Comparison of labour and birth outcomes between nulliparous women who used epidural analgesia in labour and those who did not: A prospective cohort study.

OBJECTIVE: To compare labour and birth outcomes between nulliparous women who used versus did not use intrapartum epidural analgesia. DESIGN: Prospective cohort study. SETTING: Two maternity hospitals in Ireland. POPULATION: A total of 1221 nulliparous women who gave birth vaginally or by emergency caesarean section. METHODS: Multinomial logistic regression was used to analyse categorical outcomes, with results presented as ratios of relative risks (RRR). For dichotomous outcomes we used logistic regression, with results presented as odds ratios (OR). MAIN OUTCOME MEASURES: Mode of birth, IV syntocinon use, pyrexia (≥38°C), antibiotic treatment, first stage labour ≥10h, second stage labour ≥2h, blood loss (≥500mls, ≥1000mls), perineal trauma. Neonatal outcomes included Apgar score ≥7 at 1min and 5min, admission to neonatal intensive care unit, and infant feeding method. RESULTS: Women using EA were more likely to require a vacuum-assisted birth (RRR 3.35, p<0.01) or forceps-assisted birth (RRR 11.69, p<0.01). Exposure to EA was associated with significantly greater risk of ≥10h first (OR 6.72, p=0.01) and ≥2h second (OR 2.25, p<0.01) stage labour, increased likelihood of receiving IV syntocinon (OR 9.38, p<0.01), antibiotics (OR 2.97, p<0.01) and a greater probability of pyrexia (OR 10.26, p<0.01). Women who used EA were half as likely to be breastfeeding at three months postpartum (OR 0.53, p<0.01). No differences were observed between groups in neonatal outcomes. CONCLUSIONS: Our data shows significant associations between EA use and several intrapartum outcomes.

Active versus expectant management for women in the third stage of labour.

BACKGROUND: Active management of the third stage of labour involves giving a prophylactic uterotonic, early cord clamping and controlled cord traction to deliver the placenta. With expectant management, signs of placental separation are awaited and the placenta is delivered spontaneously. Active management was introduced to try to reduce haemorrhage, a major contributor to maternal mortality in low-income countries. This is an update of a review last published in 2015. OBJECTIVES: To compare the effects of active versus expectant management of the third stage of labour on severe primary postpartum haemorrhage (PPH) and other maternal and infant outcomes.To compare the effects of variations in the packages of active and expectant management of the third stage of labour on severe primary PPH and other maternal and infant outcomes. SEARCH METHODS: For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov and the World health Organization International Clinical Trials Registry Platform (ICTRP), on 22 January 2018, and reference lists of retrieved studies. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials comparing active versus expectant management of the third stage of labour. Cluster-randomised trials were eligible for inclusion, but none were identified. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the studies for inclusion, assessed risk of bias, carried out data extraction and assessed the quality of the evidence using the GRADE approach. MAIN RESULTS: We included eight studies, involving analysis of data from 8892 women. The studies were all undertaken in hospitals, seven in higher-income countries and one in a lower-income country. Four studies compared active versus expectant management, and four compared active versus a mixture of managements. We used a random-effects model in the analyses because of clinical heterogeneity. Of the eight studies included, we considered three studies as having low risk of bias in the main aspects of sequence generation, allocation concealment and completeness of data collection. There was an absence of high-quality evidence according to GRADE assessments for our primary outcomes, which is reflected in the cautious language below.The evidence suggested that, for women at mixed levels of risk of bleeding, it is uncertain whether active management reduces the average risk of maternal severe primary PPH (more than 1000 mL) at time of birth (average risk ratio (RR) 0.34, 95% confidence interval (CI) 0.14 to 0.87, 3 studies, 4636 women, I2 = 60%; GRADE: very low quality). For incidence of maternal haemoglobin (Hb) less than 9 g/dL following birth, active management of the third stage may reduce the number of women with anaemia after birth (average RR 0.50, 95% CI 0.30 to 0.83, 2 studies, 1572 women; GRADE: low quality). We also found that active management of the third stage may make little or no difference to the number of babies admitted to neonatal units (average RR 0.81, 95% CI 0.60 to 1.11, 2 studies, 3207 infants; GRADE: low quality). It is uncertain whether active management of the third stage reduces the number of babies with jaundice requiring treatment (RR 0.96, 95% CI 0.55 to 1.68, 2 studies, 3142 infants, I2 = 66%; GRADE: very low quality). There were no data on our other primary outcomes of very severe PPH at the time of birth (more than 2500 mL), maternal mortality, or neonatal polycythaemia needing treatment.Active management reduces mean maternal blood loss at birth and probably reduces the rate of primary blood loss greater than 500 mL, and the use of therapeutic uterotonics. Active management also probably reduces the mean birthweight of the baby, reflecting the lower blood volume from interference with placental transfusion. In addition, it may reduce the need for maternal blood transfusion. However, active management may increase maternal diastolic blood pressure, vomiting after birth, afterpains, use of analgesia from birth up to discharge from the labour ward, and more women returning to hospital with bleeding (outcome not pre-specified).In the comparison of women at low risk of excessive bleeding, there were similar findings, except it was uncertain whether there was a difference identified between groups for severe primary PPH (average RR 0.31, 95% CI 0.05 to 2.17; 2 studies, 2941 women, I2 = 71%), maternal Hb less than 9 g/dL at 24 to 72 hours (average RR 0.17, 95% CI 0.02 to 1.47; 1 study, 193 women) or the need for neonatal admission (average RR 1.02, 95% CI 0.55 to 1.88; 1 study, 1512 women). In this group, active management may make little difference to the rate of neonatal jaundice requiring phototherapy (average RR 1.31, 95% CI 0.78 to 2.18; 1 study, 1447 women).Hypertension and interference with placental transfusion might be avoided by using modifications to the active management package, for example, omitting ergot and deferring cord clamping, but we have no direct evidence of this here. AUTHORS' CONCLUSIONS: Although the data appeared to show that active management reduced the risk of severe primary PPH greater than 1000 mL at the time of birth, we are uncertain of this finding because of the very low-quality evidence. Active management may reduce the incidence of maternal anaemia (Hb less than 9 g/dL) following birth, but harms such as postnatal hypertension, pain and return to hospital due to bleeding were identified.In women at low risk of excessive bleeding, it is uncertain whether there was a difference between active and expectant management for severe PPH or maternal Hb less than 9 g/dL (at 24 to 72 hours). Women could be given information on the benefits and harms of both methods to support informed choice. Given the concerns about early cord clamping and the potential adverse effects of some uterotonics, it is critical now to look at the individual components of third-stage management. Data are also required from low-income countries.It must be emphasised that this review includes only a small number of studies with relatively small numbers of participants, and the quality of evidence for primary outcomes is low or very low.

Interventions for prevention of bullying in the workplace.

BACKGROUND: Bullying has been identified as one of the leading workplace stressors, with adverse consequences for the individual employee, groups of employees, and whole organisations. Employees who have been bullied have lower levels of job satisfaction, higher levels of anxiety and depression, and are more likely to leave their place of work. Organisations face increased risk of skill depletion and absenteeism, leading to loss of profit, potential legal fees, and tribunal cases. It is unclear to what extent these risks can be addressed through interventions to prevent bullying. OBJECTIVES: To explore the effectiveness of workplace interventions to prevent bullying in the workplace. SEARCH METHODS: We searched: the Cochrane Work Group Trials Register (August 2014); Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library 2016, issue 1); PUBMED (1946 to January 2016); EMBASE (1980 to January 2016); PsycINFO (1967 to January 2016); Cumulative Index to Nursing and Allied Health Literature (CINAHL Plus; 1937 to January 2016); International Bibliography of the Social Sciences (IBSS; 1951 to January 2016); Applied Social Sciences Index and Abstracts (ASSIA; 1987 to January 2016); ABI Global (earliest record to January 2016); Business Source Premier (BSP; earliest record to January 2016); OpenGrey (previously known as OpenSIGLE-System for Information on Grey Literature in Europe; 1980 to December 2014); and reference lists of articles. SELECTION CRITERIA: Randomised and cluster-randomised controlled trials of employee-directed interventions, controlled before and after studies, and interrupted time-series studies of interventions of any type, aimed at preventing bullying in the workplace, targeted at an individual employee, a group of employees, or an organisation. DATA COLLECTION AND ANALYSIS: Three authors independently screened and selected studies. We extracted data from included studies on victimisation, perpetration, and absenteeism associated with workplace bullying. We contacted study authors to gather additional data. We used the internal validity items from the Downs and Black quality assessment tool to evaluate included studies' risk of bias. MAIN RESULTS: Five studies met the inclusion criteria. They had altogether 4116 participants. They were underpinned by theory and measured behaviour change in relation to bullying and related absenteeism. The included studies measured the effectiveness of interventions on the number of cases of self-reported bullying either as perpetrator or victim or both. Some studies referred to bullying using common synonyms such as mobbing and incivility and antonyms such as civility. Organisational/employer level interventionsTwo studies with 2969 participants found that the Civility, Respect, and Engagement in the Workforce (CREW) intervention produced a small increase in civility that translates to a 5% increase from baseline to follow-up, measured at 6 to 12 months (mean difference (MD) 0.17; 95% CI 0.07 to 0.28).One of the two studies reported that the CREW intervention produced a small decrease in supervisor incivility victimisation (MD -0.17; 95% CI -0.33 to -0.01) but not in co-worker incivility victimisation (MD -0.08; 95% CI -0.22 to 0.08) or in self-reported incivility perpetration (MD -0.05 95% CI -0.15 to 0.05). The study did find a decrease in the number of days absent during the previous month (MD -0.63; 95% CI -0.92 to -0.34) at 6-month follow-up. Individual/job interface level interventionsOne controlled before-after study with 49 participants compared expressive writing with a control writing exercise at two weeks follow-up. Participants in the intervention arm scored significantly lower on bullying measured as incivility perpetration (MD -3.52; 95% CI -6.24 to -0.80). There was no difference in bullying measured as incivility victimisation (MD -3.30 95% CI -6.89 to 0.29).One controlled before-after study with 60 employees who had learning disabilities compared a cognitive-behavioural intervention with no intervention. There was no significant difference in bullying victimisation after the intervention (risk ratio (RR) 0.55; 95% CI 0.24 to 1.25), or at the three-month follow-up (RR 0.49; 95% CI 0.21 to 1.15), nor was there a significant difference in bullying perpetration following the intervention (RR 0.64; 95% CI 0.27 to 1.54), or at the three-month follow-up (RR 0.69; 95% CI 0.26 to 1.81). Multilevel InterventionsA five-site cluster-RCT with 1041 participants compared the effectiveness of combinations of policy communication, stress management training, and negative behaviours awareness training. The authors reported that bullying victimisation did not change (13.6% before intervention and 14.3% following intervention). The authors reported insufficient data for us to conduct our own analysis.Due to high risk of bias and imprecision, we graded the evidence for all outcomes as very low quality. AUTHORS' CONCLUSIONS: There is very low quality evidence that organisational and individual interventions may prevent bullying behaviours in the workplace. We need large well-designed controlled trials of bullying prevention interventions operating on the levels of society/policy, organisation/employer, job/task and individual/job interface. Future studies should employ validated and reliable outcome measures of bullying and a minimum of 6 months follow-up.

Women's preferences for childbirth experiences in the Republic of Ireland; a mixed methods study.

BACKGROUND: How women experience childbirth is acknowledged as critical to the postnatal wellbeing of mother and baby. However there is a knowledge deficit in identifying the important elements of these experiences in order to enhance care. This study elicits women's preferences for the most important elements of their childbirth experiences. METHODS: A mixed methods design was used. An initial qualitative phase (reported previously) was followed by a second quantitative one using a discrete choice experiment (DCE), which is reported on here. Participants who had experienced labour, were over 18 and had a healthy baby were recruited from four randomly selected and one pilot hospital in the Republic of Ireland. Data were collected by means of a DCE survey instrument. Questions were piloted, refined, and then arranged in eight pair-wise scenarios. Women identified their preferences by choosing one scenario over another. Nine hundred and five women were sent the DCE three months after childbirth, with a response rate of 59.3% (N =531). RESULTS: Women clearly identified priorities for their childbirth experiences as: the availability of pain relief, partnership with the midwife, and individualised care being the most important attributes. In the context of other choices, women rated decision-making, presence of a consultant, and interventions as less important elements. Comments from open questions provided contextual information about their choices. CONCLUSIONS: Most women did not want to be typified as wanting the dichotomy of 'all natural' or 'all technology' births but wanted 'the best of both worlds'. The results suggest that availability of pain relief was the most important element of women's childbirth experiences, and superseded all other elements including partnership with the midwife which was the second most important attribute. The preferences identified might reflect the busy medicalised hospital environments, in which the vast majority of women had given birth, and may differ in settings such as midwifery led care or home births.

The prevalence of women's emotional and physical health problems following a postpartum haemorrhage: a systematic review.

BACKGROUND: Postpartum Haemorrhage (PPH) is a leading cause of maternal mortality with approximately 225 women dying as a result of it each day especially in low income countries. However, much less is known about morbidity after a PPH. This systematic review aimed to determine the overall prevalence of emotional and physical health problems experienced by women following a postpartum haemorrhage. METHODS: Eight databases were searched for published non-randomised, observational, including cohort, primary research studies that reported on the prevalence of emotional and/or physical health problems following a PPH. Intervention studies were included and data, if available, were abstracted on the control group. All authors independently screened the papers for inclusion. Of the 2210 papers retrieved, six met the inclusion criteria. Data were extracted independently by two authors. The methodological quality of the included studies was assessed using a modified Newcastle Ottawa Scale (NOS). The primary outcome measure reported was emotional and physical health problems up to 12 months postpartum following a postpartum haemorrhage. RESULTS: Two thousand two hundred ten citations were identified and screened with 2089 excluded by title and abstract. Following full-text review of 121 papers, 115 were excluded. The remaining 6 studies were included. All included studies were judged as having strong or moderate methodological quality. Five studies had the sequelae of PPH as their primary focus, and one study focused on morbidity postnatally, from which we could extract data on PPH. Persistent morbidities following PPH (at ≥ 3 and < 6 months postpartum) included postnatal depression (13 %), post-traumatic stress disorder (3 %), and health status 'much worse than one year ago' (6 %). Due to the different types of health outcomes reported in the individual studies, it was possible to pool results from only four studies, and only then by accepting the slightly differing definitions of PPH. Those that could be pooled reported rates of acute renal failure (0.33 %), coagulopathy (1.74 %) and re-admission to hospital following a PPH between 1 and 3 months postpartum (3.6 %), an appreciable indication of underlying physical problems. CONCLUSION: This systematic review demonstrates that the existence and type of physical and emotional health problems post PPH, regardless of the volume of blood lost, are largely unknown. Further large cohort or case control studies are necessary to obtain better knowledge of the sequelae of this debilitating morbidity.

Active versus expectant management for women in the third stage of labour.

BACKGROUND: Active management of the third stage of labour involves giving a prophylactic uterotonic, early cord clamping and controlled cord traction to deliver the placenta. With expectant management, signs of placental separation are awaited and the placenta is delivered spontaneously. Active management was introduced to try to reduce haemorrhage, a major contributor to maternal mortality in low-income countries. OBJECTIVES: To compare the effectiveness of active versus expectant management of the third stage of labour. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group Trials Register (30 September 2014) and reference lists of retrieved studies. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials comparing active versus expectant management of the third stage of labour. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. MAIN RESULTS: We included seven studies (involving 8247 women), all undertaken in hospitals, six in high-income countries and one in a low-income country. Four studies compared active versus expectant management, and three compared active versus a mixture of managements. We used random-effects in the analyses because of clinical heterogeneity. There was an absence of high-quality evidence according to GRADE assessments for our primary outcomes. The evidence suggested that for women at mixed levels of risk of bleeding, active management showed a reduction in the average risk of maternal primary haemorrhage at time of birth (more than 1000 mL) (average risk ratio (RR) 0.34, 95% confidence interval (CI) 0.14 to 0.87, three studies, 4636 women, GRADE:very low quality) and of maternal haemoglobin (Hb) less than 9 g/dL following birth (average RR 0.50, 95% CI 0.30 to 0.83, two studies, 1572 women, GRADE:low quality). We also found no difference in the incidence in admission of infants to neonatal units (average RR 0.81, 95% CI 0.60 to 1.11, two studies, 3207 infants, GRADE:low quality) nor in the incidence of infant jaundice requiring treatment (0.96, 95% CI 0.55 to 1.68, two studies, 3142 infants, GRADE:very low quality). There were no data on our other primary outcomes of very severe postpartum haemorrhage (PPH) at the time of birth (more than 2500 mL), maternal mortality, or neonatal polycythaemia needing treatment.Active management also showed a significant decrease in primary blood loss greater than 500 mL, and mean maternal blood loss at birth, maternal blood transfusion and therapeutic uterotonics during the third stage or within the first 24 hours, or both, and significant increases in maternal diastolic blood pressure, vomiting after birth, after-pains, use of analgesia from birth up to discharge from the labour ward and more women returning to hospital with bleeding (outcome not pre-specified). There was also a decrease in the baby's birthweight with active management, reflecting the lower blood volume from interference with placental transfusion.In the subgroup of women at low risk of excessive bleeding, there were similar findings, except there was no significant difference identified between groups for severe haemorrhage or maternal Hb less than 9 g/dL (at 24 to 72 hours).Hypertension and interference with placental transfusion might be avoided by using modifications to the active management package, e.g. omitting ergot and deferring cord clamping, but we have no direct evidence of this here. AUTHORS' CONCLUSIONS: Although there is a lack of high-quality evidence, active management of the third stage reduced the risk of haemorrhage greater than 1000 mL at the time of birth in a population of women at mixed risk of excessive bleeding, but adverse effects were identified. Women should be given information on the benefits and harms of both methods to support informed choice. Given the concerns about early cord clamping and the potential adverse effects of some uterotonics, it is critical now to look at the individual components of third-stage management. Data are also required from low-income countries.

Intervention or interference? The need for expectant care throughout normal labour.

BACKGROUND: Medico-technical intervention rates in labour, such as induction and augmentation of labour, are rising worldwide. Such interventions have adverse as well as beneficial consequences, so any intervention introduced must be based on evidence and result in more good than harm, otherwise it is just interference. AIM: To describe three common medico-technical interventions in normal pregnancy or labour in terms of their effects on women and neonates. METHOD: A comprehensive review of literature was undertaken to provide evidence of benefits and adverse effects of three routine medico-technical interventions: induction of labour, episiotomy, and active management of third stage of labour (including early cord clamping). FINDINGS: All three interventions have benefits, but can also cause distress, pain, or morbidity to mothers and babies and should not, therefore, be used routinely, but in response to clinical need. In particular, the over-use of episiotomy, and active management of the third stage (including early cord clamping), in addition to the physical harms they cause, result in an undesirable disruption of the precious minutes following birth when the new family is coming together for the first time. CONCLUSION: Further research is needed into alternative methods of inducing labour, ways to preserve the perineum intact, and trials of expectant and active management of the third stage in low-risk women cared for by midwives skilled in using both methods. Clinicians need to develop their skills in these areas and reduce unnecessary reliance on these three medico-technical interventions, to provide the best possible care for women and babies.

Outcome measures in studies on the use of oxytocin for the treatment of delay in labour: a systematic review.

OBJECTIVES: to identify primary and secondary outcome measures in randomised trials, and systematic reviews of randomised trials, measuring effectiveness of oxytocin for treatment of delay in the first and second stages of labour, and to identify any positive health-focussed outcomes used. DESIGN: eight relevant citation databases were searched up to January 2013 for all randomised trials, and systematic reviews of randomised trials, measuring effectiveness of oxytocin for treatment of delay in labour. Trials of active management of labour or partogram action lines were excluded. 1918 citations were identified. Two reviewers reviewed all citations and extracted data. Twenty-six individual trials and five systematic reviews were included. Primary and secondary outcome measures were documented and analysed using frequency distributions. FINDINGS: most frequent primary outcomes were caesarean section (n=15, 46%), length of labour (n=14, 42%), measurements of uterine activity (n=13, 39%) and mode of vaginal birth (n=9, 27%). Maternal satisfaction was identified a priori by one review and included as a secondary outcome by three papers. No further positive health-focussed outcomes were identified. KEY CONCLUSIONS: outcomes used to measure the effectiveness of oxytocin for treatment of delay in labour are heterogeneous and tend to focus on adverse events. IMPLICATIONS FOR PRACTICE: it is recommended that, in future randomised trials of oxytocin use for delay in labour, some women-centred and health-focussed outcome measures should be used, which may instil a more salutogenic culture in childbirth.

Professionals' views of fetal monitoring during labour: a systematic review and thematic analysis.

BACKGROUND: Current recommendations do not support the use of continuous electronic fetal monitoring (EFM) for low risk women during labour, yet EFM remains widespread in clinical practice. Consideration of the views, perspectives and experiences of individuals directly concerned with EFM application may be beneficial for identifying barriers to and facilitators for implementing evidence-based maternity care. The aim of this paper is to offer insight and understanding, through systematic review and thematic analysis, of research into professionals' views on fetal heart rate monitoring during labour. METHODS: Any study whose aim was to explore professional views of fetal monitoring during labour was considered eligible for inclusion. The electronic databases of MEDLINE (1966-2010), CINAHL (1980-2010), EMBASE (1974-2010) and Maternity and Infant Care: MIDIRS (1971-2010) were searched in January 2010 and an updated search was performed in March 2012. Quality appraisal of each included study was performed. Data extraction tables were developed to collect data. Data synthesis was by thematic analysis. RESULTS: Eleven studies, including 1,194 participants, were identified and included in this review. Four themes emerged from the data: 1) reassurance, 2) technology, 3) communication/education and 4) midwife by proxy. CONCLUSION: This systematic review and thematic analysis offers insight into some of the views of professionals on fetal monitoring during labour. It provides evidence for the continuing use of EFM when caring for low-risk women, contrary to current research evidence. Further research to ascertain how some of these views might be addressed to ensure the provision of evidence-based care for women and their babies is recommended.

Explicating caregiving by mothers of children with complex needs in ireland: a phenomenological study.

This qualitative phenomenological study explored mothers' experiences of caring for a child with complex needs. After ethical approval was obtained, data were collected through 11 diaries and 48 interviews with 17 mothers in Ireland. Caring for a child with complex needs involves the delivery of care in an inside world of the home, the world outside the home, and a "going-between" world. Caregiving, 1 of 8 closely linked dimensions, is presented, including its 4 categories. These are normal mothering, technical caregiving, preemptive caregiving, and individualized caregiving. Professionals require a greater understanding of the experiences of mothers caring for children with complex needs at home.

'Not enough people to look after you': an exploration of women's experiences of childbirth in the Republic of Ireland.

OBJECTIVE: Women's experiences of childbirth have far reaching implications for their health and that of their babies. This paper describes an exploration of women's experiences of childbirth in the Republic of Ireland. DESIGN: A qualitative descriptive study consisting of focus group interviews (FGIs) identified important aspects of women's childbirth experiences. SETTING: Four randomly selected maternity units in the Republic of Ireland. The pilot study unit was also included in the data collection. PARTICIPANTS: A convenience sample of 25 women who volunteered to participate in five focus group interviews. Eligible participants were >18 years, able to discuss their birth experiences in English, had experienced labour, and had a live healthy baby. DATA COLLECTION: Approximately three months following the birth, data were collected using a conversational low moderator style focus group interviews. FINDINGS: Three main themes were identified, 'getting started', 'getting there' and 'consequences'. Women experienced labour in a variety of contexts and with differing aspirations. Midwives played a pivotal role in enabling or disempowering positive experiences. Control was an important element of childbirth experiences. Women often felt alone and unsupported. The busyness of the hospital units precluded women centred care both in early labour and in the period following the birth. Some women would not have another baby due to their childbirth experiences. KEY CONCLUSIONS: The context within which women give birth in the Republic of Ireland is important to their birth experiences. Although positive experiences were reported many women felt anxious and isolated. Busy environments added to women's fears and participants appeared to accept the lack of support as inevitable. Midwives play a pivotal role in helping women achieve a positive birth experience. IMPLICATIONS FOR PRACTICE: Excluding women's views from service evaluation renders an incomplete and somewhat distorted depiction of childbirth in Ireland. Although women appear to be satisfied with a live healthy baby, the process of 'getting there' has an emotional and psychological dimension that is important to the experience. Measuring the quality of maternity services must encompass recognition of psychological and emotional well-being alongside physical safety.

Irish and New Zealand midwives' expertise in expectant management of the third stage of labour: the 'MEET' study.

OBJECTIVE: to explore the views of expert midwives in Ireland and New Zealand of the skills they employ in expectant management of the third stage of labour (EMTSL). DESIGN: university ethical approval was granted for a qualitative descriptive study in 2010. Recorded, semi-structured interviews were undertaken. Constant comparative analysis was used. SETTING: community birth settings in Ireland and New Zealand. PARTICIPANTS: 27 consenting midwives who used EMTSL in at least 30% of births, with PPH rates less than 4%. FINDINGS: the majority of respondents believed the third stage was a special time of parent-baby discovery and 'watchful waiting', with no intervention necessary. Great importance was placed on women's feelings, behaviour and a calm environment. Skin-to-skin contact, breast feeding, not clamping the cord, upright positions and maternal effort, sometimes assisted by gentle cord-traction were also used. KEY CONCLUSIONS: some components of EMTSL identified by these expert midwives are not recorded in text-books, but are based on experience and expertise. These elements of EMTSL add to midwifery knowledge and provide a basis for further discussion on how normal physiology can be supported during the third stage. IMPLICATIONS FOR PRACTICE: use of these elements is recommended for women who request EMTSL, and for those in countries without ready access to uterotonics.

Active versus expectant management for women in the third stage of labour.

BACKGROUND: Active management of the third stage of labour involves giving a prophylactic uterotonic, early cord clamping and controlled cord traction to deliver the placenta. With expectant management, signs of placental separation are awaited and the placenta is delivered spontaneously. Active management was introduced to try to reduce haemorrhage, a major contributor to maternal mortality in low-income countries. OBJECTIVES: To compare the effectiveness of active versus expectant management of the third stage of labour. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group Trials Register (15 February 2011). SELECTION CRITERIA: Randomised and quasi-randomised controlled trials comparing active versus expectant management of the third stage of labour. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. MAIN RESULTS: We included seven studies (involving 8247 women), all undertaken in hospitals, six in high-income countries and one in a low-income country. Four studies compared active versus expectant management, and three compared active versus a mixture of managements. We used random-effects in the analyses because of clinical heterogeneity. There was an absence of high quality evidence for our primary outcomes. The evidence suggested that for women at mixed levels of risk of bleeding, active management showed a reduction in the average risk of maternal primary haemorrhage at time of birth (more than 1000 mL) (average risk ratio (RR) 0.34, 95% confidence interval (CI) 0.14 to 0.87, three studies, 4636 women) and of maternal haemoglobin (Hb) less than 9 g/dL following birth (average RR 0.50, 95% CI 0.30 to 0.83, two studies, 1572 women). We also found no difference in the incidence in admission of infants to neonatal units (average RR 0.81, 95% CI 0.60 to 1.11, two studies, 3207 women) nor in the incidence of infant jaundice requiring treatment (0.96, 95% CI 0.55 to 1.68, two studies, 3142 women). There were no data on our other primary outcomes of very severe postpartum haemorrhage (PPH) at the time of birth (more than 2500 mL), maternal mortality, or neonatal polycythaemia needing treatment.Active management also showed a significant decrease in primary blood loss greater than 500 mL, and mean maternal blood loss at birth, maternal blood transfusion and therapeutic uterotonics during the third stage or within the first 24 hours, or both and significant increases in maternal diastolic blood pressure, vomiting after birth, after-pains, use of analgesia from birth up to discharge from the labour ward and more women returning to hospital with bleeding (outcome not pre-specified). There was also a decrease in the baby's birthweight with active management, reflecting the lower blood volume from interference with placental transfusion.In the subgroup of women at low risk of excessive bleeding, there were similar findings, except there was no significant difference identified between groups for severe haemorrhage or maternal Hb less than 9 g/dL (at 24 to 72 hours).Hypertension and interference with placental transfusion might be avoided by using modifications to the active management package, e.g. omitting ergot and deferring cord clamping, but we have no direct evidence of this here. AUTHORS' CONCLUSIONS: Although there is a lack of high quality evidence, active management of the third stage reduced the risk of haemorrhage greater than 1000 mL at the time of birth in a population of women at mixed risk of excessive bleeding, but adverse effects were identified. Women should be given information on the benefits and harms of both methods to support informed choice. Given the concerns about early cord clamping and the potential adverse effects of some uterotonics, it is critical now to look at the individual components of third-stage management. Data are also required from low-income countries.

Methodology in conducting a systematic review of systematic reviews of healthcare interventions.

BACKGROUND: Hundreds of studies of maternity care interventions have been published, too many for most people involved in providing maternity care to identify and consider when making decisions. It became apparent that systematic reviews of individual studies were required to appraise, summarise and bring together existing studies in a single place. However, decision makers are increasingly faced by a plethora of such reviews and these are likely to be of variable quality and scope, with more than one review of important topics. Systematic reviews (or overviews) of reviews are a logical and appropriate next step, allowing the findings of separate reviews to be compared and contrasted, providing clinical decision makers with the evidence they need. METHODS: The methods used to identify and appraise published and unpublished reviews systematically, drawing on our experiences and good practice in the conduct and reporting of systematic reviews are described. The process of identifying and appraising all published reviews allows researchers to describe the quality of this evidence base, summarise and compare the review's conclusions and discuss the strength of these conclusions. RESULTS: Methodological challenges and possible solutions are described within the context of (i) sources, (ii) study selection, (iii) quality assessment (i.e. the extent of searching undertaken for the reviews, description of study selection and inclusion criteria, comparability of included studies, assessment of publication bias and assessment of heterogeneity), (iv) presentation of results, and (v) implications for practice and research. CONCLUSION: Conducting a systematic review of reviews highlights the usefulness of bringing together a summary of reviews in one place, where there is more than one review on an important topic. The methods described here should help clinicians to review and appraise published reviews systematically, and aid evidence-based clinical decision-making.

Active versus expectant management for women in the third stage of labour.

BACKGROUND: Active management of the third stage of labour involves giving a prophylactic uterotonic, early cord clamping and controlled cord traction to deliver the placenta. With expectant management, signs of placental separation are awaited and the placenta is delivered spontaneously. Active management was introduced to try to reduce haemorrhage, a major contributor to maternal mortality in low-income countries. OBJECTIVES: To compare the effectiveness of active versus expectant management of the third stage of labour. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group Trials Register (May 2010). SELECTION CRITERIA: Randomised and quasi-randomised controlled trials comparing active versus expectant management of the third stage of labour. DATA COLLECTION AND ANALYSIS: Two authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. MAIN RESULTS: We included five studies (6486 women), all undertaken in hospitals in high-income countries. Four compared active versus expectant management, and one compared active versus a mixture of managements. Analysis used random-effects because of clinical heterogeneity. Active management reduced the average risk of maternal primary haemorrhage (more than 1000 ml) (risk ratio (RR) 0.34, 95% confidence interval (CI) 0.14 to 0.87, three studies, 4636 women) and of maternal haemoglobin less than 9 g/dl following birth (RR 0.50, 95% CI 0.30 to 0.83, two studies, 1572 women) for women irrespective of their risk of bleeding. We identified no difference in Apgar scores less than seven at five minutes. Active management showed significant increases in maternal diastolic blood pressure, after-pains, use of analgesia and more women returning to hospital with bleeding. There was also a decrease in the baby's birthweight with active management, reflecting the lower blood volume from interference with placental transfusion. There were similar findings for women at low risk of bleeding except there was no significant difference identified for severe haemorrhage. Hypertension and interference with placental transfusion might be avoided by using modifications to the active management package, e.g. omitting ergot and deferring cord clamping, but we have no direct evidence of this here. AUTHORS' CONCLUSIONS: Active management of third stage reduced the risk of haemorrhage greater than 1000 ml in an unselected population, but adverse effects are identified. Women should be given information on the benefits and harms to support informed choice. Given the concerns about early cord clamping and the potential adverse effects of some uterotonics, it is critical now to look at the individual components of third stage management. Data are also required from low-income countries.

Clients with mental health problems who sexualize the nurse-client encounter: the nursing discourse.

AIM: This paper is a report of a study of psychiatric nurses' responses to clients who were sexualizing the nurse-client encounter. BACKGROUND: Studies involving general nurses have reported incidents of 'unwanted sexual attention/behaviour' from clients. These behaviours have been identified, in the literature, as a form of sexual aggression and sexual harassment. Reported responses have included physically avoiding the person, ignoring verbal comments or adopting a no-'nonsense' professional approach. METHODS: A grounded theory study was conducted in 2005-2006 using tape-recorded unstructured interviews with 27 psychiatric nurses working in an urban mental health service in the Republic of Ireland. Tapes were analyzed, with the assistance of Nud*ist 4, Word documents, mind maps and memoing. FINDINGS: There were unwritten and unspoken professional expectations or norms that clients treated participants and nursing encounters in an asexual way. However, on occasions, clients transgressed these taken-for-granted norms and engaged in behaviour labelled 'sexualizing the nurse-client encounter'. In contrast to previous studies, our interviewees did not use the language of sexual harassment, but used the discourses of 'mad/bad' and 'inappropriate' to codify the behaviour. The tendency to view behaviour through the psychiatric discourse of badness and boundary violation gave rise to nurses either ignoring the behaviour or responding by using 'suppressive strategies'. Consequently, other possible lenses of understanding were pushed to the background. CONCLUSION: Only when educators and clinicians view clients' sexual behaviours through alternative lenses of understanding will different actions and outcomes become possible and the rights of all, both nurses and clients, be respected.

Developing inter-professional learning: tactics, teamwork and talk.

SUMMARY: Teamwork and collaboration between all health professionals results in high quality clinical care, and increased job satisfaction for staff. Encouraging inter-professional learning (IPL) may be advantageous in developing more effective teams. There is little rigorous research in this area, but many small uncontrolled studies do demonstrate positive results. IPL involves structured learning opportunities that enhance problem-solving abilities and conflict resolution. It should be clearly differentiated from shared teaching (or multidisciplinary/multiprofessional learning), where common content is taught to many professions without any intention to develop interaction. To counteract the sometimes negative attitudes in both students and staff, educators need to commence IPL early in the programme, base it in both theoretical and clinical placements and ensure that it is valued and assessed. Difficulties with timetabling and accommodation need to be solved prior to commencement. A facilitator should be employed, and a team of committed lecturers developed, with an emphasis on teamwork and the discouragement of individualism. Opportunities for student interaction and ways of improving group dynamics within non-threatening learning environments should to be sought, and instances of conflict embraced and resolved. Future IPL programmes should be rigorously evaluated and may demonstrate enhanced inter-professional relationships and improved quality of patient/client care.

Women's experiences of labour and birth: an evolutionary concept analysis.

AIM: the aim of this paper is to identify the core attributes of the experience of labour and birth. METHODS: a literature search was conducted using a variety of online databases for the years 1990-2005. A thematic analysis of a random sample of 62 of these papers identified the main characteristics of the experience of childbirth. There are multiple methodological challenges in researching the experience of labour and birth, and in developing the existing complexity of evidence. RESULTS: despite agreement across disciplines regarding the significance of the childbirth experience, there is little consensus on a conceptual definition. Four main attributes of the experience were described as individual, complex, process and life event. Through this concept analysis, the experiences of labour and birth is defined as an individual life event, incorporating interrelated subjective psychological and physiological processes, influenced by social, environmental, organisational and policy contexts. CONCLUSIONS: identification of the core attributes of the labour and birth experience may provide a framework for future consideration and investigation including further analysis of related concepts such as 'support' and 'control'. IMPLICATIONS FOR PRACTICE: practitioners and researchers have already identified the diversity and complexity of women's experiences during labour and birth. The importance of the identified attributes also requires organisational and policy development within the context of a cultural environment that acknowledges this diversity.

Recasting Hope: a process of adaptation following fetal anomaly diagnosis.

Recent decades have seen ultrasound revolutionise the management of pregnancy and its possible complications. However, somewhat less consideration has been given to the psychosocial consequences of mass screening resulting in fetal anomaly detection in low-risk populations, particularly in contexts where termination of pregnancy services are not readily accessible. A grounded theory study was conducted exploring forty-one women's experiences of ultrasound diagnosis of fetal abnormality up to and beyond the birth in the Republic of Ireland. Thirty-one women chose to continue the pregnancy and ten women accessed termination of pregnancy services outside the state. Data were collected using repeated in-depth individual interviews pre- and post-birth and analysed using the constant comparative method. Recasting Hope, the process of adaptation following diagnosis is represented temporally as four phases: 'Assume Normal', 'Shock', 'Gaining Meaning' and 'Rebuilding'. Some mothers expressed a sense of incredulity when informed of the anomaly and the 'Assume Normal' phase provides an improved understanding as to why women remain unprepared for an adverse diagnosis. Transition to phase 2, 'Shock,' is characterised by receiving the diagnosis and makes explicit women's initial reactions. Once the diagnosis is confirmed, a process of 'Gaining Meaning' commences, whereby an attempt to make sense of this ostensibly negative event begins. 'Rebuilding', the final stage in the process, is concerned with the extent to which women recover from the loss and resolve the inconsistency between their experience and their previous expectations of pregnancy in particular and beliefs in the world in general. This theory contributes to the theoretical field of thanatology as applied to the process of grieving associated with the loss of an ideal child. The framework of Recasting Hope is intended for use as a tool to assist health professionals through offering simple yet effective interventions grounded in women's experiences of this event.

Sexuality and mental health nursing in Ireland: weaving the veil of socialised inhibition.

The World Health Organisation first identified, in 1975, the need for health professionals to be educated in the area of sexuality. Since then, studies exploring aspects of educational preparation of general nurses in relation to sexuality, found that there was an 'absence' of education in this area of practice. This paper reports findings on the educational discourses that shape mental health nurses' understandings of sexuality. Unstructured interviews were conducted with 27 consenting mental health nurses working in the Republic of Ireland. Data were analysed using the principles of Grounded Theory. Findings suggest that participants were exposed to a subtle network of legitimised sexual discourses during primary, secondary, and professional socialisation. These discourses provided participants with a view of sexuality that emphasised taboo, privatisation, pathology, and control. Social, political, or rights-based discourses that could have provided participants with the knowledge and clinical competence necessary to include sexuality in an open and confident manner within the horizons of nursing practice were absent. These findings challenge educators involved in curriculum development to rethink the fundamental philosophy that is shaping mental health nursing curricula. They also challenge educators to rethink their ideas around the meaning of 'absence' in relation to education.