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Introduction: Health professionals are frequently exposed to traumatic events due to the nature of their work. While traumatic and adverse labour and birth events experienced by women are well researched, less attention has been given to midwives' and nurses' experiences of these events and the impact it has on their lives., Aims and Objectives: To undertake a meta-ethnographic study of midwives' and nurses' experiences of adverse labour and birth events., Methods: Scopus, CINHAL PLUS, MEDLINE and PUBMED databases were searched using subject headings and keywords. The search was limited to papers published in peer-reviewed journals from 2004-October 2016. Quality appraisal was undertaken using the Critical Appraisal Skills Programme tool., Inclusion Criteria: Papers had to be qualitative or have a substantial qualitative component. Studies were included if they primarily focused on midwives' or nurses' perspectives or experiences of complicated, traumatic or adverse labour and birth events., Analytic Strategy: A meta-ethnographic approach was used incorporating methods of reciprocal translation guided by the work of Noblit and Hare (1988, Meta-Ethnography: Synthesizing qualitative studies (Vol. 11). Newbury Park: Sage publications)., Findings: Eleven qualitative studies were included in the final sample. Four major themes were (i) feeling the chaos; (ii) powerless, responsible and a failure; (iii) "It adds another scar to my soul"; and (iv) finding a way to deal with it., Conclusion: Midwives and nurses feel relatively unprepared when faced with a real-life labour and birth emergency event. While many of the midwives and nurses were traumatised by the experience, some were able to view their encounter as an opportunity to develop their emergency response skills., Relevance to Clinical Practice: Witnessing and being involved in a complicated or adverse labour and birth event can be traumatic for nurses and midwives. Organisational and collegial support needs to be available to enable these health professionals to talk about their feelings and concerns., (© 2017 John Wiley & Sons Ltd.)

In Australia, approximately 75% of women who have a vaginal birth will sustain some form of perineal trauma (AIHW 2013); and over half of perineal injuries will require suturing.

Background: Midwives frequently witness traumatic birth events. Little is known about responses to birth trauma and prevalence of posttraumatic stress among Australian midwives., Aim: To assess exposure to different types of birth trauma, peritraumatic reactions and prevalence of posttraumatic stress., Methods: Members of the Australian College of Midwives completed an online survey. A standardised measure assessed posttraumatic stress symptoms., Findings: More than two-thirds of midwives (67.2%) reported having witnessed a traumatic birth event that included interpersonal care-related trauma features. Midwives recalled strong emotions during or shortly after witnessing the traumatic birth event, such as feelings of horror (74.8%) and guilt (65.3%) about what happened to the woman. Midwives who witnessed birth trauma that included care-related features were significantly more likely to recall peritraumatic distress including feelings of horror (OR=3.89, 95% CI [2.71, 5.59]) and guilt (OR=1.90, 95% CI [1.36, 2.65]) than midwives who witnessed non-interpersonal birth trauma. 17% of midwives met criteria for probable posttraumatic stress disorder (95% CI [14.2, 20.0]). Witnessing abusive care was associated with more severe posttraumatic stress than other types of trauma., Discussion: Witnessing care-related birth trauma was common. Midwives experience strong emotional reactions in response to witnessing birth trauma, in particular, care-related birth trauma. Almost one-fifth of midwives met criteria for probable posttraumatic stress disorder., Conclusion: Midwives carry a high psychological burden related to witnessing birth trauma. Posttraumatic stress should be acknowledged as an occupational stress for midwives. The incidence of traumatic birth events experienced by women and witnessed by midwives needs to be reduced., (Copyright © 2016 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Background: Traumatic birth is a phenomenon that has been identified in women's birthing experiences, yet there has been no primary research conducted into midwives experiences of witnessing traumatic birth. Traumatic stress from witnessing and working with traumatised clients has been identified in other caring professionals such as nurses, social workers and emergency department personnel. This includes evidence of posttraumatic stress disorder, secondary traumatic stress, vicarious traumatisation and compassion fatigue. A distinct gap in the literature about midwives experiences of witnessing traumatic birth and the effects of working with potentially traumatised women formed the basis for this research., Research Design and Method: A descriptive qualitative study was used to explore midwives experiences of witnessing traumatic birth. The aim of this research was to enable midwives to describe their experiences and to determine if they are at risk of negative psychological sequalae similar to those in other caring professions. Ten currently or previously Registered Midwives with varying amounts of experience were interviewed, and transcripts of those interviews formed the raw data for the study. The data were independently thematically analysed by the two authors to identify common themes used to describe the experience of witnessing traumatic birth., Results: 'Stuck between two philosophies', 'What could I have done differently', and 'Feeling for the woman', emerged as the main themes from the research. The participants described their emotional distress from feeling 'stuck' between wishing they could practice according to their midwifery philosophy, and the reality of working within a medical model of care. Feelings of responsibility for women and babies' outcomes, and repeatedly questioning what they could have done differently to prevent a traumatic birth was also reported. Feeling for the woman emerged as a major factor in midwives' experiences of witnessing traumatic birth., Conclusions: As far as we can determine this is the first study to explicitly examine the phenomenon of midwives witnessing traumatic birth from the midwives point of view. While it was anticipated that midwives might describe being emotionally distressed by their experiences, the extent of their empathy and feelings of being stuck between two philosophies provide new knowledge into what affects midwives when working with birthing women. Further research into these areas is warranted. Better understanding of how witnessing traumatic birth impacts on midwives and what kind of support after these experiences is required to ensure midwives are equipped to cope when witnessing traumatic birth., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Our objective was to compare the frequency, degree, and location of perineal trauma during spontaneous delivery with or without perineal injections of hyaluronidase (HAase). This was a randomized, controlled pilot study, conducted in a midwife-led hospital birth center in São Paulo, Brazil. Primiparous women (N = 139) were randomly assigned to an intervention group (HAase injection, n = 71) or to a control group (no injection, n = 68). Significant differences were noted between the two groups in frequency of perineal trauma (intervention, 39.4%; control, 76.5%), degree of spontaneous laceration (intervention, 0.0%; control, 82.4%), and laceration located in the posterior region of the perineum (intervention, 54.2%; control, 84.3%). When episiotomy and second-degree lacerations were considered together and women with intact perineum were excluded from the analysis, the difference between the groups was no longer significant. With the use of the HAase enzyme, the relative risk was 0.5 for perineal trauma and 0.0 for second-degree lacerations. The present findings suggest that perineal injection of HAase prevented perineal trauma. These findings provide strong rationale for a larger follow-up study.

Objective: To assess and explain deviations from recommended practice in National Institute for Clinical Excellence (NICE) guidelines in relation to fetal heart monitoring., Design: Qualitative study., Setting: Large teaching hospital in the UK., Sample: Sixty-six hours of observation of 25 labours and interviews with 20 midwives of varying grades., Methods: Structured observations of labour and semistructured interviews with midwives. Interviews were undertaken using a prompt guide, audiotaped, and transcribed verbatim. Analysis was based on the constant comparative method, assisted by QSR N5 software., Main Outcome Measures: Deviations from recommended practice in relation to fetal monitoring and insights into why these occur., Results: All babies involved in the study were safely delivered, but 243 deviations from recommended practice in relation to NICE guidelines on fetal monitoring were identified, with the majority (80%) of these occurring in relation to documentation. Other deviations from recommended practice included indications for use of electronic fetal heart monitoring and conduct of fetal heart monitoring. There is evidence of difficulties with availability and maintenance of equipment, and some deficits in staff knowledge and skill. Differing orientations towards fetal monitoring were reported by midwives, which were likely to have impacts on practice. The initiation, management, and interpretation of fetal heart monitoring is complex and distributed across time, space, and professional boundaries, and practices in relation to fetal heart monitoring need to be understood within an organisational and social context., Conclusion: Some deviations from best practice guidelines may be rectified through straightforward interventions including improved systems for managing equipment and training. Other deviations from recommended practice need to be understood as the outcomes of complex processes that are likely to defy easy resolution.

The actual effect of the use of simulations on clinical decision making is inconclusive. This pilot study used a posttest design to determine the effect of a simulation strategy on the clinical decision-making process of midwifery students. Thirty-six graduate diploma students volunteered and were randomly assigned to two groups, with the experimental group receiving two simulation sessions (normal labor and physiological jaundice), and the control group receiving the two usual lectures. The main findings were that students who received the simulation strategy collected more clinical information, revisited collected clinical information less, made fewer formative inferences, reported higher confidence levels, and for the posttest normal labor simulation, reached a final decision more quickly. Such effects are reasonable for this type of intervention with the existent variability in each group. Further research with a larger sample size and more rigorous data collection strategies is required.

Care of the laboring woman and subsequent birth interventions have generally been based on tradition rather than a systematic examination of the cost-effectiveness of the interventions. This retrospective study examined the outcomes of nurse midwifery care at a large metropolitan university clinic setting. Findings suggest that more sensitive cost and quality indicators of nurse midwifery care need to be developed, and the effect of these on outcomes needs to be elucidated.

A combined narrative review and metanalytic review was conducted to summarize published and unpublished studies completed between 1970 and 2002 on the relationship between traditional birth attendant (TBA) training and increased use of professional antenatal care (ANC). Fifteen studies (n = 15) from 8 countries and 2 world regions were analyzed. There are, to varying degrees, positive associations between TBA training and TBA knowledge of the value and timing of ANC services, TBA behavior in offering advice or assistance to obtain ANC, and compliance and use of ANC services by women cared for by TBAs or living in areas served by TBAs. There is a serious lack of information about TBA training program characteristics. Although the findings cannot be causally attributed to TBA training, the results suggest that training may increase ANC attendance rates by about 38%. This magnitude of improvement could contribute to a reduction in maternal and perinatal mortality in areas where women have access to quality antenatal and emergency obstetric care. There is an urgent need to improve capacity for evaluation and research of the effect of TBA training programs and other factors that influence women's use of ANC services.

Genital tract trauma is a common outcome of vaginal birth, and can cause short-term and long-term problems for new mothers. Preventive measures have not been fully explicated. Midwives use a variety of hand maneuvers late in the second stage of labor, in the belief that genital trauma can be reduced. However, none of these care measures have been rigorously tested to determine if they are effective. A midwifery practice offers an ideal setting to study the relationship of hand techniques by the birth attendant to reduction of genital tract trauma.

This qualitative study sought to identify the strategies used by hospital based midwives in assisting women to manage pain in labour, as well as the support they offer in all aspects of the birth process. Data were collected via participant observation of five birthing mothers and their midwives, and pre and post birth interviews. Analysis was by means of the software package QSR NUD.IST (Non numerical, Unstructured, Data, Indexing, Search and Theorizing) Version 3. Analysis of observation of labour and pre and post birth interviews revealed that all women wanted a birth with minimal intervention, however safety was an overriding consideration. During labour women relied on the midwife to oversee and direct care, and trust in care by a midwife was established as a result of prior experience, or during antenatal care. Factors inhibiting full partnership between women and midwives, and also the use of alternative pain strategies, included staffing levels, lack of emphasis on evidence based care and environmental constraints such as the room set up.

Background: Perineal lacerations are a source of significant discomfort to many women. This descriptive study examined perineal outcomes in a home birth population, and provides a preliminary description of factors associated with perineal laceration and episiotomy., Methods: Data were drawn from a prospective cohort study of 1404 intended home births in nurse-midwifery practices. Analyses focused on a subgroup of 1068 women in 28 midwifery practices who delivered at home with a midwife in attendance. Perineal trauma included both episiotomy and lacerations. Minor abrasions and superficial lacerations that did not require suturing were included with the intact perineum group. Associations between perineal trauma and study variables were examined in the pooled dataset and for multiparous and nulliparous women separately., Results: In this sample 69.6 percent of the women had an intact perineum, 15 (1.4%) had an episiotomy, 28.9 percent had first- or second-degree lacerations, and 7 women (0.7%) had third- or fourth-degree lacerations. Logistic regression analyses showed that in multiparas, low socioeconomic status and higher parity were associated with intact perineum, whereas older age (>/= 40 yr), previous episiotomy, weight gain of over 40 pounds, prolonged second stage, and the use of oils or lubricants were associated with perineal trauma. Among nulliparas, low socioeconomic status, kneeling or hands-and-knees position at delivery, and manual support of the perineum at delivery were associated with intact perineum, whereas perineal massage during delivery was associated with perineal trauma., Conclusions: The results of this study suggest that it is possible for midwives to achieve a high rate of intact perineums and a low rate of episiotomy in a select setting and with a select population.

Objective: To examine the influence of midwives' approaches on the care given to women for pain relief during labour., Design: Non-participant observation was used to collect data on midwives' behaviours during interactions with women in labour., Setting: A large teaching hospital in Northern Ireland., Participants: Observations focused on interactions that were related to pain relief and involved 11 midwives caring for 15 women throughout the first stage of labour., Key Findings: Midwives' approaches to pain relief differed; at one extreme the midwife acted as 'a cold professional' whilst at the other extreme she was observed to be 'a disorganised carer'. In the middle of these two extremes was the 'warm professional'; her approach had a positive influence on the women's experience of labour pain. IMPLICATION FOR RESEARCH: Further research is needed to develop a profile of the factors that 'make' for a warm professional. The information gained could be used to teach midwives the skills of being 'a warm professional', in particular, the value of effective communication for sensitive care such as pain relief in labour.

Joint data collection by nine nurse-midwifery practices in the United States permitted a description of pain management practices with intrapartum patients. Observational data are reported for healthy gravidas at term (N = 4,171). A wide variety of techniques for pain management, including both pharmacologic and nonpharmacologic methods, were used. High prevalence modalities were paced breathing (used by 55.2% of this clinical sample), activity and position change (42.4%), narcotics (30.0%), and epidurals (18.7%). Paced breathing plus narcotics was the most common combination. Variations are reported for subgroups of women according to age, parity, race/ethnicity, education, insurance, marital status, activity in labor, and type of delivery. The only methods associated with a lowered rate of spontaneous delivery were epidurals and intrathecal narcotics.

Objective: to review the key literature on perineal trauma, discussing the historical background, the materials and techniques used, the possible consequences of repair and assess midwives' current and potential contribution to perineal repair., Literature Search: the literature was identified using conventional search techniques: Midwifery Information Resource Service (MIDIRS) and the Cochrane Pregnancy and Childbirth Database. Keywords used during the search were: episiotomy, perineal trauma and adverse effects. Associated keywords words were sexuality, pain and psychology., Key Conclusions: current practice in the UK is inconsistent with the available evidence, perineal trauma can cause long term problems, and midwives are in an ideal position to take forward evidence-based perineal repair., Implications for Practice: midwives need adequate education and training in perineal repair but are likely to be more effective in performing the repair. Systematic evaluation of the impact of extending midwives' influence in this area is essential.

Prolonged latent phase labor can be a physical, emotional, and mental challenge for both the woman in labor, her support system, and nurse-midwife. In this article, four nurse-midwives offer suggestions for coping with this common clinical dilemma.

The diagnosis of foetal distress is complex: it is influenced by a number of factors which range from the physical examination of the mother and foetus to the psychological and social world in which the mother, the midwife and other health care professionals work. The consequences of an incorrect diagnosis of normality or foetal distress are potentially serious for both mother and baby. Recent changes in the practice and delivery of midwifery care have placed more responsibility on midwives. It is therefore imperative that midwives become more aware of the complexity of the diagnosis as well as of some of the factors which can improve the quality of their diagnosis. This paper reviews the literature associated with the diagnosis of foetal distress, physiological and pathological changes during pregnancy and labour, and the usefulness and limitation of the tools readily available to midwives for the diagnosis. It also examines the limits of the relationship that exists between intra-uterine and neonatal markers. The purpose of this paper is to provide background information that would support midwives in the diagnosis of foetal distress in the hope that the false positive diagnoses can be reduced for the benefit of mothers and babies. Ultimately an improvement in outcome should be reflected in the more efficient and effective use of resources available to maternity services.

Referrals for inadequate progress of labour from the Midwife Obstetric Units (MOUs) to the referral hospitals are responsible for a significant part (approximately 5%) of the workload of these institutions in the Peninsula Maternal and Neonatal Service Region in Cape Town. It is essential for the maintenance of community credibility in the MOUs that patients who develop complications are timely and speedily transferred to the appropriate referral hospital. A sample of 251 patients, who were transferred from the MOUs to the referral hospitals for inadequate progress of labour in the first half of 1992, was analysed. The study showed that midwives in the MOUs had largely adhered to the Departmental referral criteria for that potentially serious complication of labour and had kept excellent records. The referrals, in terms of eventual outcome for the patients and their infants, had been largely appropriate. Several areas of concern were identified. These included incomplete assessment of the stage of labour on admission and inadequate monitoring of the fetal heart in a number of patients. Provision of analgesia in labour was generally inadequate. Ambulance delay was disturbingly common. Recommendations for measures to redress these management deficiencies are presented.

Homeopathy (from the Greek homois 'similar' and pathos 'suffering') is based on the Law of Similars which states that the symptoms caused by too much of a substance are the symptoms that can be cured by a small dose of the same substance. Appropriately trained, and working within the Scope of Professional Practice midwives could use homeopathic remedies for acute situations and indeed for some of the conditions for which they would normally summon medical aid. Midwives need to know when to refer mothers to a fully qualified homeopath rather than attempting to treat a condition themselves. Short homeopathy courses designed specifically for midwives are now being developed by some colleges.

Every year 85,000 women die from obstructed labour and many many more lose their baby and have debilitating physical damage as a result. In this paper the extent of the problem is described. Methods by which obstructed labour can be prevented are given. Early detection and prompt referral for appropriate treatment are vital if damage is to be minimised. This requires particular attention in midwifery education which must include community experience which fosters dialogue and strengthens prevention. This paper is based on one originally given at the ICM/WHO/UNICEF pre-congress workshop in Kobe, Japan, October 1990.

Manual removal of the placenta carries significant risk of hemorrhage and infection plus the risks associated with general anesthesia, if used. Transporting the patient from home or birthing center to hospital or from birthing room to delivery room or operating room is also disruptive to the patient and the initial parent-infant attachment process. The injection of oxytocin into the umbilical vein is a safe procedure that can cause placental separation and delivery, thus preventing the need for manual removal for some women. This technique can be useful in a nurse-midwifery practice in the management of a retained placenta or prolonged third stage of labor. The following review of current research and example of a protocol used in a nurse-midwifery service will provide guidance for incorporating this procedure into practice. As with any new technique, the need to continue to collect and publish outcome data is important.