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Midwives recognise that asthma in pregnancy is a common chronic condition that can lead to serious complications. Asthma has been defined as a complex polygenic disease which can result from genetic susceptibility and environmental exposure (Gunawardhana et al 2014), and is characterised by experiencing tightness in the chest, wheezing, production of thick sputum, cough and breathlessness (van der Wiel et al 2013). These symptoms occur in episodes, either daily, weekly, monthly or even only a few times a year, affecting approximately 8-9 per cent of pregnant women (Chan et al 2015; Gent et al 2015). When asthma occurs in pregnancy, the woman can experience poor pulmonary function, hypoxia that can lead to adverse health outcomes for the mother and fetus. This clinical update discusses the aetiology of asthma in pregnancy; how asthma affects the woman and fetus, and the role of the midwife caring for pregnant women with asthma.

Guideline commentary takes its place alongside Cochrane corner and Research unwrapped as part of our evidence series. The aim of Guideline commentary is to support you to critique and utilise newly published guidelines, enabling translation of appropriate recommendations to practice. The objective is to scrutinise recent guidelines to encourage an understanding of the key issues, recommendations and midwifery practice implications. This month, Hannah Rogers looks at the new MBRRACE report and is struck by the addition of mental health disorders as a cause of death. She also considers the proportion of women who suffer morbidity.

With a changing society, the age range at which women are choosing to become pregnant is increasing. There are different needs associated with each end of this range, with younger and older mothers facing different challenges and decisions. The midwife needs to be confident about the associated needs and potential complications for women at each end of the maternal age spectrum, in order to navigate the journey with the mother. This article aims to address the particular needs of both younger and older mothers, and highlight the midwife's unique role within this process

A collaborative project between a community midwife and midwifery educationalist has developed a model of compassionate woman-centred care for women with high BMI. The project aim was to test a model of care that would increase midwives' confidence in caring for women with high BMI. It was important that any new model should not involve what would be perceived as time-consuming activities that would add significantly to the midwives' workload. After searching the literature a five-stage brief interventions model based on motivational interviewing (MI) theory was piloted with a team of community midwives in rural Scotland. Leaflets were developed containing information and activities based on MI principles providing women with a tool to work with. The Swinscoe-Walsh model has been well received and evaluated by both midwives and women and is being considered for wider implementation by public health services for pregnant women.

The relationship between parental mental illness and safeguarding concerns is well documented. The role of the midwife in supporting women with mental health problems can sometimes be a balancing act, especially when perinatal mental health services are few and far between. The midwife needs to be able to remain objective with regards to safeguarding and be proactive in instigating early help assessments. There should be organised joint working within a multi disciplinary team including social workers and psychiatric nurses which addresses the needs of both mother and baby. This can lead to a less problematic handover to health visiting services. Continuity of care and an open honest approach will be instrumental in providing a supportive relationship that doesn't lose sight of the baby.

Obesity is an issue seen more and more in the media, and is a leading cause of death and health complications worldwide (World Health Organization (WHO) 2014). Antenatally, women are classified as obese or overweight at booking and their midwifery care is altered accordingly, which may lead to further stress. A lot is known about the apparent dangers of obesity but not much is known about the malnourishment of obese pregnant women and the potential harm their diet could be doing to the fetus. The focus needs to be shifted from the dangers of obesity on to the importance of nutrition for both mother and fetus and the role midwives could play in this issue.

Incarcerated women are a vulnerable group with complex needs in pregnancy, birth and early parenting; and this is further complicated with a drug and/or alcohol addiction. Prior to the establishment of an antenatal outreach clinic in a Western Australian prison for women, pregnant inmates received fragmented antenatal care. Some of the women did not disclose drug and alcohol issues for fear of involvement of child protection services, and some refused to be transported for care to maternity hospitals for antenatal appointments. This is the first antenatal care clinic for pregnant women to be established within a prison population in Western Australia.

This paper describes a workshop which was supported by the Iolanthe Midwifery Trust and facilitated in Nepal. The groups were introduced to the concept of emotion work in maternity care and ways of using reflection to manage it in themselves. A practical element was used, following the belief that engaging the right side of the brain in craft frees the left side to work optimally on logical/rational thinking.

Mental health is an integral part of health and a state of wellbeing. The concept of 'parity of esteem' increases awareness that mental health needs to be treated as seriously as physical health. During the childbirth continuum, women and their partners can be at increased risk of mental health problems; therefore it is important to embrace the 'parity of esteem' concept. This article highlights links between mental and physical health problems and discusses the vital role that midwives can play in promoting better maternal mental health. It considers the challenges this can present to midwives and maternity services.

Perinatal mental illness (PMI) represents a significant public health concern affecting considerable numbers of pregnant women and mothers of infants. Depression and anxiety are key issues; however accurate identification of PMI, suitable intervention and provision of adequate services are salient contemporary challenges. Coherence in the commissioning of PMI services, appropriate and contextually sensitive to the needs of the locality, remains a critical factor in the provision of high quality, integrated and seamless care. However, such coherence has had difficulty in finding traction, largely as a consequence of complex service and organisational structures and commissioning pathways. This paper discusses many of the issues that must be considered in the provision of high quality PMI services that are sensitive and appropriate for the needs of women and their families in the community. An exemplar of the development of a local service is discussed in detail.

Spiritual care has been recognised as an aspect of nursing for many years. The purpose of this article is to prompt discussion about spirituality and spiritual care in relation to midwifery practice and birth. Application is made to the education of midwives in the U.K. including reference to NMC guidance. Research is identified relating to women's experiences.

Being overweight or obese in pregnancy is associated with an increased risk of poor pregnancy outcomes and long-term ill health for both mother and infant. Midwives, obstetricians and healthcare support workers providing care in pregnancy are ideally placed to provide women with nutritional advice and to facilitate the acquisition of a healthy diet. This survey was undertaken to assess the provision of training in nutrition for providers of maternity care at the Bradford Women's and Newborn unit, to evaluate what nutrition information is given and to find out if care providers were satisfied with the knowledge they had. All relevant staff were approached and asked to complete a questionnaire developed by members of the unit's research team. Findings from this survey highlight the wide range of nutrition information provided by care providers at the unit. Education and training needs are being addressed by managers and a dedicated service is being developed for obese women.

Anxiety and stress in pregnancy can become severe and disabling, negatively impacting on both the short and long term outcomes for mother and baby. Women often seek alternative treatments for such problems, acupuncture being a popular choice. It has been shown to have an effect on the limbic system and on serotonin production, leading to increased feelings of wellbeing. Women having acupuncture in pregnancy have reported increased self esteem and control of symptoms, leading to improved wellbeing. With appropriate training, midwives may be in a good position to offer acupuncture to support women suffering with anxiety, improving outcomes for women and babies.

The Confidential Maternal and Child Enquiry (CMACE) has firmly put maternal mental health at the forefront of maternity care (CMACE 2011). Twenty nine deaths by suicide were reported and over half of these women were married or in stable cohabitation, 30 years of age or older and had a psychiatric history. Given the predictive nature of psychiatric conditions in pregnancy, midwives need to be enabled to identify women at risk, and assess and refer women appropriately. The aim of this article is to give midwives an overview and understanding of the predictability and detectability of perinatal mental illness; to explore some of the tools available; to enable midwives to assess women appropriately for referral; and to address the issue of medication in pregnancy and whilst breastfeeding.

This article exposes the need for support for midwives, to ensure that they are equipped to meet the needs of deaf parents to be. It uncovers research which demonstrates the urgent need for an increase in awareness, education and resources; and the reasons that deaf people have higher rates of teenage pregnancy and sexually transmitted infections than the general population. With stories from midwives at a loss as to how to communicate with deaf mothers in labour, and stories from deaf women who can't understand their health professionals, nor read the literature that has been given to them--this is thought provoking reading.

Systemic lupus erythmatosus (SLE) presents many challenges in pregnancy for the midwife who is increasingly being relied upon to act as coordinator of care, guiding women with complex and high risk medical conditions through maternity pathways, as part of an integrated team. The disease and its pharmacological management are implicated in a range of complications. Primary care provision involves using skilful clinical observation of abnormal signs and symptoms and referring appropriately. The midwife plays a vital role in facilitating primary care provision and all the appropriate support, whilst ensuring that evidence based information is readily available. This enables the woman and her family to achieve the most desirable outcome.

This reflection is an anonymised account of a feticide which I witnessed as a second year midwifery student. Having cared for this woman I found myself unable to put it out of my mind until I wrote it down and asked my mentor and a lecturer to help me debrief. It describes the events themselves as well as my feelings, and uses the Gibbs reflective cycle (Gibbs 1988) to demonstrate insights into my own learning and future development as a midwife.

Experienced health professionals are sharing their skills with midwives and nurses in Ethiopia to improve the education their counterparts receive and help reduce the risks expectant mothers face. In Ethiopia, there are 676 deaths per 100,000 live births compared with an average of 290 per 100,000 in other developing countries and only 6 per cent of women have medical support during labour. International development organisation, Voluntary Service Overseas (VSO) is working with the Ethiopian Government to help them address this workforce shortage by placing experienced volunteer midwives in hospitals, universities and midwifery education institutions. There are many challenges, but volunteers can play a vital role in improving the country's maternal healthcare by teaching midwifery tutors and students and supporting permanent staff.

The musculoskeletal function of vitamin D has been well defined, prompting the population to supplement with vitamin D and calcium to maximise bone growth. However the role of vitamin D in pregnancy has not been systematically studied and is permeated with continuing controversy regarding the cause and effect relationship of vitamin D and pregnancy outcomes. Although further research is needed, the National Institute of Health and Clinical Excellence (NICE) (2008) recommend that all pregnant and breastfeeding women supplement with 10 microgrammes of vitamin D daily. Furthermore midwives and health visitors are asked to educate women about the importance of vitamin D supplementation, at booking and throughout antenatal care. Each appointment presents an opportunity to address concerns and explore options to increase levels through diet and supplementation and address any difficulties in obtaining supplements.

Obstetric cholestasis (OC) is the most common liver condition specific to pregnancy and affects around 5,000 women in the UK every year. It's generally benign for the mother although the main presenting symptom of pruritus can sometimes be so severe that the woman scratches herself until she bleeds. However, the main concerns are for the fetus, as the condition is associated with an increased risk of fetal distress, spontaneous premature labour and stillbirth. This article aims to provide information about the condition so that as a practising midwife you can offer women sufficient support should OC be suspected or diagnosed.

As midwives we strive to provide woman centred holist care and acupuncture fits this paradigm well. It creates an opportunity for a woman to gain control, an alternative to the medical solutions. Studies on neurophysiology may explain why acupuncture has a calming effect. Midwives and obstetricians are well placed to offer pregnant women acupuncture and although more research is needed, there is enough evidence to consider its development within maternity services as an option. This article provides evidence that acupuncture can be an effective treatment and should be a part of informed choice discussions for conditions related to pregnancy.

A number of ear, nose and throat symptoms are often associated with pregnancy, which although transient (most will disappear after birth), can have a significant impact on the woman's quality of life. It is essential therefore that midwives are aware of how such symptoms might present during pregnancy, in order to appropriately inform women and safely manage those symptoms. Tinnitus, the most common ear symptom experienced by women during pregnancy, for some will be a distressing experience and for others may indicate more serious conditions such as pre eclampsia, requiring careful monitoring and confident management.

With the increased advancements of corrective surgery for babies with spina bifida, more women these days affected by spina bifida are reaching child bearing age and having children of their own. This poses both obstetric an medical challenges to ensure the safe care of both the mother and child. This case study explores the healthcare needs of the woman with spina bifida and the medical and obstetric challenges that are posed, particularly in the antenatal period. It examines the role of the midwife in providing holistic co-ordinated care to ensure that the outcome is both positive and empowering.

Smoking in pregnancy has many known risks both to the mother and her developing baby. Yet despite this knowledge, many women continue to smoke throughout pregnancy or relapse postnatally if they did manage to quit before the birth. This article highlights the importance of midwives working together with other professionals to provide smoking cessation support to women and their families. They can do this by providing information about the benefits of stopping smoking, referring to expert support and continually reassessing women's motivation to quit and progress in achieving QUIT status.

Responsibility for health services in Scotland was devolved to the Scottish Parliament in 1999. This inevitably has led to differences within the UK as to how maternity services are shaped and delivered and aims to ensure that initiatives are tailor made for the Scottish population and its health needs. Changes within the Maternity services have been led and supported by policies such as A framework for maternity services (Scottish Executive 2001) and Keeping Childbirth Natural and Dynamic (KCND) (NHS Quality Improvement Scotland (NHS QIS) 2009) which promotes multi professional working and has developed and implemented care pathways.

There is evidence to suggest that pregnancy may trigger or exacerbate domestic violence. Domestic violence is recognised to be a significant contributory factor to maternal and fetal morbidity and mortality. The midwife is ideally placed to recognise domestic abuse and offer care, support and information. This article describes and discusses the multi-complex issues surrounding domestic abuse, highlights possible indicators, how to ask questions, the importance of documenting evidence and explores ways that midwives can be responsive to the needs of abused women and their children.

The UK has entered an era of superdiversity with our communities being more diverse than ever before. Migration has contributed to rising birth rates, and poor birth outcomes have been increasingly associated with ethnicity, often in areas with high concentrations of migrants. This article sets out the findings of a study looking at the maternity needs and experiences of migrant women and professionals living in the West Midlands. The study found that migrant women tended to book late or drop out of the maternity system due to a range of barriers including lack of understanding of the system, lack of information, poor language skills and poverty. Migrant women often had negative birth experiences and did not receive the follow on care they needed. Professionals recognised many of the problems migrant women experienced but lacked the time and resources to meet needs. The article concludes by recognising that additional training and time are needed to help professionals to address those needs and signposts the reader to good practice.

The simplest definition of obstetric cholestasis (OC) is 'sluggish or interrupted bile flow in pregnancy'. In affected women the normal flow of bile out of the liver is reduced and this leads to raised bile salts (also referred to as bile acids) in the blood. This, together with abnormal liver function tests and the symptom of itch, may result in a woman being diagnosed with the condition of OC. Yet OC cannot be classified as one single disease. It is more accurate to think of it as a clinical state where a pregnant woman presents with a specific collection of symptoms and blood results together. This can occur in the context of several disorders, such as hepatitis C infection, adverse drug reaction or acute fatty liver of pregnancy, or can occur as a diagnosis that is only caused by pregnancy. Regardless of the underlying cause, OC is a condition that has the potential threat of stillbirth and myriad variables all of which make it challenging for clinicians to know how to treat and manage it. In this article Jenny and Alice show what these variables are and why there may be a risk of stillbirth.

Alice Ciolino, a midwife from London spent eight months in Ethiopia with Doctors of the World. Her mission was to train Traditional Birth Attendants (TBAs). Based in the Somali region of Ethiopia, access to healthcare facilities was limited; indeed Kebri Dehar had the only hospital in the region. Here Alice shares her experience of what it is like to live and work in a remote part of the world, far from the medical facilities we take for granted in the West.

It is the midwife's role to assess the client's general health, explore her medical, surgical, menstrual, gynaecological, obstetric, psycho-emotional, social and family history thoroughly to ascertain if there are indicators of potential complications in her pregnancy, labour and birth and puerperium. In this article we examine the case of Carla; as there is history of thyroid dysfunction in her family, this could be an indicator towards a diagnosis of thyroid pathology.

With a background in fitness, the benefit of exercise in pregnancy and the postnatal period is a big passion of mine. I have trained and studied in this area since 1999, and have worked as a midwife in community, low risk and an obstetric unit for the last eight years. In addition and outside these roles I have established busy ante and postnatal exercise classes. This article will discuss an ongoing external audit of mine on labour and birth outcomes of women who maintain an exercise programme in pregnancy. It will also make comparison with past pieces of research on exercise in pregnancy.

The recently published Centre for Maternal and Child Enquiries (CMACE) report, Maternal Obesity in the UK: Findings from a National Project, has provided new information on how often we are caring for women who have a body mass index (BMI) of 35 or more, who these women are, the complications and consequences associated with obesity during pregnancy and the preparedness of maternity services to meet these women's needs. Focusing on booking, this article highlights some of the study's key recommendations and discusses the implications for midwives. Accurate calculation of BMI, discussion of dietary advice including supplementation, risk assessment and referral on are all considerations for this consultation.