Midwives' approach to the prevention and repair of obstetric perineal trauma in Spain.

AIM: Different clinical practice guidelines include recommendations on how to prevent and repair obstetric perineal trauma, as well as the use of episiotomy. To evaluate the variability in midwives' professional practices for preventing and repairing perineal trauma, as well as the professional factors that may be associated with the restrictive use of episiotomy. DESIGN: Observational cross-sectional study. METHODS: Three hundred five midwives completed an anonymous questionnaire developed by the authors and distributed across various midwifery scientific societies. The main outcomes measured were the frequencies of adopting specific practices related to perineal injury prevention and repair, episiotomy technique and restrictive episiotomy use (<10%). Odds ratios (OR) and adjusted odds ratios (aOR) with 95% confidence intervals were estimated. RESULTS: Intrapartum perineal massage was not normally used by 253 (83%) of midwives, and 186 (61%) applied compresses soaked in warm water to the perineum. Regarding episiotomy, there was a great deal of variability, noting that 129 (42.3%) adopted a restrictive use of this procedure, 125 (41%) performed it between 10% and 20%, while 51 midwives (16.7%) performed it in more than 20% of cases. In addition, 165 (54.1%) midwives followed an incision angle of 60º. Concerning tears, 155 (50.8%) usually sutured first-degree tears and 273 (89.5%) always sutured second-degree tears. Midwives attending home births (aOR = 6.5; 95% CI: 2.69-15.69), working at a teaching hospital (aOR = 3.69; 95% CI: 1.39-9.84), and the ones who recently completed their professional training (aOR = 3.58; 95% CI: 1.46-8.79) were significantly more likely to adopt a restrictive use of episiotomy. CONCLUSIONS: There is a significant variability in Spanish midwives' practices for preventing and repairing perineal tears. Moreover, the restrictive use of episiotomy is associated with midwives attending home births, working in teaching hospitals and having recent professional training. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Preventing Cesarean Birth in Women with Obesity: Influence of Unit-Level Midwifery Presence on Use of Cesarean among Women in the Consortium on Safe Labor Data Set.

INTRODUCTION: Maternal obesity is associated with slow labor progression and unplanned cesarean birth. Midwives use fewer medical interventions during labor, and the women they care for have lower cesarean birth rates, compared with low-risk, matched groups of women cared for by physicians. The primary aim of this study was to examine associations between midwifery unit-level presence and unplanned cesarean birth in women with different body mass index (BMI) ranges. Unit-level presence of midwives was analyzed as a representation of a unique set of care practices that exist in settings where midwives work. METHODS: A retrospective cohort study was conducted using Consortium on Safe Labor data from low-risk, healthy women who labored and gave birth in medical centers with (n = 9795) or without (n = 13,398) the unit-level presence of midwives. Regression models were used to evaluate for associations between unit-level midwifery presence and 1) the incidence of unplanned cesarean birth and 2) in-hospital labor durations with stratification by maternal BMI and adjustment for maternal demographic and pregnancy factors. RESULTS: The odds of unplanned cesarean birth among women who gave birth in centers with midwives were 16% lower than the odds of cesarean birth among similar women at who gave birth at centers without midwives (adjusted odds ratio, 0.84; 95% CI, 0.77-0.93). However, women whose BMI was above 35.00 kg/m2 at labor admission had similar odds of cesarean birth, regardless of unit-level midwifery presence. In-hospital labor duration prior to unplanned cesarean was no different by unit-level midwifery presence in nulliparous women whose BMI was above 35.00 kg/m2 . DISCUSSION: Although integration of midwives into the caregiving environment of medical centers in the United States was associated with overall decrease in the incidence of cesarean birth, increased maternal BMI nevertheless remained positively associated with these outcomes.

Cuidados de la matrona en la versión cefálica externa / Midwife care in external cephalic version

La versión cefálica externa (VCE) es una maniobra obstétrica que intenta convertir una presentación fetal podálica o transversa en cefálica, más favorable de cara al parto. La matrona, como parte del equipo multidisciplinar, está presente durante el proceso de su realización, aplicando los cuidados necesarios para una atención integral de la mujer gestante. El objetivo de este artículo es presentar el caso clínico de una mujer embarazada durante el procedimiento de VCE. Se elabora el plan de cuidados enfermeros basado en las necesidades básicas de Virginia Henderson y guiado por la taxonomía NANDA-NIC-NOC, donde se identifican tres diagnósticos de Enfermería, que serán la base de la realización de este proceso enfermero: temor, dolor agudo y riesgo de alteración de la díada materno/fetal. La aplicación de este plan de cuidados supuso una mejora en la atención a la mujer y en la organización del trabajo

External cephalic version (ECV) is an obstetric manoeuvre intended to change a breech or transversal fetal presentation into cephalic, more favourable in terms of delivery. The midwife, as a member of the multidisciplinary team, will be present during this procedure, implementing any necessary measures for a comprehensive care of the pregnant woman. The objective of this article is to present the clinical case of a pregnant woman during the ECV procedure. The nursing care plan is prepared on the basis of Virginia Henderson’s basic needs, and guided by the NANDA-NIC-NOC taxonomy, where three nursing diagnoses will be identified as the basis for conducting this nursing process: fear, acute pain and risk of alteration of the maternal/fetal dyad. The application of this healthcare plan represented an improvement in women care and work organization

A meta-ethnographic synthesis of midwives' and nurses' experiences of adverse labour and birth events.

INTRODUCTION: Health professionals are frequently exposed to traumatic events due to the nature of their work. While traumatic and adverse labour and birth events experienced by women are well researched, less attention has been given to midwives' and nurses' experiences of these events and the impact it has on their lives. AIMS AND OBJECTIVES: To undertake a meta-ethnographic study of midwives' and nurses' experiences of adverse labour and birth events. METHODS: Scopus, CINHAL PLUS, MEDLINE and PUBMED databases were searched using subject headings and keywords. The search was limited to papers published in peer-reviewed journals from 2004-October 2016. Quality appraisal was undertaken using the Critical Appraisal Skills Programme tool. INCLUSION CRITERIA: Papers had to be qualitative or have a substantial qualitative component. Studies were included if they primarily focused on midwives' or nurses' perspectives or experiences of complicated, traumatic or adverse labour and birth events. ANALYTIC STRATEGY: A meta-ethnographic approach was used incorporating methods of reciprocal translation guided by the work of Noblit and Hare (1988, Meta-Ethnography: Synthesizing qualitative studies (Vol. 11). Newbury Park: Sage publications). FINDINGS: Eleven qualitative studies were included in the final sample. Four major themes were (i) feeling the chaos; (ii) powerless, responsible and a failure; (iii) "It adds another scar to my soul"; and (iv) finding a way to deal with it. CONCLUSION: Midwives and nurses feel relatively unprepared when faced with a real-life labour and birth emergency event. While many of the midwives and nurses were traumatised by the experience, some were able to view their encounter as an opportunity to develop their emergency response skills. RELEVANCE TO CLINICAL PRACTICE: Witnessing and being involved in a complicated or adverse labour and birth event can be traumatic for nurses and midwives. Organisational and collegial support needs to be available to enable these health professionals to talk about their feelings and concerns.

Responses to birth trauma and prevalence of posttraumatic stress among Australian midwives.

BACKGROUND: Midwives frequently witness traumatic birth events. Little is known about responses to birth trauma and prevalence of posttraumatic stress among Australian midwives. AIM: To assess exposure to different types of birth trauma, peritraumatic reactions and prevalence of posttraumatic stress. METHODS: Members of the Australian College of Midwives completed an online survey. A standardised measure assessed posttraumatic stress symptoms. FINDINGS: More than two-thirds of midwives (67.2%) reported having witnessed a traumatic birth event that included interpersonal care-related trauma features. Midwives recalled strong emotions during or shortly after witnessing the traumatic birth event, such as feelings of horror (74.8%) and guilt (65.3%) about what happened to the woman. Midwives who witnessed birth trauma that included care-related features were significantly more likely to recall peritraumatic distress including feelings of horror (OR=3.89, 95% CI [2.71, 5.59]) and guilt (OR=1.90, 95% CI [1.36, 2.65]) than midwives who witnessed non-interpersonal birth trauma. 17% of midwives met criteria for probable posttraumatic stress disorder (95% CI [14.2, 20.0]). Witnessing abusive care was associated with more severe posttraumatic stress than other types of trauma. DISCUSSION: Witnessing care-related birth trauma was common. Midwives experience strong emotional reactions in response to witnessing birth trauma, in particular, care-related birth trauma. Almost one-fifth of midwives met criteria for probable posttraumatic stress disorder. CONCLUSION: Midwives carry a high psychological burden related to witnessing birth trauma. Posttraumatic stress should be acknowledged as an occupational stress for midwives. The incidence of traumatic birth events experienced by women and witnessed by midwives needs to be reduced.

Catheterisation: best practice in bladder care.

Bladder care is an integral part of caring for a woman in labour and the immediate postpartum period (National Institute for Health and Care Excellence (NICE) 2014a). To ensure effective bladder care, the skill of urinary catheterisation is often undertaken by a midwife and can be required in a variety of different situations. Catheterisation is a necessary intervention whether it is intermittent, indwelling, short-term or, less often, long-term. This article addresses the current recommended guidance, highlights best practice measures and provides useful hints and tips to support catheter care.

Making it happen: a programme of education in Kenya.

The number of mothers and babies from the developing world who die in pregnancy and childbirth remains unacceptably high. However, concerted efforts over the last 20 years to reduce the number of deaths have produced significant results, leading to a steady fall in maternal and neonatal mortality rates since 1990 (Unicef 2014). One initiative that is having an impact is the 'Making it happen' programme funded by the UK government and run by Liverpool's School of Tropical Medicine. A 'skills and drills'-type course covering obstetric and neonatal emergencies is delivered to health professionals across Sub-Saharan Africa and Asia. This article describes the volunteer experience of a UK midwife helping to facilitate a course in Kenya, which has some of the world's poorest health outcomes.

Perineal pain in focus: reviewing topical anaesthetic treatments.

Midwives have opportunities to help postnatal mothers to minimise perineal discomfort associated with perineal trauma following vaginal birth. Perineal trauma and associated pain is common and can have a negative impact on the physical, psycho-social transition to motherhood and family life. This article considers the role local anaesthetic agents have in helping women to relieve perineal pain. Key evidence is presented with associated practice considerations, and future research areas are suggested to broaden our understanding of this important aspect of postnatal care.

Perineal wound infections: an audit.

An audit was completed by an NHS trust to determine the rate of perineal trauma amongst vaginal births and to assess the rate of perineal wound infections. The audit results confirmed a higher than average rate of perineal wound infections amongst women who had an instrumental birth. The trust decided to separate the contents of the delivery packs into two separate packs--one pack for birth and one pack for suturing--and developed a back-to-basics update session that was delivered to staff working within the maternity setting. A re-audit the following year confirmed that these measures had worked and the overall perineal wound infection rate reduced within the trust.

Hands-on or hands-poised: what does the evidence say?

A majority of women will experience some degree of perineal trauma during vaginal birth. The morbidity of women related to perineal trauma can reveal in perineal pain, urinary or faecal incontinence and dyspareunia. Midwives can adopt many techniques to protect the perineum from injury. However, there are still no clear guidelines regarding the hands-on and hands-poised approaches of perineal management during the second stage of labour. The current evidence remains contradictory, so which technique should midwives adopt?

Perineal protection.

Perineal tearing in childbirth is common and can have a considerable impact on women. There are various hands-on techniques that midwives use routinely to protect the perineum but not all of them are evidence based. Despite this, midwives often feel that they are the determining factor in whether a woman tears or not. Furthermore, women are rarely asked permission before hands-on techniques are used. This article explores some of the techniques used to prevent perineal tears, looks at the evidence base and invites the reader to reflect on their own practice and thinking around perineal protection.

Five ways to learn to love suturing.

Suturing can be a daunting midwifery skill to learn, as it's complex and carries great responsibility. There are lots of excellent texts on suturing available in midwifery literature, but perhaps not much on the emotional side of learning. This light-hearted article addresses the anatomy and physiology of the perineum in an engaging and easy to understand way; looks at the current evidence around the decision to suture; and shares ways the author progressed from being apprehensive about suturing to being passionate about the topic and enjoying the skill.

A day in the life of a specialist perineal care clinic.

The specialist perineal care clinic has been running at Rotherham NHS Foundation Trust for over three years. This article tells of a quest to further improve perineal care for women in our care and demonstrates the process from conception to birth of the clinic, as well as the journey taken in order for this service to be set up and run efficiently. Prior to this clinic most women saw different people throughout their care, which was obviously confusing for them, as conflicting advice could be on offer. This clinic has provided consistency and continuity which has improved women's experiences and, in turn, yielded improved outcomes. It has empowered the women to further play a part in their own care from antenatal methods of reducing the chance of perineal trauma to postnatal recovery after perineal breakdown and infection. Both women and staff have benefited from this service as there is always a central point of contact.