Think:Health cultivates and articulates the best in health research and news.
The following program, which aired on Sunday 25th October 2015, features:
- how midwives cope with removing newborn babies from their mothers (01:13);
- the advantages of having a vaginal birth after a caesarean (12:01); and
- new government funding for bad behaviour in dementia residents (19:36);
Guests:
- Louise Everitt - Lecturer at the UTS Faculty of Health
- Allison Cummins - Lecturer and Course Coordinator for the Graduate Diploma in Midwifery at the UTS Faculty of Health
- Professor Hannah Dahlen - Western Sydney University
- Professor Lynn Chenoweth - Professor of Aged and Extended Care Nursing, Faculty of Health
Presenter:
- Ellen Leabeater, 2ser
Transcript:
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Male: This is Think Health on 2SER, 107.3.
Ellen Leabeater: Hello and welcome to Think Health, where we cultivate and articulate the best in new health research. I'm Ellen Leabeater and you're tuned into 2SER, 107.3. Today on the show we look at the case for having a natural birth after a c-section.
Allison Cummins: Women will recover sooner. They generally lose about half as much blood as women who have a caesarean section. They're able to get up and care for their babies sooner. They initiate breast feeding sooner.
Ellen Leabeater: And we examine the Federal Government's new plans to help dementia residents with behaviour difficulties.
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Taking a healthy baby home is what every mother wants after giving birth but for some mothers they leave the hospital empty handed. The mothers we are talking about today are the severely disadvantaged, the drug addicted, the mentally ill and those in violent relationships. In these cases child protection services often step in and remove the child from their mother. It can be a traumatic experience not only for the mother and the baby but the midwife who has helped the woman throughout her pregnancy.
Louise Everitt is the Clinical Midwifery Consultant at St George Hospital and a lecturer in the Faculty of Health at the University of Technology, Sydney. She has researched the impact of removal on midwives and found that this is a confronting experience for all involved.
Louise Everitt: Midwives have a unique role in child protection. When I was looking at all the research they talk about adult services and child services. The child services focus on the children, obviously, and then they work sort of with the parents. Then the adult services like say drug and alcohol and mental health work with the adults and so often forget the children. With a pregnant woman they can't remove the baby or become child focussed until the baby is born but midwives begin child protection like while the pregnancy is going on.
Ellen Leabeater: In New South Wales under what circumstances is a newborn removed from their parents?
Louise Everitt: It has to be under the New South Wales law court order so it has to meet all of those requirements before a newborn would be removed. Most commonly it's from vulnerable families and the vulnerable families may be someone with unmanaged mental health, drug and alcohol misuse, domestic violence, homelessness, people with developmental delay who don't have any support to help them parent a child, really young Mums, again, who don't have any support.
Ellen Leabeater: I imagine it's a decision that's not taken very lightly because removing a newborn from their parents is quite harmful to the baby?
Louise Everitt: That's right. Like it's not an easy decision to make and as I said it has to be under law that certain things are met and definitely the aim would be to try to keep the child and the mother or the family group together. However, because newborns are the most vulnerable in terms of child protection, often the babies are removed to keep them safe initially so that the parents and everything - you know, say housing gets sorted out or the mother might go to drug rehabilitation or into a mental health facility. When that's sort of - the problems or the vulnerabilities have been corrected then sometimes the child is restored to that family. But yeah, it is a really difficult decision for the child protection workers.
Ellen Leabeater: Midwives are intimately involved in this experience and your research has looked at the role of midwives in this process, how did the midwives feel during this?
Louise Everitt: It's really difficult for midwives during this process. So midwifery is known as working with women. We work with women and the families obviously for the best outcome for a pregnancy, for parenting, that that child might, you know, born into a healthy, happy environment which includes the emotional and social circumstances. To work with vulnerable families is challenging for midwives as well because we're working with people with domestic violence or mental health.
Basically midwifery is about working with well healthy women so the more complications even psychosocially it becomes challenging. Also if the baby is going to be separated from the mother when it's born, that's the total opposite to what we're aiming to do at most of the time. It is a challenging thing to do and the midwives in my study talked about weighing up what was in their head and their heart. So their head, they sort of stated and said well, we know that it had to happen, that this baby wasn't necessarily going to be safe or we know we tried our best during the pregnancy to work with this woman and engage in services and it didn't happen.
So they sort of can - what they said work in their head that, okay it had to happen, but in their heart they still felt well, this is still a mother who's had her baby removed from her, we've worked with her. Especially some of the midwives talked sometimes that they didn't necessarily agree with the decision. Sometimes they felt that the babies should have gone home with the mother or sometimes they felt the baby shouldn't have gone home with the mother. Then they were conflicted as to what they thought the outcome should have been.
Ellen Leabeater: Of course pregnancy lasts for nine months so in theory if women are showing up to their ante-natal classes there is a chance for midwives to intervene. Is that correct?
Louise Everitt: That's right. I mean the best outcome would be that the women actually engage in care early and then things can be put in place. So if Community Services are already involved, say for instance the woman already had a child removed previously, they may actually, say well we want these women to go to parenting classes or enter into drug rehab and then during the pregnancy there's a chance that things can be put in place that will mean that the mother and baby can go home together.
The later the women book and the less engaged in care they are then the more difficult it is. The midwives spoke about the challenges of that because then you've got less time in the pregnancy to try to get the woman to engage in the services and the care that they need.
Ellen Leabeater: At what point is the baby removed from the mother? Is it immediately after birth or is there a chance for the mother and baby to bond first and have the first feed and then the baby's taken away?
Louise Everitt: It really depends on the circumstances of why the baby is going to be removed. All of those things may be the case. In some cases the midwives in the study talked about that the baby was removed immediately, basically once it was born in the birthing unit. Certainly in my own practice occasionally that does happen. Usually we still like to let the woman cuddle the baby, have a breast feed. For some of the women that knew that their babies were going to be removed, they also just - they didn't want to actually see their babies, were happy almost to hand them over. The midwives were confronted with that as well because they felt we want you to keep the baby with you.
Alternatively, sometimes when there is a planned removal of a baby, we've kept women in hospital for seven days, allowed them to breast feed, bond, take photos, have some time with the babies but they knew themselves that they were going to be removed. So sometimes the decision's not made until after the baby is born. Community Services come in after the baby's born and assess the woman and the family on the ward and then make a decision. Sometimes it's not known and sometimes it is. Obviously depending on the risk to the baby depends how immediately Community Services might come.
Ellen Leabeater: When the baby is actually removed. I know the midwives in the study described it as quite an emotional experience, how do they, as the midwife, deal with those feelings and watching a baby being taken from its mother?
Louise Everitt: The midwives used words like - the most common word they used was it was hard and then they talked about being awful, traumatic, distressing. The midwives talked about that they cried either with the woman or sometimes later because they just felt that it was such a traumatic thing to remove a baby. Even…
Ellen Leabeater: How do the mothers react?
Louise Everitt: The mothers react sometimes with grief and sometimes they react aggressively so they get really angry. Even though the midwives might have worked with the women and other services and given the mother the opportunity to either change or to say that your baby is going to be removed, at the actual time that it is removed the women have a various range. You can't really describe the range of how a woman might react.
The midwives talked about in their own practice that it was like when they were with a woman who'd had a stillbirth. So that same sort of emotional feeling that this woman had lost her baby. The one midwife said that the difference is that there were some sort of completion if you'd lost a baby or if there was an adopted baby that that was often a choice but with a removal of a baby they talked about it being missing, almost like a missing person.
Ellen Leabeater: And finally is there anything that you can recommend that would help the process, make it a bit easier and less traumatic?
Louise Everitt: Just some of the suggestions that the midwives made was that we actually educate undergraduate nurses and midwives around child protection and around the fact that children are removed or babies are removed from their parents so that they can anticipate what are the actual practical things that happen in a hospital when this occurs but also how they're going to feel emotionally and how they're going to support each other or to go and get some sort of what we call clinical supervision to debrief around events like this.
Ellen Leabeater: Louise Everitt, a Clinical Midwifery Consultant at St George Hospital ending that report. You're listening to Think Health on 2SER. Coming up next the advantages of having a natural birth after caesarean.
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Ellen Leabeater: Hello and welcome back to Think Health on 2SER, 107.3. Children can be one of the most wonderful experiences in a woman's life however it doesn't always go according to plan. Complications during pregnancy may mean the mother has to give birth by caesarean section. This can be one of the safest options at the time for the mother and the baby, but it's not without its risks. But what happens for baby number two or even baby number three or four. Are women more likely to attempt a natural birth or do they default to what they know?
There is currently a push for women who have previously given birth by caesarean to have a natural birth the second time round. It's known as VBAC or vaginal birth after caesarean. It's not completely risk free but the risks are much less severe than you'd think. Jake Morcom reports.
Allison Cummins: I felt with the caesarean before, the recovery and the pain, I just felt a dragging pulling feeling for a very long time and felt nothing with having the vaginal birth after caesarean.
Jake Morcom: That's Allison Cummins. She's reading a quote from Stories in Midwifery, a book she co-wrote about women's stories in midwifery and the stories of midwives. The quote is from a woman named Trish who had a caesarean section for twins followed by a vaginal birth.
Allison Cummins: I felt very fit, healthy and so happy and I was on a real natural high for a long time with the vaginal birth.
Jake Morcom: For women who've had a caesarean the idea of having a natural birth for their next child can seem unsettling. Allison Cummins says there is reason to be cautious but more and more women are opting for vaginal birth after caesarean.
Allison Cummins: So the concerns around VBAC is that the uterus has had an incision, a cut through it and has been repaired. As the uterus grows in a normal pregnancy then the scar gets stretched and when a woman goes into labour and the uterus is contracting, then there's fears that the scar may not stay together. The rate of where the scar may de-his or open up or come apart, what we call uterine rupture, is about 1 in 200. So it's 0.5 per cent. It's very low rates but that is the fear that people have around vaginal birth after caesarean.
Jake Morcom: Even though there are fears regarding VBAC, Allison says there are also huge advantages.
Allison Cummins: Women will recover sooner. They generally lose about half as much blood as women who have a caesarean section. They're able to get up and care for their babies sooner. They initiate breast feeding sooner. So the earlier you initiate breast feeding then the longer you will sustain breast feeding and the easier it will be for you. So that's a really important advantage for the baby and the mother. They don't stay in hospital for as long. There's obvious cost savings to the public health system if women have a vaginal birth after caesarean and they have higher satisfaction around the birth.
Jake Morcom: Allison says that when you're pregnant counselling is hugely important in alerting you to both the benefits and risks of vaginal birth after caesarean.
Allison Cummins: We talked about the risk which is uterine rupture and everyone seems to be focussed on that. What they don't talk about very often are the risks of caesarean section, repeat caesarean sections. In Australia only about 12 per cent to 15 per cent of women will attempt a vaginal birth after caesarean. The rest will have a repeat caesarean. The women who have a repeat caesarean have a high chance of losing more blood. So in that early parenting period they're more likely to suffer from conditions such as anaemia. It can impact on breast feeding.
They're more likely to develop blood clots in their legs and in the worst case scenario this can go to their lung or their heart. There is increasing chances of wound infections to the woman. So there's a lot of risks associated with caesarean. It's not just you go in and have the baby. There's also a long term recovery period. It takes longer to recover from a caesarean than a vaginal birth.
Jake Morcom: For women planning to have a repeat caesarean, Allison believes not all of them understand the associated risks. Being alerted to these risks she says comes down to one thing.
Allison Cummins: It is all in the counselling. So if you see a practitioner who says I think it's safest for you and the baby to have a caesarean section, that's what you're going to do. If you see someone that gives you all the benefits and advantages of both types of birth, then women are in a much better position to make an informed choice. As we know midwifery led care reduces caesarean section rates, it would be ideal that women in Australia were having midwifery led care and in the case of having a previous caesarean section that the midwife works in collaboration with an obstetrician.
They don't automatically have to see a doctor because they've had a caesarean before. They should work alongside a doctor but they don't necessarily have to have - be excluded from midwifery led care just because they have had a caesarean before.
Jake Morcom: Allison Cummins, Course Coordinator for the Midwifery Graduate Diploma at the University of Technology, Sydney.
For some the experience of caesarean section can put them off hospitals completely. Hannah Dahlen is Professor of Midwifery at Western Sydney University. She's been undertaking research interviewing women who have had vaginal birth after caesarean and seeing why they're having their next birth at home. Hannah says home birth is low risk but VBAC home birth is not the best option.
Hannah Dahlen: What really I guess disappointed us and worried us was many of these women were not making this choice because it was their first choice. They would go to the hospital, they would say I want to have a vaginal birth after a caesarean. They try and negotiate some things that they wanted. For example they didn't want to be on the bed, they didn't want to have to have a drip put up and they didn't want to have to be continuously monitored and got told no or got bullied and harassed and felt they couldn't give birth in that system. So started to seek out someone else and another way that they could be supported. They ended up having a home birth and they had extremely positive experiences.
Many of these women felt that the trauma that had been caused by their first caesarean section got completely healed and repaired through that ability to have a normal birth that was supported. The sad thing is that if we had a system that supported VBAC and enabled women to have choice within mainstream maternity services there'd be many women not forced into making a choice that may not be their first choice.
Ellen Leabeater: Hannah Dahlen, Professor in Midwifery at the University of Western Sydney ending that story by Jake Morcom.
Thanks for tuning into Think Health this morning. I'm Ellen Leabeater. Coming up next we examine the government's new program hoping to help aged care staff deal with bad behaviour in dementia residents.
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Ellen Leabeater: Running away, hitting, yelling, they are all behaviours of an agitated resident with dementia and it's becoming increasingly difficult for aged care staff to manage them. While this type of behaviour only affects a small number of people with dementia, it can cause stress for staff that are not trained to deal with severe behaviour. But help may be on the way.
The government is set to roll out severe behaviour response teams in November. The teams of experts will visit residential care facilities struggling with dementia residents and give advice on how to better manage bad behaviour. It's coming at a cost of over $54 million but is this really a long term solution. We spoke to Lynn Chenoweth, Professor of Aged and Extended Care Nursing at the University of Technology, Sydney to find out more.
Lynn Chenoweth: I think that the severe behaviours are the ones that staff are finding very difficult to understand and also to contain. They probably would be things like the person's constantly trying to get out of the building, hitting, banging, crying out, constantly pacing where they're highly agitated because they just want to get out of the building probably to look for their home or to get out into the garden or something like that.
Other behaviours might be regarding when the staff have to provide care for them such as getting them out of bed, taking them to the bathroom, trying to change their clothes, toilet them, they might resist and refuse to cooperate and they start to get very agitated and upset. Then they might hit out at the staff or push them away or just do some harm even to themselves because of their agitation.
Ellen Leabeater: Do all people with dementia have behaviour problems like you've just described?
Lynn Chenoweth: No. No they don't, only a small number, a very small number. People who are agitated in the ways that I've described are usually in a state of ill being. What it means is that the staff are not understanding what it is that they need and the person themselves can't explain what it is that's upsetting them. Therefore it's only a very small number of people in aged care facilities would ever need to have the sort of help that the government's requiring.
Ellen Leabeater: The government has set up these severe behaviour response teams, what exactly are they and how are they going to work?
Lynn Chenoweth: They've been in operation for many years. They're rapid response teams and they have them in the emergency departments, they have them in acute aged care or just in acute hospitals and they've been happening in nursing homes for some years. Normally the dementia behaviour management service have been operating these rapid response calls either going out to review the situation, doing visitations, consultations and/or phone consultations with staff for many years. Now really what the government's proposing is nothing new, it's been happening for a long time.
What happened about three years ago is that the change in the budget for aged care meant that the behaviour management service was really only a telephone hotline and that hotline is just totally inadequate to the actual needs of staff who are dealing with these issues in the workplace. What this government's doing is just reinstating what already [was] in existence before, which is to have a hotline but also for the people at the end of that line to determine whether this is something that needs an urgent face-to-face consultation.
What they've said is that they're going to get somebody out there for urgent cases. They will actually make a visit, they'll actually have a look at what's going on, they will give advice to the staff on how to manage a situation.
Ellen Leabeater: These are responsive teams so they come when there's been a problem. Wouldn't we just be better off training people who are in the aged care facility?
Lynn Chenoweth: Yes. That is the better way to go about it. However the level of staff skill in aged care facilities is reducing so that with the deliberate reduction of registered nurses and particularly registered nurses with middle illness training or also psychogeriatric training is reducing and the number of registered nurses available within a whole facility is far less than what it used to be, we're relying on direct care workers who have really minimal training in anything much at all. They might know how to bath a person, they might know how to feed a person safely, they might know how to transfer a person in and out of a bed and they might know a little bit about how to communicate with a person with dementia.
Their level of training and their education is absolutely minimal. It's probably almost the same as what you and I might have as family members. It means that the registered nurse who doesn't have - they don't have access to psychogeriatricians in the site or they don't have access to other doctors in the site, they've really got to try and manage the situation with very few staff who've got any skill at all.
Ellen Leabeater: I'm just also wondering that, again it's the one off response, but the people who are working with these residents are there day in day out, are these employees really going to be receptive to an outside team coming in and telling them what to do?
Lynn Chenoweth: Yes, they're begging for it. They know that they're not managing. They're not able to provide the care that they're expected to provide because the person's resisting their care or whatever and also they're quite worried about other residents being injured in some way or [when] a noise in the facility if a person's screaming constantly, calling out constantly or whatever, they want help. The problem in the past has been that they couldn't get help.
I'm still quite suspicious that in fact this is going to really solve the problem. Because we've had it in the past, it hasn't been as effective as it ought to have been because we simply don't have enough of these quick response staff to come out and the need is so great and the number of staff employed is so little. Really the staff who are in the facilities would really welcome it to get the support and the education that they need.
Ellen Leabeater: I'm guessing that you would propose more education and more registered trained nurses in the facilities to solve problems like this?
Lynn Chenoweth: Yeah. If we had more registered nurses with these specialised skills in each facility we probably wouldn't need things like a quick response team because those specialist nurses would know how to help the staff manage the situation to stop the escalation of these agitated behaviours in the first place. A lot of the reason that these agitated behaviours occur is because the staff don't realise that a lot of what they do, the way that the situation is set up, the way that they have to get through tasks and the way that they go about it, can be a trigger for these agitated behaviours.
If there's specialised staff in a facility they can be working alongside the direct care staff and prevent a lot of the behaviours occurring in the first place.
Ellen Leabeater: Lynn Chenoweth, Professor of Aged and Extended Care Nursing at the University of Technology, Sydney ending that story.
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If you would like to find out more about that story or listen to any of our past programs, head to our website at 2ser.com/thinkhealth. This show is produced with the support of the University of Technology, Sydney, Faculty of Health. Please remember that you should not consider the contents of this show medical advice and you should consult your physician if you have any concerns.
I'm Ellen Leabeater, this has been Think Health. See you next week for more in health research and news.
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