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Problem: The perineal-bundle is a complex intervention widely implemented in Australian maternity care facilities., Background: Most bundle components have limited or conflicting evidence and the implementation required many midwives to change their usual practice for preventing perineal trauma., Aim: To measure the effect of perineal bundle implementation on perineal injury for women having unassisted births with midwives., Methods: A retrospective pre-post implementation study design to determine rates of second degree, severe perineal trauma, and episiotomy. Women who had an unassisted, singleton, cephalic vaginal birth at term between two time periods: January 2011 - November 2017 and August 2018 - August 2020 with a midwife or midwifery student accoucheur. We conducted logistic regression on the primary outcomes to control for confounding variables., Findings: data from 20,155 births (pre-implementation) and 6273 (post-implementation) were analysed. After implementation, no significant difference in likelihood of severe perineal trauma was demonstrated (aOR 0.86, 95% CI 0.71-1.04, p = 0.124). Nulliparous women were more likely to receive an episiotomy (aOR 1.49 95% CI 1.31-1.70 p < 0.001) and multiparous women to suffer a second degree tear (aOR 1.18 95% CI 1.09-1.27 p < 0.001)., Discussion: This study adds to the growing body of literature which suggests a number of bundle components are ineffective, and some potentially harmful. Why, and how, the bundle was introduced at scale without a research framework to test efficacy and safety is a key concern., Conclusion: Suitably designed trials should be undertaken on all proposed individual or grouped perineal protection strategies prior to broad adoption., Competing Interests: Conflict of interest The authors declare no conflict of interest., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Competing Interests: Conflict of interest None declared.

A care bundle was introduced into 28 Australian hospitals in 2018 with the aim of reducing severe perineal tears. There has been limited research regarding the impact of this bundle on women's birth experiences., Question: How does the introduction of a perineal care bundle impact on women's birth experiences in Queensland maternity hospitals?, Methods: We recruited 18 women who had birthed in five Queensland hospitals where the bundle had been implemented. Semi-structured, individual interviews were analysed using reflexive thematic analysis., Findings: Three descriptive themes were generated: 1) Lack of information and consent to bundle elements, 2) Other non-consented and disrespectful treatment and 3) Recommendations for hospitals and clinicians. Two analytic themes were generated: 1) Default-position: Prioritising policies over women's autonomy and 2) Counter-position: Women asserting their rights to autonomy and respect., Discussion: None of the women interviewed could recall having received information about the perineal care bundle from clinicians during pregnancy. While many women accepted that its elements were in their or their baby's best interests, this was not the case for all women. Some women reported coercive and non-consented application of bundle elements, which they found distressing., Conclusion: Given the broader institutional context in which the perineal bundle was implemented, the impact on information provision, informed consent and the detrimental emotional consequences for some women arising from the bundle's implementation were largely foreseeable. The potential for bundled care initiatives to impinge on women's human rights to autonomy and respectful care should be given greater preventative attention prior to implementation., (Copyright © 2022 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Problem: Women increasingly present to hospital in early labour, but admission before active labour contributes to overuse of interventions, poorer clinical and psychological outcomes, and higher healthcare costs., Background: Innovative models of early labour care have so far not improved birth outcomes., Aim: To examine if reconfiguring the early labour service in a large Australian maternity service improved (1) the birth outcomes of women who presented in early labour and (2) alleviated bed blockages by decreasing length of stay in the Pregnancy Assessment and Observation Unit., Methods: Pre-post intervention design, using routinely collected clinical data before and after the implementation of the reconfigured early labour service., Findings: There were 527 women in pre-intervention cohort and 747 in the post-intervention cohort. The two groups were similar in age, body mass index, marital status, education level and gestation at birth. Post intervention, epidural use did not change significantly, but rates of amniotomy (35.7% vs. 49.9%, p = <0.001), meconium-stained liquor (20.1% vs 26.1%, p = 0.04), and neonatal nursery admission (2.7% vs. 5.8% p =  0.01) increased. The proportion of women staying in the Assessment unit more than two hours decreased, but not significantly., Conclusion: Changing the location and model of early labour care did not influence epidural use, nor improve women's birth outcomes. For women in early labour, admission to any location within the hospital may be as problematic as admission to birth suite specifically., (Copyright © 2019 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Background: Awareness of the impact of the built environment on health care outcomes and experiences has led to efforts to redesign birthing environments. The Birth Unit Design Spatial Evaluation Tool was developed to inform such improvements, but it has only been validated with caseload midwives and women birthing in caseload models of care., Aim: To assess the content validity of the tool with four new participant groups: Birth unit midwives, Aboriginal or Torres Strait Islander women; women who had anticipated a vaginal birth after a caesarean; and women from refugee or culturally and linguistically diverse backgrounds., Methods: Participants completed a Likert-scale survey to rate the relevance of The Birth Unit Design Spatial Evaluation Tool's 69 items. Item-level content validity and Survey-level validity indices were calculated, with the achievement of validity set at >0.78 and >0.9 respectively., Results: Item-level content validity was achieved on 37 items for birth unit midwives (n=10); 35 items for Aboriginal or Torres Strait Islander women (n=6); 33 items for women who had anticipated a vaginal birth after a caesarean (n=6); and 28 items for women from refugee or culturally and linguistically diverse backgrounds (n=20). Survey-level content validity was not demonstrated in any group., Conclusion: Birth environment design remains significant to women and midwives, but the Birth Unit Design Spatial Evaluation Tool was not validated for these participant groups. Further research is needed, using innovative methodologies to address the subconscious level on which environment may influence experience and to disentangle the influence of confounding factors., (Copyright © 2018 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Background: The right to refuse medical treatment can be contentious in maternity care. Professional guidance for midwives and obstetricians emphasises informed consent and respect for patient autonomy, but there is little guidance available to clinicians about the appropriate clinical responses when women decline recommended care., Objectives: We propose a comprehensive, woman-centred, systems-level framework for documentation and communication with the goal of supporting women, clinicians and health services in situations of maternal refusal. We term this the Personalised Alternative Care and Treatment framework., Discussion: The Personalised Alternative Care and Treatment framework addresses Australian policy, practice, education and professional issues to underpin woman-centred care in the context of maternal refusal. It embeds Respectful Maternity Care in system-level maternity care policy; highlights the woman's role as decision maker about her maternity care; documents information exchanged with women; creates a 'living' plan that respects the woman's birth intentions and can be reviewed as circumstances change; enables communication between clinicians; permits flexible initiation pathways; provides for professional education for clinicians, and incorporates a mediation role to act as a failsafe., Conclusion: The Personalised Alternative Care and Treatment framework has the potential to meet the needs of women, clinicians and health services when pregnant women decline recommended maternity care., (Copyright © 2018. Published by Elsevier Ltd.)

Problem/background: Ethical and professional guidance for midwives and obstetricians emphasises informed consent and respect for patient autonomy; the right to refuse care is well established. However, the existing literature is largely silent on the appropriate clinical responses when pregnant women refuse recommended care, and accounts of disrespectful interactions and conflict are numerous. Policies and processes to support women and maternity care providers are rare and unstudied., Aim: To document the perspectives of women, midwives and obstetricians following the introduction of a structured process (Maternity Care Plan; MCP) to document refusal of recommended maternity care in a large tertiary maternity unit., Methods: A qualitative, interpretive study involved thematic analysis of in-depth semi-structured interviews with women (n=9), midwives (n=12) and obstetricians (n=9)., Findings: Four major themes were identified including: 'Reassuring and supporting clinicians'; 'Keeping the door open'; 'Varied awareness, criteria and use of the MCP process' and 'No guarantees'., Conclusion: Clinicians felt protected and reassured by the structured documentation and communication process and valued keeping women engaged in hospital care. This, in turn, protected women's access to maternity care. However, the process could not guarantee favourable responses from other clinicians subsequently involved in the woman's care. Ongoing discussions of risk, perceived by women and some midwives to be pressure to consent to recommended care, were still evident. These limitations may have been attributable to the absence of agreed criteria for initiating the MCP process and fragmented care. Varying awareness and use of the process also diminished women's access to it., (Copyright © 2016 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Background: All competent adults have the right to refuse medical treatment. When pregnant women do so, ethical and medico-legal concerns arise and women may face difficulties accessing care. Policies guiding the provision of maternity care in these circumstances are rare and unstudied. One tertiary hospital in Australia has a process for clinicians to plan non-standard maternity care via a Maternity Care Plan (MCP)., Aim: To review processes and outcomes associated with MCPs from the first three and a half years of the policy's implementation., Methods: Retrospective cohort study comprising chart audit, review of demographic data and clinical outcomes, and content analysis of MCPs., Findings: MCPs (n=52) were most commonly created when women declined recommended caesareans, preferring vaginal birth after two caesareans (VBAC2, n=23; 44.2%) or vaginal breech birth (n=7, 13.5%) or when women declined continuous intrapartum monitoring for vaginal birth after one caesarean (n=8, 15.4%). Intrapartum care deviated from MCPs in 50% of cases, due to new or worsening clinical indications or changed maternal preferences. Clinical outcomes were reassuring. Most VBAC2 or VBAC>2 (69%) and vaginal breech births (96.3%) were attempted without MCPs, but women with MCPs appeared more likely to birth vaginally (VBAC2 success rate 66.7% with MCP, 17.5% without; vaginal breech birth success rate, 50% with MCP, 32.5% without)., Conclusions: MCPs enabled clinicians to provide care outside of hospital policies but were utilised for a narrow range of situations, with significant variation in their application. Further research is needed to understand the experiences of women and clinicians., (Copyright © 2015 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Background: Efforts to increase postnatal support available to women and families are hampered by inadequate referral mechanisms. However, the discharge process in maternity services has received little research attention., Aim: To review current discharge practices in Queensland, in order to identify mechanisms to minimise fragmentation in the care of women and families as they transition from hospital-based postnatal care to community-based health and other services., Methods: A survey of discharge practices in Queensland hospitals that offer birthing services (N=55) and content analysis of discharge summary forms used by those hospitals., Findings: Fifty-two Queensland birthing hospitals participated in the study. Discharge summaries were most commonly sent to General Practitioners (83%), less commonly to Child and Family Health Nurses (CFHNs; 52%) and rarely to other care providers. Discharge summaries were usually disseminated within one week of discharge (87%), but did not capture any information about care provided by domiciliary services. Almost one-fifth (19%) of hospitals did not seek women's consent for the disclosure of their discharge summary and only 10% of hospitals had processes for women to check accuracy. Significant gaps in the content of discharge summaries were identified, particularly in psychosocial and cultural information, and post-discharge advice. The format of discharge summaries diminished their readability., Conclusion: Discharge summaries (format and content) should be consistent, comprehensive and specific to maternity services. Discharge summaries should be generated and disseminated electronically at the time of discharge from the maternity service. Women should review their discharge summaries and direct and consent to its dissemination., (Copyright © 2013 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)