birth. It makes absolute sense that women would chose to labour with their mother or sister in addition to their husband or partner. Women are naturally empathetic, supportive and strong. Research has shown that the use of an additional birthing partner or Doulas is extremely beneficial for the labouring woman. According to some research, midwives and nurses only are able to give 10% of their time in ‘supportive roles’ in labour and birth. It is not surprising then that women feel the need to find additional emotional support either in a family member, friend or through hiring a Doula. Research has found that women who laboured and birthed with a female partner showed extensive benefits to those who did not. Women had more spontaneous vaginal deliveries (91% to 71%), less analgesia use during labour (53% to 73%), less oxytocin (13% to 30%), fewer amniotomies to augment labour (30% to 54%), fewer vacuum extractions (4% to 16%) and fewer cesarean sections (6% to 13%) compared to the control group. The support of a female relative while in labour is shown to have fewer interventions and increased frequency of normal vaginal deliveries. (1) Similar findings show that the use of a professional Doulas also highly beneficial for labouring women. What’s a Doula? Doula (Greek) is a woman experienced in childbirth who provides continuous emotional support to the labouring mother and her partner. A Doula’s primary role is to the mother. Their sole focus is on the emotional well-being of the woman in labour. Unlike a midwife who may be assigned several labouring women and whose focus in on physiological/medical birth issues, the Doula’s primary focus is on one woman and is undivided emotional support. This support is reflected in the Doula ideology and Doula promises. Research has shown that due to the individual emotional support provided that women labouring with a Doula may prosper from a range of benefits. Evidenced Based Benefits Research showed: • women using a Doula have a 50% reduction rate in cesarean section • women using a Doula have a 40% reduction in the rate of forceps deliveries • women using a Doula have a 60% reduction in request for the epidural • women who used a Doula had a decrease in labour length by 25% (2) Closer to Home Doula Association of Ireland – face to face With all the talk of Doulas and hospital policy it became apparent that there is a lack of understanding with hospital administration and some members of the public as to what a Doula’s role is in Ireland. To gain greater insight, I recently attended a Doula training seminar and interviewed several Doulas working in Ireland. Doulas in Ireland work independently or with the support of an organisation called The Doula Association of Ireland. The Doula Association of Ireland is a voluntary organisation founded in March of 2006. The Association follows a Constitution mirroring ethics from DONA (an international and highly respected Doula Association) and is run by an elective committee. The Doula Association is a self-regulating, professional support network for Doulas working in Ireland. From meeting with the Doulas it was clear that there is a great need for additional support when giving birth in Ireland. As a Doula is not providing clinical care, her role is not diluted. She is a comforting and supportive, continuous presence for the labouring woman which benefits midwives who are often over stretched in Ireland’s maternity units. “ Our midwives are under tremendous pressure. Midwives are trying to provide both clinical care and emotional support in labour – sometimes to more than one woman,” describes one of the Doulas. Another adds, “Also…midwives take lunch breaks, they go home when their shift ends. As Doulas our support is continuous for the labour and birth…this is extremely important to most women.” A Doula does not replace the partner but rather encourages the partner to be as involved as his comfort level allows. As one mum describes, “My husband wasn’t initially sure about using a Doula but on the day he found it a great relief to have her there. It meant he could go through this with me – he could have his own experience knowing that my Doula would provide all the emotional support I needed. It took the pressure off of him - he was really worried about how he would perform on the day.” As an outsider with little experience of Doulas, the Doula training was simply inspiring. Listening to the principals and stories from these enthusiastic women truly brought home the degree in which we are failing women in our sterile maternity units. The room buzzed with hope, emotion, empathy, support and sadness over the stories we heard about birth in modern Ireland. There was an overwhelming sense of normality in the stories we heard relating to Doula births – it struck me as ironic that in the attempt to promote ‘normal’ birth in Ireland, many hospitals were purposely opposing a fundamental normal birth practice. From the short time I spent in the Doula training I came away with a real sense of hope and inner calm…a feeling of relief that these new recruits would make some woman’s experience that much more manageable as she will have the extra support of her Doula. The final moments in the training the DONA instructors explained an overview of the principals which encapsulate the level of emotional care that Doulas offer. These are called the Doula Promises. Promises of a Doula 1. You cannot hurt my feelings in labour 2. I won’t lie to you in labour 3. I will do everything in my power so you do not suffer 4. I will help you feel safe 5. I cannot speak for you but I will make sure that you have a voice and I will make sure you are heard Ireland is continuously training Doulas and most of Ireland’s maternity units have open policy of acceptance of Doulas. Unfortunately, due to hospital policies, women in the Dublin area who wish to have a Doula must attend Our Lady of Lourdes, |