'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.

Assessing mental health during pregnancy: An exploratory qualitative study of midwives' perceptions.

BACKGROUND: Mental health disorders are estimated to affect between 10% and 20% of women who access maternity services and can be defined as a public health issue due to the potential consequences for women, children and families. Detecting problems early in pregnancy can significantly improve outcomes for women and their families. However, mental health problems are not being consistently identified in routine midwifery practice and little is known from current literature about midwives' practice in relation to current national guidelines or the impact models of care have on assessing maternal mental health. OBJECTIVE: To identify midwives' views about barriers and facilitators to screening for mental health in pregnancy using current UK guidelines. DESIGN: Nine community midwives from a single district general hospital in the south of England were recruited to take part in focus groups. Thematic analysis was used to extract key themes from the data. FINDINGS: Three key themes were identified from the focus groups and included system factors, social factors and trust. Barriers and facilitators to screening maternal mental health were associated with the initial 'booking' appointment' and differences in models of care. Barriers to screening were defined as high workload, poor continuity, and a lack of trust between women and midwives. CONCLUSIONS: This study highlights key barriers and facilitators associated with mental health screening during pregnancy, including issues of trust and uncertainty about women's willingness to disclose mental health conditions. Further research is required to evaluate the relationship between women and midwives in contemporary practice and the influence this may have on maternal mental health.

Can common characteristics be identified as predictors for seasonal influenza vaccine uptake in pregnancy? A retrospective cohort study from a South London Hospital.

BACKGROUND: Complications due to influenza are contributory factors for maternal deaths in the United Kingdom (UK). Less than half of all pregnant women in the UK receive the influenza vaccination. Increasing immunisation rates for seasonal influenza in pregnant women must remain a public health priority. METHOD: A retrospective cohort study was undertaken, utilising the electronic health record of 4817 women who had given birth at a South London NHS Hospital from 1st January-31st December 2015. The data were then analysed to determine if there were any common characteristics of the women who received or did not receive the seasonal influenza vaccination. RESULTS: It was found that ethnic origin, age at booking, planned pregnancy, parity, and booking in the first trimester were significant predictors for receiving the seasonal influenza vaccination. Index of Multiple Deprivation Deciles, speaking English without a translator, and booking season were not clinically or statistically significant predictors for receiving the seasonal influenza vaccination. CONCLUSIONS: There are common characteristics that are associated with receiving and not receiving the seasonal influenza vaccination for women who gave birth in South London during 2015. These results could be useful to antenatal health professionals working in similarly diverse areas, and to influence the public health agenda. This research ascertains which women in the cohort did not receive the vaccination; future research should explore the factors which affect vaccine uptake and potential strategies to improve vaccination rates.