This month sees a global focus on cancer on World Cancer day. In this article Jude Jones, midwife advisor, and Pete Wallroth, Founder and CEO for Mummy’s Star, discuss the importance of the role of the midwife in recognising symptoms that could be pointing to cancer.
In Mummy’s star and in my role as midwife adviser, Pete and I are presented with questions from midwives and student midwives to enquire if new skills are required to identify symptoms of cancer. This blog aims to answer these anxieties and demonstrate that the power of the role of the midwife is to know our sphere of practice, and that this expertise means we are already equipped with the skill required. Having said that amongst the plethora of symptoms and conditions we as midwives recognise, identifying symptoms which are potentially cancer is challenging.
In the England pregnant and postnatal population cancer is uncommon at approximately 1/1000 (Cancer before, during and after pregnancy PHE 2018), but at Mummy’s Star we seek to support midwives in having the confidence to act and advocate for these individuals. Beyond our role of supporting women and pregnant people and their families during cancer in pregnancy and the first postnatal year, we work closely with midwives nationwide who are involved within this care. Furthermore, we provide an education module at many universities to equip our future midwives with the confidence to best serve those we care for.
It is understandable to be anxious about missing signs that could be cancer. When symptoms of cancer do appear in pregnancy it is recognised that diagnosis can become more difficult because the body is undergoing so much hormonal and physical change. Early indications can be masked and associated with the pregnancy itself such as changes to breast tissue and size. However, two points are essential for the role of the midwife:
- Our midwifery sphere of practice necessitates that when we recognise a symptom as a red flag, we directly refer to our MDT colleagues and then continue to act as lead practitioner for their care. It is the midwife role and expertise that enables the women’s pregnancy and birth experience as well as their baby’s wellbeing be considered and central to subsequent plan of care.
- The midwife’s role is vital in utilising our fundamental skill to develop rapport and trusting relationships with pregnant women and people, hearing their worries or concerns, and acting upon them. It is within our role to empower women and birthing people to recognise their superior knowledge of their own body, to vocalise what ‘normal’ for them means.
Now in the Covid-19 era, the role of a midwife within the cancer pathway has even more potential. With the change to GP appointments being often in a more virtual or telephonic medium, some people are reluctant to either comfortably disclose information via online triage or sharing images of a symptom. Indeed, technological difficulties, access to data, disability, health conditions and language barriers present further communication challenges which can be overcome in a face-to-face setting.
With greater opportunity to be in a face-to-face setting the midwife is key within the diagnostic pathway. When identifying a symptom which requires referral, midwives can refer to a specific MDT specialist instead of, or as well as the GP.
Some examples to illustrate:
- If a pregnant woman discloses a redness/warmth in her breasts a dermatological issue of some kind maybe suspected and require investigation by their GP, but it is also a red flag potential symptom of inflammatory breast cancer. There should be no question that the midwife can refer directly to the breast clinic for follow up
- For PV spotting/bleeds beyond the more common causes such as post coital bleeds, consideration of assessing for cervical abnormality must be planned by midwives to ensure all potential diagnosis have been eliminated
- For abdominal discomfort, extreme constipation&/haemorrhoids is a possibility but an additional consideration should be to bowel cancer warning signs
- For mastitis/nipple discharge/nipple inversion once feeding issues, sepsis, infection have been eliminated consideration of breast cancer warning signs.
Crucially as the UK NHS Trusts are working towards continuity of care model midwives are presented with the opportunity to create the collaborative relationship, we know will best benefit both pregnancy wellbeing, parenthood preparation and their wellbeing of their baby. This connection presents the key opportunity to distinguishing changes in pregnant peoples mental and physiological states. Midwives are presented with a unique chance educate the importance of maintaining regular body checks throughout pregnancy and postnatally. It is the midwife who has opportunity to be the reminder to rebook potentially cancelled smears or mammograms and to deliver the health messages that could led to early identification in the future.
In simple terms midwives in all care episodes have their own technique of asking generic ‘how are you really?’ questions which seek to pinpoint each pregnant person’s wellbeing. Open questions that allow clues of potential deviations to surface, such as ‘are there any changes in your body that are concerning you?’ or ‘Is there anything different in how you feel about yourself or your pregnancy that you would like to tell me about?’ The repetition of these questions at each appointment and visits in continuity of care model provides space for pregnant people to know they can ask a question about the weakness in their right wrist, their recent low mood, a lump on their vulva or the new rash on their breast.
Beyond the generic ‘how are you really?’ based questions we drill down under verbal and behavioural clues; ‘you said that you have felt more anxious this week, is there anything happening in your life which you feel may have led to this increase in anxiety?’ or ‘You asked about normal changes in breasts in pregnancy, is there something you have noticed has changed that you would like to tell me about?’
Although continuity provides the evidenced based relationship in which new changes within a pregnant persons’ body and mental health could be identified, there is a significant portion of our midwife community who practice in single episodes of care in hospital or clinic environments. These single episodes of care can transpire to offer additional opportunities to discuss physical changes. Top to toe examinations in a postnatal ward provides opportunity to discuss a new lump in their breast – how it feels to them, when it appeared, how are they are feeding their baby, and so on. Additionally, these methodical checks required particularly within postnatal care present midwives with the opportunity to scatter health messages within their examination e.g. normal changes in breasts, the normal appearance of lochia and how it changes, and the reminder to book in a smear.
Midwives are already powered with the skill and practice to identify any symptoms outside of the norm for those we are caring for, which may include early signs of cancer. It is midwives who have the relationships and opportunity to educate each woman and pregnant person in knowing their own body. It is midwives that hear the anxieties of those we care for and are best placed to advocate by directly referring to our MDT colleagues to ensure all symptoms are considered. When those rare occurrences of cancer do present to our profession, we do what we do best; we care and put that person at the centre. It is this we would like you to remember. This is the power of the midwife, and we would like to continue to celebrate that, giving confidence and support in any way we can.
Jude Jones RM she/her
Mummy’s Star Midwife Advisor
TALENT Groups Project Manager & Facemums Future Midwife Lead Midwife
Pete Wallroth he/him
CEO/Founder
Mummy’s Star
Mummy’s Star: Cancer Support in & around Pregnancy, Birth, Loss or Beyond