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The transformative power of birth

Induction of labour, epidural analgesia, and caesarean section are now common themes in many women’s birth stories. Women are often fearful of childbirth which may drive them to seek out medical intervention without a medical reason (Nilsson et al., 2018). Indeed, fragmented hospital maternity care supports the view that pregnancy and birth are inherently dangerous and require management and control. From this perspective, labour pain is viewed as needing ‘relief’ and the use of epidural analgesia is seen as normal practice (Newnham, McKellar, & Pincombe, 2016). The community generally lack knowledge about normal birth and in particular, the benefits of physiological birth (Wong, He, Shorey, & Koh, 2017). However, having a vaginal birth with minimal interference has considerable benefits for women and their babies in both the short and long term.

Birth is a process best supported by a known and trusted midwife

Birth is a normal and deeply significant psychological and social event in a woman’s life – and in most instances does not require medical rescue or relief. Further, there is considerable evidence that birth is best supported by a known midwife who provides reassurance, nurturing and comfort (Walsh, 2006), so that a woman can work with pain rather than resist it (Leap, Sandall, Buckland, & Huber, 2010), and feel safe enough to ‘let go’ (Anderson, 2000). When women are supported in this way, birth has the potential to be positively transformative, producing a sense of inner strength, triumph, and bliss. These transformative experiences have a lasting impact on the woman’s sense of self (Schwartz et al 2015), confidence as a new mother (Fenwick et al 2015), and relationship with her newborn (Toohill et al 2014).

New theory explains the positive potential of birth-giving

While the subject of birth trauma is gaining traction, women’s potential to positively transform through birth is not well understood. New research has addressed this gap and developed new language that can facilitate women’s conversations about their experiences. PhD candidate Ella Kurz applied feminist theory to childbirth to develop a theory that explains the transformative power of giving birth (Kurz, Davis & Browne, 2021).

The new theory, Parturescence, describes the process of women ‘becoming’ through childbirth (Kurz et al., 2021). Positive transformation results in better psycho-social well-being after birth. Whereas negative transformation includes birth trauma and psychological injury following birth. Parturescence theory refers to lines of descent (activities that bring predictability and control in birth) and lines of ascent (activities which open new ways of thinking and being). Importantly, the challenging and destabilising parts of labour and birth – and how these are mediated by maternity care – are key to women’s positive or negative transformation (Kurz et al., 2021). Midwife-woman interactions can facilitate negative or positive transformation through birth (Kurz et al., 2021). Midwives need to have the motivation and capacity to support women to feel safe, loved, relaxed and unafraid during birth – but not all midwives behave this way (Allen, Kildea, Hartz, Tracy, & Tracy, 2017). Recent research has demonstrated the importance of midwives’ social and emotional competence to establish and maintain positive relationships (Hastie & Barclay, 2021).

What does this mean for women and maternity services?

Birth has intrinsic value for women and their babies – and this should be reflected in how maternity care is organised and provided. Women and the wider community should know that women benefit from the continuous supportive presence of a known and trusted midwife who can hold the space while they transform triumphant into motherhood. Importantly, when women are treated with respect and compassion, regardless of mode of birth, there is potential for positive transformation.

Highlighted research

Kurz, E., Davis, D., & Browne, J. (2021). Parturescence: A theorisation of women’s transformation through childbirth. Women and Birth. https://doi.org/10.1016/j.wombi.2021.03.009

References

Allen, J., Kildea, S., Hartz, D. L., Tracy, M., & Tracy, S. (2017). The motivation and capacity to go ‘above and beyond’: Qualitative analysis of free-text survey responses in the M@NGO randomised controlled trial of caseload midwifery. Midwifery, 50, 148-156. https://doi.org/10.1016/j.midw.2017.03.012

Anderson, T. (2000). Feeling safe enough to let go: the relationship between a woman and her midwife during the second stage of labour. In M. Kirkham (Ed.), The Midwife–Mother Relationship. Macmillan Press.

Fenwick J, Toohill J, Gamble J, Creedy DK, Buist A, Turkstra E, Sneddon A, Scuffham PA, & Ryding EL. (2015). Effects of a midwife psycho-education intervention to reduce childbirth fear on women’s birth outcomes and psychological well-being. BMC Pregnancy & Childbirth, 15, 284. https://doi.org/10.1186/s12884-015-0721-y

Hastie, C. R., & Barclay, L. (2021). Early career midwives’ perception of their teamwork skills following a specifically designed, whole-of-degree educational strategy utilising groupwork assessments. Midwifery. https://doi.org/10.1016/j.midw.2021.102997

Kurz, E., Davis, D., & Browne, J. (2021). Parturescence: A theorisation of women’s transformation through childbirth. Women and Birth. https://doi.org/10.1016/j.wombi.2021.03.009

Leap, N., Sandall, J., Buckland, S., & Huber, U. (2010). Journey to Confidence: Women’s Experiences of Pain in Labour and Relational Continuity of Care. Journal of Midwifery & Women’s Health, 55(3), 234-242. https://doi.org/10.1016/j.jmwh.2010.02.001

Newnham E., McKellar L., & Pincombe, J. (2016). A critical literature review of epidural analgesia. Evid Based Midwifery, 14(1), 22-28.

Nilsson, C., Hessman, E., Sjöblom, H., Dencker, A., Jangsten, E., Mollberg, M., . . . Begley, C. (2018). Definitions, measurements and prevalence of fear of childbirth: a systematic review. BMC Pregnancy Childbirth, 18(1), 28. https://doi.org/10.1186/s12884-018-1659-7

Schwartz L, Toohill J, Creedy DK, Baird K, Gamble G & Fenwick J. (2015) Factors associated with childbirth self-efficacy in childbearing women. BMC Pregnancy and Childbirth, 15:29.

Wong, C. Y. W., He, H. G., Shorey, S., & Koh, S. S. L. (2017). An integrative literature review on midwives’ perceptions on the facilitators and barriers of physiological birth. International Journal of Nursing Practice, 23(6). https://doi.org/10.1111/ijn.12602

Midwives’ social and emotional competence key to quality maternity care

Midwives social and emotional skills matter – they matter to women and families, and they matter when working in a maternity care team.  Social and emotional competence starts with self-awareness, identifying one’s own reactions to situations and people, then developing the ability to widen the gap between our reaction and our response. Managing and self-regulating the emotional response when communicating with others is key to sustaining positive relationships – including when conflict arises. But empathy, self-regulation and conflict resolution skills may not come naturally and are rarely taught in undergraduate midwifery programs (Hastie & Barclay, 2021).

Interactions within the healthcare team

Positive workplace culture and effective teams are built by staff who demonstrate social and emotional competence (Hughes & Albino, 2017; Black et al., 2019). When teamwork is compromised, often through negative workplace culture, it harms mothers and babies (Rönnerhag et al., 2019), and leads to staff burnout and high turnover (Catling et al., 2017). An Australian national survey of midwifery workplace culture largely described poor communication, lack of leadership and support, and bullying (Catling et al., 2020). Teamwork function is undermined by poor communication between team members, an absence of shared goals, or lack of social and emotional skills (Best & Kim, 2019).

Skills required for teamwork can be taught

PhD candidate Carolyn Hastie recently examined whether teaching and assessing teamwork skills prepares undergraduate midwifery students to be effective team members when they graduate (Hastie & Barclay, 2021 – see article here). The researchers analysed interviews with 19 early career midwives who had learnt, practised, and assessed each other on teamwork skills developed through group assignments in their Bachelor of Midwifery program.

Teamwork central to practice

The research found that in their first year, midwifery students did not appreciate how central teamwork was to their future practice as a midwife (Hastie & Barclay, 2021). Participants described that group assignments were hard and tiresome, and some wrote off social and emotional skills as less important and “fluffy”. However, as new graduates they reflected that teamwork at university had prepared them for teamwork in the hospital setting.

Conflict inevitable but manageable

The participants acknowledged that conflict was an inevitable part of midwifery work (Hastie & Barclay, 2021). Participants found they had learnt how not to take rude or challenging behaviour personally. They reflected that they were more likely to see the situation from the other person’s viewpoint. This stance helped them to regulate their emotional reactions and to respond in a more considered and constructive way.

Advocating for self and others

These midwives used strategies they had learnt to have courageous conversations and address issues early, with one stating “rather than letting it fester, nip it in the bud”. When interacting with colleagues, that could mean asking direct questions (e.g., what was your rationale?) – or providing an alternative viewpoint (i.e., politely disagreeing, and explaining why). These skills are particularly important in terms of speaking up for safety and advocating for women.

Recommendations for practice

Midwives can strengthen their social and emotional competence by increasing their self-awareness. This might include reflecting on difficult interactions in practice through journaling or debriefing with a trusted colleague, participating in clinical supervision, or learning and practising mindfulness. Maternity services should consider the social and emotional competencies managers and midwives need to contribute to an effective team and positive workplace culture – and which steps would increase staff capability. Social and emotional competence matters to safe, quality maternity care.

References 

Best, J. A., & Kim, S. (2019). The FIRST curriculum: Cultivating speaking up behaviors in the clinical learning environment. Journal of Continuing Education in Nursing, 50 (8) (2019), pp. 355-361. https://doi.org.10.3928/00220124-20190717-06

Black, J., Kim, K., Rhee, S., Wang, K., & Sakchutchawan, S. (2019). Self-efficacy and emotional intelligence. Team Performance Management: An International Journal, 25(1/2), 100-119. https://doi.org/10.1108/tpm-01-2018-0005

Catling, C. J., Reid, F., & Hunter, B. (2017).  Australian midwives’ experiences of their workplace culture. Women and Birth, 30(2) (2017), pp. 137-145. https://doi.org/10.1016/j.wombi.2016.10.001

Catling, C., & Rossiter, C. (2020). Midwifery workplace culture in Australia: A national survey of midwives. Women Birth, 33(5), 464-472. doi:10.1016/j.wombi.2019.09.008

Hastie, C. R., & Barclay, L. (2021). Early career midwives’ perception of their teamwork skills following a specifically designed, whole-of-degree educational strategy utilising groupwork assessments. Midwifery, 102997. https://doi.org/10.1016/j.midw.2021.102997

Hughes, M., & Albino, J. (2017). Assessing emotional and social intelligence for building effective hospital teams. The Psychologist-Manager Journal, 20(4), 208-221. https://doi.org/10.1037/mgr0000058

Rönnerhag, M., Severinsson, E., Haruna, M., & Berggren, I. (2019). A qualitative evaluation of healthcare professionals’ perceptions of adverse events focusing on communication and teamwork in maternity care. Journal of Advanced Nursing75(3), 585–593. https://doi.org/10.1111/jan.13864

VBAC: How risk perception contributes to the caesarean section rate. An opinion piece.

During the final year of the Bachelor of Midwifery at Griffith University, midwifery students are asked to write an opinion piece focussed on normal birth that could be published. Dr Jyai Allen convenes this course and supported the students to complete this work. Several of these were of such good quality that we offered students the option of having them published here. This is the final one of five articles in a series. The author of this article preferred to publish anonymously. 

The current caesarean section birth rate in Australia is approximately 34% (Australian Institute of Health and Welfare [AIHW], 2019). After a caesarean section, most Australian women choose to have an elective caesarean section for subsequent births, with only 12-13% of women choosing to attempt a vaginal birth after caesarean section (VBAC) (Meredith & Hugill, 2016). The reason for this seems to be the perceived risks of VBAC as opposed to an elective caesarean, with the primary concern for women being an increased risk of uterine rupture (Black et al., 2016). Repeat elective caesarean births contribute to Australia’s high caesarean section rate, far above the World Health Organization’s recommendation based on evidence that caesarean section rates over 10% do not improve health outcomes. Given that the success rate for vaginal birth after caesarean section is 72-75%, increasing to 85-90% for women who have had a vaginal birth before (Royal Australian and New Zealand College of Obstetricians and Gynaecologists, 2019), the question can be asked why the VBAC attempt rate is so low, considering the risks of this type of birth is low.

Birth has biological, cultural, social, and political influences (Behruzi et al., 2013). Socially, birth is shaped by the society women live in, with culture, social class, and resources contributing to decision-making (Behruzi et al. 2013). Research shows that decisions regarding the mode of birth are partially influenced by discussions of birth stories with other women, which often focus on negative aspects and experiences of their births (Latifnejad Roudsari et al., 2015). Social conformity also influences birth and birth choices, with values and ideas of women often reflecting the views of those around them, including family, friends and health professionals (Behruzi, et al., 2013). In a society and country where birth primarily takes places in a medicalised environment where maternity care providers are influenced by medical culture, these views can be projected onto women in a direct or indirect way. This is certainly true during consultation and provision of information regarding mode of birth after caesarean section, with evidence showing that both direct and subtle influences by maternity care providers greatly impacting women’s decisions on mode of birth (Black et al., 2016). How statistics and information are presented to women alters their perception of risk, with VBAC often being perceived by woman as much more risky than in actuality (Meredith & Hugill, 2016).

Medicalisation of birth is an issue that women and midwives are constantly contending with while trying to achieve normal birth. Medical models of birth take a risk-based approach that assumes birth to be risky and leads women to believe that these risks can be managed and reduced with the aid of medical technology (Cummins, 2020). Media contributes to the medicalisation of birth, as most portrayals of birth in film and television are overly medicalised. While most women might be consciously aware that these depictions of birth are not factual nor a reality, it has been shown that media representations of birth are subconsciously still informing women and providing them with expectations (Cummins, 2020). With this expectation that birth should be medically managed, trust in birth decreases and women are more easily influenced into birth interventions. Research also shows that births portrayed in film and television generates fear of birth and this affects the birth choices made by women (Luce et al., 2016). Takeshita (2017) finds that as well as creating fear of birth, media trivialises women’s capacity to give birth and overlooks midwifery. Collectively this contributes to the culture of birth in Australia, where many women and families consider birth to be considerably risky. In a birth culture focused on risk, perception of risk can be disproportionate to actual risk and this is apparent when looking at the low rates of VBAC in Australia.

One way to help combat these socio-cultural issues is through provision of an antenatal care environment that is encouraging of active participation by the woman in care and discussions (Chen et al., 2019). This is especially important for women making decisions on mode of birth after a caesarean section and improves the VBAC attempt rate (Chen et al., 2019). Continuity of care with a known midwife would be the ideal model of care for active participation and holistic conversation, however fragmented care is still the norm in maternity care in Australia. Women planning VBAC who had continuity of care with a midwife felt more in control of decision- making, more confident, and more supported than those who received fragmented care or care with a doctor (Keedle et al., 2020). Midwives have a professional obligation to promote normal birth (Australian College of Midwives [ACM], 2018). However, midwives also acknowledge the necessity to remove bias when presenting women with evidence-based information and this can lead them to omit the positive aspects of vaginal birth. When providing information on VBAC, midwives should present evidence to women on both the actual risk of VBAC as well as risks associated with caesarean section birth. In addition to this, in order to promote holistic health and wellbeing, midwives should also discuss the positive benefits of vaginal birth for women and babies, rather than focusing solely on the risks of both modes of birth. According to women seeking VBAC this in not demonstrated in practice, with communication being mostly risk-orientated (Nilsson et al., 2017). In a culture that is both risk adverse and reliant on technology, failing to highlight the benefits of normal birth focusses on risk and women are more inclined to choose a medicalised technocratic approach to birth (Behruzi, 2013). Understanding social attitudes about birth is important to foster a positive understanding and attitude towards vaginal birth, in order to decrease population caesarean section rates and promote health (Latifnejad Roudsari et al., 2015). Thus fulfils midwives’ professional standards to promote health and wellbeing by identifying what is important to women as the foundation for using evidence to promote informed decision-making, participation in care, and self-determination (ACM, 2018).

Analysis of successful VBAC in countries with high VBAC rates has confirmed the importance of provision of information in a supportive manner, understanding of benefits of VBAC, the support of trusting maternity care provider during birth, letting go of past negative birth experiences, and viewing VBAC as the goal when no other complications are present (Nilsson et al., 2017). Continuity of care with a midwife for women would help all of these factors associated with increased VBAC rate. Given the low risk involved in VBAC for most women, midwives and doctors can have confidence in recommending and supporting VBAC to change the default mode of birth after caesarean section from a repeat caesarean to VBAC.

References 

Australian College of Midwives. (2018). Midwife standards for practice. Retrieved from https://www.nursingmidwiferyboard.gov.au/documents/default.aspx?record=WD18%2f252 81&dbid=AP&chksum=kYbO0%2bO7kx9I%2fBlvmKH%2bwg%3d%3d

Australian Institute of Health and Welfare. (2019). National Core Maternity Indicators. https://www.aihw.gov.au/reports/per/095/ncmi-data-visualisations/contents/labour- birth/b5

Behruzi, R., Hatem, M., Goulet, L., Fraser, W., & Misago, C. (2013). Understanding childbirth practices as an organizational cultural phenomenon: A conceptual framework. BMC Pregnancy and Childbirth, 13(1), 205. doi:10.1186/1471-2393-13-205

Black, M., Entwistle, V. A., Bhattacharya, S., & Gillies, K. (2016). Vaginal birth after caesarean section: Why is the uptake so low? Insights from a meta-ethnographic synthesis of women’s accounts of their birth choices. BMJ Open, 6(1), e008881. doi:10.1136/bmjopen-2015- 008881

Chen, M. M., McKellar, L., & Pincombe, J. (2017). Influences on vaginal birth after caesarean section: a qualitative study of Taiwanese women. Women and Birth, 30(2), e132-e139. doi:1016/j.wombi.2016.10.009

Cummins, M. W. (2020). Miracles and home births: The importance of media representations of birth. Critical Studies in Media Communication, 37(1), 85-96. doi:10.1080/15295036.2019.1704037

Keedle, H., Peters, L., Schmied, V., Burns, E., Keedle, W., & Dahlen, H. G. (2020). Women’s experiences of planning a vaginal birth after caesarean in different models of maternity care in Australia. BMC Pregnancy and Childbirth, 20(1), 1-15. doi:10.1186/s12884-020-03075-8

Latifnejad Roudsari, R., Zakerihamidi, M., & Merghati Khoei, E. (2015). Socio-cultural beliefs, values and traditions regarding women’s preferred mode of birth in the north of Iran. International Journal of Community Based Nursing and Midwifery, 3(3), 165-176.

Luce, A., Cash, M., Hundley, V., Cheyne, H., van Teijlingen, E., & Angell, C. (2016). “Is it realistic?” the portrayal of pregnancy and childbirth in the media. BMC Pregnancy and Childbirth, 16(1), 40. doi:10.1186/s12884-016-0827-x

Meredith, D., & Hugill, K. (2016). ‘Once a caesarean, always a caesarean’? Challenging perceptions around vaginal birth after caesarean. British Journal of Midwifery, 24(9), 616-623.

Nilsson, C., van Limbeek, E., Vehvilainen-Julkunen, K., & Lundgren, I. (2017). Vaginal birth after caesarean: Views of women from countries with high VBAC rates. Qualitative Health Research, 27(3), 325-340. doi:10.1177/1049732315612041

Royal Australian and New Zealand College of Obstetricians and Gynaecologists. (2019). Birth after previous caesarean section. https://ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical-Obstetrics/Birth-after-previous-Caesarean-Section-(C-Obs-38)Review-March-2019.pdf?ext=.pdf

Takeshita, C. (2017). Countering technocracy: “Natural” birth in The Business of Being Born and Call the Midwife. Feminist Media Studies, 17(3), 332-346. doi:10.1080/14680777.2017.1283341

No Pain, No Gain? An opinion piece

During the final year of the Bachelor of Midwifery at Griffith University, midwifery students are asked to write an opinion piece focussed on normal birth that could be published. Dr Jyai Allen convenes this course and supported the students to complete this work. Several of these were of such good quality that we offered students the option of having them published here. This is the fourth articles in a series of five. This article was written by Monique Matthews.

No Pain, No Gain?

Many women express wanting a ‘drug free labour’ or a ‘natural/normal birth’. The International Confederation of Midwives (ICM) definition of normal birth, requires the process to occur without any surgical, medical, or pharmacological intervention.

Pharmacological pain relief are interventions that include, epidural, opioids (morphine) and nitrous oxide (happy gas). Women not using pharmacological pain relief have many options. These include heat, hydrotherapy/water immersion (shower/bath), acupressure and acupuncture, hypnosis, relaxation, breathing, massage, yoga, transcutaneous electrical nerve stimulation (TENS), aromatherapy, sterile water injections, and a birth ball. These techniques are termed non-pharmacological pain relief.

In 2018 in Australia, 21% of women exclusively used only non-pharmacological pain relief, whereas, 78% of women used pharmacological pain relief during labour. With a high rate of pharmacological pain relief and the known negative impacts of these techniques, the question needs to be asked: why have non-pharmacological techniques, that are less invasive and more natural, become the alternative rather than the standard option?

History

Techniques for pain relief in labour have changed throughout history, largely influenced by their availability and the values of practitioners. The earliest techniques were midwifery based, which facilitated the natural physiology of labour in the home with family support and only intervened in life threatening difficulties. Many of these non-pharmacological techniques are still used today.

In the early 1700s birth moved from midwifery to obstetrics as formal biomedical training started institutionalising birth in the hospital. Doctors perspectives became greatly influential. Doctor Joseph Lee likened women’s experience of childbirth to falling on a pitchfork and he wanted to rid childbirth of “unskilled” labour assistance. This enforced the idea that women were unable to cope with labour pain and they required professional help to survive. Pain became a target of medical intervention.

Pain relief techniques in labour through the 1800s and 1900s introduced pharmacological pain relief such as chloroform, nitrous oxide and a mixture of morphine (pain relief) and scolimeine (memory loss) coined ‘twilight sleep’. Women were barely conscious while giving birth, dehumanising the process and causing extensive trauma. In the 1960s, epidural pain relief gained popularity. An interest in returning to non-pharmacological birthing practices also emerged around this time, as the experience of pain was considered empowering for women. By 1990, women’s rights to pain relief were again promoted for a technological, pain free birth.

Today, the primary healthcare provider for a woman in labour in Australia can be a doctor or midwife. Women’s views on what techniques they will use during labour are diverse, as they are impacted by their social and cultural learning, the media, and the ongoing medicalisation of birth.

Biomedical Paradigm

While the ICM’s definition of normal birth excludes the use of pharmacological intervention, the Queensland Clinical Guidelines definition includes the use of nitrous oxide, normalising pharmacological pain relief. Within the guideline the term ‘non-pharmacological support’ is consistently used. This situates these techniques within a biomedical paradigm, with risk and pathology as the dominant discourse. This implies that these natural and traditional techniques are inferior, by stating that they are ‘other’ than the dominant pharmacological techniques.

This position is often supported in media representations where women are unrealistically shown lying on a bed, out of control, screaming for pain relief. Today, this is a more common source of information than having been present at an actual birth. The expectations women form, impact their experience of pain as it is a subjective experience, influenced by social and cultural learnings.

Physiological vs medical approaches to pain

When women experience uterine contractions, the pain is physiological rather than pathological. This pain is considered beneficial, as it emphasises the need for support, heightens elation and triggers hormones to support wellbeing. During labour, women naturally produce hormones (oxytocin and endorphins) that counter the intensity of the pain experienced. Stress hormones (catecholamines and cortisol) can override this natural pain relief when women experience fear or a lack of trust. If women and midwives understand these hormonal processes and use non-pharmacological techniques to enhance them, the fear cascade can be avoided.

If labour pain is a subjective experience, why is a medical approach, based on objective principles, used?

The biomedical paradigm views birth as a mechanical process requiring intervention for efficacy and safety. Using pharmacological pain relief changes labour from a physiological process to a medical procedure as side effects require management.

Nitrous oxide can cause nausea, vomiting, dizziness, and drowsiness. Morphine crosses the placenta lowering the baby’s breathing rate and alertness at birth. Women can also experience excessive sedation, a lowered breathing rate and nausea. Epidurals increase instrumental vaginal birth rates by 500% and can increase the use of synthetic oxytocin, length of labour, low blood pressure, and a less positive birth experience.

As non-pharmacological techniques have less side effects, why are they not better promoted? The answer may lie in the cost effectiveness of these techniques, which do not make manufacturers as much money, causing them to be understudied, which lessens practitioner’s confidence in the techniques. Sara Wickham articulates this point well when she said “Ethically, medical intervention has to prove itself against nature. Not the other way around”.

Power Play

Women can be empowered during their birth experience through woman-led, self-generating techniques that involve partners. However, pharmacological pain relief shifts power from the woman to the practitioner. This phenomenon occurs as standard monitoring is required to deem whether the situation is ‘safe’ to continue labour, creating parameters that may exclude women from decisions.

The power of suggestion can impact which techniques women use during labour. If midwives and practitioners are afraid of being with women in pain, they may offer increased pain relief when they feel the woman needs it, rather than upon request. Women have described feeling coerced and being presented with false dilemmas with limited choices. Consent is not valid in these situations if the risks of pharmacological pain relief are not fully disclosed, or the information is tailored by midwives. Research on epidurals, found they are sometimes used as a substitute for continuous support.

This raises the question: Is pain relief used more often for the convenience of practitioners, rather than to meet the needs of women?

Pain relief is a human right!

Access to pain relief is considered a human right. Some women accessing maternity care may state that they want an epidural immediately or make the decision to use pharmacological pain relief when they were not initially planning to. This is their right. However, pain perception is influenced by social and cultural learnings, medicalisation, and the media. This may not include evidence-based information on birth physiology and adequate support for non-pharmacological pain relief techniques.

A study on pain relief in labour found epidurals were considered the most effective pain relief, nonetheless, water birth was associated with higher levels of satisfaction than epidural use. Predictors for a positive birth experience include a positive attitude and support from midwives, ability to mobilise, confidence & autonomy, inclusion of partners and a safe birthing environment. Birth satisfaction does not solely depend on the level of pain experienced, but the care provided. Women’s autonomy is promoted when non-pharmacological techniques are appropriately explained and used.

Reframing non-pharmacological pain relief

Non-pharmacological pain relief needs to be reconceptualised. Labour is not a problem to be solved but an experience to be worked through. Non-pharmacological techniques enhance this experience and most are easily implemented, affordable, and effective in helping women and their partners actively engage in their care. Midwives, as the protectors of normal birth, should be confident to inform, promote and facilitate the use of non-pharmacological techniques during labour.

Pain relief techniques offered to women during labour are influenced by the opinions and values of their care provider. A mindset change in the way midwives and practitioners present choices to women could increase understanding of the benefits of non-pharmacological pain relief in labour. Discussing non-pharmacological pain relief options not defined by the medical paradigm, but rather, validated in their own right, could improve women’s confidence in their labour choices. Using words such as intuitive or natural techniques would be more appropriate.

Women’s decisions are influenced by social and cultural norms. Birthing choices can be positively influenced, by providing information around birthing techniques based on evidence, that focuses on women’s needs. Comprehensive discussion during antenatal care of physiology in labour and all of the pain relief techniques available, including the risks and benefits, would ensure women are adequately informed.

Current labour care is not always focused on women’s needs. Social and cultural learnings from media sources informed by a biomedical paradigm have influenced midwives and women to discount the benefits of non-pharmacological pain relief. Pharmacological pain relief techniques are being used in a majority of births without necessarily providing the best experiences. Non-pharmacological pain relief techniques, which have been effective since traditional midwifery care, enhance the physiological process, support women’s autonomy and can facilitate a positive birth.

So, I challenge you, instead of questioning whether non-pharmacological pain relief techniques are adequate labour care, question whether all pain relief techniques are being adequately facilitated and ask – who is benefiting from these choices?

References

Abdul-Sattar Khudhur Ali, S., & Mirkhan Ahmed, H. (2018, 2018/06/01/). Effect of change in position and back massage on pain perception during first stage of labor. Pain Management Nursing, 19(3), 288-294. https://doi.org/https://doi.org/10.1016/j.pmn.2018.01.006

Amiri, P., Mirghafourvand, M., Esmaeilpour, K., Kamalifard, M., & Ivanbagha, R. (2019). The effect of distraction techniques on pain and stress during labor: a randomized controlled clinical trial. BMC Pregnancy and Childbirth, 19(1), 1-9. https://doi.org/10.1186/s12884-019-2683-y

Aune, I., Brøtmet, S., Grytskog, K. H., & Sperstad, E. B. (2020). Epidurals during normal labour and birth — Midwives’ attitudes and experiences. Women and Birth, in press. https://doi.org/https://doi.org/10.1016/j.wombi.2020.08.001

Australian College of Midwives. (2016). Scope of Practice for Midwives in Australia. https://www.midwives.org.au/sites/default/files/uploaded-content/field_f_content_file/acm_scope_of_practice_for_midwives_in_australia_v2.1.pdf

Bonapace, J., Gagné, G.-P., Chaillet, N., Gagnon, R., Hébert, E., & Buckley, S. (2018). No. 355-Physiologic basis of pain in labour and delivery: An evidence-based approach to its management. Journal of Obstetrics and Gynaecology Canada, 40(2), 227-245. https://doi.org/10.1016/j.jogc.2017.08.003

Brennan, F., Carr, D., & Cousins, M. (2016). Access to pain management—Still very much a human right. Pain Medicine, 17(10), 1785-1789. https://doi.org/10.1093/pm/pnw222

Czech, I., Fuchs, P., Fuchs, A., Lorek, M., Tobolska-Lorek, D., Drosdzol-Cop, A., & Sikora, J. (2018). Pharmacological and non-pharmacological methods of labour pain relief—Establishment of effectiveness and comparison. International Journal of Environmental Research and Public Health, 15(12), 2792. https://doi.org/10.3390/ijerph15122792

Fockler, M. E., Ladhani, N. N. N., Watson, J., & Barrett, J. F. R. (2017, 2017/06/01/). Pregnancy subsequent to stillbirth: Medical and psychosocial aspects of care. Seminars in Fetal and Neonatal Medicine, 22(3), 186-192. https://doi.org/https://doi.org/10.1016/j.siny.2017.02.004

Gönenç, İ. M., & Dikmen, H. A. (2020, 2020/03/01/). Effects of dance and music on pain and fear during childbirth. Journal of Obstetric, Gynecologic & Neonatal Nursing, 49(2), 144-153. https://doi.org/https://doi.org/10.1016/j.jogn.2019.12.005

Happel-Parkins, A., & Azim, K. A. (2016). At pains to consent: A narrative inquiry into women’s attempts of natural childbirth. Women and Birth, 29(4), 310-320. https://doi.org/10.1016/j.wombi.2015.11.004

Health, A. I. o., & Welfare. (2020). Australia’s mothers and babies 2018—in brief. https://www.aihw.gov.au/reports/mothers-babies/australias-mothers-and-babies-2018-in-brief

International Confederation of Midwives. (2014). Position Statement: Keeping Birth Normal. https://www.internationalmidwives.org/assets/files/statement-files/2018/04/keeping-birth-normal-eng.pdf

Keedle, H., Schmied, V., Burns, E., & Dahlen, H. G. (2019). A narrative analysis of women’s experiences of planning a vaginal birth after caesarean (VBAC) in Australia using critical feminist theory. BMC Pregnancy and Childbirth, 19(1), 142-115. https://doi.org/10.1186/s12884-019-2297-4

Luce, A., Cash, M., Hundley, V., Cheyne, H., van Teijlingen, E., & Angell, C. (2016, 2016/02/29). “Is it realistic?” the portrayal of pregnancy and childbirth in the media. BMC Pregnancy and Childbirth, 16(1), 40. https://doi.org/10.1186/s12884-016-0827-x

Lundgren, I., Healy, P., Carroll, M., Begley, C., Matterne, A., Gross, M. M., Grylka-Baeschlin, S., Nicoletti, J., Morano, S., Nilsson, C., Lalor, J., Sahlgrenska, a., Göteborgs, u., Gothenburg, U., Institutionen för vårdvetenskap och, h., Institute of, H., Care, S., & Sahlgrenska, A. (2016). Clinicians’ views of factors of importance for improving the rate of VBAC (vaginal birth after caesarean section): a study from countries with low VBAC rates. BMC Pregnancy and Childbirth, 16(1), 350. https://doi.org/10.1186/s12884-016-1144-0

MacIvor Thompson, L. (2019). The politics of female pain: women’s citizenship, twilight sleep and the early birth control movement. Medical Humanities, 45(1), 67. https://doi.org/10.1136/medhum-2017-011419

Mills, T. A., Ricklesford, C., Heazell, A. E. P., Cooke, A., & Lavender, T. (2016, 2016/05/06). Marvellous to mediocre: findings of national survey of UK practice and provision of care in pregnancies after stillbirth or neonatal death. BMC Pregnancy and Childbirth, 16(1), 101. https://doi.org/10.1186/s12884-016-0891-2

Nodine, P. M., Collins, M. R., Wood, C. L., Anderson, J. L., Orlando, B. S., McNair, B. K., Mayer, D. C., & Stein, D. J. (2020). Nitrous oxide use during labor: Satisfaction, adverse effects, and predictors of conversion to neuraxial analgesia. Journal of Midwifery & Women’s Health, 65(3), 335-341. https://doi.org/10.1111/jmwh.13124

Queensland Clinical Guidelines. (2017). Normal Birth. https://www.health.qld.gov.au/__data/assets/pdf_file/0014/142007/g-normalbirth.pdf

Sanders, R. (2015, 2015/09/01/). Functional discomfort and a shift in midwifery paradigm. Women and Birth, 28(3), e87-e91. https://doi.org/https://doi.org/10.1016/j.wombi.2015.03.001

Sanders, R. A., & Lamb, K. (2017). Non-pharmacological pain management strategies for labour: Maintaining a physiological outlook. British Journal of Midwifery, 25(2), 78-85. https://doi.org/10.12968/bjom.2017.25.2.78

Skowronski, G. A. (2015). Pain relief in childbirth: changing historical and feminist perspectives. Anaesthesia and Intensive Care, 43, 25-28. http://hy8fy9jj4b.search.serialssolutions.com/directLink?&atitle=Pain+relief+in+childbirth%3A+changing+historical+and+feminist+perspectives&author=Skowronski%2C+G+A&issn=0310057X&title=Anaesthesia+and+Intensive+Care&volume=43&issue=&date=2015-07-01&spage=25&id=doi:&sid=ProQ_ss&genre=article

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Access to water immersion for labour and birth during the pandemic: an opinion piece

During the final year of the Bachelor of Midwifery at Griffith University, midwifery students are asked to write an opinion piece focussed on normal birth that could be published. Dr Jyai Allen convenes this course and supported the students to complete this work. Several of these were of such good quality that we offered students the option of having them published here. This is the first of five articles in a series. The author of this article preferred to publish anonymously. 

Access to water immersion for labour and birth during the pandemic: an opinion piece

There is no denying that COVID-19 has completely changed the world (United Nations Children’s Fund, 2020). Many populations have been unequally disadvantaged by the global pandemic, including childbearing women (Gausman & Langer, 2020). It has been a period of heightened anxiety as new policies aimed at flattening the curve have limited women’s birth preferences and choices (Australian College of Midwives [ACM], 2020a). This includes the Royal Australian and New Zealand College of Obstetrics and Gynecology (RANZCOG) recommendation to suspend the use of water immersion for all labouring women within COVID-19 hotspots (ACM, 2020a). Whilst staunchly opposed by ACM (2020a), this position statement has been adopted by health services across the nation including the Department of Health and Human Services [DHHS] in Victoria (2020). The topic is controversial as the suspension of access to water immersion is not supported by evidence (Centres for Disease Control [CDC], 2020a) and devalues a woman’s autonomy and right to self-determination.

Midwives have a professional obligation to advocate for evidence-based practices that empower women and promote normal birth. Water immersion during labour is associated with positive outcomes and should be available to all low-risk women who are presumed or confirmed COVID-19 negative.

Arguments for the suspension

Let us consider the evidence for suspending water immersion in the context of a woman with a confirmed positive COVID-19 test result. The rationale behind RANZCOGs recommendation was the protection of healthcare workers (ACM, 2020a; 2020b). Concerns have been raised regarding the level of protection provided by personal protective equipment when immersed in water (DHHS, 2020; Royal College of Midwives [RCM], 2020). It was also believed the moist atmosphere of the birth pool room could increase the risk of droplet transmission (RCM, 2020).

Some evidence contradicts this viewpoint, however, finding the virus is less likely to be transmitted in humid environments (Qi et al., 2020). Given that COVID-19 is not a waterborne virus, it is believed that liquid may dilute contamination and therefore reduce the potential risk of transmission (ACM, 2020a). Another potential benefit from water immersion is that the birth pool aids in physical distancing by providing a barrier between women and care providers (Burns et al., 2020; Ulfsdottir et al., 2018).

Another concern that was raised was faecal-oral transmission of COVID-19 within a birth pool. While some studies suggest the virus can be transmitted through faeces (Wang et al., 2020; Zhang et al., 2020a), there has been no evidence of faecal-oral transmission to date (World Health Organization, 2020). Some argued that if faeces were highly contagious for COVID-19, healthcare workers would be at greater risk during land birth as the particles are not diluted (ACM, 2020a). So while water immersion has been framed as posing a risk to clinical staff, women and babies; there is limited evidence to suggest it is easily spread to humans through birth pools (CDC, 2020a).

Benefits of water immersion

It is important to recognise the known benefits of water immersion during labour and for birth. Water immersion facilitates positive birth experiences (Cooper & Warland, 2019; Lathrop et al., 2018; Neiman et al., 2019). When immersed in water during labour, women have increased feelings of empowerment and experience a greater sense of privacy, safety, control and focus (Fair et al., 2020; Ulfsdottir et al., 2018). It is also an effective pain management method which can help to avoid a cascade of intervention and therefore promotes normal birth practices (Cluett et al., 2018). Women who were prevented from accessing water immersion as a consequence of their COVID-19 status would not access these benefits. The arbitrary decision to suspend water immersion for all labouring women is consistent with historical practices in maternity care that value subjectivity over evidence-based recommendations (Cooper et al., 2017).

What the suspension really represents

It can be assumed that broader socio-cultural factors have influenced RANZCOGs recommendation. RANZCOG is an obstetric organisation that aligns itself with the technocratic model of care and values surveillance, intervention, and hierarchy (Davis-Floyd, 2001). This is demonstrated by their staunch and public opposition to practices such as homebirth – which is discussed in the context of obstetric outcomes and perinatal mortality (Licqurish & Evans, 2015).

RANZCOGs position statement on water immersion is similar. By standardising institutional practices and banning all women from using water immersion, the individual needs of women are deemed unimportant. Consequently, these clinicians retain their position at the top of the organisation’s hierarchy (Davis-Floyd, 2001). The recommendation represents authority and responsibility inherent in the healthcare provider, not the woman –  as the woman’s personal preferences are disregarded by the institution (Davis-Floyd, 2001).

Loss of choice and failing to make decisions in partnership with women may also add to women’s feelings of stress and anxiety (Jago et al., 2020). This further impacts normal birth outcomes as women are passive in decision-making and do not challenge recommended practices (Carolan- Olah et al., 2015). The prohibition of water immersion also fails to demonstrate a holistic approach to care as the social and emotional needs of women are neglected (Jago et al., 2020) during a period in history that has elevated anxiety and depression amongst pregnant women (Lebel et al., 2020).

Medicalisation of childbirth also likely influenced the decision to suspend water immersion. An obstetric approach views water immersion as inherently risky and therefore requires medical management (Licqurish & Evans, 2016; Milosevic et al., 2019). This is demonstrated by RANZCOGs recommendations for water immersion statement (2017) which focuses on rigorous protocols, exclusion criteria, and obstetric emergency drills. Their value of a medicalised approach is also apparent when considering that they have not recommended suspending the use of nitrous oxide for all labouring women (RANZCOG, 2020c), despite posing a higher risk of contracting COVID-19 through droplet or aerosol transmission (ACM, 2020a; CDC, 2020b).

The influence of medicalisation is even more obvious in the recommendation to site an epidural early in labour, in case an emergency caesarean section becomes ‘indicated’ (DHHS, 2020). This practice has been adopted by Barwon Health, along with the recommendation of continuous fetal heart rate monitoring, should a woman be suspected of COVID-19 (2020). Normal birth outcomes then become even more difficult to achieve as interventions such as instrumental birth are increased (Alfirevic et al., 2017).

To affect any sort of change, it is important for midwives to gain confidence in water immersion (Plint & Davis, 2016). Lack of training creates a workplace culture where water immersion is feared (Klein et al., 2011). Consequently, medicalised approaches are promoted as midwives do not feel confident advocating for normal birth practices.

The media also plays a pivotal role in the depiction of childbirth, often shaping public opinion irrespective of evidence (Petrovska et al., 2017). Normal birth practices are vastly underrepresented, with childbirth often portrayed as medicalised and risky (Luce et al., 2016). Commonly associated with fear, pain and intervention, high-impact dramatic stories are more often depicted in the media rather than calm, normal births (Maclean, 2014). Media portrayals will influence women’s perceptions of water immersion given that two out of three women source information from the media instead of their healthcare provider (Carlsson & Ulfsdottir, 2020). Combined with media coverage on COVID-19, it is no wonder water immersion is scarcely supported. As women become fearful of childbirth, they are disempowered to advocate for normal birth practices (Plint & Davis, 2020). It is imperative for midwives to support women in making informed choices to ensure their decisions are not influenced by fear perpetuated by the media
(Jago et al., 2020).

How do we move forward?

Maintaining the health and safety of women, babies, and healthcare workers is paramount.

Measures can be taken to minimise the potential risk of COVID-19 transmission whilst still promoting normal birth practices. Screening women for COVID-19 and fast-track testing will inform care management more accurately (RCM, 2020). Individualised risk assessments should be undertaken and midwives should demonstrate effective clinical decision making (RCM, 2020). Being up-to-date with infection control practices would be supportive (Liang & Archarya, 2020; Public Health England, 2020) along with access to appropriate personal protective equipment (RCM, 2020). Burns et al. (2020) found wearing long gauntlet gloves that are one size too small can improve the seal when immersed in water. Maintaining proper cleaning and hygiene practices reduces the risk of transmission (ACM, 2020a) as well as removing faecal matter should it contaminate the water (Gu et al., 2020).

Empowering women to guide their babies into the world while immersed in water facilitates physical distancing practices (RCM, 2020). This would be supported by antenatal education as it  instills confidence and allows women to engage in their care (ACM, 2020a; Milosevic et al., 2019; Plint & Davis, 2016). Arguably the most important factor, is that midwives must be trained in water immersion. This will ensure competence and develop a workplace culture that supports normal birth practices (Nicholls et al., 2016). Midwives should also engage in respectful conversations that promote midwifery care by challenging practices that are deemed unnecessary or not based on evidence.

In summary

Midwives have a professional obligation to protect choices for women and promote normal birth practices (ACM, 2020b). Water immersion should be available to all women. RANZCOGs recommendation is not based on evidence and has been influenced by technocratic ideologies. As gatekeepers to normal birth, midwives are in a powerful position to influence maternity reform and must continually advocate for evidence-based practices to ensure women are supported throughout their childbearing journey (McIntyre et al., 2012).

References

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Luce, A., Cash, M., Hundley, V., Cheyne, H., van Teijlingen, E., & Angell, C. (2016). “Is it realistic?” the portrayal of pregnancy and childbirth in the media. BMC Pregnancy and Childbirth, 16(1), 40. https://dx.doi.org/10.1186/s12884-016-0827-x

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Does intrapartum CTG monitoring save lives?

Dr Kirsten Small is a project lead with the Transforming Maternity Care Collaborative. Yesterday she delivered the closing keynote address at the GOLD Obstetric Conference, speaking about why it is so difficult to align clinical practice with the research evidence. Kirsten hosts the Birth Small Talk blog and her post today reviews the research evidence she summarised in her address. She has kindly shared it here as well. 

If you are interested in pursuing research relating to the use of fetal heart rate monitoring in labour please connect with us via our contact form

 

Today’s post examines the research evidence about CTG monitoring with regards to stillbirth and neonatal death. This is a deep dive for my fellow data geeks who like to read the fine print, not the executive summary. The short version is – no. Using a CTG to monitor a woman in labour doesn’t prevent the death of her baby. If you are keen to know the details, read on!

Intrapartum CTG monitoring in low risk populations

This is the least controversial area of evidence, and the one most maternity clinicians are familiar with. Of the eleven randomised controlled trials that have compared CTG monitoring with intermittent auscultation (IA) during labour, three were done in low risk populations, five in high risk populations and the remaining three in mixed risk populations or where risk was not specified (Alfirevic et al., 2017).

The three low risk trials were Kelso et al., 1978, Leveno et al., 1986 and Wood et al., 1981. A total of 16,049 births were included in this analysis, which showed no statistically significant difference in the perinatal mortality rate (RR 0.87, 95% CI 0.29 – 2.58).

It has been almost 40 years since the last of these trials was performed. It could be argued that CTG technology has improved, or that we are better at CTG interpretation now. Heelan-Fancher et al. (2019) examined a large population data set from two states in the United States, specifically looking at birth outcomes for low risk women. This was not a randomised controlled trial – rather it was a non-experimental analysis of what happens in practice when women are monitored by CTG or by IA, with a very large sample size (1.5 million births). They didn’t report on intrapartum stillbirth. They found no significant difference in the neonatal mortality rate when CTG monitoring was used.

On the basis of available evidence, there is nothing that suggests that use of CTG monitoring rather than IA reduces the perinatal mortality rate in women considered to be at low risk. That’s not all that controversial. Most people in maternity care know this particular bit of information.

Intrapartum CTG monitoring in mixed, unknown, and high-risk populations

There is a widespread assumption that the absence of mortality benefit derived from CTG monitoring in labour ONLY applies to women considered to be low risk. We wouldn’t be using CTGs so widely if they didn’t save lives, right? But what does the evidence actually say regarding the use of intrapartum CTG monitoring in women who are not at low risk?

The randomised controlled trial evidence regarding high risk populations consists of five studies published over 6 papers, over a thirty-year period, starting in 1976 and continuing to 2006 (Haverkamp et al., 1979; Haverkamp et al., 1976; Luthy et al., 1987; Madaan and Trivedi, 2006; Renou et al., 1976; Shy et al., 1987). In addition, there are four studies published over five papers which were conducted in populations with both women considered to be at lower and higher risk or where the risk profile of the population was not described (Grant et al., 1989; Kelso et al., 1978; MacDonald et al., 1985; Neldam et al., 1986; Vintzileos et al., 1993). With my co-authors Associate Professor Mary Sidebotham, Professor Jenny Gamble, and Professor Jennifer Fenwick, we have synthesised the findings from these populations (Small et al., 2020).

In the high-risk population (n = 1,975), perinatal mortality was not significantly different when CTG was compared with IA (RR 1.17, 95% CI 0.62 – 2.22). There was also no statistically significant difference in mortality in the mixed-risk population (n = 15,994, RR 0.67, 95% CI 0.36 – 1.23). The mortality rate was higher in the mixed risk population than it was for the low risk population, and higher again for the high-risk population, indicating that researchers have correctly identified populations of women with higher risk.

Note that the number of women in the high-risk population is small. It has been argued that with a larger sample size a difference would be detected but that it would be unethical to recruit women considered to be a high-risk to further RCTs because the non-experimental evidence supporting the use of intrapartum CTG monitoring is so compelling. We set out to examine this assertion and examined the nonexperimental evidence (Small et al., 2020).

Non-experimental research

Our searches located 27 papers published between 1972 and 2018 which provided evidence about the use of intrapartum CTG monitoring in high-risk populations. We then used a tool (ROBINS-I) to assess the degree to which the findings of the research might be affected by bias – that is that the findings were due to something other than CTG use. 22 papers were at critical risk of bias and another was a serious risk. Most of these papers compared a time period prior to the introduction of CTG monitoring with a period after it was introduced, without controlling for any of the other changes to practice which might improve outcomes over time. Given the high risk of bias, the findings from these papers should not be relied on to guide practice as a consequence. The remaining five studies were assessed to be at moderate risk of bias. According to the ROBINS-I tool, studies at moderate risk of bias can be relied upon to inform clinical practice.

Starting with the studies at critical or serious risk of bias, only five of these studies showed a statistically significant reduction in perinatal mortality out of fourteen where this could be calculated. In the studies at moderate risk of bias (which ranged in size from 235 to 1.2 million women), no significant differences in perinatal mortality rates were reported. The argument that the non-experimental evidence presents a compelling argument for intrapartum CTG monitoring can’t be sustained on the basis of the available evidence.

Where to next?

Where does that leave us as clinicians and what recommendations can we make on the basis of these findings? We have an ethical obligation to include information regarding the lack of effectiveness of CTG monitoring in our discussions about intrapartum fetal monitoring with birthing women, regardless of their risk profile (Sartwelle et al., 2020) and to support their informed decision making. However, doing currently places clinicians at odds with professional guidelines. Professional guidelines are meant to be evidence informed, yet this is clearly not the case for intrapartum fetal monitoring. In order to support clinicians to provide evidence-informed care, there needs to be stronger recognition in professional guidelines that the evidence in favour of intrapartum CTG monitoring is far from compelling and that using IA instead is not proof of unprofessional practice.

The full reference list is available on the post on Birth Small Talk. 

 

New research from the Transforming Maternity Care Collaborative Team

Collectively, the Transforming Maternity Care Collaborative generate a large volume of high quality, impactful research. This week has seen the publication of five new papers from our team members in the Women and Birth journal. You can access the full text of each of these via the links below. Settle in with a cuppa and enjoy getting up to date.

Intrapartum CTG monitoring does not improve perinatal outcomes.

Authors: Dr Kirsten Small, Associate Professor Mary Sidebotham, Professor Jennifer Fenwick, Professor Jenny Gamble.

This systematic literature review identified all randomised controlled trials and non-experimental evidence which has examined whether the use of CTG monitoring during labour rather than intermittent auscultation reduces perinatal mortality or cerebral palsy rates in babies born to women considered to be at high risk. No improvement in mortality was found, while an increase in the cerebral palsy rate was noted when CTG monitoring was used during preterm labour.

“High-quality research is urgently required to identify which women, if any, obtain a perinatal benefit from intrapartum CTG monitoring.”

Access this paper here.

Measuring midwifery students’ experiences of learning in clinical practice environments.

Authors: Ms Marnie Griffiths, Professor Jennifer Fenwick, Professor Jenny Gamble, Professor Debra Creedy.

Learning in a clinical environment is a key component of a comprehensive midwifery education program. Being able to measure how well specific learning environments support midwifery students as they develop the knowledge and skills required for professional practice is important. This paper reports on the development and testing of the MidSTEP tool which offers a robust way to capture students’ perceptions of the clinical practice component of their degree. Students indicated high level support for the statements that the clinical environment supported their learning, enabled them to work across the full scope of practice, and fostered a self-directed approach to learning.

Access this paper here.

Placing students in the driver’s seat.

Authors: Ms Valerie Hamilton, Professor Kathleen Baird, Professor Jennifer Fenwick

This research reports on students’ experiences of learning to provide midwifery care in a student-led midwifery clinic providing antenatal and postnatal care. Students who were on-call for individual women were supported to provide antenatal and postnatal care under the supervision and guidance of their university practice lecturer. “Being in the driver’s seat” was the major theme of the findings, with students reporting a sense of being in control and feeling like “a real midwife”. Students described growing in confidence over time and feeling competent to step into practice.

Access this paper here.

Stepping from student to employment through simulated employment interviews.