Senior Midwives Research Articles

When is collaboration not collaboration? When it's militarized

In adopting the medical lobby's preferred definition of collaboration where midwives are legally compelled to seek endorsement for their care plan from an obstetrician, Determination 2010 connotes a form of militarized collaboration and thus negates all that genuine collaboration stands for--equality, mutual trust and reciprocal respect. Using Critical Discourse Analysis, the first half of this paper analyses the submissions from medical, midwifery and consumer peak organisations to the Maternity Services Review and Senate reviews held between 2008 and 2010 showing that Determination 2010 privileges the medical lobby worldview in adopting a vertical definition of collaboration. The second half of the paper responds to the principal assumption of Determination 2010--that midwives do not voluntarily collaborate. It argues by reference to a qualitative inquiry conducted into select caseload maternity units in South Australia, Victoria and New South Wales during 2009-2010 that this presupposition is erroneous. The evidence shows that genuine collaboration is possible without legislative force but it requires a coalition of the willing among senior midwives and obstetricians to institute regular interdisciplinary meetings and clinical reviews and to model respectful behaviour to new entrants.

Multidisciplinary emergency skills training for new graduate registered midwife: AN evidence-based Italian experience

Purpose of the study: The Confidential Enquiries into Maternal Deaths has identified substandard care in a significant proportion of maternal, fetal and neonatal deaths. Introduction of multidisciplinary teamwork training with integrated acute obstetric training interventions in a simulation setting is potentially effective in the prevention of errors, thus improving patient safety in acute obstetric emergencies. To improve emergency skills and obstetric critical care in young midwives we implemented a three-day course, following a multidisciplinary approach (senior midwives, obstetric anaesthetists, Senior Obstetricians, psychologist).

Policies for care during the third stage of labour: a survey of maternity units in Syria.

BackgroundCare for women during the third stage aims to reduce the risk of major haemorrhage, but is very variable. The current World Health Organisation (WHO) recommendation is that care should include administration of a uterotonic (oxytocin, if it is available) soon after birth of the baby, delayed cord clamping, and delivery of the placenta by controlled cord traction.MethodsTo ascertain care policies used during the third stage of labour in maternity units in Syria, we conducted a survey of 69 maternity units in obstetric and general public hospitals. A brief questionnaire was administered by face to face interview or telephone with senior obstetricians and midwives. Outcome measures were the use of prophylactic uterotonic drugs, timing of cord clamping, use of controlled cord traction, and treatment for postpartum haemorrhage. Obstetricians were asked about both vaginal and caesarean births, midwives only about vaginal births.ResultsResponses were obtained for 66 (96%) hospitals: a midwife and an obstetrician were interviewed in 40; an obstetrician only in 20; a midwife only in 6. Responses were similar, although midwives were more likely to report that the umbilical cord was clamped after 1-3 minutes or after cessation of pulsation (2/40 obstetricians and 9/40 midwives). Responses have therefore been combined.One hospital reported never using a prophylactic uterotonic drug. The uterotonic was Syntometrine® (oxytocin and ergometrine) in two thirds of hospitals; given after delivery of the placenta in 60 (91%) for vaginal births, and in 47 (78%) for caesarean births. Cord clamping was within 20 seconds at 42 hospitals 64%) for vaginal births and 45 (75%) for caesarean births. Controlled cord traction was never used in a quarter (17/66) of hospitals for vaginal births and a half (32/60) for caesarean births.68% of respondents (45/66) thought there was a need for more randomised trials of interventions during the third stage of labour.ConclusionMost maternity units report using Syntometrine®, usually given after delivery of the placenta, clamping the cord within 20 seconds, and using controlled cord traction.

Workload and workforce planning: developing a learning toolkit

The second article in this series described the tools for which there is a consensus for use in nursing and midwifery workload and workforce planning (NMWWP) in Scotland, and the national programme of education and training support developed for the staff who would be using the tools in NHS boards. To help senior charge nurses, midwives and others support and manage their staff resources effectively, a learning toolkit has been developed by the NMWWP programme in partnership with NHS Education for Scotland. The NMWWP learning toolkit (NHS Education for Scotland 2008), described in this article, is a flexible, practical, work-based resource for use in NHS boards. Intended primarily for senior charge nurses, it can also be used by other professionals who aspire to senior charge nurse positions and by nurse managers as a knowledge-refresher.

The situational argument: do midwives agree or acquiesce with senior staff?

This study concerns midwives' obedience/conformity to direction from a senior person. We sought to identify whether midwives just went along with what a midwife at management level suggested, or instead altered their views to match. In the first condition, a postal Social Influence Scale‐Midwifery (SIS‐M) measured and scored 209 midwives' private responses to 10 clinical questions. In a second condition, a senior midwife successfully influenced 60 of these midwives to alter their SIS‐M decisions to agree with her suggested correct responses. In a third condition, a postal condition again measured the midwives private SIS‐M responses. The aim was to elicit whether the midwives' simply complied with the senior midwife's suggestions during interview or actually changed their opinions to match hers. A 3 (E (lowest grade), F (middle grade) & G (sister grade)) × 3 (above conditions) ANOVA found a significant main effect for conditions (F(2, 94) = 151.87, p = 0.001) with higher scores in the interview condition when the senior midwife passively influenced participant responses. Results inform that the interview manipulation had no lasting social influence effect, consistent with Milgram's transient situational argument. That is, in the presence of senior staff, midwives' decisions are profoundly influenced.

Multidisciplinary obstetric simulated emergency scenarios (MOSES): Promoting patient safety in obstetrics with teamwork-focused interprofessional simulations

We describe an example of simulation-based interprofessional continuing education, the multidisciplinary obstetric simulated emergency scenarios (MOSES) course, which was designed to enhance nontechnical skills among obstetric teams and, hence, improve patient safety. Participants' perceptions of MOSES courses, their learning, and the transfer of learning to clinical practice were examined. Participants included senior midwives, obstetricians, and obstetric anesthetists, including course faculty from 4 purposively selected delivery suites in England. Telephone or e-mail interviews with MOSES course participants and facilitators were conducted, and video-recorded debriefings that formed integral parts of this 1-day course were analyzed. The team training was well received. Participants were able to check out assumptions and expectations of others and develop respect for different roles within the delivery suite (DS) team. Skillful facilitation of debriefing after each scenario was central to learning. Participants reported acquiring new knowledge or insights, particularly concerning the role of communication and leadership in crisis situations, and they rehearsed unfamiliar skills. Observing peers working in the simulations increased participants' learning by highlighting alternative strategies. The learning achieved by individuals and groups was noticeably dependent on their starting points. Some participants identified limited changes in their behavior in the workplace following the MOSES course. Mechanisms to manage the transfer of learning to the wider team were weakly developed, although 2 DS teams made changes to their regular update training. Interprofessional, team-based simulations promote new learning.

Change in Knowledge of Midwives and Obstetricians Following Obstetric Emergency Training: A Randomized Controlled Trial of Local Hospital, Simulation Centre and Teamwork Training

Surveys in the United Kingdom have repeatedly discovered substandard care in significant proportions of maternal, fetal, and neonatal deaths. In the United Kingdom, training in obstetrical emergencies is carried out both nationally and locally in maternity units. This prospective, randomized controlled trial evaluated training in 6 hospitals in the United Kingdom. The 140 participants included 22 junior and 23 senior doctors as well as 47 junior and 48 senior midwives. They were randomized to one of 4 obstetrical emergency training interventions: a 1-day course at a local hospital, a 1-day course at a simulation center, a 2-day course with teamwork training at a local hospital, and a 2-day course with teamwork training at a simulation center. A 183-question multiple choice questionnaire (MCQ) was completed up to 3 weeks before the training intervention and again 3 weeks after the intervention. All but 7 of the 140 participants completed training and the posttraining assessment. Knowledge of obstetrical emergency management increased following training. The increase in the mean MCQ score was significant at the P < 0.001 level. All but 10 of 133 participants who completed both assessments had increased MCQ scores. Neither the location of training nor the inclusion of teamwork training significantly influenced posttraining scores. Changes in MCQ scores after training correlated negatively with pretraining scores. There were, however, no significant differences between staff groups in their relative responses to the 4 training interventions. With one exception—management of breech presentation—scores for individual components of the MCQ improved significantly. This is the first study demonstrating objective improvement in what doctors and midwives know following training in obstetrical emergency management. It remains to be determined whether this translates into lower maternal and neonatal morbidity and mortality rates. The investigators believe that all relevant staff should take part in this type of training on an annual basis.

Patient-actor perception of care: a comparison of obstetric emergency training using manikins and patient-actors

Objective:To explore the effect of training on patient-actor perception of care during simulated obstetric emergencies.Method:A subanalysis from a prospective randomised controlled trial in six UK hospitals and the Bristol Medical...

Early resort to general anaesthesia in severe shoulder dystocia

We report a case of shoulder dystocia where we believe that earlier resort to general anaesthesia (GA) could have altered the outcome. The registrar and senior midwife, who lacked the clinical expe...

Amniocentesis counselling: a role for the midwife-practitioner

SummaryRecent publication of an evidence-based clinical guideline by the Royal College of Obstetricians and Gynaecologists (RCOG ) for invasive testing in pregnancy stimulated a review of our prenatal diagnosis counselling service. This coincided with a reduction in the hours worked by obstetric trainees and a need to streamline antenatal care. We arranged for a senior midwife (KE) with extensive experience in general midwifery and fetal medicine to undergo additional training in counselling for amniocentesis. She then took over the running of the counselling service supported by an in-house care pathway. She had open access to a consultant (RF) for advice. A review of the case notes of 60 consecutive women who attended for counselling showed that the midwife followed the guidelines extremely closely both in terms of process and quality of the documentation. A total of 58 of the women were counselled solely by the midwife-practitioner. Only two required additional counselling by the consultant. Of a subset of 27 women surveyed by telephone questionnaire, only two (7.4%) were surprised to have been counselled by a midwife; 25 (93%) said the counselling was excellent or good; 17 (63%) said they would prefer to see a midwife in any future pregnancy and only one woman said she would prefer to see a doctor.

Change in knowledge of midwives and obstetricians following obstetric emergency training: a randomised controlled trial of local hospital, simulation centre and teamwork training

To explore the effect of obstetric emergency training on knowledge. Furthermore, to assess if acquisition of knowledge is influenced by the training setting or teamwork training. A prospective randomised controlled trial. Training was completed in six hospitals in the South West of England, UK and at the Bristol Medical Simulation Centre, UK. Midwives and obstetric doctors working for the participating hospitals were eligible for inclusion in the study. A total of 140 participants (22 junior and 23 senior doctors, 47 junior and 48 senior midwives) were studied. Participants were randomised to one of four obstetric emergency training interventions: (1) 1-day course at local hospital, (2) 1-day course at simulation centre, (3) 2-day course with teamwork training at local hospital and (4) 2-day course with teamwork training at simulation centre. Change in knowledge was assessed by a 185 question Multiple-Choice Questionnaire (MCQ) completed up to 3 weeks before and 3 weeks after the training intervention. There was a significant increase in knowledge following training; mean MCQ score increased by 20.6 points (95% CI 18.1-23.1, P < 0.001). Overall, 123/133 (92.5%) participants increased their MCQ score. There was no significant effect on the MCQ score of either the location of training (two-way analysis of variants P = 0.785) or the inclusion of teamwork training (P = 0.965). Practical, multiprofessional, obstetric emergency training increased midwives' and doctors' knowledge of obstetric emergency management. Furthermore, neither the location of training, in a simulation centre or in local hospitals, nor the inclusion of teamwork training made any significant difference to the acquisition of knowledge in obstetric emergencies.

How can we improve choice provision for childbearing women?

Obedience research has shown that under situational pressures and within hierarchical relationships, people have a propensity towards submission to authority (Milgram, 1974). Once they have done so, their actions are no longer guided by their own values but by the desire to fulfill authority's wishes (Meeus and Raaijmakers, 1995). When an authority figure gives direction, this may clash with a midwife's knowledge of a woman's preferred choice. Hollins Martin and Bull (2005) showed the success that a senior midwife had at socially influencing decisions of more junior midwives, even when the outcome contravened their established views of best practice. Hollins Martin and Bull (2006) showed that choice provision for childbearing women was difficult to provide because of the imposition of hospital protocols, the hierarchy and fears of challenging senior people. Acknowledging these identified constraints this paper poses eight plausible solutions to facilitate midwives with providing the choice that is advocated in social policy documents (Department of Health, 1993; DH, 2003; DH, 2004).

Getting an evidence‐based post‐partum haemorrhage policy into practice

Post-partum haemorrhage (PPH) is a potentially life-threatening complication of childbirth occurring in up to 10% of births. The NSW Department of Health (DoH) issued a new evidence-based policy (Framework for Prevention, Early Recognition and Management of Post-partum Haemorrhage) in November 2002. Feedback from maternity units indicated that there were deficiencies in the skills and experience is needed to develop the written protocols and local plans of action required by the Framework. All 96 hospitals in NSW that provide care for childbirth were surveyed. A senior midwife completed a semistructured telephone interview. Ninety four per cent of hospitals had PPH policies. Among hospitals that provided a copy of their policy, 83% were dated after the release of the DoH's Framework, but 22% contained an incorrect definition of PPH. Only 71% of respondents in small rural and urban district hospitals recalled receiving a copy of the Framework. There was considerable variation in the frequency of postnatal observations. Key factors that impede local policy development were resources, entrenched practices and centralised policy development. Enabling factors were effective relationships, the DoH policy directive (Framework), education and organisational issues/time. Greater assistance is needed to ensure that hospitals have the capacity to develop a policy applicable to local needs. Maternity hospitals throughout the state provide different levels of care and NSW DoH policy directives should not be 'one size fits all' documents. Earlier recognition of PPH may be facilitated by routine post-partum monitoring of all women and should be consistent throughout the state, regardless of hospital level.

Passive resistance: Early experiences of midwifery students/graduates and the Baby Friendly Health Initiative 10 steps to successful breastfeeding

PASSIVE RESISTANCE: Early experiences of midwifery students/graduates and the Baby Friendly Health Initiative (BFHI) 10 steps to successful breastfeeding. What factors, in relation to the BFHI 10 steps to successful breastfeeding, influence the development of breastfeeding support practice for beginning practitioner midwives? Newly graduated midwives about to commence a Graduate Midwifery Program (GMP) were recruited from two South Australian universities and one Western Australian hospital to participate in the study. This qualitative longitudinal study used critical incident technique for a series of three semi-structured interviews with each participant. The theoretical framework of the project was Bandura's Social Learning Theory with Boyatzis' Data driven approach used to thematically analyze the data. Participants highlighted experiences such as time pressure and the established clinical practices of experienced midwives that undermined their commitment to the BFHI 10 steps. Outdated practices by senior midwives and passive resistance to the BFHI 10 steps were commonplace even in participating hospitals which are BFHI accredited. The clinical working environment has a major impact on the way newly graduated midwives integrate the BFHI 10 steps into their breastfeeding support practice. Commitment to the BFHI 10 steps should not be taken for granted just because a hospital achieves BFHI accreditation. Many experienced midwives are continuing with outdated practices that confuse breastfeeding mothers and newly graduated midwives alike.

Recognition and management of critical illness by midwives: implications for service provision

The aim of this study was to explore midwives' recognition and management of critical illness in obstetric women in order to inform service provision. Critical illness is not confined to Intensive Care. Limited published work was located examining factors affecting critical care provision by midwives. A multi-method design incorporating a paper and pencil simulation (n = 11) and in-depth interviewing (n = 5) was conducted with midwives from a large London National Health Service Trust. This study details and discusses the findings. Findings indicated that frequency and type of critical illness experience impact upon midwives' critical care knowledge and skills. Midwives, especially those who were more junior, expressed anxiety regarding this aspect of practice, and considered the support of senior midwives, medical and nursing staff as crucial to effective client management. This study has yielded important insights into midwives' management of critical illness. Possible mechanisms to enhance the quality of service provision, and midwife support in this area are highlighted.

Emotion work and boundary maintenance in hospital-based midwifery

To identify and explore the emotion work of hospital-based midwives. An ethnographic approach using focus groups, observations and interviews. South Wales, UK. Phase one of the study: self-selected convenience sample of 27 student midwives in first and final years of 3-year (direct entry) and 18-month (post-nursing) programmes. Phase two: opportunistic sample of seven qualified hospital-based midwives. Phase three: Purposive sample of 10 hospital-based midwives working within one National Health Service Trust. Sample representative of a range of clinical locations, length of clinical experience and clinical grades. The emotion work of midwives was strongly influenced by the context of practice. For hospital-based midwives, relationships with midwifery colleagues were of key importance, providing the main source of feedback on individual practice. Negotiating these relationships was a major source of emotion work. Although collegial relationships could provide support and affirmation, they were also a frequent source of conflict, particularly between junior and senior midwives. This discord was underpinned by conflicting ideologies of midwifery practice. The theoretical framework of boundary maintenance was used to interpret the findings. Senior and junior midwives frequently held contradictory models of practice, resulting in competing claims for occupational jurisdiction. Midwives made use of a variety of devices in order to establish and maintain intra-occupational boundaries. Senior midwives attempted to maintain their position through unwritten rules and sanctions, supported by their claim to greater clinical expertise and experience. Junior midwives rarely challenged this authority; their responses were often subversive and designed to create an appearance of compliance. These findings contribute to our understanding of inter-collegial conflict in UK midwifery, providing insights into workplace harassment and low staff morale, which are likely to exacerbate workforce attrition. The underpinning ideological dissonance experienced by midwives must be acknowledged and tackled for these issues to be effectively addressed.

Measuring social influence of a senior midwife on decision‐making in maternity care: an experimental study

AbstractThe document Changing Childbirth produced by the Department of Health (1993) requests provision of more choice, continuity and control for women during pregnancy and childbirth. In this context this study considers whether midwives'decisions are influenced by a senior midwife. A simple, valid and reliable scale—the Social Influence Scale for Midwifery (SIS‐M)—was devised to measure and score midwives' private anonymous responses to 10 clinical decisions. The SIS‐M was initially administered as a self‐completed postal survey by 209 midwives. Following a 9‐month time gap, a stratified sample of 60 (20 E, F, G grade midwives) were invited for interview in which a senior midwife attempted to influence SIS‐M responses in a conformist direction. Overall, a 3 × 2 (E, F, G grade midwives x private and interview SIS‐M scores) analysis of variance (ANOVA) revealed midwives were significantly more conformist when influenced by a senior midwife, in comparison to private anonymous responses. No significant interaction between groups was found. These findings indicate that there is influence of a senior midwife on clinical decisions that should be woman‐centred, according to Changing Childbirth (1993). The implication is that this influence may remove choice from women. Copyright © 2005 John Wiley &amp; Sons, Ltd.

The Labour Ward Handbook

Clinical decisions on the labour ward often have to be made quickly and the choice between management options is seldom guided by the results of randomized controlled trials. For this reason, many units develop their own set of labour ward protocols, based as much on the experience of the senior obstetricians and midwives as on published evidence. The Labour Ward Handbook is based on protocols from the Royal Oldham Hospital. The first two sections deal with the care of pregnant women and the management of normal and low-risk labour. The third and last covers abnormal and high-risk labour, in six parts including medical and haematological aspects. We begin with those with cornerstones of good labour ward practice communication, documentation and incident reporting, often poorly covered in textbooks but well handled here. Another highly informative section is that on management of latex allery, which seems to be getting more common. If recognized too late in a patient this can lead to cancellation of elective procedures; and in an emergency it can greatly complicate the preparation of operating theatres and equipment, including anaesthetic machines. The book provides a list of all those items of equipment containing latex—some of which, such as cardiotocographic monitors—are not obvious, together with six recent references on latex allergy. I was also impressed by some of the flow diagrams, such as the one on management of a woman with a history of genital herpes. With its numerous headings and bullet points The Labour Ward Handbook is not something one wants to read from cover to cover. Moreover, the style is dictatorial, with scant discussion of alternative options. It should be read in conjunction with the local labour ward protocol; any differences might generate useful debate on what is best practice. Though this handbook will interest obstetricians of all levels, I would recommend it especially to those sitting examinations, and those writing or updating local labour ward protocols. It is easy to use and encourages further reading with its large number of recent references.

Does status have more influence than education on the decisions midwives make?

Hollins Martin [Social influence effects on midwives’ practice. Presentation at the British Psychological Society Social Psychology Section Annual Conference, 10th–12th September, 2003: London] developed the Social Influence Scale for Midwifery (SIS-M) to measure social influence of a senior midwife on a junior midwife’s decisions. First, midwives were asked to answer SIS-M questions in a postal survey. Second, in interviews, a senior midwife attempted to influence SIS-M responses in a conformist direction. The results of the Hollins Martin (2003) study showed that a senior midwife was able to significantly influence change to many midwives decisions, F(1,57) = 249.62, p = 0.001. The present study aims to ascertain whether decision changes were caused by social components of the relationship between interviewer and interviewee, or education shared during discussion. This is achieved by removing social influence of the senior midwife at interview. For this purpose, a workbook was devised that replicated the exact content of interview. This workbook was posted to a differing group of 60 midwives, who had also previously completed a private postal SIS-M. Overall, analysis of variance (ANOVA) showed no significant difference between the postal workbook scores and the private SIS-M scores, ( F(1,57) = 0.31, p = 0.58). In other words, participants gave similar responses to the SIS-M questions in the workbook as the private postal condition. Results exclude possibility that education during the Hollins Martin (2003) interviews adjusted participants’ schema in relation to decisions made. Furthermore, this indicates that the social relationship, in part, caused the large social influence effect during interviews. The implications for practice are: first, that a senior midwife is profoundly capable of influencing decisions that junior midwives make; second, educational content plays little part in this process. Moreover, many of the SIS-M decisions should not be the choice of a senior midwife, but the preference of the childbearing women.

A ‘one-stop’ clinic for drug using pregnant women

This study reviews the impact of a multidisciplinary team approach on maternal and fetal outcomes in women who substance-abuse during pregnancy. The multidisciplinary team includes obstetrician, senior midwife, prescribing/addiction unit doctor, health visitor and ultrasonographer. Women were seen in a hospital environment and attended every 2 weeks, or more if required. This was a retrospective study of 218 patients attending the specialised ‘one-stop’ clinics in three large hospitals from January 1999 to December 2001. Overall, the mean gestation at booking was 17.2 weeks with a decreasing trend from over 18 weeks to 16 weeks over the 3 years. The mean gestation at delivery was 38.1 weeks with a mean birth weight of 2.9 kg, demonstrating a good outcome in the majority of women. At the beginning of pregnancy, 60% of the women used heroin regularly. At discharge 6 weeks postnatally only 28% were still substance-using. Of the remaining women, 50% were on a substitution programme of either methadone or dihydrocodeine. Around 25% of the babies required treatment for neonatal abstinence syndrome. Most of the babies went home with their mother.