The social organisation of decision-making about intrapartum fetal monitoring: An Institutional Ethnography.

BACKGROUND: International guidelines recommend intrapartum cardiotocograph (CTG) monitoring for women at risk for poor perinatal outcome. Research has not previously addressed how midwives and obstetricians enable or hinder women's decision-making regarding intrapartum fetal monitoring and how this work is structured by external organising factors. AIM: To examine impacts of policy and research texts on midwives' and obstetricians' work with labouring women related to intrapartum fetal monitoring decision-making. METHODS: We used a critical feminist qualitative methodology known as Institutional Ethnography (IE). The research was conducted in an Australian tertiary maternity service. Data collection included interviews, observation, and texts relating to midwives' and obstetricians' work with the fetal monitoring system. Textual mapping was used to explain how midwives' and obstetricians' work was organised to happen the way it was. FINDINGS: CTG monitoring was initiated predominantly by midwives applying mandatory policy. Midwives described reluctance to inform labouring women that they had a choice of fetal monitoring method. Discursive approaches used in a national fetal surveillance guideline, a Cochrane systematic review, and the largest randomised controlled trial regarding CTG monitoring in labour generated and reproduced assumptions that clinicians, not labouring women, were the appropriate decision-maker regarding fetal monitoring in labour. DISCUSSION AND CONCLUSION: Guidelines structured midwives' and obstetricians' work in a manner that undermined women's participation in decisions about fetal monitoring method. Intrapartum fetal monitoring guidelines should be critically reviewed to ensure they encourage and enable midwives and obstetricians to support women to make decisions about intrapartum care.

Atuação da psicologia em unidade neonatal no contexto da pandemia da covid-19 / The work of psychology in a neonatal unit in the covid-19 pandemic / Actuación de la psicología en una unidad neonatal en el contexto de la pandemia de la covid-19

A pandemia de covid-19 provocou intensas mudanças no contexto do cuidado neonatal, exigindo dos profissionais de saúde a reformulação de práticas e o desenvolvimento de novas estratégias para a manutenção da atenção integral e humanizada ao recém-nascido. O objetivo deste artigo é relatar a atuação da Psicologia nas Unidades Neonatais de um hospital público de Fortaleza (CE), Brasil, durante o período de distanciamento físico da pandemia de covid-19. Trata-se de estudo descritivo, do tipo relato de experiência, que ocorreu no período de março a agosto de 2020. No contexto pandêmico, o serviço de Psicologia desenvolveu novas condutas assistenciais para atender às demandas emergentes do momento, como: atendimento remoto; registro e envio on-line de imagens do recém-nascido a seus familiares; visitas virtuais; e reprodução de mensagens de áudio da família para o neonato. Apesar dos desafios encontrados, as ações contribuíram para a manutenção do cuidado centrado no recém-nascido e sua família, o que demonstra a potencialidade do fazer psicológico.(AU)

The COVID-19 pandemic brought intense changes to neonatal care and required health professionals to reformulate practices and develop new strategies to ensure comprehensive and humanized care for newborn. This study aims to report the experience of the Psychology Service in the Neonatal Units of a public hospital in Fortaleza, in the state of Ceará, Brazil, during the social distancing period of the COVID-19 pandemic. This descriptive experience report study was conducted from March to August 2020. During the pandemic, the Psychology Service developed new care practices to meet the emerging demands of that moment, such as remote care, recordings and online submission of newborns' pictures and video images for their family, virtual tours, and reproduction of family audio messages for the newborns. Despite the challenges, the actions contributed to the maintenance of a care that is centered on the newborns and their families, which shows the potential of psychological practices.(AU)

La pandemia de la COVID-19 ha traído cambios intensos en el contexto de la atención neonatal, que requieren de los profesionales de la salud una reformulación de sus prácticas y el desarrollo de nuevas estrategias para asegurar una atención integral y humanizada al recién nacido. El objetivo de este artículo es reportar la experiencia del Servicio de Psicología en las Unidades Neonatales de un hospital público de Fortaleza, en Ceará, Brasil, durante el periodo de distanciamiento físico en la pandemia de la COVID-19. Se trata de un estudio descriptivo, un reporte de experiencia, que se llevó a cabo de marzo a agosto de 2020. En el contexto pandémico, el servicio de Psicología desarrolló nuevas conductas asistenciales para atender a las demandas emergentes del momento, tales como: atención remota; grabación y envío em línea de imágenes del recién nacido; visitas virtuales; y reproducción de mensajes de audio de la familia para el recién nacido. A pesar de los desafíos encontrados, las acciones contribuyeron al mantenimiento de la atención centrada en el recién nacido y su familia, lo que demuestra el potencial de la práctica psicológica.(AU)

"I'm not doing what I should be doing as a midwife": An ethnographic exploration of central fetal monitoring and perceptions of clinical safety.

BACKGROUND: Central fetal monitoring systems transmit cardiotocograph data to a central site in a maternity service. Despite a paucity of evidence of safety, the installation of central fetal monitoring systems is common. AIM: This qualitative research sought to explore whether, and how, clinicians modified their clinical safety related behaviours following the introduction of a central monitoring system. METHODS: An Institutional Ethnographic enquiry was conducted at an Australian hospital where a central fetal monitoring system had been installed in 2016. Informants (n=50) were midwifery and obstetric staff. Data collection consisted of interviews and observations that were analysed to understand whether and how clinicians modified their clinical safety related behaviours. FINDINGS: The introduction of the central monitoring system was associated with clinical decision making without complete clinical information. Midwives' work was disrupted. Higher levels of anxiety were described for midwives and birthing women. Midwives reported higher rates of intervention in response to the visibility of the cardiotocograph at the central monitoring station. Midwives described a shift in focus away from the birthing woman towards documenting in the central monitoring system. DISCUSSION: The introduction of central fetal monitoring prompted new behaviours among midwifery and obstetric staff that may potentially undermine clinical safety. CONCLUSION: This research raises concerns that central fetal monitoring systems may not promote safe intrapartum care. We argue that research examining the safety of central fetal monitoring systems is required.

Midwives must, obstetricians may: An ethnographic exploration of how policy documents organise intrapartum fetal monitoring practice.

BACKGROUND: The capacity for midwifery to improve maternity care is under-utilised. Midwives have expressed limits on their autonomy to provide quality care in relation to intrapartum fetal heart rate monitoring. AIM: To explore how the work of midwives and obstetricians was textually structured by policy documents related to intrapartum fetal heart rate monitoring. METHODS: Institutional Ethnography, a critical qualitative approach was used. Data were collected in an Australian hospital with a central fetal monitoring system. Midwives (n=34) and obstetricians (n=16) with experience working with the central fetal monitoring system were interviewed and observed. Policy documents were collected and analysed. FINDINGS: Midwives' work was strongly structured by policy documents that required escalation of care for any CTG abnormality. Prior to being able to escalate care, midwives were often interrupted by other clinicians uninvited entry into the room in response to the CTG seen at the central monitoring station. While the same collection of documents guided the work of both obstetricians and midwives, they generated the expectation that midwives must perform certain tasks while obstetricians may perform others. Midwifery work was textually invisible. DISCUSSION AND CONCLUSION: Our findings provide a concrete example of the way policy documents both reflect and generate power imbalances in maternity care. Obstetric ways of knowing and doing are reinforced within these documents and continue to diminish the visibility and autonomy of midwifery. Midwifery organisations are well placed to co-lead policy development and reform in collaboration with maternity consumer and obstetric organisations.

"My whole room went into chaos because of that thing in the corner": Unintended consequences of a central fetal monitoring system.

OBJECTIVE: Technologies for fetal heart rate monitoring have been widely introduced despite evidence of no improvement in perinatal outcomes. A significant body of research has raised concerns that healthcare information technologies can have unintended consequences. We sought to describe an unintended consequence of central fetal monitoring technology. DESIGN: The research was conducted as an Institutional Ethnography. Data generated from interviews, focus groups, and observations were analysed to generate an account of midwives' experiences with the central fetal monitoring system. SETTING: The birthing unit of one Australian maternity service with a central fetal monitoring system. INFORMANTS: 34 midwives and midwifery students who worked with the central fetal monitoring system. FINDINGS: Midwives described a disruptive social event they named being K2ed. Clinicians responded to perceived cardiotocograph abnormalities by entering the birth room despite the midwife not having requested assistance. Being K2ed disrupted midwives' clinical work and generated anxiety. Clinical communication was undermined, and midwives altered their clinical practice. Midwives performed additional documentation work to attempt to avoid being K2ed. KEY CONCLUSIONS: This is the first report of an unintended consequence relating to central fetal monitoring, demonstrating how central fetal monitoring technology potentially undermines safety by impacting on clinical and relational processes and outcomes in maternity care. IMPLICATIONS FOR PRACTICE: Current evidence does not support implementation or ongoing use of central fetal monitoring systems. Further research is needed to inform scaling down central fetal monitoring systems in a safe and supported way.

Knowledge on intrapartum care practices among skilled birth attendants in Cambodia-a cross-sectional study.

BACKGROUND: Delivery is a critical moment for pregnant women and babies, and careful monitoring is essential throughout the delivery process. The partograph is a useful tool for monitoring and assessing labour progress as well as maternal and foetal conditions; however, it is often used inaccurately or inappropriately. A gap between practices and evidence-based guidelines has been reported in Cambodia, perhaps due to a lack of evidence-based knowledge in maternity care. This study aims to address to what extent skilled birth attendants in the first-line health services in Cambodia have knowledge on the management of normal delivery, and what factors are associated with their level of knowledge. METHODS: Midwives and nurses were recruited working in maternity in first-line public health facilities in Phnom Penh municipality, Kampong Cham and Svay Rieng provinces. Two self-administered questionnaires were applied. The first consisted of three sections with questions on monitoring aspects of the partograph: progress of labour, foetal, and maternal conditions. The second consisted of questions on diagnostic criteria, normal ranges, and standard intervals of monitoring during labour. A multiple linear regression analysis was performed to identify relationships between characteristics of the participants and the questionnaire scores. RESULTS: Of 542 eligible midwives and nurses, 523 (96%) participated. The overall mean score was 58%. Only 3% got scores of more than 90%. Multivariate analysis revealed that 'Kampong Cham province', 'younger age', and 'higher qualification' were significantly associated with higher scores. Previous training experience was not associated with the score. Substantial proportions of misclassification of monitoring items during labour were found; for example, 61% answered uterine contraction as a foetal condition, and 44% answered foetal head descent and 26% answered foetal heart rate as a maternal condition. CONCLUSION: This study found that knowledge was low on delivery management among skilled birth attendants. Previous training experience did not influence the knowledge level. A lack of understanding of physiology and anatomy was implied. Further experimental approaches should be attempted to improve the knowledge and quality of maternity services in Cambodia.

Pregnancy and childbirth are natural phenomena, but sometimes have risk for mothers and babies. Therefore, childbirth should be carefully and continuously monitored by the health care professional. The 'partograph' is a useful tool that defines three monitoring aspects of the delivery progress, and conditions of the mother and intrauterine baby. However, it is often used inaccurately or inappropriately in low- and middle-income countries. We hypothesised that health professionals who assist childbirth cannot effectively monitor delivery conditions because their knowledge is insufficient. Therefore, we evaluated the knowledge on monitoring the process of childbirth and explored factors which affect the level of knowledge among health care providers in Cambodia.Midwives and nurses were targeted in this study who deal with normal deliveries in the capital city and two provinces. The questionnaire was designed to evaluate if their knowledge on three monitoring aspects is accurate.Of 542 eligible personnel, 523 (96%) participated. The mean score was 58%. Only 3% got scores of more than 90%. According to the statistical analysis, 'working in Kampong Cham province', 'younger age', and 'higher qualification' were significantly associated with higher scores. Previous training experience was not associated with the score.This study found that basic knowledge was low on delivery management among health care providers. We suspect that a deficiency of basic medical knowledge, such as physiology and anatomy, causes the lack of knowledge on the childbirth process. Further intervention should be attempted to improve the knowledge and quality of maternity services in Cambodia.

[Normal childbirth: Physiologic labor support and medical procedures. Guidelines of the French National Authority for Health (HAS) with the collaboration of the French College of Gynaecologists and Obstetricians (CNGOF) and the French College of Midwives (CNSF) - Initial assessment on admission and fetal monitoring during labor]. / Accouchement normal : accompagnement de la physiologie et interventions médicales. Recommandations de la Haute Autorité de santé (HAS) avec la collaboration du Collège national des gynécologues obstétriciens français (CNGOF) et du Collège national des sages-femmes de France (CNSF) ­ Surveillance fœtale à l'admission et pendant le travail.

OBJECTIVES: The purpose of this literature's review is to provide recommendations for measures to assess fetal "well-being" at admission and during labor in order to identify a non-reassuring fetal condition. METHODS: Consultation of the Medline database, and of national and international guidelines. RESULTS: Two fetal heart rate monitoring techniques are available at admission and during labor. In comparison with intermittent auscultation (AI), continuous cardiotocography (CTG) monitoring was associated, in a meta-analysis involving 13 trials including more than 37,000 women, with a reduction in RR neonatal seizures by half. Relative risk (RR)=0.50 with a 95% CI [0.31-0.80] without significant difference objectified with respect to cerebral palsy RR=1.75 95% CI [0.84-3.63]. In contrast, a significant increase in cesarean sections was associated with continuous CTG RR=1.63 95% CI [1.29-2.07] and women were also at greater risk for operative vaginal delivery RR=1.15 95% CI [1.01-1.33]. Current results are insufficient to demonstrate the actual impact of surveillance methods (continuous or discontinuous) on the overall perinatal mortality rate. Larger randomized trials remain to be conducted. CONCLUSION: The systematic search for the confirmation of the reassuring character of the fetal state at admission and during labor makes it possible to identify intrapartum hypoxic events.

Intrapartum fetal surveillance education in Victorian hospitals revisited.

Fifteen years ago a survey of Victorian public maternity services showed that the majority of services provided no fetal surveillance education to their staff and that only one in ten undertook any sort of assessment of staff knowledge. Today, all hospitals, public and private, provide training and all public hospitals require their midwifery and medical staff to undertake regular assessment of knowledge. The requirements of specialist obstetricians in private practice remain variable.

Effectiveness of an Electronic Partogram: A Mixed-Method, Quasi-Experimental Study Among Skilled Birth Attendants in Kenya.

BACKGROUND: Timely identification and management of intrapartum complications could significantly reduce maternal deaths, intrapartum stillbirths, and newborn deaths due to hypoxia. The World Health Organization (WHO) identifies monitoring of labor using the paper partograph as a high-priority intervention for identifying abnormities in labor and fetal well-being. This article describes a mixed-method, quasi-experimental study to assess the effectiveness of an Android tablet-based electronic, labor clinical decision-support application (ePartogram) in limited-resource settings. METHODS: The study, conducted in Kenya from October 2016 to May 2017, allocated 12 hospitals and health centers to an intervention (ePartogram) or comparison (paper partograph) group. Skilled birth attendants (SBAs) in both groups received a 2-day refresher training in labor management and partograph use. The intervention group received an additional 1-day orientation on use and care of the Android-based ePartogram app. All outcomes except one compare post-ePartogram intervention versus paper partograph controls. The exception is outcome of early perinatal mortality pre- and post-ePartogram introduction in intervention sites compared to control sites. We used log binomial regression to analyze the primary outcome of the study, suboptimal fetal outcomes. We also analyzed for secondary outcomes (SBAs performing recommended actions), and conducted in-depth interviews with facility in-charges and SBAs to ascertain acceptability and adoptability of the ePartogram. RESULTS: We compared data from 842 clients in active labor using ePartograms with data from 1,042 clients monitored using a paper partograph. SBAs using ePartograms were more likely than those using paper partographs to take action to maintain normal labor, such as ambulation, feeding, and fluid intake, and to address abnormal measurements of fetal well-being (14.7% versus 5.3%, adjusted relative risk=4.00, 95% confidence interval [CI]=1.95-8.19). Use of the ePartogram was associated with a 56% (95% CI=27%-73%) lower likelihood of suboptimal fetal outcomes than the paper partograph. Users of the ePartogram were more likely to be compliant with routine labor observations. SBAs stated that the technology was easy to use but raised concerns about its use at high-volume sites. Further research is needed to evaluate costs and benefit and to incorporate recent WHO guidance on labor management. CONCLUSION: ePartogram use was associated with improvements in adherence to recommendations for routine labor care and a reduction in adverse fetal outcomes, with providers reporting adoptability without undue effort. Continued development of the ePartogram, including incorporating new clinical rules from the 2018 WHO recommendations on intrapartum care, will improve labor monitoring and quality care at all health system levels.

Use and completion of partograph during labour is associated with a reduced incidence of birth asphyxia: a retrospective study at a peri-urban setting in Ghana.

BACKGROUND: Morbidity of birth asphyxia has been estimated to be 42 million disability-adjusted life years. The study sought to assess the impact of the use and completion of partograph during labour on reducing birth asphyxia at the St Anthony's Hospital, Dzodze, in the Volta Region of Ghana. METHODS: A retrospective study design using a quantitative approach was adopted for the study. A simple random sampling technique was used to select a total of 200 folders of labouring women who were admitted and delivered at St Anthony's Hospital, Dzodze, between 1st May 2015 and 30th April 2016. A structured checklist, which was developed by using labour and foetal monitoring parameters based on the standards of the World Health Organization partograph usage, was used to review all the 200 existing maternal records. RESULTS: The findings revealed that partographs were used by midwives at St Anthony's Hospital with the majority of the maternal folders fully completed. The use and completion of partograph were found to be associated with less non-asphyxiated birth outcomes. Labours which were monitored with partograph were 4.29 times less likely to result in birth asphyxia [AOR (95% CI) 4.29 (1.35-14.81)], and those that were monitored with a completed partograph were 5.3 times less likely to result in birth asphyxia [AOR (95% CI) 5.31 (2.011-16.04)]. CONCLUSION: Midwives used partographs during labour at St Anthony's Hospital. The use and completion of partograph were significantly associated with a reduced incidence of birth asphyxia at the hospital. Birth asphyxia could be reduced if partographs are used and completed by midwives during labour in all cases.

Use of an electronic Partograph: feasibility and acceptability study in Zanzibar, Tanzania.

BACKGROUND: The ePartogram is a tablet-based application developed to improve care for women in labor by addressing documented challenges in partograph use. The application is designed to provide real-time decision support, improve data entry, and increase access to information for appropriate labor management. This study's primary objective was to evaluate the feasibility and acceptability of ePartogram use in resource-constrained clinical settings. METHODS: The ePartogram was introduced at three facilities in Zanzibar, Tanzania. Following 3 days of training, skilled birth attendants (SBAs) were observed for 2 weeks using the ePartogram to monitor laboring women. During each observed shift, data collectors used a structured observation form to document SBA comfort, confidence, and ability to use the ePartogram. Results were analyzed by shift. Short interviews, conducted with SBAs (n = 82) after each of their first five ePartogram-monitored labors, detected differences over time. After the observation period, in-depth interviews were conducted (n = 15). A thematic analysis of interview transcripts was completed. RESULTS: Observations of 23 SBAs using the ePartogram to monitor 103 women over 84 shifts showed that the majority of SBAs (87-91%) completed each of four fundamental ePartogram tasks-registering a client, entering first and subsequent measurements, and navigating between screens-with ease or increasing ease on their first shift; this increased to 100% by the fifth shift. Nearly all SBAs (93%) demonstrated confidence and all SBAs demonstrated comfort in using the ePartogram by the fifth shift. SBAs expressed positive impressions of the ePartogram and found it efficient and easy to use, beginning with first client use. SBAs noted the helpfulness of auditory reminders (indicating that measurements were due) and visual alerts (signaling abnormal measurements). SBAs expressed confidence in their ability to interpret and act on these reminders and alerts. CONCLUSIONS: It is feasible and acceptable for SBAs to use the ePartogram to support labor management and care. With structured training and support during initial use, SBAs quickly became competent and confident in ePartogram use. Qualitative findings revealed that SBAs felt the ePartogram improved timeliness of care and supported decision-making. These findings point to the ePartogram's potential to improve quality of care in resource-constrained labor and delivery settings.

State-trait anxiety levels during pregnancy and foetal parameters following intervention with music therapy.

BACKGROUND: Research indicates that anxiety during pregnancy may be a risk factor for the development of alterations in the mental health of the pregnant woman and of obstetric complications. OBJECTIVE: to investigate the effect of music therapy on maternal anxiety, before and after a non-stress test (NST), and the effect of maternal anxiety on the birthing process and birth size. METHODS: 409 nulliparous women coming for routine prenatal care were randomized in the third trimester to receive either music therapy (n = 204) or no music therapy (n = 205) during an NST. Maternal anxiety was assessed using the Spielberger State-Trait Anxiety Inventory before and after the NST. RESULTS: After the NST, the women from the music group showed significantly lower scores in state anxiety (OR = 0.87; p < 0.001) as well as trait anxiety (p < 0.001) than the control group. Furthermore, the pregnant women from the music group presented lower levels of state-trait anxiety than the control group in relation to the variables of birth process, and higher birth weight and chest circumference in the newborn (OR = 3.5 and OR = 0.81, respectively; p < 0.05). LIMITATIONS: This study was limited by the fact that it was a single-centre study; the observers conducting the NST were not blinded to the allocation, although neither midwife had any knowledge of the maternal anxiety scores, and we could not apply the double-blind method due to the nature of the observation. CONCLUSIONS: Our findings confirm that music therapy intervention during pregnancy could reduce elevated state-trait anxiety levels during the third trimester. Further research into the influence of music therapy as intervention on maternal anxiety and on the birthing process and birth size is required during pregnancy.

Obstetric early warning score in Scandinavia. A survey of midwives' use of systematic monitoring in parturients.

OBJECTIVE: systematic monitoring has recently been implemented widely in non-obstetric departments. In the UK, Early Warning Score (EWS) systems specifically designed for the obstetric population (OEWS) are used. No information on the use of OEWS in Scandinavia has been reported. Consequently, we wanted to investigate the use of vital signs and attitude towards systematic monitoring of parturients in Denmark, Norway and Sweden. DESIGN: electronic questionnaires sent to heads of midwifery. The heads of midwifery referred two clinically active midwives. All in-hospital obstetric departments in Scandinavia were invited to participate. FINDINGS: heads of midwifery from 76 departments (68%), and 125 clinical midwives (82%) responded. Ten per cent of midwives reported use of OEWS. Reported implementation barriers to OEWS included lack of evidence and suspected impact on the parturient due to frequent interruptions. fifty-four per cent of clinical midwives reported a systolic blood pressure threshold of 90-139mmHg, while 33% reported a threshold of>160mmHg. Ninety-three per cent stated a low threshold for maternal heart rate<60 bpm whereas 10% reported an upper threshold heart rate ≥ 150 bpm. Forty-seven per cent reported call for assistance thresholds for maternal heart rate at 60-110 bpm. KEY CONCLUSIONS: OEWS is not implemented in Scandinavian obstetric departments and reported thresholds of vital signs varied considerably. Major barriers for implementation in Scandinavia include midwives' concern of interruptions for the parturient and increased workload, and unclear benefit from use of OEWS. Local departments should provide midwives with unambiguous thresholds for vital signs in parturients either through local guidelines or via OEWS.

Healthcare providers' perspectives on labor monitoring in Nigeria and Uganda: A qualitative study on challenges and opportunities.

OBJECTIVE: To explore current practices, challenges, and opportunities in relation to monitoring labor progression, from the perspectives of healthcare professionals in low-resource settings. METHODS: Thematic analysis of qualitative data (in-depth interviews [IDIs] and focus group discussions [FDGs]) obtained from a purposive sample of healthcare providers and managers in selected health facilities in Nigeria and Uganda. RESULTS: A total of 70 IDIs and 16 FGDs with doctors, midwives, and administrators are included in this analysis. Labor monitoring encompasses a broad scope of care jointly provided by doctors and midwives. A range of contextual limitations was identified as barriers to monitoring labor progression, including staff shortages, lack of team cooperation, delays in responding to abnormal labor observations, suboptimal provider-patient dynamics, and limitations in partograph use. Perceived opportunities to improve current practices included streamlining clinical team cooperation, facilitating provider-client communication, encouraging women's uptake of offered care, bridging the gaps in the continuum of monitoring tasks between cadres, and improving skills in assessment of labor progress, and accuracy in its documentation. CONCLUSION: Healthcare providers face many challenges to effective monitoring of labor progress in low-resource settings. This analysis presents potential opportunities to improve labor monitoring practices and tools in these contexts.

Women's attitudes, experiences and compliance concerning the use of Mindfetalness- a method for systematic observation of fetal movements in late pregnancy.

BACKGROUND: Maternal perception of decreased fetal movements and low awareness of fetal movements are associated with a negative birth outcome. Mindfetalness is a method developed for women to facilitate systematic observations of the intensity, character and frequency of fetal movements in late pregnancy. We sought to explore women's attitudes, experiences and compliance in using Mindfetalness. METHODS: We enrolled 104 pregnant women treated at three maternity clinics in Stockholm, Sweden, from February to July of 2016. We educated 104 women in gestational week 28-32 by providing information about fetal movements and how to practice Mindfetalness. Each was instructed to perform the assessment daily for 15 min. At each subsequent follow-up, the midwife collected information regarding their perceptions of Mindfetalness, and their compliance. Content analyses, descriptive and analytic statistics were used in the analysis of data. RESULTS: Of the women, 93 (89%) were positive towards Mindfetalness and compliance was high 78 (75%). Subjective responses could be binned into one of five categories: Decreased worry, relaxing, creating a relationship, more knowledge about the unborn baby and awareness of the unborn baby. Eleven (11%) women had negative perceptions of Mindfetalness, citing time, and the lack of need for a method to observe fetal movements as the most common reasons. CONCLUSION: Women in late pregnancy are generally positive about Mindfetalness and their compliance with daily use is high. The technique helped them to be more aware of, and create a relationship with, their unborn baby. Mindfetalness can be a useful tool in antenatal care. However, further study is necessary in order to determine whether the technique is able to reduce the incidence of negative birth outcome.

Are stipulated requirements for the quality of maternity care complied with? / Følges fastsatte kvalitetskrav i fødselsomsorgen?

BACKGROUND: The Directorate of Health's national guide Et trygt fødetilbud ­ kvalitetskrav til fødselsomsorgen [A safe maternity service ­ requirements regarding the quality of maternity care] was published in December 2010 and was intended to provide a basis for an improved and more predictable maternity service. This article presents data from the maternity institutions on compliance with the quality requirements, including information on selection, fetal monitoring, organisation, staffing and competencies. MATERIAL AND METHOD: The information was acquired with the aid of an electronic questionnaire in the period January­May 2015. The form was sent by e-mail to the medical officer in charge at all maternity units in Norway as at 1 January 2015 (n=47). RESULTS: There was a 100 % response to the questionnaire. The criteria for selecting where pregnant women should give birth were stated to be in conformity with the quality requirements. Some maternity institutions failed to describe the areas of responsibilities of doctors and midwives (38.5 % and 15.4 %, respectively). Few institutions recorded whether the midwife was present with the patient during the active phase. Half of the maternity departments (level 2 birth units) reported unfilled doctors' posts, and a third of the university hospitals/central hospitals (level 1 birth units) reported a severe shortage of locum midwives. Half of the level 2 birth units believed that the quality requirements had resulted in improved training, but reported only a limited degree of interdisciplinary or mandatory instruction. INTERPRETATION: The study reveals that there are several areas in which the health enterprises have procedures that conform to national quality requirements, but where it is still unclear whether they are observed in practice. Areas for improvement relate to routines describing areas of responsibility, availability of personnel resources and staff training.

Estimation of neonatal outcome artery pH value according to CTG interpretation of the last 60 min before delivery: a retrospective study. Can the outcome pH value be predicted?

PURPOSE: The aim of this study was to analyze whether the umbilical artery pH value can be estimated throughout CTG assessment 60 min prior to delivery and if the estimated umbilical artery pH value correlates with the actual one. This includes analysis of correlation between CTG trace classification and actual umbilical artery pH value. Intra-and interobserver agreement and the impact of professional experience on visual analysis of fetal heart rate tracing were evaluated. METHODS: This was a retrospective study. 300 CTG records of the last 60 min before delivery were picked randomly from the computer database with the following inclusion criteria; singleton pregnancy >37 weeks, no fetal anomalies, vaginal delivery either spontaneous or instrumental-assisted. Five obstetricians and two midwives of different professional experience classified 300 CTG traces according to the FIGO criteria and estimated the postnatal umbilical artery pH. RESULTS: The results showed a significant difference (p < 0.05) in estimated and actual pH value, independent of professional experience. Analysis and correlation of CTG assessment and actual umbilical artery pH value showed significantly (p < 0.05) diverging results. Intra- and interobserver variability was high. Intraobserver variability was significantly higher for the resident (p = 0.001). No significant differences were detected regarding interobserver variability. CONCLUSION: An estimation of the pH value and consequently of neonatal outcome on the basis of a present CTG seems to be difficult. Therefore, not only CTG training but also clinical experience and the collaboration and consultation within the whole team is important.

Effects of prenatal music stimulation on fetal cardiac state, newborn anthropometric measurements and vital signs of pregnant women: A randomized controlled trial.

BACKGROUND: Music has been used for medicinal purposes throughout history due to its variety of physiological, psychological and social effects. OBJECTIVE: To identify the effects of prenatal music stimulation on the vital signs of pregnant women at full term, on the modification of fetal cardiac status during a fetal monitoring cardiotocograph, and on anthropometric measurements of newborns taken after birth. MATERIAL AND METHOD: A randomized controlled trial was implemented. The four hundred and nine pregnant women coming for routine prenatal care were randomized in the third trimester to receive either music (n = 204) or no music (n = 205) during a fetal monitoring cardiotocograph. All of the pregnant women were evaluated by measuring fetal cardiac status (basal fetal heart rate and fetal reactivity), vital signs before and after a fetal monitoring cardiotocograph (maternal heart rate and systolic and diastolic blood pressure), and anthropometric measurements of the newborns were taken after birth (weight, height, head circumference and chest circumference). RESULTS: The strip charts showed a significantly increased basal fetal heart rate and higher fetal reactivity, with accelerations of fetal heart rate in pregnant women with music stimulation. After the fetal monitoring cardiotocograph, a statistically significant decrease in systolic blood pressure, diastolic blood pressure and heart rate in women receiving music stimulation was observed. CONCLUSION: Music can be used as a tool which improves the vital signs of pregnant women during the third trimester, and can influence the fetus by increasing fetal heart rate and fetal reactivity.

Consequences of delivery at home in a woman without prenatal care.

This is a case report of a 39-year-old multigravida woman without allopathic prenatal care who, after three previous caesarean sections, attempted to deliver her fourth child at home with the help of a direct entry midwife. During labour, fetal movement and fetal heart tones became undetectable, at which time the patient was referred by the midwife to the hospital. The patient was diagnosed with uterine rupture, bladder rupture and fetal demise; she was rushed to emergency surgery. The patient's lack of allopathic prenatal care, attempt of vaginal birth after three previous caesarean sections, coupled with her desire for delivery at home, led to her complicated course. The patient related that she was never made aware that attempting a home birth after three prior caesarean sections put her at increased risk for complications, and she was also unaware that midwives could have varying levels of training.

Fetal movements: What are we telling women?

PROBLEM: Information that women receive about the importance of monitoring fetal movements and what to do if there are changes is inconsistent and may not be evidence based. BACKGROUND: This paper reports a summary of the kind of messages a group of South Australian midwives (n=72) currently give pregnant women. METHODS: Comment data from two questions in a larger survey asking (1) what information midwives routinely provide to women about fetal movements and (2) their practice regarding advice they give to women reporting reduced fetal movements. Data were analysed using summative content analysis. FINDINGS: Four main recurring words and phrases were identified. With respect to information midwives give all women about monitoring fetal movements, recurring words were "10", "normal", "kick charts" and "when to contact" their care-provider. Recurrent words and phrases arising from answers to the second question about advice midwives give to women reporting reduced fetal movement were "ask questions," "suggest fluids," "monitor at home and call back" or "come in for assessment". DISCUSSION: These findings suggest that a group of South Australian midwives are providing pregnant women with inconsistent information, often in conflict with best practice evidence. CONCLUSION: As giving correct, evidence based information about what to do in the event of an episode of reduced fetal movement may be a matter of life or death for the unborn baby it is important that midwives use existing guidelines in order to deliver consistent information which is based on current evidence to women in their care.