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Aim: Different clinical practice guidelines include recommendations on how to prevent and repair obstetric perineal trauma, as well as the use of episiotomy. To evaluate the variability in midwives' professional practices for preventing and repairing perineal trauma, as well as the professional factors that may be associated with the restrictive use of episiotomy., Design: Observational cross-sectional study., Methods: Three hundred five midwives completed an anonymous questionnaire developed by the authors and distributed across various midwifery scientific societies. The main outcomes measured were the frequencies of adopting specific practices related to perineal injury prevention and repair, episiotomy technique and restrictive episiotomy use (<10%). Odds ratios (OR) and adjusted odds ratios (aOR) with 95% confidence intervals were estimated., Results: Intrapartum perineal massage was not normally used by 253 (83%) of midwives, and 186 (61%) applied compresses soaked in warm water to the perineum. Regarding episiotomy, there was a great deal of variability, noting that 129 (42.3%) adopted a restrictive use of this procedure, 125 (41%) performed it between 10% and 20%, while 51 midwives (16.7%) performed it in more than 20% of cases. In addition, 165 (54.1%) midwives followed an incision angle of 60º. Concerning tears, 155 (50.8%) usually sutured first-degree tears and 273 (89.5%) always sutured second-degree tears. Midwives attending home births (aOR = 6.5; 95% CI: 2.69-15.69), working at a teaching hospital (aOR = 3.69; 95% CI: 1.39-9.84), and the ones who recently completed their professional training (aOR = 3.58; 95% CI: 1.46-8.79) were significantly more likely to adopt a restrictive use of episiotomy., Conclusions: There is a significant variability in Spanish midwives' practices for preventing and repairing perineal tears. Moreover, the restrictive use of episiotomy is associated with midwives attending home births, working in teaching hospitals and having recent professional training., Patient or Public Contribution: No patient or public contribution., (© 2024 The Authors. Nursing Open published by John Wiley & Sons Ltd.)

Purpose: The purpose of this scoping review was to synthesize the literature on nursing support during the latent phase of the first stage of labor. In 2014, the definition of the beginning of active labor changed from 4 centimeters (cm) to 6 cm cervical dilation. More women may have an induction of labor based on results of recent research showing no causal increase in risk of cesarean birth with elective induction of labor for low-risk nulliparous women. Therefore, in-hospital latent phase labor may be longer, increasing the need for nursing support., Design: Scoping review of the literature from 2009 to present., Methods: We conducted the review using key words in PubMed, CINAHL, and Scopus. Search terms included different combinations of "latent or early labor," "birth," "support," "nursing support," "obstetrics," and "onset of labor." Peer-reviewed research and quality improvement articles from 2009 to present were included if they had specific implications for nursing care during the latent phase of labor. Articles were excluded if they were not specific to nursing, focused exclusively on tool development, or were from the perspective of pregnant women or providers only., Results: Ten articles were included. Results were synthesized into six categories; support of physiologic labor and birth, the nurse's own personal view of labor, birth environment, techniques and tools, decision-making, and importance of latent labor discussion during the prenatal period., Clinical Implications: Support for physiologic labor and birth is an important consideration for use of nonpharmacological methods during latent labor. The nurse's own personal view on labor support can influence the support that laboring women receive. Nurses may need additional education on labor support methods.

Introduction: Maternal obesity is associated with slow labor progression and unplanned cesarean birth. Midwives use fewer medical interventions during labor, and the women they care for have lower cesarean birth rates, compared with low-risk, matched groups of women cared for by physicians. The primary aim of this study was to examine associations between midwifery unit-level presence and unplanned cesarean birth in women with different body mass index (BMI) ranges. Unit-level presence of midwives was analyzed as a representation of a unique set of care practices that exist in settings where midwives work., Methods: A retrospective cohort study was conducted using Consortium on Safe Labor data from low-risk, healthy women who labored and gave birth in medical centers with (n = 9795) or without (n = 13,398) the unit-level presence of midwives. Regression models were used to evaluate for associations between unit-level midwifery presence and 1) the incidence of unplanned cesarean birth and 2) in-hospital labor durations with stratification by maternal BMI and adjustment for maternal demographic and pregnancy factors., Results: The odds of unplanned cesarean birth among women who gave birth in centers with midwives were 16% lower than the odds of cesarean birth among similar women at who gave birth at centers without midwives (adjusted odds ratio, 0.84; 95% CI, 0.77-0.93). However, women whose BMI was above 35.00 kg/m 2 at labor admission had similar odds of cesarean birth, regardless of unit-level midwifery presence. In-hospital labor duration prior to unplanned cesarean was no different by unit-level midwifery presence in nulliparous women whose BMI was above 35.00 kg/m 2 ., Discussion: Although integration of midwives into the caregiving environment of medical centers in the United States was associated with overall decrease in the incidence of cesarean birth, increased maternal BMI nevertheless remained positively associated with these outcomes., (© 2019 by the American College of Nurse-Midwives.)

Objective: To increase the percentage of cases in which quantitative blood loss (QBL) was documented by labor and delivery nurses for women giving birth., Design: Quality improvement project., Setting/local Problem: Labor and delivery unit of a community hospital in which a previous implementation of QBL measurement was not sustained., Participants: Labor and delivery nurses were the focus of the intervention, but the entire multidisciplinary team became involved., Intervention/measurements: Based on literature supporting the use of scorecard feedback to stimulate performance improvement, weekly blinded individual scorecards showing the percentage of births attended by each labor and delivery nurse with QBL documented and a run chart showing the percentage of all births with QBL documented were posted on the unit and discussed during huddles for 12 weeks. Data on blood product administration were collected, and charts comparing QBL and estimated blood loss (EBL) volumes documented were shared with nurses and physicians., Results: Over 12 weeks, the percentage of births with QBL documented increased from 22.7% to 80.0%. Consistent with previous reports comparing QBL and EBL volumes at birth, there was a significant difference between the mean QBL volume (mean = 482.20 ml, standard deviation = 358.03) and the mean EBL volume (mean = 313.15 ml, standard deviation = 211.91; p < .001) for total births. The mean QBL volume was also greater than the mean EBL volume for vaginal and cesarean births, but those differences were not statistically significant. There was no increase in blood product administration associated with the increase in QBL documentation., Conclusion: Discussing weekly scorecards and a run chart of QBL measurement was associated with an increase in documentation of QBL by labor and delivery nurses. Planning this project and discussing the results engaged the entire multidisciplinary team in more consistent measurement of QBL. The increased level of QBL documentation has been sustained for longer than 1 year., (Copyright © 2019 AWHONN. Published by Elsevier Inc. All rights reserved.)

Background: The fetal monitor safety nurse role was created as a supplemental support for nurses assessing fetal heart rate tracings in response to an adverse event. An experienced labor and delivery nurse without a patient care assignment was designated to continuously assess all active fetal monitoring tracings, via an electronic display away from the main nurses' station, as an adjunct to the care and assessment of the nurse with primary responsibility for the patient., Purpose: The purpose of this project was to evaluate the views of nurses who served as fetal monitor safety nurses about various aspects of the role., Methods: Nurses who served as fetal monitor safety nurses were invited to attend a small group session where they completed a survey about the role and then received information on the importance of fetal monitoring safety. Two weeks later, they were asked to take the survey again to evaluate potential changes in viewpoints., Results: Thirty nurses attended small group sessions and completed the survey. Of those, 22 nurses completed the post survey 2 weeks later. There was minimal change in nurses' views of the fetal monitor safety nurse role after attending the small group sessions. Nurses expressed comfort in notifying peers about concerns related to the fetal heart rate tracing and perceived overall safety benefits; however, they felt that safe staffing measures were not in place to support the role. Concerns were expressed about a nurse being in a nondirect patient care position during times of high census and acuity., Clinical Implications: The fetal monitoring safety nurse may be an innovative potential solution to minimize risk of adverse events during labor that are related to accurate assessment of electronic fetal monitoring data and timely and appropriate interventions. More data are needed on improvements in fetal outcomes and adverse events potentially related to the fetal monitor safety nurse role. Budgetary support and adequate nurse staffing are required to make the role operationally feasible and safe. Valuing and seeking nurses' input as bedside experts about perinatal safety initiatives should be a part of implementing new practices.

A new study says no, although concerns remain.

Objective: To compare the length of the second stage in nulliparous women with respect to a range of factors related to staffing and outcomes at a community hospital., Methods: This was a retrospective cohort study of nulliparous women presenting for delivery over a 2-year period. The primary outcomes were the presence of passive descent and length of the second stage. Secondary outcomes were mode of delivery, chorioamnionitis, and postpartum hemorrhage., Results: Passive descent was observed in 198 women in the second stage. When passive descent occurred, the differences in the median length of the second stage in relation to the nursing shift increments were statistically significant, with the longest times corresponding to the middle 4 h of the nursing shifts (p = .046). Physician patients were more likely than midwife patients to undergo passive descent on weekdays (36% vs. 26%, p = .034) but not on weekends (32% for both). Though the likelihood of a vaginal delivery remained high up to 6 h into the second stage, the rate of hemorrhage and chorioamnionitis increased significantly., Conclusions: When passive descent occurred, second stage length varied depending on the time of day. These findings suggest provider behaviors impact the length of the second stage.

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.)

Objective: To evaluate the use of nursing diagnoses and interventions proposed for women in labour and high-risk pregnancies., Method: This is a descriptive, retrospective study with documentary analysis of 1000 medical records and a checklist conducted from July to September 2014, at a maternity hospital in Paraiba, Brazil. It consisted of analysing descriptive measures and comparing the relationship between nursing diagnoses and interventions using NANDA - International and the Nursing Interventions Classification., Results: The most common diagnoses in labour were acute pain (62%), fatigue (24.7%), and anxiety (22%). For high-risk pregnant women they were impaired sleep and rest (100%), risk of infection (81.8%), and anxiety (77.2%). The interventions were hand washing (80.8%) and identify and accommodate patient in the bed (78%)., Conclusion: The diagnoses express needs during parturition and the psychobiological changes in high-risk pregnancy. The interventions are disconnected from the diagnoses and should therefore be reviewed and altered.

In this study, the objective was to describe and analyse reasons for obstetric admissions to the ICU, severity of illness, level and types of interventions, adverse events and patient outcomes. In a retrospective database study, we identified 291 obstetric patients during pregnancy and puerperium from four Finnish university hospitals. Most were admitted in the post-partum period and hypertensive disorders were the main indications for admissions, followed by obstetric haemorrhage. The median length of stay was 21hours. The most common intervention was blood transfusion and mechanical ventilation was required in nearly one fifth of the patients. Three patients had a prolonged stay and nine had re-admissions. One maternal death was recorded. This study found that severity of illness and organ failure scores describe the obstetric patient as having a good probability of recovery and a short length of stay. However, the obstetric patients reason for admission and their type of delivery were associated with both the severity of illness scores and level of intervention required. Those admitted for non-obstetric reasons and having had a vaginal delivery demonstrated higher severity of illness scores, organ failure scores, and levels of intervention when compared to those admitted for obstetric reasons or those who had delivered by caesarean section. In conclusion, care of these patients can be improved by understanding the severity of illness scores, common ICU interventions and patient outcomes., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Chorioamnionitis is a serious complication during labor at term and is associated with adverse neonatal outcome affecting approximately 10% of pregnancies. It is diagnosed clinically or microbiologically or by histopathologic examination of the placenta and umbilical cord. The clinical criteria for chorioamnionitis found in preterm or term women include maternal fever combined with 2 or more findings of maternal tachycardia, fetal tachycardia, leukocytosis, uterine tenderness, and/or malodorous amniotic fluid. These subjective findings are neither sensitive nor specific. However, clinical chorioamnionitis requires a high index of suspicion, timely diagnosis, prompt antibiotic treatment, and delivery, which may help reduce the potentially devastating outcome of maternal and neonatal infections. This article focuses on clinical chorioamnionitis and presents the physiologic immune response during pregnancy, the definition of chorioamnionitis, clinical diagnostic criteria, and implications for practice.

Bladder care is an integral part of caring for a woman in labour and the immediate postpartum period (National Institute for Health and Care Excellence (NICE) 2014a). To ensure effective bladder care, the skill of urinary catheterisation is often undertaken by a midwife and can be required in a variety of different situations. Catheterisation is a necessary intervention whether it is intermittent, indwelling, short-term or, less often, long-term. This article addresses the current recommended guidance, highlights best practice measures and provides useful hints and tips to support catheter care.

RATIONALE AND KEY POINTS: An episiotomy may be necessary to assist some women to give birth. An episiotomy is a surgical incision intentionally made to increase the diameter of the vulval outlet to enable childbirth. ▶ Midwives and doctors should use their clinical judgement and skills to assess when to perform an episiotomy. ▶ An episiotomy should not be performed routinely; its use should be restricted to certain indications. ▶ Adequate pain relief should be provided before performing an episiotomy. REFLECTIVE ACTIVITY: Clinical skills articles can help update your practice and ensure it remains evidence based. Apply this article to your practice. Reflect on and write a short account of: 1. How you think this article will change your practice. 2. The risk factors that can predispose a woman to having an episiotomy. 3. What you would do if a woman refused to have an episiotomy despite the presence of a clinical indication, such as fetal distress. Subscribers can upload their reflective accounts at: rcni.com/portfolio.

Background: the role of being 'with woman' during traumatic birth has been identified as having an emotional cost for midwives, but to date no research has explored traumatic experiences of student midwives., Aim: to explore student midwives׳ perceptions of what was traumatic for them and how they were supported with such events., Design: a qualitative descriptive approach, using semi structured interviews., Setting: one university in the North West of England., Participants: 11 student midwives recruited by poster campaign., Findings: five main themes emerged from the analysis. Wearing your Blues depicted what participants described as the 'bleak' landscape of practice. No Man's Land was concerned with traumatic tensions in the student role. 'Get the Red Box! ' and The Aftermath concerned traumatic events in practice and the impact of these on students. Learning to cope related to the way students coped with such incidents, as well as other stresses in the role., Key Conclusions: the student midwife inhabits a vulnerable position in the 'No Man's Land' of hospital practice. Her strong identification with the woman renders her potentially more vulnerable in traumatic situations. The study revealed a paradigmatic clash between the manualised care of a busy obstetric unit and the individualised woman-led approach they were expecting., Implications for Practice: it seems important for the profession to recognise that distressing events are not always the obvious critical incidents in care, and that a culture of support and/or debriefing after adverse events may assist students to articulate their needs and develop resilience. Educators may need to appreciate that the student midwife role in an emergency may heighten her vulnerability. This study also highlighted the potential alienation of students when placed in the maelstrom of a busy obstetric unit. The Birthplace study (Brocklehurst et al., 2011), NHS England's Five Year Forward View (NHS England, 2014) and NICE (2014) all recommend increasing the numbers of out-of-hospital births: it seems likely that such a reorganisation of care would improve the experiences of mothers and those who care for them during birth. As part of a 'design for compassionate care' (Crawford et al., 2014) it is important to foster spaces, processes and resources which are compassionate to practitioners and students., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

The number of mothers and babies from the developing world who die in pregnancy and childbirth remains unacceptably high. However, concerted efforts over the last 20 years to reduce the number of deaths have produced significant results, leading to a steady fall in maternal and neonatal mortality rates since 1990 (Unicef 2014). One initiative that is having an impact is the 'Making it happen' programme funded by the UK government and run by Liverpool's School of Tropical Medicine. A 'skills and drills'-type course covering obstetric and neonatal emergencies is delivered to health professionals across Sub-Saharan Africa and Asia. This article describes the volunteer experience of a UK midwife helping to facilitate a course in Kenya, which has some of the world's poorest health outcomes.

Objective: To determine the effect of standardized education specific to maternal resuscitation on nurses' confidence and competence during obstetric emergencies and to determine the cost savings associated with the program., Design: Pre- and postintervention surveys designed to measure perceived confidence and competence in resuscitation before and after Advanced Cardiac Life Support (ACLS) certification in combination with obstetric drills., Setting: The project was conducted at a 12-bed labor and delivery, mother/baby unit in an acute care, community-based hospital in Northwest Arkansas., Participants: Sixty-seven registered nurses (RNs) who were hospital employees with at least 6 months experience in labor and delivery or the neonatal intensive care unit completed focused education and training., Interventions/measurements: The obstetric ACLS program targeted obstetric emergencies, cardiac arrest in the mother, and simulated drills. Obstetric emergencies included cardiac arrest, postpartum hemorrhage, STAT cesarean, uterine rupture, prolapsed umbilical cord, shoulder dystocia, operative vaginal delivery, and eclampsia., Results: Comparison of pre- and postassessments revealed improvements in perceived confidence and competence when managing obstetric emergencies. Nurse confidence increased by 35% and nurse competence increased by 32%. The 2-day educational program also realized significant cost savings. Overall costs for the educational program decreased from $94849 to $42974., Conclusion: An educationally sound program that included classroom time and focused drills led to increased perceived confidence and competence for nurses and cost savings related to employee education., (© 2015 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses.)

Objective: The purpose of this structured review was to review current evidence of "hands on" and "hands off" techniques as it relates to rates of perineal laceration in order to provide direction for future research in this important area of midwifery practice., Method: A structured literature search using all identified keywords and index terms was undertaken in MEDLINE, EMBASE Joanna Briggs Institute, CINAHL, TRIP, and OVID nursing database., Findings: A total of 24 papers were identified from the initial searches as potentially relevant to the review questions. Of these a total of nine papers were considered relevant for this review. These nine included one systematic review with meta-analysis, four randomised controlled trials (RCTs), one quasi-experimental study and three cohort studies., Conclusion: "Hands on" techniques have been traditionally used but not been well defined in the literature, therefore it is currently unclear as to whether or not "hands on" technique can reduce perineal laceration. More studies are required to test the effectiveness of a standardised "hands on" technique and also to determine what part other factors such as maternal position, visualisation and use of water might play in perineal laceration rates., (Copyright © 2015 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

A better understanding of why women die during pregnancy, childbirth, or postpartum offers valuable insight into strategies aimed at preventing maternal deaths and arresting the progression in the severity of a complication. The rate of severe maternal morbidity and maternal mortality in the United States has been trending upward in recent years and has garnered national attention with concentration on bolstering reviews of maternal deaths and implementing patient safety initiatives. The obstetric nurse is in a unique position to improve maternal outcomes through the anticipation, recognition, and communication of the early warning signs of impending deterioration in maternal condition. Presented in the context of the conceptual model of Stephen Covey's Circle of Influence, the professional nurse can proactively influence maternal outcomes directly, with actions defined by the scope of professional nursing practice or indirectly through professional interactions with others. Advancing one's education, knowledge, and technical skills broadens the influential capacity.

Early recognition and treatment of sepsis are key to decreasing maternal and fetal morbidity and mortality. Timing is critical, and early intervention is associated with improved outcomes. The perinatal provider is in a unique position to identify risk factors, perform assessments, and implement the first 3 hours of the sepsis bundle. Early detection and management combined with careful assessment can assist in providing evidence-based care and moving the patient to a higher level of care when warranted.

A majority of women will experience some degree of perineal trauma during vaginal birth. The morbidity of women related to perineal trauma can reveal in perineal pain, urinary or faecal incontinence and dyspareunia. Midwives can adopt many techniques to protect the perineum from injury. However, there are still no clear guidelines regarding the hands-on and hands-poised approaches of perineal management during the second stage of labour. The current evidence remains contradictory, so which technique should midwives adopt?

An audit was completed by an NHS trust to determine the rate of perineal trauma amongst vaginal births and to assess the rate of perineal wound infections. The audit results confirmed a higher than average rate of perineal wound infections amongst women who had an instrumental birth. The trust decided to separate the contents of the delivery packs into two separate packs--one pack for birth and one pack for suturing--and developed a back-to-basics update session that was delivered to staff working within the maternity setting. A re-audit the following year confirmed that these measures had worked and the overall perineal wound infection rate reduced within the trust.

Perineal tearing in childbirth is common and can have a considerable impact on women. There are various hands-on techniques that midwives use routinely to protect the perineum but not all of them are evidence based. Despite this, midwives often feel that they are the determining factor in whether a woman tears or not. Furthermore, women are rarely asked permission before hands-on techniques are used. This article explores some of the techniques used to prevent perineal tears, looks at the evidence base and invites the reader to reflect on their own practice and thinking around perineal protection.

Midwives have opportunities to help postnatal mothers to minimise perineal discomfort associated with perineal trauma following vaginal birth. Perineal trauma and associated pain is common and can have a negative impact on the physical, psycho-social transition to motherhood and family life. This article considers the role local anaesthetic agents have in helping women to relieve perineal pain. Key evidence is presented with associated practice considerations, and future research areas are suggested to broaden our understanding of this important aspect of postnatal care.

The specialist perineal care clinic has been running at Rotherham NHS Foundation Trust for over three years. This article tells of a quest to further improve perineal care for women in our care and demonstrates the process from conception to birth of the clinic, as well as the journey taken in order for this service to be set up and run efficiently. Prior to this clinic most women saw different people throughout their care, which was obviously confusing for them, as conflicting advice could be on offer. This clinic has provided consistency and continuity which has improved women's experiences and, in turn, yielded improved outcomes. It has empowered the women to further play a part in their own care from antenatal methods of reducing the chance of perineal trauma to postnatal recovery after perineal breakdown and infection. Both women and staff have benefited from this service as there is always a central point of contact.

Suturing can be a daunting midwifery skill to learn, as it's complex and carries great responsibility. There are lots of excellent texts on suturing available in midwifery literature, but perhaps not much on the emotional side of learning. This light-hearted article addresses the anatomy and physiology of the perineum in an engaging and easy to understand way; looks at the current evidence around the decision to suture; and shares ways the author progressed from being apprehensive about suturing to being passionate about the topic and enjoying the skill.

There is sufficient evidence to support the practice of optimal cord clamping in normal labour and birth. In this paper, the physiology of meconium stained liquor (MSL), meconium aspiration syndrome and the practice of optimal cord clamping in babies born through MSL, is discussed. Guidelines suggest not stimulating babies born through MSL, at birth, to avoid aspiration. However, the obvious stimulation resulting from early clamping and cutting the cord, leaves a baby with no choice but to inhale, but this appears to be overlooked in practice. Midwives in their role as supporters of normal physiology are in a position to question this routine intervention in the absence of any evidence to support it.

The rise in births by caesarean section (CS) is a global issue. A skilled obstetrician with a midwife knowledgeable in Kielland's forceps (KF) is often able to achieve a successful rotational vaginal birth when safe. The KF, however, has risks--and outcomes must be audited. In this article we present the results of a literature review and retrospective audit, evaluate maternal and neonatal morbidity associated with KF in our unit and compliance with national standards. Our conclusion is that our unit complies with national standards and offers the woman an alternative to CS when it is safe to do so. Adverse outcomes with KF are not different from other modes of operative birth.

Stroke in association with pregnancy is an infrequent occurrence, but there is evidence that the incidence is rising. The physiological changes of pregnancy are thought to increase stroke risk, and several conditions specific to pregnancy further increase risk. The provision of optimal care to pregnant and postpartum women who experience stroke requires awareness of how the physiological changes of pregnancy may affect the course of stroke and nursing actions. This article provides an overview of current knowledge about pregnancy-related stroke including underlying pathophysiology, risk factors unique to pregnancy, and treatment issues when stroke is a complication of pregnancy. Implications for the nursing care of women with pregnancy-related stroke and maternal child considerations are discussed.