Management of the third stage of labour—focus group discussions with Swedish midwives

Objectiveto explore Swedish midwives’ experiences of management of third stage of labour.Designsix focus group discussions were performed and the analysis was based on content analysis.Settingthe midwives worked at six hospitals: three university hospitals and three provincial hospitals located from the south west to the north of Sweden.Participants32 midwives with extensive experience of assisting women in childbirth.Findingsthe analysis generated three categories: ‘bring the process under control’, ‘protect normality and women's birthing experiences’ and ‘maintain midwives’ autonomy’. This study demonstrates that management of the third stage of labour varies greatly. Not all midwives were convinced that administration of prophylactic oxytocin in the third stage of labour was always the best alternative for all women who had a normal birth.Key conclusions and implications for practicethe midwives exhibited self-confidence in evaluating the physiological process, and endeavoured to leave the physiological process undisturbed if no other risks were apparent. Their decisions concerning third stage management were based on a combination of previous experience, hospital guidelines, risk assessment and sensitivity to each woman's needs. This study demonstrates that management of the third stage of labour varies greatly. The findings show the importance of reaching a balance between treating birth as a normal process and as a biomedical event.     

Beliefs and Perspectives of Women and Obstetrical Providers in Northern Ontario on Water Births

ObjectiveThis study sought to understand the beliefs and perspectives of women in northern Ontario and their obstetrical providers with respect to water birthing as access to this service is limited in this regionMethodsAll midwives, family physicians (FPs), and obstetricians providing labour and delivery services in northern Ontario were surveyed, as were a sample of labour and delivery nurses in the region and convenience samples of regional women.ResultsOf the 362 women who completed the survey (a 90.5% response rate), 81.8% (95% CI 77.5–85.4) believed water births to be safe, 40.9% (95% CI 35.9–46) were interested in having a water birth, and 76.5% (95% CI 71.8–80.5) wanted to have the option of a hospital-based water birth. Perceptions of water birth safety varied significantly by provider type (χ² P < 0.001) with 100% (95% CI 89.6–100) of midwives but 0% (95% CI 52.3–94.9) of obstetricians considering them to be safe. Perceptions of the specific risks and benefits of water birth also varied significantly by provider type, as did understanding of consumer interest. Reflecting these perceptions, 97.1% (95% CI 85.1–99.5) of midwives and 0% (95% CI 0–27.8) of obstetricians would consider assisting in or providing hospital-based water births.ConclusionsWomen in northern Ontario are interested in water birth and in having this service available in hospitals. However, given the widely divergent views of the professional groups providing labour and delivery care in the region, hospitals should be strongly encouraged to explore interprofessional development opportunities to enable patient-centred care in this context.     

'Soothing the ring of fire': Australian women's and midwives' experiences of using perineal warm packs in the second stage of labour

Objective

to determine women's and midwives’ experiences of using perineal warm packs in the second stage of labour.

Design

as part of a randomised controlled trial (Warm Pack Trial), women and midwives were asked to complete questionnaires about the effects of the warm packs on pain, perineal trauma, comfort, feelings of control, satisfaction and intentions for use during future births.

Setting

two hospitals in Sydney, Australia.

Participants

a randomised controlled trial was undertaken. In the late second stage of labour, nulliparous women (n=717) giving birth were randomly allocated to having warm packs (n=360) applied to their perineum or standard care (n=357). Standard care was defined as any second stage practice carried out by midwives that did not include the application of warm packs to the perineum. Three hundred and two nulliparous women randomised to receive warm packs (84%) received the treatment. Questionnaires were completed by 266 (88%) women who received warm packs, and 270 (89%) midwives who applied warm packs to these women.

Intervention

warm, moist packs were applied to the perineum in the late second stage of labour.

Findings

warm packs were highly acceptable to both women and midwives as a means of relieving pain during the late second stage of labour. Almost the same number of women (79.7%) and midwives (80.4%) felt that the warm packs reduced perineal pain during the birth. Both midwives and women were positive about using warm packs in the future. The majority of women (85.7%) said that they would like to use perineal warm packs again for their next birth and would recommend them to friends (86.1%). Likewise, 91% of midwives were positive about using the warm packs, with 92.6% considering using them in the future as part of routine care in the second stage of labour.

Key conclusions

responses to questionnaires, eliciting experiences of women and midwives involved in the Warm Pack Trial, demonstrated that the practice of applying perineal warm packs in the late second stage of labour was highly acceptable and effective in helping to relieve perineal pain and increase comfort.

Implications for practice

perineal warm packs should be incorporated into second stage pain relief options available to women during childbirth.     

Health Care Providers’ Perceptions of Quality of Childbirth and Its Associated Risks in Poland

ObjectiveTo describe Polish maternity care providers’ cognitive frames of quality of childbirth and how they relate to providers’ perceptions of childbirth using Baranowska’s model of quality of care.DesignMixed-methods, cross-sectional.SettingTwenty-four hospitals and outpatient clinics that provide maternity care located in two central districts of Poland.ParticipantsObstetricians or resident physicians in obstetrics (n = 50) and midwives (n = 676) who were actively engaged in the provision of maternity care.MethodsParticipants completed a survey that included two tasks. The first was a sentence completion technique that we used as a projective method to investigate participants’ preconceived attitudes about quality of childbirth. Depending on the number of perspectives (as in Baranowska’s model) included in the statements, participants’ perceptions were categorized as strongly narrowed (zero perspectives), narrow (one perspective), intermediate (two perspectives), or holistic (three perspectives). In the second task, we asked participants to choose one statement out of three that best represented their beliefs about childbirth.ResultsParticipants had mostly intermediate (n = 436, 60%) or narrow (n = 183, 25%) perceptions of quality of childbirth. Those with less work experience tended to have more encompassing perspectives. More than half of the participants perceived childbirth as a physiologic process requiring no medical interventions (n = 385, 53%). Only 9% (n = 65) of the participants reported that childbirth is always associated with great risk. There was a main effect of work experience on the number of perspectives included in the definition of quality of childbirth with F(2, 720) = 5.532, p = .004. Participants with less work experience included more perspectives in their statements. There were no statistically significant differences in the perception of quality of childbirth between obstetricians and midwives, with F(1, 724) = .000, p = 0.991, or between participants from different workplaces, with F(3, 719) = 1.742, p = .157.ConclusionOnly a small share of participants had holistic perceptions of quality of childbirth consistent with Baranowska’s model. This may not only contribute to the medicalization of maternity care in Poland, but it also contrasts with participants’ declarations that childbirth is a physiologic process with no need for medical interventions. Considering the greater rates of medical interventions in maternity care in Poland, the latter finding requires further research.     

Meta-Synthesis of the Needs of Women Cared for by Midwives During Childbirth in Hospitals

ObjectiveTo identify and meta-synthesize results of qualitative studies on the needs of women cared for by midwives during childbirth in hospitals.Data SourcesMEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, and the Cochrane Library.Study SelectionWe restricted the bibliographic search to articles published in English to July 31, 2020. The initial search yielded 6,407 articles, and after 2,504 duplicates were removed, we screened the titles and abstracts of 3,903 articles. We conducted a full-text review of 89 articles and included 13 qualitative studies about the needs of women who were hospitalized during childbirth and had midwives as their primary maternity care providers.Data ExtractionWe extracted data (e.g., authors, publication date, type of study, sample size, results, and quotes) from the full text of each article into a standardized table. Two authors reviewed all articles using the Critical Appraisal Skills Programme tool to assess study quality and to independently score each study.Data SynthesisWe analyzed the findings of each study and synthesized them to develop themes. We found 14 major themes that reflected the needs of women during hospitalization for childbirth: Nutrition, Hygiene, Privacy, Information, Bodily Respect, Respect for Social Role, Family Intimacy, Shelter, Pain Management, Partnership, Movement, Reassurance, Support, and Empowerment. We categorized these themes in Maslow’s hierarchy of needs to better understand the phenomenon.ConclusionWe identified 14 needs that midwives and nurses can meet when they care for women in hospitals during childbirth. Standardized methods to assess these needs and to link them to specific interventions can be used by midwives and nurses, which will likely affect women’s satisfaction with their experience and overall quality of care.     

Psychosocial health and well-being among obstetricians and midwives involved in traumatic childbirth

Objectivethis study investigates the self-reported psychosocial health and well-being of obstetricians and midwives in Denmark during the most recent four weeks as well as their recall of their health and well-being immediately following their exposure to a traumatic childbirth.Material and methodsa 2012 national survey of all Danish obstetricians and midwives (n=2098). The response rate was 59% of which 85% (n=1027) stated that they had been involved in a traumatic childbirth. The psychosocial health and well-being of the participants was investigated using six scales from the Copenhagen Psychosocial Questionnaire (COPSOQII). Responses were assessed on six scales: burnout, sleep disorders, general stress, depressive symptoms, somatic stress and cognitive stress. Associations between COPSOQII scales and participant characteristics were analysed using linear regression.Resultsmidwives reported significantly higher scores than obstetricians, to a minor extent during the most recent four weeks and to a greater extent immediately following a traumatic childbirth scale, indicating higher levels of self-reported psychosocial health problems. Sub-group analyses showed that this difference might be gender related. Respondents who had left the labour ward partly or primarily because they felt that the responsibility was too great a burden to carry reported significantly higher scores on all scales in the aftermath of the traumatic birth than did the group who still worked on the labour ward. None of the scales were associated with age or seniority in the time after the traumatic birth indicating that both junior and senior staff may experience similar levels of psychosocial health and well-being in the aftermath.Key conclusions and implicationsthis study shows an association between profession (midwife or obstetrician) and self-reported psychosocial health and well-being both within the most recent four weeks and immediately following a traumatic childbirth. The association may partly be explained by gender. This knowledge may lead to better awareness of the possibility of differences related to profession and gender when conducting debriefings and offering support to HCPs in the aftermath of traumatic childbirth. As many as 85% of the respondents in this national study stated that they had been involved in at least one traumatic childbirth, suggesting that the handling of the aftermath of these events is important when caring for the psychosocial health and well-being of obstetric and midwifery staff.     

Women’s postnatal psychological functioning: the role of satisfaction with intrapartum care and the birth experience

Objective: To investigate the relationship between women’s postnatal psychological well-being and retrospective, self-reported satisfaction with intrapartum care and the birth experience. Background: The period immediately following childbirth can be marked by various problems that can affect a woman’s happiness and functioning. Previous research has suggested that aspects of the maternal experience of childbirth may act as predictors for specific indicators of women’s postnatal functioning. This study aimed to determine the relationship between satisfaction with labour and birth care and the general childbirth experience and a broad, comprehensive measure of subsequent psychological functioning. Methods: Data for this study was taken from relevant items in the Having a Baby in Queensland 2009 Pilot Survey. Researchers assessed maternal socio-demographic characteristics, perceptions of labour and birth care, satisfaction with labour and birth care, and perceived positivity of the birth experience. A dichotomous, composite measure of postnatal psychological functioning was derived from women’s responses to five separate survey items. Results: The multivariate logistic regression analysis showed that women who felt they were looked after ‘very well’ and women who rated their birth experience as ‘very positive’ were significantly more likely to experience high postnatal functioning than women who did not rate their intrapartum care and birth experience as highly. Conclusions: Reducing the risk factors for dissatisfaction is critical in order to improve the likelihood of high maternal postnatal functioning. The findings of this study emphasise the importance of intrapartum care in the development of positive functioning in women who have recently given birth.     

Cashless childbirth,but at a cost: A grounded theory study on quality of intrapartum care in public health facilities in India

Aimthis study aimed to explore and understand the perceptions and experiences of women regarding quality of care received during childbirth in public health facilities.Designqualitative in-depth interviews were conducted and analysed using the Grounded Theory approach.Participantsthirteen women who had given vaginal birth to a healthy newborn infant.Settingparticipants were interviewed in their homes in one district of Chhattisgarh, India.Data collectionthe interview followed a pre-tested guide comprising one key question: How did the women experience and perceive the care provided during labour and childbirth?Findings'cashless childbirth but at a cost: subordination during childbirth' was identified as the core category. Women chose a public health facility due to their socio-economic limitations, and to have a cashless and safe childbirth. Participants expressed a sense of trust in public health facilities, and verbalised that free food and ambulance services provided by the government were appreciated. Care during normal birth was medicalised, and women lacked control over the process of their labour. Often, the women experienced verbal and physical abuse, which led to passive acceptance of all the services provided to avoid confrontation with the providers.Conclusionsincreasingly higher numbers of women give birth in public health facilities in Chhattisgarh, India, and women who have no alternative place to have a safe and normal birth are the main beneficiaries. The labour rooms are functional, but there is a need for improvement of interpersonal processes, information-sharing, and sensitive treatment of women seeking childbirth services in public health facilities.     

The motivation and capacity to go ‘above and beyond’: Qualitative analysis of free-text survey responses in the M@NGO randomised controlled trial of caseload midwifery

Objectiveto explore whether women allocated to caseload care characterise their midwife differently to those allocated to standard care.Designmulti-site unblinded, randomised, controlled, parallel-group trial.Settingthe study was conducted in two metropolitan teaching hospitals across two Australian cities.Populationwomen of all obstetric risk were eligible to participate. Inclusion criteria were: 18 years or older, less than 24 week’s gestation with a singleton pregnancy. Women already booked with a care provider or planning to have an elective caesarean section were excluded.Interventionsparticipants were randomised to caseload midwifery or standard care. The caseload model provided antenatal, intrapartum and postnatal care from a primary midwife or ‘back-up’ midwife; as well as consultation with obstetric or medical physicians as indicated by national guidelines. The standard model included care from a general practitioner and/or midwives and obstetric doctors.Measurements and findingsparticipants’ responses to open-ended questions were collected through a 6-week postnatal survey and analysed thematically. A total of 1748 women were randomised between December 2008 – May 2011; 871 to caseload midwifery and 877 to standard care. The response rate to the 6-week survey including free text items was 52% (n=901). Respondents from both groups characterised midwives as Informative, Competent and Kind. Participants in the caseload group perceived midwives with additional qualities conceptualised as Empowering and ‘Endorphic’. These concepts highlight some of the active ingredients that moderated or mediated the effects of the midwifery care within the M@NGO trial.Key conclusioncaseload midwifery attracts, motivates and enables midwives to go Above and Beyond such that women feel empowered, nurtured and safe during pregnancy, labour and birth.Implications for practicethe concept of an Endorphic midwife makes a useful contribution to midwifery theory as it enhances our understanding of how the complex intervention of caseload midwifery influences normal birth rates and experiences. Defining personal midwife attributes which are important for caseload models has potential implications for graduate attributes in degree programs leading to registration as a midwife and selection criteria for caseload midwife positions.     

A comparison of Israeli Jewish and Arab women's birth perceptions

Background

birth is a normal physiological process, but can also be experienced as a traumatic event. Israeli Jewish and Arab women share Israeli residency, citizenship, and universal access to the Israeli medical system. However, language, religion, values, customs, symbols, and lifestyle differ between the groups.

Objectives

to examine Israeli Arab and Jewish women's perceptions of their birth experience, and to assess the extent to which childbirth details and perceptions predict satisfaction with the birth experience and the extent of assessing the childbirth as traumatic.

Methods

this study was conducted in two post partum units of two major public hospitals in the northern part of Israel. The sample included 171 respondents, including 115 Jewish Israeli and 56 Arab Israeli women who gave birth to their first (33%) or second (67%) child. Respondents described their childbirth experiences using a self-report questionnaire 24–48 hours after childbirth.

Findings

the Arab women were much less likely to attend childbirth preparation classes than the Jewish women (5% versus 24%). Forty-three per cent of the respondents reported feeling helpless, and 68% reported feeling lack of control during childbirth. Twenty per cent of the women rated their childbirth experience as traumatic, a rate much lower than the rate of medical indicators of traumatic birth (39%). The rate of self-reported traumatic birth was significantly higher among the Arab women than among the Jewish women (32% versus 14%). A higher percentage of the Arab women reported being afraid during labour (χ²=4.97, p<.05), expressed fear for their newborn's safety (χ²=12.44, p<.001), and reported that the level of medical intervention was excessive in their opinion, as compared to the Jewish women (χ²=5.09, p<.05; χ²=7.33, p<.01). However, both the Arab and Jewish women reported similar numbers of medical interventions and levels of satisfaction with their medical treatment.

Conclusions

despite universal access to the Israeli health care system, Arab Israeli women use fewer perinatal medical resources and subjectively report more birth trauma than Jewish Israeli women. Yet, they give birth in the same hospitals with the same practitioners and report similarly high levels of satisfaction with the medical services. Taking into account the fact that perceptions of the birth experience differ between ethno-cultural groups will enable professionals to better tailor intervention and support throughout childbirth in order to increase satisfaction and minimise trauma from the experience.     

The kaleidoscopic midwife: A conceptual metaphor illustrating first-time mothers' perspectives of a good midwife during childbirth. A grounded theory study

BackgroundThe literature review reveals general information about a good midwife from a range of perspectives and what childbearing women generally value in a midwife, but there is a lack of information around mothers’ perspectives of what makes a good midwife specifically during labour and birth, and even less in the context of different places of birth.AimTo conceptualise first-time mothers’ expectations and experiences of a good midwife during childbirth in the context of different birthplaces.DesignQualitative Straussian grounded theory methodology.SettingThree National Health Service Trusts in England providing maternity care that offered women the possibility of giving birth in different settings (home, freestanding midwifery unit and obstetric unit).ParticipantsFourteen first-time mothers in good general health with a straightforward singleton pregnancy anticipating a normal birth.MethodsEthical approval was gained. Data were collected through two semi-structured interviews for each participant (before and after birth). Data analysis included the processes of coding and conceptualising data, with constant comparison between data, literature and memos.FindingsThe model named ‘The kaleidoscopic midwife: a conceptual metaphor illustrating first-time mothers’ perspectives of a good midwife during childbirth’ was developed. The model is dynamic and woman-centred, and is operationalised as the midwife adapts to each woman's individual needs in the context of each specific labour. Four pillars of intrapartum care were identified for a good midwife in the labour continuum: promoting individuality; supporting embodied limbo; helping to go with the flow; providing information and guidance. The metaphor of a kaleidoscopic figure is used to describe a midwife who is ‘multi-coloured’ and ever changing in the light of the woman's individual needs, expectations and labour journey, in order to create an environment that enables her to move forward despite the uncertainty and the expectations-experiences gap. The following elements are harmonised by the kaleidoscopic midwife: relationship-mediated being; knowledgeable doing; physical presence; immediately available presence.ConclusionThe model presented has relevance to contemporary debates about quality of care and place of birth and can be used by midwives to pursue excellence in caring for labouring mothers. Independently from the place of birth, when the woman is cared for by a midwife demonstrating the above characteristics, she is likely to have an optimum experience of birth. Future research is necessary to tease out individual components of the model in a variety of practice settings.     

The golden hour in Finnish birthing units - An ethnographic study

ObjectiveTo explore midwives’ and parents’ perceptions and actions as well as the culture surrounding the first hour after the birth of a baby – the golden hour.DesignShort-term ethnographic study, which included observations, informal interviews and focus group interviews. Thematic network analysis was used to analyse the data.SettingTwo birthing hospitals in Finland.ParticipantsThe first hour following 16 births was observed and informal interviews of attending midwives (n = 10) and parents (n = 3 couples and n = 6 mothers) were conducted to supplement the observations. The 16 cases included both primiparous (n = 8) and multiparous (n = 8) women, as well as vaginal (n = 12) and elective caesarean births (n = 4). Furthermore, two focus group interviews with midwives (n = 9) were conducted to deepen the understanding.FindingsThe over-arching theme Unchallenged hospital ‘rules’ comprised the two main themes of Safety-driven support by midwives and Silent voices of the parents. The hospital guidelines and practices guided the first hour, unchallenged by parents and midwives. Based on the guidelines, all the babies were given skin-to-skin contact early but not immediately. Midwives strictly followed the guidelines and performed many activities with the mothers during the first hour. Embedded power was present: midwives were in control but tended to listen to the parents. Although the mothers displayed a strong need to be close to their babies, their voices were silent in the units. The parents’ compliance with midwives and parents’ intense focus on the baby strengthened the midwives’ embedded power.Key conclusionCare culture in birthing units was ‘rule-based’ and the guidelines and practices sometimes inhibited uninterrupted skin-to-skin contact without questioning. The golden hour was mainly controlled by the maternity care staff.Implications for practiceRe-evaluation of hospital guidelines should enable more woman- and family-centred care. The golden hour is unique to families, and unnecessary separation and interventions should be avoided.     

The relationship between prenatal control, expectations, experienced control, and birth satisfaction among primiparous women

Objectives

this paper explores the relationship between perceptions of prenatal control, expectations for childbirth, and experienced control in labour and birth and how they individually and collectively affect birth satisfaction.

Design

a repeated measures exploratory study was conducted with 31 primiparous women between 26 and 40 weeks pregnant. Standardised interviews were conducted prior to birth to assess levels of prenatal control and expectations for control during childbirth. Six weeks after the birth, women were interviewed again to assess experiences of control and birth satisfaction.

Setting

prenatal clinic, North Carolina, USA.

Findings

results show experienced control to be a significant predictor of birth satisfaction, with high levels of control correlating with high satisfaction levels. However, no correlations were found between the three aspects of control, and both prenatal control and birth expectations were found to have no significant effect on birth satisfaction. Findings also indicate that women cared for by midwives have significantly higher experienced control and birth satisfaction than women whose care was provided by obstetricians, while incidence of caesarean birth did not affect either measure.

Conclusions

experienced control during labour and birth is an important predictor of birth satisfaction. Health care providers should collaborate with the women they care for to use techniques that maximize the experience of control especially during labour and birth.