Assessment of the psychometric properties of the Italian version of the perceptions of empowerment in midwifery practice scale-revised (PEMS-R-IT) in midwives.

INTRODUCTION: A higher degree of midwives' empowerment is associated with greater job satisfaction and better midwifery care outcomes for women and their families. Empowered midwives are able to better empower women who in turn have a positive influence on the midwives' empowerment. The aim of this study was the translation, cultural adaptation, and validation of the perceptions of empowerment in midwifery scale-revised (PEMS-R) in a group of Italian midwives. METHODS: The World Health Organization (WHO) method was adopted to achieve the PEMS-R Italian version. This process involved five steps: 1) forward translation, 2) expert panel translation, 3) back-translation, 4) pre-testing and cognitive interviewing, and 5) final version. The test's internal consistency and validity were assessed by following international guidelines. Internal consistency was examined through Cronbach's alpha (α) coefficient. RESULTS: The PEMS-R-IT was administered to 147 Italian midwives from northern Italy. Factor analysis of the 19 items, extracted 4 factors that explained 74.96% of the variance. The Student's t-test for independent samples was used to identify a possible correlation between a higher/lower perception of empowerment and: 1) the education level, and 2) the years of experience of recruited midwives. No statistically significant differences were obtained in either case. The PEMS-R-IT was found to have a good internal consistency for each of its 4 subscales. CONCLUSIONS: The PEMS-R-IT is a valid and reliable tool, useful to assess midwives' empowerment. It can be used in both clinical practice and research in order to investigate the level of empowerment of midwives within the Italian national context.

Management of the second stage of labour in women with epidural analgesia: A qualitative study exploring Midwives' experiences in Northern Italy.

OBJECTIVE: To explore midwives' experiences of the management of the second stage of labour in women with epidural analgesia. DESIGN: Descriptive qualitative study using semi-structured face-to-face interviews. PARTICIPANTS: Purposive sample of twelve midwives working in three Obstetric Units. Among them six were senior midwives with more than five years' experience on labour ward and six were junior midwives with less than five years' experience on labour ward. FINDINGS: The findings included four themes: a) timing of second stage of labour and maternal pushing; b) maternal positions and mobility; c) perspectives on epidural boluses; d) midwifery presence and support. The time 'allowed' by midwives for the passive phase of the second stage of labour ranged from zero to two hours, with some of them avoiding vaginal examinations to delay the recorded starting time of active pushing. The semi-sitting and the lithotomy positions were the most used respectively in labour and at birth. Some midwives encouraged the kneeling position or the lateral position. Regarding the management of the epidural bolus during the second stage of labour, the interviewees' opinions were divided between favourable and unfavourable to the administration of analgesic boluses after the full cervical dilatation. Midwives reported their experiences of providing different care to women with epidural analgesia when compared to women without epidural, mainly due to a more medicalised approach and the midwives' sense of 'usefulness' when caring for women not experiencing labour pain. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: To our knowledge, this was the first study on this topic conducted in an Italian setting. Despite the consistent body of evidence on the effects of epidural analgesia in the second stage on birth outcomes, the lack of clear guidelines, the presence of different hospital protocols and Obstetricians' opinion, introduce uncertainty in midwifery practice and lead midwives with feelings of 'uselessness'. Across the four themes, midwives frequently had to negotiate a space for their professional autonomy with other healthcare professionals, whilst adhering to the Obstetric Units' protocols. An influencing factor on the care provided to women with epidural was the years of midwife's experience on labour ward. Further research and the development of comprehensive midwifery care guidelines on the management of the second stage of labour in women with an epidural analgesia appears essential.

First-time mothers' expectations of the unknown territory of childbirth: Uncertainties, coping strategies and 'going with the flow'.

OBJECTIVE: To explore first-time mothers' expectations of labour and birth, coping strategies they adopt during pregnancy towards childbirth and coping strategies they expect to use during labour and birth. DESIGN: A qualitative Straussian grounded theory methodology was adopted, with data collected through semi-structured interviews in the third trimester of pregnancy. Ethical approval was gained. Data analysis included the processes of coding and conceptualising data, with constant comparison between data, literature and memos. SETTING: Three National Health Service (NHS) Trusts in England offering the choice of various birth settings including home, Freestanding Midwifery Unit (FMU) and Obstetric Unit (OU). PARTICIPANTS: Fourteen first-time pregnant women in good general health with a straightforward pregnancy (single fetus) and anticipating a normal birth. FINDINGS: Three themes were identified in regard to women's expectations of childbirth and coping strategies: (a) the unknown territory of labour and birth; (b) waiting for the unknown: coping strategies; (c) going with the flow. First-time mothers acknowledged labour and birth was an unknown territory, irrespective of the planned place of birth. While waiting for the unknown, the women put in place a number of coping strategies during pregnancy: preparing; avoiding; thinking about childbirth as a shared experience among women; relying on maternal instinct; relying on pharmacological pain relief; considering birth partner(s) as voice of reason. Overall, women were flexible in regard to their birth plan and open to change if needed, referring to this open-minded state as 'going with the flow'. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Women and their families may appreciate receiving accurate and realistic information from caregivers starting in pregnancy and continuing during labour and birth to alleviate the state of uncertainty typical of the childbearing event. The midwife should address the woman's uncertainties and help her 'go with the flow' in the labour continuum. The birth plan should also be revised by the midwife and woman together if they can no longer adhere to the original one.

First-time mothers' choice of birthplace: influencing factors, expectations of the midwife's role and perceived safety.

AIM: To explore first-time pregnant women's expectations and factors influencing their choice of birthplace. BACKGROUND: Although outcomes and advantages for low-risk childbearing women giving birth in midwifery-led units and home compared with obstetric units have been investigated previously, there is little information on the factors that influence women's choice of place of birth. DESIGN: A qualitative Straussian grounded theory methodology was adopted. Fourteen women expecting their first baby were recruited from three large National Health Service organizations that provided maternity services free at the point of care. The three organizations offered the following birthplace options: home, freestanding midwifery unit and obstetric unit. Ethical approvals were obtained and informed consent was gained from each participant. METHODS: Data collection was undertaken in 2013-2014. One tape-recorded face-to-face semistructured interview was conducted with each woman in the third trimester of pregnancy. FINDINGS: Findings are presented as three main themes: (i) influencing factors on the choice of birthplace; (ii) expectations on the midwife's 'being' and 'doing' roles; (iii) perceptions of safety. CONCLUSION: Midwives should consider each woman's expectations and approach to birth beyond the planned birthplace, as these are often influenced by the intersection of various influencing factors. Several birthplace options should be made available to women in each maternity service and the alternatives should be shared with women by healthcare professionals during pregnancy to allow an informed choice. Virtual tours or visits to the birth units could also be offered to women to help them familiarize with the chosen setting.

The kaleidoscopic midwife: A conceptual metaphor illustrating first-time mothers' perspectives of a good midwife during childbirth. A grounded theory study.

BACKGROUND: The literature review reveals general information about a good midwife from a range of perspectives and what childbearing women generally value in a midwife, but there is a lack of information around mothers' perspectives of what makes a good midwife specifically during labour and birth, and even less in the context of different places of birth. AIM: To conceptualise first-time mothers' expectations and experiences of a good midwife during childbirth in the context of different birthplaces. DESIGN: Qualitative Straussian grounded theory methodology. SETTING: Three National Health Service Trusts in England providing maternity care that offered women the possibility of giving birth in different settings (home, freestanding midwifery unit and obstetric unit). PARTICIPANTS: Fourteen first-time mothers in good general health with a straightforward singleton pregnancy anticipating a normal birth. METHODS: Ethical approval was gained. Data were collected through two semi-structured interviews for each participant (before and after birth). Data analysis included the processes of coding and conceptualising data, with constant comparison between data, literature and memos. FINDINGS: The model named 'The kaleidoscopic midwife: a conceptual metaphor illustrating first-time mothers' perspectives of a good midwife during childbirth' was developed. The model is dynamic and woman-centred, and is operationalised as the midwife adapts to each woman's individual needs in the context of each specific labour. Four pillars of intrapartum care were identified for a good midwife in the labour continuum: promoting individuality; supporting embodied limbo; helping to go with the flow; providing information and guidance. The metaphor of a kaleidoscopic figure is used to describe a midwife who is 'multi-coloured' and ever changing in the light of the woman's individual needs, expectations and labour journey, in order to create an environment that enables her to move forward despite the uncertainty and the expectations-experiences gap. The following elements are harmonised by the kaleidoscopic midwife: relationship-mediated being; knowledgeable doing; physical presence; immediately available presence. CONCLUSION: The model presented has relevance to contemporary debates about quality of care and place of birth and can be used by midwives to pursue excellence in caring for labouring mothers. Independently from the place of birth, when the woman is cared for by a midwife demonstrating the above characteristics, she is likely to have an optimum experience of birth. Future research is necessary to tease out individual components of the model in a variety of practice settings.

First-time mothers' experiences of early labour in Italian maternity care services.

OBJECTIVE: The aim of this study is to explore first-time mothers' experiences of early labour in Italian maternity care services when admitted to hospital or advised to return home after maternity triage assessment. SETTING: The study was conducted in a second-level maternity hospital in northern Italy with an obstetric unit for both low- and high-risk women. PARTICIPANTS: The participants included 15 first-time mothers in good general health with spontaneous labour at term of a low-risk pregnancy who accessed maternity triage during early labour, and were either admitted to hospital or advised to return home. DESIGN: A qualitative interpretive phenomenological study was conducted. A face-to-face recorded semi-structured interview was conducted with each participant 48-72h after birth. FINDINGS: Four key themes emerged from the interviews: (a) recognising signs of early labour; (b) coping with pain at home; (c) seeking reassurance from healthcare professionals; and (d) being admitted to hospital versus returning home. Uncertainty about the progression of labour and the need for reassurance were cited by women as the main reasons for hospital visit in early labour. An ambivalent feeling was reported by the participants when admitted to hospital in early labour. In fact, while the women felt reassured in the first instance, some women subsequently felt dissatisfied due to the absence of one-to-one dedicated care during early labour. When advised to return home, a number of women reported feelings of disappointment, anger, fear, discouragement and anxiety about not being admitted to hospital; however, some of these women reported a subsequent feeling of comfort due to being at home and putting in place the suggestions made by the midwives during the maternity triage assessment. The guidance provided by midwives during triage assessment seemed to be the key factor influencing women׳s satisfaction when advised either to return home or to stay at the hospital during early labour. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: During antenatal classes and clinics, midwives should provide clear information and advice about early labour in order to increase women׳s confidence and self-efficacy, and decrease their anxiety and fear. During early labour, appropriate maternity care services should be offered according to individual needs. When home visits are not provided by midwives, a telephone triage run by midwives should be considered as a routine service for the first point of contact with women during early labour.

Early pushing urge in labour and midwifery practice: a prospective observational study at an Italian maternity hospital.

OBJECTIVE: to investigate the early pushing urge (EPU) incidence in one maternity unit and explore how it is managed by midwives. The relation to some obstetric outcomes was also observed but not analysed in depth. DESIGN: prospective observational study. SETTING: Italian maternity hospital. SAMPLE: 60 women (44 nullips and 16 multips) experiencing EPU during labour. FINDINGS: the total EPU incidence percentage was 7.6%. The single midwives' incidences range had a very wide margin, noting an inverse proportion between the number of diagnoses of EPU and midwife's waiting time between urge to push and vaginal examination. Two care policies were adopted in relation to the phenomenon: the stop pushing technique (n=52/60) and the 'let the woman do what she feels' technique (n=8/60). In case of stop pushing techniques, midwives proposed several combined techniques (change of maternal position, blowing breath, vocalisation, use of the bath). The EPU diagnosis at less than 8cm of cervical dilatation was associated with more medical interventions. Maternal and neonatal outcomes were within the range of normal physiology. An association between the dilatation at EPU diagnosis and obstetric outcomes was observed, in particular the modality of childbirth and perineal outcomes. CONCLUSIONS AND IMPLICATION FOR PRACTICE: this paper contributes new knowledge to the body of literature around the EPU phenomenon during labour and midwifery practices adopted in response to it. Overall, it could be argued that EPU is a physiologic variation in labour if maternal and fetal conditions are good. Midwives might suggest techniques to woman to help her to stay with the pain, such as change of position, blowing breath, vocalisation and use of the bath. However, the impact of policies, guidelines and culture on midwifery practices of the specific setting are a limitation of the study because it is not representative of other similar maternity units. Thus, a larger scale work should be considered, including different units and settings. The optimal response to the phenomenon should be studied, considering EPU at different dilatation ranges. Future investigations could also focus on qualitative analysis of women and midwives' personal experience in relation to the phenomenon.