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Nordic birth role models

December 24, 2018

Finnish grips, movement worries & induction

Nordic pregnancy and birth care is second to none. Midwives are well trained, and respected, and they keep accurate statistics. As a result maternal and perinatal mortality fell well before it did in the rest of Europe.  A Norwegian, Christian Kielland (click here) made the only important contribution to forceps design since Smellie introduced the pelvic curve.  A Swede, Tage Malmstrom (click here), invented the first workable ventouse. Iceland leads in genetic studies. Finnish obstetricians realised the importance of antisepsis before Semmelweis (click here) and were the the first to notice that so called, “benign” cholestasis, might not be benign after all (click here). I’m a fan.

Anglo Saxon obstetricians and midwives in contrast were slow to embrace evidence-based medicine, for which they were famously awarded the wooden spoon by Archie Cochrane in 1979 (click here). But we’ve improved. In England today it would be almost unthinkable to introduce a new way to deliver the head in the hope that it reduced vaginal tears. Imagine if obstetricians got the idea that encouraging women to call in urgently after the slightest alteration in the way their baby moved, or that inducing birth a week early, reduced stillbirths. Enthusiasts would be shown the relevant Cochrane reviews (click here, here and here), told to find out if the issue mattered to patients (click here) and if so, to test their hypotheses in randomised controlled trials. Claims to have discovered better ways to give birth or manage pregnancy, on the basis of historical or non-randomised controls, are met with derision in the UK. And that’s as it should be. Pregnant women have suffered enough from good ideas introduced with the best intentions.

But wait. Some Finns and Norwegians (click here) recently claimed that pressing on the mother’s perineum during birth using the “Finnish grip” (click here) prevented anal sphincter tears. Swedes, who let the head crown in the usual way, beat themselves up for not doing it (click here). Another group of Norwegians told women to report urgently, day or night, the slightest change in their baby’s movements and claimed to prevent stillbirths (click here). The Danes argued that a doubling of induction had done the same (click here).

And a funny thing happened. Instead of reminding the “Finnish grippers” that the rather similar HOOP (Hands On Or Poised) trial (click here) had shown no effect on perineal tears, and the “movement change worriers” that a large fetal movement counting trial had shown no effect on stillbirths (click here), the Royal Colleges of Obstetricians, and of Midwives, pushed both interventions as part of their “Obstetric Anal Sphincter Injury” (OASI) (click here) and “Saving Babies Lives” (click here) care bundles. They didn’t need to push induction. UK induction rates soared without help. The ideas had come from Scandinavia, and normal critical faculties switched off.

Fortunately not everyone was so gullible. Jane Norman and her colleagues tested the “make everyone worry about any alteration in fetal movements” hypothesis and showed that it was not only ineffective but harmful (click here and here). Now we’ve just gotta figure out how to stop doing it!

Bill Grobman and his colleagues in the US tested the “induce everyone hypothesis” and found that it didn’t reduce bad baby outcomes as much as hoped, although surprisingly, it appeared to reduce Caesareans (click here). More trials needed.

No-one seems to be doing a decent trial of the “Finnish grip” yet, although the OASI care bundle is getting push back from midwives on Twitter. Forgive the pun! Hopefully someone will do one soon.

Nordic obstetrics is great. But we should judge their ideas by the standards we require of anyone else.

Jim Thornton

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