'Hands on', 'hands off' or 'hands poised'? Exploring intrapartum midwifery decision making through ethnographic research.

ISSUE: Injury to the perineal tissues during childbirth is a frequent occurrence with most women likely to experience perineal injury during a first birth which, in some cases, can lead to significant long-term morbidity. The techniques used to minimise perineal injury are frequently termed 'hands on' and 'hands poised' or 'hands off'. These terms are often undefined and used inconsistently in the literature, making it difficult to identify the best available evidence to inform midwifery practice. AIM: This study aimed to answer the research questions: What do midwives do to minimise perineal injury during birth and what influences their decision-making? METHODS: An ethnographic study was undertaken during 2016 in a maternity unit in the southeast of England. Data were collected through participant-observation, ethnographic and semi-structured interviews and analysed using thematic analysis, informed by the pedagogic theory of threshold concepts. FINDINGS: 31 midwives participated in the study. Evidence-based decision-making to minimise perineal injury during birth was identified as a complex concept. Within the context of threshold concept theory, three main themes were identified that contributed to the complexity: troublesome language, troublesome knowledge, and troublesome environments. CONCLUSIONS: Midwifery decision-making in the context of minimising perineal injury during birth is more varied and conceptually complex than has been previously described. Identification of the various aspects of troublesomeness in this context suggests that this element of practice is a midwifery threshold concept. Addressing this within midwifery curricula and practice education to enable evidence-based decision-making is important.

Perinatal/neonatal palliative care: Effecting improved knowledge and multi-professional practice of midwifery and children's nursing students through an inter-professional education initiative.

This paper presents a study that examines the potential value of a new and innovative inter-professional education (IPE) experience for final year midwifery and children's nursing students focused on improving awareness of end-of-life care for infants in conjunction with the support of their families. The study uses an action research approach to examine midwifery and children's nursing student experiences of an IPE initiative in developing knowledge regarding perinatal/neonatal palliative care. The setting is a Higher Education Institute in the South of England that included final year midwifery students (n = 39) and children's nursing students (n = 34) taking part in the study. Qualitative and quantitative data indicated that the IPE intervention had proven worth in developing knowledge and confidence in the students as both student groupings felt they lacked knowledge and confidence about perinatal/neonatal palliative care before attending the study day. Students felt that learning with, from and about the other profession represented was important in generating their knowledge. Educators should explore innovative ways to enable the further development of the fledgling speciality of perinatal/neonatal palliative care through education on an interprofessional platform.

Experiences of student midwives learning and working abroad in Europe: The value of an Erasmus undergraduate midwifery education programme.

BACKGROUND: universities in the United Kingdom are being challenged to modify policies and curricula that reflect the changing global reality through internationalisation. An aspect of internationalisation is study abroad which the European Commission Erasmus exchange programme is just one means of addressing this. OBJECTIVE: to explore the experiences of student midwives who are engaged in the Erasmus exchange programme and the effect it has on their learning and working in an international context. DESIGN: approval for the small phenomenological cohort study was obtained from two participating universities: the University of Malta and University of Nottingham. Data were collected from 13 student midwives from a total of five cohorts in the form of diaries to explore their experiences of learning and working in another country. Thematic analysis supported by Computer-Assisted Qualitative Data Analysis Software was used to identify five recurrent themes emerging from the data: the findings of which have served further in developing this programme. FINDINGS: students valued the opportunity of undertaking study and midwifery practice in another culture and healthcare system, extending their knowledge and development of clinical competence and confidence. For some, this was the first time outside of their home country and adaptation to a new environment took time. Support from their contemporaries, lecturers and midwife mentors however, was overwhelmingly positive, enabling the students to feel 'part of the local university / midwifery team' By the end of the programme, the students recognised that they had become more independent and felt empowered to facilitate developments in practice when they returned home. IMPLICATIONS FOR EDUCATION / PRACTICE: this innovative development embracing internationalisation within the curricula has the potential to increase students' employability and further study within Europe and beyond. It can be used as a vehicle to share best practice within an international context, ultimately making a difference to the quality of care childbearing women, their babies and families experience worldwide.

Hands-poised technique: The future technique for perineal management of second stage of labour? A modified systematic literature review.

BACKGROUND: vaginal birth is often accompanied with perineal trauma that affects postpartum morbidity. There are many techniques for protecting the perineum from injury during childbirth. The Hands-On or Hands Poised (HOOP) study (McCandlish et al., 1998) was the first trial that compared different techniques of perineal protection during the second stage of labour with very little research subsequently being undertaken. OBJECTIVES: to systematically review all available literature that compares the hands-on and hands-poised techniques of perineal management during the second stage of labour. METHODS: using the principles of a modified systematic literature review, quantitative, comparative and primary research studies were selected. These were assessed for quality using the Critical Appraisal Skills Programme (CASP) framework including a data extraction form. The results were reported narratively. MAIN RESULTS: five studies were included and outlined the importance of both techniques. The hands-poised technique appeared to cause less perineal trauma and reduced rates of episiotomy. The hands-on technique resulted in increased perineal pain after birth and higher rates of postpartum haemorrhage. CONCLUSION: as the five studies selected for this review have widely differing variables, comparisons that have been drawn must be viewed with caution. Evidence would suggest that the hands-poised technique is a safe and recommended technique for perineal management and discussions of such a technique should be included in all midwifery education and training programmes. The challenge for midwives is how to support women in making informed choices about perineal management during childbirth. Until there is conclusive evidence, the choice of the hands-on or hands-poised technique will ultimately be determined by the clinical judgment of the individual midwife at the time of birth. Further research is recommended. Thorough conclusions could significantly impact on reducing postpartum morbidity and improving women's sexual health and well-being in the long term, throughout the world.

Developing midwifery practice through work-based learning: an exploratory study.

AIM: To explore what effect the introduction of a Work-Based Learning Module undertaken by midwives in a range of maternity settings has had on their personal professional development, as well as the impact on developing local maternity and neonatal care provision. METHODOLOGY: A case study approach was used consisting of mixed methods. Quantitative data were collected through questionnaires from midwives and their Clinical Supervisors at the end of the module, with a survey questionnaire to each midwifery manager, six months following the implementation of the midwives' project in practice. Qualitative data were collected by focus groups at six different work place locations, with health professionals who had experienced the midwives' projects within the workplace. Quantitative data were manually analysed whereas content analysis was used to identify recurrent themes from the qualitative data, with the support of Computer Assisted Qualitative Data Analysis Software. The University of Nottingham granted ethical approval for the study. PARTICIPANTS AND SETTING: Twelve midwives who undertook the work-based module, their respective Clinical Supervisors (n = 12), their employers/managers (n = 12) and health professionals (n = 28) within six individual National Health Service Trusts in the East Midlands of the United Kingdom took part in the study. FINDINGS: The work-based learning module not only led to the personal and professional development of the midwife, but also to improving multi-professional collaboration and the consequential development of maternity services within the local Trusts. The value of leading change by completing an innovative and tangible work-based project through a flexible mode of study strengthened the midwives' clinical credibility among colleagues and employers and supports the philosophy of inter-professional learning and working. IMPLICATIONS FOR PRACTICE: This novel Work Based approach to learning has the potential to further develop the provision of post-registration education for midwives and other health professionals, as it helps to bridge the theory-practice gap. Learning in the workplace is efficient and cost effective to employee and employer and serves in increasing the link between higher education and the workplace. Furthermore, as the principles of work-based learning could be transferred to other contexts outside of the United Kingdom, such an approach has the potential to directly influence the development of global midwifery education and maternity services and ultimately benefit mothers, their babies and families throughout the world.

The effect of the developing role of the maternity support worker on the professional accountability of the midwife.

The recent rise in the number of maternity support workers (MSWs) in the United Kingdom (UK) has been welcomed by midwifery managers and supported by social policy surrounding improvements in maternity care. The training and role of the MSW varies considerably. Whilst most training is undertaken through clinical practice, more recent advances in the preparation of MSWs have resulted in them not only being trained to National Vocational Qualification (NVQ) Level 3, but also to foundation certificate or degree level. Consequently some MSWs are performing tasks that would traditionally be undertaken by a midwife, potentially leading to the erosion of the midwife's role in the future. From current evidence, midwives are not fully aware of how the developing role of MSWs may affect their own professional accountability. This paper therefore aims to challenge midwives into reconsidering how MSWs may be effectively incorporated into the midwifery team such that the quality of care is not compromised and the midwife's professional accountability is never put at risk.