TPM JANUARY 2016

The Practising January 2016MIDWIFE Volume 19 No 1 The best job in the world www.practisingmidwife.co.ukABOUT TIMEIN THIS ISSUE:Optimal cord clamping:linking to CPD moduleonlineTime in context:caring in CongoTaking time to birthin TanzaniaMentorship issuesComing soon... Visit your new online community and learning zone to develop, prepare and share your practice www.practisingmidwife.co.uk

* World’s first of its kind Pregnacare® trial published in British Journal of Nutrition Pregnacare® tablets shown to benefit the health of pregnant mums and their babies in major UK trial As widely reported in the national press, Vitabiotics Pregnacare® tablets have been shown to benefit pregnant women and their babies in a major UK trial1, carried out by the Institute of Brain Chemistry and Human Nutrition at London Metropolitan University and the Homerton University Hospital. “TO THE BEST OF OUR KNOWLEDGE, THIS IS THE FIRST REPORTING OF SUCH FINDINGS OF ANY STUDY PERFORMED IN THE UK OR THE DEVELOPING WORLD.” The lead researcher, Dr Louise Brough, commented: “This research highlights the concerning fact that a number of women even  in the developed world, are lacking in important nutrients during pregnancy.  It  also  demonstrates  the  benefit  of  taking  a  multiple  micronutrient  supplement  such  as  Pregnacare®.  It  is  especially  important  to  have  good  nutrient  levels  during  early  pregnancy  as  this  is  a  critical  time  for  development of the foetus. Pregnacare®, as used in the study, was shown to  improve nutrient status relative to placebo.” By the third trimester, mothers who took Pregnacare® Original tablets were also found to have, relative to placebo, increased levels of iron, vitamin B1 and vitamin D3. Specially formulated by experts, Pregnacare® tablets replace a usual multivitamin and provide a careful balance of 19 essential vitamins and minerals. It includes the recommended 10mcg vitamin D and also 400mcg folic acid which contributes to maternal tissue growth during pregnancy. Plus iron which contributes to normal red blood cell formation and normal function of the immune system. The pregnancy multivitamin brand MIDWIVES RECOMMEND MOST† Before Conception NEW Original Plus Dual Pack Breast-feedingADPRGTRADEP14-10-15E Pregnacare® is the pregnancy multivitamin brand midwives * recommend most†, so you can recommend it with confidence. 1 L Brough, GA Rees, MA Crawford, RH Morton, EK Dorman (2010) Br J Nutr. 2010 Aug;104(3):437-45 † Based on a survey of 1000 midwives. For more information on this research, please visit www.pregnacare.com/mostrecommended * Nielsen GB ScanTrack Total Coverage Value and Unit Sales 52 w/e 25th April 2015. www.pregnacare.com

CONTENTS5 EDITORIAL THIS MONTH’S FEATURED ARTICLES 36 RESEARCH UNWRAPPED6 VIEWPOINT 10 The benefits of optimal cord clamping Alys Einion unwraps a recent research article on one of the key issues facing The best use of time Lisa Busellato and Sara Bayes provide an up- midwives in practice: time and workload; Jennifer Clarke to-date overview of key papers on OCC and draws her own conclusions8 NEWS 17 Emergency time: caring in Congo 39 REVIEWS13 ADVANCING PRACTICE Claire Reading puts timing into perspective 40 THINKING OUTSIDE THE BOX in a remote, rural village Clinical guidelines Whatever happened to the precautionary Elaine Uppal focuses on the part midwives 20 Learning to aid learning principle? can play in creating guidelines Sara Wickham looks at arguments used to Jacqui Richards examines the mentor’s role justify induction in healthy women33 MIDWIFERY BASICS in relation to an online quiz 42 LAST WORD 4. Managing workload and prioritising 23 Midwifery home and away care: top tips DIRECT: creating a reflective model Nisha Ridley and Kerry Taylor consider the Camella Main provides insight into the Kayley Everett describes her own reflective barriers and challenges for all midwives challenges in rural Tanzania model which she has found combines the and provide helpful tips for newly qualified best of existing models midwives 26 Domestic violence in pregnancy Gill Stonard and Emma Whapples highlight the concerns facing midwives 30 Polish women’s experiences of breastfeeding in Ireland Marcelina Szafranska and Louise Gallagher examine the interplay of influences from Poland and in IrelandCOMING SOON ONLINE @ www.practisingmidwife.co.uk CURRICULUM ARTICLES COMMUNITYOur website features a series of eLearn LINK ARTICLE THIS MONTH: Areas for prospective students, studentmodules and assessments focused around the OPTIMAL CORD CLAMPING midwives and registered midwives. Mutuallyfollowing practice themes: Read the article by Lisa Busellato and Sara Bayes supportive arena for you to chat, discuss and1 Midwifery becoming and being including in this month’s journal. Complete the eLearn give and seek advice module and assessment to gain a certificate for Also - Refectory You can look up events taking Organisation, caring and roles your portfolio, ready for revalidation and proof place in coming months, read and comment on Midwifery care of CPD the latest news stories and access midwifery- Midwifery core skills Access to current and past TPM journal articles related information2 With woman and family including Woman and childbearing Lead article each month, taking you from the CLINICAL GLOSSARY Baby and family journal to the website for a module on the3 Personal and professional development subject. This month Optimal cord clamping A-Z list of common clinical conditions andWithin these areas you will find modules by Lisa Busellato and Sara Bayes, soon linking midwifery topics to help inform your practicecovering a range of topics essential to to www.practisingmidwife.co.ukmidwives and associated roles TPM, January 2016, vol.19, issue 1 3

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VIEWPOINTTime for the common goodEver felt that time is racing by? Another year has passed - moments washed away with Anna Byrom the relentless ticking of the clock. The mechanical clock that has measured the Editor incremental passing of life; shaping how we function in society. Clock time is such a pervasive feature of contemporary society that it is now considered natural.Yet the clock Follow me on Twitter:is a socially constructed machine that, whilst accurate in application, artificially segments our @acb-midwifeexistence into seconds, minutes, hours, days, weeks, months and years. Indeed Lee and Whitley(2002) argue that the mechanical clock actually freed time from nature. Human activity, onceorganised by natural markings of time (passing of the sun, growth of plants or position of thestars) is now coordinated by the hands of a clock. This disassociation of human activity fromnature and nature from human activity has had consequences for childbearing and midwiferypractice. Aligned with the medicalisation of childbearing, mechanical time has been used as a scientifictool to measure, quantify and assess performance; both of women’s bodies and midwiferypractice. Childbearing is now governed by the clock – from menstrual cycle calculations in days,pregnancy gestation in weeks, labour in hours to the postnatal period in days.The natural rhythmof women’s bodies is set against the rigid beats of mechanical time. Midwifery care, too, isorganised against the clock with hospital routines co-ordinated by linear time. Time urges us to‘do’ to, rather than ‘be’ with, women. The pressures of time have resulted in women losingconfidence in their own ability, increases in obstetric intervention and have been associated withdissonance and dissatisfaction for both midwives and mothers (Dykes 2006). Time feels compressed, driven by advancements in information technology. It is about timethat, as midwives, we re-examined our relationship with technology and how we use mechanicaltime in our care of mothers, babies and families. In this issue we explore concepts of time withinmidwifery practice alongside some key issues associated with childbearing and motherhood.Now is the time for midwives, women and their families to unite and use technology to collatethe evidence for improving maternity services for all.This includes keeping time in its place andharnessing the accessibility of computers, the Internet and social media platforms to do good:using them to enhance communication, information sharing and the development of supportivecommunities. Our upcoming, soon-to-be-launched website will help – keep a look out.REFERENCES Darbyshire P (2004). ‘Rage against the machine? Nurses’ and midwives’ experiences of usingcomputerised patient information systems for clinical information’. Jour Clin Nurs, 13: 17-25. Dykes F (2006). Breastfeeding in hospital: mothers, midwives and the production line, London:Routledge. Lee H and Whitley E (2002). ‘Time and information technology: temporal impacts onindividuals, organisations and society’. Info Soc, 18: 235-240.TPM, January 2016, vol.19, issue 1 5

VIEWPOINT The best use of timeJenny Clarke Time stands still for no man – but can REFLECTION midwives help women to feel that time isMidwife intrapartum irrelevant, through the use of words and • Does your place of work have clocks visibleservice team at the Fylde compassion? Clocks rule so many events to women?Coast Birth Centre and within our lives and birth is no exception.Delivery Suite, Blackpool • Consider how many instances you hear timeTeaching Hospitals NHS TIME KEEPING referred to:Foundation Trust – In your workplaceFollow me on Twitter: Time keeping is so critical to the functioning of – In your home@Jenny The M modern societies that it is coordinated at an international level; how can we ever escape it? • Ask women and colleagues how they feel about time In reading this, I hope that I inspire you with my words to approach your work in maternity care with in some situations and yet totally restrictive in an alternative view of time. others. Time has given us knowledge by allowing us to gain information from history so that we I recently worked for two years on a co-located continually develop. birth centre and I felt proud that there were no clocks on the walls - some of my colleagues could not THE CLOCK understand how this was right - but my line manager was adamant that birth was about the woman and I was recently with a labouring woman who said the family, not meeting the midwife’s need to see a \"Move that clock!\" She said she felt it was ‘smirking’ clock - I learnt so much from her. at her.There are situations when a clock is necessary and useful, such as in neonatal resuscitation, and I YOUR ROLE want you to understand that I respect clocks and value the time. However, only in exactly the right As a birth worker always remember that you are also places. As midwives, we must be mindful of the a birth physiologist.You are the keeper of times and woman and how she might feel seeing a clock ticking a guardian and advocate for all women - your in front of her. endeavours must include protecting women from feeling ‘timed’ in labour or postnatally. Your actions STEP BACK IN TIME or inactions can effect a positive hormone response and facilitate the flow of useful birth hormones such Even though we might sometimes feel marginalised, as melatonin and oxytocin and negate or stop the we would not choose to go back to the place we came production of adrenaline. from as midwives. We are becoming stronger, more informed and aware of the importance of our role.My line manager was adamant that Due to our passion we are contributing to the voicebirth was about the woman and the of women globally and making it louder. Despitefamily, not meeting the midwife’s time differences, midwives, women and birthneed to see a clock workers are united on social media and working together to make a difference. SYSTEMS, PROCESSES AND TIME We have to help women back to physiology, not We are all connected and working within systems only by using time in an intelligent way but also and we work so much more efficiently when we are making the concept and visibility of time less not being rushed to meet the next schedule or apparent. deadline. A moment of kindness to and from others can make time stand still. I urge you to jump into the 'tardis of midwifery' - step back in time and see how time has helped us, The work we do is immersed in the concept of then imagine moving forward to the future of time, so how can we help women to escape from midwifery - what can you see? Women giving birth this? The late Sheila Kitzinger (2003) described time at home, or more technological births? The answer, as a technological intervention in birth – one which my dear friends, can be found within your own has not been evaluated nor its impact gauged. selves. tpm We must feel able to see why time can be useful REFERENCES Kitzinger S (2003). ‘The clock, the bed and the chair’. Birth, 30(1): 54-56.6 Viewpoint, TPM, January 2016, vol.19, issue 1

Infant care with head and heartseca makes it easy for everyone

2015: MATERNITY’S BIG YEARby Victoria Anne Morgan Lead facilitator at Every birth a safe birthMaternity is the ‘shop window’ of the NHS – the commonest reason for admission to PERINATAL MORTALITYhospital. In 2015, maternity services were in the spotlight as a series of major reportswas published about safety, and announcements made about changes to the system in The MBRRACE-UK perinatal mortalitywhich services operate. report (Manktelow et al 2015) showed a welcome decline in perinatal mortality in Here, I review the events of 2015 and consider how to capitalise on the opportunities the UK between 2003 and 2013. The fallthese events afford to make maternity services excellent. The NHS is what makes the equates to more than 1,000 fewer deaths.public most proud to be British (Quigley 2014). Let’s make our maternity services thepride, not only of the NHS, but also of the developed world. The UK extended perinatal mortality rate is six stillbirths and neonatal deaths perThe Morecambe Bay investigation 100,000 births. Local rates (adjusted for normal variation and demographic factors)Bill Kirkup’s (2015) report examined 20 unexpected neonatal deaths be reported vary from 5.4–7.1. If the UK could matchinstances of significant or major failures as serious incidents. Investigations Swedish and Norwegian mortality rates, atof care from 2004–2013 at Furness should follow a standardised process least 1,000 more lives could be saved every year.General Hospital, later part of University which: seeks input from and providesHospitals of Morecambe Bay NHS feedback to families; subjects them to Tackling health inequalities is crucial.Foundation Trust. In that period, there independent, multidisciplinary peer Risk increases by 57 per cent wherewas one preventable maternal death and review; and excludes conflicts of interest mothers live in poverty and by over 50 per11 preventable neonatal deaths. between staff. cent for black or black British, Asian or Asian British women. Failures by commissioning and Speaking to the Royal College ofregulatory bodies meant that problems Obstetricans and Gynaecologists MBRRACE-UK recommended that all unitswere not flagged up and dealt with by (RCOG) in October, Bill Kirkup review data quality; review the care that isothers in the system. The problems were summarised the key learning points from provided; and ask an outside person to helpbrought to light by ‘diligent and the investigation that maternity units can look at clinical practice.courageous families’ who made ‘efforts examine themselves against.These were:over…a prolonged period’.To build trust, MATERNAL MORTALITYBill Kirkup invited the families to observe • Promote team working, especiallythe interviews with witnesses and the between disciplines. Train in teams, Published last month, MBRRACE-UK’sinvestigation panel meetings. not tribes. analysis of how to save lives and improve mothers’ care centred on indirect causes of A series of small steps over time led • Clinical risk assessments must be mortality such as mental health, multiplethe maternity unit at Furness to drift far accurate, reviewed when risk status psychosocial problems, thrombosis,off course – it did not suddenly become a changes; and multi-disciplinary, malignancy and domestic violence.failing unit. where appropriate. This was after Knight et al (2014) showed Kirkup says: ‘The safety of maternity • Investigation and learning: report a welcome fall in maternal mortality to 10units depends on their level of vigilance incidents, investigate them per 100,000 maternities due to fewer deathsto detect risk and deviation from the effectively and implement the from direct causes, but no significantnorm, and on their taking effective action learning from the investigations. change in the indirect rate over the last 10when it is found. Every tragedy should be years. To tackle this, MBRRACE-UKscrutinised to see what has gone wrong • Beware of tunnel vision: a number recommend that:and if there are underlying problems.’ of agendas were pursued dogmatically with disastrous results; • when women are ill, there is strong co- At Morecambe Bay, a case note review for example: normal births and ordination between midwifery andof all maternal, intrapartum and neonatal public confidence. obstetric/medical teams; anddeaths and other events showed thatsub-optimal care was more prevalent at • Clinical leadership: understand your • all maternal deaths be subject to aFurness General Hospital, even though it role and take responsibility; multidisciplinary team review (including anwas a low-risk unit with half the number understand conflicts of interest and anaesthetist).of births of the other maternity unit at the mitigate them.Trust. NATIONAL NEONATAL AUDIT • Identify and respond to warning PROGRAMME The report’s 44 recommendations signs: be aware of the quality of careincluded that all maternal deaths, late at individual maternity units as well Around one in eight of all babies born willand intrapartum stillbirths and as the organisation as a whole; and be admitted to a neonatal unit (Royal when problems are identified, deal College of Paediatrics and Child Health with them constructively. (RCPCH) 2015). That is over 86,000 admissions of babies to neonatal care each year. This seems a high rate of admission and I would question whether it is a true reflection of neonatal health status. Again, there was considerable variation in network performance across the standards examined.8 News, TPM, January 2016, vol.19, issue 1

NEWS REVIEW OF THE YEARA NEW TARIFF NATIONAL REVIEW OF change and testing the results is laudable, MATERNITY SERVICES but is it achievable? In September’s editionThe enhanced tariff option (ETO) went live (Morgan 2015), I described a grass rootsfrom 1 April, with 88 per cent of trusts The National maternity review will, by now, clinical network in the USA of a group ofopting to receive a single tariff payment for have published its proposals for the ‘future cardiac units which saw a 24 per centeach stage of care (antenatal, birth and shape of modern, high quality and reduction in mortality associated withpostnatal), replacing a hotchpotch of sustainable maternity services across coronary bypass graft surgery.payment by results, ‘per item’ tariffs and England’. The group identified three key elements oflocal block contracts. Those who opted in The review’s three objectives were to: their success:shared a £500m sweetener. • examine safe and efficient models of • sharing routine data about outcomes and maternity services complications at regular meetings The ETO provides differential payments, • consider how women can be enabled to • multi-disciplinary team visits betweendepending on defined clinical risk factors – choose safe and appropriate maternity care sites to observe clinical practice andsuch as for women expecting twins or who • support staff to provide responsive care. • being trained in clinical qualityhave a high body mass index (BMI). The improvement techniques and putting thisgreater the clinical risk factors, the higher At one of the Birthtank events (which into practice – making changes and testing them.the payment. brought together leading lights in maternity services – both staff and users), participants Well designed and administered Trusts that provide high quality care – asked for practical support to develop their maternity networks can bring togetherwith fewer complications and unnecessary local systems and make the changes they multi-disciplinary teams (includinginterventions – should benefit financially. desired. This news review concludes by parents) with information about outcomesFor example, if caesarean sections are only describing a practical way of driving and in rate form (so that units can directlyperformed when clinically indicated and sustaining improvement. compare performance with one anotherthe number of procedures reduced, fewer and the network as a whole) at regularpostnatal bed days will be required, which THE OUTLOOK FOR 2016 meetings, to plan and record actions tocosts the trust less without losing any of the improve services.ETO payment. So, is 2016 likely to be the year when Could a grass roots clinical network help maternity services are given some your unit and its neighbours celebrate andINDEPENDENT PATIENT SAFETY breathing space? Not at all! There are a continuously improve the quality of itsINVESTIGATION SERVICE (IPSIS) number of key developments in the pipeline. maternity services, so that NHS maternity services are the pride of both the NHS andIn March, the Kirkup report showed the In 2016/17, OFSTED-style ratings will be the developed world?consequences of the failure to learn from introduced for maternity along with plansserious incidents. Four months later, the to increase choice. The work of IPSIS will ReferencesDepartment of Health announced it would get under way; it has been asked to consider Kirkup B (2015). The report of the Morecambecreate an independent patient safety a focus on maternity cases in its first year. Bay investigation, London:The Stationery Office.investigation service (IPSIS) - to offer By 2030, the government expects the rate of Knight M, Kenyon S, Brocklehurst P et alsupport to provider organisations’ stillbirths, neonatal and maternal deaths in (2014). Saving lives, improving mothers’ care -investigations into serious patient safety England to halve, along with a reduction in lessons learned to inform future maternity careincidents and carry out certain the number of brain injuries occurring at from the UK and Ireland confidential enquiriesinvestigations itself. The IPSIS will seek to birth or soon afterwards. This work will be into maternal deaths and morbidity 2009–12,promote the ‘just culture’ approach of the supported by a £4m fund for education and Oxford: University of Oxford.aviation industry – encouraging equipment. The RCOG’s Each baby counts Manktelow BM, Smith LK, Evans TA et altransparency, learning and continuous programme aims to halve the number of (2015). Perinatal mortality surveillance reportimprovement and where only those who intrapartum stillbirths and brain injuries by UK perinatal deaths for births from January tocover up problems or refuse to learn lessons 2020.To achieve this, work needs to start now. December 2013. Leicester: Univ of Leicester.face sanctions. Morgan V (2015). 'The power of two: GRASSROOTS CLINICAL reflections on the MBRRACE-UK maternalINVOLVING PARENTS NETWORKS and perinatal deaths reports and the London maternity strategic clinical#MatExp is a powerful grassroots campaign 2015 brought a wealth of information about network’. The Pract Midwife, 18(8): 12-15.to improve patient experience. It started as how maternity services are performing and Quigley A (2014). Maintaining pride in the‘one small pilot’ and was officially launched how they can improve. Clearly, it is NHS: the challenge for the new NHS chief exec,at ‘NHS change day’ in March. impossible to implement every London: IPSOS Mori. http:// tinyurl.com/Communicating with kindness, empathy recommendation all at once. As Kirkup, jfl5rqkand compassion is central to the #MatExp MBRRACE-UK and the Neonatal audit RCPCH (2015). National neonatal auditcampaign. At workshops, users and staff programme have shown, different programme 2015 annual report on 2014 data,(from all disciplines) play an empathetic operational units have different strengths London: RCOG. http://tinyurl.com/ gw8oz4vboard game (also used by the national and weaknesses and, therefore, differentmaternity review team at their consultation priorities for action: whether this is makingevents) and commit to make changes – improvements or sharing best practice.which have benefited staff as well as clients. Selecting priorities for action, making News, TPM, January 2016, vol.19, issue 1 9

OPTIMAL CORD CLAMPINGLINK ARTICLE Lisa Busellato Sara BayesLead article each month,taking you from the Midwifery student, Associate professor ofjournal to the website Edith Cowan midwifery, Edith Cowanfor a module on the University, Perth, University, Perth,subject. Western Australia Western AustraliaThis month: Optimal The benefits of optimal cordcord clamping by Lisa clampingBusellato and SaraBayes. Go to the module, Optimal cord clamping is known and now widely recognised as having positive consequences for thesoon coming to neonate in the short- and medium term. This review of some of the key literature published over the lastwww.practising five years on the effects of both ECC and OCC provides an insight into the evidence on this topic.midwife.co.uk The aim of this article is to summarise the key papers on the topic of the effect of timing of cord clamping, including some of those included in the Cochrane Review as well as the majority that have been published since, to provide an up-to-date overview. INTRODUCTION A comprehensive systematic review of 15 studies involving 3,911 women and newborn dyads on the As all midwives know, umbilical cord clamping is effect of the timing of umbilical cord clamping on the mechanical separation of an infant from its women and newborns, was conducted for the placenta during or following birth. Early cord Cochrane Collaboration and published in 2013 clamping (ECC) is conducted immediately after the (McDonald et al 2013).This review includes research birth while blood continues to pulse through the publications up to 2012 and, in summary, the authors umbilical cord, whereas optimal cord clamping found no significant differences between early or (OCC) involves waiting to clamp and cut until the late cord clamping for women (in relation to cord has stopped pulsating and has begun to drain. postpartum haemorrhage) or in neonates’ mortality Traditionally, OCC has been referred to as delayed or some morbidities (specifically Apgar score and cord clamping (DCC); however the term ‘optimal admission to intensive care unit). Birth weight (by an cord clamping’ is now considered a more accurate average 101g), haemoglobin level at 24-48 hours old definition of the process. and iron stores at three-six months, however, were all higher in neonates who had late (delayed) cord Many in our profession have long championed clamping, which was also associated with a greater OCC for the benefits it affords the neonate in the need of phototherapy for jaundice. short- and medium term. These have now been recognised internationally by the World Health SEARCH STRATEGY Organization (WHO) (2014) and by the British healthcare establishment in the form of National A search of health research databases, applying the Institute of Health and Care Excellence (NICE) dates 1 January 2010-25 September 2015, was guidelines (2014).The UK medical fraternity has also conducted using the initial key search term ‘delayed recently published its endorsement of and support cord clamping’ (to capture papers published prior to for OCC in the form of a scientific paper (Royal the shift to the use of the term ‘optimal’). After College of Obstetricians and Gynaecologists narrowing the search to relevant (by title and (RCOG) 2015).10 Busellato and Bayes, TPM, January 2016, vol.19, issue 1

OPTIMAL CORD CLAMPINGabstract), peer-reviewed articles, excluding preterm babies who had their cord clamped early (<15or premature babies, a manual search was seconds of birth) with those who had theirs clampedconducted of the reference lists of the remaining at three minutes post-birth. All 180 neonates had apapers, which resulted in further articles being blood test at 24 hours post-birth and again at three-included. The final number of papers for inclusion five months, from which it was determined that, atwas 11. 24 hours, infants in the OCC group had higher haemoglobin levels and a higher haematocritRESULTS reading, and by the age of three-five months, bothImplications for neonatal weight and groups had similar haemoglobin levels, but levels ofcord gas levels serum ferritin were higher in the OCC group. Again there were no cases of polycythaemia, despite theIn a small study published in 2010, Farrar and OCC babies’ higher haematocrit levels.colleagues (2010) sought to discover the volume ofblood that is left in the placenta and flows through Babies in a study by Oliveira et al (2014), whoseto the baby by way of a process called ‘placental cords were clamped at <60 seconds, had lowertransfusion’ in the few minutes after birth. Farrar et haemoglobin, iron and ferritin levels compared withal found that there was an average weight increase their counterparts in whom cord clamping wasof 87g (which equates to 83ml of blood) at five delayed by more than 60 seconds.minutes. Although blood flow from the placentastopped in the majority of infants by two minutes, it In a randomised controlled trial conducted bycontinued in some for up to five minutes. Farrar et Salari et al (2015), babies’ haematocrit levels wereal concluded that approximately 25–40 per cent of found to be higher in the OCC cohort at both two-an infant’s blood supply is still in the placenta at and 18 hours after birth.birth and is still transfusing to the baby in theminutes following. In a study that looked at the implications of cord clamping timing for older babies, Andersson et al Important data are yielded by umbilical cord gas (2011) investigated the impact that OCC had onanalysis but, anecdotally, there is some concern infants at four months of age as well as in the earlyamong clinicians that DCC will impact on the postnatal period. Around half the babies had theirquality of the blood available for testing. Andersson cords clamped within 10 seconds, and the other halfand colleagues (2012) looked into whether DCC after three minutes. Iron level and full blood countaffected the availability of cord blood for gas were measured at two days and again at fouranalysis. However, the researchers found the months. At two days, infants in the OCC group haddifferences to be insignificant: 6 per cent fewer higher haemoglobin levels and a higher haematocritsamples were valid in the DCC group. In other work value; there was no difference in iron status, buton this topic, de Paco and team (2011) were there were fewer cases of infant anaemia. Again,interested to know whether DCC had an impact on there were no cases of infant polycythaemia. By fourumbilical cord blood gas levels. In their study of the months, the infants in the OCC group hadvenous blood acid-base status and gases from 116 significantly increased serum ferritin concentrationsumbilical cords and the arterial values from 99 compared with the ECC group, as well as havingcords, the investigators found no significant fewer incidents of iron deficiency. At four months,difference in umbilical vein or artery pCO2 or however, groups did not differ in haemoglobinHCO3 when clamping was delayed by two minutes, concentration or incidence of anaemia.compared with those clamped at <10 seconds. Effect on neurological development >>>>Impact on neonatal Hb and iron levels Further research was subsequently conducted byThe majority of work so far in relation to the impact Andersson et al (2014) with the same infants whoof cord clamping timing has been conducted in had participated in their earlier studies to find outrelation to iron levels in the short- and longer term. if OCC had any effect on neurologicalShirvani and team (2010) reported their development and iron status at one year old. Thereinvestigation into the effects of ECC and OCC on appeared to be no difference in iron status orneonatal haemoglobin, haematocrit and ferritin prevalence of iron deficiency between the ECClevels at 48 hours old. In the OCC group (cord and the OCC babies.clamped >15 seconds after birth), levels were higherthan those in the ECC group (cords clamped within Most recently, a team led by Andersson (2015)15 seconds of birth). Despite the OCC babies having has published findings related to thehigher haematocrit values, there were no cases of neurodevelopmental impact of DCC at four years ofpolycythaemia. age, which led them to conclude that children in whom cord clamping had been delayed (optimised), Al-Tawil et al (2012) compared the iron levels of had higher scores in both fine motor and social skills. Busellato and Bayes, TPM, January 2016, vol.19, issue 1 11

OPTIMAL CORD CLAMPINGImportance of neonatal position for et al (2011). 'Effect of delayed versus early umbilicalplacental transfusion cord clamping on a neonatal outcomes and iron status at 4 months: a randomised controlled trial'.Finally, in a study conducted by Vain and team Brit Med Jour, 343: d7157.(2014), the effect of raising the neonate to the levelof the mother’s abdomen, on the amount of blood Andersson O, Hellström-Westas L, Andersson Dthat flows from the placenta to the infant after birth, et al (2012). 'Effects of delayed compared with earlywas assessed to see if gravity made any difference to umbilical cord clamping on maternal postpartumplacental transfusion. Results showed that there was hemorrhage and cord blood gas sampling: ano difference in average haematocrit, bilirubin randomized trial'. Acta Obs Gyn Scand, 92(5): 567-574.values or weight gain between the groups. Andersson O, Domellöf M, Andersson D et alSUMMARY (2014). 'Effect of delayed vs early umbilical cord clamping on iron status and neurodevelopment atStudies discussed in this literature review found that age 12 months: a randomized clinical trial'. JAMAOCC resulted in approximately a 25-40 per cent Pediat, 168(6): 547-554.higher blood volume or an extra 83ml of bloodtransfusing to the newborn. The OCC group had Andersson O, Lindquist B, Lindgren M et alhigher haemoglobin levels at two-, 24- and 48 hours, (2015). 'Effect of delayed cord clamping onbut there was little difference between groups at neurodevelopment at 4 years of age: a randomizedthree-five months. Haematocrit values were also clinical trial'. JAMA Pediatr, 169(7): 631-638.higher at two, 24- and 48 hours in the OCC groupthan the ECC group. Serum ferritin levels were de Paco C, Florido J, Garrido C et al (2011).higher at 48 hours and persisted till three-five 'Umbilical cord blood acid-base and gas analysismonths with OCC, which correlated to fewer cases after early versus delayed cord clamping in neonatesof infant anaemia at 48 hours and less prevalence of at term'. Arch Gyn Obs, 283(5): 1011-1014.iron deficiency at three-five months. Some of theresults showed a slight increase in risk of infants Farrar D, Airey R, Law GR et al (2010). 'Measuringrequiring phototherapy in the OCC group, but the placental transfusion for term births: weighingrisk was still low and there were no recorded cases babies with cord intact'. BJOG: Int Jour Obs Gyn,of polycythaemia in any study. The research also 118(1): 70-75.showed that there was no negative impact onholding the infant on the mother’s chest or abdomen McDonald S, Middleton P, Dowswell T et alduring OCC. (2013). 'Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomesCONCLUSION (Review)'. Coch Data Syst Rev, 7 : CD004074. DOI: 10.1002/14651858.CD004074.pub3The original research reviewed above clearlydemonstrates that, as recognised now by the WHO, NICE (2014). Intrapartum care: care of healthyNICE and the RCOG, usual practice should be to women and their babies during childbirth: NICE clinicaldefer clamping of the umbilical cord after birth on guideline 190, London: NICE. http://tinyurl.com/the basis that it has a range of positive effects and o5pbjygappears to do no harm. As outlined in the lateststatements and guidelines from these three Oliveira F, Assis K, Martins M et al (2014). 'Timingauthorities, cord clamping should be delayed by at of clamping and factors associated with iron storesleast one minute and, while the cord is intact, the in full-term newborns'. Revista Saúde Púb, 48(1): 10-baby can be placed on the mother’s abdomen or 18.chest following a vaginal birth, without detriment. RCOG (2015). Clamping of the umbilical cord andtpm placental transfusion (Scientific Impact Paper No 14). London: RCOG.FURTHER RESOURCES Salari Z, Rezapour M and Khalili N (2015). 'Late I Blood to baby http://tinyurl.com/pfnpufw umbilical cord clamping, neonatal hematocrit and Apgar scores: a randomized controlled trial'. JourREFERENCES Neonat-Perinat Med, 7(4): 287-291. Al-Tawil MM, Abdel-Aal MR and Kaddah MA Shirvani F, Radfar M, Mashemieh M et al (2010).(2012). 'A randomized controlled trial on delayed 'Effect of timing of umbilical cord clamp oncord clamping and iron status at 3-5 months in term newborns' iron status and its relation to deliveryneonates at the level of maternal pelvis'. Jour Neonat- type'. Arch Iranian Med, 13(5): 420-425.Perinat Med, 5(4): 319-326. Vain NE, Satragna DS, Gorenstein AN et al Andersson O, Hellström-Westas L, Andersson D (2014). 'Effect of gravity on volume of placental transfusion: a multicentre, randomised, non- inferiority trial'. The Lancet, 384(9939): 235-240. WHO (2014). Guideline: delayed umbilical cord clamping for improved maternal and infant health and nutrition outcomes, Geneva: WHO.12 Busellato and Bayes, TPM, January 2016, vol.19, issue 1

ADVANCING PRACTICEElaine UppalSenior lecturer in Midwifery at the University of Manchesterand Pathway leader of the MSc Advancing Midwifery Practiceand Leadership programmeClinical guidelinesThis article is part of the Advancing practice series which is aimed at exploring practice issues PRACTICE CHALLENGEin more depth, considering topics that are frequently encountered and facilitating the Choose an area of practicedevelopment of new insights. that you are interested in that may require reviewingElaine Uppal focuses on the importance of all midwives developing guideline writing skills or updating. Search for anto ensure that local, national and international midwifery/maternity guidelines are up to existing guideline on thisdate, relevant and reflect midwifery knowledge alongside ‘gold’ standard evidence.The article topic area, which may beaims to consider the development, use and critical appraisal of clinical guidelines. It will from your workplace, adefine and explain guidelines; discuss their development and dissemination; and consider national guideline such asissues relating to their use in practice. Techniques to critique and develop guidelines using NICE or from athe AGREE tool will be outlined in the form of practice challenges to be undertaken by the professional organisationindividual or in a group. such as the RCM or RCOG. Use the national library kept by the NHS.GUIDELINES – TERMINOLOGY clinical imperative or client choice (Uppal 2012).The NICE definition implies a scientific and objectiveGuidelines are systematically developed statements approach to a condition rather than individualisedto assist practitioner decisions about appropriate holistic care and, whilst expert opinion undoubtedlyhealth care for specific clinical circumstances features in NICE guidelines, it is graded at four in(Greenhalgh 2001). The National Institute of Health the hierarchy of evidence. Guidelines shouldand Care Excellence (NICE) (2012: 1.3) go further in incorporate the latest and best available quantitativedescribing them as ‘recommendations, based on the and qualitative evidence; they should also be clearbest available evidence, for the care of people by about the scope in terms of what is known about anhealthcare and other professionals. They are aspect of care. They should be reviewed regularlyrelevant to clinicians, health service managers and and updated as new evidence emerges; ultimatelycommissioners, as well as to patients and their they should not dictate practice but rather, as isfamilies and carers’. The terminology can be clearly indicated, ‘guide’ practice.confusing with a wide range of words and phrasesused interchangeably: guidelines, protocols, care BACKGROUND AND EVOLUTIONpathways, algorithms, policies and so on. Protocolsand policies are particularly referred to in many There is a long history of expert opinion and theworkplaces to imply procedures and rules that must development of scientific knowledge, research, andbe followed. There is often a perception among staff systematic review of the evidence. Guidelinesthat guidelines are legally binding in that they must present the opportunity for a more systematic andbe adhered to - it takes courage on the part of a collaborative approach to care, undoubtedlymidwife to deviate even where there is a clear emerging from the clinical governance and risk >>>> Advancing Practice, TPM, January 2016, vol.19, issue 1 13

ADVANCING PRACTICEPRACTICE CHALLENGE agendas represented historically by: Effective Health BARRIERSReview and critique the Care Bulletins; NHS Executive; Clinical Outcomeschosen guideline using the Group; and the Health Development Agency. The Guidelines are only as good as the evidence they aredomains of the AGREE tool. Scottish Intercollegiate Guidelines Network (SIGN) based on, the quality of which can causeThis could be done on an was set up in 1993, with NICE being established disagreement among experts.individual basis but would much later, in 2005.work well as part of a multi- If guidelines are too prescriptive, they can inhibitdisciplinary exercise; find TYPES OF GUIDELINE choice. Lack of choice and restrictions on access toout the processes for doing midwifery-led care can prevent women fromthis in your workplace – National guidelines such as those produced by NICE birthing at home or in a birth centre due to rigidoften as part of a practice and SIGN are usually developed by clinicians, criteria and strategic cost constraints, rather thandevelopment group. sponsored by relevant professional bodies and holistic individualised assessment and care service-user organisations to produce nationally planning.PRACTICE CHALLENGE agreed standards of care based on relevant andConsider updating an contemporaneous evidence. There is usually an There is a danger that guidelines could be used,existing guideline or write a opportunity for clinicians, service-users, members of legally, to assess competence. These factors cannew one concerning an area the public and a range of organisations to comment create client and professional anxiety and lead toof practice that you are on them during their development, in a consultation ‘defensive practice’ (Feder et al 1999).passionate about. When phase. Together with international guidelines, suchdoing so you need to as those produced by the World Health Organization Guidelines can also be difficult to produce,consider the AGREE tool. (WHO) and the International Federation of disseminate, implement and interpret (Mann 1996).Start by doing a literature Gynecology and Obstetrics (FIGO), these can bereview on the evidence drawn on to produce local guidelines which are IMPORTANT FACTORS IN GUIDELINEunderpinning the topic to ideally developed by a range of representatives of DEVELOPMENTensure your guideline is the multi-disciplinary team and adapted to thebased on the best available needs of local service users. This is where variation Impartiality is important when developing orand most recent research, in care can be seen, depending on local practices, updating a clinical guideline; and more than oneand expert opinion. practitioner opinions and diverse client groups. perspective needs to be represented with the contributions of key stakeholders. It is important to PURPOSE OF CLINICAL GUIDELINES review, critically appraise and include the latest research findings and evidence based practice, The remit of clinical guidelines is to describe bearing in mind the hierarchy of evidence.There are appropriate care based on the best available many tools to support this process, but the Cluzeau scientific evidence and/or broad consensus of expert model (better known as the Appraisal of Guidelines opinion, with the aim of reducing inappropriate Research and Evaluation (AGREE) instrument) is variation in practice, thus standardising care. They generally accepted as the most effective tool for can also promote efficient use of resources and act evaluating the effectiveness of clinical guidelines as a focus for quality control, including audit (Open (Vlayen et al 2005). Originally developed in 2001 Clinical 2011). Guidelines can be utilised as the focus (AGREE Collaboration 2001), it was later updated to for continuing professional development (CPD) a newer version (AGREE tool ll) (Brouwers et al within the multi-disciplinary team and prevent inter- 2010), designed to offer more academic rigour to the professional disputes regarding care pathways and evaluation process. protocols. AGREE TOOL II BENEFITS OF GUIDELINES This is a collaborative international network of Guidelines can improve quality of care and clinical guideline development and appraisal programmes decision making, ensuring consistent care by accessible online, its purpose to provide a framework providing clear guidance regarding processes and for assessing the quality of clinical practice procedures (Mann 1996). Innovation may be guidelines. It can facilitate the development or encouraged and supported by changing and critique of guidelines through understanding of the developing or improving practice. Unprofessional or process and methods used to develop the guideline. unsafe practice would be discouraged and women It can be utilised by: policy makers (to decide which would know what to expect from their care-givers, guidelines to recommend); guideline developers (to including the rationale for that care recommendation follow structured, rigorous development to enhance informed choice. Improved methodology); healthcare providers (to undertake communication within the multi-disciplinary team their own assessment before adopting (MDT) and with women could also help to reduce recommendations); and educators (to enhance risk and promote safety for service users and health critical appraisal skills). professionals. Components of the tool include 23 key items, organised into six domains: 1. Scope and purpose - concerned with the aim of the guideline, the specific clinical questions and14 Advancing Practice, TPM, January 2016, vol.19, issue 1

ADVANCING PRACTICE the target population. Does the guideline offer a professional or legal challenges, that the decision PRACTICE CHALLENGE specific statement of purpose? What group does can be supported by relevant evidence or justified Selecting an area of it identify? in terms of the events occurring and the woman’s midwifery practice that 2. Stakeholder involvement – focuses on the extent choices and needs. The significance depends on the could be improved, write an to which the guideline represents the perspective expectation of their development and use and outline of the key points of its intended users. Who was involved in the variation in application – the intended use needs to you would wish to include developing process, such as matrons, consultant be spelt out clearly. The guideline itself could be in your guideline. midwife, members of the MDT, and service challenged if not based on current evidence, users? regularly audited with clear objectives, statement of 3. Rigour of development - this relates to the validity, development and review procedures. Whilst strategies used to search for evidence and they are a means of guidance only and not policy, the methods to formulate recommendations and to healthcare professional needs to demonstrate good update them. Is there a review date? Are the reason for not practising within an existing references current? Also consider the criteria for guideline, from both a professional and legal inclusion or exclusion of evidence - what perspective, as reasonable care needs to be evidence would be worthwhile to include? demonstrated to meet accountability requirements; 4. Clarity of presentation - whether reading or this is particularly relevant in terms of the developing a guideline, you need to consider the expectation of a minimum standard and duty of care language and format: is it easy to read/well regulated by the NMC as a professional body (NMC presented? Also consider how the guideline is 2015; 2013). Fitness to practise and negligence, in disseminated (such as online, staff notice board, particular, would be measured by the Bolam test, team briefings or patient leaflets). which assesses reasonableness of actions and 5. Applicability – this concerns the likely benchmark of care standards to justify departure organisational, behavioural and cost implications from guidelines. of applying the guideline. If it affects change in practice – how or what needs to be done – are It is important to review, critically there any training or extra resources required, for appraise and include the latest research example. Audit and evaluation needs to be built findings and evidence based practice into a review cycle. 6. Editorial independence – the independence of PROMOTING DIGNITY the recommendations needs to be considered with acknowledgement of possible conflicts of When launching his report (Francis 2013) in Stafford interest from the development group, including funding issues. in February 2013, Robert Francis emphasised thePROMOTING AND ADVOCATING need for people to “come before numbers. PRACTICE CHALLENGEWOMEN’S CHOICE Individual patients and their treatment are what Who are the stakeholders really matters,” he pointed out. “Statistics, from whom you wouldRather than adhering to the guidelines rigidly, it is benchmarks and action plans are tools, not ends inimportant for midwives to truly advocate for womenand outline choices in an objective way, being themselves. They should not come before patients need to elicit support? Whyprepared to make decisions based on the woman’s and their experiences. This is what must be is this important? Considerchoice, the holistic assessment and knowledge of the remembered by all those who design andwoman’s condition, circumstances and evolvingevents. The Nursing and Midwifery Council (NMC) implement policy for the NHS.\" the target population - if itCode (NMC 2015: 2) advocates listening to peopleand responding to their preferences and concerns. It is not enough to deliver a baby with safe care is a midwifery guideline isThe Midwives rules and standards (NMC 2013: scope providing a heathy infant and mother, but also to there any obstetricof practice 5.2) suggests: “You must make sure the give satisfying care that is based on providing aneeds of the woman and her baby are the primaryfocus of your practice and you should work in positive experience of giving birth. Salutogenesis is involvement? Who shouldpartnership with the woman and her family,providing safe, responsive, compassionate care in an proposed as the ideal in childbirth by Downe (2010) you include in yourappropriate environment to facilitate her physical where holistic wellbeing is generated for the benefit guideline writing group?and emotional care throughout childbirth.” of the mother, her infant, family and, ultimately,LEGAL CONSIDERATIONS society. Other authors have discussed the promotion Why? of the social model rather than the medicalisedIt is an important element, particularly in the case of approach that guidelines often represent including: Davis-Floyd’s (1992; 2001) paradigms of childbirth >>>> Advancing Practice, TPM, January 2016, vol.19, issue 1 15

ADVANCING PRACTICEPRACTICE CHALLENGE Figure 1 Three paradigms of childbirth Figure 2 Medical versus social modelWhat research evidence (based on Davis-Floyd 1992; 2001) (based on Bryar 1995)supports the changes youwish to introduce? Where TECHNOCRATIC Medical model of Pregnancy as a normaland how would you find pregnancy perspectives life event perspectivesthat evidence? How would HUMANISTIC HOLISTIC G Normal in retrospect G Normal in anticipationyou evaluate evidence to G The unusual case G Each pregnancy is adetermine its suitability foryour recommendations? interesting unique eventConsider how the health G Prevention of physical G Development of thebenefits, side effects andrisks are addressed within complications individual throughthe guideline. G Doctor in charge experience of G Information restricted pregnancyPRACTICE CHALLENGE G Woman and familyConsider the decision makersimplementation of the G Information sharedguideline in your area ofpractice. How would you Outcomes Outcomesget stakeholders on board? G Live, healthy mother G Live, healthy motherWhat resource implicationsare there? How would you and baby and baby anddisseminate the satisfaction ofinformation? Would there (See Figure 1), and Bryar’s (1995) outline of the individual needsneed to be any training? features of the medical and social continuum (shown in Figure 2). 21st century’. In: Walsh D and Downe S (eds). Essential midwifery practice: intrapartum care, Oxford: CLINICAL FREEDOM Wiley-Blackwell. Even when endorsed by professional bodies, Feder G, Eccles M, Grol R et al (1999). ‘Clinical guidelines can only assist a practitioner; they cannot guidelines: using clinical guidelines’. Brit Med Jour, mandate, authorise or outlaw treatment options. It 318: 728-730. is ultimately the responsibility of practising clinicians to interpret their application, taking Francis R (2013). Report of the Mid Staffordshire account of local circumstances, needs and the NHS Foundation Trust public inquiry, London: The wishes of individual clients (Mann 1996). There can Stationery Office. be an allowance for deviation based on evidence, the clinical picture and client choice. tpm Greenhalgh T (2001). How to read a paper, 2nd edition. London: BMJ Books. Further resources Mann T (1996). Clinical guidelines. Using clinical I NHS National library for guidelines: guidelines to improve patient care within the NHS, London: Crown. http://tinyurl.com/nvt8r78 NICE (2012). The guidelines manual, London: REFERENCES NICE. http://tinyurl.com/pm9swv6 AGREE Collaboration (2001). The appraisal of NMC (2013). Midwives rules and standards, guidelines for research and evaluation (AGREE) London: NMC. instrument, London: The AGREE Research Trust. www.agreetrust.org NMC (2015). The Code, London: NMC. Open Clinical (2011). Clinical practice guidelines. Brouwers M, Kho ME, Browman GP et al for the London: Open Clinical. http://tinyurl.com/qxugmcf AGREE Next Steps Consortium AGREE II (2010). SIGN (2008). A guideline developer’s handbook, ‘Advancing guideline development, reporting and Edinburgh: SIGN. http://tinyurl.com/q66ojsc evaluation in healthcare’. Preventa Med, 51: 421–424. Uppal E (2012). 'This is how we do it...an exploration of student midwives’ experiences of Bryar R (1995). Theory for midwifery practice, variety and inconsistency in practice’. The Pract London: Macmillan. Midwi, 15(8): 22-29. Vlayen J, Aertgeerts B, Hannes K et al (2005). ‘A Davis-Floyd R (1992). Birth as an American rite of systematic review of appraisal tools for clinical passage (comparative studies of health systems and practice guidelines: multiple similarities and one medical care), Los Angeles: Univ of California Press. common deficit’. Int Jour Qual Health Care, 17(3): 235-242. Davis-Floyd R (2001). ‘The technocratic, humanistic and holistic paradigms of childbirth’. Int Jour Gyn Obs, 75(1): S5-23. Downe S (2010).‘Towards salutogenic birth in the16 Advancing Practice, TPM, January 2016, vol.19, issue 1

MIDWIFERY IN THE DEMOCRATIC REPUBLIC OF CONGO (DRC) Claire Reading Midwife working for Médecins sans Frontières in Shamwana, Democratic Republic of CongoEmergency time:caring in Congo Midwifery practice in rural central Africa is full of joys (an abundance of twins, births by candlelight and resilience and stoicism that would leave even the very experienced birth practitioner speechless), but also a lot of challenges (every obstetric emergency in your wildest nightmares and worse) that are compounded by a lack of access to a skilled birth attendant. Women here have a strong culture of traditional practices and remedies, and hospital is often not the first port of call. Caring for women who cannot, themselves, consent to emergency life-saving caesarean sections, is a cultural aspect that we accept and respect as medical professionals working in the Democratic Republic of Congo (DRC). In a busy maternity ward in a low-resource setting, in a hospital supported by emergency humanitarian medical organisation Médecins sans Frontières (MSF), just how are obstetric emergencies managed - and are the outcomes what you would expect?Iwanted to share my experiences of working as a birth; when, full of guilt, I couldn’t follow her up midwife in the Democratic Republic of Congo myself and said that I was going to DRC to work, I (DRC). Of being faced with situations I had only hadn’t meant to make her feel that her birth wasn’t read about in text books. Of team work. Of just as important as others. Wherever they are, womenpatience. Of working and living in a country where have the same fears about birth and motherhood -English is hardly spoken. My role is not to deliver culture and nationality don’t change that.babies or give hands-on care, but to support theCongolese staff to increase their skills and My role is not to deliver babies orknowledge, to educate and supervise them in apractical way and for them to understand when it’s give hands-on care, but to supporttime to call for help. the Congolese staff to increase theirBACKGROUND skills and knowledgeBefore I left to travel to southern DRC, I was workingin the antenatal clinic of a London teaching hospital. I digress.At the end of one particular long day, the last woman In the DRC, political instability and a forgottenwalked into the room with her partner. We had country post-civil war have created huge obstaclesnever met before (sound familiar?) and I was running to access antenatal care, medication and safe births.late (sound familiar too?). She requested an elective No vehicles. No roads. No infrastructure. Very little >>>>caesarean section. I listened; we madeappointments. Now that it is nine months later I amthinking of her and hope that she had a positive Reading , TPM, January 2016, vol.19, issue 1 17

MIDWIFERY IN THE DEMOCRATIC REPUBLIC OF CONGO (DRC)education for girls after primary school age. Whenyou come face to face with a woman who has walked35km to access free health care because she isunwell and pregnant, timing is put into perspective.The maternal mortality rate is 730 per 100,000 births(World Health Organization (WHO) 2015), but Iwonder how we can measure this accurately, as somany women birth in such rural areas in DRC thatthose data are not available.Only four doctors can perform acaesarean section free of charge forhundreds of kilometres Muzinga (left) and Claire (right) with twins Kyungu and KabangeMISSION round of the 16-bed maternity building that should, in theory, be all airy with its high tin roof; but inSo, timing. A precious entity. The right timing, bad truth it felt like a sauna. Here, at the MSF referraltiming, poor timing. The list goes on. I would like to hospital, we have nine maternity staff who care forshare stories from women I’ve met, and made a plethora of sexual and reproductive healthconnections with, in a special area of Katanga in complaints (such as severe malaria/threatened pre-South-East DRC. As I write this, I’m coming to the term labour due to sexually transmitted infectionsend of a nine-month mission working with Médecins or urinary tract infection/severe anaemia/severesans Frontières (MSF), based in a village called uterine prolapse, to name but a few) as well as beingShamwana where MSF has supported emergency the neonatal unit.medical and surgical activities for nine years. It’sbeen the most challenging and the happiest time of Muzinga came to the ‘salle technique’ [labourmy career and personal development. Skilled birth room] as she was worried: her waters had brokenattendants are in short supply, to say the least, and with twin one and she looked scared; already alarmthat has made being here feel more pertinent and bells rang, as women here (I learnt quickly) neveressential when providing education for local staff. ask for help. Beatrice was on duty - an experiencedThe MSF hospital is the only free secondary and ‘accoucheuse’ (not a qualified midwife, buttertiary healthcare provider for hundreds of competent with fundamental aspects of midwiferykilometres (the only four doctors who can perform a care) – and she gained consent for a vaginalcaesarean section free of charge for hundreds of examination.kilometres - can you imagine?). It’s hard to put thatinto perspective. It has also made me feel a heavy Beatrice, calmly and softly looked over to me andsense of gender inequality and frustration on the said, ‘’Mama Claire, I can feel a foot. And….a cord…’’global scale of sexual and reproductive health. EMERGENCY Two weeks after touching down in a small planeon the dusty airstrip, 2km from the MSF base, I’m I have a radio with me all the time.There is no phoneproficient with a Pinard (new skill acquisition, tick!), signal, no ‘2222’ system here. No emergency bell.managed a handful of postpartum haemorrhages Different channels call different departments. Iwith the team (no emergency bell but the full range called the medics, as the maternity staff prepared forof uterotonic drugs – hooray!) and welcomed three a caesarean section (intravenous line, urinarysets of twins into the world. One set will stay with catheter, obligatory shave and the most importantme forever. component – consent. Women here in Katanga cannot give consent for a surgical intervention; it isTWINS the decision of her husband or, if she is widowed or not married, it falls on the men in the family to giveI remember Muzinga’s orange skirt from antenatal consent for a caesarean section).clinic the previous week. I was excited to see her inthe maternity unit, as we were confident that she Beatrice and I lifted Muzinga from the bed to thecould birth her twins normally, having given birth to stretcher and carried her outside to the operatingfive healthy babies before. We had finished ward theatre about 25metres away. She was heavy! There18 Reading, TPM, January 2016, vol.19, issue 1

MIDWIFERY IN THE DEMOCRATIC REPUBLIC OF CONGO (DRC)Water collected from the pump in Shamwana We wrapped little Kyungu and Kabange up together in a dry piece of thick, brightly patternedare no porters here. cotton cloth that we give to all new mothers at the In theatre, we prepared the wooden table for the hospital. Each twin is given the same name to indicate s/he is a twin, but these babies were calledresuscitation of the twins. They use a foot-pedal Kyungu Claire and Kabange Yannick. The next day,device for suction; we had a stethoscope, two small when Muzinga was mobile, her family came andgreen squares of thick cotton to dry each of the threw chalk dust over the heads of all staff involvedbabies and then I realised we only had one bag- in the birth: a sign of celebration and thanks. Sixvalve-mask for helping both the babies to breathe, weeks later they all came back dutifully for the twins’if necessary. Only one. At this point I became (who were now chubby and active) vaccinations.severely tachycardic and began perspiringexcessively. The operating theatre or ‘bloc op’, as we TIMINGrefer to it, was also oppressively hot. Walking back over the sandy 100m stretch between Muzinga was anaesthetised, with intravenous the hospital and the MSF compound for lunch thatketamine, by Wilfred, one of two nurse anaesthetists. day, after Muzinga’s birth, with people greeting meInterestingly, patients maintain their own airway; I’d and me greeting them back, I couldn’t help but asknever seen this form of anaesthesia used. Doctor myself what would have happened to Muzinga andStephane (one of three Congolese medics who are her babies if there were no MSF hospital. And howskilled in medicine, surgery and in tropical diseases) different would it have been, had Muzinga lived inbegan the caesarean section with a nurse assistant the UK? It’s interesting to think that in a cordand one circulating staff member. It had been more prolapse emergency situation in a UK hospital, wethan 40 minutes since the medical team had called can gather a large team of qualified staff and deliveran emergency caesarean section, and 40 minutes babies in 12 minutes. I remember that 40 minutessince I had heard two heartbeats. I then questioned whizzing by, with preparation and sheer terror, andmyself as to whether I really had heard two different I don’t think we could have gone any faster in thefetal heartbeats. setting we were in.BIRTH OF TWINS Her family came and threw chalkThe first twin needed full cardiopulmonary dust over the heads of all staffresuscitation (CPR). She had a heartrate of less than60. She was floppy, pale, not breathing. In four years involved in the birth: a sign ofof working in hospital- and home settings inLondon, I had never done chest compressions on a celebration and thanksnewborn. You might think I was lucky, or maybe Iwas part of teams whereby good decisions were On reflection, I think it’s important to trust yourmade. In good time. knowledge and, even though I didn’t have hands-on experience of full newborn resuscitation, I found But, all those mandatory study days and updates that the knowledge was there when I needed it; I justresulted in an autopilot response. The lack of towels didn’t realise I was capable of taking charge of theand pairs of hands meant things were difficult. We situation. But that has taken time too: to feelgot the baby back breathing on her own after what confident enough to travel here and have afelt like a lifetime. I was dripping sweat onto the potentially positive impact rather than ‘another pairbaby, and Beatrice was called away two minutes into of hands’. My advice for anyone who wants tothe CPR to collect the second twin, who was practise in a low-resource setting? Love your skillsscreaming, so that I could concentrate on the first and drills study days – I’m sure I have internalbaby. Once we had ascertained that both babies tattoos of visual flowcharts, mannequin dolls calledwere ok, the theatre team began to make fun of me, Annie and mnemonics. tpmmimicking my military-style repetitions of ‘one, twothree, inflation…..one, two, three, inflation’. REFERENCES WHO (2015). Global health observatory country views: Democratic Republic of Congo statistics, Geneva: WHO. http://tinyurl.com/na9jdahReading , TPM, January 2016, vol.19, issue 1 19

MENTORING Jacqui Richards Midwife at Warrington and Halton Hospital TrustLearning to aid learning The National Health Service (NHS) is one of the largest employers in the world and, with 1.3 million staff, the biggest employer in Europe. With over three hundred different careers on offer (NHS 2015), the acquisition of skills and qualifications, through academic and clinical training, is an integral part of day- to-day life in the health service. As such, mentoring has become a significant feature in the preparation of healthcare professionals, to support students and ensure learning needs and experiences are appropriate to competency. This article examines the mentor’s role, in relation to a teaching innovation designed to address students’ identified learning needs to meet the requirements of the multi – professional learning and assessment in practice course NM6156.The effectiveness of the aids to learning will be assessed through an online quiz, and its usefulness will be analysed with reference to educational theories of learning and development.INTRODUCTION ‘theorist’ learners, and actually putting theory into practice may appeal to ‘activists’ as well.The Nursing and Midwifery Council (NMC) (2008: Furthermore, it can be used as a reflective tool. In19) states that mentors, once entered on the local this way, the mentee moves from observation, alongregister, are responsible and accountable for a continuum, to accommodation, whereby s/he is,“organising and co-ordinating student learning through experimentation, able to demonstrate aactivities in practice”. practical and logical approach to problem solving (Hinchliff 2009). In terms of protecting the public, the relevance ofthe mentor’s role may be even greater in view of Strongly humanist, the quiz’s emphasis is on self-concerns expressed in the literature over the direction, allowing mentees to identify aspects ofreluctance of mentors to fail students (Duffy 2007). training thus far that need further clarification, in aEtheridge (2007) suggests developing practitioners’ Maslowian tradition, whereby learning is a means ofability to exercise clinical judgement is one area self-actualisation, central to empowerment andwhere current practice is lacking professionally and autonomy. It challenges students in an informal andbetter support is needed to assist students in making fun way, without the need for direct supervision, yeta smooth transition from novice to autonomous with technical appeal to the modern student.practitioner. Information can be easily updated and questions prepared beforehand which are designed to provideHOW DO LEARNERS LEARN? formative and summative methods of assessment using formal and informal opportunities forGiven the multiplicity of roles, it is hardly surprising teaching and learning.that there are perhaps as many theories of howstudents learn as there are mentor activities. What INNOVATION BASED ON THESEis arguably one of the more well-known experiential THEORIESlearning styles, devised by David Kolb (1984), ishighlighted by Hinchliff (2009) (See Figure 1). The labour and delivery quiz was designed in The online quiz is designed to appeal to Kolb’s20 Richards, TPM, January 2016, vol.19, issue 1

MENTORINGFigure 1 Kolb’s experiential Concretelearning styles Experience Feeling Accommodating Perception Continuum Diverging (feel and do) How we think about things (feel and watch) CE/AE CE/RO Active Processing ReflectiveExperimentation Continuum How we Observation do things Doing Watching Converging Assimilating (think and do) (think and watch) AC/AE AC/RO Abstract Conceptualisation Thinkingaccordance with a competence–based model, leading to a stage where the learner can completedescribed by Gopee (2011), demonstrating how the some aspects of the skill independently, with onlymentor enables the learner to learn specific minor guidance.objectives and assesses their competence in them. Further practice development issues are Reece and Walker (2002) cited in Hand (2005: 59) described by Vygotsky (1962) as ‘scaffolding’, wherebelieve that,“Adult learning theory is highly relevant transformational changes occur in the learner, withto professions such as nursing, suggesting that motivation and encouragement from the mentor.teachers need to provide patient-centred learning Similarly, McAllister and Osbourne (2006) talk ofthat is individualised and appropriate to the ‘trigger strategies’ to generate and share ideas,patient's needs.” strengthening learning communities.Thus, pointing students to the online quiz gave plenty ofLEVELS OF COMPETENCE opportunity for feedback on what did and did not work well for each individual. It is hoped that byWhen looking at levels of competence, Steinaker using this tripartite innovation, a link will bridgeand Bell (1979) offer some insightful guidance.Their theory and practice; so important for hands-on careresearch identifies five levels of skill-acquisition that and client safety.can be used for assessment. These are: exposure,participation, identification, internalisation and A REFLECTIVE APPROACH >>>>dissemination, showing how the learner moves fromobservation to exercising the skill, then finally, McAllister and Osbourne (2006) ask what lessonshaving succeeded in testing, can pass on their can be learned from this activity, in gauging theunderstanding (cited in Hand 2006). In metaphorical success of their workshop activities. In this case itterms, the said mentee (in the first allocation of the can be said that for the author the overriding benefitsecond year) could be said to be between initial has been the improvement in informationstages of the observation and learning prcess, where technology and research skills, in addition to the richthe learner is being given detailed guidance in the information gained on learning and development.form of step-by-step very specific instructions, but As a reflective practice the author has found the Richards , TPM, January 2016, vol.19, issue 1 21

MENTORINGconsideration of her role as practitioner–mentor element of autonomy needed to encourage students,most thought–provoking. It is hoped that all appeal to their individuality and steer their learningknowledge gained on the module will be applied in a way that is specially adapted - and we havewhilst interacting with students in the future. One come full circle in discussion. Only when qualified,mentee who especially valued the feedback, assessed and deemed competent, does the realcommented that the questions made her realise how learning begin. Nurturing students’ ability tomuch she had learnt via the course. appraise situations, think critically, make not only clinically-sound but also ethical decisions and direct Technically, perhaps sub–headings could have their further learning reflectively, is an integral partbeen used, but it is the author’s intention to develop of becoming a midwife - by definition a professional,more quizzes using the Testmoz.com package, autonomous practitioner. Mentors can begin byincluding, perhaps, antenatal care and obstetric exposing their own rationale to develop reasoning,emergencies. Students did not partake in the design and link cause, effect and outcomes. Bottom–up,of the questions and this could be argued to be a learner–led, grass roots innovations like this onlineweakness, though their contribution was pivotal in quiz will assist in structuring inputs in the endlessthe opting for a reflection of their experiences on process of learning and development. tpmDelivery Suite. Another technological limitation wasthe lack of a ‘drag and drop’ tool, which meant that I Quiz available at http://testmoz.com/454819mechanisms of labour could not be ordered insequence, possible in other (fee paying) software REFERENCESpackages. Improvements in illustration, theapplication of colour and larger print may be Duffy K (2007). ‘Supporting failing students inconsidered in future use. One final suggestion for practice 1: assessment’. Nurs Times, 103(47): 28-29.the way forward in developing this innovation is torearrange the questions so that the most difficult are Etheridge SA (2007). ‘Learning to think like aat the beginning, due to the findings of research nurse: stories from new nurse graduates’. Jour Continundertaken by Joan Middendorf and Alan Kalish Ed Nurs, 38(1): 24-30.(1996): they described how human attention andretention speaks against the value of long lectures. Gopee N (2011). Mentoring and supervision inThey described how material is best divided into 18- healthcare, London: Sage Publications.minute slots to avoid lapses of learning. Hand H (2005).‘Promoting effective teaching andWHERE NEXT? learning in the clinical setting’. Nursing Stand, 20(39): 55-63.The way forward was best epitomised by onementee, who suggested other topics for learning: Hand H (2006).‘Assessment of learning in clinicalwhen is a VE indicated/contra-indicated? What practice’. Nursing Stand, 21(4).different care should a Rh-ve woman receive ante-,intra- and postnatally? How do you bleep a doctor? Hinchliff S (2009). The practitioner as teacher, 4thAnd what questions should you always include in edition. London: Churchill Livingstone.an admission conversation? At the time of writing,further quizzes have been compiled – on vaginal Kolb DA (1984). Experiential learning: experience asexamination (480137); newborn life support (482360); the source of learning and development (Vol 1).postpartum haemorrhage (486287); breech (486365); Englewood Cliffs, NJ: Prentice-Hall, cited inand pregnancy–induced hypertension (486426). Hinchliff (2009).When evaluating the success of any learningenterprise, asking what? why? when? where? and McAllister M and Osbourne SR (2006). ‘Teachinghow? has got to be a good starting point (Hinchliff and learning practice development for change’. Jour2009). This idea may be extended to include who? Contin Ed Nurs, (37)4.(who is training by and for?) if a learningenvironment is to be truly comprehensive. The Middendorf J and Kalish A (1996). ‘The “change-answer must be an inclusive one – by everyone, for up” in lectures’. Nat Teach Learn Forum, 5(2): 1-5.everyone! New technologies, such as the advent ofpaperless technologies and the employment of pre– NHS (2015). Explore roles, London: NHS.registration assistants, mean that personal growth http://tinyurl.com/qzm2bbband lifelong learning are here to stay. NMC (2008). Standards to support learning andCONCLUSION assessment in practice, London: NMC.We started this article making reference to the Reece I and Walker S (2002). Teaching training and learning: a practical guide, Tyne and Wear: Business Education Publishers. Steinaker NW and Bell MR (1979). The experiential taxonomy: a new approach to teaching and learning, New York: Academic Press. Vygotsky L (1962). Thought and language. Cambridge, MA: MIT Press, cited in McAllister and Osbourne (2006).22 Richards, TPM, January 2016, vol.19, issue 1

TANZANIACamella MainSpecialist midwife at Guy's andSt Thomas' NHS Foundation TrustMidwifery: home and awayThe challenges faced by birthing women and maternity healthcare professionals in developing countriescannot not be over estimated.The experience of a midwife in a rural Tanzanian hospital described in thisarticle gives a small insight into these challenges. With intermittent electricity, no running water, threebeds, 20 births per day and lack of midwifery or obstetric education, morbidity and mortality rates arehigh, and teaching is difficult. Conversely, where monitoring is minimalistic and time limits are notapplied, ‘normal birth’ is truly the norm and the trust in women to grow and birth their babies isconsistent and commendable. Reflection upon midwifery in developing countries can help informattitudes and practice in the UK.BACKGROUND Another mother hobbles into the labour room, where four women are currently at varying points ofA woman, clearly in advanced labour, tosses me her second stage. She tells the midwife she is leaving formaternity card; the only writing on it is the obstetric home (24 hours after her caesarean). The midwifehistory: fourth pregnancy, three term babies hands her a beautiful baby girl wrapped in a brightstillborn. As she takes off her tanga (coloured cloth orange kanga, who was stillborn. The mother takesused as a dress) and lies down on the dirty mattress, the baby, wraps her onto her back and, withoutvertex is visible. Her frame is frail and bony but her complaint, begins a four-mile walk back homebump is large. After an hour of pushing (meanwhile, where she will continue strenuous manual work inI have helped two other babies to be born), she the coffee plantation.births the large head. Shoulder dystocia ensues; thisbaby is clearly macrosomic. Gaskin manoeuvre is After 10 minutes of resuscitation, thisattempted first, then McRoberts, internalmanoeuvres and finally 6.5 minutes after the head mother of four hears the cry of a childis born, difficult removal of the large posterior armdelivers the baby. Throughout this time, the who is her own, for the first timeTanzanian midwives are telling me to ‘give up’ inbetween loud prayers that the woman (who, they An ‘ambulance’ (an ancient truck without glass >>>>assume, will die along with the baby) will go to in some windows) arrives with a woman who hasheaven. After 10 minutes of resuscitation, this birthed her baby at her mud hut up in Mount Meru.mother of four hears the cry of a child who is herown, for the first time. The scales only go up to 5kg;we assume undiagnosed, untreated diabetes has ledto her poor obstetric history and this traumatic birth. Main, TPM, January 2016, vol.19, issue 1 23

TANZANIAPostnatal ward On arrival she is unconscious, with her head in the adding to our personal bank of anecdotal knowledge footwell of the passenger seat and her legs by the or, on a larger scale, through participating in head rest. Approximately two litres of blood research which informs practice standards and surround her. We carry her out of the back door of guidelines. It could be assumed that developed the ambulance onto a trolley. After a trek up the road countries have little to learn from African midwifery. to the pharmacy and paying the pharmacist, we However, the women and healthcare workers administer ergometrine. The oxytocics as well as (midwives, doctors and traditional birth attendants) fundal massage, fluids and breastfeeding saved this in Tanzania refreshed our understanding and woman’s life and she walked home the next day with approach to birth. a handkerchief-full of ferrous sulphate tablets (after yet more manipulation of the pharmacist). NO IMPOSED TIME LIMITS Rather than implementing intervention as The lack of capacity and high birth rate at this hospital meant that women were only allowed onto a result of time limits, we should look at the labour ward when in second stage. If they were examined and found to be in first stage, they wouldthe cause of the delay and treat that instead be sent away. These women walked away from the labour ward without complaint into the courtyard MUTUAL LEARNING area where they would lie down under the tree and sleep, or mobilise if they desired. Their female The shocking events and practices (a few mentioned friends and relations would come and give them here) witnessed were overwhelmingly common sweet tea and any food available. realities. To attempt to address some of the many issues, training sessions were held and guidelines There were no time limits on any stage of labour written for infection control, postpartum because there is no way of augmenting labour. When haemorrhage management and basic neonatal we asked the midwives about it, they simply resuscitation. Extensive adaptations were necessary explained to us that all women are different, they due to the absence of running water, lack of labour at different speeds and in different ways and education, limited resources and intermittent would “birth when they could and wanted to”. Of electricity. course mortality rates are higher. But in our experience, we did not witness mortality as a result Midwives across the world learn continually from of ‘allowing’ a woman to rest for a few hours when the women in their care, either on an individual basis in ‘established labour’ or mobilise for a few hours when fully dilated with a high head. We observed that damage to the perineum was not increased when this was done because the women were not24 Main, TPM, January 2016, vol.19, issue 1

TANZANIApushing for all this time. baby, and just like a cephalic birth, if she reaches One primiparous woman who was fully dilated fully dilated, generally the rest of the birth is straightforward.”with a high head walked to the village and back(about three miles) before returning to birth her Whilst these attitudes may also be held bybaby; the baby was born healthily, with an intact healthcare professionals in the UK, sometimes theperineum. On reflection, imposing strict time limits over-complication of birth and forgetting women’s(particularly in second stage when there is no urge innate ability to birth is the cause of unsuccessfulto push) on low risk primiparous women may campaigns to normalise birth, and unnecessarilyincrease unnecessary use of instrumentally assisted high (and increasing) caesarean section rates (withbirth. Rather than implementing intervention as a no reduction in morbidity or mortality (Jonsdottir etresult of time limits, we should look at the cause of al 2009)). Whilst we should be ever protective of ourthe delay and treat that instead; delay may be a low mortality and morbidity rates in developedresult of lack of oxytocin flow, fear, poor support, countries, we must restore the simplicity of birth soneed for rest and so on (Zhang et al 2002). After all, we can promote positive, normal (whereverthe body is not a machine; otherwise midwives possible) birth, resulting in dignified childbirth, safewould be called mechanics. motherhood and satisfied healthcare professionals.RECONSIDERING LATENT PHASE tpmThe ‘cascade of intervention’ is sometimes REFERENCESmentioned on labour wards in developed countries(Tracy and Tracy 2003). Often the first intervention Janssen AP, Still DK, Klein MC et al (2006). ‘Earlyfor a primiparous woman is coming into hospital too labor assessment and support at home versusearly when still in latent phase. Experiencing a long telephone triage: a randomized controlled trial’. Obsand tiresome latent phase, when the body (strained Gyn, 108(6): 1463-1469.and desperate for rest) in connection with the mind(fearful in anticipation of the length of the labour), Jonsdottir G, Smarason A, Geirsson R et al (2009).women try to ‘keep things going’ only to experience ‘No correlation between cesarean section rates anda further lapse in energy and spirit. The Tanzanian perinatal mortality of singleton infants over 2,500 g’.women we observed expected labour to last a few Obs Gyn Scand, 88(5): 621-623.days. They rested whenever they desired, andmobilised when they had strength and willpower. Maimburg RD, Vaeth M, Durr J et al (2010). ‘Randomised trial of structured antenatal training The latent phase is a difficult stage of labour sessions to improve the birth process’. Brit Jour Obswhich can be exhausting and discouraging (Simkin Gyn, 117(3): 921-928.and Ancheta 2000). If primiparous women wereeducated with realistic expectations of labour and Page L (2014). ‘The known and trusted midwife’.birth they may feel more confident to stay at home Brit Jour Midwif, 22(4): 234-234.and self-manage their latent phase to prevent earlyadmission (Maimburg et al 2010). In addition, all low Sandall J, Gates S, Shennan A et al (2013).risk primiparous women should have home ‘Midwife-led continuity models versus other modelsassessment in labour and be supported to stay at of care for childbearing women’. Coch Data Syst Rev,home when in early stages (Spiby et al 2008; Janssen 67(8): 334-386.et al 2006). Ideally this would be done by a knowncarer; the benefits of caseload midwifery are well Simkin P and Ancheta R (2000). The labor progressdocumented, including the investment in time and handbook, Oxford: Blackwell Science.cost, as well as better outcomes and more satisfiedwomen and healthcare professionals (Williams et al Spiby H, Green J, Renfrew M et al (2008).2010; Sandall et al 2013; Page 2014). Continuity of Improving care at the primary/secondary interface: a trialcarer needs to become a priority of policy makers in of community based support in early labour. The ELSAdeveloped countries if care is to become truly trial. Report for the National Co-ordinating Centre for thewoman centred. NHS Service Delivery and Organisation R and D (NCCSDO), London: NCCSDO.CONCLUSION Tracy S and Tracy M (2003). ‘Costing the cascade:In conclusion, the faith in women to grow and birth estimating the cost of increased obstetrictheir babies was consistent (even though it was intervention in childbirth using population data’.partly out of necessity, due to lack of resources and Brit Jour Gyn, 110(8): 717-724.knowledge). For example, one doctor said aboutbreech birth: “We trust the woman can birth her Williams K, Lago L, Lainchbury A et al (2010). ‘Mothers’ views of caseload midwifery and the value of continuity of care at an Australian regional hospital’. Midwif, 26(6): 615-621. Zhang J, Troendel J and Yancey M (2002). ‘Reassessing the labor curve in nulliparous women’. Am Jour Obs Gyn, 187(4): 824-828. Main, TPM, January 2016, vol.19, issue 1 25

DOMESTIC VIOLENCE IN PREGNANCYGill Stonard Emma WhapplesMidwife at Walsall Senior lecturer inManor Hospital midwifery and course leader for return to midwifery practiceDomestic violence inpregnancy: midwives androutine questioningThe Confidential enquiry into maternal and child health (CEMACH) (2004) set the standard for maternitycare to protect women from domestic violence.Twelve women who were murdered by their partner and43 further deaths from disclosure with no appropriate referrals prompted the routine enquiry fordomestic violence to be initiated in 2000.The death rate from domestic violence had marginally decreasedslightly in the latest report from The Centre for Maternal and Child Enquiries (CMACE) (2011) with 11women murdered by their partner and 34 further deaths from disclosure with no referrals. The aim ofthis article is to review the current literature in order to explore evidence that questions the confidenceof midwives when asking about domestic violence in pregnancy. The article aims to highlight theconcerns that midwives face when confronted with a positive disclosure of domestic violence, and toprovide a flow chart to aid in referral. BACKGROUND and continuing during pregnancy (CEMACH 2004). Midwives have been expected to routinely ask Reports from CEMACH (2004) show that at least one million women in the United Kingdom will about domestic violence since 2000, as a result of experience domestic violence at some time in their recommendations from the Department of Health lives, and that many will endure domestic violence (DH) (2000), advising that routine questioning for at least 30 times before seeking help. This figure domestic violence should be introduced for all women, and to include the development of localMidwives have been expected to strategies for referral to multidisciplinary teams. Ofroutinely ask about domestic 391 women identified in the report who had diedviolence since 2000 from domestic violence-related incidents, 12 were murdered by their partner and 43 voluntarily includes 30 per cent of women who will suffer from disclosed domestic violence to the healthcare abuse starting, changing in intensity or method (for professional, as none were directly asked about example: psychological, sexual or physical abuse) domestic violence. Half of the women who were murdered continued to receive midwifery-led care with no referrals made. Routine questioning for domestic violence is generally accepted by women (DH 2000), but reports show that it is more likely that women will disclose26 Stonard and Whapples, TPM, January 2016, vol.19, issue 1

DOMESTIC VIOLENCE IN PREGNANCYdomestic violence if directly asked. Evidence from differences between midwives in Northern Ireland,the DH has shown that women who suffer from Leeds and London and included 865 hospital- anddomestic abuse rarely disclose the information to community midwives, including age ranges of 25-40their midwife for fear of intimidation, and 40-55.embarrassment or further abuse (DH 2000; Nasirand Hyder 2003). Those who do are in need of Ninety two per cent of the midwives questionedsupport, understanding and trust from their within the studies agreed that they had a major partmidwife (National Institute of Health and Care to play in screening for domestic violence; howeverExcellence (NICE) 2008). As domestic violence is only 28 per cent reported that they had raised theknown to increase during pregnancy (Royal College issue when they had performed bookingof Midwives (RCM) 1999), women need to know that appointments.midwives are confident and equipped to deal withand support disclosure when it occurs. However, the The main area for concern was thereports show that midwives are not confident tosupport them (Bacchus et al 2003). midwives’ lack of confidence when The CMACE report (2011) showed a small dealing with positive disclosureimprovement in figures for domestic violence-related maternal deaths occurring between Throughout the articles, recurring themes arose2006-2008, stating that 34 of the women who had as barriers or areas that caused concern fordied had again voluntarily disclosed domestic midwives, when asking about domestic violence.violence to their healthcare professional, and a The findings were that:further 11 were murdered by their partner. Thesefigures suggest that routine questioning does • midwives reported a lack of confidence and howimprove domestic violence disclosure. However, as to ask about domestic violence due to insufficientwomen continue to voluntarily disclose domestic education, and a lack of knowledge around theviolence, we need to explore whether midwives are subjectconfident to ask the question about domesticviolence and what concerns they have when • there were concerns around partner presenceconfronted with a positive disclosure. and lack of confidential/private areas to ask about domestic violence. Some midwives raised fearsMETHODS regarding aggression from partners, and did not feel that it was their place to deal with this and soPrimary research articles were included in the often would make no provision to remove womenliterature review as they addressed the feelings, to ask, if partners were present.stereotypes and attitudes of midwives towardsroutine questioning and domestic violence • concern was raised regarding ‘opening a can ofeducation. Semi-structured questionnaires and worms’ for fear of exposing further problemsinterview articles were also included as they (Bacchus et al 2002; Gielen et al 2000; Wathen etinvestigated concerns and barriers that midwives al 2008).faced.The articles had been granted ethical approvaland had been peer reviewed to assess the credibility • language barriers and time restraints were alsoof each article. The topics of interest extracted from raised as problem areas, as time to providethe data included barriers and concerns faced by interpreters for the questioning of domesticmidwives when asking the routine question violence would itself bring pressures to practiceenquiring about domestic violence; how to ask the (Protheroe et al 2003).question; education; lack of confidence whenaddressing domestic violence; and how to deal with The studies showed the main area for concernpositive disclosure. was the midwives’ lack of confidence when dealing with positive disclosure, and the uncertainties ofFINDINGS referral procedures.Eight studies were included that used semi- WHAT CAN BE DONE >>>>structured interviews and questionnaires to recorddata from midwives who expressed views and At present there appear to be many interventionsconcerns relating to domestic violence and and contact points for midwives to access but noeducation. The interviews were conducted before solid domestic violence policy or guideline to follow.and after domestic violence education to reflect the The introduction of a national guideline foreffectiveness and quality of programmes offered tomidwives. The studies reflected demographic Stonard and Whapples, TPM, January 2016, vol.19, issue 1 27

DOMESTIC VIOLENCE IN PREGNANCYFlow Chart 1 Appoint domestic violence midwife/ construct domestic violence policy Set up pregnancy wellbeing clinics Routine questioning by midwife Negative disclosure. Positive disclosureEnsure woman is aware that disclosure can be made at any timeRepeat questioning at 28 weeksNegative Positive Refer to pregnancy wellbeing clinic/disclosure disclosure specialist midwife, provide appointmentRepeat questioning at 34 weeks time for womanNegative Positive Individualised support dependent ondisclosure disclosure needs. Referral to safeguarding, drug/alcohol support, counselling Repeat questioning at five day postnatal visit including/excluding partner. Support for women wishing to leaveNegative Positivedisclosure disclosure relationships/referrals to safe housing Further appointments/counselling sessions, support as neededEnsure woman is aware of contact points should her situation change, leaflets/contact numbers28 Stonard and Whapples, TPM, January 2016, vol.19, issue 1

DOMESTIC VIOLENCE IN PREGNANCYdomestic violence referral may provide the support implemented to assist midwives to feel confidentfor midwives to have the confidence to perform when asking about and referring cases of domesticroutine questioning effectively. The introduction of violence in pregnancy, and to ensure that women areeducation including simulation of how to ask the given the opportunity disclose domestic violencequestion, may be beneficial in building confidence through confident effective questioning. tpmfor midwives to perform the routine enquiry, aswould the provision of leaflets for non-English It appears from the reports that midwivesspeaking women, containing information in the fivemost common foreign languages spoken in Britain. lack confidence when addressing Midwives are aware that screening and domestic violence and require moreintervention for domestic violence are an importantpart of midwifery practice, relying on timely intense educationreferrals for individualised support throughspecialist midwives and safeguarding teams. REFERENCESTherefore the appointment of a specialist domesticviolence midwife solely to formulate referral policies Bacchus L, Mezey G and Bewley S (2002).and to manage and discreetly work within ‘Women’s perceptions and experiences of routinepregnancy wellbeing clinics may provide midwives enquiry for domestic violence in a maternitywith the referral pathway they need to have the service’. Int Jour Obs Gyn, 109: 9-16.confidence to support these women. Bacchus L, Mezey GC and Haworth A (2003). The introduction of a flow chart to aid midwives ‘Midwives’ perceptions and experiences of routinein the referral process (See previous page, 29) will enquiry for domestic violence’. Int Jour Obs Gyn, 110:ensure that women who give positive disclosure will 744-752.leave the clinic with an appointment to see aspecialist midwife. The clinic itself will be an CEMACH (2004). Sixth report of the confidentialordinary looking clinic to outsiders, held within an enquiries into maternal deaths in the United Kingdom.already functioning midwifery unit, which will not Why mothers die 2000-2002, London: CEMACH.raise suspicion with the perpetrator and will allowwomen to receive support individualised to their CMACE (2011).‘Saving mothers’ lives. Reviewingcircumstances. This may be: counselling for the maternal deaths to make motherhood safer: 2006-woman; for her and her partner; drug and alcohol 2008’. BJOG: Int Jour Obs Gyn, 118(1): 203.support for her or her partner; or assistance to leaveviolent or abusive relationships.The woman may be DH (2000). Domestic abuse. A resource manual forremoved from the room for safe questioning with a healthcare professionals, London: HMSO.simple request to go to another room for height orweight measurement, where the specialist midwife Gielen A, O’Campo P, Campbell J et al (2000).would see her briefly first. ‘Women’s opinions about domestic violence screening and mandatory reporting’. Am Jour Prevent It appears from the reports that midwives lack Med, 19(4): 279-285.confidence when addressing domestic violence andrequire more intense education. Nasir K and Hyder AA (2003). ‘Violence against pregnant women in developing countries’. Euro Jour One study addressed the issue of the impact of Pub Health, 13: 105-107.domestic violence education on midwives andshowed that it improved awareness and knowledge NICE (2008). Antenatal care: routine care for thebut had no impact on midwives’ practice (Protheroe healthy pregnant woman. CG 62, London: NICE.et al 2003). There is up-to-date evidence basededucation in place for newly qualified- and student Protheroe L, Green J and Spiby H (2003). ‘Anmidwives; however there is no recent research interview study of the impact of domestic violencewhich examines whether it has made an impact on training on midwives’. Midwifery, 20: 94-103.midwives’ attitudes and midwifery practice relatingto domestic violence.Therefore there is a clear need RCM (1999). Domestic abuse in pregnancy. Positionfor further research into this area examining the paper 1999, London: RCM.impact of routine questioning and the confidence ofmidwives. One report explored women’s views of Wathen C, Jamieson E and Macmillan H (2008).routine enquiry and showed that the barriers ‘Who is identified by screening for intimate partneridentified were evident in practice. As domestic violence?’ Wom Health Issues, 18(6): 423-432.violence in pregnancy impacts on both the womanand the fetus, it is essential that measures are Stonard and Whapples, TPM, January 2016, vol.19, issue 1 29

BREASTFEEDING RATES IN IRELANDMarcelina Dr LouiseSzafranska GallagherMidwife at Coombe Assistant professorWomen’s and Infants’ at Trinity College,University Hospital, Dublin DublinPolish women's experiences ofbreastfeeding in IrelandExclusive breastfeeding among Polish mothers at three-four months (38.6 per cent) is in keeping with thelow rates of breastfeeding in Ireland overall (Begley et al 2008), and suggests that Polish women havebegun to adopt the infant feeding practices of Irish women.Therefore, the aim of this study was to explorethe factors that influence Polish women's decisions to initiate and continue breastfeeding in Ireland. Adescriptive qualitative approach was utilised to explore participants' perspectives of breastfeeding. Resultsshowed that professional and family support are key to a successful breastfeeding experience for thesemothers. Recommendations include further individualised support in order to meet the needs of Polishwomen breastfeeding in Ireland.INTRODUCTION social structure dimensions are major determinants of the choice of feeding among women. Begley et alThe rate of immigrant Polish women attending the (2008) found that Irish mothers are much less likelyIrish maternity services has significantly increased to initiate breastfeeding (50 per cent) than non-Irishin the past decade and these mothers have been mothers living in Ireland (76 per cent). However, itfound to be initiating breastfeeding in larger has been suggested that, when living in a country,numbers than their Irish counterparts (52 per cent people are forced to adapt to the culture of thatvs 82 per cent) (Begley et al 2008). Breastfeeding country (Skafida 2009), which may be influencingrates in Ireland are historically amongst the lowest the low rates of breastfeeding amongst Polishin Europe with only 52.6 per cent initiating women in Ireland at three-four months (Begley et albreastfeeding at birth, 45 per cent at discharge from 2008).hospital and 15.6 per cent of Irish womenbreastfeeding at three-four months (Begley et al Highly acculturated and bicultural mothers have2008). reported an urgency to change their feeding decision with the perceived formula feeding norm According to the National Infant Feeding Survey in the UK (Choudhry and Wallace 2012). In order to(Begley et al 2008), the largest absolute decrease in ensure that the impact of acculturation on Polishbreastfeeding was found among Polish women women is understood and that all women, includingwhere the rate falls to 68.9 per cent at discharge, and those from Poland, are provided with the requiredonly 38.6 per cent are still exclusively breastfeeding support and assistance to continue breastfeedingat three-four months (Begley et al 2008). This once initiated, this study was warranted.suggests that although Polish women initiatebreastfeeding in greater numbers, they may have AIMSbegun to adopt the feeding practices of Irish womenand this highlighted the need to explore their The overall study aim and objectives were to explorefeeding practices and experiences in Ireland. the factors that influence Polish women's decisions to initiate and continue breastfeeding in Ireland;ACCULTURATION AND ITS IMPACT ON and to gain an understanding of their experiencesBREASTFEEDING RATES in order to increase rates of initiation and duration among Polish women breastfeeding in Ireland.Street and Lewallen (2013) suggest that culture and30 Szafranska and Gallagher, TPM, January 2016, vol.19, issue 1

BREASTFEEDING RATES IN IRELAND Funding was granted by a student scholarship ATTITUDES TOWARDS BREASTFEEDINGprovided by Professor Cecily Begley. IN PUBLIC IN IRELAND AND POLANDMETHODOLOGY AND CONDUCT OF THE Participants expressed the view that they wereSTUDY generally reluctant to breastfeed in public in Ireland:A qualitative methodology was applied and a \"I went to the car and breastfed ... I was aware thatdescriptive qualitative approach was utilised as it is people find it disgusting\" (Julia)suited to exploring participants' subjectiveperspectives (Sandelowski 2000). Discomfort around breastfeeding in public was also reported in Poland. Participants reported that Six women were recruited to take part in this cultural differences between Poland and Ireland canstudy. Polish women resident in Ireland for less than determine the attitudes towards breastfeeding in10 years were included as were women who had public. Interestingly, women felt that seeing otherbreastfed a well infant for any period of time during women breastfeeding in public empowered them tothe past three years. do the same. Unstructured face to face interviews were used PROFESSIONAL SUPPORT IN THEto collect the data. Women could choose to be POSTNATAL PERIOD IN IRELANDinterviewed in English or Polish. Interviews weredigitally recorded, translated and transcribed. All Participants found that there is more professionalparticipants, as well as their children, were assigned breastfeeding support in Ireland. However, ina pseudonym to protect confidentiality. Poland the society is perceived to be much more supportive. Prior to the analysis of the data, a transcript of theinterview was sent to each participant (in Polish) in Findings also demonstrate that satisfaction levelsorder to ensure that it was truly reflective. Analysis with support for breastfeeding in the postnatalinvolved a thorough review of information gathered period in Ireland are mixed. Participants gavefrom the participants. Units of data were identified, detailed accounts of less than satisfactory care in thecoded and then compared and combined to form 11 postnatal period.categories. Subsequently, three themes and eightsub-themes were formed to identify common issues \"It was documented that he fed, I don't know whyrelating to the breastfeeding experiences of these because I explained to them that he didn't feed\" (Marta)women. Details of the data and emerging themeswere consulted with the supervisor at every stage of Women felt that the attitudes of staff alsothis study in order to ensure confirmability. This undermined their confidence in breastfeeding andcontributed to the rigour of this research. No this sometimes led to them introducing formula.language barrier was evident during data collection, However, despite the lack of support in hospital,as the researcher is a native Polish speaker, but fluent participants were generally satisfied with the one-in English, which aided the translation of the data. to-one professional help they received from community midwives and public health nurses after Ethical approval was sought and granted by the discharge.ethics committee of the faculty of health sciences atTrinity College, Dublin. Participants in this study DISCUSSION >>>>were respected throughout the research process byplacing emphasis on informed consent. It is perceived by Polish participants that breastfeeding is more common in Poland than inFINDINGS Ireland, and among Polish women living in Ireland. Initiation rates support this, as 82 per cent of Polish \"I saw a lot more women breastfeeding in Poland\" women initiate breastfeeding in Ireland, comparedFindings demonstrate that Polish women perceive with only 52.6 per cent of Irish women (Begley et althat there are differences in rates of breastfeeding 2008).between Ireland and Poland. Their views suggestthat more women breastfeed in Poland. Participants Although women valued the family support, theyalso talked about the strong influence of their Polish also felt pressurised to initiate breastfeeding by theirfamilies and how that affected their feeding families, even when those families were living inpractices. Poland.Thus, this shows that proximity to the family is not necessary for the mother to view it as a strong \"I didn't want to breastfeed my second baby but I did influence over her feeding choices and this has notbecause I knew that my family would criticise me... \" been reported in other studies.(Julia). Cultural differences were highlighted by The support of the maternal grandmother was of participants who state that breastfeeding is viewedparticular importance with regards to breastfeeding as normal in Poland, which they do not perceive toinitiation and duration. be the case in Ireland. Participants view the Irish culture as non-judgemental with regards to infant feeding choices. However, there are high formula Szafranska and Gallagher, TPM, January 2016, vol.19, issue 1 31

BREASTFEEDING RATES IN IRELANDfeeding rates in Ireland (Begley et al 2008). information; thus these may be subject to bias.Therefore, although Polish women's breastfeedingpractices appear to be highly influenced by their FURTHER RESEARCHfamilies, freedom of choice over feeding methods inIreland may, in the future, have an antagonistic Further studies of Polish women breastfeeding ineffect on breastfeeding rates among Polish women. Ireland are needed to construct support strategies in order to meet the needs of Polish women as well as Most participants were reluctant to breastfeed the needs of all breastfeeding mothers in Ireland.in public in either country, in fear of negativefeedback from the public. This is often cited as a IMPLICATIONS FOR PRACTICEreason for choosing supplementary formula orgiving up breastfeeding altogether (Mitra et al One-to-one support and evidence based policies that2004). However, societal support was reported to be enhance best practice related to breastfeeding aremuch greater in Poland and, according to the recommended. These need to be disseminatedparticipants, this is the main determinant of higher throughout the health care system and based onbreastfeeding rates. awareness of the potential cultural differences. Hence, midwives and public health nurses need to Data demonstrate that all women require be targeted to provide individualised support toprofessional breastfeeding support after discharge mothers.from hospital as it is reported to be of benefit toparticipants' overall breastfeeding experience. Cultural sensitivity is vital in the provision ofWhile Ireland has a plethora of support groups breastfeeding support as well as understanding theproviding community breastfeeding support, external influences on the choices that women makeresearch has suggested that some women are with regards to infant feeding. Midwives are in areluctant to attend support groups and hence these position to equip women with the skills andmay not be relevant to the needs of Polish women. confidence to breastfeed in public. Professionals must also be aware of the influence of Polish families Despite the extensive availability of support and assess the level of their influence on individualgroups, Castro et al (2014) state that current policies women in order to tailor support accordingly. Thisto improve breastfeeding rates in Ireland have been includes clarifying some of the traditional beliefs andineffective. Authors also argue that recent increases practices which may be offered by the maternalin breastfeeding rates can be explained by an grandmother.increase in non-Irish mothers residing in Ireland.Irish support groups may not be culturally sensitive Education on the long term benefits ofand hence not seen as optimal for meeting the breastfeeding will encourage women to breastfeedneeds of Polish mothers. Therefore, an immediate for longer durations and simultaneously normaliserevision of the quality of support, education and this form of feeding within the society. tpmpolicies on infant feeding is necessary to improveinfant feeding practices as well as target the REFERENCESdiffering needs of culturally diverse groups. Thus,recommendations include addressing individual, Begley C, Gallagher L, Clarke M et al (2008). Thefamily and cultural needs for breastfeeding national infant feeding survey, Dublin: Trinity College.information. Castro PD, Layte R and Kearny J (2014). ‘EthnicCONCLUSION variation in breastfeeding and complimentary feeding in the Republic of Ireland’. Nutrients, 6: 1832-This study has further advanced our understanding 1849.of the factors that influence the experiences andattitudes of Polish women breastfeeding in Ireland. Choudhry K and Wallace LM (2012). 'Breast is notThe findings from this study depict the needs of always best: South Asian women's experiences ofPolish mothers and highlight the significance of infant feeding in the UK within an acculturationcultural sensitivity when providing breastfeeding framework’. Mat Child Nutri, 8(1): 72-87.support to these women. Mitra AK, Khoury AJ, Hinton AW et al (2004).LIMITATIONS ‘Predictors of breastfeeding intention among low- income women’. Mat Child Health Jour, 8: 65–70.This study had a restricted sample size of six Polishwomen who have lived in Ireland for less than 10 Sandelowski M (2000). ‘Whatever happened toyears. The data relating to women’s perceptions of qualitative description?’ Res Nurs Health, 23: 334-340.breastfeeding practices and support in Poland weremostly anecdotal, as women used their perceptions SkafidaV (2009).‘The relative importance of socialand the experiences of friends to report the class and maternal education for breastfeeding education’. Pub Health Nutri, 12(12): 2285-2292. Street DJ and Lewallen LP (2013). ‘The influence of culture on breastfeeding decisions by African American and white women’. Jour Perin Neon Nurs, 27(1): 43-51.32 Szafranska and Gallagher, TPM, January 2016, vol.19, issue 1

Neesha Ridley MIDWIFERY BASICS: PRECEPTORSHIPMidwifery lecturer at Kerry TaylorUniversity of CentralLancashire Midwifery lecturer at University of Central Lancashire4. Managing workload andprioritising care: top tips Preceptorship is the 15th series of ‘Midwifery basics’ targeted at practising midwives. The aim of these articles is to provide information to raise awareness of the impact of the work of midwives on women’s experience, and encourage midwives to seek further information through a series of activities relating to the topic. In this fourth article of the series, Neesha Ridley and Kerry Taylor look into the barriers and challenges that present to all midwives, particularly in the prioritisation of care and management of workload. They provide top tips in order to help support newly qualified midwives manage their work well, thus providing safe, effective care to all women and newborns at all times.The Nursing and Midwifery Council (NMC) need to do to ensure that they remain focused and ACTVITY 1 (2015) outlines that nurses and midwives positive about the privileged and inspiring role that How do you prioritise your must prioritise people, effectively midwives have. delivering the fundamentals of care.Student midwives have the comfort of being able to STAFFING SHORTAGES workload? Do you have anyrely on qualified mentors, using their expertise and hints or tips that you couldexperience to help provide care safely, effectively Managing the workload in any area of maternityand with the ability to prioritise individual needsappropriately. The feeling of accountability and care is a challenge all midwives face, whether they pass on to others to helppressure of being a newly qualified midwife canoften mean that it is hard to prioritise care. are newly qualified or not. The Royal College of them manage their daily Midwives (RCM) (2015) has calculated that the UKCHALLENGES needs 2,600 more midwives to be able to cope with workload?Midwives have a diverse and challenging role,providing care and support to women throughout the number of births the country is experiencing.the childbearing continuum, often working longhours on shifts, being on call and working in a range Together with the ageing population of midwivesof settings. Working in this range of areas andincreasingly long hours can lead to a negative and the growing complex health needs of mothersimpact on work-life balance (Deery and Kirkham2006). Newly qualified midwives, in particular, need and babies, midwives have many challenges facingto be aware of the factors that may affect theirmidwifery career but, more importantly, what they them on a daily basis. Midwifery staffing shortages have been a concern for many years. The shortage of midwives is a global issue and has implications for women and families across the world. On a local level, the RCM (2015) states that the midwifery shortage in the UK is affecting the quality of the service that women and babies receive.The RCM (2015) has also noticed a change in the population of midwives >>>> Midwifery Basics, TPM, January 2016, vol.19, issue 1 33

MIDWIFERY BASICS: PRECEPTORSHIP ACTVITY 2 currently working within maternity services. INCREASING COMPLEXITYWhat do you find hardest to Between 2005 and 2014 the number of midwivesmanage within your working working in the NHS rose, which is a positive step The number of pregnant women with complexday? Consider how you may towards providing better care for women and health needs is increasing. In the latest MBRRACEovercome this families. However, the RCM also looked at the age report (2014), it was noted that three quarters of profile of midwives and noted that 98 per cent of the women who died had a co-existing medical increase occurred amongst midwives aged 50 or complication. Although the rate of maternal death older. Older and more experienced midwives are has decreased, caring for these women can put invaluable to the NHS, having developed a variety of increasing demands and pressures on midwives skills and experience that they can share with newer throughout the maternity services. This can cause qualified midwives; however, this becomes a concern difficulties for midwives in all parts of maternity when we consider that these midwives will retire in care, from increasing antenatal care to more complex the foreseeable future, possibly leaving the UK with management plans and possibly complex needs of a large deficit. For all midwives, this can be a fearful the baby, too. Together with the looming ‘midwifery thought, as they may already be struggling to time bomb’ (RCM 2015), the changing complex provide care to an optimum standard. The RCM health needs of women can cause great difficulty for Pressure points on postnatal planning (RCM 2014) midwives working in the current maternity services. found that overwhelmingly, two-thirds of midwives said the most important factor influencing their It can be stressful for midwives facing these workload planning was not the woman’s needs, but challenges on a daily basis. Student midwives the pressure from the service they worked for. working alongside those who are experienced can often feel fear and anxiety about how they will cope when they qualify. Newly qualified midwives share Survival guide ACTVITY 3 In order to survive and thrive in the current maternity break can cause fatigue, and mistakes tend to beIf you are a newly qualified service, this short survival guide will benefit not just made when members of staff are tired.midwife, how do you priori- newly qualified midwives but all midwives facing the 5. Be aware of changing circumstances Unexpectedtise your workload? What do daily challenges in this changing service: events occur throughout the day. Be prepared toyou struggle with the most? 1. Keep a notebook in your pocket and write down a allow for these events and try not to feelIs there a way that you could ‘to do’ list (ensure no confidential information is overwhelmed when they occur.improve this? Do you have within this).This list can be referred to and amended 6. Keep up to date Regularly read local and nationalany tips for other newly qual- throughout the day, as tasks are identified or guidance.When new practice is introduced, you willified midwives that you have completed. Look at this frequently to consider what be aware and prepared for the change. The Codefound have helped you? takes priority. (2015) highlights the need to practise with 2. Remember your numbers Remembering numerous consideration of the best evidence available. codes, phone numbers and drug calculations can be 7. Ask for help if you need it All midwives need help confusing.Write down common drug calculation from colleagues, whether they are newly qualified or formulae in your notebook.This helps to save time have many years of experience. You may also learn and can also help to prevent drug errors. new invaluable skills by asking other members of 3. Take your breaks, even if short, with enough time staff, which will benefit your future practice. to drink a hot or cold drink. Sit down while having 8. Remember… It is better to ask a question and not your drink, to rest your feet and rehydrate. make a mistake. Don’t be afraid of asking questions 4.While taking a break, sit and reflect on your work even if you think that there is a simple or easy load This will give you time to reorganise your list and answer. If ever you are unsure about something your priorities – it will give you a chance to look at always ask for clarity, even if it just for your own your work load with fresh eyes.Working through your reassurance. Safety is key!34 Midwifery Basics, TPM, January 2016, vol.19, issue 1

MIDWIFERY BASICS: PRECEPTORSHIPthese fears and are often faced with new challenges we look after our own health and wellbeing. It is up ACTVITY 4during their preceptorship period. Finding time to to us, as midwives to support one another and Reflecting on your workingorganise a workload, ensuring that the needs of practise safely at all times. tpm day, what do you think thatwomen and their babies with complex health needs you do well? What could youare met, can be a challenge, as can ensuring that all REFERENCES improve upon?women are heard. All women have the right to goodquality care, evidence based practice and care Deery and Kirkham (2006). Supporting midwives ACTVITY 5delivered in line with the six Cs, as stated in the to support women. The New Midwifery Science and If you are a mentor, do youFrancis report (2013). Completing all the Sensitivity in Practice, 2nd edition. Edinburgh: prepare student midwives fordocumentation required to meet NMC Churchill Livingstone. managing their workload inrequirements and local trust guidelines, can also be order to help them when theytime-consuming and challenging. Francis R (2013). Report of the Mid Staffordshire qualify as midwives? NHS Foundation Trust public inquiry, London: TheORGANISATION Stationery Office. http://tinyurl.com/lcsocygPrioritising workload can often be a challenge at the Mollart L, Skinner VM, Newing C et al (2011).start of the busy day in all maternity settings. More ‘Factors that may influence midwives work-relatedoften than not, maternity units can be understaffed stress and burnout’. Women Birth, 26(1): 26-32.and women waiting to be seen. It can be easy to http://tinyurl.com/nna3j56allow this pressure to affect the way the day will go.It is also easy to see to women and babies, putting MBRRACE-UK (2014). Saving lives, improvingtheir nutrition and hydration needs before our own. mothers’ care, London: MBRRACE.Mollart et al (2011) state that health care institutionscan benefit by understanding factors related to NMC (2015). The Code: professional standards ofburnout, especially in view of the consistent practice and behaviour for nurses and midwives,international shortage of midwives. As midwives, London: NMC. http://tinyurl.com/ozogs2uwe have a responsibility to ourselves, to ensure that RCM (2014). Pressure points: postnatal care planning, London: RCM. http://tinyurl.com/phsmoar RCM (2015). The state of maternity services, London: RCM. http://tinyurl.com/qbe2plmMMIADTWERIFNEIRTYY EMxicdhwainfegrey&BABY THURS 4TH FEBRUARY LONDON|2016 ILEC CONFERENCE CENTRE, HOTEL IBIS EARLS COURT LONDON, SW6 1UDPROGRAMME NOW PUBLISHED FOR FURTHER DETAILS CHECK ONLINE ATWWW.MATERNITYANDMIDWIFERY.CO.UK Midwifery Basics, TPM, January 2016, vol.19, issue 1 35

RESEARCH UNWRAPPED Dr Alys Einion Senior lecturer in midwifery at Swansea University‘Oh no, no, no, we haven't got time to bedoing that’: challenges encounteredintroducing a breast-feeding supportintervention on a postnatal wardHunter L, Magill-Cuerden, J and McCourt P (2015).Midwifery, 31(8): 798–804Research unwrapped is a popular series to help readers make sense of published research byundertaking a detailed appraisal of an article in a careful and considered manner. In doing sowe can advance our knowledge and understanding of a research topic and apply it to ourpractice.This process is designed to assess the usefulness of the evidence in terms of decisionmaking and application to practice. The research being discussed here looks at the factors affecting the implementation of abreastfeeding support intervention, on a postnatal ward, which includes considerations oftime, workload and clinical context. It has been evaluated using the Critical Appraisal SkillsProgramme (CASP) tool for evaluating qualitative research as a guide (CASP 2013).WHY THIS RESEARCH MATTERS intervention” (Hunter et al 2015: 798). As such, this makes the research highly relevant for midwives inI chose this article as it deals directly with one of the practice, as shown by their review of currentkey issues facing midwives in practice: time and literature.workload. APPROACH AND METHODOLOGY Midwifery practice and organisational issuessuch as time and the demands of hospital practices, Have the authors used the right research approach,seem to be highly topical in the current climate. It is and have they described their methods in enoughtherefore important to focus on the context in which detail?midwives deliver care and, in particular,organisational factors which can impact on Although the title of the article cites a qualitativemidwives practising truly woman-centred care. approach, the description and discussion of methodsThese are experienced researchers with significant do not directly explore qualitative methods beyondclinical and academic expertise to bring to a study the ‘realist’ approach. The authors state that theof this kind.Their goal is“to identify elements in the paper is derived from a larger study exploring anenvironment of a postnatal ward which impact on intervention to provide breastfeeding support to athe introduction of a breastfeeding support particular cohort of women. The approach seems appropriate for this research because of the focus on36 Einion, TPM, January 2016, vol.19, issue 1

RESEARCH UNWRAPPEDacknowledging context, and “the mechanisms or participants, whilst others include quotes fromprocesses are triggered when an intervention people who have not consented to participate butinteracts with a particular environment” (Hunter et were ‘overheard’.They use this to justify and explainal 2015: 799). Silverman (2013) emphasises the need the inclusion of one quote from a client.to choose research methods that are suited toanswering the research questions. Silverman emphasises the need to choose research methods that are suited Hunter et al used an unstructured approach. to answering the research questions.Observing practice without placing a set oflimitations on what would be observed, without Overall, in terms of methods and methodology,defining what the researcher is looking for, seems to sample and sampling approach, recruitment andoffer a wider scope for avoiding bias. Gerber et al selection, there is a good level of clarity. However,(2014) acknowledge the fact that bias can be an issue one thing which was not discussed in this study isin observational studies. Bias can occur when the the relationship between the researcher and theresearcher’s own preferences, perspective or participants, which is highlighted by the CASP toolknowledge influence the findings of the research. It as being an important question to consider. Theis a strength of this design that the potential for bias research team suggest that familiarity with thehas been acknowledged explicitly. researchers might improve the quality of the data. According to Holloway and Wheeler (2010), a key The subjective dimension of the qualitative feature of a good relationship between intervieweeapproach is addressed well in the semi-structured and interviewer is that it is mutually respectful andinterviews carried out with midwives and maternity conducted on a basis of equality. It might be that forsupport workers involved in the intervention. Hunter et al, this familiarity enhanced both equalitySubjectivity in qualitative research refers to the and respect in that relationship.importance of personal experiences andperspectives in providing knowledge. Semi- ETHICAL CONSIDERATIONSstructured interviews are often used withinqualitative research to allow the researcher to guide As with any research, ethical issues need to bethe discussion, but to include scope for open-ended addressed, and the key dimensions here relate toquestioning, and for the conversation to develop as sampling, the presence of clients in the clinical areathe respondent wishes (Silverman 2013). DiCicco- who are not participants and to the nature ofBloom and Crabtree (2006: 314) describe such relationships within the research process. Ethicalinterview approaches as “less structured interview approval for this study was granted by the relevantstrategies in which the person interviewed is more bodies. Edwards and Mauthner (2012) discuss thea participant in meaning-making than a conduit issues of power dynamics in feminist research, andfrom which information is retrieved.” It is evident, the points they raise about power and control aretherefore, that the methods of data collection were important for midwives to consider whennot only appropriate for the qualitative design but conducting research. The nature of any powerhighly likely to provide the right kind of data for dynamics and the potential for these to affect thetheir evaluation. An interesting dimension of this is study should perhaps have been discussed in morethe increased reliability of the research inferred. detail. I would have expected a more explicit“The interviews also provided participants with an exploration here of basic ethical issues, such asopportunity to identify mechanisms and themes that beneficence, non-maleficence and confidentiality.the researcher may have missed”(Hunter et al 2015:800). ANALYSIS OF DATA >>>> The sample size is appropriate for a qualitative One of the areas that I think is quite under-design. Ritchie et al (2014) describe qualitative represented in this research report is the datasampling as often resulting in smaller sample sizes. analysis. I know from reading many other suchThe authors have carried out purposive sampling articles that it is often the convention to reduce the(Ritchie et al 2014) which focuses on those process of analysis to a brief overview, but I feel thatprofessionals and practitioners who were involved this is a limitation of the study itself. The datain the implementation of the intervention. analysis approach appears to be that of inductiveRecruitment and selection of participants is also thematic analysis, whereby the data are read and re-transparent (Silverman 2013). There is a brief read until common themes start to emergediscussion about using material which came fromwomen who had not consented to take part in theobservation. Hunter et al discuss how otherresearchers have addressed this issue, showing thatsome avoid observing encounters with non- Einion, TPM, January 2016, vol.19, issue 1 37

RESEARCH UNWRAPPED (Silverman 2013). The authors mention data “The busyness of the staff, and their lack of saturation, which means that they felt that no new control over their working space and time, created a themes emerged from the data at the point at which stressful environment that militated against the they stopped (O’Reilly and Parker 2012). However, provision of the relational care that the intervention O’Reilly and Parker argue that this concept of sought to introduce” (Hunter et al 2015: 801). The saturation is somewhat unreliable. Given the lack of coping strategies are similarly clearly described, with transparency here about the process of analysis, I tasks being the focus of care, and midwives would be inclined to think that if this article has any managing their own workloads to cope with stress weak point in its reporting, this is it.There should be rather than working collegially. Critical dimensions much more transparency about how themes were of behaviour, resistance to change, passive resistance arrived at and how/when saturation was achieved. and hostility emerge as important points for consideration. I would have expected a more explicit These factors not only indicate the challenges ofexploration here of basic ethical issues, trying to implement a woman-centred, health- promoting intervention for breastfeeding support; such as beneficence, non-maleficence they also demonstrate key factors which affect the quality of care for all women. This widens the scope and confidentiality of the findings beyond the boundaries of the article title and the expressed aims of the research. Locating FINDINGS their findings in the context of wider research by referring to other literature (both in the literature The findings of the study are grouped according to review and in the discussion of the findings) themes from the interviews, but the authors also give enhances this broader applicability. a brief summary of findings gained from the observations.They found that there was“a high level The discussion section highlights further the of non-compliance with the intervention” and relationship between the findings of this study and therefore suggest that the “mechanisms supporting the current state of understanding of the context of this non-compliance were the stresses in the ward maternity care in the UK. Hunter et al refer to the environment and the strategies that staff had ways in which midwives cope with an unrealistic and developed for coping with them” (Hunter et al 2015: extremely challenging workload, and discuss the 800). They identify these stresses in relation to two prioritisation of medical tasks over other types of themes: lack of time and staff; and lack of control of care, which perpetuates the medical model that has the organisation of time and space. They also found resulted in this task overload in the first place. that the themes for coping strategies were “task Hunter et al discuss the implications of their insight orientation, workload reduction, and resistance to into the lack of control experienced by maternity care change” (Hunter et al 2015: 800). The CASP tool staff, and how this affects the ways in which they (CASP 2013) suggests that, when considering work. They relate this, appropriately, to theories of findings, the critical reader should look at credibility empowerment. They also discuss the resistance to of findings in terms of triangulation or having more and hostility towards research encountered when than one analyst. In this case, triangulation can be researching clinical interventions, and refer to other argued to derive from combining observation and studies which have identified similar hostility in interviews, and themes were discussed with research other contexts. supervisors, enhancing credibility. Hunter et al acknowledge the limitations of their The findings are discussed using direct quotes study, an important critical point when considering from the data, which is considered a mark of good the usefulness of research which relates to practice. qualitative reporting, and certainly makes the Their conclusions are brief, but make a strong research much more interesting and stimulating for statement about the context of maternity care and the reader. The quotes relating to all the themes are the challenges that exist when trying to implement powerful and descriptive, and appear to enhance the beneficial interventions. This concluding statement reader’s understanding of the data and the meanings relates to the need for midwives and maternity derived from them. Hunter et al draw out key support workers to be able to have control over the analytical statements from the data, which make context in which they deliver care, but also that such important points relating to midwifery practice, vital, skilled staff need to “recognise and claim their regarding lack of time and administration, reducing own power by working together to set their own time spent with women. agenda for postnatal care, creating an environment in which agreed ideals are able to flourish” (Hunter et al 2015: 801). Having explored all the factors which make the intervention difficult to sustain, however,38 Einion, TPM, January 2016, vol.19, issue 1

RESEARCH UNWRAPPEDthis statement remains idealistic because, it would qualitative research interview’. Med Ed, 40: 314-321.seem, their very argument negates the achievement Edwards R and Mauthner M (2012). ‘Mauthnerof this kind of empowered, collaborative andegalitarian approach to maternity care. ethics and feminist research, theory and practice’. In: Miller T, Birch M, Mauthner M et al (eds). Ethics inIMPLICATIONS FOR PRACTICE qualitative research, 2nd edition. London: Sage.This research sends an important message to Gerber AS, Green DP and Kaplan EH (2014).‘Themidwives about the nature of the practice illusion of learning from observational research’. In:environment, clearly highlighting shortcomings in Teele DL (ed). Field experiments and their critics: essaysthe design and management of maternity care on the uses and abuses of experimentation in the socialcontexts which limit the scope of midwives to truly sciences, London: Yale University Press.practise woman-centred care. This demonstratesthat midwives will continue to be unable to improve Holloway I and Wheeler S (2010). Qualitativepractice if they do not have the resources with which research in nursing and healthcare, 3rd edition. Oxford:to do this: the energy, capacity and time to Wiley-Blackwell.implement practice changes. Until workload,staffing and organisational issues are addressed, it Hunter L, Magill-Cuerden J and McCourt Pseems midwifery practice will always be reactive, (2015). ‘”Oh no, no, no, we haven't got time to berather than proactive, which is a shame given that doing that”: challenges encountered introducing athe potential to improve outcomes, enhance the breast-feeding support intervention on a postnatalquality of care and reduce costs in the long term ward’. Midwif, 31(8): 798–804.resides within the skill, compassion and dedicationof those midwives who no longer have time to be O’Reilly M and Parker N (2012). ‘Unsatisfactorytruly ‘with woman’. tpm saturation: a critical exploration of the notion of saturated sample sizes in qualitative research’.REFERENCES Qualitat Res, 13(2): 190-197. CASP (2013). Ten questions to help you make sense Ritchie J, Lewis J, Elam G et al (2014). ‘Designingof qualitative research, Oxford: CASP. and selecting samples’. In: Ritchie J, Lewis J, McNaughton et al (eds). Qualitative Research Practice, DiCicco-Bloom B and Crabtree BF (2006). ‘The London: Sage. Silverman D (2013). Doing qualitative research, 4th edition. London: Sage.REVIEWSChildbirth, midwifery and active management of labour, charting pregnancyconcepts of time according to timelines and monitoring duration of feeds are explained, challenged and dismantled Edited by Christine McCourt by the authors. with a foreword by Ronnie Frankenberg While concerns regarding imposition of time- 2010, Berghahn Books, 280pp, £22, frames on pregnancy, labour and birth may be pbk, ISBN 978 1 845452 94 1 familiar to researchers and practitioners, McCourt’s book adds a cultural dimension to its This book is a collection of critique that is frequently neglected in this debate. thoughtful, scholarly and Soo Downe and Fiona Dyke’s chapter ‘Countinghighly relevant chapters written by authors time in pregnancy and labour’ is particularlyincluding Soo Downe, Denis Walsh, Mavis pertinent in discussing how the rise of capitalist,Kirkham and Fiona Dykes on the relationship consumerist societies has created a more risk-between time and childbirth. Drawing on averse consumer that desires the ‘quick fix’ abovemultiple sources including case studies, research all, an ideology which becomes problematic whenand women’s own narratives, the authors dealing with the unknowingness of the birthexamine, through a socio-cultural lens, how process. This book is a must-read for midwivesadherence to time-frames has had a pivotal role and academics as well as midwifery, medical andin shaping midwifery practice, and controlling social sciences students.and managing birth across multiple maternitysettings. Practices that have become dominant Sophie Clarewithin a biomedical model of care including Staff midwife at Wexford General Hospital, Ireland Einion, TPM, January 2016, vol.19, issue 1 39

THINKING OUTSIDE THE BOXSara WickhamIndependent midwifery lecturer and consultantWhatever happened to theprecautionary principle?In this column, Sara Wickham takes a sideways look at issues relevant to midwives, students, women andfamilies, inviting us to sit down with a cup of tea and ponder what we think we know. Here, she looks atone of the latest papers to join the trend of attempting to justify induction of labour in healthy women,raising questions about the language and stance used within the research and suggesting that womenand midwives might gain from referring to the precautionary principle.Is anyone else feeling disgruntled at the ongoing almost every paper I read on keeping birth normal trend in the research literature towards clearly points outs that one of the most important attempting to justify earlier and earlier keys to reducing the caesarean section rate is for as induction of labour? A year or so ago, I many women as possible to experience spontaneousunpacked a meta-analysis which claimed that, onset of labour.contrary to the experience of midwives and asignificant volume of research, induction of labour DOUBTING NATUREactually reduces the chance of caesarean section(Wickham 2014). In case you missed that article, I The title of one recent paper that is concerning meargued that the findings are questionable, mainly is, “A risk of waiting: the weekly incidence ofbecause of the lumping together of data from a wide hypertensive disorders and associated maternal andrange of trials carried out over a long time span and neonatal morbidity in low risk term pregnancies”including very different groups of women with (Gibson et al 2015). You can probably imagine thedifferent indications for and methods of induction. results, and you can probably imagine that they lookBut whether or not the research methods are valid rather different when appraised by someone whoand robust, we are seeing more and more studies trusts women and birth, but I am more concernedwhich are seeking to justify more and more here with the approach taken in writing up thisintervention in the course of normal pregnancy and study. The title, for instance, is rather provocative. Itbirth. reads more like a tabloid headline than the lead-in to an objective analysis of a research question, and Many of these studies, including the paper that I anyone appraising this paper would suspect withindiscuss below, are coming out of the USA, but I seconds in which direction its authors were leaning.know UK midwives who are concerned about movestowards inducing labour in certain groups of This intrinsic bias is further reinforced in thewomen, including those who are older or larger than abstract, which contains more provocative language.is considered ideal. As the number of women in both By discussing the presumed benefits of normalof these groups is growing, we could well end up in pregnancy, and the maternal risks of expectanta situation where more women’s labours are being management, are the authors deliberately expressinginduced than not. This is very worrying, because doubt about a process which has worked for millennia, while simultaneously defining pregnancy40 Wickham, TPM, January 2016, vol.19, issue 1

THINKING OUTSIDE THE BOXand birth in relation to their management decisions based on this kind of research.rather than women’s agency and the abilities of theirbodies? DISCUSSING THE DOUBTOBJECTIFYING WOMEN I don’t imagine for a moment that the authors of such articles will stop this practice just because IIn the next line, the researchers refer to the women ranted about it in TPM. But I know that manyin their study as“low-risk gravid”and continue using readers of this article are practising in areas andsuch language throughout the paper. This may, in systems which may be affected by these researchfairness, be due to the stance of the journal and findings, and, if nothing else, I’d like to help otherwider medical linguistic trends rather than their midwives find ways of speaking about such studiespersonal viewpoint, but this doesn’t make it any less and papers. To me, the precautionary principle is adisempowering to those women who feel objectified great starting point. The sentence, “what happenedand frustrated that their caregivers express such to the precautionary principle?” is one of mydoubt about the ability of their bodies to grow and favourite ways of pointing out that, ethically, medicalbirth babies. intervention has to prove itself against nature. Not the other way around. tpm In any case, what happened to the precautionaryprinciple; the ethical approach wherein, if we don’t REFERENCESknow whether an action or policy or intervention issafe or not, then the burden of proof that it is not Gibson K, Waters TP and Bailit JL (2015). ‘A riskharmful falls on those recommending the action or of waiting: the weekly incidence of hypertensiveintervention? This is not the only article to be flying disorders and associated maternal and neonatalin the face of that principle. This paper is part of a morbidity in low risk term pregnancies’. Am Jour Obstrend, and it may be something that those of us who Gyn, in press. doi:10.1016/j.ajog.2015.09.095care about and work with birthing women need todiscuss with our colleagues, especially when we are Wickham S (2014). ‘Does induction really reduceasked to go along with guidelines and practices the likelihood of caesarean section?’ The Pract Midwife, 17(8): 39-40.PROFESSIONAL DEVELOPMENT Photo courtesy Elena Heatherwick-Lammers International Women’s Day Walk – Sunday 6th March Location: London Free event Paramana Doula Course Find out more: Dr Michel Odent and Liliana Lammers www.walkinhershoes.careinternational.org.uk 020 7091 6100 March 3-5, 2016 Kentish Town London NW5 Join us to walk in solidarity with women This 3 day course is also across the globe who are denied the chance open to midwives, student to gain an education or the opportunity to midwives, health work. Walk alongside Suffragette professionals and NCT descendent, Dr Helen Pankhurst, and other teachers. inspiring speakers as we unite to make a Cost: £325 (students stand against inequality. concessions available) For more information: www.paramanadoula.com Email: [email protected] Mobile: 07787 951 208 Wickham, TPM, January 2016, vol.19, issue 1 41

LAST WORD Kayley Everett PGDip student at University Campus SuffolkDIRECT: creating a reflective modelReflection is a skill practitioners are DIRECT reflective model • Is the literature review broad; encompasses taught from the beginning of their different sources and methods of research? Is education, and it also forms part of Describe the research contemporary and valid? the revalidation process (Nursingand Midwifery Council (NMC) 2015). Team Impact • Does your experience match what the literature is saying, or are there discrepancies? During my midwifery degree I struggled to Change Read thefind a reflective model that was not only easy literature • Does the literature support your practice orto understand, but also evolved my thinking does it recommend other ways?so that I could look objectively for a way Evaluateforward from the event and how I could do EVALUATEthings differently in future. • Why are you choosing to reflect on this? Is it because it was good or bad? Does it inform • What is the significance of the issue? I am now undertaking another course your practice or increase your knowledge? • What is the significance of what thewhich has a similar emphasis on reflection, literature says and how this compares with theand I find myself faced with the same • What are your thoughts and feelings on experience?reflective models, with the same issues with this issue in general, and on this specific • What have you learned through theregards to ‘stunted thought processes’. situation? experience – and reflecting upon it? • Why are these specific learning points so Therefore I created a reflective model of • How do you think your values and beliefs important and how did you come to thismy own which aimed to combine the best compare with your peers in this situation; are conclusion: was it the experience, theaspects of existing reflective models. I hope they similar? literature, the reflection?this model has clarity, and balances beingsufficiently succinct for daily practice, with • Do you think you had any preconceived CHANGEbeing comprehensive enough to provide ideas about the situation; were these founded?meaningful depth to reflection, without being • Have your values and beliefs been alteredabstract or overly-complicated (Platzer et al IMPACT in any way because of this experience /1997). I also wanted to include the team aspect, reflecting upon it / literature review?as reflection and learning from practice have • Do you think your values and beliefs couldbenefits for the whole team, not just the have impacted on the situation, either • How will the experience inform yourindividual practitioner. positively or negatively? If so, how? practice in the future? Whilst creating the model, a rather useful • Has the situation made you confront your • Has your practice already changed?mnemonic emerged, seemingly on its own. I own beliefs? If so, have they changed at all orhope that this adds to it in day-to-day are they reinforced? TEAMapplication. Along with the model I createdsupplementary information: direct questions • What was the potential and the actual • Have you reflected upon this with anywhich aim to lead to the next stage of the impact of this situation – were these the same? peers? If so were there good / bad reactions –reflection. agreement / disagreement - what was the • Why is this issue so important? outcome?DESCRIBE READ THE LITERATURE • Can you disseminate what you have • What was the situation? learned to your team? • What knowledge did you have prior to and • What does the literature say about theafterwards on the situation and general issue? situation / issue? Include key documents! REFERENCES • Were you expecting this situation? If so, doyou feel you were prepared effectively in NMC (2015). Revalidation, London: NMC.either knowledge and / or information? Platzer H, Snelling J and Blake D (1997). ‘Promoting reflective practitioners in nursing: a review of theoretical models and research into the use of diaries and journals to facilitate reflection’. Teach Higher Ed, 2(2): 103-121.42 Everett, TPM, January 2016, vol.19, issue 1

Supporting your SuccessMyles Textbook for Midwives• Designed to enable midwifery practitioners • Streamlined chapters with similar themes and to provide safe and competent care, which is approach help consolidate your learning tailored to the patient’s individual needs • Over 500 on-line multiple-choice questions to• Extensively illustrated to assist visual learning enable readers to test their knowledge with additional ‘pull out’ text-boxes to highlight key informationFor 20% o this title, go to www.elsevierhealth.co.uk and enter code PM

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