Julia Sanders Professor of Clinical Nursing and …...Myles Textbook for Midwives, 11th Ed. 1989 Julia Sanders, Professor of Clinical Nursing and Midwifery Wales & South West Maternity

Julia Sanders

Professor of Clinical Nursing and Midwifery FRCM, RN, RM, ADM, LLM, MPH, PhD

Evidenced based practice

… Lots to learn

… Lots to do

Wales & South West Maternity & Midwifery Festival 2019Julia Sanders, Professor of Clinical Nursing and Midwifery

Textbooks describe midwifery care over the

decades…

Including progress towards evidenced based

practice.


‘Research’ first appeared in the 11th Edition of Myles

Textbook for Midwives in 1998

Myles Textbook for Midwives, 11th Ed. 1989


Myles Textbook for Midwives, 3rd Ed. 1959

Shaving TrayThe razor blade should be sharp, the pubic hair well

lathered with green soap and the shaving strokes made in a downward direction to avoid

unnecessary pain.





unnecessary pain.

EnemaIt is preferable that every

woman should have her lower bowel opened at the beginning of labour.





unnecessary pain.

EnemaIt is preferable that every

woman should have her lower bowel opened at the beginning of labour.

BathThe question as to whether the

woman in labour should be permitted to have a tub bath,

because of the risk of bath water entering the vagina, is highly

controversial. From a practical point of view it has much to

recommend it : otherwise it is difficult to remove all the short

cut hair after shaving.


1981 Romney & Gordon Enema study (BMJ ) N=274 Initial resistance from midwives to randomise women.Observational study of 224 women (with / without enema, combined with 50 women randomized.Following 50 women randomised midwives were again opposed to randomising women as they felt the results were already clear.

Drayton & Rees 1984 N=222 RCT Published in the Nursing Mirror as the BMJ did not accept non-medical authors.

1987 Sally Garforth & Jo GarciaBaths, Shaves and Enemas still commonplace

Enema Trials


2018 – WHO

Routine perineal / pubic shaving prior to giving vaginal birth is not recommended.

Administration of enema for reducing the use of labour augmentation is not recommended.

Enema Trials … 30 years on


Early labour care …


Care in the latent phase of labour..

Is encouraging women to remain at or return home always best?

“You are welcome to come in for assessment but if you are not 4cm we will send you home again”

What constitutes delay in the latent phase and how should it be managed?


1990’s trials of antenatal care schedules


1990’s trials of antenatal care schedules

There is still a lack of evidence around postnatal care schedules.


1989 Know your midwife scheme

Photos: ©Corry Bevinton


1989 Know your midwife scheme

Photos: ©Corry Bevinton

Developing sustainable continuity models remains a real challenge.


Restrictive n=498Episiotomy rate 10%

Liberal n=502Episiotomy rate 51%

Primiparous 36 (17.9%) 147 (67.1%)

Multiparous 15 (5.1%) 111 (39.2%)

“These findings provide little support either for liberal use of episiotomy or for claims that reduced use of the operation decreased postpartum morbidity”

A priori sample size calculationIntention To Treat analysis10 day & 3 month follow-up response rate 89%

19% of women had urinary incontinence 3 months post delivery

2/1,000 OASI

Liberal v selective episiotomy Published 1984


Restrictive n=498Episiotomy rate 10%

Liberal n=502Episiotomy rate 51%

Primiparous 36 (17.9%) 147 (67.1%)

Multiparous 15 (5.1%) 111 (39.2%)

“These findings provide little support either for liberal use of episiotomy or for claims that reduced use of the operation decreased postpartum morbidity”

What is the best care in the second stage to minimize OASI?

Perineal wound care.

How should labial trauma be managed?

Liberal v selective episiotomy Recruitment 1982 Published 1984


NICE September 2007

‘We do not have enough

information about the possible

risks to either the woman or

her baby relating to planned

place of birth.’

“The Royal College of Midwives and the

Royal College of Obstetricians and

Gynaecologists (RCOG) support home

birth for women with uncomplicated

pregnancies. There is ample evidence

showing that labouring at home

increases a woman’s likelihood of a

birth that is both satisfying and safe.”

RCOG / RCM Joint Statement April 2007


Birthplace in England Study


With the increase in Midwifery Led unit care are our outcomes the same as Birthplace?



Why the differences and how can they be minimized?



Environment matters … But how?


BUMPES Trial – Getting evidence into practice

remains a struggle … (sometimes)

BUMPES Awarded 2018 BMJ Research paper of the year

Significantly fewer spontaneous vaginal births occurred in women in the upright group: 35.2% compared with 41.1% lying down group. aRR 0.86 (95%CI 0.78 to 0.94)


Significantly fewer spontaneous vaginal births occurred in women in the upright group: 35.2% compared with 41.1% lying down group. aRR 0.86 (95%CI 0.78 to 0.94)

Is this fully integrated into your practice?

BUMPES Trial – Getting evidence into practice

remains a struggle … (sometimes)


The (big) issue that needs more attention – staff wellbeing

Previously conducted in Australia, New Zealand, Sweden, Canada and Norway.

N=1997 Online survey May – July 2017

Over one third of participants scored in the moderate/severe/extreme range for stress (36.7%) anxiety (38%) and depression (33%).

This was well above population norms and those of other WHELM countries.


Previously conducted in Australia, New Zealand, Sweden, Canada and Norway.

N=1997 Online survey May – July 2017

Over one third of participants scored in the moderate/severe/extreme range for stress (36.7%) anxiety (38%) and depression (33%).

This was well above population norms and those of other WHELM countries.

What working arrangements give the best outcomes for mothers, babies and staff?

How can we best support newly qualified midwives?

The (big) issue that needs more attention – staff wellbeing


The (big) one we missed …

Abi and baby Esme (with permission)


Plenty to do….

Labial trauma

Postnatal perineal care

Latent Phase

Breastfeeding maintenance

Pelvic pain in pregnancy

Postnatal care schedules

Identification of the ‘truly’ infected mother / baby

Intermittent Auscultation

Birth related psychological trauma

Environment of birth

Optimal size and organisation of maternity units

And ….

Cracking sustainable continuity models ..

Photo Leah Millinshiphttp://www.leahphotography.co.uk/

http://www.leahphotography.co.uk/


Plenty to do…. Have fun and work hard

To further improve care for mothers and babies

Documents

Julia Sanders Professor of Clinical Nursing and …...Myles Textbook for Midwives, 11th Ed. 1989 Julia Sanders, Professor of Clinical Nursing and Midwifery Wales & South West Maternity