Insider knowledge as a double-edged sword: an integrative review of midwives' personal childbearing experiences.

BACKGROUND: The majority of maternity care is provided by female midwives who have either become mothers or are of childbearing age, but there is limited research exploring midwives' own personal childbearing experiences. This integrative review aims to explore the published literature and research on midwives' own experiences of pregnancy and childbirth. METHOD: An integrative review of the literature was conducted after relevant articles were identified through a search of: five electronic databases (Cumulative Index of Nursing and Allied Health Literature (CINAHL), Medline, PubMed, Scopus, and Google Scholar), cited reference lists, and networking with peers. Similar and contrasting patterns and relations within the literature were identified and grouped into themes and subthemes. RESULTS: Twenty articles were included in the review and four overarching themes were identified. Insider knowledge plays a role in decision making encompassed the way midwives used their knowledge to choose; a preferred mode of birth, maternity care provider, model of care, and place of birth. Navigating the childbirth journey demonstrated how some midwives were able to use their insider knowledge to achieve agency, while others had difficulty achieving agency. This theme also revealed the 'midwife brain' that midwives need to manage during their childbearing journey. The theme impact of care on the birth experience described how the type of care the midwives received from maternity care providers affected their overall birth experience. The fourth theme from midwife to mother explains their preparedness for childbirth and their transition to motherhood. CONCLUSION: For childbearing midwives, there is a potential conflict between their position as knowledgeable experts in maternity care, and their experience as mothers. Whilst they can use their insider knowledge to their advantage, they also experience heightened fear and anxiety through their pregnancy. It is important for maternity care providers to acknowledge and support them and provide balanced and tailored care that acknowledges the woman within the professional midwife and the professional midwife within the woman.

Childbirth and consequent atopic disease: emerging evidence on epigenetic effects based on the hygiene and EPIIC hypotheses.

BACKGROUND: In most high and middle income countries across the world, at least 1:4 women give birth by cesarean section. Rates of labour induction and augmentation are rising steeply; and in some countries up to 50% of laboring women and newborns are given antibiotics. Governments and international agencies are increasingly concerned about the clinical, economic and psychosocial effects of these interventions. DISCUSSION: There is emerging evidence that certain intrapartum and early neonatal interventions might affect the neonatal immune response in the longer term, and perhaps trans-generationally. Two theories lead the debate in this area. Those aligned with the hygiene (or 'Old Friends') hypothesis have examined the effect of gut microbiome colonization secondary to mode of birth and intrapartum/neonatal pharmacological interventions on immune response and epigenetic phenomena. Those working with the EPIIC (Epigenetic Impact of Childbirth) hypothesis are concerned with the effects of eustress and dys-stress on the epigenome, secondary to mode of birth and labour interventions. This paper examines the current and emerging findings relating to childbirth and atopic/autoimmune disease from the perspective of both theories, and proposes an alliance of research effort. This is likely to accelerate the discovery of important findings arising from both approaches, and to maximize the timely understanding of the longer-term consequences of childbirth practices.

A national survey of Australian midwives' birth choices and outcomes.

BACKGROUND: Maternity care in Australia is predominantly provided by midwives, many who give birth. There is a paucity of research on midwives' own childbearing preferences and experiences. AIM: To explore midwives childbirth preferences and outcomes when giving birth to their first child in Australia, after qualifying as a midwife. METHODS: An online national survey. Data were analysed using descriptive statistics. FINDINGS: 447 midwives responded, with the majority of midwives indicating a preference for a normal vaginal birth with a known care provider under a continuity of midwifery care model. For midwives who were first time mothers, 66% had normal vaginal births, 16.3% had an instrumental birth, and 16.8% had caesarean births. Over 85% of midwives received the model of care they wanted and 45% had continuity of midwifery care. While a quarter of midwives wanted a homebirth,11.2% achieved this. Over three quarters (75.4%) of midwives were cared for by a care provider of their choosing. DISCUSSION: There was a difference in models of care accessed and birth outcomes between midwives and other women giving birth for the first-time in Australia. Australian midwives appear to have the advantage of clinical and scientific knowledge to navigate the maternity care system to get the birth care and outcomes they want. CONCLUSION: It is possible that professional experience, insider knowledge, and existing relationships with other midwifery friends and colleagues, affords midwives a higher degree of agency and autonomy when it comes to getting the maternity care and birth outcomes that they want.

The implementation and evaluation of a mentoring program for Bachelor of Midwifery students in the clinical practice environment.

AIM: To describe the implementation and evaluation of a midwife/midwifery student-mentoring program in one Local Health District in Sydney NSW Australia. BACKGROUND: Evidence suggests well designed and supported midwife/midwifery student mentorship programs can make a difference to the clinical placement experiences and attrition rates of midwifery students. DESIGN: In the evaluation of the mentoring program, we used surveys, focus groups and individual interviews. METHODS: Eighty-six participants, including midwife mentors, midwifery students, non-mentor midwives and midwifery managers participated in the evaluation. Quantitative data were analysed using descriptive statistics and qualitative data, content analysis. RESULTS: The mentoring program increased midwives' mentoring skills and was beneficial to their professional growth and leadership skills. Students reported positive outcomes including someone to talk to, emotional support and a sense of belonging. Mentoring programs require structure, mentor training, organisational support and transparency. CONCLUSION: The mentoring program provided benefits to both midwifery mentors and students and demonstrated the value of a structured and supported mentoring program for midwifery students.

The midwife-student mentor relationship: Creating the virtuous circle.

BACKGROUND: Good mentoring is important for students to support their adjustment to and learning in the clinical environment. The quality of the mentoring relationship is key for students but there is a lack of evidence explaining how a good mentor/mentee relationship establishes and develops over time. AIM: To explore the developing relationship between mentors and mentees participating in a structured midwifery mentoring program in one Local Health District in Sydney, Australia. METHODS: A qualitative interpretive descriptive research design was utilised. Data were collected using 10 focus groups with midwife mentors (n = 31) and seven focus groups and four interviews with Bachelor of Midwifery student mentees (n = 24), over a 12-month period. Thematic analysis using an inductive approach was applied incorporating constant comparison to identify themes and sub-themes. FINDINGS: Three overarching themes and three sub-themes were identified. The first theme was 'The great unknown'. Within the second theme 'Building the relationship' were three subthemes: trying to connect; becoming known; and an insider on your side. The final theme 'the virtuous circle' described the reciprocal relationship and benefits that developed between mentor and mentee. DISCUSSION: The mentor/mentee relationship took time to develop and went through a number of phases. A positive mentor/ mentee relationship flattened hierarchical differences, increased student confidence and capacity for learning, and reflected the midwifery continuity of care relationship between midwife and woman built on respect and partnership. CONCLUSION: Developing a successful midwifery mentoring relationship takes persistence, reassurance, and mutual disclosure ultimately resulting in a recurring cycle of encouragement and support.

Correction to: One Plus One Equals Two-will that do? A trial protocol for a Swedish multicentre randomised controlled trial to evaluate a clinical practice to reduce severe perineal trauma.

An amendment to this paper has been published and can be accessed via the original article.

One Plus One Equals Two-will that do? A trial protocol for a Swedish multicentre randomised controlled trial to evaluate a clinical practice to reduce severe perineal trauma {1}.

BACKGROUND: Severe perineal trauma sustained during childbirth is a serious complication since it can lead to both short- and long-term consequences for women. Some of the methods used to prevent perineal injuries have been evaluated in clinical trials, but there are still gaps in the evidence. A new clinical practice has been introduced, adopted by more than half of the maternity wards in Sweden with the aim of reducing severe perineal trauma. This procedure involves two midwives assisting the woman during the second stage of labour. METHODS/DESIGN: In this multicentre randomised controlled trial, 2946 women will be randomised to be assisted by one or two midwives during the second stage of labour. Women age 18-47, who plan for their first vaginal birth, with a singleton pregnancy in cephalic presentation, will be asked to participate when admitted to the maternity ward. Five maternity wards comprising 19,500 births/year in different parts of Sweden will participate in this study. The sample size is powered to demonstrate a 50% reduction (from 4.1-2.0%) in primary outcome, which is the prevalence of severe perineal trauma (3rd and 4th degree). Secondary outcomes will include maternal and neonatal outcomes, women's experiences, midwives' experiences of the intervention, incontinence, and pelvic floor symptoms. The primary analysis is intention to treat. Questionnaires will be sent to the women at 1 month and 1 year after the birth to assess women's experiences, pain, incontinence, pelvic floor symptoms, sexual function, and mental health. DISCUSSION: It is important for care during labour and birth to be evidence based. There is a strong desire among midwives to reduce the risk of severe perineal trauma. This may lead to new strategies and practices being implemented into practice without scientific evidence. The intervention might have negative side effects or unintended consequences. On the other hand, there is a possibility of the intervention improving care for women. TRIAL REGISTRATION {2A}: ClinicalTrials.gov NCT03770962 . Registered on 10 December 2018.

A unified call to action from Australian nursing and midwifery leaders: ensuring that Black lives matter.

Nurses and midwives of Australia now is the time for change! As powerfully placed, Indigenous and non-Indigenous nursing and midwifery professionals, together we can ensure an effective and robust Indigenous curriculum in our nursing and midwifery schools of education. Today, Australia finds itself in a shifting tide of social change, where the voices for better and safer health care ring out loud. Voices for justice, equity and equality reverberate across our cities, our streets, homes, and institutions of learning. It is a call for new songlines of reform. The need to embed meaningful Indigenous health curricula is stronger now than it ever was for Australian nursing and midwifery. It is essential that nursing and midwifery leadership continue to build an authentic collaborative environment for Indigenous curriculum development. Bipartisan alliance is imperative for all academic staff to be confident in their teaching and learning experiences with Indigenous health syllabus. This paper is a call out. Now is the time for Indigenous and non-Indigenous nurses and midwives to make a stand together, for justice and equity in our teaching, learning, and practice. Together we will dismantle systems, policy, and practices in health that oppress. The Black Lives Matter movement provides us with a 'now window' of accepted dialogue to build a better, culturally safe Australian nursing and midwifery workforce, ensuring that Black Lives Matter in all aspects of health care.

Process evaluation of the midwifery initiated oral health-dental service program: perceptions of pregnant women.

BACKGROUND: Pregnant women in Australia seldom seek dental care and are unaware of its importance. To address these gaps the midwifery-initiated oral health dental service (MIOH-DS) program was comprehensive trialled and found effective. The aim of this study was to undertake a process evaluation of the MIOH-DS using the perspectives of pregnant women who participated in the trial. METHODS: A qualitative research design was utilized, whereby content analysis was undertaken on data from 11 semi-structured interviews with women who participated in the program. RESULTS: All participants were receptive of the MIOH-DS intervention, and found it to be an acceptable intervention that met their needs, and encouraged future positive oral health practices and health-seeking behaviours. They expressed that midwives were an appropriate professional to conduct oral health assessments, education and referrals to affordable dental services. Although some participants were initially apprehensive towards receiving treatment during pregnancy, dental staff members were able to appropriately educate and reassure them during treatment. CONCLUSIONS: The MIOH-DS represents a promising and acceptable intervention strategy for pregnant women to promote their oral health. Findings merit further investigation on whether positive outcomes achieved can be sustained when implemented in other national or international settings similar to the study setting.

Knowledge, attitude and practises of dentists towards oral health care during pregnancy: A cross sectional survey in New South Wales, Australia.

BACKGROUND: Studies internationally show a lack of consensus among dentists regarding perinatal oral health yet no study in Australia has explored the perceptions of dentists in this area. This study aims to determine the knowledge, perceptions and practises of dentists in New South Wales (NSW), Australia, about perinatal oral health. METHODS: An online survey was distributed to 1357 members of the Australian Dental Association (NSW) and 185 (13.4%) completed surveys were returned. RESULTS: Most dentists (99%) stated that pregnant women should receive a dental check, yet only 20% agreed that there was a good understanding among health professionals on this topic. Dentists were aware of safe dental practises during pregnancy but had limited knowledge about the association between periodontal disease and birth outcomes. Dentists were more likely to advise pregnant women to delay dental visits when there was a perceived lack of knowledge of the risks involved (odds ratio, 2.157) or were concerned about providing treatment without consent from their general practitioner (odds ratio, 2.449). Most dentists (95.7%) stated that they wanted further information about dental care during pregnancy. CONCLUSIONS: Findings suggest a need for continuing education for dentists and practise guidelines on perinatal oral health. Further research with a national sample is recommended to confirm these findings.

Complementary therapies for labour and birth study: a randomised controlled trial of antenatal integrative medicine for pain management in labour.

OBJECTIVE: To evaluate the effect of an antenatal integrative medicine education programme in addition to usual care for nulliparous women on intrapartum epidural use. DESIGN: Open-label, assessor blind, randomised controlled trial. SETTING: 2 public hospitals in Sydney, Australia. POPULATION: 176 nulliparous women with low-risk pregnancies, attending hospital-based antenatal clinics. METHODS AND INTERVENTION: The Complementary Therapies for Labour and Birth protocol, based on the She Births and acupressure for labour and birth courses, incorporated 6 evidence-based complementary medicine techniques: acupressure, visualisation and relaxation, breathing, massage, yoga techniques, and facilitated partner support. Randomisation occurred at 24-36 weeks' gestation, and participants attended a 2-day antenatal education programme plus standard care, or standard care alone. MAIN OUTCOME MEASURES: Rate of analgesic epidural use. Secondary: onset of labour, augmentation, mode of birth, newborn outcomes. RESULTS: There was a significant difference in epidural use between the 2 groups: study group (23.9%) standard care (68.7%; risk ratio (RR) 0.37 (95% CI 0.25 to 0.55), p≤0.001). The study group participants reported a reduced rate of augmentation (RR=0.54 (95% CI 0.38 to 0.77), p<0.0001); caesarean section (RR=0.52 (95% CI 0.31 to 0.87), p=0.017); length of second stage (mean difference=-0.32 (95% CI -0.64 to 0.002), p=0.05); any perineal trauma (0.88 (95% CI 0.78 to 0.98), p=0.02) and resuscitation of the newborn (RR=0.47 (95% CI 0.25 to 0.87), p≤0.015). There were no statistically significant differences found in spontaneous onset of labour, pethidine use, rate of postpartum haemorrhage, major perineal trauma (third and fourth degree tears/episiotomy), or admission to special care nursery/neonatal intensive care unit (p=0.25). CONCLUSIONS: The Complementary Therapies for Labour and Birth study protocol significantly reduced epidural use and caesarean section. This study provides evidence for integrative medicine as an effective adjunct to antenatal education, and contributes to the body of best practice evidence. TRIAL REGISTRATION NUMBER: ACTRN12611001126909.

The Complementary Therapies for Labour and Birth Study making sense of labour and birth - Experiences of women, partners and midwives of a complementary medicine antenatal education course.

OBJECTIVE: to gain insight into the experiences of women, partners and midwives who participated in the Complementary Therapies for Labour and Birth Study, an evidence based complementary medicine (CM) antenatal education course. DESIGN: qualitative in-depth interviews and a focus group as part of the Complementary Therapies for Labour and Birth Study. SETTING AND PARTICIPANTS: thirteen low risk primiparous women and seven partners who had participated in the study group of a randomised controlled trial of the complementary therapies for labour and birth study, and 12 midwives caring for these women. The trial was conducted at two public hospitals, and through the Western Sydney University in Sydney, Australia. INTERVENTIONS: the Complementary Therapies for Labour and Birth (CTLB) protocol, based on the She Births® course and the Acupressure for labour and birth protocol, incorporated six evidence-based complementary medicine (CM) techniques; acupressure, relaxation, visualisation, breathing, massage, yoga techniques and incorporated facilitated partner support. Randomisation to the trial occurred at 24-36 weeks' gestation, and participants attended a two-day antenatal education programme, plus standard care, or standard care alone. FINDINGS: the overarching theme identified in the qualitative data was making sense of labour and birth. Women used information about normal birth physiology from the course to make sense of labour, and to utilise the CM techniques to support normal birth and reduce interventions in labour. Women's, partners' and midwives' experience of the course and its use during birth gave rise to supporting themes such as: working for normal; having a toolkit; and finding what works. KEY CONCLUSIONS: the Complementary Therapies for Labour and Birth Study provided women and their partners with knowledge to understand the physiology of normal labour and birth and enabled them to use evidence-based CM tools to support birth and reduce interventions. IMPLICATIONS FOR PRACTICE: the Complementary Therapies for Labour and Birth Study introduces concepts of what constitutes normal birth and provides skills to support women, partners and midwives. It appears to be an effective form of antenatal education that supports normal birth, and maternity services need to consider how they can reform current antenatal education in line with this evidence.

Hyperprolactinemic anovulatory syndrome.

The functional status of the hypothalamo-pituitary-gonadal axis was investigated in 127 women with anovulatory disease. Radioimmunoassayable circulating LH, FSH, and prolactin concentrations were measured. An attempt was made to localize the functional lesion by utilizing the following criteria: 1. Hypothalamic function: a) clomiphene test based upon hormonal parameters; b) recording of the pulsatile LH fluctuation (spiking) and of basal FSH. 2. Pituitary function: determination of the gonadotropin reserve by means of a standardized LRH test. 3. Ovarian function: a) measurement of plasma E2 and progesterone levels by RIA; b) gestagen bleeding test. All patients had amenorrhea of up to 14 years duration. A total of 17 hyperprolactinemic patients (13.4%) was found. Eight of these patients never experienced galatorrhea, in 7 only transient galactorrhea was reported, and in 2 cases galactorrhea persisted. All hyperprolactinemic patients were found to be clomiphene non-responders as well as nonspikers. The pituitary LH reserve varied from practically none to normal. Baseline LH was low whereas that of FSH was normal. In accordance with this observation E2 levels, with two exceptions, were found to be in the lower range of normal female concentrations. Thus, all but two patients exhibited gestagen withdrawal bleeding. In conclusion, the hyperprolactinemic anvoluatory syndrome is not necessarily associated with galactorrhea. In all cases of amenorrhea syndromes with or without galactorrhea, hyperprolactinemia should be excluded as it is very often associated with anovulation. The hyperprolactinemic anovulatory syndrome includes the following features: 1. gestagen withdrawal bleeding. 2. subnormal to normal E2 levels. 3. clomiphene nonresponsiveness. 4. LH-hypogonadotropism. 5. lack of LH secretory episodes. 6. FSH-normogonadotropism.

Human pituitary gonadotropin index. I. Standardized LRH test criteria for evaluation of functional amenorrhea.

LRH test were carried out by giving 339 amenorrheic women and 74 normally menstruating volunteers an intravenous injection of 25 mug LRH (Hoe 471). Plasma LH and FSH were measured by RIA in two laboratories (Tuebingen and Ulm) using two standard reference preparations: LER 907 and 2nd IRP-HMG. The average conversion factors between the two standard preparations were calculated at 5.0 for LH and 25.0 for FSH. Furthermore, the estradiol-17beta levels were measured in 139 out of the 339 patients immediately before and 60 minutes after LRH injection. Taking the episodic and cyclic plasma gonadotropin fluctuations into consideration a shorthand system classifying the gonadotropin baseline (BI-BIV) and LH responses to 25 mug LRH (R0-R2) has been established and is referred to as Human Pituitary Gonadotropin Index (HPGI). It is possible to achieve reproducible gonadotropin results in two different laboratories using two different standard reference preparations. Two separate, randomly selected groups of amenorrheic women were found to have the same percent distribution of the HPGI. A correlation coefficient of r equal 0.67 between basal and LRH stimulated plasma LH levels does not sufficiently characterize the individual LH response behavior. A significant increase of plasma LH and FSH within the test period (60') reveals that the iv administration of 25 mug LRH represents an adequate dose for the LRH test in women. The HPGI which characterizes the functional state of gonadostat, may become a useful diagnostic index for evaluating women with anovulatory disease before, during, and after therapy.

Stimulation of pancreatic amylase release is associated with a parallel sustained increase of cytoplasmic calcium.

The kinetics of the changes in the cytoplasmic Ca2+ concentration (Ca2+i) and amylase release were measured in fura-2-loaded pancreatic acinar cells and perifused pancreatic acini, respectively. Cholecystokinin octapeptide (CCK-8) and its amphibian analogue caerulein induced similar dose-related increases of Ca2+i and amylase secretion with threshold concentrations of 2-6 x 10(-12) M, and maximal effects at 2 x 10(-10) M. The action of CCK/caerulein on Ca2+i was complex and similar to that of carbachol and bombesin with a prompt several-fold increase within seconds followed by a gradual decline over more than 5 min to a new sustained suprabasal level. The kinetics of amylase release in response to CCK and carbachol correlated with the changes in Ca2+i. Additions of the antagonists N2,O2-dibutyrylguanosine 3':5'-cyclic monophosphate and atropine after 30 min of CCK-8 and carbachol stimulation, respectively, were associated with prompt lowerings of Ca2+i and inhibitions of amylase secretion. The patterns observed with substance P (SP) and eledoisin were different with high concentrations (10(-8)-10(-7) M) giving monophasic increases of Ca2+i and amylase release. An initial stimulation of cells with a high dose of CCK eliminated the Ca2+i response to further stimulation with CCK, carbachol, bombesin and SP, whereas cells subjected to initial stimulation with SP responded to subsequent exposure to CCK with prolonged elevation of Ca2+i. The data indicate that stimulation with CCK, carbachol and bombesin may be associated with intracellular mobilization of calcium from more than one pool, and that an increase of Ca2+i is involved even in threshold stimulation of amylase release.

Quantitation of human chorionic gonadotrophin (hCG) by radioreceptor assay.

A sensitive radioreceptor assay was developed for pharmaceutical preparations of human chorionic gonadotrophin with the use of rat testicular membranes as receptor preparation and human 125I-chorionic gonadotrophin as tracer. The addition of unlabelled human chorionic gonadotrophin or luteinizing hormone inhibited the binding of 125I-chorionic gonadotrophin to the receptors in a concentration dependent way. Concentrations of human chorionic gonadotrophin between 30-300 mIU ml(-1) were normally used for a three-dose assay fulfilling pharmacopoeial statistical requirements for assay validity. The relative standard deviation for five assays was 7%. Estimates of potency of commercial preparations of human chorionic gonadotrophin obtained with the radioreceptor assay correlated well with corresponding estimates from in vivo assays. The proposed radioreceptor assay, however, provides a considerable saving in the number of animals required, requires less technical support, and is more precise than the in vivo method.

Effects of a new antiovulatory steroid on gonadotropins, prolactin and blood coagulation.

PIP: Effects of a new antiovulatory steroid (Ro 6-5403) on gonadotropins, prolactin, and blood coagulation were studied in 8 normally menstruating women who had previously undergone tubal ligation. Blood was obtained at 1-5 day intervals during 3 cycles: 1 cycle before treatment, 1 cycle during treatment of 2 mg Ro 6-5403 orally twice daily from cycle Day 5 through 24 and 1 cycle following treatment. Low plasma levels of progesterone and ihibition of release of luteinizing hormone and follicle stimulating hormone indicated suppression of ovulation during treatment. Prolactin levels were significantly elevated (p less than .001) during treatment. Fibrinogen concentration was significantly elevated (p less than .01) and the mean number of platelets was increased. Thromboelastography showed significantly reduced values for k-time (p less than .05) and significantly increased values for maximal amplitude (p less than .05). Thrombin time was decreased and partial thromboplastin time was significantly decreased (p less than .01) during treatment. All parameters returned to pretreatment values except thrombin time where the decrease continued to a significant difference (p less than .01). The side effects subsided after the initial day of treatment. Liver and kidney parameters remained within the physiological range. "Hypercoagulability" and elevated prolactin levels were interpreted as related to the estrogenlike activity of Ro 6-5403.^ieng

Acupuncture and acupressure for pain management in labour and birth: a critical narrative review of current systematic review evidence.

BACKGROUND: Reviews of maternity services highlight the need for a reduction of medical interventions for women with low risk pregnancies and births to prevent the potential cascade of interventions and their associated risks. Complementary medicines (CM) such as acupuncture and acupressure have claimed to be effective in reducing interventions in labour; however, systematic reviews of evidence to date are conflicting. AIMS: To examine current evidence from systematic reviews on the topic of acupuncture and acupressure for pain management in labour and birth, and to evaluate the methodological and treatment frameworks applied to this evidence. METHODS: A search limited to systematic reviews of the MEDLINE, CINAHL, PUBMED, EMBASE and Cochrane databases was performed in December 2013 using the keywords 'CAM', 'alternative medicine', 'complementary medicine', 'complementary therapies', 'traditional medicine', 'Chinese Medicine', 'Traditional Chinese Medicine', 'acupuncture', 'acupressure', cross-referenced with 'childbirth', 'birth', labo*r', and 'delivery'. The quality of the evidence is also evaluated in the context of study design. RESULTS: The RCTs included in these systematic reviews differed in terms of study designs, research questions, treatment protocols and outcome measures, and yielded some conflicting results. It may be inappropriate to include these together in a systematic review, or pooled analysis, of acupuncture for labour with an expectation of an overall conclusion for efficacy. Trials of acupuncture and acupressure in labour show promise, but further studies are required. CONCLUSION: The use of current systematic reviews of the evidence for acupuncture and acupressure for labour and birth may be misleading. Appropriate methods and outcome measures for investigation of acupuncture and acupressure treatment should more carefully reflect the research question being asked. The use of pragmatic trials designs with woman-centred outcomes may be appropriate for evaluating the effectiveness of these therapies.

Putting evidence into practice: a quality activity of proactive pain relief for postpartum perineal pain.

BACKGROUND: Perineal pain associated with perineal trauma is often underestimated. Offering regular pain relief may be advantageous compared to waiting for women to request it. Changing clinical practice in a sustained way needs a whole of team approach. AIM: To reduce women's pain following perineal trauma in the first 48 h following childbirth and to undertake this as multidisciplinary, quality activity. METHODS: In November 2008 a questionnaire was distributed to 18 new mothers who had sustained perineal trauma during the birth in order to assess pain levels in the first 48 h and to investigate pain management therapies used. Following this survey a multidisciplinary project team undertook a series of brainstorming sessions, reviewed the literature and undertook staff surveys to identify key factors impacting on women's perineal pain. A process of decision making led to education and support of women and staff. An evidence based guideline, which involved prescribing regular pain relief for women and offering an ice pack within 1h of giving birth was implemented, and a brochure was designed for women. A follow up questionnaire was distributed in June 2010 to 18 women and pain scores before and after the change in policy were compared. RESULTS: Prior to the practice change in 2008 67% of the women surveyed rated their pain as 'moderate' to 'a lot' 48 h following the birth. Following the change in practice and implementation of a new guideline a second survey in 2010 at 48 h postpartum found 60% of women in the post intervention group rated their perineal pain as 'a lot' to 'moderate'. There had been a 33% increase in women's use of pain relief options compared to the pre-intervention survey. The practice change was sustained and adopted by all the staff. CONCLUSION: By taking a multidisciplinary quality activity an effective practice change was facilitated that appeared to decrease women's perineal pain in the 48 h following birth.