Feedback: Issue 7 :: 2011

Midwives magazine: Issue 7 :: 2011

Flu vaccine – a must for all midwives, reducing CS rates at UCLH, response to acupuncture in the treatment of hyperemesis gravidarum.


Flu vaccine – a must for all midwives

From: David Green, infection control nurse and immunisation co-ordinator, NHS Calderdale and Dr Andrew Clark, deputy regional director of public health, NHS Yorkshire and the Humber

Hunt and Dabrowski in Midwives :: Issue 6, correctly identify that immunising midwives is a means of protecting mothers and newborn babies from influenza, and if large numbers of midwives receive the flu vaccine, this may in turn encourage pregnant women to be immunised (Hunt and Dabrowski, 2011).

During last winter’s flu vaccination campaign, the Health Protection Agency estimates that 38% of pregnant women in England were immunised compared with 72% of the over 65s and 50% of those under 65 in clinical risk groups (Chief medical officer (CMO), 2011). Midwives, along with GPs and others, are ideally placed to talk to women about the risks of influenza infection in pregnancy, the benefits of having the vaccine and where they can access it.  

Since 2010, the CMO has recommended that all pregnant women, whatever their stage of gestation, should be offered the flu vaccine (CMO, 2010). This is because there is evidence to show that not only are pregnant women and their unborn babies at increased risk of serious complication of influenza infection, but that immunisation is a safe and effective means of protection.

Around 15% to 20% of pregnancies end in miscarriage before 12 weeks’ gestation (Goldenberg et al, 2005) with chromosomal abnormalities accounting for approximately 50% of these (Goddijn et al, 2000). Of the remaining 50% it is thought that infection or an auto-immune reaction plays a role in fetal loss (Redline et al, 1999).

Infection with influenza virus in late pregnancy and early puerperium increases the risk of serious maternal complications such as pneumonia. Experience in the UK and other countries suggests that pregnant women are around four times more likely to develop serious complications as a result of influenza compared to women who are not pregnant. Last year, nine pregnant women died in the UK as a result of complications of influenza infection (HPA, 2011).

Immunisation against seasonal influenza can help to reduce the risk of fetal loss during pregnancy and protect the woman from serious complications secondary to influenza. A number of studies have also shown that a seasonal influenza vaccination during pregnancy provides passive immunity to infants in the first few months of life following birth (Benowitz et al, 2010; Eick et al, 2010; Zaman et al, 2008; Poehling et al, 2011).

Routine immunisation of all pregnant women has been recommended in the US since 1995 (CDC, 1995). A review of studies on the safety of influenza vaccine in pregnancy concluded that inactivated seasonal influenza vaccine can be safely and effectively administered during any trimester of pregnancy and that no study to date has demonstrated an increased risk of either maternal complications or adverse fetal outcomes (Tamma et al, 2009). It is therefore not in the interest of the expectant mother or her baby to delay administering the flu vaccine in pregnancy.

Midwives and other obstetric staff can reduce the risk of influenza transmission in the workplace by ensuring they receive the flu vaccine (CMO, 2011). We urge all midwives, GPs, practice nurses and the wider public health team to promote the flu vaccine to pregnant women regardless of the stage of pregnancy, and check that they have received it at a subsequent visit.

(See below for references)


Reducing CS rates at UCLH

From: Astrid Osbourne
Email: astrid.osbourne@uclh.nhs.uk

I am a consultant midwife working at University College London Hospital (UCLH), a tertiary referral centre, known as the Elizabeth Garrett Anderson Wing. I have a special interest in women who request a ceasarean section (CS) when there is no medical or fetal indication.
My colleague Belinda Green and I see all women who make this request, and we attempt to work with them through one-to-one antenatal care and with the support of an excellent psychotherapy team where indicated.

Many of the women have a morbid fear of birth, but there is also a small faction who want surgery because of body image, and because there’s a trend for the rich and famous to have it.
We also see a growing number of women who have had a severe trauma in their lives, whether that’s been a part of their experience in a war-torn country or from sexual abuse in childhood. There is also a significant number of women, who have had very poor birth experiences and cannot face the prospect of the same treatment again. Belinda and I caseload a number of these women and we work with a team of midwives to support them, along with a known carer during vaginal birth.

At present, our success rate for the past year is 50%. Some women will have a CS, but we know that is because they really need to have them. The rationale is not to save money, though that is very useful in today’s economic climate, but our overall motivation is to ensure that women have the necessary care and support they need.

Consequently, the CS rate has fallen at UCLH from 34% last year to 29%, which is a definite move in the right direction.

RCM Communities
What is the CS rate at your trust? What steps are you taking to reduce it? To join the discussion, please visit: http://communities.rcm.org.uk


Response to acupuncture in the treatment of hyperemesis gravidarum

From: May Stevens
Email: maystevensacupuncture@gmail.com

As a fully-trained acupuncturist (having completed the requisite three years of full-time study) and a first-year midwifery student, I am genuinely concerned by the point prescription recommended as treatment for sickness in the Feedback section of the last issue of Midwives.

Firstly, it is not at all normal to use more than two or three points on a pregnant woman and, in fact, I have treated many a woman for this condition successfully using just a couple of points. Secondly, and most importantly, LI4, GB21 and SP6 are three out of only five or six points that are contraindicated during pregnancy due to their ability to bring on uterine contractions. Thirdly, and almost incidentally, several of these points would very rarely be used as a treatment for nausea and vomiting and I struggle to figure out the rationale both for the choice of the individual points and for the recommendation of the combination of them all together.

To suggest that other midwives incorporate this treatment into their practice worries me a great deal. I hope readers will reflect on their use of acupuncture and seek advice on how to proceed. I would be happy to answer any questions, or perhaps members could contact the British Acupuncture Council, the UK’s largest regulating body on Tel: 020 8735 0400.



References

Benowitz I, Esposito DB, Gracey KD, Shapiro ED, Vázquez M. (2010) Influenza vaccine given to pregnant women reduces hospitalization due to influenza in their infants. Clin Infect Dis 51(12): 1355-61.

Centers for Disease Control. (1995) Prevention and control of influenza. MMWR 44(RR-3): 1-22.

Chief Medical Officer. (2010) The influenza immunisation programme 2010/11. Letter, 23 June 2010, Department of Health. Gateway reference number 14171.

Chief Medical Officer. (2011) Seasonal flu immunisation programme 2011/12. Letter, 25 May 2011, Department of Health. Gateway reference number 16066.

Department of Health. (2006) Immunisation against infectious disease (third edition). HMSO: London.

Eick AA, Uyeki TM, Klimov A, Hall H, Reid R, Santosham M, O'Brien KL. (2010) Maternal influenza vaccination and effect on influenza virus infection in young infants. Arch Pediatr Adolesc Med 165(2): 104-11.

Goddijn M, Leschot NJ. (2000) Genetic aspects of miscarriage. Baillieres Best Pract Res Clin Obstet Gynaecol 14(5): 855-65.

Goldenberg RL, Culhane JF, Johnson DC. (2005) Maternal infection and adverse fetal and neonatal outcomes. Clin Perinatol 32(3): 523-59.

Gu J, Xie Z, Gao Z, Liu J, Korteweg C, Ye J, Lau LT, Lu J, Gao Z, Zhang B, McNutt MA, Lu M, Anderson VM, Gong E, Yu AC, Lipkin WI. (2007) H5N1 infection of the respiratory tract and beyond: a molecular pathology study. Lancet 370(9593): 1137-45.

Hardy JM, Azarowicz EN, Mannini A, Donald N, Medearis J. (1961) The effect of Asian influenza on the outcome of pregnancy, Baltimore, 1957–1958. Am J Public Health Nations Health 51: 1182-8.

Harris JW. (1919) Influenza occurring in pregnant women: a statistical study of 1350 cases. J Am Med Assoc 72: 970-2.

Health Protection Agency. (2011) Surveillance of influenza and other respiratory viruses in the UK 2010-11. Health Protection Agency: London. 

Hunt L, Dabrowski R. (2011) Flu jab? There is no excuse. Midwives 14(6): 38-9.

Lieberman RW, Bagdasarian N, Thomas D, van de Ven C. (2011) Seasonal influenza A (H1N1) infection in early pregnancy and second trimester fetal demise. Emerging Infectious Diseases 17(1): 107-9.

Newsome K, Williams J, Way S, Honein M, Hill H, Rasmussen S, McIntyre AF, Finelli L, Jamieson D, Callaghan W, Zotti M. (2011) Maternal and infant outcomes among severely ill pregnant and postpartum women with 2009 pandemic influenza A (H1N1) United States April 2009 – August 2010. MMWR 60(35): 1193-6.

Poehling KA, Szilagyi PG, Staat MA, Snively BM, Payne DC, Bridges CB, Chu SY, Light LS, Prill MM, Finelli L, Griffin MR, Edwards KM, New Vaccine Surveillance Network. (2011) Impact of maternal immunisation on influenza hospitalization in infants. American Journal of Obstetrics and Gynecology 204(6 Suppl 1): S141-8.

Redline RW, Zaragoza M, Hassold T. (1999) Prevalence of developmental and inflammatory lesions in non-molar first-trimester spontaneous abortions. Hum Pathol 30(1): 93-100.

Stanwell-Smith R, Parker AM, Chakraverty P, Soltanpoor N, Simpson CN. (1994) Possible association of influenza A with fetal loss: investigation of a cluster of spontaneous abortions and stillbirths. Commun Dis Rep CDR Rev 4(3): R28-32.

Tamma PD, Ault KA, del Rio C, Steinhoff MC, Halsey NA, Omer SB. (2009) Safety of influenza vaccination during pregnancy. Am J Obstet Gynecol 201(6): 547-52.

Yawn DH, Pyeatte JC, Joseph JM, Eichler SL, Garcia-Bunuel R. (1971) Transplacental transfer of influenza virus. JAMA 216(6): 1022-3.

Zaman K, Roy E, Arifeen SE, Rahman M, Raqib R, Wilson E, Omer SB, Shahid NS, Breiman RF, Steinhoff MC. (2008) Effectiveness of maternal influenza immunisation in mothers and infants. N Engl J Med 359(15): 1555-64.