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Background Ceftriaxone (CRO) is a third-generation cephalosporin that is commonly prescribed due to its robust Gram-negative activity and lack of renal dose adjustments. It is also highly protein bound allowing for once daily dosing. In patients with hypoalbuminemia, however, the proportion of free drug is increased thus increasing the rate at which CRO is renally eliminated. This increased clearance could lead to lower serum concentrations and increased risk of treatment failure. Methods We performed a retrospective, cohort study to assess the impact of hypoalbuminemia (serum albumin ≤ 2.5 g/dL) on treatment failure among patients with monomicrobial Enterobacterales bacteremia. Adult patients who received > 72 hours of CRO therapy for susceptible Enterobacterales bacteremia between May 1, 2016 and April 30, 2021 were eligible for inclusion. The primary outcome of treatment failure was a composite of inpatient mortality or escalation to an intravenous anti-pseudomonal antibiotic or ertapenem. Secondary outcomes included hospital length of stay, total duration of antibiotic therapy, and time to infection resolution. Baseline characteristics and outcomes were compared using R Studio (Version 4.1.0) in a 1:1 propensity-matched cohort. Results After propensity score matching, 142 patients were included in each study group. The most common organisms in our cohort were Escherichia coli (71.5%), Klebsiella pneumoniae (14.1%), and Proteus mirabilis (5.3%). The most frequently implicated source of infection was the urinary tract (71.5%). Interestingly, treatment failure was numerically higher in the hypoalbuminemia group but was not statistically significant (12.0% vs. 7.7%, p = 0.23). All secondary outcomes were similar between groups. Among the subgroup of patients admitted to the ICU at baseline, the difference in treatment failure was even greater between patients with hypoalbuminemia and those without (23.3% vs. 7.5%, P = 0.07). Conclusion Hypoalbuminemia did not appear to have a significant impact on clinical outcomes among patients with Enterobacterales bacteremia treated with CRO. However, critically ill patients may be subject to higher incidence of treatment failure in the presence of hypoalbuminemia. Disclosures All Authors: No reported disclosures.

Background A midwife’s ability to fully support women’s autonomy and self-determination with respect to midwifery care is often challenging. This is particularly true of water immersion for labour and birth. However, the woman’s agency over what happens to her body and that of her unborn baby should be key considerations for maternity care provision. Objectives A three phased mixed-methods study was undertaken to examine how water immersion policies and guidelines are informed. Phase three of this study captured the knowledge and experiences of Australian midwives, their support for water immersion and their experiences of using policies and guidelines to inform and facilitate the practice. Methods Critical, post structural, interpretive interactionism was used to examine more than 300 responses to three open-ended questions included in a survey of 233 midwives. Comment data were analysed to provide further insight, context and meaning to previously reported results. Findings Findings demonstrated a complex, multidimensional interplay of factors that impacted on both the midwife’s ability to offer and the woman’s decision to use water immersion under the themes ‘the reality of the system’, ‘the authoritative ‘others’’ and ‘the pseudo decision-makers’. Multiple scaffolded levels were identified, each influenced by the wider macro-socio-political landscape of Australian midwifery care. Conclusions The insight gained from examining midwives’ views and opinions of water for labour and birth, has aided in contextualising previously reported results. Such insight highlights the importance of qualitative research in challenging the status quo and working towards woman-centred practice and policy.

OBJECTIVE The objective of the review is to explore and evaluate women's experiences of interactions with health care providers during their postnatal period. INTRODUCTION The postnatal period is a transformative time for women. Women experience significant change and adaptation, which could impact upon parenting confidence, health, and psychological outcomes during this time. The interaction women have with their health care providers during the postnatal period plays an integral role in improving these health outcomes. INCLUSION CRITERIA This qualitative review will explore the experiences of primiparous and multiparous women during the postnatal period with a key focus on evaluating the interactions they have with health care providers. It will include all studies that utilize qualitative methods (such as interviews and focus groups). Articles that explore the postnatal care experiences of women who have endured a pregnancy loss, given birth to a baby with complex needs, or those that solely focus on describing the neonatal and intensive care experiences, will not be included. METHODS PubMed, CINAHL, Embase, Emcare, and PsycINFO will be searched. Studies published from 2000 onwards and written in English will be assessed for inclusion. Studies that are selected initially will be assessed for methodological quality by two independent reviewers utilizing the JBI critical appraisal instrument for qualitative research. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO CRD42020186384.

Background The World Health Organization, and the 2011 and 2016 Lancet Stillbirth series as well as medical and scientific literature, have all called for stillbirth stigma to be reduced. However, few studies have explored or attempted to conceptualise the meaning of stigma in the context of stillbirth. Aim To explore the current knowledge surrounding stillbirth stigma, specifically the extent, type and experiences of bereaved parents. Methods A five-stage scoping review framework was utilised. A search of relevant databases (MedLine, EMBASE, PsychInfo, PsychArticles, and Ovid Emcare) was undertaken with several key words related to ‘stillbirth’ and ‘stigma.’ The reference lists of included studies were also searched. Findings A total of 23 resources met the inclusion criteria for this review. A thematic analysis regarding how stigma was conceptualised and/or experienced within results and/or discussion was employed on these studies. Five over-arching themes, with several sub-themes, were discovered: Type of stigma, identity, silence, bereaved mothers’ experiences of stigma in low-income countries and transformation. Discussion Stillbirth stigma remains an under-researched topic. Few articles conceptualised the experiences of the bereaved parent within a stigma framework. However, examples of bereaved parents enduring stigma were found within the literature. Common stigmatising experiences included, bereaved parents’ identities being challenged; and feelings of shame, guilt, and blame after their stillbirth. Stigmatising experiences could be different based on the bereaved parent’s cultural background. Conclusion Further research which attempts to conceptualise stillbirth stigma and explores those experiences from a bereaved parent perspective is needed to help inform stigma reduction strategies.

Background: Fetal movements are a key indicator of fetal health. Research has established significant correlations between altered fetal activity and stillbirth. However, women are generally unaware of this relationship. Providing pregnant women with information about the importance of fetal movements could improve stillbirth rates. However, there are no consistent fetal movements awareness messages globally for pregnant women. Aims: This study aimed to explore the antenatal care experiences of Australian mothers who had recently had a live birth to determine their knowledge of fetal movements, the nature and source of that information. Methods: An online survey method was used for 428 women who had a live birth and received antenatal care in Australia. Women’s knowledge of fetal movements, stillbirth risk, and the sources of this knowledge was explored. Findings: A large proportion of participants (84.6%; n = 362) stated they had been informed by health care professionals of the importance of fetal movements during pregnancy. Open-ended responses indicate that fetal movements messages are often myth based. Awareness that stillbirth occurs was high (95.2%;n = 398), although, 65% (n = 272) were unable to identify the current incidence of stillbirth in Australia. Conclusion: Women who received antenatal care have high-awareness of fetal movements, but the information they received was inconsistent. Participants knew stillbirth occurred but did not generally did not indicate they had obtained that knowledge from health care professionals. We recommend a consistent approach to fetal movements messaging throughout pregnancy which focuses on stillbirth prevention. Refereed/Peer-reviewed

Optimal management of patients with combined immunodeficiency, especially pertaining to hematopoietic stem cell transplantation (HSCT), remains unclear.To identify factors influencing HSCT and mortality in the population with combined immunodeficiency in North America.We identified 337 participants in the United States Immunodeficiency Network database with diverse forms of combined immunodeficiency and their characteristics, including demographic characteristics, laboratory values, infectious history, comorbidities, and treatment strategies. Univariate analysis was performed using logistic regression, whereas multivariate analysis was performed using multiple Cox proportional hazards.On univariate analysis, disseminated invasive viral infections and variants in STAT3, GATA2, and, DOCK8 were associated with increased odds of HSCT. Mucocutaneous fungal infections and variants in STAT3 were associated with increased odds of survival, whereas disseminated/invasive fungal infections, disseminated/invasive viral infections, and parasitic infections were associated with decreased odds of survival. On multiple variable Cox proportional hazards analysis, variants in ZAP70, nonspecific bacterial, and disseminated/invasive viral infections were associated with increased hazards of transplantation, whereas variants in multiple genes (RMRP, NEMO, DOCK8, CD40L, and CARD9), disseminated/invasive viral infections, autoimmune disease, and higher absolute lymphocyte count were associated with increased hazards of death. Importantly, demographic characteristics, basic lymphocyte subset counts, and absence of genetic diagnosis were not associated with HSCT or mortality.We determined that specific genetic diagnoses and infection burden impacts the decision to undergo HSCT in this cohort. In addition, certain genetic diagnoses and invasive viral infections carry an increased risk of mortality.

Combining one or more functional capabilities of subsystems within a structure can provide system-level savings, particularly for weight-critical applications such as air and space vehicles. Nanoengineering presents a significant opportunity for additional functionalities on the nanoscale without the necessity to modify shape, design, or load carrying capacity of the structure. Here, an integrated-multifunctional nano-engineered system was preliminarily studied in composite laminate structures. The study would support the exploration of a system designed to serve independent yet synergistic functionalities in life-cycle enhancements, energy savings during manufacturing, in-situ cure (manufacturing) monitoring, and in-service damage sensing. For the preliminary study, an integrated multifunctional composite (IMC) laminate was created via aligned nanofiber introduction into the composite interlaminar region and the laminate surfaces of Hexcel E-glass/913 unidirectional glass fiber prepreg. Various heights ranging from 10 - 40 μm-tall vertically aligned carbon nanotube (VA-CNT) arrays, as well as patterned and buckled VA-CNT architectures, were used to reinforce the weak interlaminar regions within the laminates showing a ~ 4 - 5% increase in short beam strength of VA-CNT reinforced specimens hence demonstrating interlaminar enhancement for life-cycle advancements. The same layers, being electrically conductive, can provide several additional multifunctionalities.

Refereed/Peer-reviewed Background: Some research attention has been paid to women's experiences of water immersion for labour and/or birth. Development of a psychometric scale specific to water immersion may provide further insight into women's experiences Aim: The objective of this paper is to share the development, and preliminary psychometric evaluation, of the Water immersion Agency plus Expectations and Relief (WA+ER) scale for assessing women's experiences of using water for labour and/or birth Methods: Items for the WA+ER scale were informed by a thorough literature review, and review by midwifery experts. An online survey was conducted, and 17 items were rated on a 7-point Likert scale (from entirely disagree to entirely agree) by 740 women who had used water immersion for labour and/or birth Results: An initial exploratory factor analysis was conducted to determine the initial structure of the scale. A confirmatory factor analysis showed that the initial 17-items were not a ‘good fit’ but with further statistical exploration, a good fit was achieved with 11-items. Results identified three factors with good reliability: Sense of Agency (4 items; α = 0.87;), Expectations (3 items; α = 0.83) and Relief (4 items α = 0.82). A confirmatory factor analysis confirmed good model fit (CFI=0.93; GFI=0.91; AGFI=0.85; TLI=0.90) Conclusions: The WA+ER scale is a statistically and theoretically sound tool for measuring women's experiences of labouring and/or birthing in water. Additional testing is required to further assess the validity and reliability of the scale and to determine the appropriateness of its use in other populations.

Aims: To gather, quality assess, synthesize and interpret the views, feeling, and experiences of women who used water immersion during labour and/or birth. Design: A systematic meta-thematic synthesis and GRADE-CERQual. Data sources: We searched MEDLINE, CINHAL, PsychINFO, AMED, EMBASE (MIDIRS only), LILACS, AJOL. Additional searches were carried out using Ethos (thesis database), cross-referencing against Google Scholar and citation chasing. Searches were carried out in August 2019, updated February 2020. Methods: Studies that met the selection criteria were appraised for quality. Data were extracted from the studies using meta-thematic analytical techniques; coding, descriptive findings, and analytical findings. The descriptive findings were subjected to confidence assessments using GRADE-CERQual. Results: Seven studies met the inclusion criteria. Nine key statements of findings were generated – one had high confidence, three moderate, three low and one very low confidence in the findings. The analytical findings generated three main themes: Liberation and Self-Emancipation, Synergy, transcendence and demarcation and Transformative birth and beyond. Overall, women experienced warm water immersion during labour and/or birth positively. Both the water and pool itself, facilitated women's physical and psychological needs during labour and/or birth, including offering effective analgesia. Our findings indicated that birthing pools are versatile tools that provide for a space that women can adapt and influence to best suit their individual needs. Conclusion: Women who used warm water immersion for labour and/or birth describe liberating and transformative experiences of welcoming their babies into the world. They were empowered, liberated, and satisfied. We recommend maternity professionals and services offer water immersion as a standard method of pain relief during labour/birth. Impact: Understanding women's experiences of labour and birth will inform future clinical practice. Midwives are optimally positioned to enhance women's access to water immersion. These findings have implications for education, guideline, and policy development as well as clinical practice. Refereed/Peer-reviewed

Refereed/Peer-reviewed Background: The 2011 and 2016 Stillbirth Lancet series made a call to action to identify mechanisms to reduce stillbirth stigma. This research answers that call, investigating the extent and dimensions of stillbirth stigma experienced by an international sample of mothers bereaved by stillbirth. Objective: To determine the prevalence and type as well as explore explanatory variables associated with higher levels of stillbirth stigma with bereaved mothers in high-income countries (Australia, United Kingdom, The United States of America and New Zealand). Method: An international survey of 889 bereaved mothers was conducted utilising the recently developed Still- birth Stigma Scale to explore the extent and types of stigma experienced, as well as the association between stigma and self-esteem (Rosenberg Self- Esteem Scales), perinatal grief (Perinatal Grief Scale), and perceived social sup- port (Perceived Social Support Scale). Demographic information (e.g. age, education, stillbirth history, sexual orientation and mental health) were collected to determine the association between individual demographic factors and stillbirth stigma. Results: Results of the Stillbirth Stigma Scale indicated that a majority (54%) of bereaved mothers experienced stigma. Self-stigma was the predominant type of stigma experienced (80%), followed by perceived devaluation (64.9%). Bereaved mothers also experienced discrimination (29.1%) and issues with disclosing their stillbirth to their community (36.7%). Stillbirth stigma scores were higher in bereaved mothers who had experienced the loss of their first child. High scores were associated with the mother’s mental health status (diagnoses prior to stillbirth, and/or after stillbirth (p < .05)).The other scales used indicated that higher stillbirth stigma scores were also associated with lower self-esteem (r (877) = -.304, p < .001), lower perceived social support (r (871) = -.448, p < .001) and higher levels of grief (r (829) = .609, p < .001) Conclusion: The current research was the first to identify that 54% of bereaved mothers experienced stigma, with self-stigma being the most prominent. Bereaved mothers endured discriminating experiences and had trouble disclosing their stillbirth to others within their community. The first-time mother with a self- reported history of mental illnesses appears to be the most at-risk of higher levels of stigma. Future longitudinal research needs to be conducted to determine the direction of the explanatory variables i.e. mental health, self-esteem and social support and develop interventions, which support the bereaved mother and reduce stillbirth stigma. Relevance: This study is the first to demonstrate the prevalence, extent, type and explanatory variables of stigma reported by bereaved mothers and the association between this and poorer outcomes including increased grief and decreased self-esteem. This study begins a dialogue about prevalence and explanatory variables of stillbirth stigma and its impact, to inform future prevention and support potential stigma reduction programs for community and bereaved mothers.

Purpose: This paper discusses an innovative multi-disciplinary approach to the development and evaluation of flexible, digital clinical communication learning resources to support students in twelve health disciplines to develop clinical communication skills in preparation for their clinical placements. Methods: A modified Delphi survey was sent to all stakeholders in the Division of Health Sciences to identify the most important communication skills from the list of 61 communication skills identified by Bachmann et al in 2013. Lecturers, clinical educators, clinicians, and students were invited to rate the importance of each skill. Results: A set of digital resources was created for teaching clinical communication to students across all years and disciplines and for use by clinical educators in the Division to prepare students for clinical placement. In addition, an effective methodology for course development, involving broad consultation and multi-disciplinary development teams comprised of clinicians and other educational experts, was developed. The resources were implemented in two disciplines, podiatry and midwifery, and evaluated pre- and post-placement using a qualitative and quantitative method developed with the course coordinators. Conclusions: There are identifiable clinical communication skills which are applicable across numerous health disciplines and as for other learnable skills, teaching can be enhanced by breaking them down into specific, demonstrable elements which students can observe and practice. Using the pedagogy and methods outlined in the paper, students demonstrated increased awareness of the importance of communication in the clinical context, and the capacity to evaluate their performance of those skills.

Genetic analysis of human Inborn Errors of Immunity has defined the contribution of specific cell populations and molecular pathways in the host defense against infection. The signal transducer and activator of transcription (STAT) family of transcription factors orchestrate hematopoietic cell differentiation. Patients with de novo activating mutations of STAT3 present with multiorgan autoimmunity, lymphoproliferation, and recurrent infections. We conducted a detailed characterization of the blood monocyte and dendritic cell (DC) subsets in patients with gain-of-function (GOF) mutations across the gene. We found a selective deficiency in circulating non-classical CD16(+) and intermediate CD16(+)CD14(+) monocytes and a significant increase in the percentage of classical CD14(+) monocytes. This suggests a role for STAT3 in the transition of classical CD14(+) monocytes into the CD16(+) non-classical subset. Developmentally, ex-vivo isolated STAT3 GOF CD14(+) monocytes, fail to differentiate into CD1a(+) monocyte-derive DCs. Moreover, patients with STAT3 GOF mutations display reduced circulating CD34(+) hematopoietic progenitors and frequency of myeloid DCs. Specifically, we observed a reduction in CD141(+) DC population, with no difference in the frequencies of CD1c(+) and plasmacytoid DCs. CD34(+) hematopoietic progenitor cells from patients were found to differentiate into CD1c(+) DCs, but failed to differentiate into CD141(+) DCs indicating an intrinsic role for STAT3 in this process. STAT3 GOF differentiated DCs produced lower amounts of CCL22 than healthy DCs, which could further explain some of the patient pathological phenotypes. Thus, our findings provide evidence that, in humans, STAT3 serves to regulate development and differentiation of non-classical CD16(+) monocytes and a subset of myeloid DCs.

SARS-CoV-2 infection displays immense inter-individual clinical variability, ranging from silent infection to lethal disease. The role of human genetics in determining clinical response to the virus remains unclear. Studies of outliers—individuals remaining uninfected despite viral exposure and healthy young patients with life-threatening disease—present a unique opportunity to reveal human genetic determinants of infection and disease.

Background Internationally qualified midwives comprise approximately 13% of the Australian midwifery workforce. Despite their central role in the Australian midwifery system, understanding of their transitional experiences is limited. Aim To explore the transitional experiences of internationally qualified midwives practising in Australia. Method A descriptive qualitative study was undertaken, as the second phase of a larger mixed methods study. In this paper we present in-depth insights from 11 internationally qualified midwives practising in Australia. Individual semi-structured interviews were conducted between May–August 2018, digitally recorded and then transcribed. Transcriptions were analysed using a thematic analysis approach. Findings Participants in this study identified that the different culture of the work environment, differences in midwifery practice, lack of autonomy in their practice and perceived discrimination influenced their transition into Australian midwifery practice. Four themes were identified: ‘Differences in midwifery practice’, ‘Cultural incongruence’, ‘Discrimination’ and ‘Mixed emotions’. Discussion Success during the complex transition process depends on the migrant midwives’ ability to build a sense of belonging, and to develop and adopt strategies that assist in dealing with new workplaces and an unfamiliar workforce. Conclusion A structured transition program prior to commencing practice, as well as an evidence-based workplace mentorship program with a focus on Australian midwifery care and culture, may be effective strategies to facilitate their transition. To promote awareness of multiculturalism within the work environment, this study recommends actively encouraging host staff to further develop perspectives that enable them to create positive relationships with staff from other cultures.

Clinical placement is a core feature of Australian midwifery education programs, with clinical supervision acknowledged as a key component for student success. The aim of this study was to evaluate the clinical facilitation models in South Australia, specifically the quality of clinical supervision to facilitate learning, and key stakeholder satisfaction. A mixed method evaluation research design was used to compare three models of clinical facilitation for midwifery students undertaking clinical placement across five venues. Midwifery students (n = 174), across two universities completed an anonymous e-survey utilising the validated Clinical Placement Experience Questionnaire. Midwives (n = 149) across five venues completed an anonymous purpose-designed questionnaire on their experience providing clinical supervision to midwifery students and Clinical Facilitators (n = 8) representing three facilitation models completed a self-report e-diary for two weeks and engaged in a focus group. Few differences were identified between the quality of student support and learning opportunities. Students in all models were well orientated and prepared for the clinical environment. Clinical Facilitators were supportive, educative and valuable for the students to achieve their learning objectives. One significant difference was that facilitators employed in the ‘Shared’ model were more able to provide support to midwives supervising students and maintain good liaison with the universities. Refereed/Peer-reviewed

Background Accessibility of water immersion for labour and/or birth is often dependent on the care provider and also the policies/guidelines that underpin practice. With little high quality research about the safety and practicality of water immersion, particularly for birth, policies/guidelines informing the practice may lack the evidence necessary to ensure practitioner confidence surrounding the option thereby limiting accessibility and women’s autonomy. Aim The aims of the study were to determine how water immersion policies and/or guidelines are informed, who interprets the evidence to inform policies/guidelines and to what extent the policy/guideline facilitates the option for labour and birth. Method Phase one of a three-phase mixed-methods study critically analysed 25 Australian water immersion policies/guidelines using critical discourse analysis. Findings Policies/guidelines pertaining to the practice of water immersion reflect subjective opinions and views of the current literature base in favour of the risk-focused obstetric and biomedical discursive practices. Written with hegemonic influence, policies and guidelines impact on the autonomy of both women and practitioners. Conclusion Policies and guidelines pertaining to water immersion, particularly for birth reflect opinion and varied interpretations of the current literature base. A degree of hegemonic influence was noted prompting recommendations for future maternity care policy and guidelines’. Ethical considerations The Human Research Ethics Committee of the University of South Australia approved the research.

BACKGROUND Approximately, 13% of the total Australian midwifery workforce is internationally qualified. Although they play a significant role in the Australian midwifery system, there is limited understanding of their transitional experiences. OBJECTIVE This mixed methods study aims to explore the transitional experiences and perspectives of internationally qualified midwives practising in Australia. METHODS This study uses an explanatory sequential mixed methods design incorporating two phases. The first phase of the study includes an e-survey that will be distributed to internationally qualified midwives in Australia, via the website e-bulletins of the Australian Nursing and Midwifery Federation and Australian College of Midwives. Additionally, potential respondents will be recruited via social media (Twitter, Facebook) and associated snowball sampling. At the end of the e-survey, respondents will be asked whether they are willing to take part in an interview. Data from the e-survey will be statistically analysed. The results of the e-survey and literature review will help to develop a guide for interview questions, with these interviews taking place during the second phase. A nested sample of participants will be created using the same selection criteria as for the e-survey. Semi-structured interviews will provide a deeper insight into the transitional experiences of internationally qualified midwives. Data will then be thematically analysed. RESULTS An integration of the e-survey results and interview findings will be synthesised to explore and better understand the transitional experiences of this group of midwives. The resulting data may potentially be used to formulate recommendations for future recruitment and retention practices, and to aid the Australian midwifery workforce in valuing diversity and fostering a supportive work environment. CONCLUSIONS At the time of writing this protocol, data collection had not yet commenced, however collection was subsequently completed in late 2018 and analysis is currently underway. CLINICALTRIAL This study was approved by the University of South Australia Human Research Ethics Committee (Protocol Number: 0000036397).

Background: Water immersion for labour and birth is an option that is increasingly favoured by women.Australian water immersion policies and guidelines commonly specify that practitioners, such as midwives, must undertake further education and training to become accredited. Method: A three-phase mixed methods approach was used. Phase one used critical discourse analysis to determine who or what informs policies and guidelines related to water immersion for labour and/or birth. Phase two examined policy and guideline informants’ experiences of the development of policies/guidelines, whilst phase three surveyed Australian midwives’ views and experiences of water immersion and their use of and/or involvement in the development of policies and guidelines. Findings: Practitioner accreditation for the facilitation of water immersion was a common finding across all phases of the study. An examination of policies and guidelines found that practitioners, namely midwives, were required to meet additional training requirements to facilitate water immersion.Participants of phases two and three identified and discussed accreditation as a significant challenge to the option of water immersion, particularly where there were inconsistencies across documents and in the interpretation of their content. Conclusion: The need for practitioners to be accredited to facilitate water immersion was identified as a major barrier to availability and therefore, women’s ability to access the option. Given these findings, the need for accreditation should be challenged. Refereed/Peer-reviewed

Preparing students for communication in clinical healthcare settings can be challenging, particularly given it may be the first time they have considered how and why they communicate. The challenge is to find an effective process for the development of clinical communication skills in a highly content-driven curriculum. The objective of this study was to empower first-year midwifery students to reflect on their experiences of communication to inform and expand their clinical communication by drawing on two distinct disciplines - midwifery and linguistics. This paper reports on the findings of a study that examined the implementation of innovative, preparatory workshops for first-year midwifery students. Data from quantitative and qualitative surveys were collected pre- and post-workshop, and post-clinical placement, and analysed using linguistic mapping and thematic analysis. Perceptible shifts in self-evaluation of competence were noted post the workshop and clinical placement. Students developed and used metalanguage appropriately to describe and evaluate communication while demonstrating increased awareness of the complexity of professional communication. They were able to find a balance between the vital technical information, and the interpersonal aspects of communication. This impacted positively on their perception of women as partners. Refereed/Peer-reviewed

Objective The objective of this study was to explore the views, experiences, perceptions of and access to water immersion for labor and birth in Australia. Design A sequential exploratory mixed methods study commenced in 2016. The first phase involved an online survey. The second phase is due to commence in 2019 and will involve focus groups and interviews. This paper presents a subset of results from phase one that asked women to self-rate the benefits and risks associated with water use on Likert-scales and for those who had a previous birth not involving water, how the two experiences compared. Participants A total of 740 Australian women who had used water immersion for labor and/or birth rated the benefits against 7-point Likert scales and 736 responded to 5-point Likert scales relating to commonly cited concerns surrounding the option. Results Women highly rated water immersion against all benefits. Benefits that were most highly rated (by numbers of ‘entirely agree’ on 7-point Likert scales) included sense of safety (80.14%), an alert baby (75.00%), a positive birth experience (72.70%), water as soothing (72.03%) and freedom of movement (71.35%). Women were most concerned (by selecting ‘somewhat’ to ‘extremely concerned’ on 5-point Likert scales) about being told to get out of the water when they did not want to (n = 120/736, 16.30%), their contractions going away (n = 76/736, 10.33%) and unsupportive staff (n = 65/736, 8.83%). More than 90% (n = 682/740) of women mostly to entirely agreed that they would recommend water immersion to others. Women rated water immersion as more comfortable, more satisfying and more relaxing when compared to previous births that they had that did not involve water. Key conclusions Women value water immersion for labor and birth. They have very little to no concern for the most common adverse events as documented in the literature. Implications for practice The results add to the growing evidence base surrounding water immersion for labor and birth. Whilst there remains ongoing debate about the safety of water immersion, women's experiences should be considered alongside outcome data. The results of this study may assist policy makers and clinicians in their advocacy and support of women who choose water immersion. Ethical considerations The Human Research Ethics Committee of the University of South Australia approved the research.

Background Water immersion for labour and birth is consistently challenged as a practice lacking support from high quality evidence. Despite this, the option is available to Australian women. Practitioners are guided by policies and guidelines however, given the research paucity, questions surround the way in which water immersion policies and guidelines are informed. Aims The aims of the study were to determine how water immersion policies and/or guidelines are informed and to what extent the policy/guideline facilitates the option of water immersion for labour and birth with respect to women’s choice and autonomy. Methods Phase two of a three phase mixed methods study used critical, post structural interpretive interactionism to examine the process of development and implementation of water immersion policies and guidelines from informant’s experience. Semi-structured interviews were conducted with 12 Australian participants. Findings Participants highlighted that the lack of randomised controlled trials had resulted in other forms of evidence being drawn upon to inform water immersion policies and guidelines. This was influenced in part by individual interpretations of evidence with medical views taking precedence. This sometimes resulted in policy and guideline documents that were restrictive with this impacting on women’s ability to access the option. Conclusion Perceived limitations of research and the subsequent translation of this perceived paucity of evidence into policies and guidelines, has impacted on women’s ability to exercise choice and autonomy with respect to water immersion and indeed, on the professional autonomy of practitioners who wish to facilitate it.

Background There is little published research that has examined practitioners’ views and experiences of pain relieving measures commonly used during labour and birth, particularly for non-pharmacological measures such as water immersion. Furthermore, there is minimal published research examining the process of policy and guideline development, that is, the translation of published research to usable practice guidance. Aims The aims of phase three of a larger study were to explore midwives knowledge, experiences and support for the option of water immersion for labour and birth in practice and their involvement, if any, in development of policy and guidelines pertaining to the option. Methods Phase three of a three phased mixed methods study included a web based survey of 234 Australian midwives who had facilitated and/or been involved in the development of policies and/or guidelines relating to the practice of water immersion. Findings Midwives who participated in this study were supportive of both water immersion for labour and birth reiterating documented benefits of reduced pain, maternal relaxation and a positive birth experience. The most significant concerns were maternal collapse, the difficulty of estimating blood loss and postpartum haemorrhage whilst barriers included lack of accredited staff, lifting equipment and negative attitudes. Midwives indicated that policy/guideline documents limited their ability to facilitate water immersion and did not always to support women’s informed choice. Conclusion Midwives who participated in this study supported the practice of water immersion reiterating the benefits documented in the literature and minimal risk to the woman and baby. Ethical considerations The Human Research Ethics Committee of the University of South Australia approved the research.

Research question: To gain a better understanding of women's baseline level of knowledge of induction of labour (IOL) and determine whether giving written information at the time IOL is decided, results in significant differences in knowledge and understanding of the process. Methods: Fifty pregnant women undergoing antenatal care at a small maternity hospital were recruited. A quasi experimental trial was conducted with non random selection of participants, 25 selected to act as the control group and 25 selected as the intervention group. The study was conducted to determine women's knowledge of IOL both before (non-intervention) and after (intervention) the introduction of a written information brochure. Results: Statistically significant increases in knowledge were evident in the intervention group for knowledge about action ( p = 0.002) and timing of prostaglandins ( p = 0.03), the number of side effects known ( p < 0.0001) as well as time to birth ( p = 0.001) indicating an increased understanding of the process as a result of reading an information brochure. Discussion: These results suggest that those in the non-intervention group lacked knowledge pertinent to IOL, even though they have consented to and actually arrived at the hospital prepared to undergo the IOL procedure. The most significant disparity noted between the intervention and non-intervention groups was women's knowledge of side effects of prostaglandin. Further to this, many women in the non-intervention group had unrealistic expectations of both the time for drug action and likely time from prostaglandin administration to birth. In contrast women in the intervention group knew about the common side effects of prostaglandin and possessed a more realistic understanding of the likely time to birth following this procedure. Conclusions: The results indicate that a specifically designed information brochure explaining the process of IOL in plain language has the effect of enhancing women's knowledge. This area of study warrants further investigation, especially research into the role of written information to improve women's understanding across other areas of maternity care education provision. Refereed/Peer-reviewed