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Introduction: In 2003 the World Health Organization (WHO) recommended that infants should be fed exclusively with breast milk until the age of six months. However, breast feeding rates remain lower than recommended. The crucial period for breast feeding support is the first two weeks after birth. During this period breast feeding support from the midwife is needed. The aim of this paper is to gain an in-depth understanding of the role of midwives in their support of breast-feeding women, from their own perspective., Methods: Two researchers independently conducted a systematic and comprehensive literature search. Studies needed an empirical qualitative research design (1), had to focus on the role of the midwife in the support of the breast-feeding woman from the midwife's perspective (2), and had to be published between January 2005 and December 2014 (3) in order to be included. Language restrictions were English, Dutch, German and French. Eight qualitative research studies were included, using mainly focus group and in-depth interview studies, which were reported in 11 papers representing 231 midwives and 24 maternity nurses. All but one study concerned midwives working in hospital settings. A critical appraisal was performed of each study., Findings: Midwives value breast feeding education and breast feeding support as a significant part of their role as a postnatal midwife. However, the ways in which a midwife approaches and supports the breast-feeding woman vary. We distinguished two perspectives: 'the midwife as technical expert' and 'the midwife as a skilled companion'. The 'technical expert' midwife is mainly breast centred, focuses on techniques, uses the hands on approach and sees a woman as a novice. The 'skilled companion' midwife is woman centred, focuses on the mother - infant relationship and uses a hands off approach during the breast feeding support. The midwives working in a hospital setting face many barriers when performing breast feeding support, such as time restraints, which makes it difficult for them to carry out their preferred role as a 'skilled companion'. These barriers can influence the breast feeding support negatively. Supporting factors, such as evidence based breast feeding guidelines, have a positive influence on the breast feeding support., Conclusion: On the basis of findings of a synthesis of qualitative research studies, we conclude that the majority of the midwives provide breast feeding support as a technical expert and a minority as a skilled companion. Midwives prefer to be a skilled companion but face many barriers in their working contexts., (Copyright © 2016. Published by Elsevier Ltd.)

Breastfeeding education must motivate a complete workforce in such a way that they are equipped with the fundamentals and extended skills to carry out their role as infant feeding gurus, throughout their career. To achieve this with any success, there is an intrinsic need to establish a total understanding of both the physiology and emotional importance which underlies the art of breastfeeding. Only when this is attained will passion and longevity for the 'art' be fully embraced and respected.

With a rise in caesarean births there is a rise in wound care management issues for midwives and the potential for surgical site infections (SSIs). The burden of SSIs include increases in maternal mortality, morbidity, length of hospital stay and cost. Sepsis is currently the leading cause of maternal mortality, with 50 per cent of the women who died from sepsis having had a caesarean birth (Centre for Maternal and Child Enquiries (CMACE) 2011). Wound management and the prevention of sepsis are therefore issues of great concern to midwives. This article considers the incidence of wound infections and presents the guidance available to help address this problem.

The Confidential Maternal and Child Enquiry (CMACE) has firmly put maternal mental health at the forefront of maternity care (CMACE 2011). Twenty nine deaths by suicide were reported and over half of these women were married or in stable cohabitation, 30 years of age or older and had a psychiatric history. Given the predictive nature of psychiatric conditions in pregnancy, midwives need to be enabled to identify women at risk, and assess and refer women appropriately. The aim of this article is to give midwives an overview and understanding of the predictability and detectability of perinatal mental illness; to explore some of the tools available; to enable midwives to assess women appropriately for referral; and to address the issue of medication in pregnancy and whilst breastfeeding.

Objective: the aim of the study was to ascertain the attitudes of Swedish midwives towards management of very preterm labour and birth and to compare the attitudes of midwives at university hospitals with those at general hospitals., Design: this cross-sectional descriptive and comparative study used an anonymous self-administrated questionnaire for data collection. Descriptive and analytic statistics were carried out for analysis., Participants: the answers from midwives (n=259) were collected in a prospective SWEMID study., Setting: the midwives had experience of working on delivery wards in maternity units with neonatal intensive care units (NICU) in Sweden., Findings: in the management of very preterm labour and birth, midwives agreed to initiate interventions concerning steroid prophylaxis at 23 gestational weeks (GW), caesarean section for preterm labour only at 25 GW, when to give information to the neonatologist before birth at 23 GW, and when to suggest transfer to NICU at 23 GW. Midwives at university hospitals were prone to start interventions at an earlier gestational age than the midwives at general hospitals. Midwives at university hospitals seemed to be more willing to disclose information to the parents., Key Conclusions: midwives with experience of handling very preterm births at 21-28 GW develop a positive attitude to interventions at an earlier gestational age as compared to midwives without such experience., Implications for Practice: based on these results we suggest more communication and transfer of information about the advances in perinatal care and exchange of knowledge between the staff at general and university hospitals. Establishment of platforms for inter-professional discussions about ethically difficult situations in perinatal care, might benefit the management of very preterm labour and birth., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Objective: to explore the views of expert midwives in Ireland and New Zealand of the skills they employ in expectant management of the third stage of labour (EMTSL)., Design: university ethical approval was granted for a qualitative descriptive study in 2010. Recorded, semi-structured interviews were undertaken. Constant comparative analysis was used., Setting: community birth settings in Ireland and New Zealand., Participants: 27 consenting midwives who used EMTSL in at least 30% of births, with PPH rates less than 4%., Findings: the majority of respondents believed the third stage was a special time of parent-baby discovery and 'watchful waiting', with no intervention necessary. Great importance was placed on women's feelings, behaviour and a calm environment. Skin-to-skin contact, breast feeding, not clamping the cord, upright positions and maternal effort, sometimes assisted by gentle cord-traction were also used., Key Conclusions: some components of EMTSL identified by these expert midwives are not recorded in text-books, but are based on experience and expertise. These elements of EMTSL add to midwifery knowledge and provide a basis for further discussion on how normal physiology can be supported during the third stage., Implications for Practice: use of these elements is recommended for women who request EMTSL, and for those in countries without ready access to uterotonics., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

The aim of the survey was to assess midwives' experiences and knowledge of cleft lip and/or palate (CL+/-P), confidence in supporting the families and giving feeding advice, and to identify areas for input from the cleft team. In order to do so, questionnaires were sent to maternity units across Scotland. The results were as follows: 206 questionnaires were returned (42 per cent response rate). Forty one per cent of the midwives had helped a baby with CL+/-P to be born; 23 per cent knew the incidence of CL+/-P; 33 per cent were aware of the stages in treating CL+/- P; 99 per cent were aware that feeding difficulties are a potential complication. When asked about offering support to the families, 70 per cent were not confident and 60 per cent were not confident at giving feeding advice. Regarding cleft team input, 65 per cent would like a training day, 45 per cent requested small group teaching, 50 per cent would like a website and 57 per cent would like printed literature. Our recommendations are to implement training, for midwives, along with supporting websites and literature.

Objective: to study how Swedish midwives working in low-risk labour ward units rate intrapartum risks compared to their midwifery colleagues working in standard care labour wards. A second aim was to describe midwives' attitudes toward performing different types of interventions during a normal labour., Design: an explorative study was carried out in 2009, using a web-based questionnaire containing 31 questions on midwives' risk ratings and attitudes to interventions during labour, as well as personal comments., Setting: four labour ward units in Stockholm, Sweden. Two labour ward units with expected normal deliveries ('low-risk') and two standard care units with all types of deliveries., Participants: seventy-seven registered clinically practicing midwives., Findings: midwives in all units stated that factors to be considered for risk estimation were: previous delivery outcome, result of cardiotocography test (CTG) on admission to labour ward and quality of amniotic fluid. Midwives working at the low-risk units preferred to be more expectant during normal birth than their colleagues working at the standard care units. Examples of this were regarding second vaginal examination during labour (p=0.001) and/or amniotomy (p=0.012). Furthermore, midwives working at the low-risk units more often considered that first-time mothers could give birth without epidural analgesia during labour (p=0.019) and that the labouring woman should be encouraged to push according to her own spontaneous urge (p=0.040). Midwives at low-risk units were more reluctant to use an intravenous vein catheter than their colleagues at standard care units (p=0.001) and also to use oxytocin in order to augment contractions (p=0.013). Further, the open-ended question showed that attitudes to different types of interventions differed between midwives working at low-risk units or the standard care units working with all types of deliveries., Conclusion: the Swedish midwives estimated risks similarly regardless of whether they worked in low-risk or in standard care units, but midwives working at low-risk units reported that they perform less routine interventions and have a more expectant attitude towards performing interventions., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Maternal physical and psychological wellbeing during the postnatal period can be significantly impaired by perineal trauma sustained during childbirth. Current literature emphasises preventative measures, yet there is a lack of a systematic, evidence based approach to postnatal perineal care. This is concerning as the eighth 'Saving mothers' lives' report (CMACE 2011) identifies genital tract sepsis for the first time as the leading cause of maternal deaths. The aim of this article is therefore to develop a systematic approach to improve postnatal perineal care with a focus on assessment and treatment of perineal pain as well as recovery of pelvic floor function.

Maternal physical and psychological wellbeing during the postnatal period can be significantly impaired by perineal trauma sustained during childbirth. Current literature emphasises preventative measures, yet there is a lack of a systematic, evidence based approach to postnatal perineal care. This is concerning as the eighth 'Saving mothers' lives' report (CMACE 2011) identifies genital tract sepsis for the first time as the leading cause of maternal deaths. The aim of this article is therefore to develop a systematic approach to improve postnatal perineal care with a focus on assessment and treatment of perineal pain as well as recovery of pelvic floor function.

Objective: To explore the challenges of conducting an observational study of postnatal interactions, between midwives and women, when the researcher was a midwife observing in familiar midwifery settings., Background: Participant observation conducted by researchers who are themselves midwives raises questions regarding the influence of 'identity' and 'insider' knowledge on the conduct of such projects. The insider/outsider status of researchers has been explored in other disciplines, yet this is an area which is underdeveloped in the midwifery literature where few attempts have been made to subject this issue to sustained analysis., Design: A qualitative study (investigating the provision of breast-feeding support in the first week after birth) provided the opportunity for reflexive exploration of the tensions faced by midwife researchers., Setting: Two maternity units in New South Wales, Australia., Participants: Participants included 40 midwives and 78 breast-feeding women., Findings: Possessing 'insider' midwifery knowledge was advantageous in the 'getting in' and 'fitting in' phases of this research study however unanticipated role ambiguity, and moral and ethical challenges, arose as a result of this 'insider' knowledge and status. Prolonged periods of observation challenged the midwife researcher's preconceived ideas and early decisions about the advantages and disadvantages of being an 'insider' or an 'outsider' in the research setting., Key Conclusions: Reflexive analysis of insider/outsider experiences revealed the middle ground which participant observers tend to navigate. Whilst professional insider knowledge and status offered many advantages, especially at the first study setting, some of the inherent embodied, and socially constructed features of the 'midwife' observer role, were unanticipated. Cultural competence, in these observational study settings, translated into role ambiguity, and at times, culturally entrenched role expectations., Implications for Practice: Midwifery observation of clinical practice, for research, or practice development purposes, requires a degree of juggling of insider knowledge to facilitate observation and analysis. Prior to conducting observations midwives should consider how best to occupy the middle ground between insider and outsider. Within the middle ground the midwife can draw on those aspects of 'self' required to negotiate respectful relationships with colleagues, whilst also ensuring the maintenance of an analytical degree of distancing., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Objective: To describe the perceptions of a US cohort of experienced birth doulas who were among the first in the country to be trained to provide postpartum support., Design: A qualitative, longitudinal study using ethnographic methods; participant observation and semi-structured interviews., Setting: Midwestern, urban, US; postpartum home care over three months., Participants: Four postpartum doulas; 13 families., Measurements: Participant observation during six postpartum home visits per family; 13 semi-structured interviews with doulas at the completion of each family's care; four summative interviews with doulas at the end of the study., Findings: When describing their postpartum practice, four themes emerged: supporting women, taking the mother's perspective, empowering women and empowering families. When speaking of the motivations, three themes emerged: being 'called' to practice, interest in preventing negative experiences, and career development., Key Conclusions and Implications for Practice: In the US, new mothers see midwives and doctors sporadically after discharge from the hospital. Postpartum doulas fill this gap in continuity of care by providing support for families as they transition to life with their new infant. Understanding the beliefs, values and practices of these important paraprofessionals will help midwives effectively integrate postpartum doula care into the care of women and infants., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Relationship is a central concept to the delivery of quality perinatal bereavement care. This article explores relevant bereavement research and clinically based writings about relationship in the care of families experiencing perinatal loss. Focusing on relationship provides a framework to guide interventions that will be perceived as meaningful and helpful to grieving parents. From the moment parents learn the difficult news of their baby's poor prognosis or death, nurses must strive to establish trust while building an effective working relationship with the family. A nurse with an understanding of the relationship needs can guide parents in creating a context for supporting each family member dealing with this unexpected family tragedy. Through sensitive follow-up bereavement care, nurses provide a source of hope for grieving families over time. Ultimately, nurses must find meaningful ways of self-care as a way of reinvesting in future relationship with other grieving families.

Purpose: To synthesize research regarding the low breastfeeding rates in Hispanic women living in the United States, particularly those who immigrate to this country and become acculturated., Data Sources: Extensive review of global literature on the subject., Conclusions: Exclusive and continued breastfeeding rates in the United States have increased in recent years but remain low, and no state in the United States currently meets the Healthy People 2010 recommendations. Due to the increasing number of Hispanic women immigrating to the United States and having children, it is imperative to develop appropriate culturally specific guidelines in breastfeeding promotion programs. When providing care to a Hispanic mother, clinicians can best assist this population by holistically reviewing all aspects of a woman's life including her environment and relationships with others to provide positive outcomes that ultimately benefit Hispanic mothers and their newborns., Implications for Practice: Guidelines and interventions for initiating and continuing breastfeeding in Hispanic women are proposed, including providing a bilingual personal breastfeeding advocate, as well as group classes that incorporate traditional Hispanic cultural beliefs and allow the women to devise personal breastfeeding plans.

Background: The reduction of time available to midwives during the hospital postnatal stay suggests that there is a need to review postnatal care. Innovative strategies are required which give attention to specific family needs and assist in the transition to parenthood. Nevertheless, new ideas and changes are not always readily accepted in midwifery practice., Aim: To enhance the provision of postnatal care to parents in the early postnatal period given time constraints for parents' hospital stay., Methods: Action research was employed to explore the educational experiences of parents in the postnatal period. An action research group (ARG) was established, comprising predominantly of midwives. Based on data collected from parents through questionnaires, focus groups and interviews, three actions were developed and implemented on a postnatal ward., Results: The actions were evaluated by 122 parents through self-report questionnaires. Midwives working on the postnatal ward and midwives involved in the ARG provided feedback regarding the actions through separate focus group discussions. The parents who participated in the study and, the midwives involved in the ARG, were positive about the actions and perceived them to be beneficial in preparing parents for parenthood. Many of the ward midwives, however, were negative about the actions and questioned their benefit for midwifery practice., Discussion: The negativity of the ward midwives regarding the innovations implemented in the study contrasted strikingly with the positive responses from both parents and the action research midwives. Two themes emerged which may explain the response of midwives to the actions, notably, a lack of ownership of the actions and the problematic nature of the current culture of the postnatal-care environment., Conclusion: It appears that the provision of hospital postnatal care has been influenced by an underlying culture in midwifery practice, which in turn, has impeded the change required to enhance postnatal care.