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Asthma in pregnancy is a common respiratory co-morbidity, but if this serious condition is not addressed appropriately, acute exacerbations may contribute to maternal mortality and morbidity. Indeed, any acute episode of asthma can quickly become life-threatening, and midwives should be aware of the need for urgent referral. The importance of effectively managing asthma in pregnancy includes the immediate detection of a worsening condition, along with immediate referral to a physician in order to minimise the complications associated with acute exacerbations. In order to minimise poor outcomes for women, midwives should be aware of evidence-based practice guidelines for managing asthma and to avoid complacency, midwives must be aware of the most recent report, Why Asthma Still Kills. Furthermore, as part of their scope of practice, midwives should ensure that all women have access to personalised asthma action plans, and should work across the multidisciplinary team to promote smoking cessation, infection control and vaccination against influenza. Importantly, midwives should assess compliance with women's prescribed short- and long-acting asthma medication.

Antimicrobial resistance is one of the greatest challenges to health care. With a reduced number of effective antibiotics, treatable conditions, such as ear, tooth and urine infections, may therefore become life-threatening. In order to minimise antimicrobial resistance, midwives should use clinical strategies that facilitate antibiotic stewardship, such as promoting healthy lifestyles, infection control and compliance with prescribed antibiotic treatment, and should endeavour to share knowledge and expertise with members of the wider multidisciplinary team, such as pharmacists. In addition, midwifery curricula should ensure that midwives have a knowledge of the dynamics of antimicrobial resistance and principles of antibiotic stewardship so that health professionals may share their expertise in order to combat this significant challenge, which poses the threat of a post-antibiotic era.

This article highlights principles for the safe administration of blood transfusion in maternity care. The aim is to increase awareness of the context for blood transfusion in midwifery, the components most frequently used and the process for safe blood transfusion, including clinical observations. There are serious hazards associated with this procedure so there should be a clear indication for transfusion. Midwives must not engage in the administration of blood unless they have received appropriate training, have been assessed as clinically competent and meet the requirements for periodic review or assessment in administering blood transfusion.

Adequate risk assessment by the midwife prior to the administration of medicines is crucial. No medicine should be administered without considering the possibility of error or an adverse reaction. Midwives are in a unique position in respect of the midwives exemptions, and must be clear regarding their professional accountability in this respect. This article highlights the main clinical aspects of the safe administration of medicines in maternity care and provides key points for safe clinical practice.

In the UK, fear of birth (FoB) is considered a valid reason to request an elective caesarean section, and the National Institute for Health and Care Excellence ( NICE, 2011 ) provided guidance in respect of women with a FoB requesting operative delivery. However, it was not clear how many maternity units in the UK offered support for women in line with this guidance. Consequently, a national online audit survey was undertaken to determine current service provision in maternity units. Hence in 2013, 202 maternity units were surveyed over 9 weeks; there was a 63% (n=128) response rate. It was evident that 47.3% (n=52) of all units did not offer specialist support for women with FoB. However, where support was available, this varied from the benchmark recommendation for referral to a consultant obstetrician (NICE, 2001) to specialist midwifery clinics and psychological support services. Overall, the survey revealed that care pathways for FoB had not been widely implemented in the UK.

Aim To investigate the degree of choice pregnant women at low obstetric risk had in making informed decisions on the use of intrapartum fetal monitoring techniques. Methods An exploratory descriptive design was used as part of a larger, multi-method study. A total of 63 pregnant women at low obstetric risk were approached to complete antepartum and postpartum questionnaires. Sixty-three women completed antepartum questionnaires, 38 of these 63 women also completed postpartum questionnaires. The data were analyzed using descriptive statistics. Results More than half of the sample wanted electronic fetal monitoring (EFM) in labor despite being classified at low risk for obstetric complications. Having choices and being in control was important to all respondents whilst in labor. Despite this, almost all respondents stated that midwives had not given them a choice of monitoring method. More than a half of the sample received some form of EFM. Conclusions Intrapartum fetal monitoring practices for women with normal pregnancies do not reflect current evidence. Women still expect EFM in labor. Choice and control are very complex issues and as such are difficult to measure.

PurposeThe routine use of intrapartum electronic fetal monitoring (EFM) has resulted in an increased burden of operative and vaginal instrumental deliveries for women at low obstetric risk. Such modes of delivery increase maternal mortality and morbidity risks. This study aims to explore midwives' values, attitudes and beliefs when using intrapartum fetal monitoring techniques in clinical practice.Design/methodology/approachA total of 58 registered midwives across two NHS Trusts in one region in the north of England were interviewed using a qualitative approach.FindingsMidwives attempted to manage the psychological burden of the threat from clinical negligence by using EFM. This meant that some midwives used electronic monitoring regardless of clinical need. Midwives lack confidence in the ability of EFM to accurately detect fetal compromise but are aware that the visual monitoring record is recognised as a valuable piece of legal evidence. The midwives' perceptions of professional self‐efficacy in seeking to avoid a claim in clinical negligence contributed to defensive practice. Research limitations/implications – The study was conducted in only two hospitals in one region of England; however the Trust demographics were similar and midwifery practice within the unit reflects national maternity standards of care.Practical implicationsMultidisciplinary strategies may be required to overcome barriers to the effective implementation of clinical guidelines where intrapartum fetal monitoring is concerned and Trust audit departments must undertake regular audit cycles in order to ascertain practice compliance with best evidence.Originality/valueThe paper provides information so that midwives' knowledge regarding the limitations of EFM can be improved.

Over the last 20 years in the United Kingdom, midwives have implemented the routine use of intrapartum fetal monitoring regardless of the risk status of laboring women. This practice is at odds with the published research. The discrepancy between practice and best evidence merits further investigation. A qualitative study was conducted to evaluate midwives' attitudes and experiences about the use of fetal monitoring for women at low obstetric risk. Fifty-eight midwives working in two hospitals in the north of England were interviewed by using a semistructured approach. The taped interviews were transcribed and analyzed by using a general thematic approach. Issues included midwives' perceptions of low-risk status, the socialization of midwives, and the loss of woman-centered care. Midwives subscribed to the notion of woman-centered care, but because of a complexity of factors experienced in their daily working lives, they felt vulnerable when attempting to implement evidence-based fetal monitoring practices. Midwives regretted the loss of a woman-centered approach to care when technologic methods of intrapartum fetal heart rate monitoring were used indiscriminately. An appreciation of the complex factors affecting the ability of midwives to implement evidence-based practice is important when attempting to facilitate the development of appropriate fetal monitoring practices for women at low obstetric risk.

To investigate midwives' attitudes, values and beliefs on the use of intrapartum fetal monitoring.Qualitative, semi-structured interviews.Fifty-eight registered midwives in two hospitals in the North of England.In this paper two main themes are discussed, these are: informed choice, and the power of the midwife. Midwives favoured the application of informed choice and shared a unanimous consensus on the definition. However, the idealistic perception of informed choice, which included contemporary notions of empowerment and autonomy for women expressing an informed choice, was not reportedly translated into practice. Midwives had to implement informed choice on intrapartum fetal monitoring within a competing set of health service agendas, i.e. medically driven protocols and a political climate of actively managed childbearing. This resulted in the manipulation of information during the midwives' interactions with women. This ultimately meant that the women often got the choice the midwives wanted them to have.The information that a midwife imparts may consciously or subconsciously affect the woman's uptake and understanding of information. Therefore, the midwife has a powerful role to play in balancing the benefits and risk ratios applicable to fetal heart rate monitoring. However, a deeply ingrained pre-occupation with technological methods of intrapartum fetal monitoring over many years has made it difficult for midwives to offer alternative forms of monitoring. This has placed limits on the facilitation of informed choice and autonomous decision making for women.

Journal of AdvancedNursing 52(3), 307–314Developing a tool to appraise fetal monitoring guidelines for women at lowobstetric riskAim. The aim of this paper is to report the development and use of a tool to appraiseguidelines for fetal heart rate monitoring and discuss the findings generated in theappraisal process.Background. Expert guidance on the appropriate method of monitoring the fetalheart in labour has been available for some time. However, practices not based onevidence were continuing routinely in the United Kingdom.Methods. We produced an 18-item tool for the appraisal of guidelines. Heads ofMidwifery Services were asked to send the guideline currently in use. Twenty-fourout of 28 responded, and sent 32 guidelines. Pairs of multidisciplinary reviewersappraised each guideline.Results. A prevalidated generic appraisal instrument was not found to be appro-priate for intrapartum fetal monitoring guidelines. When using our own specifically-developed appraisal tool for assessing the quality of fetal monitoring guidelines,only 11 reviewer pairs showed ‘good’ or ‘moderate’ agreement in their scores.Conclusions. Generically-validated guidelines may not be sufficiently discriminatoryfor specialized areas of practice such as intrapartum fetal monitoring.Keywords: appraisal, guidelines, midwifery

Aim: to determine whether intrapartum fetal monitoring guidelines used by midwives in one region of England for women at low risk of obstetric complications were evidence-based. Objective: to assess the quality of such guidelines using an appraisal tool. Design and setting: an appraisal of guidelines gained via a postal survey of all National Health Service Trusts supplying maternity services in one region in the north of England, conducted over a six-week period (June–July 2001). Participants: 28 Trusts were eligible to participate; 32 guidelines were returned from 24 Trusts. Data analysis: two reviewers from a multi-disciplinary panel appraised each guideline, producing two sets of data that were analysed independently of each other. Each was treated as a separate case (n=64 cases). Inter-reviewer agreement was summarised using descriptive categories. Findings: the highest possible overall quality score was 54, and the lowest 18. Whilst no guideline scored 54, five of the 64 cases scored 18. The mean overall quality score was 26.8. In 36 of the 64 cases, both reviewers rated guidelines as ‘definitely not' recommended for practice. Guidelines were scored against specific aspects of evidence-based practice. Forty-one of the 64 cases received the lowest possible quality score (=‘1') for use of systematic reviews of the literature on electronic fetal monitoring. In 47 cases, guidelines were scored ‘1' for the quality of evidence-based clinical recommendations. The quality of information on client monitoring preferences was considered low in over half the 64 cases ( n =35). There were no instances where the number of cases receiving ‘highest possible quality' scores was greater than those receiving ‘lowest possible quality' ratings. Conclusions and implications for practice: a small number of guidelines were assessed as high quality, but the majority were poorly appraised by the reviewer group in most areas. This has implications for the delivery of evidence-based midwifery care since those midwives practising according to the guidelines surveyed would not have been supported in implementing research into practice.

Midwives have welcomed the recent announcement by the Home Secretary that the handcuffing of women prisoners during labour will cease. A previous editorial in this journal addressed this undignified practice and quite properly urged midwives to question their role when delivering care in such circumstances (Todd, 1995).

I recently read with interest an article published in BJM on undergraduate preparation for student midwives and the role of education in advancing the profession (Hunt, 1997). While the author raised some interesting points, I believe some of them are fundamentally naive.