TPM MARCH 2017

March 2017 Volume 20 No 3 www.practisingmidwife.co.ukBACK TO BASICS Mechanism of labour: maternal pelvis and fetal skull Linking to CPD module online. Preview on page 13 Using clinical audit to improve quality of care Fundamental skills: recognising early warning signals New! First in a series on midwives’ wellbeing and resilience Plus online: The use of water for non-pharmacological pain managementNew website now live! Visit the online home of TPM for further articles, modularised eLearning,a supportive community, archive and more at www.practisingmidwife.co.uk

17-18 May 2017 NEC Birmingham, UK REIMARY CACelebrating its 27th successful year PUBL HEALTHPRRegister now for the UK’s leading free of charge event for UNITYmidwives, health visitors and other healthcare professionals IC COMMimproving the health of women, babies and children20 content-led and CPD approved programmes including:• Mother and baby • Public health• Child health and health visiting • Sexual and reproductive health• Women’s healthOrganised by Sterling EventsDownload a programme and register atwww.primarycarehealth.co.uk for a free placeDelegate enquiries: [email protected] enquiries: [email protected] 709 8979Supported byCPD @PrimaryCareShow Primary Care andApproved Public Health

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CONTENTSThis month in The Practising Midwife8 Article of the month 18 Advancing practice 29 Research unwrapped Mechanism of labour – Midwifery practice during birth: the interaction between the ritual companionship maternal pelvis and fetal skull Alys Einion unwraps a recent article that Elaine Uppal describes the relationship revisits the basics: the impact of the between the maternal pelvis and the midwife on a woman’s birth experience fetal skull and the passage of a baby through the process of birth Quality care matters: advancing practice through clinical audit Anna Byrom outlines the essentials of audit design and discusses its value as a tool to promote quality maternity care provision 23 The fundamental skills: reducing maternal morbidity and mortality13 Article of the month module As it has been acknowledged that the 32 Reviews questions signs of impending maternal collapse were going unrecognised, Kerry Pollard 33 Professional development Mechanism of labour – explains how the introduction of an 34 Diary the interaction between the obstetric early warning system is maternal pelvis and fetal skull providing opportunities for practitioners to act promptly and prevent Take a look at the questions and answer deterioration options for this month’s featured module, then go online to take the 26 NEW! Midwives’ wellbeing assessment and download the certificate and resilience for your revalidation portfolio 1. The resilient midwife14 Midwifery basics 5. Professional issues in practice In the first of a new series which aims to embrace and encourage midwives’ own Jancis Shepherd explores issues of wellbeing and resilience, Rebecca Knapp supervision of students’ practice and considers a definition of resilience and legal implications of misadministration how midwives can build on resilience to of medicines, and accountability enhance their wellbeing4 TPM, March 2017, vol.20, issue 3

PLUS EXTRA ONLINE CONTENTSNow available online at www.practisingmidwife.co.ukMARCH MODULE OF THE MONTH: Mechanism of labour –the interaction between the maternal pelvis and fetal skullRead the module, take the assessment, then download your certificate for CPD, appraisal and revalidation. PLUS! THIS MONTH’S EXTRA COMMUNITY ARTICLES: VIEWPOINT Midwives are mobilising, midwives are acting: the regulation of midwives Lesley Choucri and Bev Jervis consider the reasons for the huge changes facing midwifery, and champion the groups and individuals they see standing up for midwives’ freedom to provide optimum care to women and familiesPLUS! THIS MONTH’S EXTRA FEATURE ARTICLES: THINKING OUTSIDE NEWS THE BOXWhat lies beneath: water as non-pharmacological pain Read the latest news stories thatmanagement in labour Pondering domesticity matter to midwives, students and related professionals. We aim toAs the practice of midwifery incorporates the promotion of physiological Sara Wickham reflects on the update these stories during thebirth, Anne-Marie De Leo and Sadie Geraghty, explain how use of water findings of a research paper that month to bring you news andoffers women a naturalistic approach to pain relief and may prove more looks at how domesticity dictates information as it comes to lightbeneficial than conventional pharmacological pain management behaviour in the birthing spacePLUS! THIS MONTH’S Midwifery basics Visit the website to...EXPANDED FEATURE 5. Professional issuesARTICLES: in practice PREPAREMechanism of labour – Read Jancis Shepherd’s For practice, examinations, appraisal, revalidation: all in the eLearningthe interaction between the commentary on the activities in section, the place to go for CPD.maternal pelvis and fetal skull the article and join us on Facebook to suggest what you DEVELOPElaine Uppal provides more detail consider to be the issues, moston the pelvis and its function, the appropriate actions and your Extend and expand your skills by reading authoritative and thought-moulding of the fetal skull and assessment of the medicine provoking articles from this month and the archive.descriptions of long and short management errors presentedrotations SHARE Enjoy your Community Zone, where you will find blogs and opinion articles, plus links to Facebook and Twitter. See what’s coming up in Events (and remember to let us know about your forthcoming events by writing to [email protected]). TPM, March 2017, vol.20, issue 3 5

VIEWPOINT In the roomAnna Byrom We live in a technocratic world – an information era, where the complexities of life areEditor increasingly mapped with ever-more detailed accuracy. Perpetual research, documentation and identification, whilst useful and supportive, can also overwhelm us both personally and Follow me on Twitter: professionally as we seek to find the best approach to living life and practising midwifery. The@acbmidwife complex web of information that surrounds us can result in a forgetting of the fundamentals of life and work. As midwives, in those moments, when we find ourselves lost to a torrent flow of data, choices and opportunities, it can be helpful to get back to basics: back to the fundamentals of midwifery practice. But what are the basics of midwifery practice and what really matters? Getting back to basics in midwifery work, for me is illustrated literally and metaphorically by 'being in the room'. Whether our midwifery work takes us to the childbearing woman's side or to the nurturing, leadership and education of fellow- or future midwives, it can be helpful to remember to get back to ‘being in the room' – back to those in our care. I remember when I first qualified as a midwife, I felt overwhelmed with my new accountabilities. At moments when those responsibilities looked set to send me under, I soothed myself by 'being in the room': closing the door to the politics, I focused on the people in front of me, those that matter the most: the childbearing women and families I aimed to serve. Back in the room I could take things step-by-step and be led by individuals: their needs, their hopes and their experiences. Stripping away the ‘noise’ of information by being with those in our care can enhance our experience of midwifery.To enable us to ‘be in the room’, as midwives, it helps if we work to harness the information available to us, making it more accessible and manageable rather than an overwhelming distraction. Working in teams to develop robust but flexible guidelines based on the best available evidence, can be helpful. Use these to guide practice, to enable more time to be in the room, being with those we serve. This month TPM invites you to get back to basics. Take a look through the range of articles on offer both here and online, focusing on some of the basic topics related to childbearing and midwifery practice. We hope you can utilise the information shared here to support the basics of your midwifery practice and remember to look online for extra articles, expanded articles and, as always, the eLearning modules to enhance your knowledge and skills.6 TPM, March 2017, vol.20, issue 3

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MECHANISM OF LABOURARTICLE OF THE MONTH Elaine UppalLead article each month,taking you from the Senior Lecturer (teaching and scholarship) in Midwifery andjournal to the website Pathway Lead Midwifery MSc Advanced Professional Practicefor a module on the and Leadership at the University of Manchestersubject. Mechanism of labour –This month: the interaction between theMechanism of labour – maternal pelvis and fetal skullthe interaction betweenthe maternal pelvis and Ì Go to www.practisingmidwife.co.uk to read an expanded version of this article,fetal skull. including long and short rotationsGo to the module at This article considers the anatomy and physiology underpinning the mechanism of labour in terms of thewww.practising amazing journey the fetus completes through the maternal pelvis. In order to monitor maternal and fetalmidwife.co.uk wellbeing and promote progress in labour, the midwife needs a thorough understanding of: the maternal pelvis, the external structure of the fetal skull, and how the presentation and attitude of the fetusTry out our sample determines the presenting diameter of the skull.questions on page 13then go to the website COMPOSITION OF THE PELVIS at four joints: the sacrum, formed by the fusion ofto complete the module five sacral vertebrae at the rear of the pelvis; theand gain a certificate for Knowledge of the anatomy of the maternal pelvis is coccyx, formed by the fusion of four originallyyour revalidation crucial in understanding the normal mechanism of separated coccygeal bones, forming the bony baseportfolio birth, detecting any deviation from the norm and of the spinal column and pelvis; and two innominate making appropriate referrals to ensure maternal, bones which form the sides of the pelvis. The fetal and neonatal wellbeing (Nursing and innominate bones are further divided into three Midwifery Council (NMC) 2012; 2015). parts: the ilium, ischium and pubis (as shown in The pelvis consists of four bones which articulate Figure 1 Anterior (front) view of female pelvis Innominate Innominate bone bone Sacrum Coccyx Symphisis pubis8 Uppal, TPM, March 2017, vol.20, issue 3

THE INTERACTION BETWEEN THE MATERNAL PELVIS AND FETAL SKULL Figure 2 Superior view of the pelvis to show the landmarks of the pelvic brim DimSeancsrioocnotyloid 1 23 4 5 6 87 Figure 1). These bones all meet in the acetabulum, the eight points or landmarks comprise: with the fossa forming the socket for the hip joint. 1. Sacral promontory 2. Front aspect of the ala of the first sacral REGIONS OF THE ‘TRUE’ PELVIS vertebrae, also known as sacral wing of ala 3. Upper border of the sacroiliac joint The false (greater) pelvis is larger and superior 4. Iliopectineal line (above) to the true (lesser) pelvis where the pelvic 5. Iliopectineal eminence inlet is located. The greater pelvis is deemed to be 6. Upper inner border of the superior pubic ramus located abdominally, whereas the true pelvis 7. Upper inner border of the body of the pubis contains the rectum, bladder, uterus and vagina. 8. Upper inner border of the symphysis pubis. There are three sections of the true pelvis: the brim;All figures reproduced from Myles Textbook for Midwives, 16th edition, Marshall J cavity; and outlet through which the fetus rotates PLANES, ANGLES AND INCLINATION OF >>>> and Raynor M (editors). Copyright (2014), with permission from Elsevier and descends utilising the largest diameters. THE PELVIS PELVIC BRIM When standing upright, the pelvis is naturally tilted; This is oval in shape as the anteroposterior diameter the mathematical terms ‘angles’ and ‘planes’ are is reduced by the sacral promontory. Starting from the centre of the sacral promontory and tracing the applied to indicate the direction of the slopes of the brim around to the symphysis pubis (see Figure 2), pelvis: an angle occurs where two rays represented by lines meet a common endpoint; whereas a plane Figure 3 Pelvis shapes Anthropoid Android Gynaecoid Platypelloid (flat) 9 Uppal, TPM, March 2017, vol.20, issue 3

MECHANISM OF LABOURFigures 4 and 5 The pelvis, showing the degrees of inclination: inclination of the pelvic brim to thehorizontal, 55º; inclination of pelvic outlet to the horizontal, 15 º; angle of pelvic inclination, 135 º;inclination of the sacrum, 90 º 90° Figure 5 60° Figure 4 30° 15° 0°comprises the relationship between the pelvis and a FETAL SKULLflat surface such as the floor – or imagine a piece ofpaper being placed across the landmarks to form a The fetal skull provides a key partnership with theflat surface. The fetus must negotiate the changing maternal pelvis that is crucial to the success of theangles of the pelvis as it descends through the brim mechanism of labour. It is imperative to be able toand emerges through the outlet, following the curve determine the structures, regions, landmarks andof carus as it descends and rotates.There are various diameters of the fetal skull and understand how thistypes of pelvis: gynaecoid (50 per cent); android (25 knowledge enables midwives to: recognise normalper cent); anthropoid (25 per cent); and platypelloid presentations and positions of the fetus; and detect(less than 5 per cent incidence), shown in Figure 3. any deviations from the norm in order to address potential complications that can occur during theENGAGEMENT AND DESCENT OF THE birthing process (NMC 2012; 2015). The fetal skullFETAL HEAD THROUGH THE PELVIS comprises: a vault – with two frontal bones, two temporal bones, two parietal bones, one occipitalThe ischial spines of the pelvis are designated station bone – the face; and base.The lambdoidal suture lies0; when the head is above them, it is said to be -1, -2, between the occiput and the parietal bones; the-3 or -4. If the head is below the level of the ischial sagittal suture runs from the anterior to the posteriorspines the station is +1, +2, +3 or +4. If the head is at fontanelle, dividing the parietal bones; the coronalthe level of the ischial spines, this is classed as suture separates the parietal from the frontal bones;cephalic engagement as it is situated in the true and the frontal suture divides the frontal bones. Thepelvis. The widest diameters of the pelvis are vertex is bound by the anterior fontanelle (kite-transverse in the brim and antero posterior in the shaped bregma), posterior fontanelle (Y- oroutlet (as illustrated in Figure 6). triangular-shaped lambda) and the two parietal eminences (see Figure 7).Figure 6 Normal pelvic diameter measurements ASSESSING THE POSITION OF THE FETUS Anteroposterior Oblique Transverse Left occipito anterior (LOA) – posterior fontanelleBrim 11 12 13 anterior to the left, sagittal suture is in right oblique Right occipito anterior (ROA) – posterior fontanelleCavity 12 12 12 anterior to the right Right occipito posterior (ROP) – anterior fontanelleOutlet 13 12 11 anterior to the left Left occipito posterior (LOP) – anterior fontanelle anterior to the right Left occipito lateral (LOL) – posterior fontanelle to the left Right occipito lateral (ROL) – posterior fontanelle to the right10 Uppal, TPM, March 2017, vol.20, issue 3

THE INTERACTION BETWEEN THE MATERNAL PELVIS AND FETAL SKULLFigure 7 Coronal suture Anterior fontanelle (bregma) Lambdoid Vertex suture Posterior fontanelle Brow Frontal Parietal bone bone and eminenceSinciput Occipital protuberance Face Temporal Occiput Mentum bone Sub-occipital regionOccipito anterior (OA) – posterior fontanelle felt DIAMETERS OF THE PRESENTING PARTanteriorlyOccipito posterior (OP) – anterior fontanelle felt SOB – Sub occipital bregmantic 9.5cm – relatesanteriorly to OA position, extending from the nape of theMECHANISM OF LABOUR neck to the centre of the anterior fontanelle. TheThis requires consideration of the: power – in termsof the strength and regularity of contractions; attitude is complete flexion and the presentationpassage – in terms of the pelvis; and the passenger– in terms of the fetal position and flexion of the vertex.head. These combine to facilitate progress inlabour. SOF – Sub occipital frontal 10cm – relates toDEFINITIONS OF TERMS OP position undertaking long rotation and Lie – This is determined by the relationship returning to OA position, extending from the napebetween the long axis of the fetal spine and the longaxis of the maternal uterus (longitudinal, oblique or of the neck to the centre of the frontal suture. Thetransverse). attitude is incomplete flexion and the presentation Attitude – The relationship of the fetal head, spineand limbs to its body (fully flexed, poorly flexed, is vertex.deflexed or extended). OF – Occipito frontal 11.5cm – relates to OP Presentation – The part of the fetus lyinglowermost in the birth canal (cephalic, breech, face position undertaking short rotation andor brow presentation). remaining in OP position; it extends from the Position – The relationship between thedenominator and the mother’s pelvis (LOP/ROP or occipital eminence to the bridge of the noseLOA/ROA). (glabella). The attitude is marked deflexion and Denominator – A fixed point on the presentingpart that relates to position (occiput [back of head], the presentation is vertex.sacrum [buttocks], mento [chin]). MV – Mento vertical 13.5cm – relates to brow Engagement – When the head passes through thebrim of the pelvis. presentation (the point of the chin to highest point of the vertex). The attitude is midway between flexion and extension and the presentation is brow. SMV – Sub mento vertical 11.5cm – relates to brow presentation (where the chin joins the neck to highest point of the vertex). The attitude is incomplete extension and the presentation is face. SMB – Sub mento bregmatic 9.5cm – relates to face presentation. It extends from the junction of the floor of the mouth and neck to the centre of the bregma. The attitude is complete extension and the presentation is face. >>>> Uppal, TPM, March 2017, vol.20, issue 3 11

MECHANISM OF LABOURMechanism of labour left occipito-anterior (LOA)Lie LongitudinalPresentation VertexPosition Left occipito-posteriorAttitude FlexionDenominator OcciputEngaging diameter Sub-occipito bregmatic – 9.5 cmsDescent Takes place with increasing flexion of the fetal head, the occiput becomes the leading part.Internal rotation(head) The occiput meets the resistance of the pelvic floor and rotates anteriorly an eighth of aCrowning circle. There will be a slight twist in the neck now, as the shoulders are still held OA. This means that the head will be able to emerge through the widest diameter of the outlet.Extension By a movement of flexion, the occiput passes over the perineum and the head isRestitution crowned (it no longer recedes because the largest diameter has been born).Internal rotation The sinciput, face and chin escape under the symphysis pubis, sweep the perineum and(shoulders) the head is born by a movement of extension.External rotation The occiput turns an eighth of a circle to the right to realign itself with the back and shoulders.Lateral flexion The shoulders enter the pelvis in the left oblique diameter, the anterior shoulder meets the resistance of the pelvic floor and rotates an eighth of a circle to lie under the symphysis pubis the AP diameter. At the same time, the occiput turns a further eighth of a circle to the right as the head is now free, it is seen to rotate externally as the shoulders do simultaneously inside. The head will always rotate in the direction expected from the position of the fetal back. The anterior shoulder escapes under the symphysis pubis, the posterior shoulder sweeps the perineum and the body is born by lateral flexion, following the curve of carus.MECHANISM OF LABOUR – OCCIPITO mechanisms in order to be born. Midwifery care isANTERIOR POSITION crucial to ensure progress in labour and support the woman during the childbirth continuum. KeyThe fetus is round-shouldered, with head flexed and identifiable features for midwives on vaginalchin on chest.The rounded back bulges forward into examination include: suture lines; fontanelles –the soft maternal abdomen. In labour the ovoid bregma (anterior fontanelle), lambda (posteriorshape fits the lower uterine segment and presses fontanelle); sinciput (forehead); mentum (chin);evenly on the cervix, stimulating good uterine vertex (highest point of the skull); and the occiputcontractions and facilitating dilatation of the cervix. (area over the occipital bone). tpmThe smallest possible diameters stretch the pelvicfloor and perineum and the fetal head is moulded REFERENCESin the most favourable diameter. Macdonald S and Magill-Cuerden J (eds) (2011).CONCLUSION Mayes’ midwifery, 14th edition. London: Bailliere Tindall Elsevier.The pelvis is a major bone in the body comprising acomplex framework; it is vascular, consisting of NMC (2012). The midwives’ rules and standards,bone, ligaments and nerves which all facilitate London: NMC.upright movement. The pelvis plays an importantpart in protecting the internal soft organs and in NMC (2015). The Code. Professional standards ofaiding normal childbearing to facilitate the passage practice and behaviour for nurses and midwives,of the fetal skull and body in a complex series of London: NMC.12 Uppal, TPM, March 2017, vol.20, issue 3

MODULE OF THE MONTHTHIS MONTH’S MODULE: 6. In a well-flexed head, occipito anterior position,MECHANISM OF LABOUR – THE what suture line would you expect to find in theINTERACTION BETWEEN THE anterior posterior diameter of the pelvic outlet?MATERNAL PELVIS AND FETAL SKULL a. Sagittal b. LambdoidalGo to our website at www.practisingmidwife.co.uk c. Coronalwhere you will find this module, devised for you d. Bregmaby Elaine Uppal, in full. Try answering thequestions below and then take the assessment 7. Moulding is a change in the shape of the fetalwithin the module to gain a certificate for your skull caused by passage through the birthrevalidation portfolio. canal, skull bones overriding at the suture lines. Moulding makes:INTRODUCTION a. The engaging diameter shortenThis guide considers the anatomy and physiology and the diameter at right angles lengthenunderpinning the mechanism of labour in terms ofthe amazing journey the fetus completes through b. The engaging diameter lengthenthe maternal pelvis. This will be outlined in and the diameter at right angles shortenrelation to normal birth and the long and shortrotations undertaken in an occipito posterior c. The engaging diameter lengthenposition. and the diameter at right angles lengthen Questions d. The engaging diameter shorten and the diameter at right angles shorten1. Which is the most common pelvic shape that optimises normal progress in labour? 8. What is the denominator? a. Anthropoid pelvis a. The part of the fetus lying lowermost in the b. Platypelloid pelvis birth canal – for example cephalic c. Gynecoid b. The relationship to the six areas on the d. Android mother’s pelvis c. The relationship of the fetal head and limbs2. What is the engaging diameter in a vertex to its body presentation? d. A fixed position on the presenting part used a. Sub occipito bregmatic to indicate the position b. Mento vertical c. Occipito frontal 9. Assessing the position of the fetus, in a left d. Sub mento bregmatic occipito anterior (LOA) position: a. The posterior fontanelle is anterior to the left,3. What are the normal pelvic measurements of the sagittal suture is in right oblique pelvic brim? b. The posterior fontanelle is anterior to the right a. Anteroposterior – 11; oblique – 12; transverse – 13 c. The anterior fontanelle is anterior to the left b. Anteroposterior – 10; oblique – 11; transverse – 12 d. The posterior fontanelle is to the left c. Anteroposterior – 12; oblique – 12; transverse – 12 d. Anteroposterior – 13; oblique – 13; transverse – 13 10. The mechanism of labour requires consideration of:4. What are the normal measurements of the pelvic a. The power – in terms of the strength and cavity? regularity of uterine contractions a. Anteroposterior – 11; oblique – 11; transverse – 11 b. The passage – in terms of the maternal pelvis b. Anteroposterior – 12; oblique – 12; transverse – 12 c. The passenger – in terms of the fetal position c. Anteroposterior – 13; oblique – 13; transverse – 13 and flexion of the head d. Anteroposterior – 11; oblique – 12; transverse – 13 d. A combination of the above5. What are the normal measurements of the pelvic Go the website at outlet? a. Anteroposterior – 12; oblique – 12; transverse – 12 wwwwww..pprarcatcistiinsginmgidmwidfew.coi.fuek.co.uk b. Anteroposterior – 11; oblique – 11; transverse – 11 c. Anteroposterior – 11; oblique – 12; transverse – 13 and take this assessment; once you have d. Anteroposterior – 13; oblique – 12; transverse – 11 answered all the questions correctly, download your certificate to keep in your revalidation folder. Uppal, TPM, March 2017, vol.20, issue 3 13

MIDWIFERY BASICS: BECOMING A MIDWIFE Jancis Shepherd Lead Midwife for Education at University of West London Go online at www.practisingmidwife.co.uk to read Jancis Shepherd’s commentary on the activities and the outcomes that could be expected in these cases 5. Professional issues in practice Becoming a midwife is the 16th series of ‘Midwifery basics’ targeted at practising midwives and midwifery students. The aim of these articles is to provide information to raise awareness of the impact of professionalism on women’s experience, consider the implications for midwives’ practice and encourage midwives to seek further information through a series of activities relating to the topic. In this fifth article of the series, Jancis Shepherd explores issues of supervision of student midwives in perineal suturing, the practical and legal implications of misadministration of medicines and accountability issues.ACTIVITY 1 Box 1 EC directives GAINING PRACTICE KNOWLEDGEYou are Susie’s (a year three The EU requirements at point of registrationstudent) sign-off mentor. She (Article 40 of Directive 2005/36/EU) include: During the midwifery course, students attend bothhas completed perineal • Advising pregnant women, involving at least 100 theory and practice, practice placements beingsuturing three times for between 50-60 per cent of the course time.second-degree tears. You ask antenatal examinations Universities work with the hospitals to provide theSusie to prepare for suturing of • Supervising and caring for at least 40 women in practical opportunities to meet the Nursing anda second-degree tear. You both Midwifery Council (NMC) standards (2009) andposition the mother in labour meet the EC directives to gain the requisitelithotomy. You check the • Performance of episiotomy and initiation into experience (see Box 1).lidocaine following localpolicy; just as Susie is about to suturing Occasionally issues arise in practice that causeadminister this, the emergency • Personally carrying out at least 40 births concerns regarding professional behaviour. Thisbell rings. You say to Susie ‘I’ve • Supervising and caring for 40 women at risk article considers issues related to perineal suturinggot to go, you’ll be OK?” and and medicine administration.she replies “Yes”. during pregnancy, labour or the postnatal periodWhat do you expect of Susie • Supervising and caring for (including Students have to achieve success in each of thewhile she awaits your return? NMC competencies Standard 17 (NMC 2009), at examination) at least 100 postnatal women and least twice in the course, once at an initial at least 100 healthy newborn infants progression point and again for entry to the register. • Active participation with breech births (may be Students have to achieve academic and practice simulated) success at the initial progression point to be able to • Observation and care of the newborn requiring continue on the course. special care, including those born pre-term, post- term, underweight or ill The assessment of competence encompasses four domains and is subdivided further into Essential Skills Clusters (Table 1). THE PLACE OF PRACTICE >>>> Each university or group of universities will have a Practice Assessment Document (PAD) where practical achievement of the competencies is14 Shepherd, TPM, March 2017, vol.20, issue 3

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MIDWIFERY BASICS: BECOMING A MIDWIFE Table 1 completed the notes and the woman is awaiting transfer to the ward. Susie asks you to ‘check herACTIVITY 2 Domains Essential skills clusters suturing and her record keeping’.Using the NMC Code (2015),identify the issues for you as Effective midwifery Communication You realise that Susie did not have a sign-offan accountable practitioner practice midwifery mentor present when the lidocaine wasthat arise from this incident. administered, neither was she supervised while sheIdentify the issues that arise Professional and ethical Initial consultation sutured.for Susie. practice between the midwifeWhat may the midwife have and the woman The suturing was completed well, the recordsmeant when she said to Susie were accurate and the mentor completed these to'will you be ok?' Developing the midwife Normal labour and birth record the situation that had occurred. The mentorConsider what are the and others reported the incident via Datix and to the senioraccountability issues for the midwife.mentor in relation to: Achieving quality care Initiation of• Susie? through evaluation and breastfeeding Susie was asked by her mentor why she had• The woman who has research sutured the woman without a mentor present. Susie explained that she had continued to give the undergone suturing that was Medicinal product lidocaine assuming that the mentor would return unsupervised? management within a few minutes. She sutured, as the lidocaine• The administration of the had been administered, the woman was bleeding lidocaine? undertaken by a midwife with sign-off-mentor from her injury and she felt it was in the woman’sHow may the trust investigate status (NMC 2008). Students will commence in year best interests. Susie ignored the warnings in herand manage this situation? one and learn the theory and practice of the initial head not to continue. In discussion with her mentor, practical skills, such as antenatal examination and the reality of what she had done hit home. SusieACTIVITY 3 its component skills (taking blood pressure, demonstrated personal accountability as sheConsider the legislation and urinalysis, abdominal palpation, postnatal and informed the senior midwife and her practicelocal policies to identify the newborn examinations, supporting care in labour educator of the incident. Susie was advised to writeissues that Susie faces. and infant feeding). As the course progresses, a factual statement and a personal reflection.What do you think should further skills of a more complex nature will behappen next? learned, such as management of emergencies, Susie was extremely remorseful and herReview your local Fitness to postpartum haemorrhage, shoulder dystocia, breech reflection demonstrated insight using the NMC CodePractise procedures and birth, neonatal resuscitation and medicine (2015).consider what the outcomes administration and management. Once mastery offor Susie may be. the initial skills is achieved, students may also learn LEGISLATION other skills, such as suturing the perineum. Although these skills may be practical in nature Student midwives may administer medications there will be associated anatomy, physiology and under direct supervision of a registered midwife or theory to learn. nurse (UK Government 2012; NMC 2011). If medication is being administered as a ‘midwife’s ACCOUNTABILITY exemption’, then the midwife must be a sign-off mentor. Lidocaine, when used for suturing, is a The sign-off midwifery mentor remains accountable midwife’s exemption. Midwives’ exemptions for the student’s assessment and the care given to exclude the administration of controlled drugs by the woman and her baby. Students must understand students (NMC 2011). Students must also follow when direct supervision of care is required, that their university and trust policy for medicine discussion and negotiation occur so that supervision management. changes from direct to indirect supervision. The mentor and student must understand the Student midwives may undertake suturing if boundaries and limits, and that entries to records they have received appropriate training (NMC 2010; require a midwife’s counter signature as the 2012), with the direct supervision of a midwife. A midwife is the accountable practitioner. record is kept of the perineal repairs students undertake, building up experience ready for Within busy ward areas, the demands of practice qualification. and human factors, errors in practice may arise. MEDICATION ERRORS Look at the events of Activity 1. There has been a major incident and, as a result, you were unable to Midwives need to be aware of the legislation, return to supervise Susie until three hours later. national and local policies and standards for When you do return, you find that Susie has medicine management and how these relate to their administered the lidocaine, sutured the woman, role as a sign-off mentor. Where these are not understood, or administration policies are not followed, this exposes risks of giving the wrong medicine, the wrong dose, via the wrong route of16 Shepherd, TPM, March 2017, vol.20, issue 3

PROFESSIONAL ISSUES IN PRACTICEadministration at the wrong time or administering REFERENCESto the wrong patient. These incidents and theirconsequences are avoidable. NMC (2008). Supporting learning and assessment in practice, London: NMC.NEXT TIME NMC (2009). Standards for pre-registrationThis article has considered practice issues in relation midwifery education, London: NMC.to direct and indirect student supervision of perinealsuturing and medicine administration, NMC (2010). Standards for medicines management,demonstrating where there is potential for error and London: NMC.where accountability lies. The next article in theseries will discuss the implications for NMC (2011). Changes to midwives’ exemptions,students/midwives with health and learning London: NMC.difficulties. Issues of achieving competence, andstrategies to support students and maintain public NMC (2012). Midwives’ rules and standards,protection will be considered. tpm London: NMC. NMC (2015). The Code. Professional standards of practice and behaviour for nurses and midwives, London: NMC. UK Government (2012). The human medicines regulations 2012 (SI 2012/1916), London: The Stationery Office. www.legislation.gov.uk/uksi/2012/ 1916/schedule/17/made ACTIVITY 4Consider the following in medicine management errors:1. The student administers Konakion 1mg to the mother instead of Syntometrine 500 mcg/5IU2. The student administers Syntometrine 500 mcg/5IUto the baby instead of Konakion 1mg3. The midwife tells the student to administer the pain relief she has drawn up; later in the shift it isdiscovered that an ampoule of Diamorphine is missing and the student has administered this instead ofPethidine.For each of these errors:• Why may these have arisen?• What actions should occur following an error in administration of medicines?• What may be the consequences of a medicines error?• What actions could be taken to develop the midwife’s practice?• What actions could be taken to develop the student’s practice?Learn the secrets of success!Are you wondering how to start your research or dissertation journey, swimming through a sea of papers orlooking for help knitting your discussion together? Do you need advice for getting the most out of your tutor orideas to help you keep on track with your thinking, writing and analysis? What is critical analysis, in fact, andhow do you do that while still having a life?The 101 tips in this book cover a wide range of areas from how to create a good question and keywords to what RRPto do when someone publishes a ground breaking new study on your topic the week before you’re due to £9.99submit your work. Written in an accessible, friendly style and seasoned with rst-hand advice and commentsfrom others who have trodden the path, this book combines sound, practical tips from an experiencedacademic with reminders of the value of creativity, chocolate and naps as investments in your work.Available from Amazon in paperback or e-bookMore information at www.sarawickham.com Shepherd, TPM, March 2017, vol.20, issue 3 17

ADVANCING PRACTICE Anna Byrom Midwifery Lecturer at University of Central Lancashire Quality care matters: advancing practice through clinical audit This article outlines the essentials of audit design and implementation. Effective audit can be used as a tool to advance practice for quality maternity care provision. The value of audit is presented alongside some of the possible barriers and facilitators to effective use and impact within health care settings. A detailed overview of the key stages within the audit cycle is offered to support your engagement with audits in your own midwifery practice area.PRACTICE CHALLENGE INTRODUCTION Excellence (NICE) (2002) offers a well-accepted andDo you know which relevant definition:indicators and standards Improving quality throughout maternity care is theare being audited within aim of any conscientious and motivated health ‘Clinical audit is a quality improvementyour maternity services? service or individual practitioner. Striving to process that seeks to improve patient care and enhance care for all, through efficient, effective, safe outcomes through systematic review of carePRACTICE CHALLENGE and evidence-based, woman-centred approaches is against explicit criteria and the implementation ofAttend a local audit group expected of midwives, local maternity units and change. Aspects of the structure, process andmeeting/feedback session throughout national and international communities. outcomes of care are selected and systematicallyto see what standards are Whilst determining what constitutes quality care is evaluated against explicit criteria. Wherebeing assessed in your arduous, research continually strives to highlight indicated changes are implemented at anwork place best practice standards, which can be translated into individual, team or service level and further practice guidelines and action. Assessing the quality monitoring is used to confirm improvement in of a service, against recommended best practice healthcare delivery’ (NICE 2002: 1). standards, can be equally complex and requires a multifaceted approach. Clinical audit is frequently Specifically audit provides a method for heralded as a core component of quality systematically reviewing and improving practice. improvement throughout health care. During my Audit offers a way to check if maternity care is being time practising as a midwife, I have been involved delivered to the required or expected standards. in audits in clinical practice, education and research These standards of care are outlined by research settings. In this article I hope to share insights into evidence, clinical expertise and service-user the use of clinical audit to enhance midwifery requirements. Most frequently, standards of care are practice. This includes a review of audit definitions, outlined in national and local guidelines and cycles, methods and implementation. My aim is to policies. So whilst audit is connected to research, it support your practice development and encourage is different in its application and use – Table 1 more midwives to engage in audits relevant to their (opposite) identifies some of the differences between scope of practice and role. research and audit. Healthcare Quality Improvement Partnership (HQIP) (2012:3) highlights WHAT IS CLINICAL AUDIT? the difference and argues that ‘research tells us what we should be doing and clinical audit tells us Clinical audit has been variously defined over the whether we are doing what we should be doing and years. The National Institute for Health and Care how well we are doing it’ (HQIP 2012: 3).18 Byrom, TPM, March 2017, vol.20, issue 3

QUALITY CARE MATTERS: CLINICAL AUDITTable 1 Differences between research and audit Table 2 Why clinical audit is importantAudit Research Identifies and promotes good practice and can lead PRACTICE CHALLENGE to improvements in service delivery and outcomes Identify an area of yourDesigned and Designed to generate for users own midwifery practice thatconducted to produce new knowledge about would be useful to auditinformation to inform how to practise Can provide the information you need to showthe delivery of best care others that your service is effective, thus ensuring it is developed and maintainedDesigned to answer the Designed to test aquestion:‘Does this hypothesis Provides opportunities for training and educationservice reach a (quantitative research)pre-determined or explore a new area/ Helps to ensure better use of resources, increasingstandard?’ focus/topic (qualitative efficiency research) Can improve working relationships,Measures against a Creates new standards communication and liaison between staff andstandard for practice or service-users stimulates more practiceClinical audit can Research provides a time for health care teams to participate (NICEprovide high-quality basis for defining good- 2002). Additionally, follow-up actions, based on thedata for non- quality care for clinical audit findings, can be challenging in over-stretchedexperimental evaluative audit purposes health care settings. Some of these barriers can beresearch overcome in maternity services by identifying lead audit midwives and connecting them to the widerWHY AUDIT MATTERS governance team. Building a team of midwives, PRACTICE CHALLENGE obstetricians and support staff to help implement Design your own audit,Clinical audit can help with quality improvement in audits can help. Also using students could help to including aims, objectives,maternity services and health care more generally develop skills, share workload and ensure the future standards to audit(see Table 2). It has been promoted as a basic workforce is confident in audit practice.component of clinical governance throughout healthcare. The NICE (2002) publication Best practice in It is important to ensure audits are planned,clinical audit clearly sets out the challenge to implemented and followed up effectively. Followinguniversally implement good quality audit and is an audit cycle, or spiral, can help to ensure theworthwhile reading for those involved in audit on process of audit is effective and managedall levels. Essentially, HQIP (2012) advocates the appropriately in practice.value of clinical audit as a key tool to changingpractice, and that it requires a supportive THE PROCESS OF AUDIT:environment and use of appropriate methods (Potter THE AUDIT CYCLEet al 2010). However, evidence about the efficacy andeffectiveness of audit is conflicting (Grimshaw et al There is a wide range of terms used to describe the2001; Ivers et al 2012). The Cochrane systematic audit process including: criteria-based audits,review on audit and feedback suggests that only a adverse occurrence screening, critical incidentmodest improvement in the practice of health care audits and case note analysis. These terms can beprofessionals can be achieved through audit (Ivers used interchangeably and inconsistently –et al 2012). The effect of using audit and study importantly they all involve the same process: thefeedback varied widely across the included studies, audit cycle (see Figure 1, over page).ranging from little or no effect to a substantial effect.Ivers et al concluded that the effectiveness of audit The audit cycle outlines the various stages toand feedback seems to depend on baseline consider when designing and implementing aperformance and how the feedback is provided. To clinical audit. The audit cycle includes five stages:understand enhances audit effectiveness; it is useful preparation; selecting criteria and standards;to consider potential barriers and facilitators. measuring performance; making improvements; and sustaining improvements. The cycle or spiralAUDIT BARRIERS AND FACILITATORS suggests that as the process continues, each cycle aspires to a higher level of quality (Benjamin 2008).The most frequently cited barrier to successful auditis the failure of organisations to provide sufficient STAGE 1 PREPARING FOR AUDIT Preparation is an important stage of the audit cycle. During this stage you will identify the topic to be >>>> Byrom, TPM, March 2017, vol.20, issue 3 19

ADVANCING PRACTICE audited and the team who will conduct the audit. Table 3 What to audit as recommended by Selecting a topic or area of practice to audit is usually Donabedian (1966) the first step in the audit cycle. Audit topics can bePRACTICE CHALLENGE identified based on national, local or individual Element ExplanationWhat methods would you drivers.choose? Structure The availability and organisation of What can be audited? resources and personnel (for example audit of the ratios of maternity staff An early framework for assessing the quality of and grades to service users/birth rates healthcare and what can be audited in clinical or audit of the range of midwifery practice was developed, last century, by Donabedian clinics offered and attended by service (1966) who suggested that audit should focus on users). reviewing three aspects of care provision: the structure, process and outcomes of care. These have Process The activities undertaken: what is done been explained in more detail in Table 3. with the resources (for example audit the timing of appointments, how many These three broad elements can be sub-divided and how long they are).Water pool into a wide range of areas that could be identified as audit on delivery suite to assess the suitable areas for audit. In maternity care the audit processes followed. indicators are frequently identified by public health agendas, key guidelines or recommendations.These Outcome The effect of the activities on the areas can help in making decisions about which health/wellbeing of the service user, standards to select in the next step of the audit cycle. that is the changes for the individual that can be attributed to the clinical STAGE 2 SELECTING AUDIT CRITERIA care they received (for example audit of AND STANDARDS the outcomes of all breech births). Audit criteria and standards are usually identified The practice standards to be used as from the key recommendations for practice found in measurement must be clear and specific practice local, national or international research and/or recommendations and realistic for your given guidelines. Specifically, audit criteria are the clear environment; they are frequently expressed as a statements that define the outcome you plan to percentage. Standards can be based on minimum, measure. These statements should be taken directly ideal or optimum requirements. A minimum from the best available evidence. Benjamin (2008) standard describes the lowest acceptable standard of recommends having explicit selection criteria to practice performance. Using a minimum standard ensure that the data collected are precise and specific. For the criterion to be useful, an appropriate standard for practice must be defined. Figure 1 Audit cycle and stages, adapted from NICE (2002: 5) CREATING THE ENVIRONMENT Stage 1- Stage 2- Stage 3- Stage 4- Stage 5- Preparing Selecting Measuring Making Sustaining for audit criteria performance improvements improvementsFINAL PRACTICE USING THE METHODSCHALLENGEHow can you help actionsfrom audits to beimplemented?20 Byrom, TPM, March 2017, vol.20, issue 3

QUALITY CARE MATTERS: CLINICAL AUDITTable 4 Audit criteria and standard examples Audits can be conducted retrospectively (after an event) or prospectively (as events occur). Data may To measure what percentage of postnatal mothers be gathered from IT systems maintained by staff with septic shock were given anti-infective regarding service users during their use of maternity treatment. As septic shock is a condition with a high services, verbally (by talking to staff or service users mortality rate, it would be appropriate to aim for a about care provided), from clinical observations or standard of 100 per cent. from clinical records. Once data have been gathered, it is important to analyse them against the criteria To measure what percentage of childbearing and standards set (Benjamin 2008). women are encouraged to adopt an upright position for birth. Upright positions are useful to Analysis of the data gathered is important as it improve birth outcomes and experiences, but may allows an assessment of practice performance. not be chosen or appropriate for all women; as such Effective analysis is dependent on accurate and clear it would be appropriate to aim for a standard of 60 data collection and recording. Generally data are per cent of women birthing in upright positions analysed using simple data management software (this number would need to reflect the or calculations. Most audit results are presented physiological birth rate of the unit). using numerical values, generally in percentages. These results can then determine what, if any, To measure what percentage of breastfeeding practice improvements need to be made. mothers are informed of how to hand express their breast milk. Hand expressing can help mothers to STAGES 4 AND 5 MAKING AND resolve and overcome some breastfeeding SUSTAINING IMPROVEMENTS challenges. It would be appropriate to aim for a standard of 100 per cent of breastfeeding women Stages 4 and 5 are all about using your audit results shown how to hand express before discharge from hospital postnatally. to implement and/or sustain practicecan help distinguish between acceptable and improvements.These are the most difficult stages ofunacceptable practice. An ideal standard describescare expectations under ideal practice conditions the audit cycle, yet are the key purpose of audit – towithout constraints. The optimum standard liessomewhere in between and denotes the level of care enhance clinical practice. Practice improvementsmost likely to be achieved under normal conditions(Anderson 2015). It can be difficult to set optimum can be made by:standards and they are best set through carefuldiscussion and consensus, with representation from • formulating clear action plans and addressingall members of the practice team. Some examples ofaudit criteria and standards, for maternity care, are all the points raisedincluded in Table 4. • feeding back the audit results to the relevant The criteria and standard/s we choose to auditwill govern the audit methods identified and used clinicians/practitioners by key staffwithin stage 3 of the audit cycle: Measuring theperformance. members/leaders in relevant areas. It is worthSTAGE 3 - MEASURING LEVELS OF enlisting champions to disseminate feedback >>>>PERFORMANCE effectivelyThe next stage of the audit cycle is to plan how to SUMMARY OF ELEMENTS OFgather and analyse data from practice – to measure EFFECTIVE CLINICAL AUDITthis against the criteria and standard/s set.Developing an audit proforma can help those • Clinical audit should assess structure,collecting and analysing data to capture all the process or outcomes of carerelevant information and then organise it. Decisionsalso need to be made about the time period from • Audit should ideally be multidisciplinarywhich data will be gathered. and include service users Firstly, it is important to identify what data are • Choose audit topics based on nationalneeded. What staff, service users or groups do you clinical audits, national service frameworkswant to audit and what information do you require? or key recommendations from evidence- based guidelines • Derive standards from good quality guidelines • Use action plans to overcome the local barriers to change, and identify those responsible for service improvement • Repeat the audit to find out whether improvements in care have been implemented as a result of clinical audit Byrom, TPM, March 2017, vol.20, issue 3 21

ADVANCING PRACTICE • considering relevant educational approaches to www.gp-training.net/training/tutorials/ support practice improvements (such as management/audit/audabc.htm workshops, disseminating updated guidelines, mandatory training sessions) Benjamin A (2008). ‘Audit: how to do it in practice’. British Medical Journal, 336(1241).These improvements can then be sustained by: • repeat audits Donabedian A (1966). ‘Evaluating the quality of • ongoing training and support medical care’. The Milbank Memorial Fund Quarterly, • offering regular feedback to staff, including the 44(3): 166-206. strengths and areas for improvement Grimshaw JM, Shirran L, Thomas R et al (2001). Making and sustaining improvements ‘Changing provider behaviour: an overview ofthroughout maternity services is everyone’s systematic reviews of interventions’. Medical Care,business – take a look at the practice challenges 39(8S2): 112-145.accompanying this article to think about your owninvolvement in audits within your area of midwifery. HQIP (2012). What is clinical audit and otherThe following offers the key aspects of effective frequently asked questions, London: HQIP.clinical audit. Effective audits can contribute to www.hqip.org.uk/public/cms/253/625/19/262/Whatchange and enhanced care provision for mothers, %20is%20clinical%20audit%20and%20other%20FAbabies and their families. tpm Qs.pdf?realName=pOYoDm.pdfREFERENCES Ivers N, Jamtvedt G, Flottorp S et al (2012). ‘Audit and feedback: effects on professional practice and Anderson DG (2015). ABC of audit. Cleveland healthcare outcomes’. Cochrane Database ofVocational Training Scheme. Accessed online here: Systematic Reviews, 6: CD000259. DOI: 10.1002/14651858.CD000259.pub3 NICE (2002). Principles of best practice in clinical audit, London: NICE. Revalidation made simple with Maternity, Midwifery & Baby and The Practising Midwife Friday 24 March 2017 20 Cavendish Square | London | W1G 0RN www.midwiferyrevalidation.co.ukThis study day gives In-depth, clinical presentationsŞų±ÏƋĜŸĜĹčĵĜÚƵĜƴåŸĀųŸƋclass professional by leading experts include:development that alsoprovides essential hours ȏBirth Trauma Preventiontowards revalidation ȏDiabetes Management in Pregnancy ȏMaternal and Neonatal Immunisation ȏFemale Genital Mutilation (FGM) ȏRecognising & Preventing Postnatal Depression ȏChanges to Midwifery SupervisionThe cost of £90 plus VAT includes all the video, podcasts and presentations from the clinical study day, a valuable continuing professional development and revalidation resource - plus a one year subscription (or, if you alreadysubscribe, an extension) to The Practising Midwife to keep abreast of the latest thinking and research. For more information and to book your place, see the website at www.midwiferyrevalidation.co.uk

REDUCING MATERNAL MORBIDITY AND MORTALITY Kerry Pollard Lecturer in Midwifery at University of Central LancashireThe fundamental skills:reducing maternal morbidityand mortalityThe accurate assessment of basic observations such as blood pressure, heart rate, arterial oxygensaturation of blood (SpO2), respirations, temperature and level of consciousness (AVPU score) underpinthe fundamentals of basic midwifery care provision. However, after identifying that the signs ofimpending maternal collapse often went unrecognised leading to subsequent morbidities andmortalities, the confidential enquiry into maternal and child health (CEMACH) report in 2007 (Lewis2007) recommended that all obstetric women’s observations were recorded through a modified earlyobstetric warning system (MEOWS). This allows for the early detection of women who may becomecritically unwell and provides an opportunity for practitioners to act promptly and prevent deterioration(Knight et al 2016).This article provides an overview of the MEOWS scores as a tool to improve maternalmorbidity and mortality within maternity care.BACKGROUND score cannot be used. As a result, the modified early >>>> obstetric warning system (MEOWS) has beenEarly warning systems were first introduced in 1997 created to provide a more accurate assessment of a(Morgan et al 1997) whereby a patient’s vital signs woman’s wellbeing in the childbearing continuum.or observations are recorded and compared tovalues within the normal expected parameters. The scoring within this system aims to provideWeighted values are assigned to the physiological a tool to improve the timely recognition, treatmentparameters of observations to form an early warning and referral of women who have, or arescore (Singh et al 2012). developing, a critical illness (Lewis 2007). It is known that the early recognition of deterioration The degree of deviation from normal parameters in a woman’s status allows for early intervention,is scored and acts as a trigger to alert practitioners which can help to reduce future morbiditiesto identify when the further assessment of a patient (Hands et al 2013).needs to be expedited. Such early warning systemshave been developed for specific groups such as THE MEOWS SYSTEMneonates (neonatal early warning scores [NEWS]and paediatric early warning scores [PEWS]). The basic observations of blood pressure, heart rate,However, though used throughout a variety of respirations, temperature, SpO2 and level ofhealth care specialities, a national evidence-based consciousness (AVPU) are taken and recorded on astandard is still not evident within maternity care MEOWS chart and a numerical value calculated.The(Knight et al 2016). Given the physiological changes sum of these figures is calculated to provide us withthat happen in pregnancy, and the ability of a a numerical value that is referred to as the overallpregnant woman’s body to compensate for these, MEOWS score. The value increases as the readingsthe normal parameters of a generic early warning deviate from what would be expected: the higher the Pollard, TPM, March 2017, vol.20, issue 3 23

FUNDAMENTAL SKILLSnumber, the more deviant from ‘normal’ a woman’s to be well oxygenated. It is the main function of theobservations are; in reality, this means the more respiratory system to maintain adequateunwell they are likely to be. Any deviation from oxygenation of the body’s tissues and to excrete thenormal parameters and the subsequent MEOWS waste product: carbon dioxide.score should provide the practitioner with an earlyprompt that the woman is or may become unwell. Normal respiratory rates are around 12-20As a result, this should trigger the midwife to take breaths per minute. For every degree Celsius rise inimmediate action and communicate with the body temperature, the body increases its respirationappropriately trained practitioner. rate by seven breaths per minute (Dougherty and Lister 2006). An increase or rapid rate in respirationsBENEFITS AND LIMITATIONS is known as tachypnoea and is often indicative of an infection. It is one of the first clinical signs to indicateThe benefits of recording basic observations on that a woman’s condition is deteriorating (JevonMEOWS charts are that deteriorations or improvements 2010; Parkes 2011). Yet there is evidence to suggestin a woman’s status to be monitored (National that the recording of respirations is often poorlyClinical Effectiveness committee (NCEC) 2013). documented (National Confidential Enquiry into Patient Outcome and Death (NCEPOD) 2005; Smith With each physiological system having an impact et al 2008). With the ability to provide early signs ofon another, one cannot be taken and recorded in deterioration, it is essential that this observation isisolation. To provide a true picture of the woman’s both performed recorded accurately. Opposing this,overall clinical status, all observations must be respiratory depression (bradypnoea) occurs whenundertaken and recorded. However, the reliability of there is a decrease in respiration rate. This is often aa MEOWS system is dependent on the correct result of the use of opioid analgesics such asmeasurement and recording of maternal diamorphine (Pattinson 2008). With this group ofobservations and subsequent communication with medications commonly being used within thethe appropriate practitioner, should deviations occur maternity care setting, it is paramount that vigilance(Lewis 2007). is paid to the respiration rates of women who have been administered opioids. Correct observations ofIN PRACTICE maternal respirations should assess the rate, depth and pattern of breathing for one minute, followed byFor a MEOWS chart to work effectively the midwife accurate recording of findings to the MEOWS chart.must undertake the following actions: Blood pressure • An accurate measurement of maternal observations Blood pressure is one of the most common observations a midwife will perform and should be • Clear record of the findings on a MEOWS chart done at routine antenatal appointments (National • A calculation of a MEOWS score Institute of Health and Care Excellence [NICE] • Prompt action and clear communication with 2008). Hypertension (high blood pressure) in a pregnant woman can be a warning sign of pre- the appropriate practitioner when the eclampsia. If not acted upon, this can lead to serious observations are outside the normal parameters maternal morbidity and subsequent mortality. NICE • Repetition of observations according to the (2008: 27-28) outlines the correct procedure for clinical status of the woman measuring blood pressure, as outlined below: • Accurate record keeping of care provision • Regular communication with and reassurance • remove tight clothing, ensure arm is relaxed and to the woman and her family supported at heart levelTHE OBSERVATIONS • use cuff of appropriate sizeConsciousness • inflate cuff to 20-30 mmHg above palpatedAn altered neurological status is cause for concern systolic blood pressurein any woman. It is a sign of serious deterioration in • lower column slowly, by 2 mmHg per second orher condition (Brunker and Harris 2015) and oftenoccurs as a result of complications in the respiratory per beator circulatory system. The MEOWS allows for the • read blood pressure to the nearest 2 mmHgeasy recording of this status, using the AVPU score. • measure diastolic blood pressure asIt is a simple tool that assesses how responsive aperson is. As a midwife, any score that indicates a disappearance of sounds (phase V).woman is not alert should prompt immediate actionfor review by the most appropriate practitioner. Heart rate/pulseRespirations The assessment of maternal pulse should include the rate, rhythm and amplitude. The variations inIn order for tissues to function effectively they need these are sensitive to various factors, such as the24 Pollard, TPM, March 2017, vol.20, issue 3

REDUCING MATERNAL MORBIDITY AND MORTALITYeffects of the parasympathetic and sympathetic Brunker C and Harris R (2015).‘How accurate is thenervous system, chemical changes such as hormones AVPU scale in detecting neurological impairmentand electrolytes and finally physical factors, such as when used by general ward nurses? An evaluationexercise and body temperature (Dougherty and study using simulation and a questionnaire’.Lister 2006). Tachycardia is an abnormally fast heart Intensive and Critical Care Nursing, 31(2).rate, usually over 100bpm. According to BMJ BestPractice (2016), it can occur as a normal physiological Dougherty L and Lister S (eds)(2006). The Royalresponse, but it is also linked to the manifestation of Marsden Hospital manual of clinical nursing procedures,an underlying pathology. 6th edition. Oxford: Blackwell Science. Best practice should always be to physically Hands C, Reid E, Meredith P et al (2013).‘Patternspalpate the maternal pulse for one minute, as this will in the recording of vital signs and early warningallow an accurate assessment of maternal heart rate. scores: compliance with a clinical escalation protocol’. BMJ Quality and Safety, 22(9): 719-726.SpO2 Jevon P (2010). ‘How to ensure patientApproximately 98 per cent of the oxygen we inhale observations lead to prompt identification ofis carried in haemoglobin to supply the body’s tachypnoea’. Nursing Times, 106: 2.tissues (Johnson and Taylor 2005). Pulse oximetry isa non-invasive way to measure the arterial oxygen Johnson R and Taylor W (2005). Skills for midwiferysaturation (SpO2) of blood (Rowe and Stevenson practice, 2nd edition. London: Elsevier.2007). Its measurement is used in conjunction with arespiratory assessment. A reading of less than 90 per Knight M, Nair M, Tuffnell D et al (eds) on behalfcent is suggestive of hypoxaemia and, although of MBRRACE-UK (2016). Saving lives, improvingoxygen therapy can help to correct this, the mothers’ care – surveillance of maternal deaths in the UKunderlying aetiology needs to be investigated and 2012-14 and lessons learned to inform maternity carecorrected (Winter et al 2012). from the UK and Ireland confidential enquiries into maternal deaths and morbidity 2009-14, Oxford:Temperature National Perinatal Epidemiology Unit.Normal body temperature can range between 36 and Lewis G (ed) (2007). Saving mother’s lives.37.5 degrees Celsius. A significant rise in body Reviewing maternal deaths to make motherhood safer,temperature (pyrexia) is often indicative of infection. 2003-2005. The seventh report on confidential enquiriesWith confidential enquiries identifying that sepsis is into maternal deaths in the UK, London: CEMACH.yet again a direct cause of maternal death (Knight etal 2016), assessing for pyrexia and appropriately Morgan RJM, Williams F and Wright M (1997).‘Anacting on the onset of SIRS (systemic inflammatory early warning scoring system for detectingresponse syndrome) can help to prevent an infection developing critical illness’. Clinical Intensive Care, (8): 100.developing into sepsis and possible maternalmorbidity or mortality. NCEC (2013). National early warning score, National Clinical Guideline No1, Dublin: Department of Health.CONCLUSION NCEPOD (2005). An acute problem? London:Although the MEOWS systems in the UK are not NCEPOD.standardised, the use of varying MEOWS chartsthroughout maternity services can help midwives to NICE (2008). Antenatal care for uncomplicatedrecognise early deterioration in the clinical status of a pregnancies, London: NICE.childbearing woman, and prompt early intervention.However, the use of MEOWS charts is only reliable Parkes R (2011). ‘Rate of respiration: the forgottenwhen observations are taken and recorded vital sign’. Emergency Nurse, 19(2): 12-18.accurately and acted upon appropriately. Pattinson KTS (2008). ‘Opioids and the control of This article is a reminder that the fundamental respiration’. British Journal of Anaesthesia, 100(6): 747-758.skills of midwifery care provision, when performedcorrectly, have the potential to reduce maternal Rowe N and Stevenson M (2007). ‘Specialistmorbidities and consequential mortalities, monitoring technology and skills for the critically illenhancing outcomes for all. tpm woman’. In: Billington M and Stevenson M (eds). Critical care in childbearing for midwives, Oxford:REFERENCES Blackwell Publishing. BMJ Best Practice (2016). Tachycardia, London: Singh S, McGlennan A, England A et al (2012). ‘ABMJ Best Practice. http://bestpractice.bmj.com/best- validation study of the CEMACH recommendedpractice/monograph/830.html modified early obstetric warning system (MEOWS)’. Journal of The Association of Anaesthetists of Great Britain and Ireland, (67): 12-18. Smith S, Fraser J, Plowright C et al (2008). ‘An audit of nursing observations on ward patients’. Nursing Times, 104(30): 28-29. Winter C, Crofts J, Laxton C et al (2012). PROMPT Course manual, 2nd edition. Cambridge: Cambridge University Press. Pollard, TPM, March 2017, vol.20, issue 3 25

WELLBEING AND RESILIENCE Rebecca Knapp Midwife at Lancashire Teaching Hospitals NHS Foundation TrustWellbeing and resilience1. The resilient midwife“More than education, more than experience, more than training, a person’s level of resiliencewill determine who succeeds and fails.That’s true in the cancer ward, it’s true in the olympicsand it’s true in the boardroom”(Coutu 2002) Midwifery is one of the most emotional and emotive of all the health care professions. In order to be ‘with woman’, we give a part of ourselves to every woman that we care for. Such reciprocity is essential to create a relationship that will maximise a woman’s birth experience (Hunter 2006). This relationship between the woman and midwife is considered to be one of the key elements in job satisfaction, as it emulates the very essence of being with woman. In order to meet the emotional needs of a woman, the emotional involvement of the midwife is needed (Rothschild 2006); thus there is a potential emotional cost associated with care provision. This article is the first in a series of six articles looking at the maintenance and promotion of midwives’ own wellbeing and resilience.The series will cover these topics: the resilient midwife, the mindful midwife, the self-compassionate midwife, the assertive midwife, the acknowledging midwife and the relational midwife. All are aimed at embracing and encouraging a midwife’s own wellbeing and resilience.There are many definitions as to what THE COST OF LACK OF RESILIENCE resilience actually means; put simply, Rutter (1999) describes resilience as a relative In its simplest form, a lack of resilience leads to resistance to adversity. Resilience can also compassion fatigue where the carer is too fatiguedrefer to the elasticity of a material: its ability to be to have the emotional reserves required for the levelstretched and return to its original state. Literature of compassion required for their role (Thomas andsupports the concept that although some people Wilson 2004). All professionals will at some point beappear to be more resilient than others, it is also a exposed to pressures that may lead to compassionlearnt skill that can built upon. It is not a call to just fatigue or secondary traumatic stress, be these‘toughen up’ and be unaffected by the stressors and internal pressures as a result of the role, or externalstrains of a midwife’s working life; in fact it is the pressures outside of work. Relationships withinopposite. It is also important to ensure that resilience midwifery often go beyond empathy and requiredoes not become a coverup for poor organisational high levels of empathic identification (Thomas andand structural processes and situations. Wilson 2004). This puts midwives in a ‘catch-22’ situation – high levels of empathic identification are26 Knapp, TPM, March 2017, vol.20, issue 3

THE RESILIENT MIDWIFEassociated with high levels of stress to the the role extended their resilience by maintenanceprofessional involved, yet relationships of this and integration of both personal and professionalintensity have a central function in creating the identities (Crowther et al 2016; Hunter and Warrencaring relationship required, particularly for 2013). A sense of community aids a collaborativeintrapartum care (Leinweber and Rowe 2010). atmosphere and, with such collaboration, midwives feel more able to discuss and challenge stressors, as Whatever their title, there is a proportion of our well as providing support to all levels of the team –workforce, our colleagues and friends who are again increasing the levels of resilience reported.suffering and feeling unable to carry out their roleto the best of their abilities because their wellbeing CONTINUING RESILIENCEand resilience are reduced or depleted. One of the most noticeable factors within theRESILIENCE AND SUSTAINABILITY literature, was that the midwives who demonstrated continued resilience were the ones who utilisedThe concept of resilience can be viewed their coping strategies on a regular basis, rather thansimultaneously with the concept of workforce just at times of acute stress (McCann et al 2013;sustainability (Hunter and Warren 2014). In a climate Hunter and Warren 2014). Rather than using tools aswhere cost cutting appears to be at the forefront of a last resort, having them within your daily skill setthe National Health Service (NHS), sustainability of actually reduces stress and increases resilience.Thisthe workforce is paramount. It isn’t recruitment but doesn’t negate, however, a skill set that is able to berather the retention of midwives that is posing a called upon in the immediate aftermath of an acuteproblem, particularly recognising that, despite event. Such immediate skills will be covered withinrecord numbers of applicants to the undergraduate the article ‘The acknowledging midwife’ –programme, the attrition rate is highest within the acknowledging the trauma and pressure that thefirst five years after qualification (Crowther et al role of a midwife engenders and including ways to2016). The organisation therefore also needs to minimise any potential negativity.recognise the importance of creating a culture ofresilience within its staff. The University of Central SUSTAINABILITY >>>>Lancashire (UCLan) recognises this need and isincluding wellbeing and mindfulness training Midwifery is not unique within the health carewithin the undergraduate midwifery programme, in professions, inasmuch as there is a heavierorder to fully equip newly qualified midwives for the weighting of female employees than male. Thisworkplace challenges of the NHS. brings with it external pressures that often fall upon women, such as arranging childcare, reflecting thatBUILDING RESILIENCE a large proportion of midwives work part time. Whilst working part time correlates with higherA search of the literature finds common themes levels of working satisfaction and thus resilience, itwhen it comes to building resilience among health is not a viable option for a large proportion ofcare professionals. Primarily, those midwives that midwives. It does, however, demonstrate thedisplay resilience acknowledge that there is a importance of a good work-life balance and anpersonal psychological dimension to their work, ability to separate work and home situations.and a potential cost to themselves (Leinweber andRowe 2010). As well as recognising the Resilience and sustainability go hand in hand.psychological dimension, it means also including Resilience is not a single innate skill; instead it is aknowledge of oneself and the limits to which one process and series of skills that can be learnt andcan be stretched. In beginning to build resilience, it developed over time. In order to continue to provideis important that practitioners realise that there is compassionate, patience-centred care and meet theno set formula: individuality is key. What may build needs of a pregnant or postnatal woman, theresilience for one midwife, can be harmful to midwife needs also to protect herself by becoming aanother. It has been recognised that when a resilient practitioner. The concept of resilience ismidwife attempts to conform to a standard or an best likened to that mentioned at the start – like aexpected ‘type’, she demonstrates a lower level of piece of elastic that springs back to its original formresilience than the midwife who is able to express – there comes a point where the elastic snaps. Inher individuality. order for a midwife to be and develop resilience, she needs to be aware of her limits in order to maintain Literature suggests that midwives who retain a her elasticity to bounce back from repeated stressorspassion or love of midwifery also have higher levels and strains. The remainder of this series will lookof resilience, even where organisational and cultural more in depth at several of the themes identified aspressures create a challenging environment being important to creating, increasing and(Lundman et al 2010; McDonald et al 2011). In maintaining resilience among midwives.research, midwives who integrated their passion for Knapp, TPM, March 2017, vol.20, issue 3 27

WELLBEING AND RESILIENCE NEXT TIME experiences of workplace resilience’. Midwifery, 30: 926-934. The next major topic in this series is the concept of self-care: that is looking after one’s own needs. This Leinweber J and Rowe HJ (2010). ‘The costs of will be explored in the next article; however in short, ‘being with woman’: secondary traumatic stress in it refers to the ability of a midwife to recognise her midwifery’. Midwifery, 26(1): 76-87. own needs, and respond to them sooner rather than later. It also covers the concept of self protection, Lundman B, Alex L, Jansen E et al (2010). ‘Inner whereby the midwife is aware of her limitations and strength: a theoretical analysis of salutogenic is able to clarify not only the expectations of the concepts’. International Journal of Nursing Studies, 47: organisation, but also the expectations she places 251-260. upon herself. The concept of self-care along with practical examples will be covered within the article McCann CM, Beddoe E, McCormick K et al ‘The self compassionate midwife’. tpm (2013). ‘Resilience in the health professions: a review of recent literature’. International Journal of Wellbeing, REFERENCES 3: 60-81. Coutu DL (2002). ‘How resilience works’. Harvard McDonald G, Jackson D, Wilkes L et al (2011). ‘A Business Review, 80(5): 46-55. work based educational intervention to support the development of personal resilience in nurses and Crowther S, Hunter B, McAra-Cooper J et al midwives’. Nurse Education Today, 32: 378-384. (2016). ‘Sustainability and resilience in midwifery: a discussion paper’. Midwifery, 40: 40-48. Rothschild B (2006). Help for the helpers – the psychophysiology of compassion fatigue and vicarious Hunter B (2006). ‘The importance of reciprocity in trauma, New York: WW Norton and Company. relationships between community-based midwives and mothers’. Midwifery, 22(4): 308-322. Rutter M (1999). ‘Resilience concepts and findings: implications for family therapy’. Journal of Hunter B and Warren L (2013). Investigating Family Therapy, 21: 119-144. resilience in midwifery: final report, Cardiff: Cardiff University. Thomas R and Wilson J (2004). ‘Issues and controversies in the understanding and diagnosis of Hunter B and Warren L (2014). ‘Midwives’ compassion fatigue, vicarious traumatisation and secondary traumatic stress disorder’. International Journal of Emergency Mental Health, 6: 81-92. 2XUWK<HDU0$0$&RQIHUHQFHUHWXUQVEHWWHUWKDQHYHULQ:HOHWWKHFRPPRQWKHPHRIPDWHUQLW\UXQDVRXUELQGLQJWKUHDGWKURXJKRXUFRQIHUHQFH:HNQRZWKDW0DPDZLOORQFHDJDLQEHDIDQWDVWLFLQVSLUDWLRQDODQGXSOLIWLQJH[SHULHQFHIRUHYHU\GHOHJDWHDQH[SHULHQFHWKDWZLOOVHQG\RXDZD\IHHOLQJUHFKDUJHGDQGUHLQYLJRUDWHG<RXUH[SHULHQFHORRNVOLNHLQVSLULQJGD\VDW0$0$&RQIHUHQFH:RUOGFODVVVSHDNHUV_LQFOXGLQJ,QD0D\6KHHQD%\URP PDQ\PRUH 'DWHVWK WK$SULODW WKH 3ULQFHVV5R\DO6XLWH,QWHUDFWLYHVHVVLRQV $\U5DFHFRXUVH$\UVKLUH 6FRWODQG'HOHJDWHEDJV %RRNDQGUHFHLYH\RXUH[FOXVLYH5HIUHVKPHQWV-RQDUULYDOPLGPRUQLQJ DIWHUQRRQ 730GLVFRXQW_HPDLOWKHWHDP 9LVLWZZZPDPD-FRQIHUHQFHFRXNFRXUVHKRWEXIIHWOXQFKERWKGD\V$QH[SHULHQFHQRWWRIRUJHW RIILFH#ELUWKVSDUNVFRXN0DNHWKLV\RXU\HDUIRU0$0$&RQIHUHQFH28 Knapp, TPM, March 2017, vol.20, issue 3

MIDWIFERY PRACTICE DURING BIRTH: RITUAL COMPANIONSHIP Alys Einion Associate Professor of Midwifery at Swansea UniversityResearch unwrappedMidwifery practice during birth:ritual companionshipReed R, Rowe J and Barnes M (2016)Women and Birth, 29(3): 269-278 Research unwrapped is a popular series to help readers make sense of published research by undertaking a detailed appraisal of an article in a careful and considered manner. In doing so we can advance our knowledge and understanding of a research topic and apply it to our practice.This process is designed to assess the usefulness of the evidence in terms of decision making and application to practice. The research being discussed here is a qualitative study focusing on perhaps the most fundamental dimension and function of midwifery practice: that of the impact of a midwife on a woman’s birth experience.As midwives it is always good to take the and progress; and how midwifery practice time to revisit the ‘basics’, which for me influences women’s experiences of birth”(Reed et al means revisiting the fundamental purpose 2016: 270). This is skilful use of language in setting and philosophy of my midwifery practice. the context of the research, as it uses positiveI chose this article to review because it looks at language that is professional but also implies aperhaps the most well-known and core aspect of woman-centred approach.midwifery practice: that of the provision of expertsupport to women in labour and birth. It uses positive language that is professional but also implies aBACKGROUND woman-centred approachThis article begins by re-stating what many of us The authors also refer to other key concepts that >>>>already know: that midwifery supports women are fundamental to midwifery practice, includingthrough the ‘profound experience’ of labour and women’s sense of control, and their individual needsbirth (Reed et al 2016: 270). By doing so, the authors and choices, alongside confidence and satisfaction,set the scene strongly for the reader by summarising continuing on to summarise issues around thethe role of the midwife during this part of the midwife-mother relationship and the concept of thechildbearing and parenting journey. This is a very woman as expert in her own birth.useful beginning as it not only reminds us of ourcore values as midwives, but emphasises importantpractice issues that grow from those values,including the need to “understand how midwivespromote physiological birth and monitor wellbeing Einion, TPM, March 2017, vol.20, issue 3 29

RESEARCH UNWRAPPED After effectively setting out these core concepts, how and why. Reed et al used purposive sampling, the authors then briefly review research relating to which is appropriate for this kind of study, and also midwifery care during birth, citing a range of clearly define what purposive sampling is. This aids different studies which they use to show the reliability and transparency further. Their sample humanistic and holistic nature of the birth includes midwives from across a range of midwifery experience, and introduce some issues midwives settings, which suggests that the authors were face in balancing this aspect of care with the more attempting to gain as wide and diverse a sample as ‘clinical’ tasks they are expected to carry out. possible, and the focus is on women with a “physiological, uncomplicated birth in a range of The aim of the research is very clearly stated:“to settings” (Reed et al 2016: 271). It is good to see the explore midwifery practice during an authors use this terminology rather than the uncomplicated, physiological birth … [capturing] restrictive and reductive term of ‘normal’ birth. midwifery practice from both the perspective of midwives, and from women experiencing their The process of recruitment and the inclusion practice”(Reed et al 2016: 270).This paper reports on criteria for the women are also clear. Reed et al the midwives’ practice element of this study. describe reaching ‘theoretical saturation’ which is derived from the discipline of Grounded Theory and The participant was asked to tell the refers to a point where no new information is emerging from the data, regardless of continuedstory of their experience of a birth, with data collection. Whilst this is a common concept now in qualitative methods, it can also be argued that the no specific questions asked Grounded Theory method is distinct and specific to itself, and abstracting elements of that process may METHODOLOGY not be appropriate (Glaser and Holton 2007). This is a qualitative research project, using a Data were collected via a single, one-to-one narrative inquiry methodology. Qualitative research interview in which the participant was asked to tell is particularly useful for midwifery because it the story of their experience of a birth, with no focuses on how people live, and how they make specific questions asked, which should encourage sense of the world (Holloway and Wheeler 2010), both women and midwives to tell the stories from which aligns with woman-centred practice. In line their own perspective. However, more transparency with good research reporting, the authors identify about what prompting or probing questions might that the study was part of a PhD, and that the have been used would have been useful here. research was carried out by a single researcher. The authors clearly define narrative research and the The data management and analysis process is relationship to the prevalence of story as a means of very transparent, which would aid replicability, and communication within midwifery and childbearing. the authors refer to reflexivity, which is fundamental This reflects a growing awareness within midwifery in carrying out this kind of social research (Cooper practice and indeed within social research, of the 2008). Reflexivity is about acknowledging the importance, power and presence of storytelling influence of the researcher and their own (Elliot 2005). The exploration and definitions of perceptions and knowledge on the research process. narrative research here are good, as this promotes The authors also state that they gained ethical transparency and suggests auditability, which approval and indicate good ethical practices around means that the process of arriving at the research consent and confidentiality. All of these factors results can be clearly understood and evaluated by enhance the strength of this study as a source of outsiders. This enhances its usefulness as evidence information for midwifery practice. for informing our midwifery practice. FINDINGS Reed et al are clear about their analytical approach, which involved using a ‘paradigmatic The authors discuss the nature of the interactions process’ that shows not just themes that emerge from between midwives and mothers, describing them as the data, but relationships between themes which, it ‘complex’ and referring to the theory of ‘rites of could be argued, adds extra meaning to the data. passage’. They link this to rituals that surround experiences or activities, and relate this to The recruitment and sampling frame is also commonly performed actions or behaviours within clearly described, another key aspect of good quality the birth room.They identify two types of midwifery research. It is vital to understand who was recruited, practice – ‘rites of passage’ and ‘rites of protection’ – and relate these to the institution in which practice takes place, which includes both the profession and body of knowledge of midwifery and the culture, policies, practices and location of the physical place30 Einion, TPM, March 2017, vol.20, issue 3

MIDWIFERY PRACTICE DURING BIRTH: RITUAL COMPANIONSHIPof birth. approach to care. This study is a powerful reminder There is some very important information here of exactly what a midwife is supposed to be during birth – an expert friend – and questions the rites ofabout the context in which midwifery practice takes protection that we carry out because birth is stillplace, and this, in particular, sheds a very interesting viewed as inherently risky. Reed et al highlight theand useful light on how midwives are challenged fact that many of these practices do not have a soundwhile providing this fundamental aspect of care to evidence base and that routine practices such aswomen. They ‘manage distractions’ (Reed et al 2016: vaginal examinations, and the timing of fetal heart272) and try to promote privacy and an appropriate auscultations are all being questioned as webirth space for clients, but this is seen as much more challenge current conceptualisations of labourdifficult within the hospital environment.They carry progress.out their clinical function of monitoring maternalcondition and the progress of labour but try to do Midwives are ‘ritual companions’this in ways that avoid negative impacts on the who accompany women through the hugelywoman’s experience. The midwives in the study significant rite of passage that is birthemphasise the value of observation as a means ofassessing women, and also the use of intuition, This study also restates what many midwiveshighlighting a dissonance between the value of already know: that there is a conflict between theintuitive knowing for midwives and the recognition ideologies of woman-centred midwifery practice andof this knowledge by the institution of birth. One the ideologies of the institutions within whichpowerful finding here is that midwives could women give birth. Thus, the paper serves to remindpractise this intuitive way of knowing in a home birth us to question routine practices and revisit our ownbut know that this would not be allowed in a hospital ideology of birth. It also recognises and validates thesetting, which highlights just how much impact the struggle that midwives face daily when juggling theplace of birth has on the way midwives practise. competing demands of their profession, their employer, their clients and their own convictions and Midwives in this study were seen to “reflect beliefs about their role and the ways in which theywomen’s inner wisdom back to them” and to feel they should practise. tpmreinforce women’s belief and trust in their bodiesand their own ability to birth (Reed et al 2016: 273). REFERENCESClinical assessments were viewed as rites ofprotection, and as routinised actions carried out at Cooper G (2008). 'Conceptualising social life'. In:particular time intervals, and these activities were Gilbert N (ed). Researching social life, London: Sage.viewed as disrupting women and reinforcingexternal wisdom, which seems to take the power and Elliot J (2005). Using narrative in social research.focus away from the woman and her personal London: Sage.experience of birth (Reed et al 2016). Midwivescarried out some of these practices in a defensive Glaser BG and Holton J (2007). 'Remodellingmanner. Midwives also highlight their own sense of grounded theory'. Historical Social Research:being scrutinised and working under surveillance Supplement, 19: 47-68.and suggest that they were under pressure toconform to obstetric interventions based on ‘hospital Holloway I and Wheeler S (2010). Qualitativerules and time frames’ which went against their own research in nursing and healthcare, 3rd edition. Oxford:knowledge and confidence in the birth process (Reed John Wiley and Sons.et al 2016: 275). Reed R, Rowe J and Barnes M (2016). 'MidwiferyWHAT WE CAN LEARN FROM THIS practice during birth: ritual companionship'. Women and Birth, 29: 269-278.The key message from this valuable and importantstudy is that midwives are ‘ritual companions’ whoaccompany women through the hugely significantrite of passage that is birth and help to foster apositive birth environment. Midwives share and honour the power andautonomy of their clients, assisting and guidingrather than directing, controlling or even instructingwomen. This study shows how the ritualistic natureof routine midwifery practices can impact onwomen’s birth experiences, and that these routinisedpractices are often at odds with a woman-centred Einion, TPM, March 2017, vol.20, issue 3 31

REVIEWSRosemary Proactive support of laborMander The challenge of normal childbirth (2nd edition)Emeritus Professor of Paul Reuwer, Hein Bruinse and Arie FranxMidwifery, University of 2015, Cambridge University Press, 203pp, £44.99, pbk, ISBN 978 1 107 42658 0Edinburgh Glancing at the within; some of these messages are powerful – support O’Driscoll’s active management of extensive contents, challenging accepted norms. labour and attempts to clarify some of the this book develops misunderstandings and controversy the from identification of An outline of how maternity services are authors feel distort the benefits. An emphasis ‘medical excesses’ in organised in other countries, using the medical on the recognition and correction of normal childbirth, model, should serve as a warning to UK birth dysfunctional labour is at its core. However, I progressing through centres, as this could become our future. suspect not all content will sit well with UK biological/ Reasons for obstetric interventions and their birth centre/low-risk midwives, but the physiological chapters consequences are discussed, and where promotion of personal attention and discussion and many other women-centred rather than provider-centred on supportive care will. Likewise the strategy to interesting concepts, care is recommended to enhance the birth prevent a long labour (chapter 15) by ensuringending with organisational reforms that the experience for women, seems to be at the heart an upper boundary of 12 hours be applied isauthors feel enhance proactive support and of this book. likely to generate debate here in the UK.improve women’s satisfaction with birth. UK readers will need to see beyond the The book questions the traditional I enjoyed reading the book and found itdescription of content applying to other areas physiological definitions of labour stages and stimulating. I agree with the authors’ targetof the globe and connect with the messages explores the validity of Friedman’s curve, the readership and would certainly recommend it basis for many UK guidelines used in labour to UK midwives/student midwives. wards/birth centres. Chapter 12 appears toJoy James Why the politics of breastfeeding matterSenior Lecturer inMidwifery, Gabrielle PalmerUniversity of South Wales 2016, Pinter and Martin Ltd, 144pp, £7.99, pbk, ISBN 978 1 78066525 2 This is one of a series generally uses humour to good effect. What professionals and others (www.pinter of pocket-sized books emerges is that breastfeeding, like so many andmartin.com/why-it-matters.html). Whilst I that seek to present aspects of childbearing and childrearing, is a would ordinarily be more than happy with evidence-based political matter and that political action is Palmer’s academic style of writing, providing aspects of parenting. necessary in order to ensure that mothers both references and footnotes, I am not certain Gabrielle Palmer’s throughout the world are able to feed their that this style would appeal to ‘new parents’ engaging style of babies appropriately and safely. who are endeavouring to satisfy a small baby. writing draws the reader in to her Unfortunately, though, this book raises as The transatlantic origins of the writing are discussion of the many questions as it answers. As with her barely noticeable in the text. The dollar signs issues, which provide other publications, the evidence base of much on the front cover, however, may serve to deter a veritable banquet of of Palmer’s writing is clearly apparent, but those who are wary that cultural differencesfood for thought. As with her other books, she here the pervasive historical underpinning is may diminish the relevance of the message.demonstrates the relevance of research less well supported.evidence to the practicalities of infant feeding. Palmer has authored a little book that willThrough her attention to a multiplicity of While the intended audience is not actually be of value to students and, possibly,recent and current global issues, Palmer’s mentioned in the book itself, the midwives. I am less convinced, though, thatargument is consistent, persuasive and accompanying press release states that it is ‘for they will be able to recommend it to their new parents’. The website extends the clients and their families. intended audience to include health32 Reviews, TPM, March 2017, vol.20, issue 3

Upcoming Events at the RCOGRisk Management and Medico-Legal Issuesin Women’s Health Care25-26 May 2017, RCOG LondonThis meeting provides a forum for learning the basics of healthcare risk management, learning from patientsafety incidents and sharing good practice.This event is the only national conference on risk managementin obstetrics and gynaecology.• Gain familiarity with theoretical foundations and practical problems relating to risk management• Acquire knowledge about some UK laws pertinent to clinical practice• Receive tips for safe clinical practiceManagement of the Labour Ward20-23 June 2017, RCOG London%XXIRHXLMWQIIXMRKXSPIEVREFSYXGPMRMGEPKSZIVRERGIVMWOQEREKIQIRX'278ERH247%WTIGM½GEPP]MRrelation to obstetrics and learn how to set up skills and drills training in your own unit.• Understand the importance of promoting and maintaining normality in childbirth• +EMRGSR½HIRGIMRHMWGYWWMRKFMVXLSYXGSQIW[MXL[SQIRERHXLIMVTEVXRIVW• Learn how to better recognise the medically unwell, pregnant woman• Receive up-to-date knowledge in a range of practical obstetric skillsSpecial rate for midwives –visit rcog.org.uk/eventsRoyal College of Obstetricians and Gynaecologists27 Sussex Place, Regent’s Park, London, NW1 4RGweb rcog.org.uk/eventstel +44 20 7772 6245email [email protected] © Royal College of Obstetricians and Gynaecologists 2017 | Registered Charity No. 213280

DIARYMarch training. PROMPT 3 Train the bereavement-care- Bristol, £495 for the over-Sands, £400 (£1354 March professionals@uk- trainers. London. Info: training-workshop-liv six days. Info: per day). Contact: LizBeing the change you sands.org / 0203 598 rcog.org.uk/events erpool-492017-tickets- www.wellmother.org/ Roberts healthconwant to see in 1955 Info: 0207 772 6245 / 27624740342 midwives- [email protected] services. www.eventbrite. [email protected] maternity/course-shia5th Midwifery co.uk/e/sands- 7 September PROMPT tsu-maternity-care 3 Octoberconference in bereavement-care-trai 10 June 3 Plus. London. Info: 26 September Bereavement careassociation with ning-workshop-leeds- PROMPT 3 Plus. rcog.org.uk/events Maternity, midwifery training workshopsMaidstone and 442017-tickets-276256 London. Info: 0207 772 6245 / and baby conference. for healthcareTunbridge Wells local 29000 rcog.org.uk/events [email protected] Manchester, free of professionals.RCM. Maidstone, 0207 772 6245 / charge. Info: Southampton, £85 /£40/£25. Contact: 5 April [email protected] 8 September PROMPT www.maternityandmi £65. Contact:Mtw-tr.wandc Maternity, midwifery 3 Train the trainers. dwifery.co.uk 0207 training.professionalsdivisionalsecretary@n and baby conference. 18-22 June London. Info: 324 4330 / 07984 @uk-sands.org / 0203hs.net Bristol, free of charge. 31st ICM triennial rcog.org.uk/events 188166 / karen. 598 1955 Info: Info: congress, Toronto 0207 772 6245 / stewart@neilstewart www.event16 March www.maternityandmi Canada. Info: [email protected] associates.co.uk brite.co.uk/e/sands-PROMPT 3 Plus. dwifery.co.uk Contact: http://internationalm bereavement-care-traiLondon. Info: 0207 324 4330 / idwives.org/events/ 21-22 September Final October ning-workshop-rcog.org.uk/events 07984 188166 / karen. two days of a six-day 2-4 October Normal southampton-3102017Contact: 0207 772 stewart@neilstewarta 22-23 June course: Shiatsu for labour and birth -tickets-276281645846245 / events@ ssociates.co.uk Middle two days of a maternity care. conference. Grange-rcog.org.uk six-day course: Shiatsu 7-8 April for maternity care. PROFESSIONAL DEVELOPMENT16-17 March LCGB 2017 conference: Bristol, £495 for theFirst two days of a six- 21st century six days. Further dates CENTRE FORday course: Shiatsu for breastfeeding. are 21-22 September. ULTRASOUND STUDIESmaternity care. Swanwick. Info: www.wellmother.org/Bristol, £495 (early www.lcgb.org. midwives- Basic Gynaecology and Early Pregnancybird £465 by 15 Contact: maternity/course-shia Ultrasound CourseJanuary) for the six [email protected] tsu-maternity-caredays – or £180 (£160 CASE Accreditedearly bird) for the first 28-29 April 30 Junetwo days. Further Mama conference, Maternity, midwifery This programme has been designed, piloted anddates are 22-23 June Ayr. Info: www.mama- and baby conference. developed to train nurses, midwives and obstetricians inand 21-22 September. conference.co.uk/ Birmingham, free ofInfo: charge. Info: the safe use of ultrasound in the diagnosis of earlywww.wellmother.org/ May www.maternityandmi pregnancy related problems.midwives- 4 May Bereavement dwifery.co.uk Contact:maternity/course-shia care training 0207 324 4330 / The programme is particularly aimed at Sexual andtsu-maternity-care workshops for 07984 188166 / Reproductive Health Clinics and Early Pregnancy healthcare karen.stewart@neilste Assessment Unit (EPAU) sta who wish to add diagnostic17 March professionals. wartassociates.co.ukPROMPT 3 Train the Liverpool, £85 / £65. ultrasound to their clinical skills.trainers. London. Info: Contact: Septemberrcog.org.uk/events training.professionals 4 September Stage 1: Seminar 9th - 10th May 2017 £750Contact: 0207 772 @uk-sands.org / 0203 Bereavement care6245 / events@ 598 1955 Info: training workshops AECC is an Associate College of Bournemouth Universityrcog.org.uk www.event for healthcare brite.co.uk/e/sands- professionals. For more information visit: www.cusultrasound.co.uk orApril bereavement-care-trai Birmingham, £85 / contact Kerry Budd: T: 01202 436506 E: [email protected] April Bereavement ning-workshop- £65. Contact:care training liverpool-452017-ticket training.professionalsworkshops for s-27628001095 @uk-sands.org / 0203healthcare 598 1955 Info:professionals. Leeds, June www.event£85 / £65. Contact: 9 June brite.co.uk/e/sands-34 TPM, March 2017, vol.20, issue 3

Supporting your SuccessSkills for Midwifery Practicez Presents over 150 essential z Ideal for use as a basis for teaching midwifery procedures in an easy- and assessment to-read, quick reference format z Explains the underlying physiologyz Refers to the latest evidence and associated with pregnancy and research, including current national childbirth and international guidelines )RURȆWKLVWLWOHJRWRwww.elsevierhealth.co.uk and enter code PM20www.elsevierhealth.co.uk

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