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A woman bleeds to death after childbirth approximately every six minutes. Postpartum haemorrhage is the leading cause of maternal death worldwide, with the overwhelming majority of bleeding deaths occurring in low income countries. While the risk of death from postpartum hemorrhage in high income countries is vanishingly low, PPH is responsible for 100,000 deaths annually. These deaths occur due to a complex network of biological and socioeconomic factors, including changes to haemostasis and fibrinolysis during pregnancy.
‘The WOMAN Trial’ was an ambitious interventional trial collaborated on an epic scale, involving 20,060 women from 193 hospitals in 21 countries and thousands of doctors, midwives and nurses participated.
doctorportal learning in partnership with Osler have created ‘The WOMAN Trial’ module designed for clinicians who care for post –partum patients, and for whom haemorrhage is a life threatening event. Accredited for CPD by ACRRM, ACEM, CICM and ANZCA, the module is a well-structured, easy to understand, and step by step guide to understanding the WOMAN trial. The module covers:
It’s very common for women to feel anxious about labour and birth. Worries about the pain of contractions, interventions and the uncertainty of the process are not unusual. But for some women, the fear of labour and birth can be so overwhelming that it overshadows their pregnancy and affects daily functioning.
This severe fear of birth is called tokophobia – which literally means a phobia of childbirth. And for some women, this also includes a dislike or disgust with pregnancy.
Tokophobia can be split into two types – primary and secondary. Primary tokophobia occurs in women who have not given birth before. For these women, a fear of birth tends to come from traumatic experiences in their past – including sexual abuse. It can also be linked to witnessing a difficult birth or listening to stories or watching programmes which portray birth as embarrassing or dangerous. Whereas women who suffer from secondary tokophobia, tend to have had a previous traumatic birth experience which has left them with a fear of giving birth again.
It is difficult to say how common tokophobia is. Research suggests that between 2.5% and 14% of women are affected by tokophobia. But some researchers believe this figure could be as high as 22%.
These figures vary so much because women with different levels of tokophobia were included in the research. So while some women may have relatively mild tokophobia, for others, the condition is much more severe. The figures may also include women who have anxiety and depression rather than tokophobia.
Not a happy occasion
Women with tokophobia come from a wide variety of backgrounds. It is difficult to predict who might be affected, although it is clear that women with tokophobia are also more likely to experience difficulties with anxiety and depression and other mental health problems.
Research suggests some women with the condition choose to avoid pregnancy altogether – or may consider a termination if they find themselves in that position. When pregnant, women with tokophobia may request a caesarean section to avoid the process of actually having to give birth.
Some women find pregnancy itself very difficult, particularly dealing with the growing bump and feeling the baby’s movements. Anxiety, insomnia, sleeplessness, eating disorders and antenatal depression or increased risk of postnatal depression, have all been identified as consequences of tokophobia.
Some of the consequences for women with tokophobia – which emerge during labour – are longer labours. These are usually with an epidural and increased need for forceps or ventouse – this a cup-shaped suction device which is applied to the baby’s head to assist the birth. All of which can have implications for both the woman and her baby.
Afterwards some women with tokophobia may have a less satisfying bond with their babies. And a difficult experience of birth can make women more afraid of birth if they become pregnant again.
Anecdotal evidence indicates that clinical care for women with tokophobia is patchy. But the good news is that there is help out there for women with this condition. Some women find it helpful to talk through a previous experience of a traumatic birth, others might be reassured by information about labour and birth. Other women, however, may need more targeted treatment – a number of counselling approaches can be helpful.
Many women also find it helpful to visit the maternity ward and talk to midwives and obstetricians during pregnancy. Some women find the condition can be very isolating, feeling that nobody else shares this intense fear. For these women, simply knowing that they are not alone, can be very comforting and helpful.
Overcoming a phobia
In Hull and East Riding of Yorkshire, where there is an established perinatal mental health service for women and their families, there has been a recognised need for a consistent approach to caring for and supporting women with tokophobia.
This has led to a group of practitioners, academics and patients to work together to explore the care and support available to these women – and to help address the gaps in service provision.
This pioneering work, which is at the forefront of tokophobia service provision and research in the UK, aims to ensure that women get the right support, and that their psychological and pregnancy needs are met.
Tokophobia can have debilitating effects on women and their families. Some women will avoid pregnancy, even though they might want to have children. For those who do become pregnant, the condition can overshadow pregnancy and affect the choices they make for labour and birth. This is why we need to work towards preventing tokophobia if possible – as well as providing effective treatment for women who suffer from this difficult condition.
Was it the thought of slippery little beings being delivered into my welcoming hands? Was it a feeling of bored complacency? Or – perish the thought – a midlife crisis? The prospect of change enticed me when I applied for entry into the Advanced Diploma of Obstetrics traineeship. Naysayers and sceptics abounded, with sagas of sleep deprivation, eight-litre postpartum haemorrhages and lightning ambulance trips with arms, elbows and shoulders up vaginas supporting uterine inversions. “You’ll come crawling back to general practice begging for your job back” they sniggered.
My initial few weeks were a terrifying blur of inexplicable acronyms, abbreviations and staccato instructions yelled in rapid transit. “CTG” no longer meant “close the gap”, “stretch and sweep” didn’t connote house work, and third stage had little to do with opera. I learnt to wear only meconium coloured clothes, to roll up my sleeves before rupturing membranes, and that amniotic fluid rots the Velcro on shoes.
The seriousness and difficulty of my new challenge was quickly apparent. Simple procedures like cannulation, long forgotten, had to be perfected. My first few vaginal examinations during labour left me perplexed. Didn’t these women have cervixes? I wish someone had taken the trouble to describe them as a stretched balloon with a hole, instead of the nose like structure to which I was accustomed in general practice. I now use this handy analogy as a teaching tool.
Twelve hour days, plus nights on call, with missed meals were followed by intense studying for the written and clinical exams. Challenging for the young, but nearly impossible in one’s sixties. My energetic, obsessive personality prevented me from leaving until every “i” was dotted and ”t” crossed, so my hours escalated in a malignant fashion, inversely proportional to my sleep time. I hated living away from home and my long-suffering husband. My first rental accommodation was cockroach ridden, dark and depressing – a far cry from the beautiful rural farm that is my home. I missed my children and grandchildren, my friends, my life. Family events came and went in my absence. I suffered severe insomnia as well as horrific nocturnal leg cramps. I’d awake up to six times a night, screaming in agony, with my gastrocnemius muscles caved in. Initially I blamed my marathon walking on hard surfaces, until the correlation with the most stressful days became evident. How my neighbours must have loved me!
Learning skills from people the age of my children was humbling, and often humiliating. Negotiating different, and often aberrant, personalities amongst consultants was challenging. It was evident that one particular “boss” thought I should be at home knitting, while others patiently tolerated my slow but steady acquisition of skills. Another was openly disdainful. Initially, I simply tried too hard. To my horror, a patient complained that I hadn’t finished an examination when she’d asked me to do so. My boss had told me it was IMPERATIVE to complete this examination to avoid a dire clinical outcome and I’d gone at it like a bull at a gate. Naturally, I apologised, but my first ever patient complaint distressed me and crushed my already waning confidence.
The competitive atmosphere of the hospital took me by surprise. Gone was the collegiate atmosphere of General Practice. It was dog eat dog now! Fights for the caesarean lists, scrambling for labour ward shifts, crafty manipulation to avoid certain consultants. And I was as guilty as anyone! Those – like me- who were less aggressively competitive, missed out.
Surgery almost proved my nemesis. It had been nearly forty years since I’d graced an operating theatre or studied anatomy. Scrubbing, gloving and turning to tie up sterile gowns were nearly my undoing. Gnarled theatre sisters rubbed their withered hands with glee when I contaminated myself yet again, or forgot the name of some ubiquitous, obscure instrument! I mean, why the eponymous title for forceps? (Greene Armytage? Moynihans? Wrigleys?). Pointing or referring to them as “that one” didn’t really inspire confidence!
Surgical knot tying practice left my home resembling a sadomasochism den. Although I can certainly tie a hook on my fishing line better now! Other trainees learnt surgery so much more easily than I did! Yet, learn I painstakingly did. It seemed to take forever, but I can now perform straightforward caesareans, challenged occasionally by the odd impacted or high floating head. Instrumental births were difficult, but I am gaining my confidence. I passed my theoretical and clinical examinations with flying colours, and my “case syntheses” were marked as “excellent”.
After 18 interminable months, my traineeship is effectively over. Other trainees are progressing well but I still have a couple of skills to sign off. This, of course, presents a new challenge! I have begun ad hoc locums as an obstetrics registrar, but I am now the bottom of the pecking order as far as skills acquisition goes. Where to from here?
I look back at these 18 months with a mixture of horror and deep satisfaction. The knowledge that I was accumulating was massive and interesting, the studying strangely enjoyable, the care of mothers in labour and birth exhilarating. I’m often asked: ”Why? What are you planning to do with these skills?” My original plan was GP Obstetrics in remote and third world regions. Now I am assailed with self-doubt. Am I capable? Do I have the stamina? Can I cope with the stress and the inevitable occasional adverse outcome?
At this stage I can’t answer these questions. But the other day, as I delivered a beautiful baby boy with forceps, following a long and exhausting labour, I felt that slippery little bundle in my welcoming hands and witnessed the joy and relief on his parents’ faces, and all those negative memories flew out the window as I immersed myself in the miracle of new life, and felt so grateful to be a small part of this exquisite epiphany.
Births by caesarean section are rising, worldwide. The latest figures (2016) show that 25% of births in Western Europe were by caesarean delivery; in North America it was 32%, and in South America 41%. Given these statistics, it’s not surprising that people are interested in new evidence that looks at the potential harms (and benefits) of this procedure. However, I read the latest review of the evidence with mixed feelings.
The review, published in PLOS Medicine, focused on three main outcomes: pelvic floor problems in the mother (such as urinary incontinence), asthma in the child, and death of the child in subsequent pregnancies (stillbirth or neonatal death). The headline findings were: compared with vaginal delivery, there is a decreased risk of urinary incontinence and vaginal prolapse with a caesarean delivery. There is an increased risk of asthma in children delivered by cesarean section, up to the age of 12. And pregnancy after caesarean delivery was associated with increased risk of miscarriage and stillbirth, but not of neonatal death.
As a scientist, I can appreciate the effort made in conducting a systematic review on the topic, but as an obstetrician I worry that the results can be over-interpreted by patients – not to mention obstetricians and midwives – and caesarean section “marketed” as a safe way to avoid pelvic floor problems.
The results of the study, conducted by the University of Edinburgh, are based on an analysis of the combined data (a “meta-analysis”) of one large randomised controlled trial and 79 observational studies, all from wealthy countries.
Overall, it is a well-conducted review. But there are weaknesses (which the authors acknowledge), such as not taking into account the type of caesarean section (emergency versus planned operations) and not taking into account the stage of labour when the operation was done. (Performing a caesarean section during the late stages of delivery is probably going to harm the pelvic floor in some ways.)
Driven by fears of urinary incontinence
As an obstetrician, I meet many women who are concerned about their coming delivery and have a strong wish for a safe caesarean section. They often think it is a good way to avoid the pelvic floor problems that can occur after a natural birth. The benefits of a caesarean section for preventing pelvic floor problems are widely debated on social media, and in parenthood and pregnancy magazines, which contributes to the increased demand for caesarean deliveries.
Women are well aware of the discomfort and embarrassment associated with urinary incontinence and have an understandable fear of sexual dysfunction. But despite the reported findings that suggest decreased risk with a caesarean delivery, these problems are manageable, treatable and, importantly, not life threatening.
There are, however, life-threatening risks associated with a caesarean delivery on subsequent pregnancies, including increased risk of miscarriage, stillbirth and problems with the placenta – such as placenta praevia (the placenta covering the birth canal), placenta accreta (when the placenta grows too deep into the wall of the uterus) and placental abruption (where the placenta partially or completely separates from the womb before the baby is born).
A caesarean section delivery can also affect children. The results from this latest review show that it increases the risk of childhood asthma (21% increased risk) and the risk of obesity (59%) in children up to the age of five, compared with children born by vaginal delivery.
All risks are not created equal
Clearly, it does not make sense to compare the risk of urinary incontinence, say, with the risk of a stillbirth. Obstetricians are aware of the various risks of caesarean versus vaginal delivery and should help to guide the patient in making a decision. In order to prevent any further increase in the caesarean section trend, obstetricians need to take responsibility for how this information is conveyed to patients, taking the patient’s full reproductive life into account, and also aiming to minimise the risks for any following pregnancies.
It is an educational and ethical challenge for doctors to balance the potential risk factors of current versus future pregnancies. While women are being given more choice, I don’t think that it is ethical or advisable to let the patient prioritise between different outcomes as the authors suggest. Rather, patients should be informed of all of the risks – at all life stages, for mother and child – and assess their options based on that.