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Background Supporting women to continue breastfeeding is a global challenge. The Milky Way Program is an effective face to face intervention to increase breastfeeding rates up to six months postpartum. The sustainability and access to the Milky Way Program could be enhanced by transforming it into a mobile application allowing women to access relevant information from their own place at a convenient time. Aim To explore the process of transforming the Milky Way Program into an acceptable and usable mobile health application. Method Stakeholders including multidisciplinary researchers and end-users designed the application based on the Milky Way Program by using Persuasive System Design principles. A mixed-method approach was used in the development and evaluation process. Seven women were recruited through convenience sampling to pilot test the application. The women’s feedback was collected through an online survey six weeks after birth and individual interviews at four months postpartum. Findings Women in the pilot study reported that the breastfeeding application was well designed, easy to use, interactive, reassuring and evidence-based with credible sources of information. Conclusion The Persuasive System Design model combined with end-user engagement can feasibly inform the development of an acceptable and usable mobile health application for breastfeeding based on a proven clinical intervention. Further rigorous testing is required to evaluate the effectiveness of the application on breastfeeding initiation and duration.

Long-term breastfeeding, including exclusive breastfeeding for six months and continuation of breastfeeding with complementary food until two years of age, has been recommended by the World Health Organization. However, despite the clear benefits of long-term breastfeeding (six months and beyond), the rates of breastfeeding still continue to remain low. Although there are some individual interventional studies that aimed to increase prolonged breastfeeding rates among both multiparous and primiparous women, there is no systematic review or meta-analysis to examine the effectiveness of those interventions among primiparous women who had no previous breastfeeding experience.The aim of this review was to identify the effects of professional educational and support interventions on breastfeeding rates at six months and up to two years postpartum compared to the standard care among primiparous women.Studies that included primiparous women aged 18 and over who intended to breastfeed.Studies that investigated the effect of educational and support interventions provided by health professionals during the antenatal, postnatal period or both.Randomized controlled trials.Studies with reported breastfeeding rates at six months or up to two years postpartum.A three-step search strategy was utilized in this review. The search was conducted in Cochrane, MEDLINE and CINAHL databases. Only trials that met the inclusion criteria and published in English were considered for this review. Databases were searched from their commencement year to May 2016.Two independent reviewers selected the papers using the standardized critical appraisal tool from the Joanna Briggs Institute.Data was extracted using the standardized Joanna Briggs Institute data extraction instrument. Quantitative data were, where possible, pooled in statistical meta-analysis using RevMan v5.3 (Copenhagen: The Nordic Cochrane Centre, Cochrane). In the absence of trials comparing the same outcomes, meta-analysis could not be performed; the findings have therefore been presented in a narrative form, including tables and figures to aid in data presentation where appropriate.Ten randomized controlled trials were included in this review. Interventions with only one antenatal or postnatal component were not effective in increasing breastfeeding rates at six months. However, based on one trial, an intervention that included antenatal education and support in combination with postnatal education and support doubled the rate of breastfeeding at six months among primiparous women randomized to the intervention group compared to the control group (p = 0.28).Despite the good methodological quality of the trials, due to the heterogeneity of the interventions and outcome measures (types of breastfeeding) it was not possible to identify any specific effective intervention. However, based on a single trial, it appears that a combination of antenatal and postnatal education interventions may be useful in increasing breastfeeding rates at six months.

Objective To determine the incidence of immediate, uninterrupted skin-to-skin contact and breastfeeding after birth; and which factors are associated with it. Design Cross-sectional e-survey was developed and piloted prior to distribution. Sampling was purposive and included snowball sampling. Associations between maternity care practices and the primary outcome measure were examined using logistic regression. Setting Australia. Participants Women who birthed a term baby within the previous three years, in any Australian setting (hospital, birth centre or at home), were eligible to participate. Measurements and findings 1200 postpartum women met the eligibility criteria and completed the e-survey. The primary outcome, ‘pronurturance', included: (1) immediate mother/baby holding; (2) skin-to-skin contact; (3) uninterrupted holding for at least 60 min; 4) breastfeeding in the birth setting. Of 1200 participants, 22% (n = 258) experienced pronurturance. Pronurturance was less likely following caesarean section (adjusted Odds Ratio (aOR) 0.07, 95% Confidence Interval (CI) 0.03–0.17). Pronurturance was more likely with a known midwife during labour and birth (aOR 1.89, 95% CI 1.35–2.65). Contributing to the low rate of pronurturance were lack of antenatal skin-to-skin information; babies being wrapped; women wearing clothing; and non-urgent caregiver interruptions including weighing the baby or facilitating the mother to shower. Key conclusion Health services must strategically address the institutional processes which delay and/or interrupt skin-to-skin contact and breastfeeding in birth suite and operating theatre settings. Implications for practice Midwives and midwifery students providing continuity of carer are best placed to provide pronurturance to mothers and babies. Caregivers should educate women about pronurturance antenatally, and actively support immediate, uninterrupted mother/baby skin-to-skin contact and breastfeeding after birth.

Summary Background Teamwork is a ‘soft skill’ employability competence desired by employers. Poor teamwork skills in healthcare have an impact on adverse outcomes. Teamwork skills are rarely the focus of teaching and assessment in undergraduate courses. The TeamUP Rubric is a tool used to teach and evaluate undergraduate students’ teamwork skills. Students also use the rubric to give anonymised peer feedback during team-based academic assignments. The rubric’s five domains focus on planning, environment, facilitation, conflict management and individual contribution; each domain is grounded in relevant theory. Students earn marks for their teamwork skills; validity of the assessment rubric is critical. Question To what extent do experts agree that the TeamUP Rubric is a valid assessment of ‘teamwork skills’? Design Modified Delphi technique incorporating Feminist Collaborative Conversations. Participants A heterogeneous panel of 35 professionals with recognised expertise in communications and/or teamwork. Methods Three Delphi rounds using a survey that included the rubric were conducted either face-to-face, by telephone or online. Quantitative analysis yielded item content validity indices (I-CVI); minimum consensus was pre-set at 70%. An average of the I-CVI also yielded sub-scale (domain) (D-CVI/Ave) and scale content validity indices (S-CVI/Ave). After each Delphi round, qualitative data were analysed and interpreted; Feminist Collaborative Conversations by the research team aimed to clarify and confirm consensus about the wording of items on the rubric. Results Consensus (at 70%) was obtained for all but one behavioural descriptor of the rubric. We modified that descriptor to address expert concerns. The TeamUP Rubric (Version 4) can be considered to be well validated at that level of consensus. The final rubric reflects underpinning theory, with no areas of conceptual overlap between rubric domains. Conclusion The final TeamUP Rubric arising from this study validly measures individual student teamwork skills and can be used with confidence in the university setting.

REVIEW QUESTION/OBJECTIVE The objective of this review is to identify the effects of educational and supportive interventions provided by health professionals on long-term breastfeeding rates at six months and up to two years post partum among primiparous women who intend to breastfeed.

Background The importance of optimising maternal/baby psychophysiology has been integrated into contemporary midwifery theories but not in the detail required to really understand the underpinning biological basis. Method The functioning of the autonomic nervous system, as it relates to the uterus is reviewed. The physiology of myometrial cell contraction and relaxation is outlined. The main focus is on the factors that affect the availability and uptake of oxytocin and adrenaline/noradrenaline in the myometrial cells. These are the two key neuro-hormones, active in the 3rd and 4th stages of labour, that affect uterine contraction and retraction and therefore determine whether the woman will have an atonic PPH or not. Discussion The discussion explains and predicts the physiological functioning of the uterus during the 3rd and 4th stages of labour when skin-to-skin contact and breastfeeding occurs and when it does not. Conclusion This biologically based theory hypothesises that to achieve and maintain eutony and eulochia, midwives and birthing women should ensure early, prolonged and undisturbed skin-to-skin contact for mother and baby at birth including easy access for spontaneous breastfeeding.

Summary Background Women who have problems in early pregnancy frequently present to the emergency department (ED). The aim of this qualitative study was to describe the experience of early pregnancy care in the ED from the perspective of women. Methods This study used a qualitative design involving semi-structured interviews with women who attended five hospital EDs in Hunter New England Area Health Service during late 2009 and early 2010. Out of 200 letters sent, 16 women agreed to be interviewed to describe their experience of care in the ED. Thematic analysis was used to analyse the interview transcripts. Results Privacy, dignity, compassion and respect were important to participants. Many women reported that they were not given a private room in the ED and were distressed by the constant traffic of people nearby. Overall, participants reported that ED staff treated them with compassion and respect, though this was sometimes limited by the busy environment. Most participants wanted more information such as pamphlets and few were offered follow-up support or a counselling referral. Conclusions The findings of this study suggest that EDs should enhance their management of women with problems in early pregnancy including allocating them to beds with sufficient privacy, providing them with access to written information and referrals to counselling.

The first author of this paper a Thai midwife conducted a feminist action research project aimed at collaboratively developing a model for group-based antenatal education in Thailand. Should a midwife wear a uniform when facilitating midwife-led group-based antenatal education sessions in the hospital setting? This paper reports on a single example of reflection in and on midwifery practice that aimed to answer the guiding question. The practice and reflection occurred over a number of months at the beginning of the feminist action research project. The midwife should wear normal clothes when facilitating group-based antenatal education as a symbol of equality in power relationships within the group. When power relationships between women and the midwife are equalized women are more able to take responsibility for their health as they are less likely to defer to the expert. Reflection in and on practice is a powerful tool to allow the midwife to understand and change her own practice as required to meet those goals. Self-change is a critical first step because there can be no change in the way maternity care is provided without each midwife being willing to be self-aware and open to appropriate self-change. (c) 2011 Blackwell Publishing Asia Pty Ltd.

What are the strengths and limitations of existing Decision-Making Theories as a basis for guiding best practice clinical decision-making within a framework of midwifery philosophy? Each theory is compared in relation with how well they provide a teachable framework for midwifery clinical reasoning that is consistent with midwifery philosophy. Hypothetico-Deductive Theory, from which medical clinical reasoning is based; intuitive decision-making; Dual Processing Theory; The International Confederation of Midwives Clinical Decision-Making Framework; Australian Nursing and Midwifery Council Midwifery Practice Decisions Flowchart and Midwifery Practice. Best practice midwifery clinical Decision-Making Theory needs to give guidance about: (i) effective use of cognitive reasoning processes; (ii) how to include contextual and emotional factors; (iii) how to include the interests of the baby as an integral part of the woman; (iv) decision-making in partnership with woman; and (v) how to recognize/respond to clinical situations outside the midwife's legal/personal scope of practice. No existing Decision-Making Theory meets the needs of midwifery. Medical clinical reasoning has a good contribution to make in terms of cognitive reasoning processes. Two limitations of medical clinical reasoning are its reductionistic focus and privileging of reason to the exclusion of emotional and contextual factors. Hypothetico-deductive clinical reasoning is a necessary but insufficient condition for best practice clinical decision-making in midwifery.

Summary Question What modifiable factors positively influence breastfeeding duration to 6 months postpartum? Aim This question was posed in order to be able to develop a midwifery intervention aimed at prolonging breastfeeding. Method An online literature search was conducted in Medline, CINAHL, Maternity and Infant Care, and Cochrane Database of systematic reviews. The search strategy included the following keywords: breastfeeding, duration, initiation, cessation, factors, intervention, education, partner, intention, confidence, self-efficacy and support. Additional studies were located and extracted from online publications of New South Wales Department of Health, Australia. Bio-psycho-social factors that are positively associated with breastfeeding duration were identified. Results Modifiable factors that influence women's breastfeeding decisions are: breastfeeding intention, breastfeeding self-efficacy and social support. Existing midwifery breastfeeding promotion strategies often include social support but do not adequately address attempts to modify breastfeeding intention and self-efficacy. Conclusion The modifiable factors that are positively associated with breastfeeding duration are the woman's breastfeeding intention, her breastfeeding self-efficacy and her social support. Intervention studies to date have focussed on modifying these factors individually with variable results. No interventional studies have been conducted with the aim of positively modifying all three factors simultaneously.

Summary Problem Access block is an increasing problem in delivery suites due to the rising birth rates. As well as more labouring women, more women are presenting to delivery suite with pregnancy concerns (at 18 weeks gestation and over). Waiting times for women with pregnancy concerns were prolonged because, prior to the implementation of the present project, these women were required to be assessed by a midwife and then a medical officer. Aim The aim of this project was to safely and effectively reduce the length of stay of pregnant women presenting with pregnancy concerns who were managed as outpatients in the delivery suite. Project setting The project was undertaken in the Delivery Suite of a major tertiary referral hospital, NSW, Australia. Methods The project team used clinical practice improvement methodology (clinical audit, outpatient flow mapping, flowcharting, cause and effect diagrams, brainstorming, multi-voting and Pareto charting) to investigate and propose recommendations to improve the clinical process for this group of women. Subjects Five hundred thirty two pregnant women who were not in labour. Intervention The interventions involved developing the new clinical midwifery pathways and standing orders for the categories of cases where the midwives were able to assess, order tests and make independent clinical decisions; selecting, training and accrediting the advanced practice midwives; implementing the new clinical pathways; and evaluating the effectiveness, cost and stakeholder satisfaction levels with the changes. Findings The average length of stay was reduced from 178.4 to 91.5 min (49%) p Conclusion The use of advanced practice midwives reduced the overall length of stay for women with pregnancy concerns. There were no adverse events or complaints. Women, midwives and doctors all evaluated the change positively. These findings provide evidence to support this advanced practice midwifery model in other similar maternity services.

In normal birth there should be a valid reason to interfere with normal processes. Yet, active management of third stage labor is being imposed on women who have no known risks of postpartum hemorrhage. This article examines the evidence from existing randomised trials comparing active and physiological third stage care for its relevance and validity to the effectiveness of physiological third stage care for women who are at low risk of postpartum hemorrhage. Consideration is given to midwifery and medical perspectives of the following definitions: 'postpartum hemorrhage'; 'low-risk status'; 'active'; 'expectant' and 'physiological' third stage care. A systematic search of the research literature regarding the third stage of labour is described. Four randomised trials and a meta-analysis by Cochrane were considered. These studies are examined in terms of their potential generalisability to women who are at low risk of postpartum hemorrhage. All trials included women who were at high risk of postpartum hemorrhage. The existing research does not provide relevant and valid evidence about the effectiveness of physiological third stage care, as defined by midwives, for women who are at low risk of postpartum hemorrhage.

Summary Background Active management of the third stage of labour is routine in delivery suites. New South Wales (NSW) Health has a policy which prescribes active management because medically designed randomised controlled trials have claimed a reduced blood loss in third stage with active, compared with ‘physiological’, management. In home and birth centre settings however, physiological third stage is common as women who access these settings prefer to labour without medical intervention and midwives who work in these settings adopt a holistic approach to working with women. The holistic approach is psychophysiological as the midwife engages with and supports integration of the woman's spirit, mind and body in her childbearing process. Purpose To present midwifery theory that describes, explains and predicts how women and midwives work together to enable selected women to safely experience an optimal psychophysiological third stage of labour. Method Key terms are defined. The literature relevant to psychophysiology and management of the third stage of labour is reviewed. An expanded understanding of risk factors for postpartum haemorrhage is presented and justified. A theoretical framework of Midwifery Guardianship is presented and discussed and applied to third stage care. Conclusions A psychophysiological third stage is quite different from what has been defined as ‘physiological management’ in the medically designed randomised trials comparing active versus physiological care. The conditions for deciding if a particular woman, in a particular context with a particular midwife is a good candidate for a psychophysiological third stage are presented and discussed. Only if all these conditions are met it is safe to proceed with a psychophysiological third stage. Research about the effectiveness of midwifery care in a psychophysiological third stage of labour urgently needs to be conducted.

This article presents the findings from a study examining midwives' interactions with women who smoke in pregnancy. The aim of this study was to find out how midwives currently interact with women who smoke in pregnancy, in relation to the women's health and wellbeing. The study used an interpretive interactionism design. There were two major findings: there is incongruity between midwives' internal discourses and expressed discourses when working with women who smoke in pregnancy and smoking cessation advice interactions typically do not involve a dialogue. Smoking cessation advice interactions are predictable, monotonous and non-productive. This type of interaction is best understood as a game with set rules and roles. Midwives need a woman-centred discourse from which to engage in an effective dialogue with women who smoke in pregnancy. Recommendations for practice and education are discussed.

This paper by Deborah Sundin and Kathleen Fahy critiques Denzin's interpretive interactionism in light of critical and postmodern ideas that undermine its theoretical foundations. The authors argue that interpretive interactionism can be improved by acknowledging insights from critical social theory. They present modifications and adaptations to arrive at a methodologically robust research design called critical, post-structural, interpretive interactionism.

The rules for writing a research report for publication are well defined but are much less clear for scholarly scientific papers. The purpose of this paper is to enable new writers to confidently apply the skills of scientific writing within a scholarly paper for publication. Similarities and differences between scientific argument and debating are discussed. Achieving the right 'tone' and emphasis in writing is considered. How to use the correct verb tense is outlined. The importance of a clearly defined question is explained. The elements of an effective scholarly paper are presented and examples given. The elements are the: question, thesis, introduction, body of the paper, conclusion and finally, an abstract.

Since the subordination of midwifery by medicine and nursing in the 19th and 20th centuries the standard approach to childbirth has been dominated by rationality. This approach proceeds by creating dichotomies and then prioritising one half of the dichotomy whilst rejecting the opposite term. Rationality itself is prioritised, for example, by contrasting it with the rejected opposite: irrationality. Expert clinical practice is, however, increasingly identified as being inclusive of more than merely rational ways of knowing and behaving. This paper is based on a post-structural study concerning changes to women's embodied sense of self during childbearing. We expose the limitations of pure rationality in the context of childbirth and use the concept of safety to exemplify the limitations that pure rationality imposes. The paper draws on philosophical and spiritual theory to present an analysis of ideas about mind, body, soul and spirit. The standard rational/irrational dichotomy is critiqued and contrasted with the embodied reality of nonrational experiences that are individual, contextual and 'in-the-moment'. Nonrational experiences are identified to be inclusive of power and knowledge that are both rational and nonrational. This revised conceptualisation provides a theoretical basis that allows for and promotes more possibilities and thus more holistic ways of knowing in midwifery. Our thesis is that midwives and women need to take conscious account of nonrational knowledge and power during the childbearing year. We argue that pure rational thinking limits possibilities by excluding the midwife's embodied ways of knowing along with the ways of knowing embodied by the woman. The inclusion of women's and midwives'nonrational ways of knowing in childbearing situations opens us up to knowledge and power that provides for a more complete, and therefore a more optimal, decision-making process.

Background Postpartum haemorrhage (PPH) rates continue to rise in the developed world. A recent study found that any skin-to-skin contact and breastfeeding within 30 min of birth was associated with an almost 50% reduction in PPH rates. Improved oxytocin release is the biological reason proposed to explain this. The combination of skin-to-skin contact and breastfeeding within 30 min of birth is termed ‘Pronurturance’. Midwifery theory and research claims that optimal third stage care is more holistic than simple Pronurturnace which suggests that further reductions in PPH rates may be possible. Question What can midwives and women do to minimise blood loss in the third and fourth stages of labour? Method We present a new theory that describes and explains how to optimise the woman's reproductive psychophysiology in the third and fourth stages of labour to ensure a well contracted uterus which inhibits excessive bleeding regardless of risk status or whether active management was used. In developing the Pronurturance Plus theory we expand upon what is already known about oxytocin in relation to simple pronurturance to integrate concepts from birth territory theory, cognitive neuroscience, mindfulness psychology and the autonomic nervous system to develop an holistic understanding of how to optimise care and minimise PPH. Conclusion Pronurturance Plus is a psycho-biologically grounded theory which is consistent with existing evidence. It is free, natural and socially desirable.

Background Health professionals have put much effort into supporting women to continue breastfeeding up to six months and beyond. The majority of those efforts have not been successful for primiparous women. Primiparous women who engaged in the Milky Way Programme had an improvement in breastfeeding rates of almost 50% at six months when compared to women in a control group. Purpose To provide details of the Milky Way Programme including the educational structure, content and strategies as well as the process of postnatal telephone support. Overview The details of the Milky Way Programme are presented including a summary of literature review that was used to design the programme. The structure and content of the programme is then presented. Finally, the strategies with some practical examples are outlined in more detail. Conclusion The programme is evidence-based, theoretically informed and woman-centred. This paper provides the necessary information to health professionals who are trained to educate and support breastfeeding women to implement similar programmes in their workplaces.

Background Lack of teamwork skills among health care professionals endangers patients and enables workplace bullying. Individual teamwork skills are increasingly being assessed in the undergraduate health courses but rarely defined, made explicit or taught. To remedy these deficiencies we introduced a longitudinal educational strategy across all three years of the Bachelor of Midwifery program. Aim To report on students’ experiences of engaging in team based assignments which involved mark-related peer feedback. Methods Stories of midwifery students’ experiences were collected from 17 participants across the three years of the degree. These were transcribed and analysed thematically and interpreted using feminist collaborative conversations. Results Most participants reported being in well-functioning teams and enjoyed the experience; they spoke of ‘we’ and said ‘Everyone was on Board’. Students in poorly functioning teams spoke of ‘I’ and ‘they’. These students complained about the poor performance of others but they didn’t speak up because they ‘didn’t want to make waves’ and they didn’t have the skills to be able to confidently manage conflict. All participants agreed ‘Peer-related marks cause mayhem’. Conclusion Teamwork skills should be specifically taught and assessed. These skills take time to develop. Students, therefore, should be engaged in a teamwork assignment in each semester of the entire program. Peer feedback should be moderated by the teacher and not directly related to marks.

The literature presents teenage childbearing as a problem for the mother, her infant and society at large. Most adolescents experience becoming a teenage mother as a painful psychosocial process but not for the reasons the literature describes. This is a post-structural, feminist, praxis study. It presents the young mothers' own stories of suffering. This dissertation argues that the process of becoming a teenage mother is not inherently imbued with suffering, rather, it is the result of being the object of coercive po\ver. Health care providers (as individuals) and the health care system (as a social structure) frequently cause suffering for adolescent mothers. A number of power stru ggles which occurred between teenage mothers and health care providers are presented and deeply interpreted. Theoretical perspectives used includes Foucault's disciplinary power, Butkr"s subject positions and discourse as citation and Neitzschean and feminist ideas about the body and embodiment. The use of multiple theories allowed various perspectives to be explored in order to develop a fuller understanding of how power operates. This also helped to explain why young women mostly comply with the expectations of health care providers even when it is not in their best interests to do so. The study concludes by recommending changes to the provision of maternity services for all women.

The purpose of this paper is to evaluate the quality and significance of contemporary Australian midwifery research as reported in the Australian Midwifery Journal 2002–2004. The evaluation involved grading the research. The ultimate aim is to recommend some research strategies and areas of focus for our discipline over the next five to 10 years. The average score for quantitative research was 2.3 out of a possible 4 (with 4 being the highest possible). The average grades for significance as evidence for practice were calculated with 1 being the highest possible grade and 5 being the lowest possible. For qualitative research, the average grade was undesirably high at 4.2 and for quantitative research it was 4.4. The grading exercise demonstrated that our current research output is, with some exceptions, not of high enough quality to be able to create evidence for practice. Thus, our first step must be to improve the quality of both our qualitative and quantitative research. Multi-site, team based, programmatic research is recommended as a multi-pronged strategy to improve the quality of our research, enhance our research training and become successful in funding applications. A limitation of the study is that the exercise would be strengthened if two or more reviewers had completed the reviews independently.

Background Although the benefits of breastfeeding to six months are well-established, only about half of Australian women succeed. The factors associated with successful breastfeeding are rarely translated into effective interventions. A new educational and support program, called the Milky Way program has been demonstrated to be effective in supporting women to achieve prolonged breastfeeding. In the Milky Way program, breastfeeding is considered an embodied performance which requires an engaged combination of body, mind and spirit. This paper aims to explain how the two theories that informed the program were used to better enable women's long term breastfeeding success. Method The theory of self-efficacy is first described as a way to develop women's cognitive processes to organise and execute the course of actions to breastfeed for a longer period of time. Birth territory theory is then presented. This theory discusses women as embodied selves; an essential concept for breastfeeding success. Birth territory theory also describes the effects of the holistic environment on the woman and explores the effects of power that is used in the environment. This power can be used integratively to strengthen the woman's breastfeeding confidence and success or, disintergratively which reduces her confidence and undermines her success. Conclusion Strategies based on self-efficacy theory are helpful, but are not sufficient to promote breastfeeding to six months. Health educators also need to foster the woman's connection to, and trust in, her body and her baby's body to breastfeed spontaneously. Being aware of environmental impacts on how the woman and baby breastfeed; and using one's own power integratively is crucial to women being able to achieve prolonged breastfeeding.

to examine the effect of skin-to-skin contact and breast feeding within 30 minutes of birth, on the rate of primary postpartum haemorrhage (PPH) in a sample of women who were at mixed-risk of PPH.retrospective cohort study.two obstetric units plus a freestanding birth centre in New South Wales (NSW) Australia.after excluding women (n=3671) who did not have opportunity for skin to skin and breast feeding, I analysed birth records (n=7548) for the calendar years 2009 and 2010. Records were accessed via the electronic data base ObstetriX.skin to skin contact and breast feeding within 30 minutes of birth.outcome measure was PPH i.e. blood loss of 500ml or more estimated at birth. Data was analysed using descriptive statistics and logistic regression (unadjusted and adjusted).after adjustment for covariates, women who did not have skin to skin and breast feeding were almost twice as likely to have a PPH compared to women who had both skin to skin contact and breast feeding (aOR 0.55, 95% CI 0.41-0.72, p0.001). This apparently protective effect of skin to skin and breast feeding on PPH held true in sub-analyses for both women at 'lower' (OR 0.22, 95% CI 0.17-0.30, p0.001) and 'higher' risk (OR 0.37 95% CI 0.24-0.57), p0.001. KEY CONCLUSIONS AND IMPLICATION FOR PRACTICE: this study suggests that skin to skin contact and breastfeeding immediately after birth may be effective in reducing PPH rates for women at any level of risk of PPH. The greatest effect was for women at lower risk of PPH. The explanation is that pronurturance promotes endogenous oxytocin release. Childbearing women should be educated and supported to have pronurturance during third and fourth stages of labour.

The aim of this research is to understand how power operates in the medical encounter with the childbearing woman and to theorize ways in which midwives can empower women to experience control over what happens to them. Thirty-three Australian pregnant young women and the researcher participated in this study. A post-modern, feminist praxis approach was the research method used. Data was collected using participant observation, in-depth interviewing and reflective journaling. Data was analysed using Michel Foucault's theoretical concepts concerning disciplinary power/knowledge. Key theoretical findings are: knowing how power operates allows midwives to predict what will happen if the woman is intending to resist standardised medical birthing practices. When disciplinary medical power is used the purpose is to coerce patients to do what the doctor wants. Power and knowledge are inseparable, as each strengthens the other, thus Foucault writes of a single concept--Power/Knowledge. Medical power operates most effectively with the co-operation of the midwife and the submission of the childbearing woman. Medical power is normally invisible; it only becomes visible when resistance is encountered, whereupon rewards, threats and punishments are used in an attempt to gain submission. Women can be more empowered if the midwife shares knowledge, not just about pregnancy, labour and birth, but also about the woman's legal rights and what might happen if she decides to refuse standardised medical care. In this way women's empowerment can be facilitated so that they are more likely to experience the type of childbirth they desire.

Background: clinical reasoning was once thought to be the exclusive domain of medicine – setting it apart from ‘non-scientific’ occupations like midwifery. Poor assessment, clinical reasoning and decision-making skills are well known contributors to adverse outcomes in maternity care. Midwifery decision-making models share a common deficit: they are insufficiently detailed to guide reasoning processes for midwives in practice. For these reasons we wanted to explore if midwives actively engaged in clinical reasoning processes within their clinical practice and if so to what extent. The study was conducted using post structural, feminist methodology. Question: to what extent do midwives engage in clinical reasoning processes when making decisions in the second stage labour? Methods: twenty-six practising midwives were interviewed. Feminist interpretive analysis was conducted by two researchers guided by the steps of a model of clinical reasoning process. Six narratives were excluded from analysis because they did not sufficiently address the research question. The midwives narratives were prepared via data reduction. A theoretically informed analysis and interpretation was conducted. Findings: using a feminist, interpretive approach we created a model of midwifery clinical reasoning grounded in the literature and consistent with the data. Thirteen of the 20 participant narratives demonstrate analytical clinical reasoning abilities but only nine completed the process and implemented the decision. Seven midwives used non-analytical decision-making without adequately checking against assessment data. Conclusion: over half of the participants demonstrated the ability to use clinical reasoning skills. Less than half of the midwives demonstrated clinical reasoning as their way of making decisions. The new model of Midwifery Clinical Reasoning includes ‘intuition’ as a valued way of knowing. Using intuition, however, should not replace clinical reasoning which promotes through decision-making that can be made transparent and be consensually validated. Refereed/Peer-reviewed

Background Poor teamwork is cited as one of the major root causes of adverse events in healthcare. Bullying, resulting in illness for staff, is an expression of poor teamwork skills. Despite this knowledge, poor teamwork persists in healthcare and teamwork skills are rarely the focus of teaching and assessment in undergraduate health courses. Aim To develop and implement an assessment tool for use in facilitating midwifery students’ learning of teamwork skills. Methods This paper describes how the TeamUP rubric tool was developed. A review of the literature found no research reports on how to teach and assess health students’ teamwork skills in standing teams. The literature, however, gives guidance about how university educators should evaluate individual students using peer assessment. The developmental processes of the rubric were grounded in the theoretical literature and feminist collaborative conversations. The rubric incorporates five domains of teamwork skills: Fostering a Team Climate; Project Planning; Facilitating Teams; Managing Conflict and Quality Individual Contribution. The process and outcomes of student and academic content validation are described. Conclusion The TeamUP rubric is useful for articulating, teaching and assessing teamwork skills for health professional students. The TeamUP rubric is a robust, theoretically grounded model that defines and details effective teamwork skills and related behaviours. If these skills are mastered, we predict that graduates will be more effective in teams. Our assumption is that graduates, empowered by having these skills, are more likely to manage conflict effectively and less likely to engage in bullying behaviours.

The diagnosis of Amniotic Fluid Embolus (AFE) is often missed clinically leading to the incorrect attribution of a major post-partum haemorrhage, which may accompany AFE, to uterine atony. This paper reviews the research on AFE with particular emphasis on the clinical presentation and diagnosis; both before and after death. It begins by dealing with the difficulty of defining AFE due to confusion about the underlying pathophysiological events. As this paper will demonstrate, the theory that AFE is an embolic event is no longer valid. A description of the clinical manifestations is provided so that these can be explained by the contemporary theory of AFE as an 'anaphylactoid' reaction. Finally, the difficulties of diagnosis, particularly laboratory diagnosis, will be discussed. The research indicates that it is not possible to accurately diagnose AFE, either, pre or post mortem, by any currently available laboratory tests. Because of better diagnosis it is now known that AFE in not uncommon and, if it is diagnosed early, a much higher rate of intact survival can be achieved than was previously thought possible.

Burnout is a major contributor to shortages of experienced nurses. The research literature shows a correlation between moral distress and burnout in critical care nurses. This paper reports on part of an interpretive interactionist study concerning nurses' experiences of moral distress which prompted attempts to advocate for vulnerable patients. One critical incident is used as an example of the qualitative findings of the study. In this paper, we theorize about what happened when nurses advocated for their patients by challenging medical treatments which the nurses believed to be both inappropriate and to contributing to patient suffering. When attempts at advocacy were unsuccessful, the nurses experienced intensified moral distress, frustration and anger. Being an unsuccessful advocate resulted in nurses being relocated within the hospital, nurses being scapegoated and/or burning out. The theoretical links which this paper makes between advocacy, moral distress and burnout are supported by empirical data from the study.

While Parsons’ theory of the sick role has been widely criticized, the alternatives that have been proposed are inadequate. Here subject positions theory is put forward as a viable approach to analysing medical encounters, which combines the advantages of sick role theory with those of its competitors. The approach is demonstrated through ethnographic material taken from a post-structural feminist praxis research project involving a midwife researcher and teenage mothers. This shows that actors move through a variety of subject positions in negotiating medical encounters. While subject positions theory provides a powerful new way of analysing these encounters, it is not yet clear how it can be used to challenge medical dominance.

Background Midwives should be skilled team workers in maternity units and in group practices. Poor teamwork skills are a significant cause of adverse maternity care outcomes. Despite Australian and International regulatory requirements that all midwifery graduates are competent in teamwork, the systematic teaching and assessment of teamwork skills is lacking in higher education. Question How do midwifery students evaluate participation in team-based academic assignments, which include giving and receiving peer feedback? Participants First and third year Bachelor of Midwifery students who volunteered (24 of 56 students). Methods Participatory Action Research with data collection via anonymous online surveys. Key findings There was general agreement that team based assignments; (i) should have peer-marking, (ii) help clarify what is meant by teamwork, (iii) develop communication skills, (iv) promote student-to-student learning. Third year students strongly agreed that teams: (i) are valuable preparation for teamwork in practice, (ii) help meet Australian midwifery competency 8, and (iii) were enjoyable. The majority of third year students agreed with statements that their teams were effectively coordinated and team members shared responsibility for work equally; first year students strongly disagreed with these statements. Students’ qualitative comments substantiated and expanded on these findings. The majority of students valued teacher feedback on well-developed drafts of the team's assignment prior to marking. Conclusion Based on these findings we changed practice and created more clearly structured team-based assignments with specific marking criteria. We are developing supporting lessons to teach specific teamwork skills: together these resources are called “TeamUP”. TeamUP should be implemented in all pre-registration Midwifery courses to foster students’ teamwork skills and readiness for practice.

This paper is a critique of a Cochrane systematic review where the primary objective of the review was to evaluate the effects, on labour and birth outcomes, of care in a home-like birth setting compared with care in a conventional hospital labour ward. The unanticipated finding of that review was a trend towards higher perinatal mortality in the home-like setting group. Our critique focuses on one important question: is the Cochrane review of birth setting based on studies of sufficient scientific rigour to be able to establish whether or not there may be an added risk of perinatal mortality associated with intrapartum care in a home-like setting? In this commentary we critique two aspects of methodological quality in the studies underpinning the Cochrane review: the high levels of non-compliance with the planned treatment, and the low levels of 'treatment fidelity' even if subjects received the planned treatment. Of the 41 deaths in the home-like setting group 35 (85%) were not associated with intrapartum care in a home-like setting. We conclude that the Cochrane review of birth setting cannot be relied upon to make valid statements about whether there may be an added risk of perinatal mortality associated with experiencing intrapartum care in either setting. In the process of our analysis we uncovered what may be two broader problems for Cochrane systematic reviews. The Cochrane Reviewers' Handbook should be expanded to give specific guidance for researchers and reviewers about how to enhance or evaluate research quality in relation to non-compliance with assigned treatment and treatment fidelity.

Background Preterm birth is a significant global health problem with serious short and long term consequences. This paper reviews the research literature to answer the question how effective are the medical interventions that aim to reduce the rates of preterm birth? Methods A systematic search was carried out in CINAHL, Cochrane, Medline and Embase in relation to following medical treatments aimed at preventing preterm births: anti-infective medications, tocolytics, progesterone and cervical cerclage. The research underpinning each type of intervention is critically analysed in order to establish the validity of knowledge claims that are made for each type of intervention. Findings In relation to reducing the rates of preterm births, anti-infectives are only effective in the presence of known infection. Screening for infections during pregnancy is ineffective. Tocolytic agents are not effective in decreasing the preterm birth rates. Progesterone seems to be effective in a select group of pregnant women at higher risk of preterm birth. Cervical cerclage plays a small and an occasional role in preventing some preterm births. Conclusions This literature review demonstrates that medical interventions aimed at preventing, not just delaying, preterm birth, are not effective at a population level. Providing holistic, antenatal midwifery care for women living in socio-economic disadvantage and/or with an increased risk of preterm birth seems to be a promising strategy to address the negative effects of the social determinants of disease and thus to reduce the rate of preterm births at an individual and a population level.

Question Is 'holistic psychophysiological care' in the third stage of labour safe for women at low risk of postpartum haemorrhage? Background Although there have been four randomised trials and a Cochrane Review on the safety and effectiveness of care during the third stage labour, no previous study has focussed only on women at low risk of postpartum haemorrhage and no previous study has tested a form of physiological third stage care that is provided by skilled midwives in an appropriate setting. Design Retrospective cohort study involving a maternity unit at a tertiary referral hospital and a freestanding, midwifery-led birthing unit. Participants All low risk women who gave birth at either unit in the period July 2005-August 2008. Interventions 'Active management' of the third stage of labour compared with 'holistic psychophysiological third stage care'. Results At the tertiary unit, 344 of 3075 low risk women (11.2%) experienced postpartum haemorrhages (PPH). At the midwifery-led unit, PPH occurred for 10 of 361 women (2.8%), OR=4.4, 95% CI [2.3, 8.4]. Treatment received analysis showed that active management (n=3016) was associated with 347 postpartum haemorrhages (11.5%) compared with receiving holistic psychophysiological care (n=420) which was associated with 7 (1.7%) PPH OR=7.7, 95% CI [3.6, 16.3]. Conclusion This study suggests that 'holistic psychophysiological care' in the third stage labour is safe for women at low risk of postpartum haemorrhage. 'Active management' was associated with a seven to eight fold increase in postpartum haemorrhage rates for this group of women. Further prospective observational evaluation would be helpful in testing this association.

Question is using ‘transition to motherhood theory' the best way to guide midwives in providing woman-centred care? Background contemporary research about changes to women's embodied sense of self during childbearing is influenced by foundational research and theory about the transition to motherhood. Rubin and Mercer are two key nursing authors whose work on transition to motherhood theory still shapes the ways in which a woman's experience of change during childbearing is understood in midwifery. Methods using a feminist post-structural framework, Rubin and Mercer's theory and research is described, critiqued and discussed. Findings Rubin and Mercer used pre-existing theories and concepts that had the effect of finding similarities and discarding differences between women. Rubin and Mercer's theory and research is an expression of humanistic philosophy. This philosophy creates frameworks that have an assumed, disempowered role for childbearing women. Their research used a logico-empirical, quantitative approach. Qualitative interpretive or constructivist approaches offer more appropriate ways to study the highly individualised, embodied, lived experience of a woman's changing self during childbearing. Conclusion Rubin and Mercer's theory is baby-centred. Transition to motherhood theory privileges the position of experts in directing how a woman should become a mother. This has the effect of making midwives agents for the social control of women. Implications for practice Rubin and Mercer's transition to motherhood theory is a well-intentioned product of its time. The theory is inconsistent with contemporary midwifery philosophy which promotes a woman-centred partnership between the midwife and the woman. The usefulness of this outdated nursing theory in midwifery teaching, research or practice is debatable.

Background Communication problems between clinicians are the most common cause of preventable adverse events in hospitals. In spite of these known risks the ‘turf wars’ between midwives and doctors continue unabated. Question What factors affect inter-professional interactions in birthing units? Participants 9 doctors and 10 midwives from 10 Australian maternity units. Methods Interpretive Interactionism was the research design. Probing in-depth interviews were conducted to elicit stories of inter-professional interactions and their perceived effects on birthing outcomes. Analysis resulted in two theoretical models of inter-professional interaction: one positive and the other negative. Findings Midwives and doctors agree that positive interactions are collaborative, include the woman and her partner and are associated with the best possible outcomes and experiences possible. In contrast, they agree that negative interactions involve power struggles between the professionals and these are associated with adverse outcomes. All participants are able to demonstrate emotional and social competence when interacting and applied those skills sometimes. Factors related to the organisational culture within the ‘birth territory’ of a particular maternity unit seem to be predictive of the type of interactions that are likely to occur there. Conclusion Interventions to enhance inter-professional collaboration should be directed first at changing organisational structures and policies to promote easy opportunities for natural dialogue between doctors and midwives.

Summary Background Clinical decision-making was initially studied in medicine where hypothetico-deductive reasoning is the model for decision-making. The nursing perspective on clinical decision-making has largely been shaped by Patricia Benner's ground breaking work. Benner claimed expert nurses use humanistic-intuitive ways of making clinical decisions rather than the ‘rational reasoning’ as claimed by medicine. Clinical decision-making in midwifery is not the same as either nursing or medical decision-making because of the woman–midwife partnership where the woman is the ultimate decision-maker. Method CINHAL, Medline and Cochrane databases were systematically searched using key words derived from the guiding question. A review of the decision-making research literature in midwifery was undertaken where studies were published in English. The selection criteria for papers were: only research papers of direct relevance to the guiding research question were included in the review. Findings Decision-making is under-researched in midwifery and more specifically birth, as only 4 research articles met the inclusion criteria in this review. Three of the studies involved qualified midwives, and one involved student midwives. Two studies were undertaken in England, one in Scotland and one in Sweden. The major findings synthesised from this review, are that; (1) midwifery decision-making during birth is socially negotiated involving hierarchies of surveillance and control; (2) the role of the woman in shared decision-making during birth has not been explored by midwifery research; (3) clinical decision-making encompasses clinical reasoning as essential but not sufficient for midwives to actually implement their preferred decision. Conclusion We argue that existing research does not inform the discipline of the complexity of midwifery clinical decision-making during birth. A well-designed study would involve investigating the clinical reasoning skills of the midwife, her relationship with the woman, the context of the particular birthing unit and the employment status of the midwife. The role of the woman as decision-maker in her own care during birth also needs careful research attention.