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• Abnormal lie, Malpresentation and Malposition
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Abnormal Fetal lie, Malpresentation and Malposition

Original Author(s): Anna Mcclune Last updated: 1st December 2018 Revisions: 12

• 1 Definitions
• 2 Risk Factors
• 3.2 Presentation
• 3.3 Position
• 4 Investigations
• 5.1 Abnormal Fetal Lie
• 5.2 Malpresentation
• 5.3 Malposition

The lie, presentation and position of a fetus are important during labour and delivery.

In this article, we will look at the risk factors, examination and management of abnormal fetal lie, malpresentation and malposition.

Definitions

• Longitudinal, transverse or oblique
• Cephalic vertex presentation is the most common and is considered the safest
• Other presentations include breech, shoulder, face and brow
• Usually the fetal head engages in the occipito-anterior position (the fetal occiput facing anteriorly) – this is ideal for birth
• Other positions include occipito-posterior and occipito-transverse.

Note: Breech presentation is the most common malpresentation, and is covered in detail here .

Fig 1 – The two most common fetal presentations: cephalic and breech.

Risk Factors

The risk factors for abnormal fetal lie, malpresentation and malposition include:

• Multiple pregnancy
• Uterine abnormalities (e.g fibroids, partial septate uterus)
• Fetal abnormalities
• Placenta praevia
• Primiparity

Identifying Fetal Lie, Presentation and Position

The fetal lie and presentation can usually be identified via abdominal examination. The fetal position is ascertained by vaginal examination.

For more information on the obstetric examination, see here .

• Face the patient’s head
• Place your hands on either side of the uterus and gently apply pressure; one side will feel fuller and firmer – this is the back, and fetal limbs may feel ‘knobbly’ on the opposite side

Presentation

• Palpate the lower uterus (above the symphysis pubis) with the fingers of both hands; the head feels hard and round (cephalic) and the bottom feels soft and triangular (breech)
• You may be able to gently push the fetal head from side to side

The fetal lie and presentation may not be possible to identify if the mother has a high BMI, if she has not emptied her bladder, if the fetus is small or if there is polyhydramnios .

During labour, vaginal examination is used to assess the position of the fetal head (in a cephalic vertex presentation). The landmarks of the fetal head, including the anterior and posterior fontanelles, indicate the position.

Fig 2 – Assessing fetal lie and presentation.

Investigations

Any suspected abnormal fetal lie or malpresentation should be confirmed by an ultrasound scan . This could also demonstrate predisposing uterine or fetal abnormalities.

Abnormal Fetal Lie

If the fetal lie is abnormal, an external cephalic version (ECV) can be attempted – ideally between 36 and 38 weeks gestation.

ECV is the manipulation of the fetus to a cephalic presentation through the maternal abdomen.

It has an approximate success rate of 50% in primiparous women and 60% in multiparous women. Only 8% of breech presentations will spontaneously revert to cephalic in primiparous women over 36 weeks gestation.

Complications of ECV are rare but include fetal distress , premature rupture of membranes, antepartum haemorrhage (APH) and placental abruption. The risk of an emergency caesarean section (C-section) within 24 hours is around 1 in 200.

ECV is contraindicated in women with a recent APH, ruptured membranes, uterine abnormalities or a previous C-section .

Fig 3 – External cephalic version.

Malpresentation

The management of malpresentation is dependent on the presentation.

• Breech – attempt ECV before labour, vaginal breech delivery or C-section
• Brow – a C-section is necessary
• If the chin is anterior (mento-anterior) a normal labour is possible; however, it is likely to be prolonged and there is an increased risk of a C-section being required
• If the chin is posterior (mento-posterior) then a C-section is necessary
• Shoulder – a C-section is necessary

Malposition

90% of malpositions spontaneously rotate to occipito-anterior as labour progresses. If the fetal head does not rotate, rotation and operative vaginal delivery can be attempted. Alternatively a C-section can be performed.

• Usually the fetal head engages in the occipito-anterior position (the fetal occiput facing anteriorly) - this is ideal for birth

If the fetal lie is abnormal, an external cephalic version (ECV) can be attempted - ideally between 36 and 38 weeks gestation.

• Breech - attempt ECV before labour, vaginal breech delivery or C-section

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Labour and Delivery Care Module: 8. Abnormal Presentations and Multiple Pregnancies

Study session 8  abnormal presentations and multiple pregnancies, introduction.

In previous study sessions of this module, you have been introduced to the definitions, signs, symptoms and stages of normal labour, and about the ‘normal’ vertex presentation of the fetus during delivery. In this study session, you will learn about the most common abnormal presentations (breech, shoulder, face or brow), their diagnostic criteria and the required actions you need to take to prevent complications developing during labour. Taking prompt action may save the life of the mother and her baby if the delivery becomes obstructed because the baby is in an abnormal presentation. We will also tell you about twin births and the complications that may result if the two babies become ‘locked’ together, preventing either of them from being born.

Learning Outcomes for Study Session 8

After studying this session, you should be able to:

8.1  Define and use correctly all of the key words printed in bold . (SAQs 8.1 and 8.2)

8.2  Describe how you would identify a fetus in the vertex presentation and distinguish this from common malpresentations and malpositions. (SAQs 8.1 and 8.2)

8.3  Describe the causes and complications for the fetus and the mother of fetal malpresentation during full term labour. (SAQ 8.3)

8.4  Describe how you would identify a multiple pregnancy and the complications that may arise. (SAQ 8.4)

8.5  Explain when and how you would refer a woman in labour due to abnormal fetal presentation or multiple pregnancy. (SAQ 8.4)

8.1  Normal and abnormal presentations

8.1.1  vertex presentation.

In about 95% of deliveries, the part of the fetus which arrives first at the mother’s pelvic brim is the highest part of the fetal head, which is called the vertex (Figure 8.1). This presentation is called the vertex presentation . Notice that the baby’s chin is tucked down towards its chest, so that the vertex is the leading part entering the mother’s pelvis. The baby’s head is said to be ‘well-flexed’ in this position.

During early pregnancy, the baby is the other way up — with its bottom pointing down towards the mother’s cervix — which is called the breech presentation . This is because during its early development, the head of the fetus is bigger than its buttocks; so in the majority of cases, the head occupies the widest cavity, i.e. the fundus (rounded top) of the uterus. As the fetus grows larger, the buttocks become bigger than the head and the baby spontaneously reverses its position, so its buttocks occupy the fundus. In short, in early pregnancy, the majority of fetuses are in the breech presentation and later in pregnancy most of them make a spontaneous transition to the vertex presentation.

8.1.2  Malpresentations

You will learn about obstructed labour in Study Session 9.

When the baby presents itself in the mother’s pelvis in any position other than the vertex presentation, this is termed an abnormal presentation, or m alpresentation . The reason for referring to this as ‘abnormal’ is because it is associated with a much higher risk of obstruction and other birth complications than the vertex presentation. The most common types of malpresentation are termed breech, shoulder, face or brow. We will discuss each of these in turn later. Notice that the baby can be ‘head-down’ but in an abnormal presentation, as in face or brow presentations, when the baby’s face or forehead (brow) is the presenting part.

8.1.3  Malposition

Although it may not be so easy for you to identify this, the baby can also be in an abnormal position even when it is in the vertex presentation. In a normal delivery, when the baby’s head has engaged in the mother’s pelvis, the back of the baby’s skull (the occiput ) points towards the front of the mother’s pelvis (the pubic symphysis ), where the two pubic bones are fused together. This orientation of the fetal skull is called the occipito-anterior position (Figure 8.2a). If the occiput (back) of the fetal skull is towards the mother’s back, this occipito-posterior position (Figure 8.2b) is a vertex malposition , because it is more difficult for the baby to be born in this orientation. The good thing is that more than 90% of babies in vertex malpositions undergo rotation to the occipito-anterior position and are delivered normally.

You learned the directional positions: anterior/in front of and posterior/behind or in the back of, in the Antenatal Care Module, Part 1, Study Session 3.

Note that the fetal skull can also be tilted to the left or to the right in either the occipito-anterior or occipito-posterior positions.

8.2  Causes and consequences of malpresentations and malpositions

In the majority of individual cases it may not be possible to identify what caused the baby to be in an abnormal presentation or position during delivery. However, the general conditions that are thought to increase the risk of malpresentation or malposition are listed below:

Multiple pregnancy is the subject of Section 8.7 of this study session. You learned about placenta previa in the Antenatal Care Module, Study Session 21.

• Abnormally increased or decreased amount of amniotic fluid
• A tumour (abnormal tissue growth) in the uterus preventing the spontaneous inversion of the fetus from breech to vertex presentation during late pregnancy
• Abnormal shape of the pelvis
• Laxity (slackness) of muscular layer in the walls of the uterus
• Multiple pregnancy (more than one baby in the uterus)
• Placenta previa (placenta partly or completely covering the cervical opening).

If the baby presents at the dilating cervix in an abnormal presentation or malposition, it will more difficult (and may be impossible) for it to complete the seven cardinal movements that you learned about in Study Sessions 3 and 5. As a result, birth is more difficult and there is an increased risk of complications, including:

You learned about PROM in Study Session 17 of the Antenatal Care Module, Part 2.

• Premature rupture of the fetal membranes (PROM)
• Premature labour
• Slow, erratic, short-lived contractions
• Uncoordinated and extremely painful contractions, with slow or no progress of labour
• Prolonged and obstructed labour, leading to a ruptured uterus (see Study Sessions 9 and 10 of this Module)
• Postpartum haemorrhage (see Study Session 11)
• Fetal and maternal distress, which may lead to the death of the baby and/or the mother.

With these complications in mind, we now turn your attention to the commonest types of malpresentation and how to recognise them.

8.3  Breech presentation

In a b reech presentation , the fetus lies with its buttocks in the lower part of the uterus, and its buttocks and/or the feet are the presenting parts during delivery. Breech presentation occurs on average in 3–4% of deliveries after 34 weeks of pregnancy.

When is the breech position the normal position for the fetus?

During early pregnancy the baby’s bottom points down towards the mother’s cervix, and its head (the largest part of the fetus at this stage of development) occupies the fundus (rounded top) of the uterus, which is the widest part of the uterine cavity.

8.3.1  Causes of breech presentation

You can see a transverse lie in Figure 8.7 later in this study session.

In the majority of cases there is no obvious reason why the fetus should present by the breech at full term. In practice, what is commonly observed is the association of breech presentation at delivery with a transverse lie earlier in the pregnancy, i.e. the fetus lies sideways across the mother’s abdomen, facing a sideways implanted placenta. It is thought that when the placenta is in front of the baby’s face, it may obstruct the normal process of inversion, when the baby turns head-down as it gets bigger during the pregnancy. As a result, the fetus turns in the other direction and ends in the breech presentation. Some other circumstances that are thought to favour a breech presentation during labour include:

• Premature labour, beginning before the baby undergoes spontanous inversion from breech to vertex presentation
• Multiple pregnancy, preventing the normal inversion of one or both babies
• Polyhydramnios: excessive amount of amniotic fluid, which makes it more difficult for the fetal head to ‘engage’ with the mother’s cervix (polyhydramnios is pronounced ‘poll-ee-hy-dram-nee-oss’. Hydrocephaly is pronounced ‘hy-droh-keff-all-ee’)
• Hydrocephaly (‘water on the brain’) i.e. an abnormally large fetal head due to excessive accumulation of fluid around the brain
• Placenta praevia
• Breech delivery in the previous pregnancy
• Abnormal formation of the uterus.

8.3.2  Diagnosis of breech presentation

On abdominal palpation the fetal head is found above the mother’s umbilicus as a hard, smooth, rounded mass, which gently ‘ballots’ (can be rocked) between your hands.

Why do you think a mass that ‘ballots’ high up in the abdomen is a sign of breech presentation? (You learned about this in Study Session 11 of the Antenatal Care Module.)

The baby’s head can ‘rock’ a little bit because of the flexibility of the baby’s neck, so if there is a rounded, ballotable mass above the mother’s umbilicus it is very likely to be the baby’s head. If the baby was ‘bottom-up’ (vertex presentation) the whole of its back will move of you try to rock the fetal parts at the fundus (Figure 8.3).

Once the fetus has engaged and labour has begun, the breech baby’s buttocks can be felt as soft and irregular on vaginal examination. They feel very different to the relatively hard rounded mass of the fetal skull in a vertex presentation. When the fetal membranes rupture, the buttocks and/or feet can be felt more clearly. The baby’s anus may be felt and fresh thick, dark meconium may be seen on your examining finger. If the baby’s legs are extended, you may be able to feel the external genitalia and even tell the sex of the baby before it is born.

8.3.3  Types of breech presentation

There are three types of breech presentation, as illustrated in Figure 8.4. They are:

• Complete breech is characterised by flexion of the legs at both hips and knee joints, so the legs are bent underneath the baby.
• Frank breech is the commonest type of breech presentation, and is characterised by flexion at the hip joints and extension at the knee joints, so both the baby’s legs point straight upwards.
• Footling breech is when one or both legs are extended at the hip and knee joint and the baby presents ‘foot first’.

8.3.4  Risks of breech presentation

Regardless of the type of breech presentation, there are significant associated risks to the baby. They include:

• The fetal head gets stuck (arrested) before delivery
• Labour becomes obstructed when the fetus is disproportionately large for the size of the maternal pelvis
• Cord prolapse may occur, i.e. the umbilical cord is pushed out ahead of the baby and may get compressed against the wall of the cervix or vagina
• Premature separation of the placenta (placental abruption)
• Birth injury to the baby, e.g. fracture of the arms or legs, nerve damage, trauma to the internal organs, spinal cord damage, etc.

A breech birth may also result in trauma to the mother’s birth canal or external genitalia through being overstretched by the poorly fitting fetal parts.

Cord prolapse in a normal (vertex) presentation was illustrated in Study Session 17 of the Antenatal Care Module, and placental abruption was covered in Study Session 21.

What will be the effect on the baby if it gets stuck, the labour is obstructed, the cord prolapses, or placental abruption occurs?

The result will be hypoxia , i.e. it will be deprived of oxygen, and may suffer permanent brain damage or die.

You learned about the causes and consequences of hypoxia in the Antenatal Care Module.

8.4  Face presentation

Face presentation occurs when the baby’s neck is so completely extended (bent backwards) that the occiput at the back of the fetal skull touches the baby’s own spine (see Figure 8.5). In this position, the baby’s face will present to you during delivery.

Refer the mother if a baby in the chin posterior face presentation does not rotate and the labour is prolonged.

The incidence of face presentation is about 1 in 500 pregnancies in full term labours. In Figure 8.5, you can see how flexed the head is at the neck. Babies who present in the ‘chin posterior’ position (on the right in Figure 8.5) usually rotate spontaneously during labour, and assume the ‘chin anterior’ position, which makes it easier for them to be born. However, they are unlikely to be delivered vaginally if they fail to undergo spontaneous rotation to the chin anterior position, because the baby’s chin usually gets stuck against the mother’s sacrum (the bony prominence at the back of her pelvis). A baby in this position will have to be delivered by caesarean surgery.

8.4.1  Causes of face presentation

The causes of face presentation are similar to those already described for breech births:

• Laxity (slackness) of the uterus after many previous full-term pregnancies
• Multiple pregnancy
• Polyhydramnios (excessive amniotic fluid)
• Congenital abnormality of the fetus (e.g. anencephaly, which means no or incomplete skull bones)
• Abnormal shape of the mother’s pelvis.

8.4.2  Diagnosis of face presentation

Face presentation may not be easily detected by abdominal palpation, especially if the chin is in the posterior position. On abdominal examination, you may feel irregular shapes, formed because the fetal spine is curved in an ‘S’ shape. However, on vaginal examination, you can detect face presentation because:

• The presenting part will be high, soft and irregular.
• When the cervix is sufficiently dilated, you may be able to feel parts of the face, such as the orbital ridges above the eyes, the nose or mouth, gums, or bony chin.
• If the membranes are ruptured, the baby may suck your examining finger!

But as labour progresses, the baby’s face becomes o edematous (swollen with fluid), making it more difficult to distinguish from the soft shape you will feel in a breech presentation.

8.4.3  Complications of face presentation

Complications for the fetus include:

• Obstructed labour and ruptured uterus
• Cord prolapse
• Facial bruising
• Cerebral haemorrhage (bleeding inside the fetal skull).

8.5  Brow presentation

In brow presentation , the baby’s head is only partially extended at the neck (compare this with face presentation), so its brow (forehead) is the presenting part (Figure 8.6). This presentation is rare, with an incidence of 1 in 1000 deliveries at full term.

8.5.1  Possible causes of brow presentation

You have seen all of these factors before, as causes of other malpresentations:

• Lax uterus due to repeated full term pregnancy
• Polyhydramnios

8.5.2  Diagnosis of brow presentation

Brow presentation is not usually detected before the onset of labour, except by very experienced birth attendants. On abdominal examination, the head is high in the mother’s abdomen, appears unduly large and does not descend into the pelvis, despite good uterine contractions. On vaginal examination, the presenting part is high and may be difficult to reach. You may be able to feel the root of the nose, eyes, but not the mouth, tip of the nose or chin. You may also feel the anterior fontanel, but a large caput (swelling) towards the front of the fetal skull may mask this landmark if the woman has been in labour for some hours.

Recall the appearance of a normal caput over the posterior fontanel shown in Figure 4.4 earlier in this Module.

8.5.3  Complications of brow presentation

The complications of brow presentation are much the same as for other malpresentations:

• Cerebral haemorrhage.

Which are you more likely to encounter — face or brow presentations?

Face presentation, which occurs in 1 in 500 full term labours. Brow presentation is more rare, at 1 in 1,000 full term labours.

8.6  Shoulder presentation

Shoulder presentation is rare at full term, but may occur when the fetus lies transversely across the uterus (Figure 8.7), if it stopped part-way through spontaneous inversion from breech to vertex, or it may lie transversely from early pregnancy. If the baby lies facing upwards, its back may be the presenting part; if facing downwards its hand may emerge through the cervix. A baby in the transverse position cannot be born through the vagina and the labour will be obstructed. Refer babies in shoulder presentation urgently.

8.6.1  Causes of shoulder presentation

Causes of shoulder presentation could be maternal or fetal factors.

Maternal factors include:

• Lax abdominal and uterine muscles: most often after several previous pregnancies
• Uterine abnormality
• Contracted (abnormally narrow) pelvis.

Fetal factors include:

• Preterm labour
• Placenta previa.

What do ‘placenta previa’ and ‘polyhydramnios’ indicate?

Placenta previa is when the placenta is partly or completely covering the cervical opening. Polyhydramnios is an excess of amniotic fluid. They are both potential causes of malpresentation.

8.6.2  Diagnosis of shoulder presentation

On abdominal palpation, the uterus appears broader and the height of the fundus is less than expected for the period of gestation, because the fundus is not occupied by either the baby’s head or buttocks. You can usually feel the head on one side of the mother’s abdomen. On vaginal examination, in early labour, the presenting part may not be felt, but when the labour is well progressed, you may feel the baby’s ribs. When the shoulder enters the pelvic brim, the baby’s arm may prolapse and become visible outside the vagina.

8.6.3  Complications of shoulder presentation

Complications include:

• Trauma to a prolapsed arm
• Fetal hypoxia and death.

Remember that a shoulder presentation means the baby cannot be born through the vagina; if you detect it in a woman who is already in labour, refer her urgently to a higher health facility.

8.7  Multiple pregnancy

In this section, we turn to the subject of multiple pregnancy , when there is more than one fetus in the uterus. More than 95% of multiple pregnancies are twins (two fetuses), but there can also be triplets (three fetuses), quadruplets (four fetuses), quintuplets (five fetuses), and other higher order multiples with a declining chance of occurrence. The spontaneous occurrence of twins varies by country : it is lowest in East Asia n countries like Japan and China (1 out of 1000 pregnancies are fraternal or non-identical twins), and highest in black Africans , particularly in Nigeria , where 1 in 20 pr egnancies are fraternal twins. In general, compared to single babies, multiple pregnancies are highly associated with early pregnancy loss and high perinatal mortality, mainly due to prematurity.

8.7.1  Types of twin pregnancy

Twins may be identical (monozygotic) or non-identical and fraternal (dizigotic). Monozygotic twins develop from a single fertilised ovum (the zygote), so they are always the same sex and they share the same placenta . By contrast, dizygotic twins develop from two different zygotes, so they can have the same or different sex, and they have separate placenta s . Figure 8.8 shows the types of twin pregnancy and the processes by which they are formed.

8.7.2  Diagnosis of twin pregnancy

On abdominal examination you may notice that:

• The size of the uterus is larger than the expected for the period for gestation.
• The uterus looks round and broad, and fetal movement may be seen over a large area. (The shape of the uterus at term in a singleton pregnancy in the vertex presentation appears heart-shaped rounder at the top and narrower at the bottom.)
• Two heads can be felt.
• Two fetal heart beats may be heard if two people listen at the same time, and they can detect at least 10 beats different (Figure 8.6).
• Ultrasound examination can make an absolute diagnosis of twin pregnancy.

8.7.3  Consequences of twin pregnancy

Women who are pregnant with twins are more prone to suffer with the minor disorders of pregnancy, like morning sickness, nausea and heartburn. Twin pregnancy is one cause of hyperemesis gravidarum (persistent, severe nausea and vomiting). Mothers of twins are also more at risk of developing iron and folate-deficiency anaemia during pregnancy.

Can you suggest why anaemia is a greater risk in multiple pregnancies?

The mother has to supply the nutrients to feed two (or more) babies; if she is not getting enough iron and folate in her diet, or through supplements, she will become anaemic.

Other complications include the following:

• Pregnancy-related hypertensive disorders like pre-eclampsia and eclampsia are more common in twin pregnancies.
• Pressure symptoms may occur in late pregnancy due to the increased weight and size of the uterus.
• Labour often occurs spontaneously before term, with p remature delivery or premature rupture of membranes (PROM) .
• Respiratory deficit ( shortness of breath, because of fast growing uterus) is another common problem.

Twin babies may be small in comparison to their gestational age and more prone to the complications associated with low birth weight (increased vulnerability to infection, losing heat, difficulty breastfeeding).

You will learn about low birth weight babies in detail in the Postnatal Care Module.

• Malpresentation is more common in twin pregnancies, and they may also be ‘locked’ at the neck with one twin in the vertex presentation and the other in breech. The risks associated with malpresentations already described also apply: prolapsed cord, poor uterine contraction, prolonged or obstructed labour, postpartum haemorrhage, and fetal hypoxia and death.
• Conjoined twins (fused twins, joined at the head, chest, or abdomen, or through the back) may also rarely occur.

8.8  Management of women with malpresentation or multiple pregnancy

As you have seen in this study session, any presentation other than vertex has its own dangers for the mother and baby. For this reason, all women who develop abnormal presentation or multiple pregnancy should ideally have skilled care by senior health professionals in a health facility where there is a comprehensive emergency obstetric service. Early detection and referral of a woman in any of these situations can save her life and that of her baby.

What can you do to reduce the risks arising from malpresentation or multiple pregnancy in women in your care?

During focused antenatal care of the pregnant women in your community, at every visit after 36 weeks of gestation you should check for the presence of abnormal fetal presentation. If you detect abnormal presentation or multiple pregnancy, you should refer the woman before the onset of labour.

Summary of Study Session 8

In Study Session 8, you learned that:

• During early pregnancy, babies are naturally in the breech position, but in 95% of cases they spontaneously reverse into the vertex presentation before labour begins.
• Malpresentation or malposition of the fetus at full term increases the risk of obstructed labour and other birth complications.
• Common causes of malpresentations/malpositions include: excess amniotic fluid, abnormal shape and size of the pelvis; uterine tumour; placenta praevia; slackness of uterine muscles (after many previous pregnancies); or multiple pregnancy.
• Common complications include: premature rupture of membranes, premature labour, prolonged/obstructed labour; ruptured uterus; postpartum haemorrhage; fetal and maternal distress which may lead to death.
• Vertex malposition is when the fetal head is in the occipito-posterior position — i.e. the back of the fetal skull is towards the mother’s back instead of pointing towards the front of the mother’s pelvis. 90% of vertex malpositions rotate and deliver normally.
• Breech presentation (complete, frank or footling) is when the baby’s buttocks present during labour. It occurs in 3–4% of labours after 34 weeks of pregnancy and may lead to obstructed labour, cord prolapse, hypoxia, premature separation of the placenta, birth injury to the baby or to the birth canal.
• Face presentation is when the fetal head is bent so far backwards that the face presents during labour. It occurs in about 1 in 500 full term labours. ‘Chin posterior’ face presentations usually rotate spontaneously to the ‘chin anterior’ position and deliver normally. If rotation does not occur, a caesarean delivery is likely to be necessary.
• Brow presentation is when the baby’s forehead is the presenting part. It occurs in about 1 in 1000 full term labours and is difficult to detect before the onset of labour. Caesarean delivery is likely to be necessary.
• Shoulder presentation occurs when the fetal lie during labour is transverse. Once labour is well progressed, vaginal examination may feel the baby’s ribs, and an arm may sometimes prolapse. Caesarean delivery is always required unless a doctor or midwife can turn the baby head-down.
• Multiple pregnancies are always at high risk of malpresentation. Mothers need greater antenatal care, and twins are more prone to complications associated with low birth weight and prematurity.
• Any presentation other than vertex after 34 weeks of gestation is considered as high risk to the mother and to her baby. Do not attempt to turn a malpresenting or malpositioned baby! Refer the mother for emergency obstetric care.

Self-Assessment Questions (SAQs) for Study Session 8

Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering the following questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.

SAQ 8.1 (tests Learning Outcomes 8.1, 8.2 and 8.4)

Which of the following definitions are true and which are false? Write down the correct definition for any which you think are false.

A  Fundus — the ‘rounded top’ and widest cavity of the uterus.

B  Complete breech — where the legs are bent at both hips and knee joints and are folded underneath the baby.

C  Frank breech — where the breech is so difficult to treat that you have to be very frank and open with the mother about the difficulties she will face in the birth.

D  Footling breech — when one or both legs are extended so that the baby presents ‘foot first’.

E  Hypoxia — the baby gets too much oxygen.

F  Multiple pregnancy — when a mother has had many babies previously.

G  Monozygotic twins — develop from a single fertilised ovum (the zygote). They can be different sexes but they share the same placenta.

H  Dizygotic twins — develop from two zygotes. They have separate placentas, and can be of the same sex or different sexes.

A is true.  The fundus is the ‘rounded top’ and widest cavity of the uterus.

B is true.  Complete breech is where the legs are bent at both hips and knee joints and are folded underneath the baby.

C is false . A frank breech is the most common type of breech presentation and is when the baby’s legs point straight upwards (see Figure 8.4).

D is true.   A footling breech is when one or both legs are extended so that the baby presents ‘foot first’.

E is false .  Hypoxia is when the baby is deprived of oxygen and risks permanent brain damage or death.

F is false.   Multiple pregnancy is when there is more than one fetus in the uterus.

G is false.   Monozygotic twins develop from a single fertilised ovum (the zygote), and they are always the same sex , as well as sharing the same placenta.

H is true.  Dizygotic twins develop from two zygotes, have separate placentas, and can be of the same or different sexes.

SAQ 8.2 (tests Learning Outcomes 8.1 and 8.2)

What are the main differences between normal and abnormal fetal presentations? Use the correct medical terms in bold in your explanation.

In a normal presentation, the vertex (the highest part of the fetal head) arrives first at the mother’s pelvic brim, with the occiput (the back of the baby’s skull) pointing towards the front of the mother’s pelvis (the pubic symphysis ).

Abnormal presentations are when there is either a vertex malposition (the occiput of the fetal skull points towards the mother’s back instead towards of the pubic symphysis), or a malpresentation (when anything other than the vertex is presenting): e.g. breech presentation (buttocks first); face presentation (face first); brow presentation (forehead first); and shoulder presentation (transverse fetal).

SAQ 8.3 (tests Learning Outcomes 8.3 and 8.5)

• a. List the common complications of malpresentations or malposition of the fetus at full term.
• b. What action should you take if you identify that the fetus is presenting abnormally and labour has not yet begun?
• c. What should you not attempt to do?
• a. The common complications of malpresentation or malposition of the fetus at full term include: premature rupture of membranes, premature labour, prolonged/obstructed labour; ruptured uterus; postpartum haemorrhage; fetal and maternal distress which may lead to death.
• b. You should refer the mother to a higher health facility – she may need emergency obstetric care.
• c. You should not attempt to turn the baby by hand. This should only be attempted by a specially trained doctor or midwife and should only be done at a health facility.

SAQ 8.4 (tests Learning Outcomes 8.4 and 8.5)

A pregnant woman moves into your village who is already at 37 weeks gestation. You haven’t seen her before. She tells you that she gave birth to twins three years ago and wants to know if she is having twins again this time.

• a. How would you check this?
• b. If you diagnose twins, what would you do to reduce the risks during labour and delivery?
• Is the uterus larger than expected for the period of gestation?
• What is its shape – is it round (indicative of twins) or heart-shaped (as in a singleton pregnancy)?
• Can you feel more than one head?
• Can you hear two fetal heartbeats (two people listening at the same time) with at least 10 beats difference?
• If there is access to a higher health facility, and you are still not sure, try and get the woman to it for an ultrasound scan.
• Be extra careful to check that the mother is not anaemic.
• Encourage her to rest and put her feet up to reduce the risk of increased blood pressure or swelling in her legs and feet.
• Be alert to the increased risk of pre-eclampsia.
• Expect her to go into labour before term, and be ready to get her to the health facility before she goes into labour, going with her if at all possible.
• Get in early touch with that health facility to warn them to expect a referral from you.
• Make sure that transport is ready to take her to a health facility when needed.

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and malpresentations

Chapter 64 Malpositions and malpresentations Paul Lewis Learning Outcomes After reading this chapter, you will be able to: • have an understanding of the factors which predispose to malpositions and malpresentations of the fetus • recognize features of malpositions and malpresentations and, where necessary, take appropriate action • consider the management and care to facilitate normality, ensuring a safe and positive experience for the woman and baby • use appropriate sources of evidence to support safe, effective and women-centred practice • understand the complex, controversial and uncertain state of knowledge that surrounds the management of malpositions and malpresentations and use this to inform your clinical judgements; appropriately advising and supporting women in their choices of care. Introduction This chapter considers the recognition, management and care of the fetus when it presents in an occipitoposterior (OP) position, by the breech, face or brow and when an oblique or transverse lie results in a shoulder presentation. Compound presentation is also discussed. Malposition and malpresentations of the fetus can occur in both pregnancy and labour. The midwife has a key role in identifying these, using best evidence to inform and support the mother and effective skills to undertake safe management and care. With associated higher rates of maternal and perinatal morbidity and mortality, it is essential that careful attention be given to the diagnosis of malposition and malpresentations in order to maximize fetal outcomes ( Baxley 2001 , Cheng & Hannah 1993 , Hannah et al 2000 , Pritchard & MacDonald 1980 ). While primarily a practitioner of the ‘normal’, the midwife must be fully conversant with the problems and practicalities that both malposition and malpresentations can present. In such circumstances, skills are often tested to the limit and the midwife’s ability to gain the confidence of the woman and to work effectively with the wider healthcare team is paramount in achieving a safe and successful outcome for both mother and baby ( ALSO 2003 ). In dealing with malpositions and malpresentations of the fetus, the midwife needs to be knowledgeable about the latest evidence or lack of it, that will help to inform a woman’s decisions in relation to her care and provide her with the options available ( Evans 2007 ). This may be difficult and, in spite of the evidence, some women may choose a path, for personal, cultural or religious reasons, that is not in keeping with the recommended evidence or accepted institutional practices. Nevertheless, it is a woman’s right to choose for herself and the midwife needs to ensure that in such circumstances, the woman continues to receive the relevant information, advice and support necessary. In achieving this, the midwife should consult with her supervisor of midwives and, with the woman’s permission, share the proposed plan of care with her and the lead obstetrician. All discussions with the woman must be clearly documented in her maternity notes and accurately reflect the advice given, the options available and choices she has made. Identifying Malpositions and Malpresentations of the Fetus Midwives must be able to employ a range of skills to assist them in identifying the fetus in: Malpositions (where the occiput is in one or other posterior quadrant of the pelvis): deflexed attitude such as an occipitoposterior (OP) position. Malpresentations (any presentation other than vertex): extended attitude: – face – brow breech presentation shoulder presentation/oblique lie. These require midwives to take a detailed history, keenly observe the woman’s body and behaviours, and carry out a considered and careful clinical examination. Above all, they must be able to draw the findings together in order to analyse and make sense of them. From this, the midwife can then make a diagnosis, upon which discussions with the woman, clinical decisions and further professional judgements will be based. Incidence The incidence of malpositions and malpresentations varies according to lifestyle, gestation and parity, as well as the condition of the mother and fetus. The midwife needs to consider the likelihood and the reasons why these presentations might occur as part of the assessment, diagnosis and plan of the woman’s care. It is essential that the midwife recognize that a malposition is the commonest cause of non-engagement of the fetal head at term in a primigravida. It is the commonest cause of prolonged labour and mechanical difficulties associated with the birth. Persistent OP position was a significant factor in caesarean section and instrumental deliveries with less than half of the OP labours ending in a spontaneous birth of the baby ( Fitzpatrick et al 2001 ). Clinical Assessment In identifying malpositions and malpresentations, the midwife should take into account the gestational age of the fetus, the woman’s parity, and any history that might suggest the likelihood of such anomalies or abnormalities. The clinical skills of abdominal and vaginal assessment that the midwife may perform as part of a woman’s antenatal and intrapartum care, are central to the recognition of the presentation, engagement, attitude, lie and position of the fetus. Underlying this is the need to be fully conversant with the anatomy of the maternal pelvis, the engaging diameter of the fetal presentations, and the implications of these for the birthing process. Malposition of the Occiput The fetus is in an occipitoposterior position (OPP) when the fetal occiput lies adjacent to the sacroiliac joint and occupies either the left or right posterior quadrants of the mother’s pelvis with the brow directed anteriorly. Occipitoposterior positions occur in approximately 10–25% of pregnancies during the early stage of labour and in 10–15% during the active phase, most of which end normally ( Gardberg & Tuppurainen 1994a ). Causes of OPP include the following: • Modern lifestyle of less physical activity and poor posture has increased the risk of OPP. With some positional changes/movement, many fetuses can be persuaded to change their position before labour begins, but midwives need to consider different strategies to support mother and fetus if the baby remains in an OPP ( Sutton 2000 ). • Use of epidural anaesthesia ( Saunders et al 1989 , Thorp et al 1993 ): the anaesthesia reduces the tone of the pelvic floor muscles and resistance to the presenting part. This causes failure of the vertex to rotate, increasing the chance of persistent OPP, asynclitism and transverse arrest of the fetal head. In one study ( Gardberg et al 1998 ), persistent OPP at birth primarily resulted from a malrotation rather than the absence of rotation. • Android pelvis : the narrow forepelvis forces the fetal head to adjust and take up a posterior position in order to enter the pelvic brim. • Anthropoid pelvis : may also lead to a persistent OPP. • Pendulous abdomen or a flat sacrum. • Anterior placenta is also associated with an OPP towards term ( Gardberg & Tuppurainen 1994b ). Sutton and Scott (1996) highlighted the use of optimal fetal positioning (see website) in helping women to increase their chances of normal childbirth. Other work suggests that such strategies for reducing persistent OPP at birth may be more complex ( Hunter et al 2007 ) (see website). Occipitoposterior positions ( Fig. 64.1 ) throw a heavy responsibility on the midwife, but being overly pessimistic does little to help the mother. Where the labour is progressing satisfactorily, the outcome is likely to be spontaneous rotation to an anterior position followed by a normal vertex delivery. Figure 64.1 Occipitoposterior positions. A. Abdominal findings – the anterior shoulders are well out from the midline or fetal limbs are easily palpable. This may cause a misdiagnosis of multiple pregnancy. B. Vaginal findings – on vaginal examination, the anterior fontanelle is easily felt and recognized by its shape and size. While malpositions can and do resolve, the midwife should be aware of the potential for delay and the possibility of adverse outcomes that may arise when the labour is prolonged or the OPP persists. Slow progress should alert midwives to the possibility of abnormal labour and they must be vigilant to promptly recognize any complications that may arise and call for assistance. They should be ready to act and make decisive professional judgements when indicated by the maternal or fetal condition, poor progress of labour, or the mother’s psychological state and frame of mind. In the presence of an obstetric urgency or emergency, such as deep transverse arrest (DTA) or cord prolapse, the midwife must seek immediate medical assistance. In caring for a woman in prolonged labour, the midwife has the exacting task of maintaining a close watch on the progress she is making, attending to her physical care and providing the encouragement, reassurance and emotional support that the woman needs. The midwife also needs to be aware of the altered mechanism of a fetus in a posterior position, during which the fetus tends to be in a deflexed attitude, with the anterior fontanelle immediately over the internal cervical os. The fetal spine is towards the forward curve of the maternal lumbar spine, so that the fetus finds it difficult or impossible to adopt a flexed position. As the fetal spine straightens, the fetus tends to ‘square’ the shoulders and raise the chin from the chest, resulting in a deflexed, erect ‘military’ attitude of the fetal head, as shown in Figure 64.2 . Figure 64.2 The ‘military’ posture of the fetus in an occipitoposterior position. A. Well-flexed fetus. B. OP position. Deflexed with straight spine and wider engaging diameter. Such movements bring the fetal head into a more difficult relationship with the inlet of the maternal pelvis. Misaligned above the pelvic brim, the fetal head is slow to engage as its larger diameters present. This ill-fitting presentation may also result in early rupture of the membranes and the danger of cord prolapse. There is a loss of fetal axis pressure , contractions are not effectively stimulated and descent is delayed. This can lead to slow, uneven cervical dilatation and prolonged labour. In the process of birth, the engaging diameter of the fetal head is reduced, with that at right angles being elongated. In an occipitoposterior position, the fetal head is compressed in unfavourable diameters, resulting in ‘s ugar loaf ’ moulding, creating a greater risk of damage to the tentorium cerebelli and the likelihood of intracranial haemorrhage. With a persistent occipitoposterior position, these wider diameters may also result in increased trauma to the woman’s vagina and perineum. Diagnosis of the occipitoposterior position During pregnancy The diagnosis is often made by abdominal examination. On inspection, the abdomen appears flattened, or slightly depressed, below the umbilicus (see Fig. 64.3 ). On palpation, the fetal head is commonly high. If the fetus is almost occipitolateral, the deflexed head may feel large, because the occipitofrontal diameter is palpated. Figure 64.3 Abdominal contour: A. when the fetus is in the occipitoposterior position, compared to B. the more rounded contour of the occipitoanterior position. The occiput and brow may be felt at the same level at the pelvic inlet, while the fetal back can be palpated out in the flank. If the occiput is markedly posterior, the high head feels small, as the bitemporal diameter is palpated; movements of the fetal limbs can often be seen or easily felt and it may be impossible to feel the back (see Fig. 64.1 ). The fetal heart sounds can be heard in the midline just below the umbilicus. If the heart sounds are audible in one flank, it suggests that the fetal back is directed towards that side. During labour The diagnosis may be made by abdominal examination, though as labour advances, the head may become flexed and engaged. The cephalic prominence of the sinciput can be felt above the pubic bone and on the opposite side to the fetal back. The midwife should be alert whenever the cephalic prominence is felt on the same side as the fetal back and should consider the possibility of a face or brow presentation and seek to exclude these. A deflexed head prior to or in the process of engagement in the maternal pelvis can become extended to a brow, or hyperextended to a face presentation. ‘Coupling’ of contractions is associated with occipitoposterior positions ( ALSO 2003 ). The midwife may identify this phenomenon when she palpates the mother’s abdomen or else on the tocograph tracing if electronic fetal monitoring is in progress. On vaginal examination the findings depend on the degree of flexion of the fetal head. Palpation of the anterior fontanelle is usually diagnostic of an occipitoposterior position. When the head is partially or well flexed, the anterior fontanelle is felt towards the front of the pelvis, while occasionally the posterior fontanelle is just within reach at the back. With a deflexed head, the anterior fontanelle is almost central and, unless obscured by caput, easily recognizable by its size and shape. Progress in labour The progress of labour will depend upon the regularity and strength of uterine contractions and the degree of flexion of the fetal head. The shape of the maternal pelvis and the maternal position may be significant in determining how the fetus negotiates the pelvic inlet, cavity and outlet. Flexion of the fetal head If the head is flexed, labour will probably be completely normal. The engaging diameter is the suboccipitofrontal (10 cm). The occiput reaches the pelvic floor and rotates anteriorly through three-eighths of a circle and the baby is born with the occiput anteriorly ( Fig. 64.4 ). Figure 64.4 Possible outcomes of an occipitoposterior position. The fetal head enters the pelvis with the occiput posteriorly. When the head remains deflexed, it tends to remain high or is slow to engage. Labour is slow to become established, with hypotonic and irregular uterine contractions. However, flexion may improve, and once the head becomes flexed, labour usually accelerates and continues normally, with a long internal rotation and an occipitoanterior birth ( Fig. 64.4A ). Deflexion of the fetal head The midwife needs to be fully conversant with the mechanism of the persistent occipitoposterior position and how this translates into what the woman experiences. If the head remains deflexed, labour is likely to be prolonged and painful, with backache a prominent characteristic. The outcome is then dependent on the size, shape and dimensions of the pelvis in relation to those of the fetal skull. Persistent occipitoposterior position (POP) The mechanism is that the lie is longitudinal, presentation vertex and attitude deflexed – the engaging diameter is the occipitofrontal and measures 11.5 cm. The position may be either right or left occipitoposterior and the presenting part is the anterior aspect of the right (ROP) or left (LOP) parietal bone. Descent takes place with deficient flexion and the biparietal diameter of the fetal head is held up on the sacrocotyloid diameter of the maternal pelvis, so that the sinciput becomes the leading part. When the sinciput meets the resistance of the pelvic floor, it rotates forward one-eighth of a circle ( Fig. 64.4C ). The sinciput passes under the pubic arch and the occiput into the hollow of the sacrum. With good contractions, spontaneous delivery ensues and, with flexion, the occiput sweeps the maternal perineum and, once the glabellar is visible, the brow and face are delivered by extension. The rest of the mechanism follows that of a normal, vertex presentation (see Ch. 37 ). This is called persistent occipitoposterior position or ‘ face-to-pubes ’ delivery and is often associated with an anthropoid pelvis ( Fig. 64.4C ). Deep transverse arrest (DTA) DTA ( Fig. 64.4B ) may occur if the head remains deflexed. The fetal head may attempt a long rotation, but because of wider diameters and prominence of the ischial spines, it can become caught in the transverse diameter of the obstetric outlet, between the ischial spines. DTA should be suspected if there is delay in the second stage of labour. On vaginal examination, the sagittal suture is found in the transverse diameter of the pelvis with a fontanelle at each end, close to the ischial spines. In such circumstances, appropriately skilled midwifery or medical assistance should be obtained and, with the use of vacuum extraction (ventouse), the fetal head may be rotated to an anterior position and delivered. Manual rotation of the occiput may also be considered. The midwife should be knowledgeable about this procedure ( NMC 2008 ), and needs to explain the procedure fully to the woman, obtaining informed consent (see website). This should not delay summoning additional assistance. Occasionally, caesarean section is necessary to deliver the fetus in an occipitoposterior position. This is likely when complications such as cord prolapse and fetal distress occur, or when true cephalopelvic disproportion is diagnosed. Extension of the fetal head It is possible that the fetal head may either be in a slightly extended position, or may adopt this as labour progresses, resulting in a brow presentation ( Fig. 64.4D ). Unless the fetus is particularly small or preterm, then it is unlikely that it will be born vaginally. Full extension of the fetal head may lead to a face presentation, which, if mento-anterior, may deliver vaginally ( Fig. 64.4E ). Complications of OPP Midwives need to carefully consider complications that might arise ( Table 64.1 ) and be fully aware of what action should be taken to prevent or minimize these occurring in their management and care of a woman whose baby is in an occipitoposterior position. Table 64.1 Complications of occipitoposterior (OP) position Complication Reason Early rupture of the membranes Poorly fitting presenting part and uneven pressure on the forewaters Cord prolapse As with any ill-fitting presenting part, the membranes tend to rupture early and the cord may prolapse Prolonged labour This is associated with a deflexed head, poorly fitting presenting part and misaligned fetal axis pressure. A slightly contracted pelvis may compound this. Hypotonic and inefficient or over-efficient uterine contractions may result. In such circumstances, the development of either fetal or maternal distress is more likely and operative intervention and anaesthesia are often necessary. Postpartum haemorrhage is therefore an added risk Retention of urine This may occur with prolonged labour and the pressure on the urethra that results from the wider diameters of the OP position Premature expulsive effort The wider diameter of the OP position results in pressure on the sacral nerves and the woman may feel the need to push before full dilatation of the cervix. Early distension of the perineum and dilatation of the anus can also occur while the head is still high Infection This is more likely because of early rupture of the membranes, especially if labour is prolonged, and can be compounded by an increased number of vaginal assessments Trauma to the mother’s soft tissues The risk of trauma is increased with the wider diameter of the OP position. When this is persistent, the biparietal diameter and large occiput distend the maternal perineum. Instrumental delivery may also increase the risk of maternal trauma Post-traumatic stress disorder or postnatal depression Prolonged, difficult, painful and traumatic labour might result in mental ill-health. This can be exacerbated when the mother has no control over events and is not involved in decision-making. This, together with maternal exhaustion and an unsettled baby, may lead to difficulty in maternal–infant bonding Maternal exhaustion In prolonged labour, maternal exhaustion may follow the birth Unsettled or difficult-to-feed infant In an OP position and a prolonged labour, the baby’s head will have been compressed in an unnatural angle, resulting in discomfort and pain Fetal intracranial haemorrhage Upward moulding of the fetal skull may lead to stretching and damage of the tentorium cerebelli and consequent tearing of the great vein of Galen, resulting in haemorrhage and intracranial damage Increased perinatal mortality and morbidity This might result from cord prolapse, prolonged labour, instrumental delivery, infection and intracranial haemorrhage, and is increased because of hypoxia and birth trauma Care in labour When caring for a woman in labour whose baby is in an occipitoposterior position, the following aspects of care are paramount: • communication and support • one-to-one care • general comfort and pain relief • ambulation and position • assessment of progress • effective assessment of maternal and fetal wellbeing • appropriate and decisive clinical decisions • appropriate referral when necessary • accurate and detailed record-keeping • careful debriefing following the birth of the baby. Malpresentations of the Fetus Malpresentation refers to the orientation of the fetus and may be diagnosed during pregnancy or in labour. Any presentation other than vertex is termed a malpresentation and this therefore includes breech , face , brow and shoulder . When midwives encounter a malpresentation of the fetus, they will draw upon similar knowledge and many of the skills they use in the care and management of women whose babies were in an occipitoposterior position. In all malpresentations there is commonly an ill-fitting presenting part: often associated with early rupture of the membranes because of uneven pressure on the bag of forewaters. This results in an increased risk of cord prolapse. An ill-fitting presenting part is also associated with poor uterine action and slower cervical dilatation, and therefore labour may be prolonged with the concomitant risk of infection and operative intervention. Breech presentation A breech presentation occurs when the fetal buttocks lie lowermost in the maternal uterus and the fetal head occupies the fundus. The lie is longitudinal, the denominator is the sacrum and the presenting diameter is the bitrochanteric, which measures 10 cm. Breech presentation is common before 37 weeks’ gestation, with a suggested incidence of 15% at 29–32 weeks’ gestation reducing to 3–4% at term ( Hannah et al 2000 , MIDIRS 2008 ). One fetus in four will present by the breech at some stage in pregnancy. In preterm labour it is not surprising to find the breech presenting and these infants comprise a quarter of all babies born by the breech. However, by the 34th week of pregnancy, the majority will have turned to a vertex presentation. Types Four types of breech presentation are described ( Fig. 64.5 ). They are determined by the way in which the fetal legs are flexed or extended, and these have implications for the birth. • Flexed or complete breech: the fetus sits with the thighs and knees flexed with the feet close to the buttocks. This is more common in multigravidae. • Extended or frank breech: the fetal thighs are flexed, the legs are extended at the knees and lie alongside the trunk, with the feet near the fetal head. This is the commonnest type of breech presentation and occurs most frequently in primigravidae towards term. This is because their usually firm uterine and abdominal muscles allow only limited fetal movement and the fetus is therefore unable to flex its legs and turn to a cephalic presentation. • Footling presentation: one or both feet present below the fetal buttocks, with hips and knees extended. This relatively rare type of breech presentation is more likely to occur when the fetus is preterm. A foot may occasionally be felt at the level of the buttocks and might be confused with a footling presentation. Usually, as labour advances, it slips behind the buttocks, returning to an obvious flexed breech position. • Knee presentation: one or both knees present below the fetal buttocks, with one or both hips extended and the knees flexed. This is the least common of all types of breech presentation. Figure 64.5 Types of breech presentation. A. Flexed. B. Extended. C. Knee. D. Footling. There is a higher perinatal mortality and morbidity rate with breech presentation, which is largely due to prematurity and congenital abnormalities of the fetus, as well as birth asphyxia and birth trauma ( Cheng & Hannah 1993 , Hannah et al 2000 ). The clinical setting, failure to respond to delay and lack of clinical experience may also contribute to poorer outcomes ( Kotaska et al 2009 ). In providing care, the midwife needs to be conversant with the latest developments surrounding the management and optimal mode of delivery. While the outcomes of the ‘Term Breech Trial’ have dominated the discourse around the mode and management of breech births ( Hannah et al 2000 ) and significantly influenced practice in the United Kingdom and abroad, the evidence is at best uncertain, conflicting and contradictory ( Glezerman 2006 , Goffinet et al 2006 , Hofmeyr & Hannah 2003, Kotaska 2004 , Kotaska et al 2009 , Van Idderkinge 2007 , Waites 2003 , Whyte et al 2004 ). However, as Shennan & Bewley (2001) point out, the need to provide expertise in vaginal breech delivery will not disappear. Some women present too late, even when a policy of planned caesarean section is in place, and some women will reject the choice of a planned caesarean section and choose to have a vaginal breech birth in either the hospital or home setting because of personal, cultural or religious reasons. Causes The fetus may adopt the breech position for a variety of reasons, though the true cause is often unknown. Waites (2003) found that in most cases no single cause can be identified, and it may result from a random occurrence ( Bartlett & Okun 1994 ). The most common cause is likely to be a ‘ benign error of orientation ’ in which the fetus sits in the breech for no known cause and without any obvious abnormalities. Other causes include: • abnormal size and shape of the pelvis • uterine causes: placenta or fibroids occupying the lower uterine segment • abnormal liquor volume • multiple pregnancy • maternal conditions or fetal abnormalities resulting in poor postural tone • congenital anomalies: incidence known to be two to three times higher in those fetuses that present by the breech ( Lauszus et al 1992 ). See Table 64.2 . Table 64.2 Causes of breech presentation Primigravidae Firm abdominal and uterine muscles may prevent flexion of the fetal legs, especially when they are already extended. Uterine anomalies Bicornuate uterus may restrict fetal movement. Previous breech birth may also be strongly associated with a uterine anomaly. Oligohydramnios Reduced liquor volume restricts the ability of the fetus to turn in the uterus. The condition may also be associated with fetal anomalies and fetal compromise. Placental location Placenta praevia may prevent the fetal head from fitting into the lower uterine segment and entering the pelvis. A placenta situated in one or other cornua of the uterus reduces the breadth of space in the upper segment and can lead to a breech presentation. Uterine fibroids

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Presentation and position of baby through pregnancy and at birth

9-minute read

If you are concerned about your baby’s movements, contact your doctor or midwife for advice immediately.

• If you baby is in a breech presentation, your doctor may recommend trying a technique called an external cephalic version to try and move your baby while they are still in the uterus for an easier birth.

What does presentation and position mean?

Presentation refers to the part of your baby’s body that is facing downwards in the direction of the birth canal.

Position refers to where your baby’s occiput (the bottom part of the back of their head) is in relation to your body.

If your baby is in a breech presentation , then position refers to where your baby’s sacrum (lower back) is in relation to your body.

People — including medical professionals — sometimes use these terms incorrectly. Sometimes when speaking about babies in breech presentation, the word ‘position’ will be used to refer to their presentation. For example, you may read information or hear people say ‘breech position’ instead of ‘breech presentation’.

What are the different types of presentation my baby could be in during pregnancy and birth?

Most babies present headfirst, also known as cephalic presentation. Most babies that are headfirst will be vertex presentation. This means that the crown of their head sits at the opening of your birth canal.

In rare cases, your baby can be headfirst but in face or brow presentation, which may not be suitable for vaginal birth.

If your baby is in a breech presentation, their feet or bottom will be closest to your birth canal. The 3 most common types of breech presentation are:

• frank or extended breech — where your baby’s legs are straight up in front of their body, with their feet up near their face
• complete or flexed breech — where your baby is in a sitting position with their legs crossed in front of their body and their feet near their bottom
• footling breech — where one or both of your baby’s feet are hanging below their bottom, so the foot or feet are coming first

Read more on breech presentation .

What are the different positions my baby could be in during pregnancy and birth?

If your baby is headfirst, the 3 main types of presentation are:

• anterior – when the back of your baby’s head is at the front of your belly
• lateral – when the back of your baby’s head is facing your side
• posterior – when the back of your baby’s head is towards your back

How will I know what presentation and position my baby is in?

Your doctor or midwife can usually work out your baby’s presentation by feeling your abdomen. They may also double check it with a portable ultrasound. Your baby’s presentation is usually checked around 36 weeks .

Your doctor or midwife will also confirm your baby’s head position in labour by examining your belly and using an ultrasound , and they may also do a vaginal examination . During the vaginal examination they are feeling for certain ridges on your baby’s head called sutures and fontanelles that help them work out which way your baby is positioned.

What is the ideal presentation and position for baby to be in for a vaginal birth?

For a vaginal birth, your baby will ideally be headfirst with the back of their head at the front of your belly, also known as being in the anterior position. This position is best for labour and birth since it means that the smallest part of your baby’s head goes down the birth canal first.

When does a baby usually get in the ideal presentation and position for birth?

Your baby will usually be in a headfirst position by 37 weeks of pregnancy. Around 3 in every 100 babies will be in breech presentation after 37 weeks.

Your baby’s position can change with your contractions during labour as they move down the birth canal, so their exact position can change during labour.

What are my options if baby isn't in the ideal presentation or position for a vaginal birth?

If your baby is in a breech presentation, your doctor may recommend a technique called an external cephalic version (ECV) to try and move your baby while they are still in the uterus . An ECV involves your doctor using their hands to apply pressure on your belly and help turn your baby to a headfirst position. It has a 1 in 2 chance of success and is a safe option in most pregnancies.

There is no evidence to show that alternative therapies, such as exercises, acupuncture or chiropractic treatments, help your baby change from a breech presentation to headfirst.

If your baby remains breech, your doctor may discuss having a breech vaginal birth. Not all doctors and hospitals offer this option. They may also suggest you birth your baby with a planned caesarean section .

If your baby’s presentation is headfirst but the position of your baby’s head is not ideal for labour, it can lead to a longer labour, and potential complications . The position of your baby’s head will often change as your labour progresses. If it doesn’t, sometimes you can still give birth without assistance, or you may need your doctor to help turn your baby’s head or help your birth with a vacuum or forceps .

Any procedure or decision for a type of birth will only go ahead with your consent . You will be able to discuss all the options with your doctor, and based on your preferences for yourself and your baby’s safety, make a decision together .

Resources and support

The Royal Australian and New Zealand College of Obstetrics and Gynaecology has a factsheet about the options available to you if your baby is in a breech presentation at the end of your pregnancy .

Mercy Perinatal has information on external cephalic version (ECV) safety and benefits if your baby is in a breech presentation at the end of your pregnancy.

The Women’s Hospital has information about the different presentations and positions your baby could be in, and how it can affect your birthing experience.

Speak to a maternal child health nurse

Call Pregnancy, Birth and Baby to speak to a maternal child health nurse on 1800 882 436 or video call . Available 7am to midnight (AET), 7 days a week.

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Last reviewed: October 2023

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External cephalic version (ecv), malpresentation, breech pregnancy, search our site for.

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External Cephalic Version for Breech Presentation - Pregnancy and the first five years

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Malpresentation is when your baby is in an unusual position as the birth approaches. Sometimes it’s possible to move the baby, but a caesarean maybe safer.

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Having a baby

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What is a Midwife?

• What Is a Midwife?
• Responsibilities
• Training and Professional Background

How to Find a Midwife

Pregnancy and childbirth are exciting and nerve-wracking experiences requiring proper medical attention to ensure a healthy parent and child. While most people think an OBGYN is the only provider who can care for a parent and baby, it is important to know the services other health professionals like midwives, can provide. The midwife profession has been around for centuries and tends to have a more natural approach to childbirth.

This article will explore who midwives are, their responsibilities, and their accessibility.

Not a Doula, So What Is a Midwife?

There are several different types of providers who practice midwifery. The three different types of midwifery professionals are:

• Certified Nurse Midwives (CNM)
• Certified Midwives (CM)
• Certified Professional Midwives (CPM)

A graduate-level degree is required for certification in CNM and CM. In contrast, a high school diploma and demonstrated competency in specified skill areas are required for a CPM.

The responsibilities of a midwife may vary from state to state within the United States and country to country. Traditionally, midwives deliver care during pregnancy, labor, the postpartum phase, and beyond.

Responsibilities: The Role of the Midwife

In addition to providing maternal and familial support during preconception, pregnancy, childbirth, and the postpartum phase, midwives can also provide primary care services to women. Both are qualified to care for newborns during the first month (28 days) of life. Some other responsibilities of midwives include but are not limited to:

• Comprehensive assessments and physical examinations
• Order and interpret diagnostic testing
• Prescribe medications including controlled substances and contraception
• Admit, manage, and discharge patients
• Deliver babies
• Family planning, health promotion, disease prevention

CNMs and CMs can work in any setting, including hospitals, birth centers, and homes. While considering the roles and responsibilities of midwives, it is important to remember that certain roles, such as prescriptive authority, vary within the United States. Currently CNMs have prescriptive authority in all 50 U.S. states.

Certified professional midwives can provide counseling, education, and support to women and their families. They are trained to identify abnormal or dangerous conditions that can harm maternal or fetal health, requiring a referral to another healthcare professional. They do not often prescribe drugs.

OB-GYN vs Midwife

While both midwives and OBGYNs can deliver babies and provide extensive medical care to mother and child, the biggest difference between the two is educational training and experience. OBGYNs are graduates of 4 years of medical school, residency, and often fellowships.

Midwife Training and Professional Background

Since there are three different types of midwife professions there is some variation in their trainings. A graduate level degree is required for certification of CNMs and CMs, while a high school diploma or equivalent and demonstrated competency in specified areas of skill is required for professional midwives to become certified.

Certification of CNMs and CMs occurs through the American Midwifery Certification Board (AMCB). CPMs are certified by the North American Registry of Midwives. After meeting the initial requirements for certification to practice midwifery, recertification is required every five years for CNMs and CM and every three years for CPMs to ensure they are up-to-date on the most recent developments in the field.

Midwife and Insurance

National and private insurers cover many midwifery services. Medicaid is mandated to reimburse CNM care in the United States. In this case, calling the insurance provider directly and inquiring about covered services is best.

There are several ways to find a qualified midwife in your area, such as searching The America College of Nurse-Midwives' "Find a Midwife" tool or checking local and state health department websites. Another way is to check with your insurance companies to see which midwives are in-network to avoid additional medical costs.

A midwife is a healthcare provider who helps pregnant people with pregnancy corners and the birthing process. They receive formal medical training and work in any setting.

American College of Certified Nurse Midwives. Comparison of certified nurse-midwives, certified midwives, and certified professional midwives .

American College of Nurse-Midwives. Definition of midwifery and scope of practice of certified nurse midwives and certified midwives .

Western Governors University. Certified nurse-midwife job description and salary .

Osborne K. Regulation of prescriptive authority for certified nurse-midwives and certified midwives: A national overview .  Journal of Midwifery & Women’s Health . 2011;56(6):543-556. doi:10.1111/j.1542-2011.2011.00123.x

University of Illinois College of Medicine. Education, training, and certification for OBGYN .

American Midwifery Certification Board. About American Midwifery Certification Board (AMCB) .

National American Registry of Midwives. NARM certification and recertification .

American College of Nurse Midwives. Essential facts about midwives .

By Katherine Alexis Athanasiou, PA-C Athanasiou is a certified physician assistant in New York with clinical experience in rheumatology and family medicine. 

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Models for midwifery care: A mapping review

Tine s. eri.

1 Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway

2 Sahlgrenska Academy, Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden

3 The Obstretic Unit, Sahlgrenska University Hospital, Gothenburg, Sweden

4 Centre for Women’s, Family and Child Health, Faculty of Health and Social Sciences, University of South-Eastern Norway, Kongsberg, Norway

Helga Gottfreðsdóttir

5 Department of Midwifery, Faculty of Nursing, University of Iceland, Reykjavík, Iceland

6 Women´s Clinic, Landspitali University Hospital, Reykjavík, Iceland

Eva Sommerseth

Christina prinds.

7 Institute of Clinical Research, University of Southern Denmark, Odense C, Denmark

8 Department of Research, University College South Denmark, Haderslev, Denmark

INTRODUCTION

According to WHO, midwives are found competent to provide evidencebased and normalcy-facilitating maternity care. Models for midwifery care exist, but seem to be lacking explicit epistemological status, mainly focusing on the practical and organizational level of care delivery. To make the values and attitudes of care visible, it is important to implement care models with explicit epistemological status. The aim of this paper is to identify and gain an overview of publications of theoretical models for midwifery care.

A mapping review was conducted with systematic searches in nine databases for studies describing a theoretical model or theory for midwifery care that either did or was intended to impact clinical practice. Eligibility criteria were refined during the selection process.

Six models from six papers originating from different parts of the world were included in the study. The included models were developed using different methodologies and had different philosophical underpinnings and complexity gradients. Some characteristics were common, the most distinctive being the emphasis of the midwife–woman relationship, secondly the focus on woman-centeredness, and thirdly the salutogenic focus in care.

CONCLUSIONS

Overall, scarcity exists regarding theoretical models for midwifery care with explicit epistemological status. Further research is needed in order to develop generic theoretical models with an epistemological status to serve as a knowledge base for midwifery healthcare.

All healthcare is based on values and attitudes that are sometimes explicitly expressed in theoretical frameworks or condensed as models for care, but which are mostly tacit. Such frameworks increase the facilitation of awareness of having an epistemological basis for healthcare, and function as important guiding tools for the organization of such healthcare. Maternity healthcare, including the period before, during and after childbirth and the parenthood transition, is subject to different epistemological statuses representing different professional and scientific traditions, including both midwifery and medical models 1 - 4 .

The approaches to health and illness affect the way in which care models are positioned. Models for care have emerged, often relating to epistemological status, as well as being appealing at the practical level in terms of how to organize care. However, entangling the practical and epistemological levels of a model may require a more analytical approach, since these two levels often overlap, thus leaving merely one lens through which we are to understand health and hence organize care around. Opposed models of care exist in the field of maternity care, and especially around childbirth, which have been labelled for example ‘medical’ versus ‘social and women-centered’ 5 , ‘technocratic’ versus ‘holistic’ 6 , or ‘pathological’ versus ‘salutogenic’ models 7 . The reason for these opposed perspectives should be sought in relation to the choice of positioning pregnancy and childbirth in the medical specialty of obstetrics: ‘Pregnancy in western society, in fact, straddles the boundary between illness and health: the status “pregnant” is unclear in this regard and women perceive that others are not sure whether to treat them as ill or well’ 8 .

Whether pregnant women are regarded as ill or well; pregnancy, childbirth and the surrounding maternity services are culturally sensitive. This leaves women, their partners and children in various culturally dependent statuses at the global level. It also leaves maternity care in the hands of different health professionals. Facilitating health in childbirth, however, is a complex task that successively includes a risk management perspective, driven by rules and protocols that overlook individual needs and circumstances 9 . The situation of one pregnant woman is influenced by factors far beyond her needs and circumstances, and practitioners and researchers have thus put forth theories intended to shed light on the complexity of healthcare systems like maternity care 10 , 11 . Furthermore, a taxonomy for complexity theory has been developed to increase understanding of how some techniques become widely adopted although on a country-specific basis 12 , 13 .

To care for a normal physiological pregnancy and childbirth and secure normalcy, professional midwives seem to be the relevant choice 14 . Unfortunately, professional midwives are only available in certain parts of the world, whereas in other parts, childbirth attendants are primarily obstetricians, obstetric nurses or practically trained laymidwives 15 . Models for care with explicit epistemological status are therefore important in order to implement evidence-based and normalcy-facilitating care 16 . Several care models already exist, but a previous mapping review that explored the characteristics of antenatal care models found that several models lacked an explicit epistemological basis 17 . Some researchers have developed and attempted to implement different models for care 18 - 21 . Furthermore, the International Confederation of Midwives (ICM) has developed a core document that outlines the organization’s model of midwifery care with an underpinning philosophy of care 22 .

There is no consensus about what is meant by a model, and after reviewing the literature, the distinction between a care delivery model outlining practical details about care provision and a theoretically-developed care model with a clear epistemological basis seems blurry. According to Walker and Avant 23 , the graphic representation of a theoretical framework can be called a model, hence the term ‘theoretical model’ in order to make the distinction from organizational models of care. However, there appears to be a gap in the overview of existing models and, to our knowledge, no overview of existing scientifically-developed theoretical models for midwifery care has been published. The aim of this paper is therefore to identify and gain an overview of publications containing theoretical models for midwifery care.

To fulfil the objective of the paper, we conducted a mapping review, which is a method designed to provide a wide overview of a research area, establish if research evidence exists on a topic and provide an indication of the quantity of the evidence. The method is used to map out and categorize existing literature on a particular topic and identify gaps in research literature from which to commission further reviews and primary research 24 , 25 . According to the SALSA framework, the main types of literature reviews are classified into four key stages: 1) Search, 2) AppraisaL, 3) Synthesis, and 4) Analysis. For a mapping review, the search for literature is extensive and systematic 26 . Usually, there is no appraisal or formal quality assessment as the aim is limited to mapping out and categorizing existing literature. The synthesis stage of the mapping review focuses on the visualization of data, which may be graphical and tabular. The analysis stage often involves characterizing quantity and quality and other key features of relevance to the review questions 24 , 26 . A description of how we applied these stages to our review is now given.

The search phase

This phase comprised an extensive, systematic search in relevant databases and a systematic screening and selection of studies.

Eligibility criteria

Inclusion and exclusion criteria were established in advance, and subsequently further developed along with the screening process. We did not pose any time limit on the searches. Inclusion criteria were as follows, and all criteria had to be fulfilled:

• Full text available, papers published in peer-reviewed journals, studies that describe a theoretical model or theory for midwifery care (or some part of a model or theory), studies that describe a model or theory that either have or are intended to impact clinical practice.

Exclusion criteria were as follows, and one criterion was enough for exclusion:

• Studies that describe models that are strictly philosophical (which are not intended to impact practice), studies that describe organizational models only (care provision, service models, care delivery etc.) without describing or explaining in part or in whole the theoretical model or theory of midwifery care underpinning the proposed organization of care, and studies that describe the practical details of implementing care without giving the underlying concepts.

Search strategy

The search strategy was designed and developed with the assistance of a specialist librarian. A scoping search including the keywords midwife/midwifery, model/theory/framework, nursing models/nursing theory and woman-centered care was conducted in the MEDLINE, Cinahl, and Maternity and Infant Care databases in May 2018. We continued by refining the study objectives, choice of keywords and inclusion/exclusion criteria before conducting a systematic search in September 2018. The following databases were included: Ovid MEDLINE(R), Ovid Nursing, PsycINFO, Cinahl, Trials (Cochrane Library), Maternity and Infant Care, Academic, Scopus, and Web of Science. Keywords included a variety of terms used to describe midwifery models and care. Language was limited to include papers in English, Danish, French, German, Icelandic and Norwegian.

In total, 11132 citations were identified. The search results were imported into a reference manager software (EndNote) and duplicates were removed, leaving 5449 titles. When imported into a systematic review management software, a further 55 duplicates were removed, leaving 5394 titles and abstracts to be screened for inclusion.

Selection and screening of studies

We managed the screening process in the review management software Covidence, and we distributed the titles and abstracts randomly among the review team comprising the six authors. The screening and selection process consisted of two subsequent phases. The first was the title and abstract screening, where 5159 studies were found to be irrelevant to the aim of the review in accordance with the inclusion and exclusion criteria. The second phase then encompassed 234 papers for further investigation. These were randomly distributed among the review team, and two reviewers assessed each paper for inclusion to obtain consensus.

During this process, it was necessary to discuss and refine the eligibility criteria because the term ‘model’ was used in different ways and had different meanings in the sample. It was necessary to specify that we were not looking for studies that describe organizational models only, or studies that describe the practical details of implementing care; the aim of the review was to identify theoretical models for midwifery care. We resolved conflicts either by assigning a third reviewer, or by discussing them in the team. An example is the extensive discussion involving the whole team about the assessment and possible inclusion of two important papers: The Lancet paper on the QMNC framework 27 and the Cochrane review on midwife-led continuity models versus other models of care 19 . Neither of the two papers were included in the final selection. We excluded both because they do not describe the development of a theoretical model for midwifery care. The former 27 describes a framework on the macro-level about how to secure quality maternity and newborn care in all settings. The latter 19 compares outcomes of different ways of organizing maternity care.

Of the 234 papers assessed in full text, further discussions on inclusion led to the selection of 10 papers for more detailed review. These were discussed in relation to the inclusion criteria and of the ten, four were found to be outside these criteria. The flow of the selection of studies is shown in Figure 1 .

Flow diagram

The analysis and synthesis phases

We extracted the following data from each paper: authors and year of publication, setting for the study, name of the model, aim of the model, methodology behind the development of the model, philosophical ideas underpinning the model, description of the concepts on which the model is built, scope of the model, and suggested use of the model. Finally, we noted if there was an illustration of the model.

The described models were analyzed in terms of complexity and orientation. According to Kannampallil 28 , the range of complexity depends on the number of components and their interrelatedness. Interrelatedness refers to the influence of system components on each other. We placed the models on a continuum, stretching from very simple to very complex. The orientation of the models was mainly towards care, relationships, professionalism or health.

Furthermore, we mapped the components of each model to identify similarities and differences between them. Inspired by the ‘idiomatic translation’ of metaethnography 29 , we chose one reference paper as the vantage point. We worked with each model and separated its components to see if it could be understood in the same way as the components of the reference paper, or that the authors used different concepts to describe identical meaning content. If not, we added a new line for each new concept that was not covered by the previous models in the map.

The findings are presented in three sections consisting of an overview, followed by a brief description of each model and concluding with a mapping of relevant components of the models. In the following presentation, each model is given a short label based on the original paper.

The six included publications describe six models (labels in brackets):

• Women-with-midwives: a model of interdependence (Women-with-midwives) 30
• A model of exemplary midwifery practice (Exemplary midwifery practice) 31
• A midwifery model of care for childbearing women at high risk: genuine caring in caring for the genuine (Midwifery at high risk) 32
• A woman-centred childbirth model (Woman-centred SA) 33
• The primacy of the good midwife in midwifery services: an evolving theory of professionalism in midwifery (The primacy of the good midwife) 34
• A midwifery model of woman-centred childbirth care – In Swedish and Icelandic settings (Woman-centred Nordic) 35

Data for the developed models were collected in New Zealand and Scotland (Women-with-midwives) 30 , the United States (Exemplary midwifery practice) 31 , Sweden (Midwifery at high risk) 32 , South Africa (Woman-centred SA) 33 , and Sweden and Iceland (The primacy of the good midwife) 34 (Woman-centred Nordic) 35 . An overview of descriptive data for the models is given in Table 1 .

Descriptive data of the included models

Methods used to develop the models were; grounded theory (Women-with-midwives) 30 , the Delphi method (Exemplary midwifery practice) 31 , research synthesis (Midwifery at high risk) 32 , qualitative design (Woman-centred SA) 33 , theory synthesis (The primacy of the good midwife) 34 , and qualitative hermeneutic design (Woman-centred Nordic) 35 . Three of the models were based on original empirical data (Women-with-midwives) 30 , (Exemplary midwifery practice) 31 , (Woman-centred SA) 33 , two were secondary analyses of original studies (Midwifery at high risk) 32 , (The primacy of the good midwife) 34 , and one model was developed through secondary analysis of original studies followed by validation testing (Woman-centred Nordic) 35 .

In terms of assessed complexity on a continuum ranging from very simple to very complex, one of the models was perceived as very simple (The primacy of the good midwife) 34 and two as very complex (Exemplary midwifery practice) 31 , (Woman-centred SA) 33 . The three remaining models (Women-with-midwives) 30 , (Midwifery at high risk) 32 , (Woman-centred Nordic) 35 were placed somewhere in the middle of the continuum. An overview of the characteristics of the models is given in Table 2 , and a visualization of the models in Figures 2 – 4 .

Characteristics of included models

Overview over two included visual models (Fleming, 1998 and Kennedy, 2000) (with permission from the publishers)

Overview over two included visual models (Halldorsdottir & Karlsdóttir, 2011 and Berg et al, 2012) (with permission from the publishers)

Brief description of the six models

Model 1: ‘women-with-midwives’.

A model of interdependence that is oriented towards the woman–midwife relationship. It was developed on the basis of unstructured interviews and observations of interactions between midwife and client, collected in New Zealand and Scotland, using a grounded theory approach. The model consists of six major categories, formed as three pairs, representing women and midwives, respectively: ‘attending – presencing’, ’supplementing – complementing’, and ‘reflection – reflexivity’. The model represents a relationship that is episodic and not always equally balanced, and the basic social process of reciprocity embraces the whole midwife–client relationship. In the visualization of the model, it is shown how the midwife and client meet as strangers, have a period of meetings that can be episodic and not always balanced, and that there are contextual factors influencing the relationship 30 ( Figure 2 ).

Model 2: ‘Exemplary midwifery practice’

The model was developed based on a framework of three aspects, and with an orientation towards health for woman and families, and towards midwifery professionalism. A Delphi study was conducted in the US with a sample comprising exemplary midwives and women who had received their care. The model encompasses essential alignments within three dimensions. The outcome of the first dimension, ‘therapeutics’, is that the woman and/or infant in the given situation has optimal health. The outcome of the second dimension, ‘caring’, is that the woman and the family have a respectful and empowering healthcare and birth experience, while the outcome of the third dimension, ‘profession of midwifery’, is that the profession of midwifery is enhanced. These three dimensions and outcomes are placed in a circle in the center on a background of midwives’ qualities and traits 31 ( Figure 2 ).

Model 3: ‘Midwifery at high risk’

This is a practice care-oriented model, which describes what constitutes ideal midwifery care for childbearing women at high risk. It was developed through a research synthesis of three phenomenological interview studies in Sweden with women (n=2) and midwives (n=1), in which the author served as the primary investigator. The essence of the model is ‘genuine caring in caring for the genuine’, which includes three constituents: ‘a dignity-protective relationship’, ‘embodied knowledge’, and ‘a balancing act of the natural and medical perspective’. Each constituent comprises two to five elements 32 ( Figure 3 ).

Overview over two included visual models (Berg, 2005 and Maputle, 2010) (with permission from the publishers)

Model 4: ‘Woman-centred SA’

The model was developed to assist midwives in the facilitation of mutual participation during childbirth and through enhancing the implementation of the ‘Batho–Pele principles’ for consultation, service standards, assessment, courtesy, information, openness and transparency. A qualitative design was used. Data were collected from two interview and observation studies with women having given birth at one hospital in South Africa and with their attending midwives. The model is complex and strongly orientated towards relationships. The process of providing woman-centred care takes place in three phases: 1) the ‘dependence phase’ signified by limited mutual participation between the mother and the midwife; 2) the ‘interdependence phase’ including strategies to facilitate mutual participation and comprising procedures and dynamics; and 3) the ‘independence phase’,

which focuses on outcomes of care. There is a dynamic relationship between the phases, which exists in the context of the childbirth unit and the child 33 ( Figure 3 ).

Model 5: ‘The primacy of the good midwife’

In this model the midwife’s professionalism is central. Through using a theory synthesis method, data were analyzed from 9 studies conducted by any one or more of the authors, sometimes in collaboration with other researchers. Most of the original data were collected in Iceland, except in one study that was a secondary analysis of studies conducted in Iceland, Sweden and Finland. The professionalism of being a good midwife is constructed from five main aspects: ‘the midwife's professional caring’, ‘the midwife's professional competence’, ‘the midwife's interpersonal competence’, ‘the midwife's development’, and ‘the midwife's professional wisdom’ 34 ( Figure 4 ).

Model 6: ‘Woman-centred Nordic’

This model is oriented towards practical midwifery care during labor and birth. It was developed through a synthesis of 12 interview studies with women (n=8) and midwives (n=4) focusing on their experiences of childbirth. The studies were conducted by one or more of the three authors, mostly in collaboration with other researchers. The model consists of five intertwined themes. Three of these themes are central and overlapping: ‘reciprocal relationship’, ‘a birthing atmosphere’, and ‘grounded knowledge’. These are surrounded by two themes: ‘cultural context’ and ‘the balancing act’, which describe how care takes place in a cultural context comprising both promoting and hindering norms, and how midwives then need to conduct a balancing act in striving towards woman-centred care 35 ( Figure 4 ).

Mapping the components of the models

We chose the most recently published model, ‘the midwifery model of woman-centred childbirth care’ (Women-centred SW) 35 , as the reference model when we mapped the central components of each model to identify similarities and differences. We mapped the remaining models with their respective central concepts in relation to this reference model. The names given to the components used to describe the constructed models vary, the reason being that different qualitative methods have been used in the analyses, and because some models were deductively developed from already defined frameworks. Furthermore, the number of components varied between the models, from having components in only one line (Women-with-midwives) 30 to six lines (Exemplary midwifery practice) 31 . Table 3 provides a matrix overview of the mapping of the components of each model.

Mapping of the single components of the models

Below follows a summary of similarities and differences, with the reference model as a basis. We start with the components described in the reference model and end with the components not present in the reference model.

Birthing atmosphere: This component, or similar one, was evident in four models (Exemplary midwifery practice, Midwifery at high risk, Woman-centred SA, Woman-centred Nordic) 31 - 33 , 35 .

Reciprocal relationship: All six models broach a component about the relationship between woman and midwife in some way.

Grounded knowledge: This component, or similar meaning, exists in four models (Exemplary midwifery practice, Midwifery at high risk, The primacy of the good midwife, Woman-centred Nordic) 31 , 32 , 34 , 35 .

Cultural context: This component exists only in the reference model (Woman-centred Nordic) 35 .

Balancing act: This component, or similar one, was evident in four models (Exemplary midwifery practice, Midwifery at high risk, The primacy of the good midwife, Woman-centred Nordic) 31 , 32 , 34 , 35 . The midwife’s development and profession appeared in two models (Exemplary midwifery practice, The primacy of the good midwife) 31 , 34 .

Therapeutics: The goal of optimal health of the woman/infant was only part of one model (Exemplary midwifery practice) 31 .

Two processual concepts were evident in one model (Woman-centred SA) 33 : 1) the process of responsibility sharing, which leads to independence and enhanced self-reliance for the woman; and 2) human and material infrastructure. The mapping of the components revealed that only one model mentioned the family (Exemplary midwifery practice) 31 , and that the woman’s partner is not apparent as a part of any of the models.

The aim of this study was to identify and obtain an overview of theoretical models for midwifery care. Below, we discuss our findings related to the characteristics of the included models, the scarcity of models and the underlying salutogenic perspective.

Similarities and differences between the included models

We identified six models. There is variation in several characteristics among the models, for example the philosophical ideas underpinning the models, the methodology used to develop them, and the degree of complexity. Our conclusion was that all included models were generated with the intention to form an evidence-based theoretical basis for midwifery care, and none of the models had been developed based on earlier developed and published midwifery models of care. However, the mapping of the components revealed several differences, among them the content and extent of the models. Furthermore, the mapping of components revealed similarities, for example that all six models comprised a component relating to the relationship between the woman and the midwife. The analysis shows that the models are mainly oriented towards four dimensions: health, care, relationships and the midwifery profession.

The six defined studies originate from Sweden, Iceland, Scotland, the US, New Zealand and South Africa. The characteristics of the models might represent the context of the country from where they emerged, since the structure of healthcare differs, as well as the role and status of midwives 36 . In the Nordic countries, New Zealand and Scotland, midwifery exemplifies a profession that appears to be strong yet seems to be struggling to maintain independence. For example, the organization of maternity care appears fragmented in some of these countries, meaning that although women usually meet the same midwife throughout their pregnancy, they might be attended by an unknown midwife during birth and postpartum. Emphasis on relationships and midwifery knowledge is of importance to midwifery care in that context. In the US, although there is an intra-country difference, midwives generally provide only a small part of the care during pregnancy and birth 37 . This could be the reason for the thorough explanation of the model presented by Kennedy 31 , with emphasis on most of the components that are highlighted in the sample of models 38 . The South African model is developed in a tertiary hospital and highlights the woman in the center. It is a work built on the concept analysis of woman-centered care by the same author 39 . The model has its background in ‘Batho–Pele’, a political initiative in South Africa, and stands for better delivery of good service. This might explain the detailed description of the phases of the model’s development and the elements it outlines 33 .

The midwife-woman relationship was a common focus in all six models and two models specifically highlighted ‘woman-centered care’ 33 , 35 . Woman-centered care has been referred to as a concept 40 , a tool, a framework, and a philosophy 41 . It has been associated with highquality maternity services and has been used to underpin organizational documents, and as a framework for policy documents and standards due to its strong midwifery-specific focus 40 , 41 . Woman-centered care has not been defined explicitly but is associated with a variety of care models and dimensions such as reciprocity, shared decision-making, continuity of care, relationship and empowerment 40 , 41 . Thus, the concept is closely linked to a midwife–woman relationship that is dynamic and reciprocal 41 . In a recent paper that develops a hierarchical model of the means and targets of midwifery, Peters et al. 42 demonstrate that midwifery care is based on a trusting relationship. They further show that in order to establish a trusting relationship, midwives must provide individual and woman-centered care. Although only two of the models included in our paper specifically refer to the concept of woman-centered care 33 , 35 , all models refer to the dual relationship between the woman and the midwife. Furthermore, the models focus on supporting the woman’s autonomy and engaging her in the care process. These values are closely linked to woman-centered care, salutogenesis and a biopsychosocial model of childbirth 41 . Except for Kennedy’s 31 model of exemplary midwifery practice, none of the models included in our review refers to the women’s baby, family or partner. According to Leap’s definition of the concept, woman-centered care includes the needs of the baby, family and other persons that are important to the woman ‘as defined and negotiated by the woman herself’ 40 . She argues that, when women are empowered, they have the potential to empower their families and communities. Others argue that the scant referral to family, partner and child requires further attention and that these elements should be included in the theory 41 , 43 . Carolan and Hodnett 43 even imply that the concept of woman-centered care in itself excludes the woman’s partner and her family.

Scarcity of models

Only six studies were found to be eligible for inclusion. This small number could relate to the fact that midwifery, although having a very long history overall, only has a short history when it comes to developing knowledge and theory, and conducting research in the field of maternity care. Midwifery has been seen as a profession that does practical work. In Europe, the development of midwifery research was initiated in the English-speaking countries during the 1980s and 1990s 44 . As late as 2010, the term ‘midwifery’ was not a MESH or subject heading in many of the relevant databases 45 . This phenomenon could be one of the reasons why theoretical models based on systematic and scientific development are scarce, while descriptions of ways of organizing care are broad. This resonates with research developed in the aftermath of the development of a new evidence-informed quality maternal and newborn care (QMNC) framework 27 . A mapping of midwifery-led antenatal care models in relation to the QMNC framework showed that the organization of care was the best described component, while underlying values and philosophies concerning care were poorly reported 17 . There is reason to believe that the same phenomenon not only relates to models for antenatal care, but to all care models during the maternity episode.

A salutogenic perspective

Several of the models seem to function from an underlying focus on what facilitates health rather than what hinders risks related to childbirth. This is expressed in the models’ goals and ideals which underline, for example, terms such as: normalcy of birth, presence, interpersonal competencies, and power-sharing or empowerment. These few examples enhance what could be interpreted as implicit also in medical models of maternity services, but are ostensibly not, for example the phrase supporting the normalcy of birth. Facilitating health is a more complex task than hindering demarcated risks, and somehow the models seem to reflect this task in their very depiction. All models are multi-directional, and attempt to incorporate the complexity in a care model, rather than focusing on risk-avoidance, which tends to be more one-directional 46 . This is also elaborated in several of the studies, for example in Kennedy 31 , who highlights ‘the art of doing nothing well’ 31 . This is an expression comparable to what can also be found in the Lancet series on maternal health 47 , stressing that good quality maternity care should be ‘neither too much, too soon, nor too little, too late’ 48 . Thus, there seems to be a tendency towards an underlying salutogenic focus cultivating the models 7 . This is in line with complexity theory, which challenges the behavior of a healthcare system as a linear process. The taxonomy for complexity theory has been developed to further understand how certain techniques and procedures become widely adopted 12 .

Methodological considerations

The scope of this review was broad. We did not aim to provide an overview of organizational models of care that included models for providing care or services, but to map theoretical models for midwifery care that were developed in a scientific and systematic way. The literature searches were inclusive as there is no consensus on the meanings of the different terms used to describe models for midwifery care. Although we conducted extensive literature searches guided by an experienced librarian, our choice of search terms and inclusion criteria may have been inconclusive. The use of nine databases provided a comprehensive list of articles. We did not include grey literature or perform a manual journal search for additional papers, but we searched the reference lists of the papers included in the study.

Being a group of researchers residing in four different countries, we found computer software for managing the references helpful since it enabled us to work efficiently and simultaneously with the screening process. However, the software only allows for one screening prior to the full-text screening, and we found this challenging since our eligibility criteria were refined throughout the screening process. One of the authors (MB) is the first author of two of the included papers. We therefore arranged the screening process in a way that ensured that other members of the team made decisions about these two papers.

We are aware that our preunderstandings may have influenced our work. However, we conducted the analysis in collaboration and allowed time for discussion when we encountered concepts or parts of a model that were challenging to understand. This reduced the risk of selection bias.

Mapping reviews do not usually include a quality assessment process. Consequently, we did not assess or score the included papers, but we are aware that their quality differs to some extent.

Conclusions

The aim of this study was to identify and gain an overview of theoretical models for midwifery care. Through the four key stages of the SALSA framework consisting of systematic searches, appraisal, synthesis and analysis, we identified six models originating from Sweden, Iceland, Scotland, the US, New Zealand and South Africa. Although stemming from different contexts, the included models seemed to share some characteristics, the most prominent being the relationship between the woman and the midwife, which was understood as an important component in all the models. This is interpreted as a shared grounded belief that midwifery care should be individual and woman-centered. Furthermore, we found a tendency towards an underlying salutogenic focus cultivating the models, which emphasizes health facilitation rather than risk hindering.

Overall, scarcity exists in relation to theoretical models for midwifery care with explicit epistemological status, contrary to the existence of many descriptions of ways of organizing care that are not epistemologically underpinned. This might be because of the recent and relatively short history of scientific theory-development and research in the field of midwifery care. Midwifery has been seen as a profession that does practical work. On the basis of our findings and analyses, we argue that a sound knowledge base needs to be theoretically based to be able to safeguard the midwifery profession and the underlying foci of, for example, women- and relation-centered approaches and a salutogenic point of departure. Therefore, there is a need for more research aimed at the development of theoretical models for midwifery care.

CONFLICTS OF INTEREST

The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none was reported.

There was no source of funding for this research.

PROVENANCE AND PEER REVIEW

Not commissioned; externally peer reviewed.

Global Midwifery: Principles, Policy and Practice pp 71–85 Cite as

Midwifery Regulation

• Joy Kemp 4 ,
• Gaynor D. Maclean 5 &
• Nester Moyo 6  
• First Online: 06 January 2021

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The second pillar of a strong midwifery profession is regulation. Studies have shown this pillar to be the weakest of the three. This chapter describes midwifery regulation across the globe, the value of regulation and how regulation contributes to the strength of the profession. It concludes with resources available for developing and implementing midwifery regulation.

• Midwifery regulation
• Midwifery practice
• Regulatory authority
• Legislation

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These terms are defined in Annex 5.1.

Cambodia, China, Lao People’s Democratic Republic, Papua New Guinea, Solomon Islands, Viet Nam.

Afghanistan, Djibouti, Morocco, Pakistan, Somalia, Sudan, Yemen.

American College of Nurse-Midwives, American Midwifery Certification Board, Midwives Alliance of North America, Midwifery Education Accreditation Council, National Association of Certified Professional Midwives, North American Registry of Midwives, Accreditation Commission for Midwifery Education.

Additional Resources for Reflection and Further Study

Foundation documents are found at https://www.internationalmidwives.org/regulation

Principles for Model U.S. Midwifery Legislation and Regulation. https://www.usmera.org/wp-content/uploads/2015/11/US-MERALegislativeStatement2015.pdf

The Midwifery Education Accreditation Programme. https://www.internationalmidwives.org/what-we-do/

WHO Nurse Educator Core Competencies. https://apps.who.int/iris/handle/10665/258713

Africa Health Professional Regulation Collaborative for Nurses and Midwives (ARC) (2013). https://www.google.com/search?sxsrf=ACYBGNQcc9ra9M5GFfNVFmT57kB7HnXZLA%3A1573485008258&source=hp&ei=0HnJXenjDY-LlwSM6aDYCw&q=african+health+professional+regulatory+collaborative+for+nurses+and+midwives

Bharj KK, Luyben A, Avery MD et al (2016) An agenda for midwifery education: Advancing the state of the world’s midwifery. Midwifery 33:3–6

Article   Google Scholar  

Borgren MU, Berg M (2012) Midwifery education, regulation and association in six South Asian Countries – a descriptive report. Swedish Assoc Midwives 3(2):67–72

Google Scholar  

Brodie P, Barclay L (2001) Contemporary issues in Australian midwifery regulation. Aust Health Rev 24(4):103–118

Article   CAS   Google Scholar  

Camacho CK, Collins-Fulea C, Krulewitch C et al (2015) The United States midwifery, education, regulation, and association work group: what is it and what does it hope to accomplish? J Midwifery Womens Health 60(2):125–127

Castro Lopes S, Titulaer P, Bokosi M et al (2015) The involvement of midwives’ association in policy planning bout the midwifery workforce: a global survey. Midwifery 31:1096–1103

Castro Lopes S, Nove A, ten Hoope-Bender P et al (2016) A descriptive analysis of midwifery education, regulation and association in 73 countries: the baseline for a post-2015 pathway. Hum Resour Health 14(37):0134–0137

Elwood TW (2013) Patchwork of scope-of-practice regulations prevent allied health professionals from fully participating in patient care. Health Aff 32(11):1985–1989. https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2013.0530 . Accessed 30 April 2020

Gross MJ, McCarthy CM, Verani AR et al (2018) Evaluation of the impact of the ARC program on national nursing and midwifery regulations, leadership, and organisational capacity in East Central and Southern Africa. BMC Health Serv Res 18:406. https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-018-3233-4 . Accessed 30 April 2020

ten Hoope-Bender P, de Bernis L, Campbell J et al (2014) Improving maternal and newborn health through midwifery. Lancet 384:1226–1235. http://linkinghub.elsevier.com . Accessed November 2019

International Confederation of Midwives (2011) Philosophy and model of midwifery care. https://www.internationalmidwives.org/documents

International Confederation of Midwives (2013a) Global standards for midwifery education. https://www.internationalmidwives.org . Accessed 30 March 2020

International Confederation of Midwives (2013b) Member Association Capacity Assessment Tool (MACAT). https://www.internationalmidwives.org/what-we-do/association-coredocuments/macat.html . Accessed November 2019

International Confederation of Midwives (2013c) Global standards for Midwifery regulation. www.internationalmidwifery.org/regulation-resources/ . Accessed 30 March 2020

International Confederation of Midwives (2014) Definition of the midwife. https://www.internationalmidwives.org/documents

International Confederation of Midwives (2015) Model curriculum for midwifery education. https://www.internationalmidwives.org/education

International Confederation of Midwives (2016) The regulation toolkit. www.inertnationalmidwives.org/regulation-resources . Accessed 30 March 2020

International Confederation of Midwives (2017) The ICM Midwives map. https://www.internationalmidwives.org/midwives_map . Accessed 30 March 2020

International Confederation of Midwives (2019) Essential competencies for basic midwifery practice. https://www.internationalmidwives.org/competencies . Accessed 30 March 2020

International Council of Nurses (2013) Regulatory and Governance Toolkit. https://www.icn.ch/sites/default/files/inline-files/2014_Regulatory_Board_Governance_Toolkit.pdf . Accessed 30 March 2020

Kennedy HP, Myers-Ciecko JA, Camacho Carr K et al (2018) United States model of Midwifery Legislation and regulation: development of consensus document. J Midwifery Womens Health 63:652–659

McCarthy FC, Voss J, Salmon M et al (2013a) Nursing and Midwifery regulatory reform in East Central and Southern Africa: a survey of key stakeholders. Hum Resour Health 2013:11–29

McCarthy FC, Voss J, Verani AR et al (2013b) Nursing and Midwifery regulation and HIV scale up: establishing a baseline in east, central and southern Africa. J Int AIDS Soc 16(1):18051

Osborne K (2015) Regulation of prescriptive authority for certified nurse-midwives and certified midwives: national overview. J Midwifery Womens Health 60(5):519–533

Renfrew MJ, MacFadden A, Bastos MH et al (2014) Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care. Lancet 384(9948):1129–1145

Royal College of Midwives (2019) Review of midwifery regulation by the Nursing and Midwifery Council (NMC) - a briefing paper. www.rcm.uk . Accessed October 2019

UNFPA (2011) State of the World’s Midwifery. Delivering health, saving lives. United Nations Population Fund, New York

UNFPA (2014) State of the World’s Midwifery. A universal pathway. A woman’s right to health. United Nations Population Fund, New York

US Midwifery Education, Regulation, and Association (2015a) US MERA statement of Commitment to Health equity in maternal and new-born health and to greater diversity in Midwifery, 15 Sept 2015. US Midwifery Education, Regulation, and Association: http://www.usmera.org/index.php/2015/09/15/us-mera- . Accessed Nov 2019

US Midwifery Education, Regulation, and Association (2015b) Principles for model US Midwifery legislation and regulation, 12 Oct 2015. US Midwifery, Education, Regulation, and Association. http://www.usmera.org/index.php/2015/11/20/principles-for-model-u-s-midwifery-legislation-regulation/ . Accessed Nov 2019

Vedam S, MacDorman M, Declercq E et al (2017) Collaboration Across Birth Settings in the United States. Obstetrics & Gynecology 129:183S

World Health Organisation (2002) Strategic directions for strengthening nursing and midwifery. WHO Geneva 2002

World Health Organization (2016) Strengthening quality midwifery education. WHO meeting report, 25– 6 July 2016. www.who.int/maternal_child_adolescent/en. Accessed 10 Oct 2019

World Health Organisation (2017) Strengthening quality midwifery education: meeting report July 25–26 2016. WHO Geneva 2017

World Healht Organisation (2019) Strengthening quality midwifery education for universal health coverage 2030: framework for action. WHO Geneva 2019

World Health Organization Regional Office for Africa (2016) The regional professional regulatory framework for Nursing and Midwifery: creating a common approach to regulation, educational preparation and practice: future directions for nursing and midwifery development in the African Region. https://apps.who.int/iris/handle/10665/331472 . Accessed 30 March 2020

World Health Organization Regional Office of the Eastern Mediterranean; Regional Office for Europe Cairo (2002) Nursing and Midwifery: a guide to professional regulation. WHO technical publication series: 27. https://apps.who.int/bookorders/anglais/detart1.jsp?codlan=1&codcol=45&codcch=27 . Accessed 30 March 2020

Yang TY, Attanasio LB, Kozhimannil KB (2016) State of scope of practice laws, nurse-midwifery workforce, and childbirth procedures and outcomes. Womens Health Issues 26(3):262–267

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Annex 5.1: Definition of Terms

Accreditation: A voluntary self-regulatory process by which non-governmental associations recognise educational institutions or programmes that have been found to meet or exceed standards and criteria in the quality of education. Accreditation also assists in the further improvement of the institutions or programmes as related to resources invested, processes followed and results achieved. This process also ensures professional development opportunity and validation of faculty (WHO AFRO 2016 ).

Regulation: All the legitimate and appropriate means and rules (governmental, professional, private and individual) through which order, identity, consistency and control are brought to the profession (governance). Regulation defines the professional, the profession, the scope of practice and the type of education one has to undergo, including what constitutes ethical and competent practice. Regulation also stipulates systems of accountability.

It is the set of criteria and processes arising from the legislation and prescribed by the regulatory authority that controls the practice of midwifery in a jurisdiction, including identifying who can hold the title ‘midwife’ and practise midwifery. Regulation includes registration, licensure, accreditation of education programmes, setting standards of practice and conduct and processes of holding midwives accountable to professional standards (ICM Regulation standards 2011 ).

Regulatory body: A formal organisation designated by law or an authorised governmental agency to implement the regulatory processes, procedures and reform in a manner which maintains order, consistency and control to the profession.

Registration: The process of providing authority to use an exclusive title to those persons entered onto a register after successful completion of a prescribed midwifery programme in an accredited institution of that country. Registration acknowledges qualification but is not synonymous with it. Qualification is a pre-requisite for registration. The possession of a midwifery qualification does not automatically entitle an individual to registration. Just as registration does not permit an individual to practise. Licensure does. In other words, qualification is a pre-requisite of registration provided the registering authority is convinced that the qualification is from a programme that meets certain standards (accredited). Being on a professional register is a pre-requisite to licensure as long as the licensing agency is convinced that the individual is competent in the skills, knowledge and attitudes that enable the individual to practise safely and competently (proof of competence).

Register: A documentation of persons and their qualifications in a particular field of practice. Individuals may be registered in more than one part of the register, for example, midwives who are also nurses can be on the nurses’ and the midwives’ registers. The register is maintained and updated by an authorised regulatory body.

Licensure: This is a process sanctioned by law that grants exclusive power or privilege to persons who meet established standards which allow them to engage in a given occupation or profession and to use the specific title as designated by law. Licensure confers on an individual the right to practise their profession according to the dictates of the law. Licensure confirms fitness to practise one’s profession safely and the required standard.

Re-licensure: A process that confirms that a practitioner is still fit to practise. This is usually after a break in service or after practising for a designated period of time.

Legislation: A law or act of parliament which sanctions the existence of the profession, the titles used, the scope of practice and criteria for the education process of the professionals. It provides protection for all categories of midwives and midwifery practice. Only people who meet certain criteria can use the title ‘midwife’. Legislation forms the basis for regulation. Legislation should be informed by policy and linked to overall policy for development of human resources for health.

Source: Derived from McCarthy et al. ( 2013a , b ); Africa Health Professional Regulation Collaborative for Nurses and Midwives (ARC), International Council of Nurses ( 2013 ) and International Confederation of Midwives ( 2016 ).

Annex 5.2: The 73 Countdown Countries

• Source: A descriptive analysis of midwifery education, regulation and association in 73 countries: the baseline for a post-2015 pathway (Castro Lopes et al. 2016 )

Key Messages

Midwifery regulation is the anchor of midwifery education and association as it provides benchmarks for quality and professional identity.

Midwifery regulation, when well developed and implemented enhances the autonomy of the profession.

Without effective midwifery regulation, it is difficult to establish a true niche for midwives in the provision of maternal and newbirn health care.

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Kemp, J., Maclean, G.D., Moyo, N. (2021). Midwifery Regulation. In: Global Midwifery: Principles, Policy and Practice. Springer, Cham. https://doi.org/10.1007/978-3-030-46765-4_5

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Perinatal mood and anxiety disorders (PMADs) include a spectrum of commonly-occuring mental health disorders. About 17% of postpartum mothers worldwide experience depression, with rates climbing to 60% in some low social-economic status women and adolescent mothers. However, less well-known PMADs include perinatal panic disorder, perinatal obsessive-compulsive disorder (OCD), and perinatal post-traumatic stress disorder (PTSD). These often include very distressing intrusive or bizarre thoughts, behaviors, or flashbacks. Perinatal bipolar disorder and postpartum psychosis are particularly dangerous due to severe depression, and reckless or bizarre behavior that can endanger mother and baby. Women with bipolar disorder may have stopped medications during pregnancy and are experiencing mood instability. They may also not realize they have bipolar disorder and require careful diagnosis, since twenty-two percent of depressed women postpartum have bipolar depression. Postpartum psychosis is an emergency and occurs in 1 to 2 of every 1,000 deliveries. This requires immediate hospitalization for safety, due to a 5% suicide rate and 4% infanticide rate. The midwife is part of the safety net for postpartum mothers and is a vital first step for identifying possible PMADs and referring the mother for mental health treatment and support.

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Aromatherapy in Midwifery Practice: Clinical Pearls" will highlight the most important uses for aromatherapy during the perinatal period, from the moment of conception through the first month of postpartum. This discussion will begin with a short introduction to aromatherapy which will include the primary methods of essential oil application, a brief overview of why aromatherapy is an effective natural therapy, and key safety considerations that are unique for use during maternity. Following the introduction, for each specific indication discussed, participants will learn the recommended method of application, essential oil options, safety considerations, dilution ratios, and frequency of application. These "clinical pearl" guidelines will be derived from overlapping evidence-based research, anecdotal evidence, and personal experience to ensure both safe and effective use. The presentation will end with practical advice on how to walk away being able to safely and effectively apply essential oils for at least 10 specific indications that are common during pregnancy, birth and postpartum.

In this presentation, Dr. Meek will explore the latest evidence and issues around Vaginal Birth After Caesarean (VBAC) internationally and then focus on new research about supporting women planning a VBAC. The four factors that impact how women feel about their birthing experience will be explored with a focus on how health care providers can use these factors to provide the best support for women and birthing people planning a birth after caesarean.

Breast milk is a diverse array of immunological components, such as antibodies, cytokines, growth factors, and immune cells. These maternal immune factors can prevent infections and promote immune tolerance in the neonate. Antibodies, particularly secretory immunoglobulin A (IgA), provide a first line of defense at the mucosal surfaces of the infant's gastrointestinal and respiratory tracts, offering protection against many infectious organisms. Beyond direct pathogen defense, breast milk immunology influences neonatal health through various mechanisms. Maternal immune factors modulate immune development by promoting the maturation of immune cells and aiding in the establishment of the infant microbiome. These processes have been associated with protection against autoimmune diseases and allergies as well as improved nutrient absorption and reduced risk of gastrointestinal disorders. However, breast milk is still an understudied immunological compartment and there is much to be learned about human breast milk and its role in neonatal health. This presentation will define the immunological components in breast milk, the scientific evidence of breast milk's protective potential and the gaps in knowledge. Understanding and harnessing the power of breast milk's immune-boosting properties can pave the way for interventions that enhance neonatal health outcomes and lay the foundation for a healthier future.

Asthma is the most common chronic medical condition to affect pregnancy. For example, in Australia 12.7% of pregnant women have asthma. Poorly controlled asthma leading to exacerbation of symptoms can lead to poor maternal and neonatal outcomes such as preterm birth and low birth weight babies. Asthma in pregnancy can be unpredictable in that approximately 1/3 of women experience a worsening of their asthma symptoms with the other two thirds either experiencing an improvement of their asthma symptoms or no change. Recommendations for the management of asthma during pregnancy is clearly stated in clinical practice guidelines. These include regular review of asthma symptoms, having a multidisciplinary team approach to management, ensuring ongoing prescribed medication use and having an asthma action plan. Previous research has identified the need for improved knowledge and awareness of asthma in pregnancy among health professionals and pregnant women. Innovative management techniques and educational resources are being developed and implemented to continue to meet these needs and to improve the outcomes for women and babies whose pregnancy is affected by asthma.

Wanting to be heard is a normal human need. This need to be listened to, validated and understood is especially strong when a birth does not go the way the birthing parent had hoped. When parents do not feel seen, it can lead to trauma that can have a powerful impact during the vulnerable period after birth. This presentation explores the importance and nuances of debriefing following a traumatic or difficult perinatal experience. Highlighting causes of trauma, importance of trauma informed care, the value of debriefing as well as discussing the risks of trauma and the contributors to perinatal trauma and how they can be avoided. Included are tips on reflection including how to, when and with whom, along with advice on when and how to signpost and discussion around debriefing for healthcare professionals.

Gestational diabetes affects around 20 million patients per year internationally, with long-term consequences for the health of mother and child. Women with gestational diabetes are at increased risk of pre-eclampsia, perinatal trauma and operative delivery, and are more likely to develop type 2 diabetes (T2D) and cardiovascular disease (CVD) in later life. Affected offspring are at increased risk of obesity, insulin resistance and metabolic syndrome in childhood and adolescence. The lack of a standardized diagnostic pathway internationally and inadequate access to treatment creates real challenges in optimizing care for affected women and their children. Gestational diabetes is managed using medical nutrition therapy, metformin and/or insulin. After pregnancy, women should be screened for the development of diabetes. Longer-term interventions are needed to reduce the risk of T2D postnatally. The aim of this presentation is to discuss the causes, treatment and longer-term management of patients with gestational diabetes. We will focus on the use of nutritional advice, medication and lifestyle changes on gestational diabetes incidence and management. We will outline key strategies for preventing T2D in affected patients after gestational diabetes and highlight the role of breastfeeding in improving women’s longer-term metabolic health.

Hypertension in pregnancy is a global public health threat complicating approximately 2-3% of pregnancies worldwide. The hypertensive spectrum ranges from mild, essential, or gestational hypertension to severe disease including the pre-eclampsia spectrum, HELLP syndrome, and eclampsia. These hypertensive disorders account for approximately 50,000 maternal deaths worldwide and have become a leading cause of maternal mortality. The incidence of hypertensive disorders of pregnancy has also increased worldwide, disproportionately affecting pregnant people of color. Staying up to date with the latest research and thoughts on best practice for identification of disease and clinical management of hypertension in pregnancy can prepare practitioners to efficiently identify and treat pregnant people with hypertension thereby reducing complications and improving maternal and fetal mortality and morbidity rates.

We exist on this planet because of the vital metals like sodium, potassium, magnesium, and calcium that easily dissolve in our body's water. Equally important are iron, zinc, and copper, found in nearly half of our proteins. Iron plays a crucial role in our blood, with four iron atoms in hemoglobin storing and transporting oxygen. Inadequate iron in early childhood leads to reduced attention span, difficulty grasping concepts, irritability, social withdrawal, and delays in language and motor skills. Iron deficiency during pregnancy increases the risk of premature birth, low birth weight, birth asphyxia, maternal infections, pre-eclampsia, and hemorrhage. Approximately two billion people or 25% of the global population lack sufficient dietary iron and iron stores. Anemia (the last stage of iron deficiency) caused 50 million years of healthy life lost due to disability in 2019 alone. This presentation aims to educate healthcare providers and birth workers on the magnitude of this epidemic and provide guidance on the essential laboratory assessments, symptoms and the new evidenced-based values for evaluating iron status in patients. It will also cover important aspects of proper treatment approaches.

Botanical medicine options are utilized by over 80% of our global population as a form of primary care. Many individuals report wanting to consider using herbs in pregnancy and beyond but are often unsure what is safe or appropriate. Clinicians play an essential role in helping individuals understand the risks and benefits of herbs for mood support in the perinatal period. By identifying meaningful resources and reliable information around botanical options, health professionals can empower families to make safe, informed choices. “Nature’s Nurturers” critically examines the use of herbal options to support perinatal mood concerns such as anxiety and depression. This talk focuses on the foundational need for individualized support when it comes to botanical discussion and selection.

Early detection and addressing of potential breastfeeding issues is known to improve breastfeeding outcomes. Assessment and counselling of pregnant parents must begin prenatally, preferably during each prenatal check-up, in order to detect and foresee common preventable breastfeeding problems. Depending on whether the potential red flags are anatomical, metabolic, psychological, social or cultural, health care professionals responsible for prenatal and immediate postnatal care of the parent-baby dyad can play a significant role in helping them overcome the hurdles to successful breastfeeding by targeted counselling. Existing health issues or those that surface during pregnancy; previous fertility, birthing, breastfeeding and parenting experience; home and work situation, self-efficacy, etc. are some of the factors which may pose breastfeeding challenges. Anticipatory guidance can go a long way in enabling parents to be better equipped to deal with such challenges as they arise, to ensure long term breastfeeding success.

Somatic Movement is an exploratory field that invites phenomenological exploration, or an in-depth focus on the nuances and perceptions of the body from within, to promote sustained positive change. Midwifery refers to the provision of clinical care that safeguards childbirth and the continuums before, after and in lieu of childbearing as normal events; while centering the informed choices, preferences, and values of each care-seeking individual; minimizing unnecessary intervention; and working autonomously within an integrated interprofessional team. This session will explore how one midwife, across an array of global contexts and settings, has infused these two fields to become one. Explorations will include applications of Somatic Movement in midwifery using examples from client care, midwifery education, provider development, advocacy and leadership development. Participants will leave this session with a baseline understanding of Somatics and, with concepts like experiential anatomy, therapeutic touch, movement patterns, authentic movement, and elements from craniosacral therapy woven across the session, equipped with somatic concepts ready to be used irrespective of the direction of their greatest force, whether through practice, teaching, advocacy, or leadership.

In 1903, Whitridge Williams declared “A characteristic sign of impending asphyxia is the escape of meconium”. It’s unlikely this statement was founded on robust, peer-reviewed research, though there has since been research a-plenty based on the underlying inference that in-utero meconium passage is associated with poorer outcomes. Had researchers instead begun with questioning if meconium is indeed an independent marker for those poorer outcomes, then we may nowadays have a better understanding of why most infants with a poor outcome do not pass meconium in labour (Greenwood et al 2003) and most babies exposed to meconium liquor are born in good condition. Using the findings from an extensive review of the literature, this presentation will begin by exploring the theories of meconium passage. It will review the research that is currently shaping our meconium guidelines (meconium as pathological) and analyse the data that supports the concept of meconium passage as a physiological, i.e., ‘normal’, event. Then, using the evidence, it will critique the current assessment and management practices of meconium labours and infants born through meconium. Does meconium deserve its reputation as an omen for poor outcomes? Or have we been unjustly scared meconiumless??

This presentation will discuss the importance of midwives being an integral stakeholder in the systems-level response practices for intimate partner violence (IPV). We will identify clinical presentations of exposure to violence during childbearing, responder-inflicted harms, and barriers and facilitators to help-seeking. Next we will develop an understanding of how midwives can play a crucial role in decreasing re-victimization, morbidity, and mortality by responding with a survivor-centered approach. This presentation uses a social justice lens that addresses the complexities of IPV-related outcomes for marginalized individuals, offering actionable ways to use the midwifery model of care for individual needs by engaging a range of community-facing services.

Family members and other support people are an important part of the birth experience but what do we do when their behaviour is disruptive for the birthing parent? Family centered maternity care means caring not just for the person in labour, but also for those they have chosen to be in the birth room for support. Join us for an engaging panel discussion that will explore the potential reasons for disruptive behaviour from family members, the impact of the midwife’s own emotional regulation and helpful strategies for turning family members and other support people in the birth room into supportive allies.

Comprehensive Care for Six Newborn Challenges: Diagnosis, Treatment, and Support Lecture Pack:

There are numerous issues that may present themselves in the newborn period, and whether it's dealing with an unsettled baby, a baby with symptoms of cardiac issues, or something in between, it requires expertise to assess and treat the concern while supporting and educating distressed parents. Being able to provide comprehensive care for newborn challenges requires a strong knowledge of the latest research and thoughts on best practice. Join our expert speakers to learn more about how to recognize, manage and provide support for concerns that can present themselves during the early weeks of life. Advance your knowledge of how to provide holistic care for a distressed baby, and how to help families overcome breastfeeding challenges and learn more about the latest on managing complications such as tongue-tie, newborn hypoglycemia, jaundice and congenital heart disease.

*To purchase this lecture pack along with the main conference, you may add it when registering for the conference, or anytime afterwards (during the conference period).

*Only those registering for the main conference, or have registered for the main conference will have the ability to purchase this lecture pack. You will have the opportunity to purchase this add-on at the time of conference registration, or anytime afterwards (during the conference period).

This presentation will explore how tongue-tie impacts feeding in infants. Learn more about what we know about tongue function in relation to infant feeding and how this informs our assessment of babies who are having difficulty with feeding. The various tools available to assess for tongue-tie in infancy will be explained, highlighting the key functional deficits to observe for. The rationale for treatment in infants, the procedures used to treat tongue-tie in babies, and the potential complications arising from treatment and treatment efficacy will be discussed.

Jaundice is an important problem in the first week of life. It is a cause of concern for the midwife and a source of anxiety for the parents. Jaundice is the most common morbidity in the neonatal period with nearly 60% of term newborn becoming visibly jaundiced in the first week of life. Preterm babies are at greater risk. While in most cases, it is benign and no intervention is required, approximately 5-10 % of newborns have clinically significant hyper-bilirubinemia mandating the use of phototherapy . Neonates who are exclusively breastfeeding have a different pattern and degree of jaundice as compared to artificially fed babies. Because high bilirubin levels may be toxic to the developing central nervous system and may cause neurological impairment even in term newborns, it is important to know how to determine if a baby is significantly jaundiced, risk factors involved and when treatment is indicated.

Critical congenital heart defects (CCHDs) are serious malformations that are an important cause of neonatal mortality and morbidity. The clinical presentations of CCHD are shock, cyanosis, or respiratory distress, which may be similar to that of other neonatal conditions. Failure to diagnose these conditions early on after birth may result in acute cardiovascular collapse and death. Simple screening methods have been found to be efficient in distinguishing newborns with CCHD and other hypoxemic illnesses, which may otherwise be potentially life-threatening. Risk factors, symptoms, screening methodologies and indications, and proper management strategies will be discussed.

Unsettled behaviour in the early weeks and months of a baby's life is a common reason for presentation to a healthcare provider. Parents have worries about reflux, allergies, colic and pain. The distress and worry can also be associated with mental health difficulties in the caregiver(s), such as anxiety and depression. Parents often eliminate foods or trial medications without clear indications due to their perception of their baby's pain and distress. Managing the healthy but unsettled baby involves taking a holistic view of unsettled behaviours shaped by an understanding of neurodevelopment, family dynamics and caregiving practices, and evidence-based interventions. This presentation will review the research on neurodevelopment and the distress curve, reasons for crying, and what we know about how to reduce distress.

This lecture will describe the normal physiology of infant blood sugar regulation before diving into a detailed conversation about neonatal hypoglycemia. We will explore risk factors for hypoglycemia as well as observation, management and treatment protocols for infants experiencing symptomatic and asymptomatic low blood sugars in the newborn period.

Latch problems are common among new breast/chestfeeding parents. Research has identified that latch issues are one of the biggest barriers to breast/chestfeeding success, along with painful, sore nipples. Not surprisingly, latch issues, including babies who are not latching at all, may lead to early breastfeeding cessation without professional help. Parents who are struggling with latch may also have perceived low milk supply and decreased bonding with their baby. By investigating reasons illustrated through a series of case studies, attendees will be able to identify how to help these families. Attendees will come away with solid assessment and intervention tools designed to help struggling dyads turn latch challenges into successful breast/chestfeeding.

The Labour & Birth Toolkit: Strategies, Techniques & Support Lecture Pack:

Research tells us that healthcare professionals have an important role to play in helping to create a safe and positive birth experience that helps set parents and their infants up for success. Join our expert speakers to learn about the latest research, tools and guidelines for providing effective and parent centered care during labour and birth. Enhance your clinical skills and learn more about upright pushing, mindfulness as a tool in L&D, releasing tension in the pelvis to improve labour progress, fetal monitoring, neonatal resuscitation and managing fear of childbirth.

Important: Please note that this package is available on the GOLD Learning CE website as "GOLD Learning Labour & Delivery Online Symposium 2023". If you have previously purchased and viewed this series of lectures, you will not be able to claim another accreditation certificate again.

*Only those registering for the main conference, or have registered for the main conference will have the ability to purchase this lecture pack. You will have the opportunity to purchase this add-on at the time of conference registration, or anytime afterwards (during the time of the conference).

Jiggling the external pelvic soft tissues by hand is a highly effective and recommended way to mobilize the pelvis, release tension, synchronise body systems, create more space to optimise or change the baby's position, and calm the nervous system – in pregnancy and in birth. It has also been known to facilitate labour progress in general, and in particular when labour has stalled. Highly enjoyable and simple to implement, it is an easy-to-teach practice for both care-providers and couples. This presentation will cover the why and how of pelvic jiggling, including touch considerations and contraindications.

Fear of childbirth can have significant impacts and it’s important for care providers to be familiar with effective methods of management. It is central that the couple is not only met by a solution of planned cesarean section as a treatment. With tools and cases, you will learn how to help clients determine the details of their fear, how to work through previous traumatic experiences and increase the feeling of safety that is often central in the problem. Also addressed will be ways to prevent trauma during birth which can help reduce the risk of fear of childbirth in subsequent pregnancies.

Bringing the practices of mindfulness to our patients and ourselves can significantly impact our patients' relationship to pain and fear in labor, birth, and life. In this hour long presentation, participants will have an opportunity to experience a mindfulness practice and learn ways to implement mindfulness in childbirth and parenting. Participants will be exposed to how mindfulness meditation can decrease stress during pregnancy and beyond and hear about mindfulness skills for working through pain and fear in childbirth. Further, participants will learn how to encourage mindfulness life skills for parenting with wisdom, kindness, and connection from the moments of birth, as well as how mindfulness skills may be implemented as a way to disrupt intergenerational patterns of suffering. In particular, this presentation will offer concrete ways to bring mindfulness to the contractions of labor, and to the space in between the contractions of labor. The potential for separating ""pain"" from ""suffering"" using mindfulness practices will be explored, which can be applied to labor, and of course, to life. We will examine the research around mindfulness based interventions, the relationship between perinatal stress and outcomes, and the potential that mindfulness strategies have for reducing health disparities.

This presentation will assist labor & delivery nurses in sharpening their skills and foundation for interpreting fetal heart monitoring tracings. Beginning with a brief review of the basic physiology of acid base interpretation, we will discuss appropriate terminology for electronic fetal monitoring (EFM) using the terminology established by the National Institute of Child Health and Development. We will compare and contrast categories of fetal heart rate patterns and discuss their associated interventions. Finally, we will establish a core set of elements for creating a plan with the patient and care team for the physiologic management of the second stage of labor. This presentation offers labor and delivery nurses the opportunity to ensure their ability to read and respond to EFM during labor is up to date and consistent with national and international guidelines.

All of the evidence, professional organizations, and birth physiology supports giving birth in a variety of positions but somehow, despite nurses' best efforts, most birth givers end up in a supine position. Learn the powerful, trauma-informed steps to advocate for your labor and birth patients in upright pushing positions. Join this lecture, discussion, and demonstration as we identify and demonstrate the 5 simple steps to overcoming these barriers to upright pushing.

Karen Strange delves into the subject that she knows best: neonatal resuscitation! Karen has accumulated over 1000+ hours of case reviews from birth professionals across the globe. From these debriefs, she’s identified exactly what gets missed, typical misunderstandings and the role that fear and panic play when delivering skills. In this presentation, Karen clearly explains and defines the when, why and how to respond to a newborn either not breathing or not breathing well, while providing trauma-free care regardless of where the baby might be born. At a fully equipped hospital, in a developing country or at home. You’ll leave her presentation with a new sense of clarity and deeper understanding as you confidently respond to babies who need your help.

Be at Your BEST During Birth Emergencies Lecture Pack:

Hypertension and its pregnancy-related disorders are a leading cause of preterm birth, fetal growth restriction and a multitude of emergencies. Despite modern advancements in maternity care globally, hypertensive disorders of pregnancy remain at the root of appalling morbidity and mortality statistics. Birth Emergency Skills Training® and GOLD Learning have partnered to present an in-depth examination of these often insidious, yet potentially lethal conditions. It is imperative that all community centered birth workers learn to recognize and respond to these disorders as they develop. Based on the latest research about risks, clinical manifestations, long-term health implications, and effects of COVID-19 on pregnancy, this program includes best practice guidelines and client centered educational resources. Join us and discover how you can play a role in the blueprint addressing this ongoing health crisis.

Important: Please note that part of this package is available on the GOLD Learning CE website as "BEST Practice Updates for Clinical Care of Hypertension in Pregnancy". If you have previously purchased and viewed this series of lectures, you will not be able to claim another accreditation certificate again.

Despite the many advances in medical treatment, postpartum hemorrhage (PPH) remains one of the leading causes of maternal mortality around the world. Excessive bleeding plays a role in 25-35% of maternal deaths, and the United States (US) is no exception. In the US, postpartum hemorrhage was responsible for 12% of maternal deaths in 2016 and that figure is rising. STOP postpartum hemorrhage in its TRACs offers a clear, up-to-date overview of postpartum hemorrhage using the mnemonic TRAC as a guide. TRAC stands for the 4 primary etiologies of PPH - Trauma - Retained Placenta - Atony - Coagulopathy. In this lecture, we present the physiology behind each etiology, prevention, early recognition and responsive, effective management from the least invasive to the most invasive stabilization techniques including anti-hemorrhagic medications, treatment for shock, the use of Non-pneumatic Antishock Garment (NASG) and a host of other life saving options. Treatments are adapted for out of hospital practice including low resource global applications. Come join us and learn to effectively, efficiently and calmly manage PPH, alleviate fear, increase your confidence and improve maternal outcomes.

Managing Weight Gain in the Breastfed Infant Lecture Pack:

Infant weight gain is a critical marker of feeding progress, and any professionals working with chest/breastfeeding families need to know how to monitor, assess, and intervene for positive outcomes when necessary. We have gathered expert speakers Prashant Gangal, Shel Banks, and Mary Ryngaert to discuss the latest evidence on why and how we use infant weight charts, what they can tell us and what they can't, and how to intervene when weight gain is inadequate. Advance your understanding of why and how we track infant growth and the consequences when infant growth falters. Learn more about how to implement an effective care plan when working with a baby with poor weight gain and consolidate your knowledge by working through clinical case studies.

Important: Please note that this package is available on the GOLD Learning CE website as "GOLD Learning Day: Managing Weight Gain in the Breastfed Infant". If you have previously purchased and viewed this series of lectures, you will not be able to claim another accreditation certificate again.

When families are breastfeeding, all too often any concerns about weight gain quickly result in suggestions of formula supplementation; in this session we will look at ways to keep babies exclusively breastfed whilst protecting their health and their growth, promoting empowerment and satisfaction of the parents, and how to delicately and supportively advocate for the baby when exclusive breastfeeding may actually not be possible. Understanding how to develop effective and supportive evidence-based care plans for babies whose weight and/or growth is faltering, is absolutely key to the toolkit of those who are working with breastfeeding babies. Find out more in this presentation.

When an infant does not gain weight or loses weight there are many factors to consider. Lactation professionals, working in tandem with anxious families and health care providers can help to problem-solve to determine what the issues are and how best to address these so that infant health is promoted and the family's plan to breastfeed is supported. This presentation will offer three clinical scenarios that Lactation professionals may encounter—the newborn who does not gain well initially, the four-week-old infant who begins losing weight after normal gain in the first weeks, and the infant who does not gain well despite interventions. For each infant, there will be discussion regarding the possible reasons for poor gain, suggested clinical interventions, and communication strategies with the family and providers.

Infancy is a period of rapid growth & development. Any adversity has a profound impact on physical, mental & psychological outcomes for entire life. Growth Charts are the meter of infant's Nutrition-Health-Nurturing & reflect any adversity. Hence, tracking infant growth is important. The World Health Organization (WHO) released new international growth standards in 2006 to monitor growth of children 0-59 months of age. All Health Care Providers should use these charts to complement Infant & Young Child Nutrition (IYCN) Counselling. Every growth chart has a story to tell. I found WHO growth charts to be accurate and extremely useful for knowing past events and use the information to promote optimal growth and development in future. Every contact with the child in general & especially immunization is an opportunity to discuss nutrition & development. The concepts of Severe Acute Malnutrition and Mild Acute Malnutrition (SAM-MAM) need to be understood. The Infant feeding professionals should also understand science behind WHO Growth Charts and how to use this information for ideal IYCN Counselling. Prematurely born infants need different charts for monitoring growth during infancy & experts need to be aware about the current concepts & opinions of monitoring growth of Premature & Low Birth Weight infants. Impact of individual components of breastmilk on growth is the new science frontier.

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April 10, 2024

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Midwife continuity of care model linked to positive experiences during pregnancy

by King's College London

Increasing midwifery continuity of care has been identified as a key priority for maternity services in the United Kingdom (UK). Published today in Cochrane Database of Systematic Reviews , a study led by Professor Jane Sandall and colleagues, which builds on previous research, compares how outcomes for women and their babies who received a midwife continuity of care model differed from other models of care.

Midwife continuity of care models provide care from the same midwife or team of midwives during pregnancy, birth, and the early parenting period, in collaboration with obstetric and specialist teams when required. Midwife continuity of care models have been a key approach to transforming Maternity Services in England since 2016, with the aim of making birth safer, more personalized, and equitable.

The review found that women receiving midwife continuity of care models were less likely to experience a cesarean section or instrumental birth and were more likely to experience spontaneous vaginal birth and report a positive experience.

Additionally, midwife continuity of care provides benefits for health services through cost savings in the antenatal (care during pregnancy) and intrapartum (care during labor and birth) period, and women who experience midwife continuity of care models also reported more positive experiences during pregnancy, labor, and postpartum.

"The studies included models of care that offered intrapartum care in hospitals, midwife birth centers co-located in a maternity unit and home birth. We found that midwife continuity of care models, as compared to other models of care, increase spontaneous vaginal birth, reduce cesarean sections and instrumental vaginal birth (forceps/vacuum), and may reduce episiotomy," says Sandall.

The team identified trials that compared midwife continuity of care throughout the antepartum and the intrapartum period (and postnatal period where offered) with other models of care. The results of the trials were compared, summarized, and rated in the evidence based on factors such as study methods and size, and in total, 17 studies were identified that involved a total of 18,533 women in Australia, Canada, China, Ireland, and the United Kingdom.

Although women who received midwife continuity models of care were less likely to experience certain interventions and more likely to be satisfied with their care, there was uncertainty about the effect, as compared to other models of care, on fetal loss at or after 24 weeks gestation, neonatal death, third or fourth-degree tear or maternal readmission within 28 days of birth.

The researchers found that midwife continuity models resulted in little to no difference in preterm birth , intact perineum, postpartum hemorrhage, and admission to a special care nursery/ neonatal intensive care unit .

The review gives implications for future research, suggesting that further evidence may change the results and focus should be given to the impact of midwife continuity of care models on women with social risk factors, those at higher risk of complications, and low- and middle-income countries.

Additionally, a team of researchers at the National Institute for Health and Care Research (NIHR) Applied Research Collaboration South London, led by Professor Jane Sandall, is carrying out work in this area, exploring the benefits of midwife continuity models for diverse groups of women, including women at risk of preterm birth, and women belonging to ethnic minorities or living in disadvantaged areas.

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Kick-off: Current Landscape and Conversation Track Overview for All Battery Types

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When batteries are discarded improperly in household trash or curbside recycling, critical materials inside batteries are lost and cannot be recycled into new batteries. Additionally, batteries in trash and recycling can start fires, threatening worker safety and contributing to air pollution in already overburdened communities. To address these challenges, EPA is developing battery collection best practices and battery labeling guidelines.

On March 19, 2024, EPA hosted a webinar to kick-off the battery collection and labeling initiative. During the webinar, EPA shared background and context around the on-going battery collection and labeling efforts and discussed how interested parties can get involved. EPA provided next steps for attendees, which included sharing dates and goals for upcoming meetings, providing an interest form for the June in-person working session, and encouraging participants to submit additional input via [email protected] .

• Nena Shaw, Director,​ Resource Conservation and Sustainability Division​, U.S. EPA.
• Ellen Meyer, Batteries and Critical Minerals Senior Scientist, RCSD​, U.S. EPA.
• Pat Tallarico, Facilitator, Eastern Research Group Support Team.
• Presentation Slides (pdf) (1.8 MB).
• Recording of this session .
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