BIRTHING

Vol. 22 No. 3 | Spring 2020

a RANZCOG publication The College

5 From the President Vol. 22 No. 3 Spring 2020 Vijay Roach

O&G Magazine Advisory Group 9 From the CEO Dr John Schibeci Chair and Diplomates Rep, NSW Vase Jovanoska Dr Sue Belgrave Fellows Rep, New Zealand Dr Brett Daniels Fellows Rep, TAS Dr Jenny Dowd Fellows Rep, VIC 11 Leaders in focus Dr Marilla Druitt Fellows Rep, VIC Nisha Khot Dr Fiona Langdon Young Fellows Rep, WA Dr William Milford Fellows Rep, QLD Dr Alyce Wilson Trainees Rep, VIC Birthing

O&G Magazine Editor 15 Editorial Sarah Ortenzio Brett Daniels Layout and Production Editor Sarah Ortenzio 16 Maternity care for First Nations Australians Design Yvette Roe and Sue Kildea Brendan Jones Mieka Vigilante Whitehart 19 Physiological-based cord clamping Sasha Skinner and Stuart Hooper Editorial Communications O&G Magazine Advisory Group RANZCOG 22 What does respect for autonomy require in birth? 254–260 Albert Street Naomi Holbeach, Emma Tumilty and Annabelle Brennan East Melbourne, VIC 3002 Australia (t) +61 3 9417 1699 (e) [email protected] 24 Pain relief in labour Advertising Sales Chris McGrath Bill Minnis Minnis Journals 27 Quality and safety performance reporting (t) +61 3 9836 2808 (e) [email protected] Roshan Selvaratnam and Euan M Wallace AM

Printer 30 Training and simulation: labour ward emergencies Southern Colour Edward Weaver OAM and Rachael Nugent (t) +61 3 8796 7000

O&G Magazine authorised by Ms Vase Jovanoska 33 Management of an obstetric emergency © 2020 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists Chris Polchleb and Hayley Messenger (RANZCOG). All rights reserved. No part of this publication may be reproduced or copied in any form or by any means without the written 36 The future of monitoring the during labour permission of the publisher. The submission of Vinayak Smith, Deborah Fox RM, Beverley Vollenhoven articles, news items and letters is encouraged. and Euan M Wallace AM For further information about contributing to O&G Magazine visit: ogmagazine.org.au. 39 Is 39 weeks the ideal time to deliver? The statements and opinions expressed in articles, Richard Murphy letters and advertisements in O&G Magazine are those of the authors and, unless specifically stated, are not necessarily the views of RANZCOG. 41 Methods of labour induction

Although all advertising material is expected to Michelle Wise conform to ethical and legal standards, acceptance does not imply endorsement by the College. ISSN 1442-5319

Cover image ©seasoning_17 43 Homebirth in Australia: from shadows to mainstream RANZCOG New Zealand Committee Te Kāhui Oranga ō Nuku Miranda Davies-Tuck, Colleen White and Caroline Homer AO Dr Celia Devenish Chair Catherine Cooper Manager Level 6, Featherston Tower, 45 Woman-centred respectful care 23 Waring Taylor Street, Lesley Dixon Wellington 6011 / PO Box 10611, The Terrace, Wellington 6143, NZ (t) +64 4 472 4608 (e) [email protected] 47 VBAC-2: a review of current evidence Amanda Whale and Andrew Woods RANZCOG State and Territory Committees Government Relations and National Offices Mel Pietsch Head 50 Suite 13, 18 National Cct Complications of advanced maternal age Barton, ACT 2600 Alice Whittaker (t) +61 2 6100 1160 (e) [email protected]

53 Australian Capital Territory Twin births: trends and tribulations Prof Julie Quinlivan Chair Yizhen (Amy) Liu, Mary-Ann Davey and Euan M Wallace AM Victoria Peisley Executive Officer Suite 13, 18 National Cct Barton, ACT 2600 56 (t) +61 2 6169 3993 Instrumental : a safe choice? (e) [email protected] John Svigos AM, Henry Murray, Stephen Robson and Darren Roberts New South Wales Dr Karen Mizia Chair Dee Quinn Executive Officer 58 Maternal heart disease in labour Suite 2, Ground Floor, 69 Christie Street St Leonards, NSW 2065 Fiona Stewart (t) +61 2 9436 1688 (e) [email protected]

60 Managing complicated by obesity Queensland Dr Thangeswaran Rudra Chair Glyn Teale Sylvia Williamson Executive Officer Suite 2, Level 2, 56 Little Edward Street, Spring Hill, Qld 4000 Women’s health (t) +61 7 3252 3073 (e) [email protected]

South Australia/Northern Territory 65 Q&A: How would you manage lichen sclerosus? A/Prof Rosalie Grivell Chair Gayle Fischer OAM Tania Back Executive Officer First floor, 213 Greenhill Road Eastwood, SA 5063 68 Case report: Ovarian cancer presenting as haemoperitoneum (t) +61 8 7200 3437 Tanushree Rao, Jyothi Marry and Murad Al-Aker (e) [email protected] Tasmania Dr Lindsay Edwards Chair The College Madeleine Bowers Executive Officer College House, 254–260 Albert Street East Melbourne, Vic 3002 70 Obituaries (t) +61 3 9114 3925 (e) [email protected]

72 College Statements update July 2020 Victoria Yee Leung Dr Charlotte Elder Chair Madeleine Bowers Executive Officer College House, 254–260 Albert Street 72 Remembering Our Fellows East Melbourne, Vic 3002 (t) +61 3 9114 3925 (e) [email protected]

Western Australia Dr Patty Edge Chair Claire Siddle Executive Officer 34 Harrogate Street, West Leederville, WA 6007 (t) +61 8 9381 4491 (e) [email protected]

Vol. 22 No. 3 Spring 2020 | 3 THE COLLEGE us toremember that birthisalso anemotional Birth ismore thanaphysical process anditbehoves ethical andsocialprerogative. legal, potential outcomes,isamore contemporary some. Theneedtoinform women,aboutoptionsand intervention, andevenwithout,canbetraumatic for is greater recognition that thebirthexperience,with avoidance of anideological,reactive debate. There require careful, evidence-basedevaluation and monitoring, inductionandcaesarean section The merits,orotherwise,of increased rates of outcome, hasmeantincreased intervention. birth that theydesire, anddeliveringa‘perfect’ of supportingwomen’srightstoexperiencethe under enormouspressure. Balancingtheimportance absolute. Meetingthoseexpectations placesdoctors outcome forthemselves,andtheirbabies,isalmost morbidity, maternal expectations of a‘normal’ are older, obesityrates are higher, withassociated andbirthin2020isdifferent. Women cultural sensitivityisalsoexplored. section andemergencyscenarios.Theimportanceof monitoring, cardiacdisease,birthafter caesarean remit andtheauthorsinthisissuediscuss primary pathophysiology of thebirthprocess. That isour the responsibility tounderstandthephysiologyand intervention. SpecialistandGPobstetricianscarry and specificcircumstances require medical uncomplicated, butvigilanceisalwaysrequired most women,thephysicalexperienceof birthis birth, theirinvestigation andmanagement.For medical conditionsthat canpotentiallycomplicate This issueof O&GMagazinefocusesonthemany ensure hersafety, andthat of herbaby, ishumbling. trust inustowalkalongsideher, toguideherand responsibility.extraordinary That sheplacesher life supportsystemforanotherhumanbeing,an and beyond.Apregnant womanisthe24-hour to share theirjourneyduringpregnancy, birth pregnant women.We are giftedwiththeopportunity my opinion,anevengreater privilege:thecare of doulas, doctorsandbirthattendants –share, in Those involvedinmaternity care –midwives, of nurturing,loveandhopeforauniquebeing. new lifecaptivates ourimagination, evokes feelings the arrivalof thebaby. Certainly, thewonderof There are manyquotesaboutbirththat focuson President Dr VijayRoach From thePresident to womeninAustralia,NewZealand andbeyond. your professionalism andthecare that youprovide authority inwomen’shealth,a reflection onyou, has clearlydemonstrated leadership, advocacyand our staff andourtrainees. At thistime,RANZCOG the supportthat youhavegivenme,ourCollege, message of gratitude toallof you.Thankyoufor made adifference. I’ll endonthat note, sending a one hourof reflection, honestyandvalidation really illness, therestrictions andtheeconomichardship, rather low, whenit’shardtoseeanendthe happiness ‘bucket’. At atimewhenwe’re allfeeling and compassiontheneedtoreplenish our connecting witheachother, thevalueof kindness of thepandemiconallof us,theimportanceof Jovanoska. We discussedthepsychologicalimpact Dr Katrina CalvertandRANZCOG CEO, Vase Working Group, DrPaulHowat andDeputyChair, Brett McDermott,Chairof theRANZCOG Wellbeing Webinar withpsychiatrists DrKym JenkinsandProf The CollegehostedaHand-n-Hand Wellbeing work environment hasbeenexemplary. commitment andadaptation toanewanddifficult working from homesinceMarch. Theirworkethic, to acknowledgetheRANZCOG staff whohavebeen level of communication withthoseaffected. Iwant The Collegehasendeavoured tomaintainahigh exams, assessmentsandprogress through training. and otherteachingopportunities,uncertaintyabout significant hardshipwith reduced accesstosurgery pressure isenormous.Ourtraineesare experiencing there isgenuinephysicalriskandthepsychological economic andsocialimpacts,forhealthcare workers experiencing anewoutbreak. Apartfrom theobvious and apparently eliminating thedisease,maybe in NSW. NewZealand, after enduringlockdown experiencing afulllockdown andcasesare rising and ourpatients. At thetimeof writing,Victoriais devastating impactonourcommunity, ourmembers The COVID-19 pandemiccontinuestohavea their innerstrength.’ capable motherswhotrustthemselvesandknow Birth isaboutmakingmothers–strong, competent, beautifully ‘Birth isnotonlyaboutmakingbabies. Sociology, BarbaraKatz Rothman,expresses it and spiritualexperience.AmericanProfessor of THE COLLEGE and relocation of movingtheCollege from Albert relocate there. We havebudgetedthat thefit-out some renovation andfit-outis required before we goodcondition, While theproperty isinvery College premises at 1BowenCrescent, Melbourne. We excited are all very bythepurchase of thenew policies andprocedures movingforward. do andwillformanimportantpartof theCollege’s we incorporated across theCollegeineverything the broader membership.Thenewvalueswillbe Values Working Group (OVWG) inconsultation with and Kindnesswere developedbytheOrganisational Excellence, Education, Respect,Integrity, Advocacy The College’sneworganisational valuesof return of somestaff backtothe office. some States andTerritories, wehavehadagradual to CollegeHouseinMelbourne.InNewZealand and still uncertainastowhenwewillbeablereturn went toworkingfrom homeconditions–anditis home –ithasbeenmore thanfivemonthssincewe continue toworkefficientlyandeffectively from challenges wehavefacedthisyear. Staff inMelbourne College workcontinuesagainstalladversityand meaningful outcomesthrough theworkthat wedo. women’s health,aswecontinuetostriveachieve though, isourcommitmenttotheCollegeand together hasvastlychanged.What hasnotchanged and howweconductbusiness,thewaywork Zoom hasbecomeanintegralpartof ourdailylife and wecreated onlineworkshopsandwebinars. cancelled manyof ourevents/workshopsandexams, We havehadtoadjustthenewnormal;we future, whatever that maylooklike. lives aswehopethingsreturn to‘normal’inthenear order androutine tocreate inour someeveryday try plan anything.Amongstallthechaosinworld,we There issomuchuncertainty,to difficult anditisvery is at stagefourrestrictions andinastate of disaster. all of us.AsIwritethisreport, Metropolitan Melbourne challengingfor The lastfewmonthshavebeenvery Chief Executive Officer Vase Jovanoska From theCEO obstetricians inregional/rural communitiesandhow two occasionstodiscusstheimportantrole of GP and LocalGovernment,HonMarkCoultonon Minister forRegionalServices,Decentralisation in regional andremote Australia.We havemetthe with key stakeholders inwomen’shealthservices The Collegehasincreased itsadvocacyefforts opportunities forimprovement inbothcountries. existingchallenges,gaps,andpossible identifying on analysingthecurrent O&Gworkforce trends, had theirinauguralmeetingandare startingtowork Both workinggroups inAustraliaandNewZealand groups, one in Australia and the other in New Zealand. Recently, theCollegesetuptwoworkforce working on thehospital’seducation requirements. objective istocreate amore bespoke offering based and managementof emergencies.Theoverarching teamwork, clinicalleadership,workplaceculture, video contentandactivitiesaround communication, provide thefoundation forthecourse,withreadings, of webinars.Theonlinematerials will and delivery on thedevelopmentof onlinematerials, acaselibrary, limitations inface-to-faceteaching,wewillfirstfocus course isprogressing well.Giventhecurrent Training inHospitalEmergencyResponse(MOTHER) Development of theMulti-professional Obstetrics the newRANZCOG websiteisalsoinprogress. myRANZCOG isprogressing well.Developmentof Equally, workonIntegrate, the replacement for planned tobeimplementedbytheendof theyear. (replacement forCLIMATE) isinprogress andis Learning ManagementSystem namedAcquire committees at theCollege.Developmentof anew framework wasshared forconsultation withtraining for theCurriculumReviewProject, andthedraft A newgovernancestructure hasbeenputinplace We aimtomovethenewpremises byJune2021. with constructionandfit-outworktofollowsoon. currently finalisingthedesignphase of theproject Street toBowenCrescent tobecostneutral.We are THE COLLEGE Please staysafe andkeep well. to persevere. need thesupportandencouragementof everyone our colleaguesandcommunityinVictoriawe ever. Ithasbeenanexceedingly difficulttimefor and supporteachotherduringthistimemore than we are usedto.We needtolookafter eachother quality servicesbutthrough different modesthan enormous pressure tocontinuedelivergood for usallthanitisrightnow, whenweare allunder Wellbeing supporthasneverbeenmore important members andexternalmentalhealthexperts. webinar washeldinAugustbyapanelof RANZCOG Information SessionandPanelDiscussionviaZoom our membersandtrainees.Thefirst Wellbeing planning anumberof initiatives that willsupport (WWG) hadtheirinauguralmeetingandhavebegun The newlyestablishedWellbeing Working Group College CouncilandBoardelections. set apolicyforgenderequitytargetsnextyear’s 20% eithergender. TheGEDWG willnowdevelopand suggested compositionof 40%female,maleand inequity at CollegeBoardandCouncillevel,witha a specifictransitionaltooltoaddress gapsingender RANZCOG Boardhaveapproved adoptingtargetsas pursuit of genderequityacross Collegebusiness.The (GEDWG) ismakingsignificantprogress inthe The GenderEquityandDiversityWorking Group the CollegeAGM inNovember. the College,before theyare presented forapproval at out forwiderconsultation withallvotingmembersof amongst otherconstitutionchanges,are currently Strait IslanderpositionsonCouncil.Thesechanges, representation of MāoriandAboriginalTorres and Councilrecently approved, inprinciple, (RAP) hasjustcommenced.TheRANZCOG Board Work onthenewReconciliation ActionPlan consumers, andbarrierstoeffectiveservicedelivery. of Australia,aswelltheuptake of servicesby available inallrural,regional andremote areas coverage andtypeof maternal healthservices comprehensive mapthat documentsthegeographic mapping project. Theproject aimstoproduce a been generated intheCollege’sruralhealth A considerableamountof publicinterest has improve thematernity servicesintheselocations. the CollegecanworkwithCommonwealthto THE COLLEGE

Vol. 22 No. 3 Spring 2020 | 7 Vol. Prof Homer is the Co-Program Director of Maternal, Maternal, of Director the Co-Program Homer is Prof the Burnet Institute. Health at Child and Adolescent of the University at a Visiting Professor She is also and an Honorary Professor Sydney, Technology and the Deakin University Monash University, at Homer is a Fellow Prof Melbourne. of University Health and Medical of the Australian Academy of the Australian of Sciences. She is Co-Chair Health and Ageing of Commonwealth Department Development of Expert AdvisoryNational Executive, She is a member of Guidelines. Pregnancy National and Perinatal Maternal Health Organization the World Group Guideline Development Health Executive the appointed as Chair of been and has recently AdvisoryExperts for of Group and Technical Strategic and Adolescent Health and Newborn, Child Maternal, the Perinatal Elect of Nutrition. She is the President and has been Australia and New Zealand Society of Midwives. the Australian College of of the President for you? What does a typical day look like home time, a typical day is working from In COVID COVID, to do with research and working on a lot of Asia in the programs but also my other research region. My day begins early in the morning Pacific meetings with the North Americans and with Zoom with the Europeans. ends late years, my day also involved teaching In previous and clinical practice, but these days it is research and development. Can you tell me about your childhood? was then called Rhodesia, now I was born in what maize tobacco and was a cattle, Zimbabwe. My father the Harare, 100km north of lived around We farmer. home schooled in were Zimbabwe. We capital of school. By our early years and then went to the local It went then, the civil war had begun in Zimbabwe. the mid-70s to the 80s, and things became from on police was My father hard and scary. pretty had We the time. so he was away a lot of reserve, to escorted we were to move houses to stay safe, the risk of school by an armed guard because of domestic terrorism. decided to move When I was about 11, my parents great-great-grandmother to Australia. My father’s was born in Australia, but the family had moved relative to England, so he had this one matriarchal have any papers or didn’t Australia. We from Australia would told that passports, but we were with no money and took a left Africa accept us. We we if we arrived today, I reckon ship to Freemantle. would be sent to Nauru or Manus island. When we we could told that we were landed in Freemantle, relative only enter Australia if we had a patriarchal Even relative. born in Australia, not a matriarchal thinking how I can remember as an 11-year-old, in was. But the officer that outrageous and unfair the port felt sorrycharge at for us and gave us these years became our passports. Three blue books that My family settled granted citizenship. we were later, up. The rest I grew where in Queensland and that’s normal, but these early my childhood was pretty of social justice. experiences shaped my views of #CelebratingLeadership @RANZCOG @Nishaobgyn @RANZCOG #CelebratingLeadership This feature sees Dr Nisha Khot in This feature with women’s health conversation leadership range of leaders in a broad you find this an hope positions. We and inspiring read. interesting on Twitter Join the conversation Dr Nisha Khot AFRACMA, FRANZCOG FRCOG, MBBS, MD, A Birthing-themed issue would be incomplete without a midwife. An obstetrician is not needed at every birth, but every to woman needs a midwife 2020 WHO has declared support her during labour. the Nurse and Midwife, of Year the International a leader in to feature so it seems only appropriate RANZCOG midwifery in O&G Magazine. Recently, Midwives signed a and the Australian College of understanding to promote historic memorandum of bodies and, collegiality between both representative In this Leaders hence, between the two professions. and talk Homer AO Caroline in Focus, I interview Prof in Australia. care maternity of to her about the future between the two discuss the tricky relationship We midwifery of and obstetrics closely allied professions global leadership in women’s health. and explore Prof Caroline Homer AO RM, MMedSc(ClinEpi), PhD Could you please take me through your career? I am a hospital-trained nurse and midwife. This means that I didn’t go to university to get an undergraduate degree. I did my nursing training at the Royal Brisbane Hospital and then went to Sydney soon after as a newly graduated nurse. I loved nursing and I was an efficient, well-organised nurse. I was working in a bone marrow transplant unit and really wanted to pursue a career in oncology nursing, but I didn’t get into the course and I was quite upset at the time. I was sharing a house with a friend at the time and she asked me to accompany her to St Margaret’s and do midwifery. I remembered the time when I had worked in a rural centre in Queensland looking after a family who had a baby at 28 weeks (or maybe earlier, this was 30 years ago so my memory isn’t accurate). For some reason that I can’t recall, the family had decided not to resuscitate this baby. I sat with them all night watching this baby die and supporting the parents in their grief. This was one of those profound, life changing moments. As a nurse, you didn’t get such experiences in the big hospitals. The midwives would take over and protect you from this. When it came to decision-making, I was reminded of this experience and felt that I would make a good midwife. Also, midwifery at the time was a one-year course and you got paid to do it. Prof Caroline Homer AO This was a big advantage as well. I didn’t get into St Margaret’s but got into the Royal Women’s Hospital in Paddington.

Soon after I graduated as a midwife, I went to work the cup has popped off three times. This should in a Mission Hospital in Malawi. I was totally useless not be perceived as criticism but instead should be there. I used to carry a textbook around and I would seen for what it is, a support, a qualified person who quickly read up about breech birth before delivering can provide some checks and balances in a critical a breech baby. My training had involved helping situation. In the context where we work as part of a and assisting the doctors and here I was, the on- well-qualified team, midwives don’t need to perform call midwife, expected to do vacuum extractions vacuum births themselves. and having to double-up as the anaesthetist for caesarean sections. However, there are many situations in low-income countries across the Asia Pacific where a midwife I returned to Sydney and worked in clinical practice. is the only birth attendant. In these situations, yes, In 1996, I started at St George Hospital in Sydney. midwives do need to perform vacuum births. I think This was an incredibly lucky move because I got to the more crucial skill for both midwives and doctors work with Lesley Barclay who became my mentor. is to learn when not to do a vacuum (or forceps) We worked in a midwifery continuity of care model birth, to learn when this is the more dangerous and I subsequently did my PhD in this. At the same option and to learn when they need to ask for help. time, I started teaching undergraduate midwifery students and went on to run a research unit. Those We can’t shy away from the medical-midwifery ten years of doing clinical work and being on-call conflict. What do you see as a way to resolve was one of the most important things I did. It kept me this conflict? grounded and it is one of the things I miss most. The medical-midwifery conflict is a huge disadvantage to providing good care to women. I got to where I am today by a combination of luck When it happens, it is horrible for everyone involved. and bravery. I had to be brave in Africa as a newbie And when it doesn’t happen, no one seems to notice and I have had to be brave taking on research and how well these teams work. Time and again, we see leadership. I have had some fantastic mentors collaborative teams have good outcomes and fewer and teachers who inspired me to be a good role complaints. Both of our professions need to work out model myself. where our boundaries are, and then we need to learn to respect not only those boundaries but each other. You said you learned how to do vacuum births in We can, and should, support each other to do the Malawi. Do you see midwives in Australia doing best we can for women and babies. this in the future? In Australia, performing vacuum births is not part Midwives need to lean in more. Its not okay for of the midwifery scope of practice. I do teach midwives to say ‘That’s a doctor’s job. I don’t do midwives to perform vacuum births as part of the this.’ We are qualified, educated, regulated and ALSO/AMARE courses. In Australia, we are fortunate accredited by a national body to national standards. to work alongside good doctors. As midwives, it is We need to step up and do more. At the same time, our job to support doctors and to be the safety net I ask our medical colleagues to lean out more. They for when things are not going well. As midwives, can have confidence that midwives can be trusted understanding the procedure of vacuum births to work within their scope of practice and escalate means that we can remind doctors when they have appropriately. Take a step back and be supportive of done three pulls, when there is no descent, when midwifery skills and knowledge. THE COLLEGE

Vol. 22 No. 3 Spring 2020 | 9 Vol. Getting over ourselves and our pre-conceived ideas and ideas pre-conceived ourselves and our Getting over we can work together mutual position where come to a and babies. will benefit women effectively doing advice to those considering What is your a PhD? loved it and it has almost by accident. I I did a PhD been very lot useful to me because I learned a whole But I don’t think everyone needs stuff very of quickly. scholarship, should engage in to do one. Everybody learn should all change. We evidence for in gathering is to us. There presented the evidence to be critical of midwives doing research, towards still some negativity Both professions rapidly. although this is changing the because that’s in research should actively engage midwifery Instead of good care. only way we can provide we need to do maternity and medical research, research women in our research together and engage research us provides when research Most importantly, projects. we have a A being better than B, with the evidence for choose. A is the option we that to ensure responsibility What three words describe your life? and determined. exciting Lucky, How do you sustain yourself? What do you do when you are not working? times, I love bush walking and I have big In non-COVID entertaining. dinner parties because I love cooking and is good for my a lot because that These days, I exercise I have more. body and my mind. I have started cooking I am working my way cookbooks that a few lockdown in touch a time. I try at one recipe to keep through, dinner Zoom with people. Since I can’t entertain, I have long walks. parties instead. My partner and I both love a group with to Tokyo Kyoto from we walked Last year, did have a walk planned in Portugal next friends. We of Flinders going to walk the but instead, we are year, friends is good because you can with Ranges. Walking quietly beside stories or walk talk if you want to, share and no no phones, no internet are There each other. you come work, and from break emails, so it is a real refreshed. back feeling properly if you could What would you tell your younger self go back in time? too much about brave and don’t care ‘Be I would say, people say’. Justwhat to say be disrespectful. is not That hospital trained, I always things to heart. Being don’t take I had not been to I wasn’t good enough because felt like I would tell my younger self to get over it and university. I must say your way. come on the opportunities that take I this stage. I think at though, I don’t have many regrets have been very have done good work. lucky and Homer for sharing her valuable insights with I thank Prof to think of readers her words will inspire us. I hope that midwifery the same body. and obstetrics as two arms of but The body can function with one arm if necessary, for a much easier and more having both arms makes enjoyable life. I would especially encourage trainees and aspiring obstetricians to find midwiferyrole models with relationships and to form collaborative to emulate midwifery colleagues. I think training together helps develop this mutual this mutual together helps develop I think training very are There for few opportunities respect. especially together, doctors to learn midwives and I think if we start their careers. stages of in the early together, stage and grow career the early from our scope of a better understanding we develop and roles understand each other’s We practice. of them. Junior doctors need between the difference do and junior midwives midwives to see what doctors need to achieve junior need to see what multi- need more We to complete their training. both disciplines that so conferences professional aim to both professions Ultimately, learn together. for mothers and babies. achieve the best outcomes should do this together. We give to an intern or a junior What advice would you pursue a career in obstetrics? doctor who wants to soak up everyMy advice would be to single every from experience and to learn experience. at Engage with all the disciplines in the hospital I would encourage anyone seniority. all levels of in obstetrics to spend some considering a career clinics antenatal time with the midwives. Attend with the Midwifery Practice midwives, be Group just sit in a her labour, with a woman throughout normal labour and birth, attend corner and watch a homebirth, accompany the midwife on postnatal chance they will to be the only visits. This is likely As they advance experiencing normality. have of in their training, they will deal with complexity, deal as they should. They will see complications, with postpartum haemorrhage, , seen But having pre-eclampsia. obstructed labour, all of the centre at that they will remember normality, No matter the complexity is a woman having a baby. many tests how her medical issues, no matter what technology what matter no baby, her or her on do we and this we use, this is still a woman having a baby Keeping the is the most significant event in her life. all decisions and plans will of the centre woman at once doctors have a good naturally come more them This will make normality. understanding of and kind obstetricians. empathetic What do you see as the challenges for both obstetrics and midwifery in the future? need to work out how to work Both professions This is no longer optional; it better with each other. has to happen. have always must also design better systems. We We now need to do designed systems for women. We about creative must be more this with women. We we must build back better. our systems. Post-COVID, changes that COVID the bits of This means keeping the pre-COVID work well and add in the bits from well. worked systems that we do. When what of centre the must be at Women of care, options options, different women want more we have to listen to them and deliver these options. have to be brave enough to leave our own We not hide behind the old-fashioned zones, comfort doing things and embrace change instead. ways of BIRTHING BSc, PhD, MBBS,FRANZCOG Dr BrettDaniels Editorial of consenttobirthandthepractices around birth of birthlocation orchoiceof attendant, thequestion homebirth inAustraliaandNewZealand. Regardless Australian women,andthecurrent experienceof forFirstNations drive towards‘Birthing onCountry’ outcome of maternity care inNewZealand, the contains articlesregarding theorganisation and importance.Thisissue by isadiscussionof primary Where awomangivesbirthandwhosheisattended outcome formotherandbaby. and different approaches toachievethebest context of birthacross AustraliaandNewZealand publication, Ifoundthat manyinformed meof the all circumstances. Readingthesearticlespriorto no singletemplate that willworkforallwomenin the singlethemeof birthing,butinreality, there is for whomIcare. Thisissueof O&GMagazinehas beliefs andthedesires of thepeople is informed bymylocation, training,personal of themotherandbaby. Like allof us,mypractice birth experience;myover-riding priorityisthesafety endeavour toprovide arespectful woman-centred I don’tattend birthsoutsideof ahospitalsetting.I of singletonsand perform vaginalbreech delivery and vaginalbirthof twinswhere appropriate. Idon’t hospitals. Idoprovide vaginalbirthafter caesarean primarily inahealthypopulation inprivate andpublic I amawhitemalespecialistobstetrician.practice experience and make their own decisions. In my case, their carers prioritisedifferent aspects of theirbirth There isnocorrect waytogivebirth,andwomen breath andbegunlifeseparated from theirmother. magazine hasemergedintotheworld,taken theirfirst personreading this doctors, familymembers–every planned orspontaneous,attended bymidwives, In hospitalorat home,bycaesarean orvaginally, we haveallplayedacentralrole inat leastonebirth. irrespective of age,gender, wealthorethnicity, but There are fewexperiencesthat uniteallpeople help themintheirquest. experienced obstetricianwillfind somethingnewto Read thisissueof O&GMagazineandeventhemost and empathy tohelpthembesafe andempowered. respect theirchoices,anduseourknowledge,skills dangerous, momentsof theirlife.We shouldstriveto can bethemostjoyous,butalsooneof the most lives caringforwomenandtheirbabiesat what We have thegoodfortunetospendourworking available inAustraliaandNewZealand. the variousobstetricemergencytrainingcourses response tocommonobstetricemergenciesand instrumental delivery, andaccounts of boththe We have includedarticlesonbothtwinbirthsand offer assistancetoabirthingwomanwhen required. other birthattendants mustalsopossessskillsto current developmentsinthisfield.Obstetriciansand the articleonfetalmonitoringinlabourhighlights provide accessibleupdates of theseareas, while cardiac diseaseinpregnancy andpainrelief inlabour changes at thiscrucialtransition.Thereviews of provides anexcellent accountof thephysiological readers toreview thearticleonthistopicwhich or ‘delayed’cordclamping,Iwouldencourageall readers. Asimilarlyemergentpracticeisphysiological practice inmanycontextsandisrelevant toall the publication of theARRIVEtrial,hasalsoaltered labour, atopicbrought intosharperrelief following The idealtimingof delivery, andhenceinductionof changes inmyclinicalpracticeoverthelastdecade. and methodsof inductionof labourhighlight in womenof advancedmaternal ageandthetiming context inwhichIpractice,thearticlesonpregnancy reviews of areas of interest inobstetrics.Inthe This issuealsoprovides anumberof up-to-date having thesediscussionspriortolabour. consent around childbirthandhighlightstheutilityof article byHolbeachetaldiscussestheissueof is facedbyallwomenandtheirpractitioners.The BIRTHING years. preterm birthalmostdouble;andunchangedin12 disability mortality Ngykena Yaruwu Nations Charles DarwinUniversity College ofNursing&Midwifery, Co-Director, MollyWardaguga Research Centre PhD, MPH, BA A/Prof YvetteRoe Nations Australians Maternity careforFirst the inversecare law inaction–where thosewho do notreach intomanyof theseareas and we see of non-Indigenous women.Ourmaternity services remote andregional areas, compared toonly27% 71% of FirstNations birthingmotherslive inrural, areas, alittle-knownfactisthat approximately Although manyFirstNations families liveinurban other Australianwomen. when comparingFirstNations mothersandbabiesto maternal, newbornandchildhealth(MNCH)indicators 2008) there hasbeenlittleornoimprovement inkey the Gap’,forpast12years(sincetargetswere setin years and,despitenational initiatives suchas‘Closing mortality across thelifespan.Thisstartsinearly bear anexcessive burdenof disease,disabilityand Islander (hereafter, respectfully, FirstNations) people It iswelldocumentedthat AboriginalandTorres Strait Charles DarwinUniversity College ofNursing&Midwifery, Co-Director, MollyWardaguga Research Centre RN, RM,BaHSc(Hons)PhD Prof SueKildea times higher, 3 is the largest contributor to child Preterm birthisthelargestcontributortochild 2 3 andchronic diseasesinadulthood. and is associated with significant childhood andisassociated withsignificantchildhood 2 perinatal deaths 1.7 timeshigherwith 1 Maternal death remains 3–5 Maternal death remains 3–5 3 Directions forAustralianMaternity Services services are recommended inthenational Strategic in SouthEastQueensland.BirthingonCountry model resulted ina50%reduction inpreterm birth communities formaximumhealthgains. service redesign inpartnershipwithFirstNations trialled andtestedsolutionstofasttracksignificant servicesprovide access tocare. BirthingonCountry by takingurgentpracticalactiontosupportimproved health forFirstNations women,babiesandfamilies, in record time.We coulddothesametoimprove significant changes(suchastransitiontotelehealth) respond tothenovelcoronavirus byimplementing healthcare systemadjustandseekinnovations to In thelastfewmonths,wehaveseenAustralian poorest accesstoservices. have thehighestburdenof disadvantagehavethe Nations, reported maternal andinfant outcomes on thetraditionallandsof the Turbal and Jagera serviceinBrisbane (Meanjin), The BirthingonCountry impact onoutcomes have aprofound services Birthing onCountry servicesare describedinBoxBirthing onCountry 1. services.Thekey and tertiary elements of the primary carer delivered withinanintegrated systemlinking of FirstNations people,andcontinuityof midwifery service planninganddelivery, increased employment service redesign, increased FirstNations control of servicesconsistof significant Birthing onCountry becoming areality isbestcaptured inthefollowing: aspirations andurgencyof BirthingonCountry fordecades.The drive tohaveBirthingonCountry First Nations womenacross Australiahaveledthe beststarttolife services: Birthing onCountry achieve healthequityinmaternal andinfant health. time weextendthisactiontoFirstNations familiesto rapid strategic actiontosafeguard ourhealth:it’s to thispandemichasproved that weare capableof Commonwealth governments. Serviceshasbeenendorsedbystate and Country the National guidanceforimplementingBirthingon National Birthing on Country WorkshopNational BirthingonCountry 2012. Australians to the land.’ Djapirri Mununggirriti at the connectsIndigenous [Birthing onCountry] usthroughtothefuture; leadership tocarry came from;toensurepride,passion,dignityand to knowtherouteandidentity of wherethey to amother andchild.ourgeneration needs Birthing isthemostpowerfulthingthat happens with inthecurrent systems. socio-cultural andspiritualriskthat isnot dealt .(it) dealswith than justthelabouranddelivery bio-physical outcomes.it’smuch,muchbroader culturally appropriate modelof care;‘not only because itprovidesanintegrated, holisticand and Torres Strait Islanderbabies andtheirfamilies metaphor .forthebeststartinlifeAboriginal should]beunderstoodasa ‘[Birthing onCountry 5 Australia’sresponse 8 Thisservice 4 and 6 BIRTHING Vol. 22 No. 3 Spring 2020 | 12 Vol. to enable Aboriginal Community 10 Controlled Health organisations to utilise Health organisations Controlled funding for midwiferyMedicare services - supported by the whole were recommendations panel included doctors / obstetricians. listen. If how to respond, not sure If you’re If you’re research. to read, what not sure you’re becomes sure’ ‘Not to do, donate. what not sure it’s not enough to be ‘not ‘not my problem’ women and babies are when First Nations sure’ especially when we have the dying prematurely, a difference. makes evidence that Additional funding to Aboriginal Community Additional funding to Aboriginal Community to employ Health organisations Controlled services care midwives to work in continuity of and embed and monitor cultural safety implement the recommendations Immediately for Medicare the Review of in the Report of Midwives COVID-19 provides an example of how things can how things can an example of provides COVID-19 and change rapidly when politicians, health services against to unite motivated the wider community are has been an there Concurrently, a common threat. Lives to support the Black groundswell international dramatic demonstrated have movement. We Matter With in ‘black’ birthing outcomes. improvements medical, obstetric and government widespread on support, we could all get behind the Birthing Country black babies lives show that movement and too. mater institutions can feel and healthcare Policy makers the list overwhelmed and be slow to act; however, you can do to help the things that below provides Birthing on Country movement: • there are key areas that if implemented immediately immediately if implemented that areas key are there and in maternal difference a profound could make babies and mothers, outcomes for First Nation infant families; these are: 1. 2. 7 7

10 The service is called Birthing in Our 1 of the service. the service. governance of First Nations between tertiaryintegration Improved sector. and Aboriginal community-controlled postnatal. and up to six weeks birth of midwiferyContinuity during pregnancy, 24/7 carer Support Workers, : Family workforce and capacity building the First Nations for increasing Strategy student midwifery senior management, midwifery cadets, new graduate workers, positions, transport manager. and program psychologist, practice nurse worker, social administration, and clinical supervisionCultural staff. for frontline health and women’s specialised paediatric or outreach with access to resident Community-based hub emotional wellbeing team. services and social and days, arts program. and connection and revival programs: culture strengthening Cultural families (keeping preservation focus on family women and families: strong Intensive support for to parents). children (returning together) and restoration birthplace). Birth Centres (i.e. choice of Controlled First Nations Redesign the health system and services health and infant Invest in the maternal workforce the First Nations to grow workforce is workforce the non-Indigneous and ensure culturally safe family capacity Strengthen Embed community engagement, governance services over health and research and control Key elements of the Birthing on Country elements of the Key service • • • • • • • • • The RISE Framework for implementation includes: for implementation The RISE Framework • • • • by learnings has been informed The RISE Framework case on maternity research over a decade of from women, babies and families. studies for First Nations can be locally adapted to the The RISE Framework while community, each First Nation diverse needs of also assessing and utilising the available resources etc. However, infrastructure such as the workforce, Community. The improvements are across numerous numerous across are The improvements Community. workforce, including First Nations categories women are services that and wrap-around integrated early community engagement and baby centred, a from 2). They resulted and clinical outcomes (Box Strait partnership between two Aboriginal and Torres Organisations Health Islander Community Controlled and a tertiary the Institute for Urban hospital: Strait Indigenous Health, the Aboriginal and Torres and Islander Community Health Service Brisbane Mothers’ Hospital. The partners worked the Mater 2012. and deliver services from together to redesign The RISE Framework for implementing Birthing for implementing Birthing Framework The RISE that have not been witnessed in Australia for the have not been witnessed in Australia for that past decade. on Country Birthing on Country a complex intervention that is health and infant maternal a redesigned incorporates It operates quality and safety. service for greater governance framework and within a First Nations living by rapidly the determinants of addresses providing and workforce the First Nations increasing services to support integrated comprehensive family’s capacities and opportunities. by First Nations is informed The RISE Framework people, animals, of (interconnectedness) relationality The intersections plants, place, time and ceremony. knowledge to bring First Nations and synergy that is critical in understanding First Nations the forefront services and, and infant for maternal aspirations clinically the design of how to inform importantly, services. and culturally safe Key elements of the Birthing on Country Birthing the of elements service. 1. Key Box BIRTHING Box 2.BirthinginOurCommunityoutcomes. • • • Figure 1.TheRISEFramework andcharacteristicsof thepossibleimplementation phases. • • • • • • • • • Increases in: Birthing inOurCommunityoutcomes continue. bystanders allowthisunacceptablebehaviourto Call outracismwheneveryouseeit:silent care fortheirfamilies. organisations canemploymidwivestoprovide that Aboriginalcommunity-controlled health in thereview of Medicare forMidwivesso Support thechangesthat are recommended www.naccho.org.au with theserviceyouworkin:letthemlead. services, explore orsupportapartnership example: increase theprovision of outreach Service –askhowcanyouworktogether, for Strait IslanderCommunityControlled Health Reach outtoyourlocalAboriginalandTorres to FirstNations peoples. Regulation Agency, Board NursingandMidwifery recommended byAustralianHealthPractitioner privilege, culturalbeliefsandprotocols; as content onhistory, colonisation, racism,white Islander-specific cultural safety training,including at haveparticipated inAboriginalandTorres Strait Ensure youandthestaff at thehospitalyouwork these discussionsinatimelymanner. feedback andrecommendations generated from for speakers. Remembertofollowupon at yourworkplaceensuringproper renumeration everyday, create one,suchasapaneldiscussion the chance.Ifyoudon’thavechanceinyour FirstNations voiceswheneveryouhave Amplify Exclusive breastfeeding at discharge Cultural activities Cultural supportforfrontline workers Women presenting earlierandmore frequently forcare baby centred Integrated wrap-around servicesthat are womenand First Nations maternal infant healthworkforce (~550%) centre services inpartnershipwiththetertiary First Nations governanceandcontrol of maternity 11 Learnhowtobeagoodaccomplice 12

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• • Full reference listavalable online 2. 1. References campaign=p_cp+share-sheet source=customer&utm_medium=email&utm_ gofundme.com/f/birthing-on-country?utm_ GoFundMe project:on Country www. Donate toWaminda SouthCoastBirthing Capabilities Framework). Aboriginal andTorres Strait IslanderCultural implementation plans(eg.QueenslandHealth and Torres Strait Islander-specific policies and health andyourstate andterritories’Aboriginal guide forAboriginalandTorres Strait Islander Safety andQualityHealthServiceStandards user Health CurriculumFramework ,theNational National AboriginalandTorres Strait Islander Islander HealthPerformanceFramework ,the Health Plan,theAboriginalandTorres Strait the National AboriginalandTorres Strait Islander date inimplementingrecommendations from Ensure yourorganisation andstaff are upto Australian MedicalAssociation. Australia IndigenousDoctorsAssociation and Strait IslanderNursesandMidwives(CATSINaM), of Australia,Congress of AboriginalandTorres aihw-per-99-printable-PDF-of-web-report.pdf.aspx gov.au/getmedia/558ae883-a888-406a-b48f-71f562db3918/ Australia 2016. Canberra:AIHW; 2018. Available from: www.aihw. Australian Instituteof HealthandWelfare. Maternal deaths in from: https://ctgreport.niaa.gov.au/content/closing-gap-2020 Department of thePrimeMinisterandCabinet;2020. Available Australian Government.ClosingtheGapReport2020. Canberra: • • • • Reduction in: Admissions toneonatal intensive care Caesarean sections Low birthweightinfants Preterm birthby~50% 9 Reproduced withpermission. BIRTHING

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1 Vol. 22 No. 3 Spring 2020 | 14 Vol. Cardiac output can Cardiac output can 3,6-8 1,2 In preterm infants, who typically take who typically take infants, In preterm 1 4,5 Additionally, removing the low-resistance placental placental the low-resistance removing Additionally, systemic vascular abruptly increases circulation and blood pressure. resistance What about babies that need resuscitation? immediate outcomes of assessing neonatal Studies babies requiring excluded versus delayed UCC guidelines recommend as current resuscitation, the mother. away from resuscitation immediate and so have usually hypoxic are These infants vital their cardiac output to protect redirected UCC organs, including the brain. As immediate However, prior to aeration, PVR remains high high PVR remains prior to lung aeration, However, occurs before Thus, If UCC low. and so PBF remains (by cardiac output rapidly decreases lung aeration, from 60%) as blood supply to the left heart around PBF. in by an increase the placenta is not replaced on the neonatal Do we see the effects of UCC transition in clinical practice? with increase UCC of immediate The adverse effects as throughout and lung aeration, time between UCC Most babies low. this time cardiac output will remain birth and so this interval is at spontaneously breathe UCC immediate short. Nevertheless, routine relatively in otherwise heart rate reduces neonatal significantly well babies. oxygenation. Oxygenated blood returning from the from blood returning Oxygenated oxygenation. the ductus venosus andplacenta is shunted through the right ventricle and ,foramen ovale, bypassing the body. be pumped around to the left ventricle to onset triggers a major re- In the newborn, breathing birth at Lung aeration the circulation. of organisation pulmonarysubstantially reduces resistance vascular pulmonary increases flow blood (PVR), which greatly ventricular output to the right (PBF) by redirecting blood than the placenta. Oxygenated lungs rather ventricle. to the left the lungs is then delivered from the placenta over from the lungs take In this way, of and the source gas exchange as both the site of blood volume for cardiac output. What is the impact of cord clamping during this transition? of UCC After birth, the haemodynamic effects most At aerated. depend on whether the lungs are quickly establishes breathing, births, the neonate the lungs to blood through of allowing redirection to the left ventricle. delivered and be oxygenated longer to establish ventilation, immediate UCC UCC immediate longer to establish ventilation, and oxygenation, stabilisation impairs blood pressure intraventricular haemorrhage of rates increases necrotising (IVH), periventricular leukomalacia, need for blood transfusion and poor enterocolitis, outcomes. neurodevelopmental this point, removing the placenta by UCC does not the placenta by UCC this point, removing PBF can as elevated circulation impact the infant’s placenta as the blood flow from replace immediately blood volume for cardiac output. of the source only be restored by aerating the lungs so that PBF PBF the lungs so that by aerating only be restored can increase. Prof Stuart Hooper Fellow Principal Research NHMRC BSc, PhD, The Ritchie Centre Fetal and Neonatal Health Group Head, Research Hudson Institute of Medical Research Melbourne Monash University, At birth, all newborns must transition from fetal to birth, all newborns must transition from At liquid-filled lungs the previously life, where neonatal theover from so they can take must be aerated While umbilical gas exchange. placenta as the site of performed at is routinely cord clamping (UCC) the placental abruptly removing birth, the impact of during this transition is usually notcirculation that evidence is increasing there However, considered. the timing particular, is not an innocuous act. In UCC onset may be crucial to to breathing in relation UCC of transition and, for some infants,optimise the neonatal significant morbidity and mortality. prevent What is the difference between the fetal and neonatal circulation? the body from During fetal life, blood returning beingenters the right ventricle, but instead of the liquid-filled lungs, this blood ispumped through via the ductus arteriosus, to the placenta fordirected, Dr Sasha Skinner level 2 trainee MBBS, BMedSci, FRANZCOG Department of Obstetric and Gynaecology Melbourne Monash Health, cord clamping cord Physiological-based Physiological-based BIRTHING blood pressure. improved stabilisation intheneonate’s heartrate and results demonstratePreliminary feasibility, safety and until adequate ventilation isachieved(Figure 1). to thebedside,keeping the umbilicalcordintact and processes tomoveneonatal resuscitation and intheNetherlandshaveestablishedequipment Monash MedicalCentre, TheRoyalWomen’s Hospital umbilical cordintact.Current clinicalstudiesat this meansproviding supportwiththe respiratory is established).Forinfants requiring resuscitation, UCC (i.e.whenspontaneousorassistedventilation optimaltimingof infant’s physiologytoidentify Physiological-based cordclampingusesthe What isphysiological-basedcordclamping? umbilical cordintact. requires neonatal resuscitation tooccurwiththe – eitherspontaneouslyorassisted.However, this from delayingUCC untillungaeration isestablished infants requiring resuscitation maybenefitmost component. effective uterotonic administration isthe primary significantly reduces postpartum haemorrhage(PPH), administration. Whileactivemanagement controlled cordtractionandearlyuterotonic ‘active’ managementof thirdstage,alongwith Immediate UCC wasadopted asacomponentof Where didimmediatecordclampingcomefrom? susceptibility tohypoxic-ischaemic injury. this protective mechanismincreases theinfant’s dramatically reduces cardiacoutput,impairing Image courtesyof Knoletal. Figure 1.Schematic of physiologicalbasedcordclampingapproach toneonatal resuscitation. not reduce PPH, includingat ,and 12 Indeed,routine immediate UCC does 9-11 9 7 Thus, 9,10

guidelines. is nolongerincludedinthirdstagemanagement persisting uptosixmonthsof age. with reduced incidenceof iron deficiencyanaemia infant birthweight,haemoglobinandiron stores mechanism, delayedUCC significantlyincreases then re-equilibrates after birth.Regardlessof the causes bloodtomoveintotheplacentawhich compression of theneonate duringvaginaldelivery significantly increase therisk of IVH. pressurelarge fluctuations incarotid and artery occlusion andrelease of theumbilicalcordcauses conflicting data regarding needforphototherapy. expense of increased serumbilirubin,thoughwith ventilation inanimalstudies. gravity, neonatal spontaneous breathing orassisted transfusion isnotexplainedbyuterinecontractions, balanced fetal-placentalcirculation. Placental unclear what triggersthischangefrom thepreviously blood from theplacentatoinfant after birth.Itis Placental transfusionrefers tonetmovementof What aboutplacentaltransfusion? immediate UCC istoprovide neonatal resuscitation. few methodsare effective. accelerate placentaltransfusionat birth,although Umbilical cordmilkinghasbeenproposed to What aboutcordmilking? infants notrequiring resuscitation. Cordmilkingisnot UCC forat least60secondsinbothtermandpreterm The World HealthOrganization recommends delaying What shouldwedonow? 4,9 Currently, themainindication for 15 However, repetitive 13,14 One theory isthat Onetheory 4 Thisisat the 15,16

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@ranzcog Vol. 22 No. 3 Spring 2020 | 16 Vol. ‘Join the ‘Join conversation’ au.linkedin.com/company/ranzcog facebook.com/ranzcog Dawson JA, Kamlin COF, Wong C, et al. Changes in heart rate in heart rate et al. Changes C, Wong Kamlin COF, JA, Dawson . Ed Fetal Neonatal Arch Dis Child after birth. in the first minutes 2010;95:F177-F81. in delayed cord clamping Bansal A. Role of Kabra NS, Garg BD, a neonates: in preterm enterocolitis necrotizing of prevention Med. 2019;32:164-72. Fetal Neonatal J Matern review. systematic cord clamping is AM. Delayed ZA, Liao SM, Mathur Vesoulis and autoregulation cerebral dynamic improved with associated hemorrhage in preterm intraventricular of incidence decreased 2019;127:103-10. Physiology. Applied Journal of infants. trial to controlled R. A randomized A, Yadav Kumar V, Datta brief delay in cord clamping in preterm of the role evaluate neurobehavioural (34-36 weeks) on shortterm neonates . 2017;63:418-24. Pediatrics Tropical outcome. Journal of et al. Physiological- T, E, van den Akker Knol R, Brouwer based cord clamping in very — Randomised infants preterm Resuscitation. of stabilisation. trial on effectiveness controlled 2020;147:26-33. et al. Physiological-based ASN, E, Knol R, Vernooij Brouwer using a new purpose-built infants cord clamping in preterm Arch Dis Child Fetal study. table: A feasibility resuscitation . 2019;104:F396-F402. Ed Neonatal Omar F Kamlin C, et al. Baby-directed Badurdeen S, Blank DA, Resuscitation. study. umbilical cord clamping: A feasibility 2018;131:1-7. Prophylactic et al. Williams MJ, SJ, Leathersich JA, Salati labour to prevent for the third stage of oxytocin Rev. Syst Database postpartum haemorrhage. Cochrane 2019;4(4):CD001808. of body position et al. Effect Zahra VA, KJ, Crossley Hooper SB, on umbilical arteryand ventilation and venous blood flows lambs. Arch during delayed umbilical cord clamping in preterm . 2017;102:F312-F9. Ed Dis Child Fetal Neonatal of spontaneous GR, et al. Effect Polglase Pas AB, E, Te Brouwer on umbilical venous blood flow and placental breathing lambs. Arch transfusion during delayed cord clamping in preterm . 2020;105:F26-F32. Ed Dis Child Fetal Neonatal M, et al. Haemodynamic effects Polglase GR, Kluckow Blank DA, sheep during the neonatal umbilical cord milking in premature of 2018;103:F539-F46. Ed. transition. Arch Dis Child Fetal Neonatal cord et al. Umbilical Ananthan A, Jain V, Balasubramanian H, and meta- review A systematic infants: milking in preterm 10.1136/ doi: 2020. Ed. analysis. Arch Dis Child Fetal Neonatal archdischild-2019-318627.

5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. , thus necessitating ® Neonatal cardiac output cardiac Neonatal and heart rate oxygenation Cerebral systemic vascular Neonatal and blood resistance pressure birth weight Neonatal for Bilirubin levels and need phototherapy* and stores iron Neonatal haemoglobin levels deficiency iron of Rates anaemia persisting to six months old Intraventricular haemorrhage enterocolitis Necrotising Periventricular leukomalacia need for blood Haematocrit, transfusion neurological Severe morbidity or mortality onset sepsis* Late oxygenation Cerebral blood flow Cerebral autoregulation and gross Neurobehavioral motor function scores Reduction in: Reduction • • in: Increase • Reduction in: • • in: Increase • • of in rates No difference postpartum haemorrhage of: rates Increased • • • • • • Reduction in: • • • Bhatt S, Alison BJ, Wallace EM, et al. Delaying cord clamping Wallace Alison BJ, S, Bhatt birth cardiovascular function at onset improves until ventilation Physiology. 2013;591:2113-26. lambs. Journal of in preterm onset M, et al. Ventilation Kluckow Polglase GR, Dawson JA, prior to umbilical cord clamping (physiological-based cord in oxygenation systemic and cerebral clamping) improves lambs. PLoS One. 2015;10:e0117504-e. preterm of the M, et al. The influence Keel F, Stolkin Baenziger O, in oxygenation cerebral cord clamping on postnatal timing of . trial. Pediatrics controlled A randomized, neonates: preterm 2007;119:454-9. of Effect PS. Morris T, Dowswell Middleton P, McDonald SJ, on maternal term infants umbilical cord clamping of timing of Rev. Syst Database outcomes. Cochrane and neonatal 2013;2013(7): CD004074.

Cardiovascular transition Effects of immediate vs physiological-based vs physiological-based of immediate Effects cord clamping Infants Term Preterm infants Effects of immediate vs delayed cord clamping of immediate Effects *Conflicting evidence *Conflicting Effects of cord clamping. of cord 1. Effects Table References 1. 2. 3. 4. recommended. Simple measures such as vigorous Simple measures recommended. important as most are the infant of stimulation spontaneously with these measures. babies breathe require babies needing resuscitation Currently, transfer to a Resuscitaire prompt early UCC. However, pilot data suggests resuscitation suggests resuscitation pilot data However, early UCC. andwith the umbilical cord intact is feasible and safe ongoing clinical trials may change the way we provide birth. at not breathing to infants resuscitation BIRTHING medical procedures. informed consentprocess, asitisprovided forother a pregnant person’sautonomyrequires aformal there are alternative options. significant risksassociated withvaginalbirthand The argument,asitismade,states that there are to consentpregnant peopleforvaginaldelivery. The issuehasbeenraisedwhetheritisnecessary to anissuethat requires somefinertools. pregnant people,buttheirsolutiontakes ahammer provision of care (informed decision-making)for for thissteprecognise animportantissueinthe autonomy requireinbirth? What doesrespectfor Melbourne Law School,Vic RANZCOG Trainee andGraduateResearcher BSc, LLB(Hons),MBBSMRMed Dr NaomiHolbeach Barwon Health, Vic Obstetrics andGynaecologyRegistrar, MBBS /LLB(Hons) Dr AnnabelleBrennan Lecturer andBioethicist,DeakinUniversity, Vic PGDipHealSci(Bioethics),PhD BA, Dr EmmaTumilty discuss herongoingcare. at 38.4 degrees, butothervitalsignsare normal.You attend theroom promptly toreview thepatient and and intravenouscannulasplans forphysiologicalthirdstage.You’ve beeninformed thepatient isfebrile outlines herpreference forminimalintervention, includingavoidingcontinuouselectronic fetalmonitoring and wouldlike toconsideranalgesicoptions.Priorseeingthe patient, you review herbirthplan,which On vaginalexamination at home,thecervix was8cmdilated andsheisattending nowasshefeelsexhausted husband, adoulaandmidwife. 20 hours.Becauseof concernsregarding COVID-19, shedecidedtolabourat homewiththesupportof her She hasbeencontractingregularly forover24 hours andhermembraneshavebeenruptured foralmost and reports noothermedicalco-morbidities. She hasnothadthirdtrimestergrowth scansbuthasmeasured appropriately for dates. ShehasaBMIof 40 access toherresults, shereports tothemidwifethat there havebeennoissues throughout thepregnancy. postpartum haemorrhage.Shehashadherantenatal care through alocal birth centre; whileyoudon’thave caesarean forfetaldistress at 8cmwitha4kg babyinocciputposteriorpositioncomplicated bya1000ml It’s 2amonbirthsuiteandanewpatient hasarrivedinlabour. Sheisa38-year-old womanwithaprevious Case 1-2 We believethat thosecalling 1-2 Therefore, torespect decision voluntarily. to understandinformation, andtheymustmake a time- anddecision-specific),theymustbeable must havecapacity(where thisisconsidered requires thedisclosure of information, thepatient perspective, theyare taughtthat informed consent ways relevant tothisdiscussion.From anethical Doctors learnaboutinformed consentintwo capacity inrelation todecisionsasneeded. that labourimpairscapacity, toassess itisnecessary want toemphasisethat itshouldnotbeassumed impaired orfluctuate duringlabour, andwhilewe and responsive actions.Apatient’s capacitymaybe and canbecomeemergent,requiring immediate once labourhasbegun,situations canchangerapidly multiple occasions.Amongstthechallengesare that the variousoptionsincludingrisksandbenefits,on discussions around apatient’s values,goals,and Antenatal care offers opportunitiestohavein-depth information isprovided anddiscussedwithpatients. challenges andopportunitiesforthewaycare and ways inwhichbirthisauniquesituation that presents We hopethat thiscasedemonstrates anumberof 3. 2. 1. Points toconsider: providing agoodoutcomeforherandthefetus. and balancehergoalof minimalinterventionwith that sheideallywantedtoavoid.Nowyoumusttry faced withdiscussinginterventionsapatient This caseischallenging.Asanobstetrician,youare

potential responses tothesemuchearlier? toavoidspecifically,trying andwhy?)the reasons forminimalintervention(what isshe labour, address herspecificrisks,understand the opportunitytodiscusswhat mightoccurin How different doesthiscaselookifyouhad communicating information? navigate possibleimpaired capacitywhen and maydesire analgesia.Howdoyou She’s obviouslytired, inpainandfebrile, you communicate this? Some interventionwillbenecessary, howdo 3 Thesediscussionsfocuson BIRTHING

10-12 13-14 Additionally, Additionally, Despite this, 12 11 Vol. 22 No. 3 Spring 2020 | 18 Vol. note, there is a decline note, there 1 has recently argued that: ‘Empowering a a ‘Empowering argued that: has recently 9 Barriers to using PDAs in Australian obstetric Barriers to using PDAs care. practice/maternal regarding of PDAs of use Most effective timing birth and labour options. Comparison clinician versus other health delivery option/risk information professional of or other means) early in pregnancy (via PDA cost-effectiveness, etc). (efficacy, Dietz HP, Callaghan S. We need to treat pregnant women as pregnant need to treat We Callaghan S. Dietz HP, normal at adults: women should be consented for an attempt with risks and potential delivery, vaginal birth as for operative explained. ANZJOG. 2018;58(6):701-3. complications delivery: An Response to Vaginal Callaghan S. Dietz HP, consent. ANZJOG. 2019;59(1):165. argument against requiring A step further towards consent process: Kadam RA. Informed making it meaningful! Perspectives in Clinical Research. 2017;8(3):107.

It is not always possible for the clinician providing It is not always possible for the clinician providing during labour to have had these conversations care person, but it is important that with the pregnant they has had them. Clinicians can ensure patient and patient clearly with a pregnant communicate but this is the last necessary, seek consent where efforts must make We conversations. step in care begins much earlier and this process to ensure to best be supported through This is likely robustly. and health PDAs collaborations, interprofessional and support. system resourcing needed Research • • • if, as Dietz & Callaghan if, woman with the language of consent and offering consent and offering of woman with the language to empowering her in her women choices is key to motherhood.’ transformation to this philosophy believe this model conforms We and choices cannot consent that by recognising within a communication occur without respectful therapeutic partnership. these early discussions is ensuring The problem decision- Patient happen, and appropriately. birth have a for labour and making aids (PDAs) showing largely encouraging good evidence-base persons can with pregnant outcomes. Using PDAs and anxiety, their knowledge, decrease increase decisional uncertainty and regret. decrease References 1. 2. 3. online reference list avalable Full There is some work to indicate that using PDAs early PDAs using that is some work to indicate There 1 and 2) is most helpful. (Trimesters in pregnant people who will see a doctor during people who will see a doctor during in pregnant to have then finding the opportunity care, antenatal We need to consider this discussion appears difficult. to is provided information the ways in which robust labour, people and their families, before pregnant with Early conversations using tools such as PDAs. their and not only help patients full disclosure they may and what families understand the process but also helps health decisions about, have to make values and goals, understand patient professionals which can aid in their clinical decision making. feeling not Especially when the experience of with listened to is something generally associated those who experience birth as traumatic. they do not seem to be used widely. While some individual procedures during vaginal vaginal during procedures some individual While deliverydelivery consent, vaginal may require (which not. During labour consenting itself does is on what or verbal, depending may be written is what of informed a patient or keeping occurring) a is the end of (in an emergent situation) happening labour. before should have begun long that process Hawke

4,8 6

7 4

5 Negligence is the mechanism by Negligence is the mechanism 4-5 The term ‘informed consent’ combines The term ‘informed 6 If we view information giving within the doctor- If we view information duty discharging that as part of relationship patient consent, it is less than an issue of to warn, rather both aligned with the cases of and more problematic and MontgomeryRogers v Whitaker v Lanarkshire. the requirement that the competent patient gives the competent patient that the requirement so the in doing and that permission for the procedure risk to the expected standard.doctor communicates supports these legal concepts adequately Neither of ethical practice is people’s autonomy, pregnant to achieve this. required and consent familiar with navigating Doctors are procedures. to risks with respect the duty to warn of something done to the usually reflect Procedures to manage a medical complaint. Proposing patient and vaginal birth (which is viewed as a natural that consent, requires inevitable end to a pregnancy) both birth and consent. To challenges our concept of vaginal birth, of the ‘naturalness’ some, it threatens of medicalisation potentially leading to increased section rate. caesarean birth and an increased In practice, however, we see that the concepts of we see that In practice, however, and conflated frequently consent and negligence are confused. the need for informed consent in order to respect a to respect in order consent for informed the need we tend a legal perspective From autonomy. patient’s . Rogers v Whitaker the case of to focus on warn about risks, the duty to case concerned That of a patient a doctor to inform which requires treatment. to a proposed relating risks material patient the reasonable that risks include risks Material this to and risks that significance would attach Failure significance to. attach would particular patient Viewed this care. standard of the to do so breaches is information to warn and provide the failure way, given and the action the care tied to the quality of has suffered the patient that in negligence requires harm as a result. Consent is the permission given by the patient to Consent is the permission given by the patient threshold The the doctor to perform a procedure. the the general character of for valid consent is that the and that was communicated specific procedure consent was given by a person who was competent given. freely decision and it was that to make in trespass, the action the heart of Autonomy lies at provision. information but it has a lower standard of as a In contrast to negligence, no harm need occur with a because the interference the trespass of result person’s autonomy is sufficient. The obligation to provide information to patients to patients information to provide The obligation nor reduced and is neither removed exists separately We therapeutic alternatives. by the unavailability of to have options available to women fortunate are with knowledge about when empowered who may, their bodies and birth, choose which consequences and live with long term. willing to endure they are would want to know about patient The reasonable it, and as a result birth and the consequences of the risks. Some women will is a duty to warn of there have particular concerns or risk factors and require birth on some aspects of detailed information more to others. This does not necessarily require compared an intentional and tailored a consent form but rather with the aim to care antenatal discussion throughout about the journey ahead. patients inform which the law holds clinicians accountable for harm which the law holds clinicians their work. of caused in the course underpin that the principles and values Notably, underpin to those that different negligence are to trespass. which relates consent, the concept of BIRTHING emotional andpsychologicalsequelae. the birth.Thishaspotentialtoyieldlong-term woman’s overallsatisfaction withherlabourand of painrelief used,cansignificantlyinfluence the The levelof painexperienced,andtheeffectiveness Background reference tothemostup-to-date evidence. context of thelabouringwomanforchildbirth,with strategies availabletohealthcare providers inthe This articleseekstooutlinethecommonanalgesic our armamentarium. the bestevidence-basedtherapiesthat wehavein these issuesandtobalancetheminthecontextof As medicalpractitioners,itisimportanttoconsider choice, societalexpectations andculturalfactors. access tospecialisedmedicalresources, individual will determinewhichstrategies are used,including different individualsandcultures. Avariety of factors Analgesic strategies between andpreferences vary pain inasafe andcontrolled manner. medicine that wenowhavetheabilitytomitigate this a patient mayeverendure. Itisatruemarvelof is recognised aspotentiallythemostsignificant The painassociated withlabourandchildbirth safe andeffectiveanalgesiaforwomenduringlabour. haverevolutionised theabilitytoprovide century Advances inmodernmedicineduringthe20th Fiona StanleyHospital,WA Anaesthesia andPainMedicine Consultant Anaesthetist Dr ChrisMcGrath Pain reliefinlabour during thelabour itself. of labourandthesupportnetworks availabletoher previous preparation andeducation of theprocess the environment sheisin,hercultural background, can beinfluenced byherindividual circumstances, to it.Awoman’sexperienceof thepainof labour range of responses and exhibitanequallyvarying Women degrees of paininlabour experiencevarying 2,3 1 summarised intheliterature. degrees of supportingevidence,havebeen varying A varietyof non-pharmacologicalmethods,with Non-pharmacological techniques and safe forboththemotherandbaby. circumstance, itisimportantthat itisbotheffective Regardless of thetechniqueusedforeachindividual’s • • labour into: We cansplittheavailableoptionsforpainrelief in Available strategies andepisiotomy.delivery medical interventionssuchasinstrumentalvaginal presentation, obstructedlabourandtheneedfor labour, aswellcomplicating factorssuchasfetal induced), theaugmentation andduration of by thetypeof onsetof labour(spontaneousversus The requirement forpainrelief isalsoinfluenced • • TENS • Massage andreflexology • Acupuncture • • Continuous support • Hypnosis • Relaxation therapies Brief pointsonthesetechniquesinclude: importance.consent forthepatient isof primary definitive analgesia.Education andinformed limitations withwhat canbepotentiallyless appreciate theirbenefitsbutalsotheinherent caregivers tounderstandthesestrategies, It isimportantformedicalpractitionersand personal preferences orculturalbeliefs. benefit fordifferent individualsbasedontheir Pharmacological techniques Non-pharmacological techniques demonstrate significantanalgesiceffect a systematic review of eightRCTs failed to easy touse itisnon-invasiveand based onthe‘gate-theory’, emotional benefits also distraction,withdata showingphysicaland inhibits paintransmission,provides supportand +/- release natural endorphin needles that mayinhibitpainsignaltransmission stimulates specificpointsonthebodywithfine with theirexperience have painrelief inlabourandbemore satisfied evidence showsthesepatients are lesslikely to psychological experienceof labour requires atrainedsupportpersontoimprove the gain bettercontrol overpain under supervisionfrom atrainedtherapistto involves thepatient enteringahypnoticstate better managepain use one’semotionalcopingmechanismstohelp 4,5 Thesemayhave 5 BIRTHING

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6 Epidural local anaesthetic solutions are administered administered Epidural local anaesthetic solutions are or via patient- either by bolus, continuous infusion higher concentrations pumps. Boluses of controlled local anaesthetic, as used in the earlier years, of dense motor block with more have been associated pelvic tone decreased mobility, in reduced resulting usually the bearing-down sensations and loss of labour. experienced in the second stage of of local anaesthetic (with or without adjuncts such local anaesthetic (with or without adjuncts such of as fentanyl). close to the spinal The local anaesthetic is delivered stimuli from normally transmit painful nerves that the contracting uterus (visceral pain) and vaginal pain). Local anaesthetic canal (visceral and somatic inhibits nerve conduction by blocking sodium preventing channels in nerve membranes, thereby to signals along these nerve fibres of the propagation the the central nervous system, thus aiming to render during her labour. comfortable woman more Epidural analgesia was first used in obstetric practice in recent in 1946 and its use in labour has increased women choosing it in 40% of decades with around Australia in 2018. Pethidine rapidly crosses the placenta and the and the the placenta crosses rapidly Pethidine occur 2–3 hours plasma concentrations highest fetal Respiratory administration. depression maternal after due to immature neonate in the likely is more concentration free-drug greater respiratory centres, and ion trapping. Morphine used parenteral Morphine is another commonly use for labour has widespread opioid that 2.5–5mg IV at is titrated analgesia. The dose used effects for morphine are or 5–10mg IM. The side similar to pethidine, although dose-dependent and do not have convulsant effects morphine metabolites the pethidine. Morphine rapidly crosses those of like in results elimination placenta but rapid maternal lower fetal drug load. PCA Remifentanil analgesia (PCA) is Remifentanil patient-controlled fentanyl of opioid derivative an ultra-short-acting is rapidly that analgesic properties with strong blood cell and tissue esterases. metabolised by red so the drug is non-saturable, These enzymes are time. over and does not accumulate short-acting the for Remifentanil PCA is a useful alternative strategies definitive labouring parturient when more unavailable or analgesia are such as regional a higher degree It is does require contraindicated. monitoring, expert midwiferyof and close medical to supervision during set up and ongoing use, safety. ensure involves a 30µg IV bolus of A typical regimen over 60 seconds with a two- delivered remifentanil pump programmed a dedicated, from minute lockout good device. Remifentanil PCA has demonstrated analgesic effect and outcomes, moderate neonatal satisfaction. patient of high degrees techniques 3. Regional Epidural analgesia Epidural analgesia is a nerve blockade technique via Tuohy involves siting an epidural catheter that lumbar the lower needle into the epidural space of the spine and the subsequent injection of region

6 It also causes dose-dependent 5 gravid uterus in sterile water 0.1ml injection of involves the four points over the sacrum in pain during labour but potential reduction it as women do not rate other evidence shows strategies effective as other analgesic the sensation of warm water is postulated to to is postulated warm water of the sensation the signals as well as support inhibit pain respiratory depression and hypoventilation. respiratory depression Nitrous oxide has a low blood gas solubility, meaning low blood gas solubility, has a oxide Nitrous with blood, is rapidly washed- it rapidly equilibrates ceased. in during use and rapidly washed-out when 10 full use is important, with around The technique of achieve to required or 50 seconds breathing breaths maximum effect. that in 2012 demonstrated A Cochrane review than placebo, better pain relief provided Entonox dizziness, drowsiness, with more but was associated in no differences were nausea and vomiting. There between people rates or caesarean in Apgar scores and those who had a placebo or who used Entonox no treatment. limited benefit Other studies have shown more even though that it is postulated and with Entonox analgesia may not be significantly improved, may be maintained or improved satisfaction maternal to with this technique as it enables the patient their own analgesia. control 2. Opioids Pethidine Pethidine has a long history use and is the most of opioid. Its typically widely used and investigated IM. Studies analgesic dose is 1mg/kg administered of pethidine the efficacy have shown midwives rated it and it is thought than the women receiving more the side to some of this may be attributable that confusion of control, of loss effects for the patient and sedation. Intradermal injection of sterile water Intradermal • • of the above techniques Reported effectiveness such Strategies studies. varies between different and hypnosis acupuncture as immersion, massage, for pain management in may be helpful therapies and such as aromatherapy Other techniques labour. but for some patients, a role may have homeopathy definitive benefit. has demonstrated no data Pharmacological techniques Pharmacological analgesic methods include opioids and parenteral oxide, nitrous of inhalation epidural anaesthesia in the form of also regional and combined-spinal-epidural during labour. the most analgesia in labour remains Non-regional used method worldwide. frequently 1. Inhalational methods Entonox been used in have mixtures oxide/oxygen Nitrous (50% nitrous Entonox obstetric practice since 1880. in obstetric ubiquitously is located in oxygen) oxide the world and has a long track units throughout for the labouring parturient. 53% safety of record in analgesia labouring women used this form of of Australia in 2018. Immersion • BIRTHING A CochraneReview ofrecentevidence Brief summary maintained through theremaining duration of labour. of epiduralanalgesiawhere continuinganalgesiais and more reliable analgesia),withtheadvantages (faster onsetof painrelief from thetimeof injection CSE combinestheadvantagesof spinalanalgesia subsequent insertionof anepiduralcatheter. fentanyl) intothesubarachnoidspace,aswell injection of localanaesthetic(withorwithout Combined spinal-epidural(CSE)involvesasingle Combined spinal-epiduralanalgesia assisted vaginalbirth,suchastheuseof forceps. also preserves herabilitytobeardownandavoidan enables thepatient tomoveherlegsmore freely and preserved agreater degree of motorfunction.This has seeneffectiveanalgesiamaintainedandalso of localanaestheticincombination withopioid More recently, atrend tousealowerconcentration • • Key Findings to thereview. than 11,000 womenthat contributedinformation labour. Theyassessedover40trialsinvolvingmore compared withnon-epiduralornopainrelief during (including CSE)onthemotherandbaby, when effectiveness of allkinds of epiduralanalgesia been introduced as patient-controlled epiduralanalgesiahave and more modernepiduraltechniquessuch of lowerconcentrations of localanaesthetic studies conductedafter 2005, where theuse birth; however, thiseffectwasnotseenin may bemore likely tohaveanassistedvaginal have anepiduralinsteadof opioidanalgesia Early studiesdemonstrated somewomenwho relief compared toother, non-epiduralmethods and increases maternal satisfaction withpain during labour(asexpressed bylowerpainscores) analgesia maybemore effectivein reducing pain Low-quality evidenceshowsthat epidural you explore online. Find similararticleswhen 7 7 in2018setouttoassessthe

for thepatient, isimportant satisfaction andtooptimisetheoverallexperience analgesic strategies toensure safety, maintain expectations of eachindividualwitheffective rewarding experience.Balancingtheneedsand Certainly, childbirthshouldbeanextremely experiences awomanmayendure inherlifetime. has thepotentialtobeoneof themostpainful Labour andchildbirth,intheabsenceof analgesia, Conclusion • • • 7. 6. 5. 4. 3. 2. 1. References

women inopioidanalgesiagroups more likely tohaveoxytocin augmentation than first andsecondstages of labour, andwere Patients withanepiduralalsoendured longer retention blockade, feverandurinary epidural, includingmore hypotension,motor Side effectswere reported inpatients with to neonatal intensivecare determined byApgarscores) orinadmissions an immediate effectonneonatal status (as term backacheanddidnotappeartohave of caesarean sectionorincidenceof long- Epidural analgesiahadnoimpactontherisk Cochrane Database Syst Rev. 2018;5:CD000331. non-epidural ornoanalgesiaforpainmanagementinlabour. Anim-Somuah M,SmythRMD, Cyna AM.Epiduralversus 36. Cat. no.PER108. Canberra:AIHW. mothers andbabies2018:inbrief. Perinatal statistics seriesno. Australian Instituteof HealthandWelfare 2020. Australia’s Pain. 2005;5(1):9-13. techniques. Continuing Education inAnaesthesia,CriticalCare& Fortescue C,Wee M.Analgesiainlabour:non-regional Cochrane Database Syst Rev. 2006;2006(4):CD003521. and alternative therapiesforpainmanagementinlabour. Smith CA,CollinsCT, Cyna AM,Crowther CA.Complementary 2000;37:493-503. influencing personalcontrol inpain relief. Int JNursingStudies . McCrea H, Wright ME,Stringer M.Psychosocialfactors . Drugs.1999;41(1):69-80. Brownridge P. Treatment optionsfortherelief of painduring labour pain.UgeskriftforLaeger.2002;164(42):4927-9. Christiansen P, KlostergaardKM,Terp of MR,etal.Long-memory BIRTHING

1 Allan would 4 Vol. 22 No. 3 Spring 2020 | 22 Vol. In many ways, 2 New Zealand has had New Zealand 3 5 a similar publicly released report since 2012, the New report a similar publicly released Clinical Indicators. Maternity Zealand Allan and his work established outcome reporting outcome reporting Allan and his work established would what of forerunner the were practices that Council on Obstetric become Victoria’s Consultative and Morbidity (CCOPMM), Mortality and Paediatric – and essence, Allan asked established in 1962. In we?’ are continues to ask – ‘how good CCOPMM times, as with other branches of recent In more has outcome reporting pregnancy healthcare, There evolved to embrace performance indicators. distinguish that features key a number of are traditional outcome from performance reporting typically, are, First, performance indicators reporting. granular level – by health service a more at reported Second, or nation. than by state or hospital rather so-called benchmarking, comparative, they provide de- This has been traditionally done using data. an individual hospital so that identified data others, of knows only its own identity but not that Health Roundtable or from such as in the reports Australasia (WHA). However, Healthcare Women’s agencies, number of this is changing. An increasing seeking identified including government, are Benchmarking allows individual hospitals reporting. also ‘how we?’ but to ask not only ‘how good are to others?’ For example, we compared good are Services Performance in Victoria the Perinatal clinical comparative (PSPI) has reported Indicators by individual hospital on over ten performance data for almost 15 years. indicators be proud. He argued for central oversight of health He argued for central oversight of be proud. of the problems many performance, finding that is no central because ‘there in 1920s Victoria were State.’ of the the health affairs authority controlling However, being government-led in itself doesn’t being government-led in itself doesn’t However, leads to improved performance reporting that ensure or territory, state national, outcomes. Whether at clarity can be lack of or health service level, there So often drive improvement. about how such data opportunities for improvements in care. Only a few in care. opportunities for improvements of called for the creation Allan had years earlier, to improve essential measure clinics as an antenatal outcomes. and maternal perinatal Very similar findings to Allan’s were made nearly a similar findings to Allan’s were Very Victorian of a report Zero, century in Targeting later by public hospital clinical governance, itself triggered service failure. a maternity Allan’s 1 Obstetric practice has a long tradition of recording recording Obstetric practice has a long tradition of may senior readers outcomes. More and reporting labour ward the large leather-bound remember everyledgers into which details of mother and birth 1). In Victoria, handwritten each day (Figure were foundational provided those meticulous chronicles to Dr Marshall Allan, newly recruited information for his inquiry Brisbane in 1925, to Melbourne from into Victorian obstetric outcomes, commissioned concerns. quality and safety because of Dr Roshan Selvaratnam Dr Roshan and student at Monash University MD-PhD Care Victoria Safer performance reporting performance Quality and safety safety and Quality inquiry, and similar activities in New South Wales and South Wales and similar activities in New inquiry, the formal beginnings in Australia Queensland, were being used to identify obstetric outcome reporting of Excerpt of a labour ward birth register, c1870. a labour ward birth register, of Figure 1. Excerpt Prof Euan M Wallace AM Prof Euan M Wallace FAHMS FRANZCOG, FRCOG, MBChB, MD, Professor and Head of Department of Carl Wood Monash University Obstetrics and Gynaecology, BIRTHING born after 40weeksgestation (Figure 2). fold reduction intherate of babieswithsevere FGR fetal growth restriction (FGR)there hasbeenafour- measure designedtoimprove thedetectionof severe some indicators. Forexample,bypubliclyreporting a an approach appearstobeworking–at leastfor government, and,more recently, consumers.Such partnerships betweenclinicians,healthservices, implemented. Thishasyieldedgenuineandtrusted the improvement activitiesare locallydesignedand support forimprovement. But,andthisisimportant, expected, offering insightsfrom otherservicesand phone’ toserviceswhere outcomesare poorer than they shouldbereported. Governmentthen‘liftsthe clinicians decidedwhat data were relevant andhow clinicians. From beginningsof thePSPI, thevery care. Centraltothisapproach isengagementwith opportunitiesforimproved approaches toidentifying level –aspublishedinthePSPIoneof itskey performance reporting at thehealthservice healthcare improvement agency, hasused Over recent years,Safer Care Victoria,thestate’s ‘Knowing isnotenough.We mustapply.’ by that? AstheGermanphilosopherGoetheopined, for compliance.Howare patient outcomesimproved reporting almostforthesake of reporting. Orworse, seem usefultotheclinicianorconsumer–data in healthcare weare surrounded bydata that don’t Figure 2.Improvement insevere FGRdetectioninVictoria. by 24%. the rate of stillbirthamongthesebabieshasfallen had reached aceiling. was retired in2009becausecliniciansadvisedthat it 83% in2001to90%2008, suchthat theindicator Victorian publicmaternity servicesincreased from before 34weeksgestation. Performanceacross PSPI wastherate of antenatal steroid administration could be better targeted. For the last three years, the could bebetter targeted. Forthelastthree years,the were that were sustainingOASI sothat interventions They wantedbetterinsightsinto whothewomen indicator wasn’tuseful,at leastinitscurrent form. (Figure 3).Cliniciansadvisedthat theperformance in thePSPI, buttherate hasbeenrising,notfalling tears instandardprimiparaehas alwaysbeenreported (OASI). Therateinjury of third-andfourth-degree need toreduce therate of obstetricanalsphincter In more recent times,clinicianshavehighlightedthe 6 Similarly, alongstandingindicator inthe 7

6 As a result, Asaresult, 6

(adapted from Selvaratnam etal.BJOG.2019;127:581-9). measurable goals. have avisionfortheirimprovement withclear, of highperforminghealthservicesisthat theyeach – ‘howgooddowewanttobe?’Oneof thehallmarks to others?’,underpinssuccessfulqualityimprovement ‘how goodare we?’and‘howgoodare wecompared This introduces thethirdquestionthat, togetherwith collaborative wastoreduce therate of OASI by20%. national improvement collaborative. Theaimof the and ClinicalExcellence Commission(WHA-CEC) participated inaWomen’s Healthcare Australasia Queensland, SouthAustraliaandWestern Australia, along with18otherhospitalsinNewSouthWales, funded bySafer Care Victoria,10Victorianhospitals, assisted vaginalbirth.Applyingthisknowledge,co- the needtoreduce OASI amongwomenhavingan vaginal birth(Figure 3).Thishasmademore visible primiparae whohavehadanunassistedorassisted degree tearshasseparately reported therate for PSPI performanceindicator forthird-andfourth- in womenhavinganassistedvaginalbirth. WHA-CEC collaborative sawan18%reduction inOASI of outcomeslinked togovernmentactionmay be Indeed, wehavearguedthat transparent reporting desire of clinicianstobeasgoodthey canbe. to intervention,and,bestof all,harnessestheinnate variation inoutcomesmore visible andaccessible This allowstransparent benchmarking, makes health servicesbynameandbe publicly accessible. hospitalsor performance reports shouldidentify designof themeasures. Next, clinicians inthevery This requires theinvolvementof consumersand what actionsorinterventionsmightimprove care. clear insightstobothconsumersandcliniciansof good proxies foroutcomesof importanceandgive most. Ashortlistof measures shouldrepresent meaningful tothoseforwhomtheyshouldmatter or regulation. Second,theindicators shouldbe for performanceimprovement, notcompliance First, tobeclearaboutthepurpose.Itshould of performancereporting toimprove outcomes? So, what are somelessonsforthesuccessfuluse clinicians, supportedbygovernment. Victorian maternity services,ledbyconsumersand work isnowbeingspread more widelyacross other perineal tearintheparticipating hospitals. 500 fewerwomensustainedathird-orfourth-degree 8 With an improvement goal set, the Withanimprovement goalset,the 9 9 This This Almost Almost BIRTHING - Vol. 22 No. 3 Spring 2020 | 24 Vol. Allan R. Report on Maternal Mortality and Morbidity in the State Mortality and Morbidity in the State Allan R. Report on Maternal Victoria. Med J Aust. 1928;6:668-85. of clinics. Med J Aust. 1922;2:53-4. Allan R. The need for ante-natal et al. Victorian perinatal TE, Davey M-A, Ryan-Atwood Hunt RW, Care Melbourne: Safer 2018–19. services performance indicators bettersafer from: Available Victoria, Victorian Government; 2019. care.vic.gov.au/sites/default/files/2019-02/Vic%20perinatal%20 services%20performance%20indicators%202017-18.pdf. Clinical Indicators Maternity Ministry Health. New Zealand of www. from: Available Ministry Health; 2019. of Wellington: 2017. health.govt.nz/system/files/documents/publications/new- zealand-maternity-clinical-indicators-2017-jul19.pdf. supporting zero: Targeting Cuddihy M, Newnham H. S, Duckett avoidable harm the Victorian hospital system to eliminate the Review of Report of care. quality of and strengthen Victoria. Melbourne: and Quality Assurance in Hospital Safety Health and Victoria Department of Government of State www.dhhs.vic.gov.au/ from: Available Human Services; 2016. publications/targeting-zero-review-hospital-safety-and-quality- assurance-victoria. et al. Does public reporting Anil S, Davey M-A, RJ, Selvaratnam clinical improve restriction fetal growth the detection of of BJOG. 2019;127:581-9. cohort study. outcomes: a retrospective services performance Health. Victorian maternity Department of health.vic.gov.au/about/ from: 2009-10; 2012. Available indicators publications/researchandreports/Victorian%20maternity%20 service%20performance%20indicators%202009-2010. the England quality in Improving J. Dixon Ham C, Berwick D, 2016. Fund; for action. England: The King’s A strategy NHS: www.kingsfund.org.uk/sites/default/files/ from: Available field/field_publication_file/Improving-quality-Kings-Fund- February-2016.pdf. Perineal Australasia. Reducing Harm from Healthcare Women’s 2020. Collaborative. Success WHA National Celebrating Tears: women.wcha.asn.au/collaborative/evaluation. from: Available

References 1. 2. 3. 4. 5. 6. 7. 8. 9. compare themselves to others, setting new goals for new goals setting to others, themselves compare Care for Safer The next step will be improvement. identifyVictoria to hospitals and high performing with others. their strategies share a general framework we have provided In summary, can drive purposeful reporting for how performance just about reporting It is not improvement. by weighing it. It is a cow can’t fatten outcomes. You all involved in maternity of the collaboration through clinicians, and foremost), – consumers (first care experts, improvement health service executives, can performance reporting and government – that and drive improvement, be harnessed to target births for all women and safer delivering better and the work just an evolution of their babies. This is all his colleagues first formally Marshall Allan and that began almost a century ago. (adapted from PSPI reports) (adapted from

6 Benchmarking Benchmarking 6 also allows health services and government to set health services and government also allows like goals for improvement, evidence-informed or the 20% reduction in OASI the 20% reduction by the Stillbirth established recently in stillbirth Baby the Safer (CRE) for Excellence of Centre This clear and collaborative. Bundle improvement stillbirth of the rate measurable goal to reduce Victoria, Care by Safer been adopted has already and Commission, the NSW Clinical Excellence us to Queensland. This takes Clinical Excellence to the improvement government action. Central government to not approach agenda is the need for to act but rather underperformance punitively, be To and improvement. change as an enabler of need to be initiatives successful, improvement Formal care. the providing are who those by designed such as the WHA-CEC collaboratives, improvement CRE Safer or the Stillbirth perineal tear collaborative clinicians and consumers Baby Bundle, begin with to work in likely are interventions advising on what critical Government then plays a their environment. learning shared of in leadership and coordination role health services, supporting across and collaboration in training activities and providing improvement methods. formal improvement of central government less visible, benefit Another, any unintended consequences of oversight is that For can be detected quickly. initiatives improvement FGR in severe detection of example, the improved a cost. The cost has been a four- Victoria has come at early delivery of in the rate for normal fold increase admission of babies and a doubling in the rate grown unit. care intensive these babies to the neonatal of all that is required for improvement. is required all that Such unintended consequences are often not readily not readily often Such unintended consequences are but, due an individual health service level at apparent visible to a system level, they are to larger numbers at and government. This allows the rapid development so-called – measures compensating of introduction – whose purpose is to monitor balance measures unintended consequences. This year, and mitigate Victorian in the PSPI, reporting routine as part of a new balance measure hospitals will be provided harm in their to monitor the unintended ‘collateral’ alongside the FGR. When reported detection of FGR detection, hospitals severe of existing measure will be able to see both their sensitivity and specificity FGR detection in tandem. And they will be able to of Rates of third- and fourth-degree tears in Victoria. third- and fourth-degree of Rates Figure 3. BIRTHING of reproductive ageworldwide. haemorrhage (PPH);stillthebiggestkillerof women The commonestobstetricemergencyispostpartum life of amotherorbaby, are relatively infrequent. emergencies, where there isadirect threat tothe Intrapartum andimmediate postpartumobstetric SMO O&GSunshineCoastUniversity Hospital,Qld BSc, MBBS,MPH, FRANZCOG Dr RachaelNugent Sunshine Coast,Qld Griffith UniversitySchoolofMedicine, Clinical SubDean SMO O&GSunshineCoastUniversity Hospital FRANZCOG, FACM(Hon) A/Prof EdwardWeaver OAM labour wardemergencies Training andsimulation: result in powerful learning experiences. result inpowerfullearningexperiences. used effectively, simulation-based education can to ensure competenceinsafe patient care. When management of infrequently occurringemergencies, maternity care staff routinely traininthecorrect or twiceinacareer, ifat all.Becauseof thisrarity, midwives willonlyseesomeof these conditionsonce incidence) are infrequent, andmanyobstetricians than 0.5% incidence),uterineinversion(less than 0.1% labour (lessthan0.5% incidence),cordprolapse (less emergencies, suchasplacentalabruptionduring interactive manner.’ substantial aspectsof thereal worldinafully guided experiencesthat evoke orreplicate real experienceswithto replace oramplify ‘Simulation isatechnique,nottechnology, 1

2 Other intrapartum Otherintrapartum

and improving knowledgeandskills, with apositiveimpactoncollaborative teamwork, errors. Arecent metanalysisshowedIPE isassociated continue tobe,frequent causesof harmful medical and interprofessional communication were, and where itwasrecognised that failures of teamwork in IPEgrew outof thepatient-safety movement, sort of traininglocally. available inAustraliaandNZ2013providing this al estimated that there were 12different courses Zealand (NZ)overthepast10–15years.Calvertet management haveproliferated inAustraliaandNew training, avarietyof coursesinobstetricemergency To provide thissortof teams-basedsimulation in AustraliaandNewZealand Obstetric emergencytrainingcoursesavailable that often existamonghealthcare groups. shown toreduce thebarriersandpreconceptions and improve healthoutcomes’. with eachothertoenableeffectivecollaboration two ormore professions learnabout,from and interprofessional education (IPE)asoccurring‘when The World Health Organization defines patient care Interprofessional educationandimproved of a(rare) emergency. know howtoescalate apatient’s care intheevent are familiarwiththeirworkingenvironment and improve CRMskillsandtoensure that participants 3 program. PROMPTanditspeersare designedto continue, utilisingtherecently upgradedPROMPT midwives, andhashadwidethat islikely to championed bysomededicated cliniciansand In NZ,thecoursegrew more organically, being and Queenslandwithlessuptake intheotherstates. in different jurisdictions, remaining strong inVictoria licence toRANZCOG. Uptake sincehasbeenvariable the PROMPTMaternity Foundation UKandgiftedthe purchased theAustralianLicenceforPROMPTfrom 2010, whentheVictorianManagedInsuranceAgency PROMPT wasformallyintroduced intoAustraliain ofPROMPT inAustraliaandNZ History internationally bythePROMPTMaternity Foundation. NZ isPROMPT, aUK-developed course,nowrun most widelyundertaken courseinAustraliaand interprofessional immersivesimulations. The teaching competency-basedsimulations tolarge, use simulation inavarietyof settings,from a deteriorating clinicalsituation. Thecourses communication, andimproved awareness of principles, are basedonCrisisResource Management(CRM) Many of thecitedcoursesshare similarities:they Obstetric, Neonatal Training). Crisis Resource RiskManagement),andFONT(Fetal, Trauma), NOVICE, INTIME,MACRRM (Maternity MOET (ManagingObstetricEmergenciesand Training), ALSO(AdvancedLifeSupportinObstetrics), as PROMPT(PracticalObstetricMulti-Professional 4 andemphasiseteamtraining,improved 3 Theseincludecoursessuch 5 Therecent interest 7 andhasbeen 8

6

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18 Vol. 22 No. 3 Spring 2020 | 26 Vol. Further robust robust Further 9,17

to ensure units of varying units of to ensure 19 A library of resources to be used for case- to be A library resources of learning. These cases allow based peer-assisted other emergencies not currently of exploration by PROMPT (e.g. mental health covered violence and difficult emergencies, occupational interactions). Case-based learning will patient other training, such as also allow embedding of within the cases. interpretation CTG to use for performing resources A suite of in hospitals, simulations various types of including: – Skills-based SIMs to cover skill gaps in delivery including breech various staff, and shoulder dystocia will be developed that – immersive simulations and scripted, allowing engagement with in the other hospital teams who have roles obstetric emergencies team management of anaesthetists, obstetric (e.g. neonatologists, emergency medicine staff. physicians, ICU staff, SIMs, which will be familiarisation Workplace familiar are all staff that designed to ensure can operate with their working environment, emergency equipment, and can easily access workplace instructions, policies and procedures. acuity and resources can access the materials can access the materials acuity and resources with the course. associated to be programs as a suite of is designed MOTHER tool to run in hospitals, primarily as an educational care teams-based training for maternity facilitate work. These resources in their place of providers will feature: a. b. c. A course such as this allows a hospital to work courses to and develop bespoke with RANZCOG particular workplace activities to address undertake an adverse outcome to needs such as simulating of the rollout or simulating went wrong, see what (e.g. Category new policy initiatives 1 CS protocol positive woman). The emphasis of in a COVID-19 and attainment is on the educational MOTHER in the clinical skills of improvement incremental simulation-based training program in Tanzania in Tanzania training program simulation-based 2.1–1.3%. from in PPH 38% reduction in a resulted The authors commented that this is particularly commented that The authors anaemia of prevalence with a high region crucial in a simulation-based banking. While blood and lack of intervention medical can prevent team training it may that settings, it is possible in low-resource environment, it in the high-resource increase to PPH. particularly with respect research is required to investigate the use of the use of to investigate is required research range of its impact on a broad training and simulation outcomes. and neonatal maternal The MOTHER course commissioned Board has The RANZCOG Obstetric a Multi-professional development of (MOTHER) in Hospital Emergency Response Training deficiencies in perceived course to address to specifically enhance and available resources multi- broader simulation, of the incorporation Further, disciplinary and online delivery. involvement the need for content that the Board recognised needs, adapted to meet unique local could be readily Islander and Strait including Aboriginal and Torres and Māori health and the challenges facing rural services. healthcare remote in different delivered activities are Simulation learning goals. MOTHER each with different formats, as realistic adopts the ARRON rule (as reasonably objectively needed),

10

12 11 Several 13 This analysis 10 associated associated 17

17 Participants in PROMPT Participants 9 or trauma while subsequent review safety and improved and improved safety 9 14-16 9,10 Training healthcare professionals that that professionals healthcare Training 10 Both authors hypothesised that these outcomes Both authors hypothesised that recognition and by increased affected were management. In the same willingness to escalate morbidity for action can decrease readiness way that with shoulder dystocia, it can increase associated to PPH. medical intervention with respect these findings are that It is important to recognise setting. Deliveryof a specific to a high-resource other authors have also demonstrated a reduction a reduction other authors have also demonstrated brachial plexus injury, of know how to adapt within a team to an evolving know how to adapt within that may help to ensure emergency clinical situation the professionals from care receives each patient most suited to their needs. poor workplace evidence that is accumulating There outcomes. patient can lead to worse culture The described increase in invasive management alignsThe described increase randomised a Dutch multicentre with findings from trial examining a one-day simulationcontrolled was associatedcourse, which showed attendance with four or treatment of with a two-fold increase embolisation blood transfusion, cells of packed more a PPH. in the case of or The reduction of complications associated with the associated complications of The reduction shoulder dystocia appears a clear management of training. with team simulation benefit associated Bristol showed published from data Twelve-year yearly team training using PROMPT methodology permanent brachial with no cases of was associated plexus injury follow up, four years of in the last vaginal births. than 17,000 involving more of retrospective data examining outcomes pre- and examining outcomes pre- data retrospective of post-delivery PROMPT in Australia suggested no of change in a composite overall outcome. report skill acquisition across multiple domains multiple across skill acquisition report communication, in principles and an improvement an emergency in and prioritisation leadership situation. Staff attending PROMPT have reported significant significant reported have PROMPT attending Staff teamwork, in increases Workplace culture can be difficult to change, as it can be difficult to change, culture Workplace leadership, ineffective human poor of can be a result workplace practices, practices, entrenched relations Training in to complain. staff of and a reluctance for senior it is mandated assuming that simulation, an opportunity to tackle offers to participate, staff ways. these issues in innovative Clinical outcomes following team training teamwork improved of Despite a clear demonstration with teams-based and skill acquisition associated with respect data is mixed training, there simulation Cochrane clinical outcomes. A recent to improving providers healthcare interactive training of of review emergencies life-threatening on the management of low or in hospital found existing evidence was of a regarding and suggested uncertainty very quality, change in clinical practice change to morbidity rates, care. of outcomes or change in organisation with the management of shoulder dystocia following shoulder dystocia with the management of training courses. simulation training courses on simulation The impact of Initialother clinical outcomes is less impressive. the PROMPT Australian pilot of review retrospective Apgar 1, cord lactate of suggested an improvement and baby’s stay, length of did demonstrate an increase in rates of transfer to of in rates an increase did demonstrate of (OT) in rates and an increase theatre operating PPH. severe Bakri balloon use for management of perception of management. of perception BIRTHING its impactonclinicaloutcomes. to assessbothitseffectivenessasatrainingtool,and linked withtheintroduction of theMOTHER course outcomes. Itisessentialthat adequate evaluation is poorer mentalhealthintraineesandworsepatient and bullying,whichhasalsobeenshowntolead less tangibleproblems, suchasworkplaceculture management andprocedural skills,butalsototackle in obstetricemergencytrainingtoupskillclinical educational approaches toassistallstaff involved an opportunityforRANZCOG toemploydifferent The introduction of theMOTHER courseprovides continue tobeassessed. associated withteams-basedsimulation trainingmust of unintendedandunanticipated consequences and procedural competenceisevident,thepossibility importance of improving teamwork,communication current modelsof trainingexamined.Whilethe and furtheranalysisof outcomesassociated with improving obstetricoutcomesshouldbeencouraged, outcomes. Further simulation research focusedon the impactof teams-basedsimulation onclinical to recognise thelimitedexistingevidencetoexamine shoulder dystociaandbreech delivery. Itisimportant of skills-basedprocedures suchasmanagementof well asimproved clinicianconfidence intheexecution communication andteamworkarisingfrom IPEas resource management.Itsbenefitsincludeimproved role inmodernobstetricemergencytrainingandcrisis Teams-based simulation trainingplaysanimportant Summary requirements of theunit. complexitytocater tothe and casesof varying participants, withclearlyoutlinedlearningobjectives, 4. 3. 2. 1. References

anaesthesia. BJA.2010;105(1):3-6. Gaba D. Crisisresource managementandteamworktrainingin Obstetric Simulation Training. ANZJOG. 2013;53(6):509–16. Calvert KL,McGurganPM,DebenhamEM,etal.Emergency brief_8_per-82.pdf.aspx gov.au/getmedia/b59e8c8c-2b78-4f13-8b70-b46814a7e9ee/ 8. Postpartumhaemorrhage.Available Primary from: www.aihw. National Maternity Data DevelopmentProject. Research briefNo Health Care.2004;13(Suppl1):i2–i10. Gaba D. Thefuture visionof simulation inhealthcare. QualSaf you explore online. Find similararticles when 19. 18. 17. 16. 15. 14. 13. 12. 11. 10. 9. 8. 7. 6. 5.

2003;102(2):388-92. for traininginobstetricsandgynecology. ObstetGynecol. Macedonia CR,GhermanRB, Satin AJ. Simulation laboratories Childbirth. 2017;17(1):301. intervention studyinalow-resource setting.BMCPregnancy and managementof postpartumhaemorrhage:aneducational patient outcomeafter simulation-based traininginprevention Nelissen E,ErsdalH, MdumaE,etal.Clinicalperformanceand trial. BJOG.2017;124(4):641-50. patient outcome:amulticentre, clusterrandomisedcontrolled training formulti-professional obstetriccare teamstoimprove Fransen AF, vandeVen J, SchuitE,etal.Simulation-based team Obstet Gynecol.2011;204(4):322-e1. training ontheincidenceof brachialplexusinjury. AmericanJ Inglis SR,FeierN, ChetiyaarJB, etal.Effects of shoulder dystocia Gynecol. 2011;205(6):513-7. introduction of ashoulderdystociaprotocol. AmericanJObstet Grobman WA, MillerD, Burke C,etal.Outcomesassociated with Childbirth. 2018;18(1):361. the pedagogicalpractice–atimeseriesstudy. BMCPregnancy obstetric outcome,clinicalmanagement,staff confidence, and simulation-based shoulderdystociatraining–impacton Dahlberg J, NelsonM,Dahlgren MA,etal.Ten yearsof interrupted time-seriesstudy. BJOG.2016;123(1):111-8. yearsof shoulderdystociatraining:an brachial plexusinjury—12 Crofts JF, LenguerrandE,BenthamGL,etal.Prevention of Rev. 2019;9(9):CD012177. threatening emergenciesinhospital.Cochrane Database Syst training of healthcare providers onthemanagementof life- Merriel A,FicquetJ, BarnardK,etal.Theeffects of interactive systematic review protocol. BMJOpen.2016;6(12):e013758. organisational andworkplacecultures, andpatient outcomes: Braithwaite J, Herkes J, LudlowK,etal.Association between mixed methodsstudy. BMJOpen.2018;8(2):e017451. patient outcomesinAustraliausingKirkpatrick’s framework:a Practical ObstetricMulti-Professional Training anditsimpacton Kumar A,Sturrock S, Wallace E,etal.Evaluation of learningfrom 2014;121(13):1710-8. intomaternity unitsinVictoria,Australia.BJOG. (PROMPT) introducing practicalobstetricmulti-professional training Shoushtarian M,BarnettMcMahonF, FerrisJ. Impactof Qual PrimCare.2012;20(3)231-8. interprofessional education module:students’perceptions. Cusack T, O’DonoghueG.Theintroduction of an Kaohsiung JMedSci.2018;34(3):160-5. education inhealthcare: Asystematic review andmeta-analysis. Guraya SY, BarrH. Theeffectiveness of interprofessional to quality. Washington, DC:National AcademiesPress, 2003. Institute of Medicine(US).Healthprofessions education: abridge action/en/ 2010. Available from: www.who.int/hrh/resources/framework_ and collaborative practice.Geneva:World HealthOrganization, WHO. Framework foractiononinterprofessional education BIRTHING per 6 2 Warning Warning 4 The anterior 3 and 0.04 5 Vol. 22 No. 3 Spring 2020 | 28 Vol. and the former can 7 shoulder becomes impacted behind the symphysis pubis during vaginal birth, delaying delivery the of additional the head is born and requiring body after axial traction. beyond routine manoeuvres allow delivery of the posterior shoulder. Subsequent allow delivery the posterior shoulder. of minute after delivery morbidity minute after the head. Maternal of to PPH and perineal trauma. related is often shoulder The most crucial steps in management of the diagnosis to the room, stating dystocia are the call for help and commencement of directing favourability initial management, which is to improve to bisacromial pelvic diameters in relation of fours’) or McRobert’s diameters. Gaskin (‘all (‘knees to nipples’ position) may resolve manoeuvre shoulder dystocia up to 90% of signs may include slow progress and crowning or and crowning signs may include slow progress consequences can the head. Neonatal ‘turtling’ of injury, and hypoxic fractures include Erb’s Palsy, with fetal pH falling by between 0.011 skills. This clinician could be from any discipline or be from skills. This clinician could a team leader effectively seniority level. Observing emergency is empowering and manage an obstetric they bring in their direction, inspiring. Calm and clear with a confident the situation to control a sense of With and patients. tangible to colleagues presence they simultaneously assess awareness, this situational or treatment and provide care escalate the patient, with the woman tasks while communicating delegate They must guard against and her support person. rapport and have ‘tunnel vision’ or task fixation, and her with the clinical team, the birthing woman to be support person, allowing concerns or ideas further contributing to an overall coordinating aired, or ‘helicopter view’ and optimising outcomes. Being the only clinician in the hospital to provide responder management is an everydayfirst reality for healthcare our widely dispersed rural and regional With obstetricians, anaesthetists and theatre workers. identify to on call, the threshold teams remotely an lower emergency or call for help may need to be – sometimes, this can to consider local resources In city hospitals, and role-shifting! creativity require those we call to help may be unavailable and sometimes it can feel just as lonely. obstetric emergencies, of In a complete review of it would be prudent to consider management extraction, internal and breech resuscitation, obstetric haemorrhage, neonatal collapse and perimortem caesarean maternal of section, amniotic fluid embolism, management and epidural eclampsia the obstetric trauma patient, these of Many or spinal anaesthetic complications. so topics deserve their own focused attention, less of refreshers on ‘snack-sized’ we focus here common, specifically obstetric, emergencies with a element. procedural Shoulder dystocia and an unpredictable Shoulder dystocia is often obstetric emergency with an unpreventable and 0.70%. between 0.58% incidence of 1 The fundamentals of early recognition and early recognition The fundamentals of management can be applied to any obstetric first to stay calm and call remembering emergency, airway, danger, assessment of for help. Systematic (and haemorrhage control), circulation breathing, each step at correction disability and immediate The fetus may be vulnerable to maternal is key. to both attention requiring hypotension and hypoxia, and Assessing for danger to the patient patients. of our at the forefront is easy to overlook, but staff pandemic, alerting us minds amidst the COVID-19 equipment prior to to consider personal protective entering the emergent situation. the team leader during an obstetric of The role strong emergency is multi-dimensional, requiring decision making and management communication, Management of an obstetric emergency is the Management of everyone of responsibility involved in routine junior doctors to specialist from care, maternity obstetricians, midwives and anaesthetists. All staff birthing women should be of involved in care in emergency management and, given the educated many obstetric emergencies, periodic incidence of training and drills should also be undertaken. Dr Hayley Messenger FRANZCOG Group Gippsland Healthcare West obstetric emergency emergency obstetric Dr Chris Polchleb FRACGP Adv candidate DRANZCOG Group Gippsland Healthcare West Management of an of Management BIRTHING the fetus,withanincidenceof 0.1–0.6%, descends withorbefore thepresenting partof Cord prolapse occurswhentheumbilicalcord Cord prolapse careful perinealandPRexamination andafter care. with therequirement forneonatal resuscitation, shoulder dystocia,PPHshouldbeanticipated along not relieve what isabonyobstruction.Following an episiotomyhelpsonlytoallowaccessbutwill be doneinanyorder. Itshouldberemembered that child. Thiscanrequire somequickthinkingandmay obstruction withtheleastmorbiditytomotherand systematic approach –thegoalbeingtimelyrelief of Figure 1.RubinImanoeuvre. Delivery of posteriorarm. Figure 2.Delivery manoeuvre (Figure 2). delivered, andisrecommended asafirst-lineinternal from thevaginaallowsanteriorshouldertobe by flexingtheelbowandgentlypullingarm of theposteriorarm (Rubin I)(Figure 1).Delivery shoulder todislodgefrom underthepubicsymphysis or slightrocking motionmayallowtheanterior suprapubic pressure withcontinuouspressure as HELPERR Many clinicianswillusemnemonicdevices,such , maybe considered aslastresort. deliver bycaesarean) orpurposefulcleidotomy Zavanelli manoeuvre (pushingthefetalheadupto effect delivery. Rescuemanoeuvres, suchasthe reverse Wood’s screw manoeuvre (Figure 4)can which maybeaddedtoRubinIImanoeuvre, orthe shoulders usingWood’s corkscrew manoeuvre, (Figure 3).Rotating theanteriorand/orposterior ‘hook’ theposteriorshoulderanddeliverthisfirst with aninfant feedingtubehasbeendescribedto 8 orsimilar, toensure theymaintaina 3 Posterior axillary slingtraction Posterioraxillary 9 and Figure 4. Wood’s screw maneouvre. safety forthemother. anaesthetic, iffetalheartrate permits,improving a spinalanaesthetictobeusedinstead of ageneral presenting partoff thecord.A full bladdermayallow to instil500mlintothematernal bladdertoliftthe catheter,urinary salinebagandgivingset,ready or trolley canbeequippedwithanindwelling planned for. Inanysetting,acordprolapse box for caesarean sectionshouldbeexpectedand In manyruralsettings,adelayintransfertotheatre their leftside,withheadlowerthanthepelvis. position onallfourswiththeirbottomintheair, oron woman shouldbepositionedinadeepknees-to-chest birth ifisimminent).Whilethisdone,the emergency caesarean section(orassistedvaginal presenting partwhilepreparations are madeforan Cord pressure shouldberelieved byelevating the after spontaneousorartificialrupture of membranes. pattern withruptured membranes:inparticular, soon there isabnormal(especiallysudden)fetalheartrate occlusion. Cordprolapse shouldbesuspectedwhen dire, withfetalhypoxia tocord occurringsecondary undetected ormismanagedcordprolapse canbe necessitates immediate birth.Theoutcomeof Figure 3. slingtraction. Posterioraxillary BIRTHING 14 Vol. 22 No. 3 Spring 2020 | 30 Vol. Standardised morbidity and mortality Standardised 15 Singh A, Nandi L. Obstetric Emergencies: Role of Obstetric Singh A, Nandi L. Obstetric Emergencies: Role of Outcome. J Obstet Gynaecol India. Drill for a Better Maternal 2012;62(3):291-6. learning from of E, et al. Evaluation Wallace S, A, Sturrock Kumar and its impact on Training Practical Obstetric Multi-Professional framework: a outcomes in Australia using Kirkpatrick’s patient BMJ Open. 2018;8(2):e017451. methods study. mixed E, Laxton C, et al (Eds) Sowter M, Weaver J, Winter C, Crofts Training Beaves M. PROMPT PRactical Obstetric MultiProfessional Edition. 2008. Course Manual, Australian and New Zealand Shoulder dystocia: Intrapartum diagnosis, Rodis JF. www. from: Available management, and outcome. 2019. uptodate.com/contents/shoulder-dystocia-intrapartum- diagnosis-management-and-outcome et al. Head-to-body delivery D, Sahota O, Stuart Leung T, ischaemic fetal acidosis and hypoxic interval and risk of review. in shoulder dystocia: a retrospective encephalopathy BJOG. 2010;118(4):474-9. Time - An Important Benning H. C, Hing Ng K, Hounslow D, Wood BJOG. 1973;80(4):295-300. in Normal Delivery. Variable Guideline No. 42. Shoulder Dystocia. 2012. Green-top RCOG. www.rcog.org.uk/globalassets/documents/ from: Available guidelines/gtg_42.pdf et al. Shoulder dystocia: an D’Emidio L, Cignini P, Politi S, Med. 2010;4(3):35-42. J Prenat approach. Evidence-Based Cord Prolapse. Umbilical Guideline no. 50. Green-top RCOG. www.rcog.org.uk/globalassets/documents/ from: Available 2014. guidelines/gtg-50-umbilicalcordprolapse-2014.pdf the Khan R. Acute inversion of R, Odejinmi F, Bhalla R, Wuntakal uterus. The Obstetrician & Gynaecologist. 2009;11(1):13-18. the inverted of A new concept in replacement Johnson AB. nine cases. Am J Obstet Gynecol. of uterus and report 1949;57:557–62. Abdominal Mass B. FS, Huntington JL, Irving FC, Kellogg the puerperal uterus. Am J in acute inversion of reposition Obstet and Gynaecol. 1928;15:34-8. uterine inversion by chronic of The treatment Haultain FWN. with a successful case. Br Med J. abdominal hysterectomy, 1901;2:974. Labour debriefing is crucial for good psychological care. S. Axe 2000;8:626-31. Br J Midwifery. Blacklock E. Interventions Following a Critical Incident: Management Team. Developing a Critical Incident Stress Nursing. 2012;26(1):2-8. Psychiatric Archives of

review to capture critical events are needed to needed critical events are to capture review identify quality improvement and support continual learning. This is an and inter-professional as a on how best to collaborate opportunity to reflect multidisciplinary considering systemic, clinical team, wheel and human factors as small cogs in the giant healthcare. maternity of References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Staff, too, may need added support after a critical after too, may need added support Staff, and discuss to review incident and a formal process and team function should emotional responses be offered. Document, discuss, debrief, develop debrief, discuss, Document, role the to allocate it is ideal allow, numbers If staff purpose person has an important scribe. This of given and time track of in keeping as liaison between can sometimes act elapsed, and emergency and managing the the team, directly transfusion (e.g. haematologist, support staff as well as allowing services), lab, or retrieval contemporaneous documentation. clinical issues, actions taken, A discussion about the with the for the future follow up and implications the event is the time of at woman and her supports serious events this would essential, and with most day and in a few weeks’ the following be revisited the to aid understanding from time. This is important as an evolving reassure, perspective and patient’s well managed clinically) emergency (even when and frightening for can appear rapid, confusing, stress it. Post-traumatic experiencing those directly birth a potential consequence of disorders are mental distress. trauma and debrief may reduce 10 12,13 A uterine relaxant can A uterine relaxant 11 Johnson’s manoeuvre. Figure 5. be given to aid manual replacement. If manual If be given to aid manual replacement. with fails, the vagina can be filled replacement 6) to distend the vagina (Figure warm sterile water and push the fundus upwards using hydrostatic (O’Sullivan’s method). Surgical methods pressure ring to may be used, such as incising the cervical to pull the or laparotomy allow manual replacement, ligaments uterus cephalad by grasping the round (Huntington and Haultain procedures). Early detection is imperative to enable immediate to enable immediate Early detection is imperative with planning resuscitation, and manual replacement the placenta only when in a safe to manually remove adhesive disorder and placental where environment, can be managed. If cervical obstetric haemorrhage should be considered. shock is evident, atropine a palpable uterine fundus, an Signs include loss of a uterine mass on vaginal examination, abnormal soft is shock fundus visualised externally or any time there to haemorrhage. disproportionate 5) is first line – (Figure Johnson’s manoeuvre mass, inserting the hand grasping the uteroplacental into the vagina and the forearm and two-thirds of umbilicus the raising the fundus above the level of of the cervical ring, allowing the passage to relax the ring. fundus through Uterine inversion Uterine emergency where obstetric is a rare Uterine inversion cavity with potential turns into the uterine the fundus and hypovolaemic neurogenic ensuing profound uterine cause of most well-established shock. The to traction being applied early or excessive inversion is the placenta. of separation cord before the umbilical fundal uterine atony, Other risk factors include placenta, manual removal an adherent of implantation short umbilical cord, labour, placenta, precipitate of tissue disorders. placenta praevia and connective Figure 6. O’Sullivan’s method. BIRTHING Monash University, Melbourne Department ofObstetricsandGynaecology, RANZCOG Trainee/Clinical Research Fellow, MBBS, MRepMed, DLaw Dr VinayakSmith the fetus duringlabour The futureofmonitoring Obstetrics and Gynaecology, Monash University Carl Wood ProfessorandHeadofDepartment MBChB MDFRCOG FRANZCOG FAHMS Prof EuanMWallace AM Monash University, Melbourne Deputy HeadofObstetricsandGynaecology, MBBS, PhD, FRANZCOG, CREI Prof BeverleyVollenhoven Family Health University ofTechnology Sydney Senior Lecturer, Childand CentreforMidwifery, BMid, MSc,PhD Dr DeborahFox RM to prevent birthasphyxia. inorder decision makingregarding timingof delivery intention behindthisistodynamicallyguideclinical tofetalhypoxia.changes whichoccursecondary The EFM encompassesscreening forpatterns of FHR Broadly speaking,therationale that underpins and averageDopplerwaveformstoderivetheFHR. CTG usesautocorrelation techniquestocompare FHR asbeinganapproximate measure here since transducer viatheDopplereffect. We describethe detects thedispersedwaveformsthrough a of 1.5MHztoisonate fetalheartandsubsequently CTG approximates FHRusinganultrasoundwave fetal monitoring(EFM).BasedonDopplerultrasound, surveillance -aprocess weallrefer toaselectronic by manyasthe‘gold standard’inthefield of FHR (CTG) andhowitremains regarded maternity care providers, weare alltoofamiliarwith by CarlWood andPeterRenouinMelbourne. fetal heartrate (FHR)monitoringwere conducted randomised clinicaltrials(RCTs) of intrapartum since the1970swhensomeof theworld’sfirst fetus duringlabourhasbeenlargelyunchanged The technologyaround themonitoringof the technology itself. the limitation imposedbyDopplerultrasoundasa One of thefundamentalshortcomingsof CTG is Limitations ofcurrentEFM technology outcomes aswellwomen’sbirthexperiences. intent of improving bothmaternal andneonatal innovation underpinningintrapartumEFMwiththe a visionof pushingtheboundariesof technological EFM inover60years!We seektochangethis.We have meaningful advancesinthetechnologythat underpins is stillsomewhat surprisingthat there havebeenno that there isnosuitablealternative. Nonetheless,it has withstoodthetestof timepurely onthebasis assessing fetalwellbeing.Somehavearguedthat it acknowledged, limitations withitasanapproach to high-income countries,there are several,andwidely method of electronic intrapartumfetalsurveillancein Although CTG stillremains themostwidelyused and theinabilitytodetectfetalarrythmias. artefacts (i.e.doubleandhalfcounting of theFHR), include alackof truebeat-to-beat FHRdata, signal the CTG that makes interpretation difficult.These often compromises thevisualoutputsgenerated for data duetotheapproximation process that ituses challenges, deficiencieswiththesignalquality of FHR overweight orobesewomen.Beyondtheseclinical stage of labour. Thesechallengesare heightenedin MHR andFHRisparticularlycommoninthesecond labours. Lossof signalorconfusion betweenthe monitoring, whichoccursinasmany15−40%of and FHRconfusion aswellsignallossduring Next, there are issueswithmaternal heartrate (MHR) clinician. Thislimitsmobilityof thelabouringwoman. repositioning andsubsequentsupervisionbya the FHRrequires initialplacement,frequent available overthe lastdecade,suchasnon-invasive However, newertechnologythat hasbecome 4 First,thetransducerforcollecting 2,3 5-7

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8,25 Even though the evidence is equivocal at is equivocal at though the evidence Even 23,24 Wood C, Renou P, Oats J, et al. A controlled trial of fetal heart trial of et al. A controlled J, Oats C, Renou P, Wood Am J Obst monitoring in a low-risk obstetric population. rate Gynecol. 1981;141(5):527-34. D, Gyte GM, Cuthbert A. Continuous Z, Devane Alfirevic fetal monitoring electronic as a form of cardiotocography (CTG) Database Cochrane (EFM) for fetal assessment during labour. 2017;2(2):Cd006066. Rev. Syst Nair A, et al. A systematic S, Arunthavanathan Smith V, cardiac time intervals utilising non-invasive fetal of review in normal . BMC Pregnancy and electrocardiogram Childbirth. 2018;18(1):370. et al Beat-to- Andriessen P, ED, ten Broeke Peters CH, Doppler ultrasound fetal heart rate: detection of beat cardiotocography ECG to direct cardiotocography compared domain. Physiological Measurement. in time and frequency 2004;25(2):585-93. Chandraharan E. FIGO Spong CY, D, Ayres-de-Campos consensus guidelines on intrapartum fetal monitoring: J Gynecol Obst. 2015;131(1):13-24. Int Cardiotocography. The Geijn HP. AA, Van Verstraeten PC, Colenbrander GJ, Bakker J Obst monitoring. Eur intrapartum fetal heart rate quality of Gynecol Reprod Biol. 2004;116(1):22-7.

We hope this review helps shed some light on hope this review We fetal to the art with respect of state the current to reiterate would like We monitoring during labour. be to all considered these are present, at that, but with the ability to approaches, investigational this, Through bear fruit clinically in the near future. both the improving possibility of is a realistic there unnecessary EFM, reducing clinical management of the the quality of intervention and increasing birth for both mothers and clinicians. experience of precision-based where look forward to a future We techniques can be used in our decision making and move fetal monitoring into the 21st century. Similarly, fetal blood sampling is another commonly fetal blood sampling is Similarly, of the in the identification used adjunct test to aid its utility, fetus. The evidence surrounding hypoxic with some suggestion is largely equivocal however, caesarean number of the it may reduce that Much consort with the CTG. sections when used in itself criticism has been levelled towards the test to the patient such as it being unfriendly however, and and clinician, highly invasive, time consuming and intra-operator inter- of having a high degree test performance This invariably affects variability. which obtained, are that and the subsequent results approach may serve to explain these findings. One these issues is the development to overcoming can continuously monitor fetal biosensors that of goal The end dynamically during labour. lactate can be applied to the fetus is a device that here continuously transvaginally to monitor lactates unnecessary could prevent The results during labour. the decision to sections or could prompt caesarean is reached. expedite birth when a critical threshold to developing such a several approaches are There on this working biosensor with several groups lactate in early phase studies, these are Most of concurrently. a fully functional device but we can anticipate such functions in the near future. capable of best in this area, NIFECG allows us, for the first time, allows us, for the first NIFECG area, best in this increasing is There non-invasively. this to replicate as toward using this feature work being directed signal metrics intrapartum to well as several novel identify hypoxia dynamically evolving intrapartum for this to applications in the fetus. The potential period with utility also being extend to the antenatal for intrauterine in the screening demonstrated restriction. growth References References 1. 2. 3. 4. 5. 6. acidemia. However, a recent expert opinion piece piece expert opinion a recent However, acidemia. to trial the evidence with respect revaluated that and statistical outcomes of design, heterogeneity in this superior to CTG it was that methods suggested regard. The technology is 9,10 18-20 Proponents of CTGs CTGs of Proponents 3,14 2,21,22 2,21,22 To the clinician, the output the clinician, the To 8 17

13 The ability to ‘set and forget’ the NIFECG forget’ the NIFECG The ability to ‘set and No wonder that a significant proportion of a significant proportion No wonder that 9,11,12 9,11,12 15,16 also ‘BMI agnostic’, unaffected by maternal obesity, obesity, by maternal agnostic’, unaffected also ‘BMI and mobility during and supports full ambulation labour. sensor, instead of the incessant repositioning of a of incessant repositioning the instead of sensor, allows the clinician to focus Doppler transducer, less on the machine. A on the woman and more it that confirmed a NIFECG trial of multicentre recent its closely and even suggested that outperforms CTG a fetal scalp of the performance measures resembled (FSE). electrode ST segment analysis using FSE is one these proposed ST segment analysis using FSE is one these proposed identifying of methods which is based on the premise dynamic changes in the fetal ST segments that delivery. to prompt to hypoxia occur in response high-quality evidence for invasive ST Previously, segment analysis use during labour did not suggest neonatal in reducing CTG any advantage over routine Identification of the hypoxic fetus Identification of the hypoxic poor at are CTGs interpretation, of Irrespective identifying Whether assessed fetal acidaemia. is an urgent need for by AI or by clinicians, there technology with better sensitivity and specificity for hypoxaemia/acidaemia. So, could artificial intelligence (AI) be the answer So, could artificial intelligence (AI) be the to this very Certainly, problem? ‘human factors’ active research of is an area computerised CTG neural seeks to harness machine learning and that work is this networks. The long-term vision of affords a clinical decision support system that to support interpretation CTG consistent and reliable expert obstetric decision making. and inform computerised of RCTs per se, as with CTGs Sadly, have not yet shown them to interpretation CTG AI is not to say that outperform ‘human eyes’. That of the should be abandoned - ongoing refinement pace, underlying algorithms continues to advance at algorithms to learn from including the ability of itself (machine learning/deep learning) as the data opposed to being ‘trained’ by the clinicians. It’s just for prime time. not yet ready fetal electrocardiogram (NIFECG), offers promise in promise offers (NIFECG), fetal electrocardiogram challenges. The clinical and technological solving the the maternal from obtains FHR information NIFECG of visualisation time real provides abdomen and obtain To process. the fetal electrophysiological is simply placed device the wireless the signal, using patch, an adherent like on the abdomen to those used in adult similar surface electrodes electrocardiography. obstetric litigation involves the interpretation of the of involves the interpretation obstetric litigation intrapartum CTG. may be visually indistinguishable to that obtained to that may be visually indistinguishable over but the advantages the traditional CTG, from signal loss several fold. Using this, the are the CTG both in the confusion, FHR and MHR of and rate significantly are of labour, first and second stage the CTG. less than occurs with Obstetric decision making: computerised CTG Obstetric decision making: computerised CTGs failed to show that have consistently RCTs outcomes mortality or longer-term perinatal improve On the palsy. such as cerebral with injury, associated with an increase its use has been associated contrary, in obstetric intervention. have often argued that this is largely due to poor argued that have often than technological rather the CTG of interpretation there is no question that deficiencies per se. There variation and intra-observational is significant inter- even between experts, and interpretation, in CTG miss the at-risk those experts may frequently fetus. BIRTHING 16. 15. 14. 13. 12. 11. 10. 9. 8. 7.

2020;3(2):e1921363. Encephalopathy inNewZealand. JAMANetworkOpen. Cardiotocography AmongNeonates WithandWithout Identification of BirthAsphyxiaUsingIntrapartum Farquhar CM,Armstrong S, MassonV, etal.Clinician 6934(20)30031-6. monitoring. BestPractResClinObstetGynaecol.2020;S1521- Knupp RJ, Andrews WW, TitaATN. Thefuture of electronic fetal 2013;5:Cd006066. assessment duringlabour. Cochrane Database Syst Rev. (CTG) asaform of electronic fetalmonitoring(EFM)for Alfirevic Z,Devane D, GyteGM.Continuouscardiotocography org/10.1111/aogs.13873 observational study. ActaObstetGynecolScand.https://doi. invasive electrophysiological monitoring:Aprospective Lempersz C,NobenL,vanOstaG,etal.Intrapartumnon- techniques. ActaObstetGynecolScand.2014;93(6):590-5. index onaccuracyandreliability of externalfetalmonitoring Cohen WR,Hayes-Gill B. Influence of maternal bodymass Journal of Pregnancy. 2017:8529816. Heart Rate duringLabor:AComparisonof Three Methods. Euliano TY, DarmanjianS, NguyenMT, etal.MonitoringFetal 2012;25(8):1517-20. and Dopplertelemetry. JMatern FetalNeonatal Med. comparison of trans-abdominal fetalelectrocardiogram maternal heartrate confusion duringintra-partummonitoring: Stampalija T, Signaroldi M,Mastroianni C,etal.Fetaland 2013;75(2):101-8. Electrocardiogram. GynecologicandObstetricInvestigation. and AbdominalFetalElectrocardiogram withMaternal Heart Rate Ambiguity:AComparisonof Cardiotocogram Reinhard J, Hayes-Gill BR,SchiermeierS, etal.Intrapartum 2019;19(1):230. intra uterinegrowth restriction. BMCPregnancyandChildbirth. of non-invasive electrophysiological assessment in evaluating for Smith V, NairA,Warty R,etal.Asystematic review ontheutility 2001;29(5):408-16. invasively: areview of methods.Journalof Perinatal. Medicine Peters M,Crowe J, PieriJF, et al.Monitoringthefetalheartnon- 27. 26. 25. 24. 23. 22. 21. 20. 19. 18. 17. A new paradigm

2010;(3):CD006174. reassuring fetalheartrate trace.Cochrane Database Systc Rev. lactate samplingforfetalassessmentinthepresence of anon- East CE,LeaderLR,SheehanP, etal.Intrapartumfetalscalp 2018;18(8)2648. Hypoxia andMetabolicAcidosis:AReview. Sensors(Basel). Cummins G,Kremer J, BernassauA,etal.SensorsforFetal Restriction. Frontiers inPhysiology.2017;8:437. Fetal Electrocardiography inEarlyIntrauterineGrowth Velayo CL,Funamoto K,SilaoJNI, etal.Evaluation of Abdominal Obstet GynecolScand.2016;95(1):16-27. systematic review andmeta-analysis of randomized trials.Acta cardiotocography aloneforintrapartumfetalmonitoring:a Blix E,BrurbergKG, ReierthE,etal.STwaveformanalysisversus forward. AmJObstGynecol.2019;221(6):577-601.e511. monitoring: acriticalappraisalof conflicting evidenceandaway electrocardiography ST-segment analysisfor intrapartum Amer-Wåhlin I, UgwumaduA,YliBM,etal.Fetal Gynecol Obst.2015;131(1):25-9. intrapartum fetalmonitoring:Adjunctivetechnologies.Int J Visser GH, Ayres-de-Campos D. FIGOconsensusguidelineson 2018;231:25-9. analysis of CTG findings.Eur JObstGynecolReprodBiol. hypoxia inacohortof acidemicneonates: Aretrospective deltapHandtypeofumbilical vein-to-artery intrapartum Ghi T, ChandraharanE,FieniS, etal.Correlation between 2017;389(10080):1719-29. labour (INFANT): arandomisedcontrolled trial.Lancet. Computerised interpretation of fetalheartrate during design hampersfindings.Lancet.2017;389(10080):1674-6. Belfort MA,ClarkSL.Computerisedcardiotocography-study and Obstetrics.2019;300(1):7-14. systematic review andmeta-analysis. Archivesof Gynecology interpretation of intrapartumfetalheartrate (FHR)tracings:a Balayla J, Shrem G.Useof artificialintelligence(AI)inthe 2019;126(12):1437-44. codingtaxonomy.application andrevision of anNHSLA BJOG. legal claimsforqualityimprovement inmaternity care: Nowotny B, Basnayake S, Lorenz K,etal.Usingmedico- Contributor pagesshowallprevious articles Submit alettertotheeditor Support multimedia Feature topicalarticlesfrom thearchive See ‘mostviewed’article Search bykeyword, issue,author ogmagazine.org.au BIRTHING

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9 10

12 Induction 6 8 Cochrane 5 Vol. 22 No. 3 Spring 2020 | 34 Vol. 11 and a reduction in perinatal mortality is seen with IOL in perinatal and a reduction every to 41 weeks. 37 at from gestation What about long-term neurological outcomes outcomes about long-term neurological What induced labour? Educational after for children for achievement has been shown to be the same 39 or 40 weeks as those whose induced at children managed expectantly past 39 weeks. mothers were IOL? benefits the most from group Which patient deliveryat the median gestation When we look at between the IOL and the expectant management vs 40+0, is 39+4 in ARRIVE, the difference group but still not much in a 280 day significantly different is in the interquartile difference The real pregnancy. range, 39+1 to 39+5 for IOL vs 39+3 to 40+7 for expectant management. It is by intervening in those would otherwise have progressed that pregnancies the biggest benefit will be found. furthest where knowing exactly is no way of there Unfortunately, when labour will start. is evidence in women with hypertensive There of IOL is benefit term showing the greatest disease at cervixes. have the most unfavourable for those that morbidities with IOL for fetal macrosomia. morbidities with IOL for in August 2018 is the The ARRIVE trial published at induction for looking final piece to this puzzle, for no traditional indication low-risk women with showed a significant intervention. The authors delivery in caesarean reduction with IOL, 18.6% as well as less CI 0.76-0.93, versus 22.2%, RR 0.84, hypertensive disease. babies the fetal outcome though? Are of What life? better placed for later gestations later born at beyond 42 progressing pregnancies Preventing stillbirth, of with lower rates weeks is associated shows a policy of IOL at or beyond term is associated or beyond term is associated IOL at shows a policy of perinatal of all-cause with a significantly lower risk as well as and stillbirth (RR 0.33), (RR 0.33) death deliveries 426 induced section (RR 0.92). caesarean death. one perinatal needed to prevent are IOL in postdates pregnancy results in fewer results pregnancy IOL in postdates to expectant management. compared caesareans It is those women who are destined to progress destined to progress It is those women who are to most likely are that furthest past their due date of risks from decreased IOL, benefiting benefit from section, hypertensive disease, shoulder caesarean death. dystocia, stillbirth and perinatal tried to induce As someone who has routinely for over six years, all mothers by their due date delivering via non- my initial fear was patients of result section as a direct elective caesarean to establish in labour. my intervention and failure getting women My personal experience is that into labour is not as hard as we have been led to to establish labour is a sign believe. The failure to deliver at uterus programmed the unready of labour ward Considered gestation. a much later a little and often management is needed here after 36 weeks for gestational hypertension or mild 36 weeks for gestational after outcomes. better maternal showed pre-eclampsia 5,6 to get a feel for 2 Choosing the time 1 3,4 and significantly more vaginal deliveries and significantly more 7 with less shoulder dystocia and associated co- with less shoulder dystocia and associated mid-20th century not to obstetrics. It is now rare have a very know the number of due date, accurate the placenta and whether any fetuses, position of While vaginal present. structural abnormalities are delivery time, it is the dawn of has existed since ‘no- our entrenched, worth considering some of the these is the idea that brainer’, practices. One of initially idea ideal. This is labour of onset spontaneous the due date traditional practice, where evolved from uncertain, the ability to alter the course of was often complications and/or manage iatrogenic a pregnancy limited. more were This support for spontaneous labour subsequently studies comparing from found support, incorrectly, labour (IOL) with women undergoing induction of women in spontaneous labour. Following this, randomised controlled trials for Following this, randomised controlled in showed no difference specific high-risk groups with IOL for women 35 years section rates caesarean or older The practice of obstetrics has changed enormously The practice of over the last few decades. I would recommend Dr read all O&Gs in Australia and New Zealand Now & autobiography, Smith’s fascinating Margaret Then: A Gynaecologist’s Journey, Nowadays, debate on the best time to deliver largely Nowadays, debate The timing vaginal delivery. focuses on the timing of ideally section is less controversial, caesarean of individual by 39 weeks unless dictated occurring at the risk to mother or where clinical circumstances, with delaying deliverybaby associated until 39 weeks justify respiratory morbidity neonatal the increased with earlier delivery. associated Dr Richard Murphy FRANZCOG MBBS, FRACGP, St John of God Hospital Subiaco Fertility Specialists Applecross time to deliver? to time Is 39 weeks the ideal ideal the weeks Is 39 of spontaneous labour is not a choice any women of cohort studies retrospective will ever have. Later comparing IOL with expectant management from both of showed a lower rate the same gestation deliverycaesarean morbidity. and neonatal www.ogmagazine.org.au/contribute O&G Magazine,goto: For more information aboutcontributing to Contributions are welcome from allCollegemembers. can interviewyouandwritethearticlefor you. Don’t havetimetoprepare awrittencontribution? We in low-tomiddle-income countries are appreciated. pieces that highlightwomen’shealthissuesorinitiatives about globalwomen’shealth.Articlesandopinion The Collegeisseekingcontributions for O&GMagazine women andtheirfamilies,includinginthePacific region. RANZCOG iscommitted toimproving thehealthof Share your inO&GMagazine story in low- to countries? middle-income youDo have working experience or volunteering BIRTHING midwifery colleagues. midwifery acceptable towomen,theirfamiliesandalsoour to betheabilitydevelopmethodsof induction kitwillhave and oneof themajortoolsineveryone’s profession. Theartof obstetricswillevolvewithtime invariably abadthingischallengeforusallas to apublicledbelievethat inductionisalmost isclear.The scienceontimingof delivery Sellingthis induction recently. nicelyvaginallywitha39-week nullipara deliververy term pregnancies. Similarly, Ihavehada45-year-old eclampsia orgrowth restriction asIdoforlow-risk for preterm pregnancies needinginductionwithpre- becomes easier. Iroutinely usethesametechnique low riskwomenisthat IOLforhigherriskpatients One of thesidebenefits of routine inductionfor pathological CTGs are rare events. the process. You suddenlyfindthat meconiumand labour, removing mostof theunpredictability from induction process endsupdoingisstandardising by lunchtimesheisneverunhappy. What the a nulliparaisinducedandhasbabyinherarms laboured easilystilldosoand,inmyexperience,if gestation. Thosewomenwhowillalwayshave population, at riskof stillbirthwithongoing via emergencycaesarean represent avulnerable their unhappinessinlabourandare delivered Even more importantly, thosefetusesthat declare it ishardtoseehowwaitinglongerwillhelpthis. needed. Ifthere isobstructioninlabourat 39weeks, oxytocin receptors andready itselfforlabouris more timetoallowtheuterusandcervixupload

14. 13. 12. 11. 10. 9. 8. 7. 6. 5. 4. 3. 2. 1. References

trial. BJOG.2012;119:1123-30. pre-eclampsia analysisof at theHYPITAT term?Anexploratory decision forlabourinductioningestational hypertensionormild Tajik P, etal.Shouldcervicalfavourabilityplayarole inthe Open. 2020;3(4):e202503. Management WithChildAcademicOutcomes.JAMANetwork Werner etal.Association of Term LaborInductionvsExpectant Open. 2014;4:e005785. induction paradigm:results of anational intervention.BMJ Hedegaard etal.Reductioninstillbirthsat termafter newbirth 2018:379:513-23. Management inLow-Risk Nulliparous Women. NEnglJMed. Grobman W, etal.LaborInductionversusExpectant 1992;326:1587-92. antenatal monitoringinpost-termpregnancy. NEnglJMed. Hannah M,etal.Inductionof laborcompared withserial randomised controlled trial.Lancet.2009;374:979-88. after 36weeks’gestation (HYPITAT): amulticentre, open-label monitoring forgestational hypertensionormildpre-eclampsia Koopmans CM,etal.Inductionof labourversusexpectant trial. Lancet.2015:385:2600-5. management forlarge-for-date fetuses:arandomisedcontrolled Boulvain Metal.Inductionof labourversusexpectant or Older. NEnglJMed.2016;374:813-22. Randomized Trial of LaborInductioninWomen 35Years of Age Syst Rev. 2018;5(5):CD004945. outcomes forwomenat orbeyondterm.Cochrane Database Middleton Petal.Inductionof labourforimproving birth BMJ. 2012:344:e2838 compared withexpectantmanagement:population basedstudy. Stock Setal.Outcomesof electiveinductionof labour weeks’ gestation. JObstetGynaecolCan.2009;31:1124-30. caesarean sectioninlow-riskpregnancies between37and41 Dunne C.Outcomesof electivelabourinductionand 2011;56:25-30. women undergoingelectiveinductionof labor. JReprodMed. Vardo J. Maternal andneonatal morbidityamongnulliparous Crumplestone Press, 2010. Smith M.Now&Then:AGynaecologist’sJourney. at-term-(c-ob guidelines/obstetrics/timing-of-elective-caesarean-section- 23. 2018. Available from: https://ranzcog.edu.au/statements- RANZCOG. Timingof elective caesarean sectionat term.C-Obs BIRTHING

® Thus, 4

gel, there is gel, there ® Vol. 22 No. 3 Spring 2020 | 36 Vol. Hospitals can 10 Although not evidence- 8 If your hospital is considering 1 3 It makes sense to source a Foley sense to source It makes 9 Misoprostol is not approved for is not approved Misoprostol 5,6 However, the use of misoprostol in misoprostol the use of However, 7 and use in childbirth is not an approved indication and use in childbirth is not an approved 1 childbirth has been widely researched internationallychildbirth has been widely researched It is Health Organization. and endorsed by the World supported for use in NZ. controlled-release pessarycontrolled-release to Prostin balloon catheter that is intended to inflate to 50mL. is intended to inflate that balloon catheter of birth in mode seems to be little difference There butbetween single- or double-balloon catheters, experiencedwomen with double-balloon catheters pain and less satisfaction. more in Australia. hospitals can offer either or both methodshospitals can offer administration. of a PGE1 analogue,Some hospitals use misoprostol, is moderate- There prostaglandin. as their preferred in no difference is probably there quality evidence that between vaginal misoprostol section rates caesarean andand vaginal PGE2, or between oral misoprostol vaginal PGE2. starting to use misoprostol, consult early with your consult early with starting to use misoprostol, havepharmacy colleagues and local hospitals that this process. been through already a non-pharmacologic and are Balloon catheters trials cervical ripening. In all inexpensive method of situ in remained the balloon catheter here, reviewed evidence is moderate-quality for 12 hours. There in caesarean no difference is probably there that vaginal deliverysection or operative between balloon of The main benefit and prostaglandins. catheters uterine is less risk of there is that balloon catheter changes with fetal heart rate hyperstimulation to prostaglandins. compared Some clinicians perform membrane sweeping at the membrane sweeping at Some clinicians perform a formal labour induction.same time as performing showing that RCTs This is supported by several increases probably membrane sweeping concurrent shortens the induction to vaginal birth, of the rate mothers of the exposure birth interval and reduces and babies to oxytocin. as PGE2 (dinoprostone) Some hospitals use vaginal Comparing Cervidil prostaglandin. their preferred cervical ripening in the setting of induction of labour in induction of cervical ripening in the setting of NZ based, it makes sense to offer this mechanical method this sense to offer based, it makes may be of uterine hyperstimulation to women where consequence, such as women with previousgreater section or babies with suspected small forcaesarean midwives age. In some hospitals, interested gestational which being upskilled to place balloon catheters, are is fantastic. the inflating evidence that is moderate-quality There than 30mL probably to more single-balloon catheter hours birth within 24 in a higher chance of results volume, with no difference to low inflation compared section. in caesarean decide which balloon is preferred by hospital staff,decide which balloon is preferred accounting for cost. moderate to high-quality evidence that these are to high-quality evidence that moderate within 24 similar to each other to achieve vaginal birth section. in caesarean hours, with no difference

2 presented via RANZCOG webinar (available via RANZCOG presented 1 Consequently, women with an unfavourable cervix women with an unfavourable Consequently, their cervical ripening to increase should be offered their chances of and hopefully improve Bishop score a successful induction. from https://ranzcog.eventsair.com/cmspreview/ from ranzcog-webinar-nz/archives). we do has no what (a) much of I have learned that evidence to support best high-quality research practice, so it is up to individual clinicians or hospital to support is research to decide, and (b) there culture labour induction but we still maysome elements of reasons. not implement best practice for a variety of have that areas to summarise the few I would like evidence to support conditional quality of moderate questions and pose some research recommendations, projects. could lead to some feasible registrar that women we should offer I will conclude that Finally, of cervical ripening and methods several different decision-makinglabour induction and have a shared model to manage an individual woman’s care. Which methods are supported by research evidence? cervical evidence that is moderate-quality There the improves probably ripening with prostaglandins hours for women vaginal birth within 24 chance of alone. cervix over oxytocin with unfavourable When you move hospitals, let alone countries, you When you move hospitals, let alone countries, for take start to question any practice you used to Toronto, granted. I trained in university hospitals in then back to NZ, Canada, then moved to Whangarei, a suburban hospital, and now live Canada to work at in trends and work in Auckland. I have noticed several made me look up the evidence labour induction that the my practice. I also chaired to support or refute a clinical practice guideline on development of Zealand New labour for the Aotearoa induction of context Dr Michelle Wise MSc, FRANZCOG BSc, MD, Department of Obstetrics and Senior Lecturer, FMHS Gynaecology, NZ of Auckland, University induction Methods of labour labour of Methods

RANZCOG is committed to improving the health of the to improving is committed RANZCOG region. women and their families, including in the Pacific O&G Magazine for The College is seeking contributions about global women’s health. Articles and opinion highlight women’s health issues or initiatives that pieces appreciated. are countries in low- to middle-income We a written contribution? Don’t have time to prepare you. can interview you and write the article for all College members. from welcome Contributions are to about contributing information For more O&G Magazine, go to: www.ogmagazine.org.au/contribute Do you have experience working or volunteering volunteering or experience working have Do you middle-income countries? to in low- story in O&G Magazine your Share BIRTHING 3. 2. 1. comparisons: of vaginalbirth.Thesewouldbemytopthree outcome labour at 37weeksormore, withaprimary a population of womenundergoinginductionof suggest arandomisedcontrolled trialdesign,with to achievewithintheirtrainingtimeframe,Iwould questions that were importanttoanswerandfeasible If aregistrar approached metodiscussresearch Research questions sensible approach, it’snotyetevidence-based. outpatient ballooncatheter induction–althougha mothers andbabies.Somehospitalsalready offer of outpatient ballooncatheter inductionforboth better inform usaboutsafety andeffectiveness auckland.ac.nz) andtogetherthesetrialsshould OBLIGE trialinNewZealand isongoing(www.oblige. for babiesthaninpatient prostaglandins. power toshowthat outpatient balloonwassafer Australia endedearlyanddidnotachieveenough about outpatient management.ThePINCtrialin insufficient evidencetomake recommendations Regarding settingof inductionof labour, there is induction versusaugmentation. for womenwithprevious caesarean section,orfor different protocols fornulligravidaversusmultipara, dosing interval,andmaximaldose,norabout to make recommendations aboutstartingdose, Regarding oxytocin, there isinsufficientevidence and timingof thesetwocommoninductionmethods. evidence tomake recommendations abouttheorder alone withdelayedoxytocin, there isinsufficient ARM), andcombination of ARM/oxytocin versusARM membranes (ARM)(e.g.startingoxytocin withdelayed Regarding earlyversuslate artificialrupture of effectiveness of anymethod. evidence tomake recommendations aboutsafety or previous caesarean section,there isinsufficient Regarding inductionof labourforwomenwith repeat doses,totaldoseortimeframe. release pessary, noraboutdoseof gelbyparity, about duration andrepeat dosesof controlled- insufficient evidencetomake recommendations Regarding vaginalprostaglandin E2,there is evidence? Which methodsarenotsupportedbyresearch or more) starting oxytocin orafter cervix6cmdilated oxytocin) orlate ARM(either12hoursafter ARM (priortoorwithinonehourof starting For womenwithfavourablecervix,eitherearly (12 hoursinsitu) of prostaglandins, orswaptoballooncatheter hours of prostaglandins, eitheranother12hours For womenwithunfavourable cervixafter 12 or byBishopscore) eitherbyparity 1mg vs2mgProstin gel(stratify dose of 1mgvs2mgProstin gelandnextdose For womenwithunfavourable cervix,starting 11 The

participating intheOBLIGEresearch trial If youare reading thisinNZ,pleaseconsider and benefits,valuesbeliefs. or shortvideotohelpwomenchoosebasedonrisks balloon onoffer, withanaccompanieddecisionaid sense tohaveoneortwoprostaglandins andone preferences, resources andhospitalculture. Itmakes and consumers,make decisionsbasedon consider broad consultation withdoctors,midwives points that are notevidencebased.Forthelatter, recommendations andacknowledgethosepractice they usetheresearch evidencetounderpinany that are lookingtoupdate theirguidelines,that I wouldsuggestthat forhospitalmaternity services Conclusions 12. 11. 10. 9. 8. 7. 6. 5. 4. 3. 2. 1. References NZ haveaninduction. research isfeasible,giventhat oneinfourwomen so manyideasworthlookingat; inductionof labour you are interested inaresearch project, there are participant, towardsasamplesize of 1550. Andif the timeof writing,wehaverecruited our800th

s13063-020-4061-5 randomized controlled trial.Trials . 2020. https://doi.org/10.1186/ inpatient prostaglandin forinductionof labour(OBLIGE):a Wise MR,MarriottJ, Battin M,etal.Outpatient balloonvs 2020;127:571-9. an outpatient: amulticentre randomisedcontrolled trial.BJOG. using prostaglandin E2asaninpatient versusballooncatheter as Beckmann M,GibbonsK,FlenadyV, Kumar S. Inductionof labour J Perinatol. 2018;38:217-25. and systematic review of randomisedcontrolled trials. double ballooncatheters forlabourinduction:ameta-analysis Salim R,SchwartzN, Zafran N, etal.Comparisonof singleand 2014;36(8):678-87. A systematic review andmeta-analysis. JObstetGynaecolCan. lower caesarean sectionrate thanalowvolumefoleycatheter? ripening at termusingahighvolumefoleycatheter result ina Berndl A,El-Chaar D, MurphyK,MacdonaldS. Doescervical 2012;3:CD001233. methods forinductionof labour. Cochrane Database Syst Rev. Jozwiak M,BloemenkampKWM, Kelly AJ, etal.Mechanical obstetrics,the-use-of-(c-obs-12). edu.au/statements-guidelines/obstetrics/misoprostol-in- gynaecology (C-Obs-12). 2016. Available from: https://ranzcog. RANZCOG Statement. Theuseof misoprostol inobstetricsand Syst Rev. 2010;10:CD000941. cervical ripeningandinductionof labour. Cochrane Database Hofmeyr GJ, Gülmezoglu AM,PileggiC.Vaginal misoprostol for labour. Cochrane Database Syst Rev. 2014;6:CD001338. Alfirevic Z,Aflaifel N, WeeksA.Oralmisoprostol forinduction of Cochrane Database Syst Rev. 2014;6:CD003101. prostaglandin (PGE2andPGF2a)forinductionof labourat term. Thomas J, Fairclough A,KavanaghJ, Kelly AJ. Vaginal a meta-analysis. ArchGynecolObstet.2018;297:623. induction methodtoincrease thespontaneousvaginaldelivery: Liu J, SongG,MengTetal.Membranesweepingaddedtoformal Syst Rev. 2009;4:CD003246. cervical ripeningandinductionof labour. Cochrane Database Alfirevic Z, Kelly A,Dowswell T. Intravenous oxytocin alonefor mhsfaculty.auckland.ac.nz/inductionNZ/ a clinicalpracticeguideline,2019. Available from: https:// Wise MR,etal.Inductionof labourinAotearoa NewZealand; 12 –asof

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8-10 Over 3 The 7 The drivers 3 Vol. 22 No. 3 Spring 2020 | 38 Vol. Specifically, low-risk Specifically, 8 6 of variation and change in rates are complex but can are in rates and change variation of to demand, supply relating classified as be broadly and/or access. the past nine years, the rates of homebirth in some of rates the past nine years, the South Australia, Victoria and jurisdictions (Western while in others (Queensland, Australia) have fallen, increased. have and Tasmania) the ACT A recent meta-analysis of women with low-risk of meta-analysis A recent in high-income countries confirmed pregnancies with planned homebirth was not associated that and was associated death in perinatal an increase morbidities some maternal of with a lower rate and obstetric interventions. current numbers of PPMs are unknown. Accessing PPMs are numbers of current is available a PPM in Australia is expensive. Medicare but not the birth. care, and postnatal for antenatal cost for women giving pocket The average out of While $5000. home with a PPM is around birth at PPMs practice in accordance with the majority of and referral, for consultation guidelines the ACM individual PPMs may vary in their inclusion criteria service. a homebirth of to the provision with regard in accessibility of additional variation This can create homebirth services for women. and territories in Australia, excluding All states public homebirth options Queensland, also offer of (16 in total), albeit to only a small number suitable women. For example, in Victoria where year, women give birth each 78,000 approximately offer services only two public Victorian maternity available homebirth. Public homebirth models are live who only to women with a low-risk pregnancy within a defined travel distance to the health service. in both the eligibility also variations are There For programs. different of criteria and requirements nulliparous exclude example, some public programs or women, those wishing to have a waterbirth physiological third stage. For all women accessing their birth is free, a public homebirth, the cost of for by midwives employed by the cared and they are health service. women and their of to the safety Concerns relating commonly cited as barriers to offering babies are homebirth services. or supporting the availability of These concerns pertain to who is most suitable to the care home, who should provide give birth at is a need for urgent and the outcomes when there home. at cannot be provided that medical care for is The evidence for whom homebirth is safest studies now well established. Large population-based and metanalyses reviews and subsequent systematic planned homebirth is a that consistently demonstrate option for women with low-risk pregnancies. safe Variation in homebirth rates also differ across differ across also in homebirth rates Variation all births in of 0.1% at rates Australia with the lowest in Tasmania. 0.9% at and the highest rates NSW, women access homebirth options The majority of midwives practising engaging with privately through that identified 2015, from figures, (PPMs). The latest the country midwives across who 241 were there homebirths as a primaryattended midwife. In contrast, 3 Despite this, the rates of of Despite this, the rates and approximately 2% of 2% of and approximately 1,2 4 give birth at home each year. home each year. give birth at 5 3.4% in New Zealand 3.4% women in the UK homebirth in Australia are low. In 2018, 0.3% of of 0.3% In 2018, low. homebirth in Australia are home. Australian women gave birth at Meeting the needs of women is a hallmark of a women is a hallmark of Meeting the needs of Australian system. A decade of high-quality maternity have highlighted that service reviews maternity care, access to models of women want increased including homebirth. Prof Caroline Homer AO Prof Caroline Homer AO RM, MMedSc(ClinEpi), PhD Child and Director Maternal, Co-Program Burnet Institute Adolescent Health, Colleen White RM RN, and Children’s Operations Director of Women’s, Frankston Peninsula Health, Adolescent Health, Dr Miranda Davies-Tuck Dr Miranda Davies-Tuck BBioMedSci(Hons), PhD Perinatal Epidemiologist, The Ritchie Centre, Hudson Institute of Medical Research from shadows to mainstream shadows from Homebirth in Australia: in Australia: Homebirth BIRTHING ranging from 9%upto28%. planning homebirthreport intrapartumtransferrates interventions ifrequired. Studies of low-riskwomen across thecountry, andreassuring evaluations, their babies.Thegrowth of publiclyfundedmodels is suitableforandtheoutcomesof womenand of alltransferswomenexperienced. urgent transfer, contributingtojustoveronequarter 4% of plannedhomebirthsresult inapotentially across fourNordiccountriesidentifiedthat around potentially urgentreasons. Areview of transfers progress inlabour, maternal preference orfor Reasons fortransfersincludepainrelief, slow service women mustlivewithin30minutesof thehealth stipulate Public homebirthmodelsacross thecountry homebirth outintothemainstream. can accesssafe evidence-basedcare, thusbringing women whoare suitableandwouldlike ahomebirth care. Ultimately, thegoalshouldbetoensure that all also furtherdemonstrate thesafety of thismodelof homebirth are at mostriskof adverseoutcomes. a transfertohospitalinlabourfrom aplanned generally considered that womenorbabiesrequiring homebirth relates tothehospitaltransfer. Itis The otherkey concernregarding thesafety of normal vaginalbirth(OR2.93; 95%CI2.13–4.03). 0.73; 95%CI0.55–0.96) andare more likely tohavea CI 0.40–0.81) andpostpartumhaemorrhage(OR lower rates of severe perinealtrauma(OR0.57; 95% planning ahomebirthexperiencedsignificantly women whoplanahospitalbirth.Low-risk 95% CI0.78–1.27) whencompared withsimilar 0.94; 95%CI0.76–1.17) orneonatal death (OR1.00; significantly higherrate of stillbirth(OddsRatio[OR] before bycaesarean inthepastdonotexperiencea healthy singletonpregnancy that havenotgivenbirth women, thosefree of medicalcomplications, witha parous women. 52% fornulliparous womenandfrom 3%to11%for rate of intrapartumtransferrangesfrom 22%to and parous womenare considered separately, the when transferwasrequired. the riskof adversematernal andperinatal outcomes anincrease in in low-riskwomendidnotidentify recent Victorianstudyof 3200plannedhomebirths Australian-specific data, We now havealargebodyof evidence,including has beensignificantgainstoaddress theseconcerns. homebirth inAustralia.Overthepastdecade,there that ithasbeenchallengingtoincrease accessto wider healthsystem.Itistherefore understandable which themajoritydo,theyare invisibletothe social commentary. Whenhomebirthsgowell, outcomes are thesubjectof mediaheadlinesand It isatopicthat polarisespeople,where poor maternity care option,relegated totheshadows. Homebirth haslargelybeenconsidered analternative experience higherrates of adverseoutcomes. experienced bynulliparous women,theydonot homebirth. their babiesrequiring transferfollowingaplanned are loweragainwithbetween3–7%of womenor 12 toensure fastaccesstoemergencyobstetric 13-17 Despitethehigherrates of transfer 13-17 Therates of postpartumtransfers 15,18 todefinewhohomebirth 13-17 15

Whennulliparous 16 Reassuringly, a 8

19,20 11 8

20. 19. 18. 17. 16. 15. 14. 13. 12. 11. 10. 9. 8. 7. 6. 5. 4. 3. 2. 1. References

birth program inAustralia.Women Birth.2019;19:30055-1. White C,etal.Apathway toestablishapubliclyfundedhome the ACT. In:BurnetInstituteM,editor. 2020. Scarf VL,etal.Evaluation of PubliclyFunded HomebirthTrial in study. BMJOpen.2019;9(10):e029192. place of birthinAustralia2000-2012:Alinked popoulation data Homer C,etal.Maternal andperinatal outcomesbyplanned descriptive study. SexReprodHealthc. 2018. model withaffiliation toaDanish Universityhospital-a Maimburg RD. Homebirthorganisedinacaseloadmidwifery Gynecol Scand.2016;95:420-8. Nordic countries-aprospective cohortstudy. ActaObstet Blix E,etal.Transfers tohospitalinplannedhomebirthfour data. BMCPregnancyandChildbirth.2018;18(1):357. 2000-2015: aretrospective cohortstudyof Victorianperinatal Davies-Tuck M,etal.Plannedprivate homebirthinVictoria 2016;16(1):329. cohort studyintheNetherlands.BMCPregnancyandChildbirth. interventions andmaternal outcomesamonglow-riskwomen:a Bolten N, etal.Effect of plannedplace of birthonobstetric prospective cohort.BMJ. 2011;343:d7400.. with lowriskpregnancies: theBirthplaceinEnglandnational maternal outcomesbyplannedplaceof birthforhealthywomen Birthplace inEnglandCollaborative Group. Perinatal and birth-program publications/policiesandguidelines/implementing-public-home- services. 2015. Available from: www2.health.vic.gov.au/about/ home birthprogram: GuidanceforVictorianpublichealth Victorian Departmentof Health.Implementingapublic systematic review. BMCPregnancyChildbirth.2014;14:179. Blix E,etal.Transfer tohospitalinplannedhomebirths:a EClinicalMedicine. 2020:100319. to givebirthinhospital:Asystematic review andmeta-analyses. home compared towomenof lowobstetricalriskwhointend among womenwhobeginlabourintendingtogivebirthat Reitsma A,etal.Maternal outcomesandbirthinterventions EClinicalMedicine. 2019;14:59-70. give birthinhospital:Asystematic review andmeta-analyses. compared towomenof lowobstetricalriskwhointendto who intendat theonsetof labourtogivebirthat home Hutton EK,etal.Perinatal orneonatal mortalityamongwomen Midwifery. 2018;62:240-55. high-income countries:Asystematic review andmeta-analysis. place of birthamongwomenwithlow-riskpregnancies in Scarf VL,etal.Maternal andperinatal outcomesbyplanned Canberra: AustralianInstituteof HealthandWelfare; 2016. AIHW. workforce 2015. Nursingandmidwifery Cat. no.WEB141. Oct-2013.pdf files/migrated/Medical-Practice-Variation-Background-Paper- Available from: www.safetyandquality.gov.au/sites/default/ Medical practicevariation: background paper. Sydney, 2013. Australian CommissiononSafety andQualityinHealthCare. birthcharacteristicsinenglandandwales2017 Wales: 2017. UK,2019. Available from: www.ons.gov.uk/releases/ Office for National Statistics. BirthcharacteristicsinEnglandand maternity-2017 2019. Available from: www.health.govt.nz/publication/report- of Health.ReportonMaternity 2017.Ministry Wellington, and-babies-2018-in-brief/contents/table-of-contents. www.aihw.gov.au/reports/mothers-babies/australias-mothers- Australian InstituteforHealthandWelfare; 2020. Available from: AIHW. Australia’smothersandbabies2018—inbriefCanberra: strategic-directions-for-australian-maternity-services health.gov.au/resources/publications/woman-centred-care- for Australianmaternity services.2019. Available from: www. COAG HealthCouncil.Woman-centred care: Strategic directions publishing.nsf/Content/msr-report 2009. Available from: www1.health.gov.au/internet/publications/ Australia: thereport of theMaternity ServicesReview. Canberra, Commonwealth of Australia.Improving maternity servicesin BIRTHING found 6 Skinner 5 Vol. 22 No. 3 Spring 2020 | 40 Vol. Continuity of care benefits care Continuity of 2 and the midwives providing 3 Women who have medical, obstetric or who have medical, Women 4 women and babies neonatal concerns are referred to the secondary referred concerns are neonatal also team within the hospital but will often maternity withhave a midwife LMC, who works collaboratively the of elements the team. The LMC midwife provides intrapartum in the community and often woman’s care in the hospital.care Maternity care provider important Finding the right midwife for the woman is College of for both the woman and the midwife. The women supports a website that Midwives provides (www.findyourmidwife. to find a midwife nationally The website identifies co.nz) in her town/city/area. the of the time available at the midwives who are their care, their philosophy of woman’s due date, units they practice colleagues, and the maternity (includes homebirth, care access when providing primary units and secondary/tertiary maternity hospitals within the region). Options for place of birth homebirth, of women have options New Zealand midwifery-led unit birth, secondary/tertiary maternity formal are 1). In addition, there unit birth (Figure for those care and shared for referral structures women who need obstetric, physician, anaesthetic expertise. or neonatal for obstetric consultation Referral with Obstetric andThe Guidelines for Consultation Medical Services (Referral Guidelines) are Related and supportused as the basis to support referrals transfer and co- consultation, consistency of providers. across care of ordination Organisation of maternity care Organisation of maternity the provision requires care Adaptable woman-centred decision making in all and informed information of woman should be able Each care. maternity of areas birth and the place of provider, to choose her care needs and expectations. best suits her that the care women can choose a midwife,In New Zealand, her care practitioner to provide obstetrician or general (LMC), with the majority Carer as her Lead Maternity continuity of and receiving choosing a midwife (94.1%) labour and birth and up to six pregnancy, through care weeks following the birth. that care. that Place of labour and birth in New Zealand in 2017. labour and birth in New Zealand Figure 1. Place of

However, the desire for autonomy and a the desire However, 1 Hospitals were considered a locus of infection infection a locus of considered Hospitals were restricted or Hospital policies significantly inhibited visitors or support people support people with them wanted more Women when giving birth positive experience? positive birth experience is not limited to women birth settings. Women choosing out-of-hospital and have different diverse backgrounds come from and challenges but all want the needs, expectations – a healthy baby and care maternity same thing from a positive childbirth experience. a woman may hospital settings where In maternity often health providers, different meet a number of how do we ensure for the first time when in labour, met and she has a are her expectations that Ensuring a positive experience and providing Ensuring a positive experience and providing is a fundamental care woman-centred respectful New services in Australia, maternity of expectation to getting to The pathway and globally. Zealand maternity this goal may differ for each woman, so the of services need to be adaptable and supportive woman’s context. many countries lockdown During the COVID-19 women about from interest increased reported to a refers Freebirth homebirth and/or freebirth. without the home woman’s intention to give birth at The increased a health professional. assistance of settings was in giving birth in out-of-hospital interest for several reasons: • • • the because of freebirth Some women considered support for a health professional unavailability of published paper exploring homebirth. In a recently prior to (undertaken for freebirth women’s motivation for autonomy, women identified a desire COVID-19) hospital experience and concerns negative a previous about interruptions and unnecessary interventions to consider during labour and birth as reasons freebirth. Dr Lesley Dixon PhD Midwifery Advisor, New Zealand College of Midwives respectful care respectful Woman-centred Woman-centred BIRTHING RANZCOG or more peopleworkingtogethertoachieveagoal’. Collaboration canbedefinedasthe‘process of two Collaboration trust andrespect. communication, co-operation andthebuildingof of professional relationships are collaboration, The core principlesthat supportthebuilding and confusion aboutroles andresponsibilities. negative andhomebirth perceptions of midwifery between healthprofessionals. Theseincluded organisation of care andinterprofessional tensions and collaborative care were often related tothe systems andorganisation of maternity care. right withinNewZealand andisreflected inthe and supportinganinformed decisionisaconsumer expectations forlabourandbirth.Informing women a birthplanthat setsoutherindividualneedsand Working withthewoman,midwifedevelops mutual trust,respect andunderstanding. woman andstartstobuildapartnershipbasedon screening andcare planning.Shegetstoknowthe information, healthpromotion, healthassessment, During pregnancy, themidwifeprovides education, Information sharingandinformed choice in collaboration withspecialistservices. care most midwivescontinuedtoprovide midwifery for avarietyof reasons butthat followingreferral, that 35%of womenwere referred toobstetricservices used in hospitals is the ISBAR – introduction, situation, used inhospitalsistheISBAR–introduction, situation, that supporteffectivecommunication. One commonly is notalwaysintuitiveandthere are anumber of tools over care tohospitalmidwives.Good communication during labourandbirth–although somewillhand midwives inNewZealand willcontinuetoprovide care one healthprofessional toanother. Most LMC exchange of context-appropriate information from Effective communication isvitaltoensure the Communication and improve collaboration. health professionals toensure clarityandconsistency Referral Guidelinessetouttheguidingprinciplesfor so that theindividualwoman’sneedsare met.TheNZ promote participation of different healthdisciplines their babiesandmaternity servicesshouldactively to supportimproved outcomesforwomenand in Canada studysetinfourruralcommunities exploratory and philosophiesworkingtogether. Onequalitative professionals withdifferent expertise,expectations to achievewhenthere are different health Providing anintegrated response canbedifficult Interprofessional relationships team) andbackagainfollowingbirth. care (obstetric (community midwives)tosecondary interface whichrequires care referrals from primary integrated care refers totheprimary-secondary cohesive andresponsive way. InNewZealand, and ensure that herneedsare metinaconnected, put thewomanat thecentre of maternity care maternity healthprofessionals worktogetherto Woman-centred maternity care requires that Working asateamtosupportwoman-centredcare the contextandwoman’slabourbirthprocess. potential foradditionalordifferent care dependenton plans are adaptableandmidwiveswilldiscussthe 8 9 foundthat barrierstointegrated identify that collaboration isimportant identify 7 Birth Birth Full referencelistavalable online and respectful care from thehospital team. (when needed)alongwithanintegrated response organised tosupportreferral andtransferof care andthematernity systemis her maternity history), of maternity care (gettingtoknowthe womanand Zealand, communitymidwivesprovide continuity supportive interprofessional relationships. InNew guidelines andreferral structures andpositive Integrated care worksbestwhenthere are clear Conclusion perspective andoutlook. mutual respect andtrustforeachprofessional’s and commonunderstanding.Principlesinvolve brings theirownexpertisealongwithashared goal anaesthetist andpaediatrician. Eachteammember obstetrician, hospitalandcommunitymidwife, her andbaby. Team membersmayincludethe needs are metwhilstsupportingasafe birthfor work togetherasateamtoensure that thewoman’s maternity itrequires midwivesandobstetriciansto needs are metisparamountinanycollaboration. In Working togethertoensure that thewoman’s Co-operation andteamwork decision making. the referral isimportanttoensuringfullyinformed woman andhercare plansandexpectations during background, assessmentandresponse. Includingthe a positiveexperience. birth planhadbeenhonoured. Overallithadbeen induction, that shehadbeenlistenedtoandher her experienceanddecisiontogoaheadwiththe happywith an induction.Shetoldmeshewasvery careful questionsabouthowshefelthaving I debriefedwithJenniferafewdayslater, with and within hours had given birth to a healthy baby. stopped thesyntocinon.Shecontinuedtolabour started tocontractfrequently, at whichpointwe We commencedtheinductionandJennifer we wouldneedtostartitagainiflabourstalled. the labourwasestablished,withproviso that agreed that wewouldstopthesyntocinononce explored thepotentialbenefitsandrisks– concerns andpotentialsolution.Together we and, withJennifer’sagreement, Iexplainedher the birthingsuite,wemeton-callobstetrician obstetrician. Followingareferral andadmissionto We agreed todiscussthisideawithan syntocinon oncetheinductionwascommenced. She asked ifitwaspossibletostoporslowthe went from zeroshorttime. to‘fullon’inavery feel outof control. Shefeltthat thecontractions rapidly tothesyntocinonandshehadstarted previous inductions,herbodyhadresponded to beinduced.Sheexplainedthat withhertwo weeks andexplored herreasons fornotwanting increased riskof stillbirthifpregnancy passed42 not wanttobeinducedagain.We discussedthe signs of labourbutwasadamantthat shedid progressed andat almost42weeks,shehadno for aspontaneouslabourthistime.Herpregnancy didn’t wanttobeinducedagainandwashoping assisted birthandthesecondanormalbirth.She an different reasons –herfirstbabyhadbeen previous twobirths,bothhadbeeninduced–for pregnant withherthirdbaby. We discussedher I metJenniferwhenshewaseightweeks Woman-centred careinaction BIRTHING

630 (6.39) 192 (6.03) Fever Vol. 22 No. 3 Spring 2020 | 42 Vol. 553 (8.85) 90 (8.49) 1321 (9) 75 (11.2) 90/1156* (7.78) NNU Whilst there is no Whilst there 3 1 (0.01) 1 (0.09) 17 (0.05) 3 (0.09) 3/3285* (0.09) PND/ Asphyxial injury 51 (0.63) 9 (0.40) 42 (0.19) 8 (0.56) 14/2512* 14/2512* (0.55) Hysterectomy elective repeat. This rate sounds considerably high, This rate elective repeat. 33% average of with the Australian but is in keeping with 85% being elective repeats. questioning a CS can be a life-saving procedure, questioning a CS can be a life-saving procedure, being operations number of is a growing there Whilst performed without a true medical indication. daily practice, one cannot is part of the procedure and maternal mortality, maternal the risk of ignore complications of rate fetal morbidity and increased pregnancies With one in three pregnancies. in future (VBAC) caesarean vaginal birth after ending in CS, feel counselling has become something we all has very doing, as a successful VBAC comfortable and fetal benefits. significant maternal Our department booking in, if the women’s last birth was a CS At the doctor completing the first visit completes the Checklist – Supporting NSW Health form ‘Antenatal 172 (1.67) 47 (1.68) 358 (1.21) 41 (1.99) 49/2428* 49/2428* (0.55) Transfusion In 2019, In 2019, 1,2 12 (0.11) 31 (1.09) 327 (0.72) 69 (1.59) 74/5431* 74/5431* (1.36) Uterine rupture 38814 38814 (76.5) 3276 (71.7) 4064 (71.7) Success 10897 2829 50685 4565 5666 Number VBAC-2 VBAC-2 vs RCS VBAC-2 VBAC-2 vs VBAC-1 VBAC-2 Group Values in parenthesis are expressed as percentages expressed are in parenthesis Values studies across outcomes measured numbers due to different patient *Varying Summary of pooled results from Tahseen and Griffith’s looking at VBAC-2 , VBAC-2 vs VBAC-1 and and vs VBAC-1 , VBAC-2 at VBAC-2 and Griffith’s looking Tahseen 1. Summaryfrom pooled results of Table vs RCS(third). VBAC-2 As a first-year registrar, a woman presented in in a woman presented registrar, As a first-year (TOL) labour spontaneous labour planning a trial of my sections (CS). Was caesarean two previous after a mild tachycardia and general of initial reaction, in uneasiness, justified? The woman had engaged on been counselled and reviewed care, antenatal This multiple occasions by a senior consultant. does questions for me: What a couple of sparked two or more after evidence show about TOL current discussing CS? Should this be something we are with women? Background the most commonly performed CS is one of continuing to rise. worldwide with rates operations up to 10% decreases a CS rate that WHO states while a and fetal morbidity and mortality, maternal higher then this has no added benefit. rate Dr Andrew Woods FRANZCOG MBBS, MRCOG, current evidence evidence current Dr Amanda Whale BMed VBAC-2: a review of a review VBAC-2: our departmental average was 33.4% with 60% being our departmental average was 33.4% BIRTHING an appropriate birthinglocation. CS isacceptablegiventheyare aware of risksandin conclusions that TOL inawomenwithtwoprevious Caesarean Birth’. SCOG’s ‘Guideline forVaginal BirthAfterPrevious No. 45‘Birth AfterPrevious Caesarean Birth’and also makes mentionof RCOG’s Green-top Guideline Table 2.Outcomesof twostudiesthat compared VBAC-2, VBAC-1 andRCS. studies lookingat VBAC-2 vsVBAC-1. the guidelineisatablecomparingoutcomesof six analysis that isreviewed below. their thirdRCS. The data referenced isfrom ameta- undergoing VBAC-2 issimilartothat undergoing previous CS. morbidity compared towomenwhohaveone higher rates of bothuterinerupture andmaternal birth after twocaesareans sections(VBAC-2) and states that there isalowersuccessrate of vaginal RANZCOG’s ‘Birth after previous caesarean section’ The guidelines and augmentation of labour. spontaneous labouronset,usuallyavoidinginduction an individualisedcare planexistsandencourage care inlabourtooptimisebirthoutcomes.We ensure monitoring of labourprogress etc)andcollaborative access, continuouselectronic fetalmonitoring, standard considerations forVBAC (intravenous counselled byaseniorconsultant.We recommend present requesting aTOL theyare reviewed and in womenwithtwoormore previous CS, ifthey the departmentdoesn’tactivelypromote VBAC repeat caesarean section(RCS)occurs.Whilst ensure non-biasedcounsellingof bothVBAC and contraindications toVBACreport/s, and identify woman’s wishes,review of previous operation (NBAC)’. Women intheirNextBirthAfterCaesarean Section Study RCS VBAC-1 and VBAC-2, comparing study Cohort (USA 2005) Marcones RCS VBAC-2 vs and VBAC-1 VBAC-2 vs comparing study cohort Prospective (USA 2006) Landon 4 Thischecklistisaguidetohighlightthe 5 Maternal morbidityforwomen population Study excluded) classical (previous 12535 VBAC-1 2888 RCS 1082 VBAC-2 excluded) classical (previous previous CS RCS after two VBAC-1 6035 CS) 16915 four previous and 20with three previous cases with (including 84 975 VBAC-2 6,7 Bothof whichcometosimilar 5 Methods and 73%RCS CS hadatrial two previous subjects with 27% of RCS trial, 85% CS hada two previous subjects with 14% of AppendixBof 5 Theguideline management Labour 34% vs augmentation Syntocinon 29% 30% vsVBAC-1 IOL VBAC-2 vs 71% epidural 58% 25% vs32% augmentation Syntocinon 23% vs26% VBAC-1 IOL VBAC-2 vs widely referenced. small numbers.Tahseen andGriffith’spaperismost are retrospective caseseriesorcohortstudieswith VBAC-2 withVBAC-1 orRCS. Themajorityof papers There are norandomisedcontrol trialsassessing The evidence VBAC-2 group. in VBAC-2 successrate 66%compared to74% in Landon etalalsofoundasignificantdifference group. (ranging from 45–85%)compared to76.5% inVBAC-1 with twoprevious CShasasuccessrate of 71.7% Tahseen andGriffithillustrated that TOLinwomen of results. table isasummary studies usedbothVBAC-1 andRCS(third).Thebelow used VBAC-1, eightstudiesusedRCS(third)andtwo after twoormore CS. Ascomparisons,sixstudies a totalof 5666womenundergoingaplannedTOL 75.5% respectively. significant difference between groups 74.6% and significant withanOR1.48 (95%CI1.23–1.78). analysis showedthisdifference tobestatistically to assess.Additionally, thedefinitionfor‘rupture’ small absolute,numbersmaking itadifficultoutcome rupture isarare eventandthestudiesreviewed had 1.36%(0–5.4%). Theyalsoacknowledgedthat uterine rate of uterinerupture intheVBAC-2 group was most significantconsequences. Tahseen andGriffiths uterine rupture, asitisthecomplication that hasthe Great emphasishasalwaysbeenplacedontherate of difference betweengroups. limited butthere doesnotappeartobeasignificant when compared totheVBAC-1. Theneonatal data is and RCS(third);however, higherintheVBAC-2 group morbidity) rates were comparablebetweenVBAC-2 (hysterectomy, bloodtransfusionandfebrile Success rate undergo trial more likely to were delivery vaginal previous women with VBAC-1, 2, 75.5% 74.6% VBAC- undergo trial more likely to delivery vaginal previous Women with VBAC-1. 2, 74% in 66% VBAC≥ 8 Althoughtheseseemcomparable,meta- 8 8,9 WhilstMarcones etalfoundno 8 8,10 Seventeenpaperswere usedwith outcome Maternal VBAC-2 RCS vs8.8% in Fever 12.7% 1.18% inRCS 0.68% and vs VBAC-1 VBAC-2 0.92% transfusion VBAC-1 0.9%, VBAC-2 1.8% vs Uterine rupture to CS comparable morbidity Maternal 1.6% VBAC-1 3.2% VBAC-2 vs transfusion 0.2% VBAC-1, 0.6% VBAC-2 vs Hysterectomy 0.7% VBAC-1. 0.9% VBAC-2 vs Uterine rupture Adversematernal outcomes outcome Neonatal HIE 0%vs0.1% 0.08%, term NND 0.15% vs vs 0.01%,term stillbirth 0% intrapartum vs9%, Term admission 11% Term NICU 8

BIRTHING Vol. 22 No. 3 Spring 2020 | 44 Vol. Written by experts. Written World Health Organization, Human Reproduction Programme. Programme. Reproduction Human Health Organization, World Available April 2015. section rates. on caesarean WHO statement www.who.int/reproductivehealth/publications/maternal_ from: perinatal_health/cs-statement/en OECD Indicators. a Glance 2019: OECD Health at OECD. https://doi.org/10.1787/4dd50c09-en 2019. Publishing. Paris, Health Australia’s and Welfare. Health of Australian Institute Available 2018. 222.Canberra:AIWH. no AUS Cat 2018: In brief. www.aihw.gov.au/getmedia/fe037cf1-0cd0-4663-a8c0- from: 67cd09b1f30c/aihw-aus-222.pdf.aspx?inline=true in their Next Birth After NSW Health. Supporting Women Checklist. 2: Antenatal Attachment Section (NBAC). Caesarean www1.health.nsw. from: Available 2014. NSW Kids and Families, gov.au/pds/Pages/doc.aspx?dn=GL2014_004 section. Melbourne, caesarean previous Birth after RANZCOG. https://ranzcog.edu.au/statements- from: Available Vic; 2019. guidelines/obstetrics/birth-after-previous-caesarean-section- (c-obs-38) Obstetricians and Gynaecologists. Birth after Royal College of London Guideline No.45). Birth (Green-top Caesarean Previous www.rcog.org.uk/globalassets/ from: Available UK; 2015. documents/guidelines/gtg_45.pdf Canada. Obstetricians and Gynaecologists of The Society of Birth. Caesarean previous Birth after Guidelines for Vaginal http://sogc.org/wp- from: Available Ottawa, Canada; 2004. content/uploads/2013/01/155E-CPG-February2005.pdf sections after two caesarean Vaginal birth Griffiths M. S, Tahseen success of with meta-analysis review systematic (VBAC-2)—a 1 and repeat versus VBAC- VBAC-2 and adverse outcomes of rate sections. BJOG. 2010;117:5-19. (third) caesarean with uterine rupture Thom E, et al. Risk of Spong CY, Landon MB, labor in women with multiple and single prior cesarean a trial of Obstet Gynecol. 2006;108:12-20. delivery. outcomes in E, et al. Obstetric Macones GA, Cahill A, Pare deliveries: Is vaginal birth women with two prior cesarean delivery cesarean after Am J Obstet Gynecol. a viable option? 2005;192:1223-9. a of AM, et al. Validation Allshouse AA, Faucett Metz TD, Delivery After Cesarean Birth Model in Prediction Vaginal Deliveries. Obstet Gynecol. Prior Cesarean With Two Women 2015;125(4):948-52. RANZCOG RANZCOG Patient Information Pamphlets ranzcog.edu.au/patient-information-pamphlets

References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. But given 11 8,9,10 The general risks of VBAC and RCS VBAC risks of The general uterine 71.7%, of rate success The VBAC-2 maternal 1.36% and that of risk rupture transfusion) is morbidity (hysterectomy, RCS(third) of comparable to that abnormal placentation risk of The increased morbidity with RCS as well as increasing CS of number with increasing can expedite Birthing in a facility that surgical delivery for reports operation previous Where for CS can be uterine incision and indication suitability ensure in advance to reviewed successful Individual factors affecting vaginal delivery: vaginal i.e. previous diabetes fetal lie and size, age, BMI, delivery, and pre-existing) or (both gestational hypertensive disease Their own individual birth plan to the NICHD MFMU calculator Review of success rate of estimate give a rough TOL is acceptable for women who have who have for women TOL is acceptable regarding been counselled • • • • • • • • the overall low numbers of uterine rupture, previous previous uterine rupture, the overall low numbers of for vaginal delivery a prerequisite considered is not sections. caesarean with two previous TOL cannot be and Griffiths Tahseen of Limitations studies included, varying the timespan of ignored: and inclusion of practice over time and regions due women with unknown scar type. Additionally, factors/cohort to the study design, individual patient and study bias were age, fetal size) variants (BMI, and assessed which can make unable to be reviewed difficult. the data of extrapolation cohort studies have been a handful of There and Griffiths Tahseen of published since the release come to the same conclusions. On an interesting that note, Metz et al found in a small secondary analysis the NICHD the use of 359 women in 2015 that of to successful VBAC for predicting MFMU calculator for women similar to actual rates estimates provide CS. two previous after TOL attempting Discussion regarding data high-powered Despite the lack of seems to be a consensus when it there VBAC-2, and my initial CS, two previous after comes to TOL feelings an over-reaction. Conclusion is a place for In contemporary there care, maternity achieving which can be supported safely VBAC-2, both short- and long-term health benefits for women varied considerably across studies as well as how it studies as well as varied considerably across after of uterine scar was identified (manual palpation was a common practice in the past).successful VBAC included who had unknown patients were There inuterine incisions (i.e. classical and lower vertical) with syntocinon.some studies and IOL/augmentation women who had a previous It was identified that and to undergo a TOL likely vaginal birth was more VBAC-2. or thus a successful VBAC-1 BIRTHING with donoroocytes. autologous oocytes,butimprove to 28.6–42.5% rates perAustralianIVFcycleare 1.4–12.5% with to considerdonoroocytes.Past age40, livebirth end of theirfertilityjourney. Othersmaybewilling own eggsisnotsuccessfuland sadly, that willbethe conceive. Forsomewomenof AMA, IVFwiththeir help after to six,rather thantwelvemonthsof trying age of 35, theadviceisforwomentoseekfertility a more rapiddeclinefrom around age37. Afterthe begins tofallsignificantlyfrom around age32,with Due toreduced oocytequalityandquantity, fertility Fertility consequences of AMA,whichwewillnowaddress. between 35–40andabove.There are multiple defined internationally andvariesintheliterature The termadvancedmaternal age(AMA)isnotclearly are otherfactors. technology (ART), access tocontraceptionandassistedreproductive stability andlater partnering,aswellimproved for later ageof childbearing.Reducedrelationship financial goals,are some of thebiggest reasons cited and adesire toachievecareer, educational and access tohighereducation andcareer opportunities, Brisbane, Qld QEII Hospital Mater Health Services, MBBS (Hons),FRANZCOG Dr AliceWhittaker advanced maternalage Complications of compared with4.4/1000 birthsin1980. aged 40andolderwere at 12.9/1000 birthsin2017, ever before. InAustralia,birthrates forwomen Women are delayingchildbearingmore todaythan 2 1 Improved function diminishes. resistance increase andthevascular endothelialcell resistance andperipheral vascular AMA, uterineartery Studies demonstrate that inpregnancy inwomenof maladaptive cardiovascularresponse topregnancy. eventbehinddefective placentation isa the primary • • increased rates of: AMA inotherwiselow-riskwomenisassociated with considering comorbidities,parityandmultiparity, optimisation of theseconditions;however, evenafter highlights theimportanceof pre-conception such asdiabetes,hypertensionandobesity. This of comorbiditiesthat cancomplicate pregnancy, As womenage,theynaturally havehigherrates Second andthirdtrimestercomplications transfers whenpossible. the contextof ART, withconsensusof singleembryo record internationally forlowrates of multiparityin today ismostlyduetoART. Australiahasanexcellent can result inmore thanonedominantfollicle)but AMA increases theriskof multiparity(risingFSHlevels tubal pathology. as multiplesexualpartners,pelvicinfection and to anaccumulation of riskfactorsovertime,such The increased riskof ectopicpregnancy islikely due combined firsttrimesterscreening. or offered, eithernon-invasiveprenatal testing(NIPT) from age35(Figure 1);aneuploidyscreening shouldbe The riskof ababywithaneuploidyincreases drastically spontaneous miscarriagerate seeninAMA(Figure 1). explainthemajorityof theincreased embryos telomeres todamage.Chromosomally abnormal 1, where DNAisvulnerabletooxidative stress and time theiroocyteshavebeensuspendedinMetaphase of womenof AMA,attributedembryos tothelonger Chromosomal abnormalitiesare more commonin • • • • AMA isassociated withincreased rates of: Early pregnancy • • • • women age. of theaboveonabnormalplacentation seenas Traditional thinkinghassoughttoattribute much Gestational diabetes(OR3.7 AMA≥40) Hypertensive disordersof pregnancy (RR4.1) Multiple pregnancy Ectopic pregnancy aneuploidy Chromosomal abnormalities,including Spontaneous miscarriage (OR 1.5AMA≥40) Iatrogenic andspontaneouspreterm birth Fetal growth restriction (OR1.5AMA≥40) embolism (OR2.4Pulmonary AMA≥40) abruption Placenta praevia(RR3.16), accreta and 8 Agreater bodyof worknowsuggests 7 9 6

6 6 6

4,5

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4,5 3 After AMA pregnancy, CVD may be higher. It is be higher. CVD may After AMA pregnancy, women who experience well established that (PET) to toxaemia pre-eclampsia twice as likely are In addition, it may be that in life. CVD later die of to an aging additional stress AMA adds at pregnancy cardiovascular system. Short birth interval may further increase risk. Women risk. Women further increase Short birth interval may interpregnancy had six-month AMA ≥35 years who of with 18-month intervals had intervals compared morbidity or maternal severe of higher rates in younger women. This was not seen mortality. Parenting is age maternal some good news? Increasing Finally, health and development in with improved associated of Children including cognitive ability. their children, the have described benefits, including older parents as parents, their of and attention devotion, patience well as their emotional and financial stability. Maternal mortality and long-term maternal maternal and long-term mortality Maternal complications cardiovascular in ICU an increase demonstrate Several studies AMA. of in women death and maternal admission cardiovascular are AMA in the context of Risk factors and operative diabetes, obesity disease (CVD), delivery. Adapted from Fretts et al. Fretts Adapted from

4 The risk 10 5 11 The risk increases further as women further The risk increases 6 Caesarean section (CS) (RR 4.1) Caesarean Postpartum haemorrhage increases with advancing gestation, such that women such that gestation, with advancing increases 39 stillbirth at the same risk of age have ≥40 years of gestation. of 41 weeks have at weeks, as 20-year-olds will advise induction of most centres As a result, weeks for AMA. 39 labour (IOL) after Intrapartum complications of: rates increased with AMA is associated • age. Prevalence of stillbirth is 0.9% among mothers is 0.9% stillbirth of age. Prevalence age 50 years and over, 1.0% aged 40–49 years and aged 20–39 years. to 0.5% compared Stillbirth stillbirth is well between AMA and The relationship A large and consistently observed. established 1.75 births gave an OR of 44 million of meta-analysis for age ≥35. First trimester complications of AMA. of Figure 1. First trimester complications • to is partly attributed CS rate The increased for and a lower threshold complications pregnancy independent However, elective or emergency CS. and CS labour dystocia risk of this, AMA increases of for fetal distress. The increased risk of gestational diabetes mellitus mellitus diabetes gestational of risk The increased B-cell pancreatic due to the fact that (GDM) is also with age. insulin sensitivity fall function and BIRTHING educational, career orfinancialpoint of view? mothers earlierwithoutdisadvantagingthemfrom an can wecreate opportunitiesforwomentobecome (and atrainingcollege)weneedtoaskourselves:how underestimated bythepublic.Finally, asasociety risk AMAbringstoapregnancy. Theserisksare widely be educating womenandsocietyabouttheincreased pregnancy assafe aspossible.Secondly, weshould clinicians workingwithwomen,ourrole istomake certainly wouldnotwanttorelinquish. Firstly, as our feministforbearers foughthardforandthat we and financialadvancementinwomen)are advances led totheriseinAMA(that is,educational, career and pregnancy journey. Thesocietalfactorsthat have increased risksacross allstagesof thefertility, birth Women at AMAfaceawiderangeof significantly Summary 3. 2. 1. References

• • • • • • • • • • Pregnancy managementtipsforAMA age-on-pregnancy www.uptodate.com/contents/effects-of-advanced-maternal- maternal ageonpregnancy. UpToDate, 2019. Available from: Fretts RC,Wilkins-Haug L,SimpsonLL.Effects of advanced org/10.1111/ajo.13179. autologous versusdonoroocytes.ANZJOG.2020. https://doi. assisted reproductive technology:Thereproductive dilemmaof Hogan R,Wang A,LiZ,etal.Havingababyinyour40swith Australian Bureau of Statistics, 2018. Australian Bureau of Statistics. Births,Australia2017. Canberra: maternal death Discuss interpregnancy interval(from birthtoconception)of 12–18monthsduetoreduction in choose electiveCS. Make IOLat 39weeksstrongly advised.Very aplanfordelivery: advancedmaternal agemaywishto cessation, discussfetalmovementpatterns andsidesleeping Make aplanforstillbirthriskprevention: discussotherstillbirthriskfactors,encouragesmoking Consider growth ultrasounds Warn aboutrisksof GDM,PETandplanamodelof care accordingly Consider screening forGDMinfirsttrimester Low doseaspirinfrom 12–36weeks Aneuploidy screening: consideration toNIPTgivenitshighersensitivityandspecificity Avoid multiplepregnancy ifundertakingART and iodine Preconceptual counselling:warnof risk,optimisemedicalconditions,preconceptual folicacid to update yourdetailstoday. Visit themy.RANZCOG.edu.au memberportal Change ofaddress? 12 12. 11. 10. 9. 8. 7. 6. 5. 4.

2018;178(12):1661-70. Outcomes AccordingtoMaternal Age.JAMAIntern Med. Association of ShortInterpregnancy IntervalWithPregnancy Schummers L,HutcheonJ, Hernandez-Diaz S, etal. Scand. 2020. doi:10.1111/aogs.13828. maternal age:Anational cohortstudy. ActaObstetGynecol Kortekaas JC,Kazemier BM,Keulen JKJ, etal.Advanced 2020;9(1):153-6. Women intheUnited States: 2003–2017. Int JMCHandAIDS. Dongarwar. Stillbirths amongAdvancedMaternal Age of Physiology. 2019;317(2):H387. maternal andoffspring cardiovascularhealth.AmericanJournal Cooke C,DavidgeS. Advancedmaternal ageandtheimpacton arpa.2019-0481-OA. Examination? ArchPathol 2020. LabMed. doi:10.5858/ Maternal Age:AnIndependentIndication forPathologic Torous V, RobertsD. PlacentasFrom Women of Advanced 2018;34(2):e00206116. abruption: ameta-analysis. CadernosdeSaudePublica. age anditsassociation withplacentapraeviaandplacental Martinelli K,Garcia EM,SantosNetoE,etal.Advancedmaternal analysis. PLoSOne.2017;12(10):e0186287. adverse pregnancy outcomes:Asystematic review andmeta- Lean SC,DerricottH, JonesRL,etal.Advancedmaternal ageand maternal health.FertilityandSterility. 2015;103(5):1136-43 Sauer M.Reproduction at anadvancedmaternal ageand Port. 2019;32(3):219-26. Adverse Outcomesof Pregnancy, AMeta-Analysis. ActaMed Pinheiro R,Areia A,MotaPintoetal.AdvancedMaternal Age:

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9 Eight 5 Almost all of Almost all of 10 while other have Vol. 22 No. 3 Spring 2020 | 48 Vol. 6,7 Most recently, a re-analysis of a re-analysis Most recently, 8 Consistent with the Twin Birth Birth Consistent with the Twin 10 Over this time, there has been a Over this time, there it wasn’t until 2013 that the Twin the Twin it wasn’t until 2013 that 10 3,4 we didn’t find any evidence that the increased the increased we didn’t find any evidence that 3 study, three-fold increase in both planned and unplanned increase three-fold born twins of section. The proportion caesarean 76% to 29%. vaginally has fallen from this change happened before 2005. Since then, the 2005. this change happened before section and vaginal birth for twins caesarean of rates 1). stable (Figure have been relatively Next, we sought to understand the principal reasons birth over time. Were for the changes in mode of complex twin pregnancies, they due to increasingly co-morbidities or pre-existing maternal or more over found that, We disease? They weren’t. maternal time, ‘twins’ itself has become the main indication This section, with no other indication. for caesarean We age or parity. maternal of was true irrespective of in the rate regional variation also found significant (Figure the state section for twins across caesarean varying2), with rates by over 25%. After adjusting previous age, body mass index, parity, for maternal and use of care, section, public or private caesarean women living in technology, assisted reproductive to have twins born by half as likely Gippsland were section than women living in north-west caesarean Melbourne or the Grampians (adjusted metropolitan 0.46). odds ratio argued the opposite. Australian hospitals participated in the study. One in the study. Australian hospitals participated there, would end the debate might have expected that But, no! with a definitive RCT. the Birth study, the Twin of Since the publication further cohort has continued. Authors of debate is as planned vaginal birth studies have argued that section, as elective caesarean safe Birth study, the first randomised (RCT) the first randomised of Birth study, electivein twins, showed that birth planned mode of with betternot associated section was caesarean planned vaginal birth. outcomes than perinatal preferred mode of birth for ‘uncomplicated’ twins. This for ‘uncomplicated’ birth mode of preferred high-level lack of in part, to the relative owing, is likely practice. While a numberevidence to guide clinical had suggested that cohort studies retrospective of than planned was safer section elective caesarean vaginal birth, No wonder confusion reigns, both among women reigns, No wonder confusion with twins and among the clinicianspregnant mode is the preferred So, what them care. providing we sought to birth for twins in Australia? Recently, of question for Victoria and to understandanswer that for any changes. possible explanations birth for the mode of at looked First, the changes. We period, in Victoria over a 33-year twin pregnancies 1983 to 2015. the Twin Birth study, taking into account gestation Birth study, the Twin that outcome, showed of as a possible confounder section than caesarean planned vaginal birth was safer an 37 weeks onwards 32 to 37 weeks, but from from favourable. section may be more elective caesarean use of caesarean section has been associated with section has been associated caesarean use of outcomes. better perinatal was only two years between theOf course, there Birth study and the end of the Twin of publication

1 no maternity care clinician care no maternity 2 is unfamiliar with the complexities and challengesis unfamiliar much debate In particular, twin pregnancies. of thecontinues about choices and decisions regarding Prof Euan M Wallace AM Prof Euan M Wallace FAHMS FRANZCOG, FRCOG, MBChB, MD, Professor and Head of Department of Carl Wood Monash University Obstetrics and Gynaecology, Compared to their singleton counterparts, twins haveCompared and a half times higher, three mortality rate a perinatal Dr Mary-Ann Davey RM MEpi, GradDipSoc, BEd, DipAppSc, RN, DPH, Department Obstetrics Fellow, Senior Research Monash University and Gynaecology, Dr Yizhen (Amy) Liu BMedSci (Hons), MBBS Monash University and tribulations and Twin births: trends trends births: Twin a rate that has seen minimal change over the past 20 that a rate It care. years despite significant advances in perinatal while twins account for lessis no surprise then that, all pregnancies, than 3% of BIRTHING Figure 2.Rates of twincaesarean sectionbyVictorianregion. (adaptedfrom Liuetal) Figure 1.Trends inmodesof twinbirthinVictoriabetween 1983–2015. (adaptedfrom Liuetal) that arecent surveyof RANZCOG membersand new vaginal birthsayear. Itshouldn’tbesurprising then crudely equates toeachtraineeattending twotwin 152 FRANZCOG traineesacross six-year levels.This In 2015, there were 320. Thesame year, there were data set,there were 502setsof twinsbornvaginally. of askilledworkforce. In1983, thefirstyear of our our observations isinrelation tothemaintenance However, perhapsamore pressing implication of time forthefindings of thestudytochangepractice. the data setthat weanalysed.Possiblyinsufficient births. did notfeelsufficientlyexperiencedintwinvaginal Fellows foundthat 34%of traineesand15%of Fellows choice inhowtheir babiesare born.’ competent workforce toenablewomen tohaveareal paper, ‘We shouldensure that wehaveaskilledand about modeof birth.Aswearguedin ourrecent to offer womenwithatwinpregnancy safe choices we couldhaveaFellowshipworkforce that isunable competence intwinvaginalbirth. Withoutduecare, training syllabusfortraineestodemonstrate 11 There isnorequirement withintheRANZCOG 10 10 10 ae.ma conversation’ ranogeda ‘Join the a au.ed.mmaya BIRTHING

Vol. 22 No. 3 Spring 2020 | 50 Vol. au.ed.mmaya Smith GC, Shah I, White IR, et al. Mode of delivery of IR, et al. Mode White the and Shah I, Smith GC, twins at among death delivery-related perinatal risk of births. BJOG. 8073 study of cohort term: a retrospective 2005;112(8):1139-44. et al. Determinants of C, Persad V, Armson BA, O’Connell morbidity in the second and serious neonatal mortality perinatal 1):556-64. 2006;108(3 Pt twin. Obstet Gynecol. Trial Randomized ME, Hutton EK, et al. A JFR, Hannah Barrett Pregnancy. Delivery for Twin or Vaginal Planned Cesarean of N Engl J Med. 2013;369(14):1295-305. Between Planned Prunet C, Azria E, et al. Association Schmitz T, DeliveryCesarean Mortality and Morbidity in Twin and Neonatal 2017;129(6):986-95. Obstet Gynecol. Pregnancies. section caesarean CA. Planned Crowther JF, Barrett GJ, Hofmeyr Rev. Syst Database Cochrane for women with a twin pregnancy. 2015;2015(12):CD006553. van der Hoeven M, et al. Comparison S, Ensing Goossens S, delivery planned caesarean of and planned vaginal delivery in study. wide cohort A nation women with a twin pregnancy: Biol. 2018;221:97-104. J Obstet Gynecol Reprod Eur or et al. Planned Cesarean P, Tajik Goossens S, MH, Zafarmand planned vaginal delivery for twins: a secondary a analysis of Obstet Gynecol. 2019. trial. Ultrasound controlled randomized doi: 10.1002/uog.21907. twin of Davey MA, Lee R, et al. Changes in the modes Liu YA, MJA. 2020;212(2):82-8. birth in Victoria, 1983-2015. Experience and Lee PYA. Rolnik DL, Regan JA, SGJ, Yeoh and twin deliveries among obstetric in vaginal breech confidence trainees and new specialists in Australia and New Zealand. ANZJOG. 2019;59(4):545-9.

3. 4. 5. 6. 7. 8. 9. 10. 11. a ‘Join the ‘Join ranogeda conversation’ Consultative Council on Obstetric and Paediatric Mortality and and Paediatric Council on Obstetric Consultative and 2014 Babies and Children Victoria’s Mothers, Morbidity. from: Available 2017. Melbourne: Victorian Government; 2015. www.bettersafercare.vic.gov.au/reports-and-publications/ victorias-mothers-babies-and-children-report-2014-15 Australia’s mothers Health and Welfare. Australian Institute of from: Available 2017. Canberra: AIHW; and babies 2015—in brief. www.aihw.gov.au/reports/mothers-babies/australias-mothers- babies-2015-in-brief/contents/table-of-contents References References 1. 2. However, perhaps not all is lost. That the rate of twin of the rate That not all is lost. perhaps However, in over 15 changed hasn’t materially vaginal birth it is time, if Perhaps reassuring. years is somewhat a twin pregnancy all women with that not overdue, by multidisciplinary for cared are clinical teams with vaginal including multiple pregnancy, expertise in twin of not arguing for centralisation are birth. We is not city hospitals. That to large care pregnancy women. In of in the best interests nor necessary, twin vaginal birth is in a of Victoria, the highest rate arguing for women we are hospital. Rather, regional for by clinicians to be cared with a twin pregnancy and skilled in being experienced, confident who are outcomes way, choices. That safe them able to offer and training opportunities improve, would likely units. into dedicated could be better concentrated ae.ma BIRTHING safe delivery option. safe delivery women from choosingassistedvaginalbirthasa questionable scientificinformation discouraging response totheperception of negative socialand Murray,(Stephen Robson,Henry JohnSvigos) in experienced FellowsandRANZCOG examiners In 2012,aconversation resulted betweenthree stream’ maternal morbidityasaresult. along withanincrease inshort termand‘downthe tangible improvement inperinatal outcomes, section (CS)rate that haddevelopedwithoutany was accompaniedbyanincreased caesarean delivery: asafe choice? delivery: Instrumental vaginal option forwomen. able toprovide assistedvaginal birthasalegitimate training of thenextgeneration of obstetricianstobe reflected aloss of confidence inthe teachingand of cliniciansexpressed theview that thesechanges On behalf oftheBirthMasterClassFaculty Adelaide, SA Women’s &Children’sHospital Senior VisitingObstetrician&Gynaecologist MBBS, FRANZCOG Dr DarrenRoberts The CanberraHospital,ACT Senior SpecialistinObstetrics&Gynaecology Australian NationalUniversity Medical School FACOG, FRANZCOG BMedSc, MBBS,MMed,MPH, MD, PhD, FRCOG, Prof StephenRobson Hunter NewEnglandHealth NSW Head Women’s Health andMaternityNetwork John HunterHospital,Newcastle Senior Obstetrician&MFM Specialist University ofNewcastle Faculty ofHealth &Medicine School ofMedicine&PublicHealth MBChB, MRCOG, FRANZCOG, CMFM Murray A/Prof Henry Lyell McEwin Hospital,ElizabethVale, SA Senior Consultant Obstetrician&Gynaecologist University ofAdelaideSA Faculty ofHealth &MedicalSciences Discipline ofObstetrics&Gynaecology MBBS, DRCOG, FRCOG, FRANZCOG A/Prof JohnSvigosAM 3

1 Thelossof choiceforwomen 2 Anumber instrumental vaginalbirth. rise inCSthelastdecademirroring thefallin just under10%of birthsinNewZealand, withthe for approximately 11%of birthsinAustraliaand forceps assistedvaginalbirthbothaccounting RANZCOG, ACOG andRCOG) withvacuumand practice encouragedbyreputable colleges(including training toallowwomenhaveachoiceandis obstetrics’ isabletobemastered byobstetriciansin birth inthispaperwillconfirm that the ‘art of both generalandspecific, of instrumentalvaginal commentsandexplanation of thenuances, Ancillary under theguidanceof experiencedclinicians. are slowlymastered overaperiodofdelivery time accurately andthenexecute asafe instrumental birth, thetechnicalskillstoassesslabourdystocia whomaybesuitableforinstrumental identify While traditionalguidelinesandprotocols may instrumental vaginalbirthasasafe choiceforwomen. This paperwillconcentrate ontheperformanceof an women withthechoiceof asafe assistedvaginalbirth. required togivethemtheconfidence toprovide instrumental vaginalbirthandassociated procedures breech delivery, of selectedtwins, vaginaldelivery day-long workshopof traininginselectedvaginal rural andremote practitionershaveundergonea senior RANZCOG trainees,GPobstetriciansand To date, atotalof 226consultantobstetricians, perinatal practice. contemporary anaesthetist andneonatologist) intunewith enthusiastic faculty(seniorobstetricians,midwives, comprised amulti-disciplinary, experiencedand workshop (andthesubsequent10BMCWorkshops) from becomingaself-fulfillingprophecy. That Scientific Meetingasan attempt tohaltthisprocess organised at the2012CanberraRANZCOG Annual The inauguralBirthMasterClass(BMC)Workshop was new labourcurves of progress andaccompanying to labourdystociawiththedesign andadoptionof rate duea contributortotheincreased CSdelivery progress of labourhavereceived intensescrutiny as Over thelastdecade,traditional patterns of the be successfulandsafe forthe motherandbaby. compromise maybeabbreviated to what islikely to Whereas thediscussiontimewithsuspectedfetal informed consent. with theparents andattending staff andobtainan order toallowdiscussionof theseoptionsat length in consider theoptionsformodeof delivery second stageof labourthenthere maybetimeto If thesituation issolelydelayedprogress inthe much timeisavailabletoeffectthedelivery. isbeingconsidered andhow why anassisteddelivery reviewing thecore information inordertodetermine assessment of boththemotherandfetus, willconductaclinical an instrumentaldelivery A judiciousobstetricianconsultedtoconsider 4 BIRTHING 11 Vol. 22 No. 3 Spring 2020 | 52 Vol. the choice for the obstetrician is 12 A nested study by the BMC Faculty of 40 senior of A nested study by the BMC Faculty who undertook the Workshop registrars RANZCOG those of with a two year follow-up has found that use of the to an institution where who returned was encouraged, all continued Kielland’s forceps with the practice while not surprisingly those was not the practice to an institution where returning practice. encouraged, only 25% continued with the position requiringWith babies in the occiput-anterior delivery in the second stage due to the traditional to progress failure fetal compromise, of indications ofand malposition, along with the fulfilment for instrumental vaginal birth,the requirements pudendal nerve block of including consideration further perhaps requiring anaesthesia, then apart from fetal position of assistance with the determination by ultrasound, A number of critical strategies have evolved to have evolved strategies critical of A number Kielland’s the use of of this re-evaluation assist with a of these include the involvement and forceps analgesia/anaesthesia anaesthetist for the committed ward with an in labour patients of requirements and timely relaxation pelvic floor effective epidural, a of the execution being fundamental to vaginal delivery rotational with forceps. safe changed favourably to now management has Theatre instrumental birth a trial of of allow the provision as if necessary, to move to CS, with the propensity contemporarypart of obstetric practice. instrumental vaginal delivery with potential Failed by the been addressed morbidity has neonatal to deal with the impacted strategies development of the Fetal Pillow, use of CS with the fetal head at in the modified lithotomy the CS the conduct of obstetricians with training of position and simulation for dis- Debra’ to develop strategies ‘Desperate techniques. and ‘Pull’ impaction including the ‘Push’ that of which instrument to use, with ventouse being which instrument to use, with ventouse of that to the mother as being less traumatic promoted being less traumatic forceps and Simpson’s pattern is usuallyto the fetus. The obstetrician’s preference the presence but possibly modified by, predominating, analgesia and/or fetal compromise. adequate of As with any instrumental birth, a discerning the possibility of obstetrician would anticipate concomitant shoulder dystocia, postpartum haemorrhage and the potential need for neonatal contingencies such for be prepared and resuscitation, delivery a safe in order to ensure option for women. to may give confidence The BMC Workshop women with the choice of obstetricians to provide timely instrumental vaginal birth. Apart from a safe the initial the workshop can provide practice revision, of positive learning experience, but reinforcement this experience is dependent on continued practice and supervision by experienced clinicians ensuring the instrumental techniques not only are that associated the required but that performed correctly taught are potential complications skills to mitigate audit and and encouraged along with debrief, being integral to the process. credentialing Hence, to answer the original question: yes, women vaginal birth. instrumental a safe the choice of may take Acknowledgements The authors wish to acknowledge the unqualified SA&NT Back and the RANZCOG Tania support of Regional Committee. online reference list avalable Full 8 10 6 7 this incompletely 9 which in turn led to an to an in turn led which 5 acceptance of an increased duration of labour labour of duration an increased of acceptance under the traditional seen to that compared guidelines. fall (not initial modest After the anticipated delivery achieved) in the CS consistently to rate justify has not the change, this potential advantage have now been left with a been sustained and we traditional and new systems of the hybrid version of management. labour assessment and evaluated strategy, in order to be successful, requires in order to be successful, requires strategy, evaluated and cervical dilatation 8–9cm of early assistance at becomes early in the second stage as the procedure difficult to perform, or even potentially more hazardous to the fetus, if its institution is delayed. to use Kielland’s For those practitioners not confident to deal with fetal malposition in the second forceps may be achieved by early stage, a compromise the ventouse of and application manual rotation the Kiwi cup), but this will not cover all (preferably a premature particularly in the face of situations, is caput and less than 34–35 weeks or if there infant with which may interfere present, moulding already an effective chignon to aid in the development of may be required. that autorotation has been ofIn contemporary there centres perinatal of Kielland’s the benefits of a positive re-evaluation late a fetal malposition of in the situation rotation forceps the cervix. of full dilation deep in the pelvis at How can we make/how have we made an have How can we make/how instrumental vaginal delivery choice for a safe women to consider? of labour with the first stage Astute management of urgency the to dystocia will reduce early attention of fetal compromise) (in the absence of and duration labour with the second stage of the management of than a passive, an active, rather encouragement of management style with timely assistance. to as a strategy manual rotation In the case of deal with malposition (occiput transverse, occiput in labour, posterior) detected late This practice, as with the other strategies mentioned, This practice, as with the other strategies maternal has been accompanied with increased duration the prolonged not only from morbidity, also labour particularly in the second stage, but of by to deliver the baby either vaginally attempts from circumstances instrumental birth under unfavourable in the pelvis deep or by CS with the fetal head often in the occiput-posterior position with a concomitant morbidity. and maternal in neonatal increase This failed strategy is not all that surprising as the CS not all that is This failed strategy delivery most rapidly during the decades rose rate in traditional labour was no change when there for their interpretation. curves or in the guidelines has vaginal birth, there to instrumental With regard the traditional second of been a similar recalibration modified by the presence labour duration, stage of physically analgesia, to almost neuro-axial of impossible limits (primigravid woman pushing a normal vaginal hours) in the hope that for three delivery might be achieved. management was modified to This form of ‘delayed pushing’ in the a policy of incorporate the demoralising prospect second stage, usually after a woman in labour allowing her previously of ‘morale-saving’ epidural to wear off. management guidelines, management BIRTHING Table 1.ModifiedWHOCriteriaIandII. and delivery at aspecialisedhospital. and delivery specialist managementwithacardio-obstetricteam women at highermWHO riskrequire individualised consider womenat mWHO risklevels1and2as Auckland CityHospital,NZ Department ofCardiology, MBChB, FRACP Dr FionaStewart in labour Maternal heartdisease cardiovascular risk. Organization (mWHO) classification of maternal been bestclassifiedbythemodified WorldHealth abnormality anditsseverity. Cardiovascularriskhas complete picture of thetypeof underlyingcardiac prepregnancy orearlyinthepregnancy, togaina pregnancy isacareful cardiacassessment,ideally Critical tomanagingwomenwithheartdiseasein Risk stratification socioeconomic groups. remote areas andmothersfromliving invery low higher inolderwomen,Indigenouspeople,those or thefirst 24 hours after delivery. Mortalitywas 20% of maternal deaths occurred duringbirth In thelatest Australianmaternal mortalityreview, cardiac eventscanoccurrapidlyandunexpectedly. of themother’sunderlyingcardiaccondition,but cardiac problems are predictable withknowledge leading indirect causeof maternal death. Many Throughout theworld,heartdiseaseremains the • • • • • one of thefollowing: Women withnormalleftventricularfunctionand Modified WHOCriteriaIandII Atrial arrhythmiasand ectopicbeats Mitral valveprolapse andmild MR Small ASDorVSD Tetralogy of Fallot drainage ASD, VSD, venous PDA, anomalouspulmonary Repaired simplecongenitalheartdisease – 2,3 Thisdiscussionwillonly 1 cardiac disease but can cause coronary vasospasm. cardiac diseasebutcancausecoronary oxytocin. Misoprostol isusuallysafe forwomenwith artificial rupture of themembranesanduse of Labour maybeinducedincardiacwomenwith hypertension andforsomewhoare anticoagulated. artery stenosis, intractableheartfailure, pulmonary aortic pathology, severe mitraland aorticvalve disease are onlyrecommended forwomenwith caesarean sectionsforwomenwithcardiac be determinedbyobstetricindications. Elective should In lowerriskwomen,themodeof delivery increase inafterload totheheart. hypertension orpreeclampsia duetothesudden decompensate rapidlyiftheydevelopgestational Women withunderlyingheartdiseasemay immediately availableat alltimes. It isessentialthat thisiswelldocumentedand the mother, isimportanttominimisecomplications. planningfordelivery,Multidisciplinary discussedwith fluids given.Use of acontinuousepidural and careful blood pressure orvolumeoverloadfrom intravenous and anaesthesiatominimisesudden fallsinmaternal needs tobetaken withtheuseof epiduralanalgesia cardiac stress byreducing maternal tachycardia.Care Good analgesiaforlabourwillreduce maternal fluid administration isimportant forallwomen. Careful attention tomaternal bloodpressure and pressures are significantlyelevated at thistime. defect whenthemotherispushing,asrightheart risk of introducing airembolithat couldcross the taken withperipheralvenouslines becauseof the with intracardiacshunts(ASD, VSD)care needstobe give emergencyantiarrhythmictherapy. Forwomen available whocaninterpret theECG changesand planned, itisimportantthat suitablytrainedstaff are room. Ifcardiacmonitoringis in thedelivery monitoring (andmedication totreat thearrhythmia) of arrhythmiasitiswisetohaveECGwith ahistory inlabourbutforwomen women isnotnecessary Cardiac ECG monitoringformostlow-riskcardiac and 40weeks. pregnant womenwithcardiacdiseasebetween39 recommends electiveinductionof labourin The AmericanCollegeof ObstetricsandGynecology • • • • • • • • • planningchecklist Delivery Postpartum monitoring Ecbolic Labour plan Anaesthesia/analgesia Maternal monitoring Mode of delivery Timing of delivery anaesthetics, obstetrics,midwifery plan–cardiology,Multidisciplinary condition Recent assessmentunderlyingcardiac 5 4

BIRTHING Vol. 22 No. 3 Spring 2020 | 54 Vol. 8 9 CPR compressions 100/min CPR compressions 30:2 Ventilation manual left uterine Continuous displacement Defibrillation Antiarrhythmic medications and adrenalin) (amiodarone – minimise hypoxia Airway management deliveryPerimortem caesarean – 5-minute window Australian Institute of Health and Welfare 2020. Maternal deaths deaths Maternal 2020. Health and Welfare Australian Institute of Canberra: AIHW. No. PER 106. Cat. in Australia 2015–2017. et al. 2018 Bauersachs J, JW, Roos-Hesselink V, Regitz-Zagrosek cardiovascular diseases ESC Guidelines for the management of Heart J. 2018;39(34):3165-3241. Eur during pregnancy. outcomes Baris L, Johnson M, et al. Pregnancy J, Roos-Hesselink over 10 I women with cardiovascular disease: evolving trends years in the ESC Registry and Cardiac disease Pregnancy of Heart J. 2019;40:3848-55. Eur (ROPAC). CA, Bradley E, et al. Cardiovascular Warnes Mehta LS, A scientific patients. in caring for pregnant considerations . Circulation the American Heart Association. from statement 2020;141:e884-e903. and heart disease. Practice Bulletin No. 212: pregnancy ACOG Obstet Gynecol. 2019;133:e320-e356. al. Pregnancy- et MN, Barakkat Jainapurkar S, Elkayam U, of a review acute myocardial infarction: associated contemporary experience inn 150 cases between 2006 and 2011. . 2014;129:1695-1702. Circulation in et al. Cardiac arrest CM, Lipman S, Jeejeebhoy FM, Zelop the American Heart from A scientific statement pregnancy: . 2015;132:1747-73. Circulation Association. and cardiac arrest Maternal Sela HY. Kaufman N, Einav S, delivery:perimortem caesarean evidence or expert-based? . 2012;83:1191-1200. Resuscitation Gada R. Supraventricular tachycardia S, Farrakh CW, Bircher achieving vaginal birth and in labour: A case report presenting Obstetric Medicine. 2016;9:96-7. the literature. of review Cardiopulmonary resuscitation in pregnancy • • • • • • •

Rare causes of ventricular tachycardia presenting in ventricular tachycardia presenting causes of Rare postpartum include long QT labour or immediately choice for drugs of the are Beta blockers syndrome. these patients. unexpected will always be a risk of There but with cardiac women in labour, complications woman, labour the pregnant assessment of careful the between planning and good communication multidisciplinaryreduce risk will significantly team outcome for the a good pregnancy and help ensure mother and baby. References 1. 2. 3. 4. 5. 6. 7. 8. 9. Arrhythmia commonly in All arrhythmias occur more occur In an otherwise well woman, SVTs pregnancy. delivery. most commonly and may complicate Management is the same as for a nonpregnant and, manoeuvre Valsalva woman: with immediate if unsuccessful, intravenous adenosine as first-line if therapy followed by verapamil or metoprolol normal the goal is to restore unsuccessful. In labour, hypotension to minimise maternal rhythm promptly and fetal compromise. by perimortem caesarean section. Maternal survival survival section. Maternal by perimortem caesarean when deliveryis significantly improved five is within 57 deliveries in a series of but the arrest, minutes of survival occurred maternal following cardiac arrest, to 22.6 mins compared + 7.2 with delivery 10.0 at cardiac arrest. of mins in non-survivors + 13.3 + 11 14 an average of survival was seen at Neonatal 13.3 to 22 + compared cardiac arrest minutes from minutes in non-survivors.

2 Important 2,4 7 Risk is increased Risk is increased 6 disease) disease) cardiomyopathy (stress) 2% Takotsubo Aetiology of myocardial infarction (MI) Aetiology of myocardial infarction 43% Spontaneous coronary artery dissection 27% Atherosclerosis 17% Thrombus 11% MINOCA (MI with no obstructive coronary CPR is recommended as for nonpregnant patients patients as for nonpregnant CPR is recommended to airway management to attention with careful delivery of and early consideration minimise hypoxia Maternal cardiac arrest immediate necessitates cardiac arrest A maternal where the mother and treatment of resuscitation the underlying cause. possible of Aortic dissection With a An aortic dissection is a medical emergency. deliveryviable fetus, immediate section by caesarean for Stanford the aorta is recommended of with repair type A dissection (involves ascending aorta) and B dissection Type medical management for Stanford to the descending thoracic aorta). (confined in labour may cardiac problems with undiagnosed Women an acute in labour or may deliver after present cardiac event. Myocardial infarction occur 3–4 times Acute myocardial infarctions than in an age- commonly in pregnancy more Events population. nonpregnant matched occur most commonly postpartum (73%) and in the third trimester (21%). fluid management can minimise this and is the this can minimise management fluid for cardiac women. approach preferred cardiac improve position will in the lateral Labouring labour cause of heart. The active stages to the return right heart changes increasing many haemodynamic and the blood to the heart of return the pressures, cardiac output. An maternal need for an increased assisted delivery but cardiac work maternal will reduce is not usually necessarywomen. for low-risk cardiac of for the prevention Antibiotic prophylaxis for delivery recommended endocarditis is no longer heart disease. in women with valvular is the ecbolic of infusion Oxytocin given by a slow may be given for postpartum choice. PGE analogues and PGF analogues haemorrhage but ergometrine to vasoconstriction. should be avoided due changes continue in the Major haemodynamic in early postpartum period. Mothers should remain over this time. hospital and under close observation Managing the unexpected cardiac problems with the administration of ergotamine causing ergotamine causing of with the administration there emboli where vasoconstriction, paradoxical of or ventricular septal defects or as part atrial are pregnancy. of state the hypercoagulable differential diagnoses in a woman presenting with diagnoses in a woman presenting differential aortic dissection and pulmonarychest pain are by embolus. Diagnosis is made predominantly rise with changes and troponin ECG history, indicated. echocardiography and angiography where BIRTHING Western Health, Victoria Joan KirnerWomen’s andChildren’s Women’s andChildren’sServices Director Clinical Services BSc, MRCP, MD, MRCOG, FRANZCOG A/Prof GlynTeale ‘diabesity’ – obesity and gestational diabetes mellitus –obesityandgestational diabetesmellitus ‘diabesity’ mitigate risk.Reportsthat outcomesforwomenwith potentially resulting inmissedopportunitiesto concern asthere isatendencytoseethisas‘normal’, (around 17%)seemstoobtundthelevelof clinician complicated byobesity Managing pregnancies (Table 2). it isnotjusttheextremes of BMIthat are concerning discernible at abodymassindex(BMI)of ‘only’ 30, so significantly increased risk of stillbirth;ariskthat is or hypertension,obesepregnant womenstillfacea Even intheabsenceof complications suchasdiabetes represented inoverweightorobesewomen. Almost alladverseoutcomesof pregnancy are over- (Table 1).Someruralareas report rates over65%. South Wales to52%inSouthAustraliaandTasmania. are overweightorobese,rangingfrom 42%inNew In Australia,approximately 45%of womengivingbirth Table 1.Prevalence of overweightandobesityacross Australia2017. Data derivedfrom: www.aihw.gov.au/reports/mothers-babies/australias-mothers-and-babies-2017-in-brief/data & obese Total overweight 40.0–49.9 Class IIIobesity: 50 andover Extreme obesity: Overweight: 25.0–29.9 30.0–39.9 Class IandIIobesity: BMI (kg/m 3 The sheer prevalence of class I and II obesity Thesheerprevalence of classIandIIobesity 2 ) NSW 42.2 24.3 15.3 0.2 2.4 26.9 47.0 17.1 Vic 0.3 2.7 2 1 44.2 23.4 17.4 Qld 0.3 3.1 48.5 28.2 17.8 WA 0.2 2.3 limited adviceonkey aspectsof care. are disparitiesintheseguidelinesandsomeprovide the managementof obesepregnant women.There There are severalpeak-body-issued guidelinesfor and obesitywhoreceive intensivesurveillance. and managedthewaytheyare forwomenwithGDM suggest that therisksof obesityare notrecognised (GDM) –are betterthanthoseforobesityalone are gradedas‘consensus based’. ‘Management statement of ObesityinPregnancy’ almost allof therecommendations intheRANZCOG experience. information of riskandpotentialnegative patient there isabalancetobeachievedbetweenproviding conversations aboutweightdifficulttoinitiate and measures that willbeoffered. Manycliniciansfind various additionalsurveillanceandscreening is importantandmayassistcompliancewiththe Counselling aboutincreased risksrelated toweight Early pregnancy update onrecent evidencewhere available. concentrate onpracticalaspectsof care, withan recommendations, thefollowingdiscussionswill statement iscommonsense.Rather thanrepeating risks, andmuchof theadvicecontainedwithin a paucityof high-levelevidenceformitigating the assessment fordepression. postnatally, supportingtheneedforroutine of majordepressive symptomsantenatally and Obesity isassociated withagreater likelihood language andseemstobeacceptable. to being‘above ahealthyweight’avoidspejorative pregnancy that Iwouldlike totalkyouabout.’ extra investigations andmonitoringthroughyour the healthy weight range.Iwouldsuggestafew ‘I seefromyourweight that youarecurrently above 20.8 52.6 27.7 0.5 3.6 SA 7 Afactual,non-judgementalreference 52.8 26.7 21.3 Tas 0.6 4.2 ACT 47.3 26.7 16.9 0.5 3.2 8 6 This highlights Thishighlights 20.6 28.3 51.4 0.2 2.3 NT 5 It is notable that Itisnotablethat Australia 45.6 25.6 17.0 0.3 2.7 4 BIRTHING 95% Data from Data 12 intervals 1.62–1.83 1.89–2.21 2.54–3.81 2.28–2.74 this supports confidence confidence 3 Presentations Vol. 22 No. 3 Spring 2020 | 56 Vol. 13 3 1.71 3.11 2.50 2.04 Adjusted hazard ratio Over 40% of spontaneously Over 40% of 16 Unfortunately, routine ultrasound routine Unfortunately, 6 Given the lack of ability to reliably Given the lack of 14,15 Class I (BMI 30–34.9) Class II (BMI 35–39.9) Class III (BMI ≥40) Extreme BMI (≥50) Obesity class Adjusted hazard ratio for stillbirth and class class and for stillbirth ratio hazard 2. Adjusted Table obesity. of routinely offering induction or delivery offering at 38–39routinely evidence that is increasing There weeks for this group. obese women is not associated induction of routine birth and may caesarean risk of with an increased and neonatal maternal with reduced be associated morbidity. labouring nullipara with Class III obesity will birth by scans are also subject to significant error and a one- also subject to significant error scans are at 35– third trimester scan, especially if performed off fetal size. of 36 weeks, is a poor predictor monitor fetal growth in women with Class III obesitymonitor fetal growth Health also ultrasounds, Western despite regular at 39 weeks for this group. induction offers routinely management for women with Class IThe appropriate and II obesity is unclear and being actively debated. is strongly emergency caesarean of The likelihood by BMI. influenced Hazard ratio calculated with Cox proportional hazard regression hazard regression proportional with Cox calculated Hazard ratio normal weight (BMI 20–24.9). group: analysis; baseline comparison 2014. et al, AJOG, Yao Derived from for DFM are more common and, importantly, may be common and, importantly, more for DFM are with adverse outcomes in associated strongly more DFM assessment of Thorough women with obesity. and the management should consideris appropriate stillbirth and the challenges of risk of the increased assessing fetal wellbeing. Timing and mode of delivery 39 weeks for stillbirth rise exponentially at The risks of obesity (BMI>50); women with extreme Western Health (submitted for publication) suggest for publication) Health (submitted Western in restriction the sensitivity for detecting growth that and onlywomen with Class II/III obesity is below 10% women whose scan suggests 50% of approximately dates’ will go on to deliver a ‘large for macrosomia is important macrosomia of The poor prediction baby. and delivery, to consider in counselling for mode of identifying of shouldthe problems restriction growth delivery. when deciding on timing of be remembered in fetal movement monitoring routine The value of uncertain; remains the general obstetric population highlighted, obesity is significantly as already however, stillbirth. A recent with a higher risk of associated of decreased the significance of review systematic the perceptionfetal movements (DFM) suggests that by maternal fetal movements is not affected of is needed for research although more body size, women with Class II and III obesity. assessment of fetal growth with symphysio-fundal fetal growth assessment of obesity, For women with Class III height is unreliable. ultrasounds, for growth without another indication reasonable. and 36 weeks are 33 28, serial scans at routine third a offering recommends RANZCOG trimester scan. This screen is widely This screen 11 9 The most appropriate response to this response The most appropriate 10 ‘Regular, daily exercise can be helpful for you and be helpful can exercise daily ‘Regular, how much weight It can also help limit your baby. you would be able to fit in a you gain. Do you think 30-minute walk every in your pregnancy?’ day situation remains unclear, but the possibility should but the possibility unclear, remains situation be discussed beforehand. pre- of risk the increased of Potential mitigation of administration eclampsia supports routine for low-dose aspirin and calcium supplementation to obese women. With an understandable resistance this compliance with in pregnancy, taking by the is low and may be improved recommendation written information. of provision II or III obesity have a 20% who have Class Women having an abnormal early (<20 weeks) chance of oral glucose tolerance test. practiced, although there is little evidence that is little evidence that practiced, although there for GDM is beneficial to early screening routine this negative, outcomes. For those who screen 26–28 weeks. at should be repeated approximately Routine ultrasound scanning at to identify20 weeks is less likely significant abnormalities in obese women and it is worth the need to repeat the frequent warning of which can be time consuming and investigation It may be helpful to consider anxiety provoking. or MFM subspecialist for to a COGU specialist referral BMI. women with Class III or extreme Mid-pregnancy a low- complications, Given the substantial risk of appointments is not appropriate risk schedule of of for overweight or obese women. The frequency co- of visits should be determined by the presence morbidities and the BMI. is useful Regular urine testing for proteinuria UTIs and asymptomatic risk of given the increased bacteriuria and to support possible early detection pre-eclampsia. of Routine 26–28 week bloods should assess for iron necessary, haemoglobin and, where adequate a postpartum risk of the increased to mitigate stores haemorrhage. the underlying is likely restriction growth Undetected stillbirth risk and clinical the increased cause of When ordering non-invasive (NIPT)When ordering non-invasive prenatal it increased is important to counsel on the significantly fetal fraction due to low not obtaining a result risks of 5% in class I obesity rising to (no-call); approximately and even higher in Class III in some 10% in Class II, studies. Information on diet adjustments and weight gain on diet adjustments Information to a dietician by referral can be supported limitation (such as, online resources available or with where www.eatforhealth.gov.au/sites/default/files/files/the_ guidelines/n55h_healthy_eating_during_pregnancy. pdf). weight difficult to limit While it has proven the need supports meta-analysis gain in many RCTs, to weight gain advice adhere to least attempt to at in a variety of reduction with subsequent potential complications. pregnancy Conversations about exercise, diet and weight gain diet and exercise, about Conversations women, of Most pregnant be routine. should limitation a daily 30–45-minute undertake can safely any weight, patient swimming; RANZCOG regular brisk walk or advice. can support the leaflets information BIRTHING in asensitivebutaccurate manner. Thetendency it isimportanttoprovide appropriate information the increased likelihood of manycomplications, who are obeseandpregnant iscommonsense.Given Much of theadviceformanagement of women Summary ensure theyunderstandtherisksof non-compliance. specific counsellingforobesewomenisimportantto to resort tointernalmonitoring. but hardertoachieveandthere iscommonlyaneed restricted baby, optimalfetalmonitoringisimportant With increased likelihood of anundetectedgrowth various complications that are more likely tooccur. appropriately skilledandexperiencedtomitigate the Staff caringforobeselabouringwomenshouldbe labour toestablish. additional patience isprobably helpfultoallowactive rates. obesity, withBishopscore reliably indicating success induction, whichmaybeashigh37.5% forClassIII being similar. There isalsoagreater chanceof failed latent phase,withactivefirststageandsecond less likely toinitiate breastfeeding. Women inhigherobesityclassesare progressively Postpartum care serious maternal andneonatal complications rise. andtherisksof chance of successfulvaginaldelivery obesitynegatively impactsthe caesarean (VBAC), For those who wish to contemplate vaginal birth after increases thechanceof dissatisfaction andcomplaint. exchanged. Failing toinform of theoptionsandrisks and history, butitisimportantthat theinformation is The counsellingwillbeinfluenced bycomorbidities the balanceof risksmayfavourelectivecaesarean. be discussedwiththewoman.Forsomewomen, are unclearbutrepeatedly reported andthisshould emergency caesarean. Thereasons forthisincrease reviewed intheSpring2019issueof O&GMagazine. need togotheatre intra-orpostpartumwere Considerations forthecare of obesewomenwho recourse toadditionalmeasures. ensuring adequate largebore cannulation, andearly be mitigated byactivemanagementof thethirdstage, increased risksof apostpartumhaemorrhageshould is alsoneededtoachievevaginaldelivery. following induction. women, whethertheylabourspontaneouslyor Time toachievefulldilatation isprolonged forobese Intrapartum care unrealistic forobesewomen. be provided towomeninthehealthyweightrange,is benefits; usingsuccessfigures ofcirca 75%,asmight information whencounsellingaboutrisksand with ClassIIIobesity, soitisvitaltoprovide accurate Chances of successmaybeaslow20%forwomen frequency orlengthof treatment recommendations; studies suggestthat more than30%failtocomplywith postpartum#goto-thromboprophylaxis. Compliance ehandbook/obesity-during-pregnancy-birth-and- gov.au/resources/clinical-guidance/maternity- more information seewww.bettersafercare.vic. recommended formanyobesewomen– Routine postpartumthromboprophylaxis is should beprovided. on thebenefits of breastfeeding andextrasupport the highestBMIsshouldbeparticularlycounselled 20 Higherdosesandlongerexposure tooxytocin 18,19 Most of this extra time is in the Mostof thisextratimeisinthe 22 The substantially Thesubstantially 24 Women with 21 Overall, Overall, 17

23 25

adverse outcomesthat are somuchmore prominent. risks of obesity‘front of mind’wecanreduce the levels of obesity. Hopefully, byhavingtheincreased management decisionsshouldreflect thisrisk at all to mitigate risks;stillbirthriskisconsiderableand of associated complications, canleadtoafailure to normaliseobesity, particularlyintheabsence 25. 24. 23. 22. 21. 20. 19. 18. 17. 16. 15. 14. 13. 12. 11. 10. 9. 8. 7. 6. 5. 4. 3. 2. 1. References

J ThrombThrombolysis.2020;49(2):304-11. with women’sadherence topostpartumthromboprophylaxis. Rottenstreich A,KarlinKalishY, etal. Factors associated Med. 2018;31(22):3021-6. breastfeeding rates byobesityclass.JMatern FetalNeonatal Ramji N, ChallaS, MurphyPA, etal.Acomparisonof O&G Magazine.Vol 21,No3, Spring2019. Neel A,Teale G.Considerations fortheobeseobstetricpatient. Med. intrapartum electronic fetalmonitoring. JMatern FetalNeonatal Brocato B, LewisD, MulekarM,Baker impacton S. Obesity’s Am JPerinatol. 2020;37(4):349-56. Obesity onOxytocinRequirements toAchieveVaginal Delivery. Adams AD, CovielloEM,DrassinowerD. TheEffect of Maternal Acta ObstetGynecolScand.2020;99(5):637-43. induction of laboramongpregnant womenwithClassIIIobesity. Kerbage Y, Senat MV, DrumezE,et al.Riskfactorsforfailed the firststage of labor. ObstetGynecol.2012;120(1):130-5. Norman SM,Tuuli MG,OdiboAO, etal.Theeffects of obesityon analgesia. JMatern FetalNeonatal Med.2020;33(13):2195-2201. on laborduration amongnulliparous womenwithepidural Polónia Valente R,SantosP, FerrazT,et al.Effect of obesity Fetal Neonatal Med.2019;32(8):1256-61. term inpregnancies complicated bymaternal obesity. JMatern outcomes associated withtrialof laborafter cesarean sectionat Yao R,CrimminsSD, ContagSA,etal.Adverseperinatal metaanalysis. AmJObstGynecolMFM.2019;1(4). mass indexandpregnancy outcomes:asystematic review and I,D’Souza R,Horyn PavalagantharajahS, etal.Maternal body Women andTheirOffspring. ObstetGynecol.2018;131(1):12-22. Induction of LaborandPregnancy OutcomesAmongObese Gibbs Pickens CM,KramerMR,HowardsPP, etal.Term Elective J Med.2018;379(6):513-23. Expectant ManagementinLow-Risk Nulliparous Women. NEngl Grobman WA, RiceMM,ReddyUM, etal.LaborInductionversus Obstet GynecolScand.2018;97(1):13-24. overweight orobesepregnant women:asystematic review. Acta the associations andsignificance of fetalmovementsin Bradford BF, ThompsonJMD, Heazell AEP, etal.Understanding 10.1080/14767058.2019.1648420. women. JMatern FetalNeonatal Med.2019:1-6. doi: growth disordersusingultrasoundinobesenulliparous Dude AM,DavisB, DelaneyK,Yee fetal LM.Identifying severe obesity. ActaObstetGynecolScand.2012;91(4):447-51. gestational diabetesmellitusinwomenwithmoderate and O’Dwyer V, Farah N, HoganJ, etal.Timingof screening for 2020;99(6):744-50. and maternal obesity:Areview. ActaObstetGynecolScand. HartwigTS, AmbyeL,etal.NoninvasiveprenatalJuul LA, testing Review andMeta-analysis. JAMA.2017;317(21):2207-25. Weight GainWithMaternal andInfant Outcomes:ASystematic Goldstein RF, Abell SK, Ranasinha S, et al. Association of Gestational Fetal Neonatal Med.2017;30(16):1897-1901. association withmaternal mentalhealthsymptoms.JMatern Ruhstaller KE,ElovitzMA,Stringer M,etalObesityandthe 2020;15(1):e0227325. An evidencesynthesisof qualitative research. PLoSOne. influences of choiceinpregnant womenwithobesity. Relph S, OngM,VieiraMC,etal.Perceptions of riskand (c-obs-49) guidelines/obstetrics/obesity-in-pregnancy,-management-of- 2017. Available from: https://ranzcog.edu.au/statements- RANZCOG. Managementof ObesityinPregnancy. C-Obs 49. Med. 2019;32(15):2580-90. comparison of fournational guidelines.JMatern FetalNeonatal Vitner D, HarrisK,MaxwellC,Farine D. Obesityinpregnancy: a Matern FetalNeonatal Med.2018;31(5):640-3. onoutcomesof singletongestations.combination J (‘diabesity’) gestational diabetes,pre-gravid maternal obesity, andtheir Blickstein I, DoyevR,Trojner Bregar A,etal.Theeffect of Obstet Gynecol.2014;210(5):457. e451-9. and theriskof stillbirth:apopulation-based cohortstudy. AmJ Yao R,AnanthCV, ParkBY, etal.Perinatal Research C.Obesity metaanalysis. AmJObstGynecolMFM.2019;1(4):100041. mass indexandpregnancy outcomes:asystematic review and I,D’Souza R,Horyn PavalagantharajahS, etal.Maternal body 2013;198(1):39-42. in alargeruralVictorianobstetriccohort.MedJAust. Cunningham CE,Teale GR.Aprofile of bodymassindex 2019;32(1):92-4.

WOMEN’S HEALTH there are otherconditions that canmimicit(for maintain that thediagnosiscanbe made clinically, be doneinfiveminutes.Although someauthors however, itisimportanttobesure andthetestcan whitest area. Somepatients findittraumatic, using a2mmpunch,takingthe samplefrom the treatment. Thiscanbedoneasanoffice procedure way toconfirm iswithabiopsyprior tostarting important tobesure of thediagnosis.Thebest Because of thepotentialseriousnessof LS, itis due toembarrassmentandfear. treated. Patients often refrain from presenting early disease remains poorlyrecognised, diagnosedand and sexualfunction.Thewholesubjectof vulval terms of generalwellbeing,self-esteem,bodyimage and inadequate treatment canbelife-changingin involved, theconsequencesof delayeddiagnosis of theskin,lessthan1%of bodysurfacearea, is condition onawoman.Even though asmallarea It iseasytounderestimate theimpactof this also beanelementof atrophy contributingtothis. menopausal agegroup commonlyaffected, there may Dyspareunia is often present; however, inthepost- These are variable,butitchisthecommonest. Patients usually, butnotalways, havesymptoms. hyperkeratosis andtexturalchange. be purpura,fissures anderosions. There istypically produce thisappearance.Inaddition,there may feature isthewhitecolour. Fewotherconditions symmetrical. Theimportantdifferentiating skin andisusually, butnotinvariably, bilaterally involve anypartof thevulva,perineumandperianal The typicalappearanceisof awhiteplaquethat may complications appearpreventable withtreatment. carcinoma involvingaffected skin.Both of these untreated, there isa5%riskof squamouscell completely obliterate allvulvalstructure. Further, it canbecomplicated bysevere scarringthat may consequences. Unlike mostotherskinconditions, 50 and,ifnottreated, canresult indevastating Lichen sclerosus (LS)isnotrare inwomenover the future? you manageitnowandinto lichen sclerosus.Howwould rash, whichIsuspectis I have apatientwithvulval and gynaecology. questions inobstetrics to thosecurly-yet-common readership, balancedanswers For thebroaderO&GMagazine although notspecifically effectiveforLSitself, is In post-menopausalwomen,topical oestrogen, other signsandsymptoms. some residual hypopigmentation despite lossof achievable inmostpatients, although there canbe preparation, particularlyforsevere disease. Itis up tosixmonthsof dailytreatment onthepotent the potentpreparation iscontinued.Thiscantake reduced; however, untilthisoutcomeisachieved is backtonormal, potencymaybe The first review shouldbe at sixweeks.Iftheskin extensively researched andvalidated. treatment choiceandreassure that ithasbeen importanttoexplainyourconsultation: itisvery pharmacist. You mustfullydiscussthisat thefirst own research online)andpossiblythedispensing will beresistance from yourpatient (after their topical corticosteroid forthegenitalarea that there likelyIt isvery whenyouprescribe suchapotent furoate hasatendencytosting. is avalidalternative. Onthevulva,mometasone item. Betamethasonediproprionate 0.05% ointment depending onsymptomseverity. ThisisnotaPBS Australia. Thisisappliedonceortwiceaday, reliable optioninin optimisedvehicle)isavery OV (betamethasonediproprionate 0.05% ointment mild.Diprosoneall casesunlessthediseaseisvery remains potenttopicalcorticosteroid forvirtually asymptomatic. Thegoldstandardtreatment LS shouldalwaysbetreated, evenwhen association withotherconditionsthat are. itself, there iscircumstantial evidencerelated toits been proven that LSisanauto-immunedisease presence of anormalTSH. Althoughithasnever disease orthyroid auto-antibodies, eveninthe Approximately 15%of patients haveknownthyroid has beenestablished. patient toknowhowproceed unlessadiagnosis subsequent medicalattendants caringforthe example, lichenplanus)anditcanbehardfor Dermatologist MBBS, MD, FACD Prof GayleFischerOAM www.ogmagazine.org.au/contribute O&G Magazine,goto: For more information aboutcontributing to Contributions are welcome from allCollegemembers. can interviewyouandwritethearticlefor you. Don’t havetimetoprepare awrittencontribution? We in low-tomiddle-income countries are appreciated. pieces that highlightwomen’shealthissuesorinitiatives about globalwomen’shealth.Articlesandopinion The Collegeisseekingcontributions for O&GMagazine women andtheirfamilies,includinginthePacific region. RANZCOG iscommitted toimproving thehealthof Share your inO&GMagazine story in low- to countries? middle-income youDo have working experience or volunteering WOMEN’S HEALTH there are noorminimalsideeffects. long-term topicalcorticosteroid treatment of LS, not havetobereduced. Ingeneral,evenwithvery are nosideeffects,treatment continuesanddoes potent astheinflammation reduces. Aslongasthere irritation, occurifthetreatment becomestoo telangiectasiaand,insomecaseserythema, ‘thin skin’thisisnotinfacttheproblem. However, Although laypeoplewillexpress concernsabout If appliedat night,thisislessof aproblem. not acceptabletoallbecauseof thestickyfeeling. than cream, andlesslikely tocauseallergy, butis side effects.Ointmentisgenerallymore effective to response sothat control ismaintainedwithout hydrocortisone 1%)isrequired, titrated upanddown (such asmethylprednisolone aceponate 0.1% and treatment withmoderate toweakpreparations do this,howeverongoingtopicalcorticosteroid that treatment isforlife.There isnosinglewayto there maybecasesthat remit, itisbesttoassume Maintenance therapyistheruleforLS. Although unable toexperiencepain-free intercourse. LS control, patients mayremain symptomatic and this isnotaddressed, eveninthepresence of good Ifoften helpfultoreduce vaginalandvulvaldryness.

it canbecompletelyprevented. still notenoughevidencetocategorically assure that treatment hasdevelopedacancer, however, there is experience, nopatient onadequate suppressive to vulvalscarringandmalignancy. Inmyown and neverdevelopthelong-termproblems related emotional issues,mostcanbecomeasymptomatic treatment andstrong reassurance toaddress with ongoingmonitoringtoensure adequate challengingforsome.However,of LScanbevery Candidiasis, oremotionalissues.Acceptingthereality have eitheraconcurrent separate problem suchas or impactonqualityof lifeshouldbeassumedto Patients whohaveongoingissueswithsymptoms course of thediseasecanbemodifiedbytreatment. Well controlled LShasanexcellent prognosis andthe often allthat isrequired. controlled disease,onetotwoyearfollowupis follow upshouldbeat leastsix-monthly. Instable of adequate potency. Duringthefirsttwoyears, key tocomplianceandadherence tocorticosteroid In patients onlong-termtreatment, followupisa Dermetol. 2015;151(10):1061-7. Lichen Sclerosus: AProspective CohortStudy of 507Women. JAMA Lee A,BradfordJ, FischerG.Long-termManagementof AdultVulvar Further reading WOMEN’S HEALTH as haemoperitoneum Ovarian cancerpresenting Gynae oncologystaff specialist,LiverpoolHospital FRANZCOG, CGO Dr MuradAl-Aker cyst inalow-risk-age-group woman. presenting asaninnocuousruptured ovarian ovary present acaseof endometroid carcinoma of the cancer presenting asacuteabdomen. could findonlyonedocumentedcase of ovarian or deepveinthrombosis. Upon literature review, we pleural effusions,ascites,smallbowelobstructions habits.Acutely,urinary patients maypresent with pain anddistention,constipation, andchangesin symptoms, suchasbloating, earlysatiety, abdominal present withvaguepelvicandabdominalsigns affecting womeninAustralia. Women often Ovarian canceristheeighthmostcommon O &Gstaff specialist,LiverpoolHospital MBBS, FRANZCOG, MMed Dr JyothiMarry AGES Fellow MS, MRCOG Dr Tanushree Rao Case report complex cyst. Figure 1.Ultrasoundscandemonstrating leftovarian

1 Here we mass from thepelvicsidewallandsigmoidcolon. a leftsalpingoopherectomy after mobilisingthe cystectomy. Henceadecisionwasmadetoperform difficulty inachievinghaemostasis afteran attempt at The largercystwasfoundtobefriableandthere was cm) simplecystswere alsofoundinthesameovary. from theabove-mentionedcyst,twoothersmall(2x1 projections. Apart smooth surfacewithnopapillary to theleftpelvicwallandsigmoidcolon.Ithada multiloculated leftovariancystwasfoundadherent haemoperitoneum of 1litre wasfound.A5x6cm the generalgynaecologyteam.Intraoperatively, cystectomy +/-leftsalpingoopherectomy by with diagnosticlaparoscopy +leftovarian was made,andadecisiontaken toproceed A presumptive diagnosisof ruptured ovariancyst obliterating theMorrison’spouch. with largevolumeof hemoperitoneumseen structure, appearancesuggestiveof endometriosis scan demonstrated an8×7.5 ×8cmcomplexcystic well asanelevated lactate of 3.9mmol/L. Ultrasound of 102g/LleucocytosiswithaWBCcountof 31.8 as exam. Labworkshowedanegative betaHCG, Hb mass wasappreciated ontheabdominalandvaginal guarding,nopelvic tenderness. Duetovoluntary cervical motiontendernessandbilateral forniceal cervix andvagina.Thepelvicexamination revealed Speculum examination revealed anormallooking percuss, andpositiveforbothrebound andguarding. her abdomenwasdistended,diffuselytender, dullto tachycardia of 100bpm.Onphysicalexamination, On examination, hervitalsignswere stablewithmild family andsocialhistorieswere non-contributory. to date. Herpastgynaecological,medical,surgical, period was10daysago,andherpapsmearswere up in onsetanddiffusenature. Herlastmenstrual pain forthepast16hours.Thewasgradual emergency departmentreporting severe abdominal A young29-year-old G1P0, whopresented tothe Case description Figure 2.Free fluid. WOMEN’S HEALTH

2 However, this this However, Vol. 22 No. 3 Spring 2020 | 61 Vol. 6 5 The prognosis of early-stage ovarian early-stage ovarian of The prognosis 4 Zhou ZN, Tierney C, Rodgers WH, et al. Ruptured clear cell et al. Ruptured Tierney C, Rodgers WH, Zhou ZN, the ovary of as acute abdomen. Gynecol carcinoma presenting Oncol Rep. 2016;16:1-4. Ann Oncol. New insight into ovarian cancer pathology. J. Prat 2012;23(10):111–117. ovarian cancer: Lessons of Shih IM. Pathogenesis RJ, Kurman morphology and molecular biology and their clinical from 2008;27:151-60. J Gynecol Pathol. Int implications. Staging FIGO committee on gynecologic oncology. J. Prat fallopian tube, and of the ovary, for the cancer classification J Gynaecol Obstet. 2014;124(1):1-5. peritoneum. Int Ovarian cancer clinical practice guidelines in oncology. NCCN including fallopian tube cancer and primary cancer. peritoneal www.nccn.org/professionals/physician_gls/ from: Available 2015. the M. Cancer of L, Friedlander Kumar ST, Kehoe JS, Berek J Gynaecol Obstet. fallopian tube, and peritoneum. Int ovary, 2018;143(2):59-78.

Early-stage ovarian cancer includes FIGO Stage Ia, Ia, Stage Early-stage ovarian cancer includes FIGO Ib, and Ic. cancer is good, with a five-year survival rate of of cancer is good, with a five-year survival rate surgical adequate and removal 70–90%. Tumour staging, followed in most cases by adjuvant the primary for represent treatment chemotherapy, Adjuvant chemotherapy early-stage ovarian cancer. may be avoided for low-risk, optimally staged, G1–G2); (FIGO Stage-Ia/Ib, patients Stage-I surgery after chemotherapy is indicated for patients G3). disease (FIGO Stage-Ic, with high-risk Stage-I low-risk suboptimal surgical staging of In case of of adjuvant benefits and effect patients, Stage-I chemotherapy should be discussed with each individual patient. Approximately two-thirds of all epithelial ‘ovarian’ all epithelial ‘ovarian’ of two-thirds Approximately diagnosis IV at III or Stage Stage cancers are with vague abdominal pain or presenting and dyspepsia, menstrual irregularities, discomfort, other mild digestive disturbances. References 1. 2. 3. 4. 5. 6. Figure 4. Multicystic left ovary with papillary Figure 4. excrescences. ovarian tumours represent Endometrioid epithelial occur in often They all ovarian cancer. 10% of mostly are younger women than other subtypes and early stage with good outcome. diagnosed at case demonstrates rare presentations of cancer cancer of presentations rare case demonstrates the such as acute hemoperitoneum. It highlights suspecting cancer in otherwise importance of a general for seemingly benign suspected pathology of the first point they are gynaecologist as often for such presentations. reference 2 3 In contrast, high-grade 3 Lap left salpingo-opherectomy. Lap left salpingo-opherectomy. Figure 3. endometrioid carcinomas and carcinosarcomas and carcinosarcomas endometrioid carcinomas obscure more thought to evolve rapidly from are as type II tumours. All designated and are precursors nearly always are these high-grade carcinomas of in the TP53 gene. with mutations associated Low grade endometroid tumours are thought to tumours are Low grade endometroid conditions precursor lower-grade evolve slowly from (endometriotic cysts, cystadenomas, etc) and are classified as type I tumours. The procedure was uneventful and haemostasis was was uneventful The procedure achieved. Her left ovary but nil was mildly enlarged seen. The haemoperitoneum obvious cysts were was was suctioned out. A drain was left in situ and on day 2 postoperatively subsequently removed which was no further drain output, after when there she was discharged home. showed a well differentiatedFinal pathology (FIGO grade 1) adenocarcinoma endometroid involving both the ovary referral and tube. Immediate she waswas made to the gynae oncology team, where a multidisciplinarydiscussed at team meet. A decision with open total abdominalwas made to proceed salpingooperectomy and unilateral hysterectomy was a possibilitywith staging. In the interim, as there she also endometrial cancer, synchronous of underwent pipelle biopsy which showed proliferative postendometrium. Her final histopathology endometroid showed a residual second laparotomy and (1mm) involving the left adnexa adenocarcinoma aortic malignancy on her pelvic, para no evidence of any and abdominal biopsies. She did not receive adjuvant chemo/radiotherapy. Discussion cancer, Ovarian neoplasms include epithelial ovarian all ovarian tumours, about 90% of which represents including stromal and non-epithelial ovarian cancer, epithelial and germ cell tumours. Morphologically, ovarian cancer is classified into five main histologic which accounts for subtypes: high-grade serous, low-grade serous, all epithelial cancer, 70% of tumours. endometrioid, mucinous, and clear-cell THE COLLEGE Obituaries loved andrespected byall. obstetrician, withoutarrogance, softly spoken and indeed atruespecialistinthedaysof thegentleman great patience andgenerosity of spirit.Hewas specialty, includingmyself. Healwaystaughtwith generations of doctorsandmidwivesinour He lovedtoteachandtaughtcountlessfuture consultant at thesehospitals. worked andbecamearespected andmuch-loved also at St GeorgeHospital.Forthenext30yearshe at theRoyalHospitalforWomen inPaddingtonand settled inWoollahra andtookupanHMOposition With theiryoungfamily, theyreturned toAustralia, Judy byhisside,worked intheUKfrom 1961to1966. also trainedtobecomeananaesthetist.Graham,with While Grahamcompletedhisobstetricstraining,Judy (1963) andCharles(1968). of RCOG. WithJudy, theyhadtwochildren, Bruce custom at thetime)andobtainedhismembership In 1960, hewentoff totheUKstudyO&G(aswas in 1958. medicine in1956andmarriedJudyWilliamson University forhismedicaleducation. Hecompleted Graham wenttoSt PaulsCollegeandSydney Williams, anotedobstetricianof education. Paddington on4July1933, thesonof HBruce at CumnockinruralNSW. Grahamwasbornin of DrGrahamKnox2020 Williamson12January It iswithmuchsadnessthat werecord thedeath 1933–2020 Dr GrahamKnox WilliamsAM belief that shewasmaking adifference forwomen passionately, notfrom stubbornnessbutfrom a a womanof strong viewsthat shedefended women’s healthandforlifeingeneral. Shewas 2011withapassionforCanada,in February enthusiastic redhead whocameto us from Canada We willallremember Margotasthevibrant, fiery, developing nations, includingatriptotheUkraine. program where shetraineddoctorsandmidwivesin colleague. Duringthistime,Margotparticipated ina where shesetupanOBGYNpartnershipwitha this, shemovedtoRossland,BritishColumbia, Her residency wasspentinVancouver. Following contracted malariaduringherservice. medical student,sheworked in Malawiwhere she of heradventurous spiritcanbeseenwhen,asa University andMedicalSchool.Anearlyglimpse Manitoba, thenwenttoToronto toattend She wenttohighSchoolat St MichaelsinWinnipeg, Saskatchewan, Canada,andgrew upinCanada. Margot Barclay wasborninSaskatoon, 1969–2020 Dr MargotJocelyneBarclay

FRCOG, FRANZCOG A/Prof LouisIzzo onGraham’slife. this commentary his lifelongfriend,andsonsinhelpingmeprepare I wouldlike toacknowledgeAlisterHarvey-Sutton, our profession. Vale Graham–atruegentlemanandhonourto and theirchildren, Douglas,MorganandJames. He issurvivedbyhistwosons,BruceandCharles, at theageof 86. 2020died quicklyandunexpectedlyon12January Judy, hischildren andgrandchildren dearly. Graham Above allthis,Grahamwasafamilymanwholoved Hospital whilstJudyworked at DubboHospital. Graham alsoworked at timesasalocumat Wagga fecundity that alsoproduced superiorqualitywool. farmer, specialisinginMerinosheepwithhigh For thenext20years,Grahambecameacapable a property Judyhadinheritedfrom herfather. opportunity totake overtheday-to-dayrunningof to gointoretirement. GrahamandJudyusedthis In 1998, after 30yearsof medicine,hedecided university andevenintheUK. in hisyoungeryears,playingforCranbrook, at Cranbrook Schoolandalsoatalentedcricket player of medicine,hewasamemberof theCouncilof the AMforhiscontributionstomedicine.Outside board memberformanyyears,andwasawarded back asNSWPresident of theAMAandNSWmedical Graham hadabusypractice,butalsogavesomuch number of midwifery andobstetric staff membersnumber of midwifery 2020. Herfuneral wasattended byalarge Margot Barclay waslaidtorest on24 January for herstrength inthisregard. belief andwillberemembered fondlyby everyone beyondoutcome. Sheshowedcourage andbravery support andprepare hertwochildren forthe final protracted treatment regimes andstrugglingto absences from thejob,battling recurrences and tenure inthisposition,forcing hertotake longer The developmentof breast cancermarred her first femalehead of anydepartment at Liverpool. of thenewmaternity servicesrebuild. Shewasthe participated strongly inthedesignanddevelopment of Departmentfrom July2015toOctober2018and risk antenatal clinicformanyyears.ShebecameHead laparoscopic surgery, andparticipated inthehigh- services, especiallyinthearea of colposcopyand At LiverpoolHospital,shedrove gynaecological Wales inthissport. boat racerandintimerepresented NewSouth us from Canada,shebecameanenthusiasticdragon in ourcare. Surprisinglyforsomeonewhocameto

THE COLLEGE Vol. 22 No. 3 Spring 2020 | 63 Vol. All those who spoke of her remembered her fondly her fondly remembered her of who spoke All those dry intelligence, wit and enthusiasm for her keen friends was her family and love of for life. Her evident. abundantly Rest in peace, be remembered. She will always Margot Barclay. Dr Ian Fulcher FRANZCOG his gynaecologic work, he immeasurably increased he immeasurably increased his gynaecologic work, many women and families life for so the quality of in Melbourne.’ here Campbell, said ‘With Dr John Former President, the lost one of RANZCOG Arthur Day, of the death his gynaecology in Victoria. Arthur served doyens of superbly in veryCollege and profession many ways. Monash the Queen Victoria Hospital and then the At he was an outstanding gynaecologicalMedical Centre, Unit.’surgeon and lead the Gynaecological Oncology ofHe was a mentor and friend to a huge number teachercolleagues and trainees. He was an excellent specialists an future of to generations and provided would to obstetrics and gynaecology which approach careers. assist their future greatly of associations He served on the Senior Medical Staff the Queen Vic and Monash, the Victorian Regional College, College Council, andCommittee of to For his services other organisations. numerous and for Medal, College he was awarded the President’s the AM. his services to gynaecology, missed. He will be greatly Dr John Campbell, Charles Day and Jobling Prof Tom Dr Arthur Joseph Day Dr Arthur Joseph Day 1933–2020 who Day, in for Dr Arthur have poured Tributes passed away in May. JimIn tributes published online in The Age, A/Prof Endoscopy Unit the Gynaecological head of Tsaltas, Day’s marks an death Monash Health, said ‘Mr at his for an era. He will always be remembered end of pursuit surgical skills, uncompromising superlative and his sound ethical foundation, with excellence, of gynaecological surgeons.’ of generations mentoring of helped immensely ‘Arthur Dr Daya Jayasinghe wrote cervical cancer screening a national to introduce Lions by the in Sri Lanka, an effort initiated program Wheelers Hill in the early 2000s. Across Club of many the talent of he helped nurture his career, and he Australian oncologists and gynaecologists, talent this professional upon some of skilfully drew Lanka. in Sri program in building the pilot screening In fact, Arthur Day’s contribution to the program have is in no small part why cervical cancer rates there. decreased recently this wholehearted Melbournian It is inspiring that in public health outcomes gave so much to improve Sri Lanka. As well, through developing countries like lamenting the passing of someone who strove to to strove who someone of the passing lamenting in of women the wellbeing to a difference make Her Health District. Local Sydney the Southwest as humour was in evidence of sense irreverent on the Bright Look to Always exhorted we were were the Service. We Life midway through Side of as she determined self-assuredness her of reminded the funeral parlour to the of was accompanied out . I Did it My Way strains of THE COLLEGE • gynaecological practice(WPI12) Locum positionsinspecialistobstetricand • Midurethral slings(C-Gyn 32) • (C-Gyn 30) Gynaecological examinationsandprocedures • Zealand (C-Gyn 19) cancerscreeninginAustraliaandNewCervical • banking forfamiliesatrisk(C-Obs 18) Altruistic anddirectedumbilicalcordblood approved byRANZCOG CouncilandBoard: The followingCollegestatements were recently Revised CollegeStatements • (C-Gyn 8b) Vaginal screeningafter hysterectomyinNZ by RANZCOG CouncilandBoard: The followingnewstatement wasrecently approved New CollegeStatement July 2020 College Statementsupdate yu ee e. d maaee an oreadore? Minor wordingchangesonly Rewrite Rewrite NZ CervicalScreening Guidelines Recommendations amendedinlinewith2020 Minor wordingchangesonly Australian CervicalScreening Guidelines. NZ recommendations whichdifferfrom thosein hysterectomy inAustralia(C-Gyn 8a)tooutline College Statement Vaginal screeningafter This newStatement isinadditiontotheexisting ogmagazine.org.au

RANZCOG Women’s Health Committee Chair Prof Yee Leung Information-Pamphlets. Womens-Health/Patient-Information-Guides/Patient- viewed andordered from: www.ranzcog.edu.au/ pack of 18pamphlets.Allof theseproducts canbe Pamphlets, includingthePregnancy andChildbirth There are 41RANZCOG Patient Information RANZCOG PatientInformation the RANZCOG Guidanceapp. website (ranzcog.edu.au/statements-guidelines) and Statements andGuidelinespageof theRANZCOG A fulllistof CollegeStatements canbeviewedonthe in Australia(WPI6) Non-Specialist Obstetricianspractisingobstetrics Credentialing forGPObstetriciansandRural • Antenatal care in Australian public hospitals (WPI 10) The followingstatements havebeenretired: Retired CollegeStatements • expert witnessregister(C-Gen 1) College MembersparticipatingintheRANZCOG • • • • • • Fellows that havepassedaway: Our Collegeacknowledgesthelifeandcareer of Remembering OurFellows Maternity Care inAustralia. Information iscovered intheCollegedocument Rewrite 31 July2020 Dr GythaWade Betheras,Vic, 10 July2020 Dr Biswanath Mukerjee, ACT, 26 May2020 Dr JohnCunninghamAnderson, NSW, 25 May2020 Dr ArthurJosephDay,Vic, 12 May2020 Dr Francis ClementChapman,NSW, 1 May2020 Dr BenjaminAzukaOnyeka,Vic