Midwives holding the space for women undergoing termination of pregnancy: A qualitative inquiry.

PROBLEM: Hospital midwives are the main care givers for women undergoing termination of pregnancy after 20 weeks. Midwives' role and potential impact of regular involvement in termination of pregnancy (TOP) are poorly understood. SETTING: New Zealand. BACKGROUND: TOP after 20 weeks may be performed to save a woman's life or preserve her physical and mental health. Throughout the process midwives play a key role in supporting women's complex psychological and clinical needs. OBJECTIVE: To gain a deeper understanding of the role of midwives in TOP care after 20 weeks, including the support they might need and the impacts caring for women who are having a TOP may have on them. METHODS: Eight midwives from two District Health Boards were interviewed about their experiences of caring for women having a TOP after 20 weeks. Transcripts were analysed by applying a hermeneutic-phenomenological lens. FINDINGS: Three themes emerged: "A different kind of midwife", "Staying true to oneself" and "Melting an Iceberg". TOP care is a different role within midwifery as midwives facilitate death in the space of birth. Immersing themselves in women's emotional space they create meaningful connections to support their complex needs and provide a positive birth experience. Yet, midwives are unprepared for the emotional effects of repeatedly caring for women undergoing TOP. Lacking appropriate support they can experience increasing, lasting grief. CONCLUSION: Midwives' experiences of providing TOP care are complex, intense and have lifelong impact. Their role in the context of TOP is highly specialised and must be valued and supported.

Confidence: Fundamental to midwives providing labour care in freestanding midwifery-led units.

The aim of this study was to reveal what enables, safeguards and sustains midwives to provide labour care in freestanding midwifery-led units. DESIGN: A hermeneutic phenomenological study was undertaken in the Auckland region of New Zealand. In-depth interviews were conducted with 14 participants: 11 midwives who provide care in freestanding midwifery-led units and three obstetricians who provide antenatal consultations on site in midwifery-led units. MAIN FINDINGS: Confidence is necessary to provide intrapartum care in freestanding midwifery units. This confidence is cultivated by working in the community or freestanding unit and believing this unit is an appropriate space for healthy women to labour and birth. Normal labour and birth are commonplace in this space which in turn reinforces midwives' confidence. Maintaining confidence for midwives to work in these units requires trusting relationships in the midwifery team. Further, there needs to be mutually respectful relationships with obstetric colleagues. Midwives who have lesser experience, or experience in obstetric unit only, may need support to step into the role of providing labour care in freestanding midwifery units. When the midwife feels supported, when s/he witnesses women and families experiencing their normal birth, one's resolve to practising in this manner is strengthened. The midwife holds confidence. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Confidence required to provide labour care in a midwifery-led unit is cultivated through immersion in these units.

Sustainability and resilience in midwifery: A discussion paper.

BACKGROUND: midwifery workforce issues are of international concern. Sustainable midwifery practice, and how resilience is a required quality for midwives, have begun to be researched. How these concepts are helpful to midwifery continues to be debated. It is important that such debates are framed so they can be empowering for midwives. Care is required not to conceptually label matters concerning the midwifery workforce without judicious scrutiny and diligence. AIM: the aim of this discussion paper is to explore the concepts of sustainability and resilience now being suggested in midwifery workforce literature. Whether sustainability and resilience are concepts useful in midwifery workforce development is questioned. METHOD: using published primary midwifery research from United Kingdom and New Zealand the concepts of sustainability and resilience are compared, contrasted and explored. FINDINGS: there are obvious differences in models of midwifery care in the United Kingdom and New Zealand. Despite these differences, the concepts of resilience and sustainability emerge as overlapping themes from the respective studies' findings. Comparison between studies provides evidence of what is crucial in sustaining healthy resilient midwifery practice. Four common themes have been identified that traverse the different models of care; Self-determination, ability to self-care, cultivation of relationships both professionally and with women/families, and a passion, joy and love for midwifery. CONCLUSIONS: the impact that midwifery models of care may have on sustainable practice and nurturing healthy resilient behaviors remains uncertain. The notion of resilience in midwifery as the panacea to resolve current concerns may need rethinking. Resilience may be interpreted as expecting midwives 'to toughen up' in a workplace setting that is socially, economically and culturally challenging. Sustainability calls for examination of the reciprocity between environments of working and the individual midwife. The findings invite further examination of contextual influences that affect the wellbeing of midwives across different models of care.

Midwifing the notion of a 'good' birth: a philosophical analysis.

OBJECTIVE: to ponder afresh what makes a good birth experience in a listening manner. DESIGN: a hermeneutic approach that first explores the nature of how to listen to a story that is already familiar to us and then draws on Heidegger's notion of the fourfold to seek to capture how the components of a'good birth' come together within experience. SETTING: primary birthing centre, New Zealand PARTICIPANTS: the focus of this paper is the story of one participant. It was her second birth; her first birth involved a lot of medical intervention. She had planned to travel one hour to the tertiary birthing unit but in labour chose to stay at the Birth Centre. Her story seems to portray a 'very good birth'. FINDINGS: in talking of birth, the nature of a research approach is commonly to focus on one aspect: the place, the care givers, or the mode of care. In contrast, we took on the challenge of first listening to all that was involved in one woman's story. We came to see that what made her experience 'good' was'everything' gathered together in a coherent and supportive oneness. Heidegger's notion of the fourfold helped reveal that one cannot talk about one thing without at the same time talking about all the other things as well. Confidence was the thread that held the story together. KEY CONCLUSIONS: there is value in putting aside the fragmented approach of explicating birth to recognise the coming together of place, care, situation, and the mystery beyond explanation. Women grow a confidence in place when peers and community encourage the choice based on their own experience. Confidence of caregiver comes in relationship. Feeling confident within 'self' is part of the mystery. When confidence in the different dimensions holds together, birth is 'good'. IMPLICATIONS OR PRACTICE: one cannot simply build a new birthing unit and assume it will offer a good experience of birth. Experience is about so much more. Being mindful of the dimensions of confidence that need to be built up and sheltered is a quest for wise leaders. Protecting the pockets where we know 'good birth' already flourishes is essential.

Risk of severe postpartum hemorrhage in low-risk childbearing women in new zealand: exploring the effect of place of birth and comparing third stage management of labor.

BACKGROUND: Primary postpartum hemorrhage is a leading cause of maternal mortality and morbidity internationally. Research comparing physiological (expectant) and active management of the third stage of labor favors active management, although studies to date have focused on childbirth within hospital settings, and the skill levels of birth attendants in facilitating physiological third stage of labor have been questioned. The aim of this study was to investigate the effect of place of birth on the risk of postpartum hemorrhage and the effect of mode of management of the third stage of labor on severe postpartum hemorrhage. METHODS: Data for 16,210 low-risk women giving birth in 2006 and 2007 were extracted from the New Zealand College of Midwives research database. Modes of third stage management and volume of blood lost were compared with results adjusted for age, parity, ethnicity, smoking, length of labor, mode of birth, episiotomy, perineal trauma, and newborn birthweight greater than 4,000 g. RESULTS: In total, 1.32 percent of this low-risk cohort experienced an estimated blood loss greater than 1,000 mL. Place of birth was not found to be associated with risk of blood loss greater than 1,000 mL. More women experienced blood loss greater than 1,000 mL in the active management of labor group for all planned birth places. In this low-risk cohort, those women receiving active management of third stage of labor had a twofold risk (RR: 2.12, 95% CI: 1.39-3.22) of losing more than 1,000 mL blood compared with those expelling their placenta physiologically. CONCLUSIONS: Planned place of birth does not influence the risk of blood loss greater than 1,000 mL. In this low-risk group active management of labor was associated with a twofold increase in blood loss greater than 1,000 mL compared with physiological management. (BIRTH 39:2 June 2012).

Planned place of birth in New Zealand: does it affect mode of birth and intervention rates among low-risk women?

BACKGROUND: Midwives providing care as lead maternity caregivers in New Zealand provide continuity of care to women who may give birth in a variety of settings, including home, primary units, and secondary and tertiary level hospitals. The purpose of this study was to compare mode of birth and intrapartum intervention rates for low-risk women planning to give birth in these settings under the care of midwives. METHODS: Data for a cohort of low-risk women giving birth in 2006 and 2007 were extracted from the Midwifery Maternity Provider Organisation database. Mode of birth, intrapartum interventions, and neonatal outcomes were compared with results adjusted for age, parity, ethnicity, and smoking. RESULTS: Women planning to give birth in secondary and tertiary hospitals had a higher risk of cesarean section, assisted modes of birth, and intrapartum interventions than similar women planning to give birth at home and in primary units. The risk of emergency cesarean section for women planning to give birth in a tertiary unit was 4.62 (95% CI: 3.66-5.84) times that of a woman planning to give birth in a primary unit. Newborns of women planning to give birth in secondary and tertiary hospitals also had a higher risk of admission to a neonatal intensive care unit (RR: 1.40, 95% CI: 1.05-1.87; RR: 1.78, 95% CI: 1.31-2.42) than women planning to give birth in a primary unit. CONCLUSIONS: Planned place of birth has a significant influence on mode of birth and rates of intrapartum intervention in childbirth.

Nurses' perspectives on the care provided to cancer patients.

BACKGROUND: Optimal care for patients with cancer involves the provision of effective physical and psychological care. Nurses are key providers of this care; however, the effectiveness of care is dependent on the nurses' training, skills, attitudes, and beliefs. OBJECTIVE: The study reported in this article explored cancer nurses' perceptions of their ability to provide psychosocial care to adults with cancer and their subsequent evaluation of the effectiveness of the care provided. This study was the first part of a larger project that evaluated the effectiveness of Proctor's model of clinical supervision in an acute care oncology environment. METHODS: An exploratory qualitative design was used for this study. One focus group interview was conducted with 10 randomly selected registered nurses working within the oncology units at a major Melbourne tertiary referral hospital. Analytic themes were developed from the coded data using content analysis. RESULTS: The 4 analytic themes to emerge from the data were frustration, difficult to look after yourself, inadequate communication processes, and anger. CONCLUSION: The findings from this study indicate that, although informal mechanisms of support are available for oncology nurses, most of these services are not accessed. IMPLICATIONS FOR PRACTICE: Leaders in cancer care hospital settings need to urgently develop and implement a model of support for their oncology nurses who are attempting to provide psychosocial support to oncology patients.

Low-distortion, high-strength bonding of thermoplastic microfluidic devices employing case-II diffusion-mediated permeant activation.

We demonstrate a new method for joining thermoplastic surfaces to produce microfluidic devices. The method takes advantage of the sharply defined permeation boundary of case-II diffusion to generate dimensionally controlled, activated bonding layers at the surfaces being joined. The technique is capable of producing bonds that exhibit cohesive failure, while preserving the fidelity of fine features in the bonding interface. This approach is uniquely suited to production of layered microfluidic structures, as it allows the bond-forming interface between plastic parts to be precisely manipulated at micrometre length scales. Distortions in microfluidic device channels are limited to the size scale of the permeant-swollen layer; 6 microm deep channels are routinely produced with no detectable cross-sectional distortions. Conventional thermal diffusion bonding of identical parts yields less strongly bonded microfluidic structures with increasingly severe dimensional compressions as bonding temperatures approach the thermoplastic glass-transition temperature: a preliminary rheological analysis is consistent with the observed compressions. The bond-enhancing procedure is easily integrated in standard process flows, uses inexpensive reagents, and requires no specialized equipment.