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The exploration of water immersion policies/guidelines and the impact upon practice of labour and birth: a mixed methods study


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Background The accessibility of water immersion (WI) for labour and/or birth is dependent on the views of the care provider/institution and the policies/clinical practice guidelines (CPGs) that underpin practice. With little quality research on the safety and efficacy of WI the policies and CPGs informing current practice lack the sound evidence base necessary to ensure they are well informed. Aims The aims of the study were to determine how WI policies and/or CPGs are informed, who interprets the evidence to inform policy/guideline development and to what extent the policy/guideline facilitate the option of WI for labour and birth. Method This study used a mixed-methods approach that included a critical analysis of Australian policies/CPGs, semi-structured interviews with policy/guideline informants and a survey of views of Australian midwives. Results Results reveal a limited evidence-base for use of water during labour and birth and that subjective opinion and views inform policy/CPGs and practice. Policies and CPGs pertaining to the use of water for labour and/birth are written from a risk perspective rather than providing the best available evidence to facilitate decision making for women considering this option. Implications for research and practice In order to overcome the current paucity of quality research available to determine the extent to which WI is used during labour and birth and more, to address concerns surrounding safety and risks surrounding the practice, there is a need for population level data to be collected. Furthermore, the need for both qualitative and quantitative research is pressing not only to determine outcomes of WI but also to determine experience, perceptions and views of both health practitioners and women within their care. The recommendations from this research can assist in the development of local, national and international policies/CPGs that are reflective of the current evidence-base and may lead to further review and critical analysis of policies and CPGs for WI. Conclusion A comprehensive evidenced-based approach to policy and guideline development for WI, including the best available evidence with incorporation of qualitative data examining views and experiences, is needed to better inform policy/CPGs. Such an approach would assist birthing women and their care providers to make an informed choice about the option of WI for labour and birth. Ethical Considerations The research was approved by the Human Research Ethics Committee of the University of South Australia. Conflict of Interest The Author declares no conflict of interest
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... Historically, Australian maternity policies and guidelines have generally been developed and implemented within individual institutions leading to varied interpretations of the evidence base available and therefore, varied clinical practice across venues. 1,8 Regardless, these documents are seen to be important in ensuring a level of practitioner accountability and consistency particularly if informed by high quality evidence [9][10][11] and therefore, such documents are an important means of ensuring, as much as possible, reduced risk and increased safety for the woman and baby. 11 There has been very little research undertaken to provide insight into care providers views, experiences and knowledge of water immersion (WI) for labour and birth and less to indicate their experiences of informing policies and CPGs in order to facilitate the practice. ...
... This paper presents one phase of a large three phased study 8 examining Australian Midwives knowledge, experiences as well as involvement in the development of WI policy and CPGs. A survey used by Meyer et al. 4 informed this phase. ...
... Personal experience has been shown to positively influence practitioner views of WI as an option. 8,17 Not only did Russell 17 demonstrate this in her study examining midwives experiences of water birth but Cooper 8 also highlighted that experiencing water immersion reduced practitioner fear and therefore acceptance of the practice, not only for midwives, but also medical practitioners including obstetricians. This was also found to be the case in this phase highlighted by the fact that nearly all participants who completed the survey suggested that they had firsthand experience of supporting women using water. ...
Background: There is little published research that has examined practitioners' views and experiences of pain relieving measures commonly used during labour and birth, particularly for non-pharmacological measures such as water immersion. Furthermore, there is minimal published research examining the process of policy and guideline development, that is, the translation of published research to usable practice guidance. Aims: The aims of phase three of a larger study were to explore midwives knowledge, experiences and support for the option of water immersion for labour and birth in practice and their involvement, if any, in development of policy and guidelines pertaining to the option. Methods: Phase three of a three phased mixed methods study included a web based survey of 234 Australian midwives who had facilitated and/or been involved in the development of policies and/or guidelines relating to the practice of water immersion. Findings: Midwives who participated in this study were supportive of both water immersion for labour and birth reiterating documented benefits of reduced pain, maternal relaxation and a positive birth experience. The most significant concerns were maternal collapse, the difficulty of estimating blood loss and postpartum haemorrhage whilst barriers included lack of accredited staff, lifting equipment and negative attitudes. Midwives indicated that policy/guideline documents limited their ability to facilitate water immersion and did not always to support women's informed choice. Conclusion: Midwives who participated in this study supported the practice of water immersion reiterating the benefits documented in the literature and minimal risk to the woman and baby. Ethical considerations: The Human Research Ethics Committee of the University of South Australia approved the research.
... This demonstrates an obvious disparity particularly given that there are known risks associated with these interventions. Despite this, women are required to be informed of and consent to water use and may be unable to access it due to practitioners' own personal views and opinions of WI (Cooper 2016). The use of water is still seen by many practitioners as an unnecessary and unnatural option and this would seem to be influenced in part by the practice being non-mainstream when compared to other forms of labour and birth analgesia. ...
... The use of water for labour and birth, although recognised by many people for its benefits, continues to be challenged for the most part due to a perceived lack of substantial and definitive quantitative research (Cluett & Burns 2009, Davies 2012). However, even with this gap in evidence, WI and birth continue to be offered in selected places globally, but with what appear to be policies and guidelines that are both restrictive, somewhat unsupported and based on authoritative opinion and views (Cooper 2016). This is highlighted in the differing views of how third stage should be managed when water is utilised. ...
... The finding that women were not always made aware of or offered the option supports anecdotal evidence that midwives and other healthcare providers are actively discouraged from offering the option of water immersion. This is now supported by research 25,26 . In Australia, women generally must actively seek out and request the option. ...
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Introduction: Recent research highlights that women experience great benefits from immersing in warm water during labor and birth. While there has been an increase in research examining women's experiences of using water, there has been little investigation of the views and perceptions of women who have not. The objective of this study was to examine the views and perceptions of water immersion from women who had birthed in Australia but had not used the option. Methods: An e-survey was distributed to women using purposive and snowball sampling methods between November 2016 and October 2017. Email, text, social media, and parenting forums maximized recruitment. A total of 395 women who had not used water immersion for labor or birth participated. Results: Three quarters of all women surveyed suggested that they would have considered using the option of water immersion if it was offered to them. Nearly 20% of all women did not know it was an option and, therefore, were only made aware of it as a result of completing this survey. Women indicated that they most often learned about water immersion from a midwife. When asked to rate the benefits and concerns, the majority held very little concern and generally agreed that water immersion would probably provide the associated benefits that are commonly cited in the literature. Conclusions: Water immersion offers women many benefits although may not always be discussed antenatally. In light of these results, water immersion could be included in the discussions about labor and birth options antenatally and better supported during labor and birth.
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Background Critically appraising the quality of clinical practice guidelines (CPGs) is an essential element of evidence implementation. Critical appraisal considers the quality of CPG construction and reporting processes, and the credibility of the body of evidence underpinning recommendations. To date, the focus on CPG critical appraisal has come from researchers and evaluators, using complex appraisal instruments. Rapid critical appraisal is a relatively new approach for CPGs, which targets busy end-users such as service managers and clinicians. This paper compares the findings of two critical appraisal instruments: a rapid instrument (iCAHE) and a complex instrument (AGREE II). They were applied independently to 16 purposively-sampled, heterogeneous South African CPGs, written for eleven primary health care conditions/health areas. Overall scores, and scores in the two instruments’ common domains Scope and Purpose, Stakeholder involvement, Underlying evidence/Rigour of Development, Clarity), were compared using Pearson r correlations and intraclass correlation coefficients. CPGs with differences of 10 % or greater between scores were identified and reasons sought for such differences. The time taken to apply the instruments was recorded. Results Both instruments identified the generally poor quality of the included CPGs, particularly in Rigour of Development. Correlation and agreement between instrument scores was moderate, and there were no overall significant score differences. Large differences in scores for some CPGs could be explained by differences in instrument construction and focus, and CPG construction. The iCAHE instrument was demonstrably quicker to use than the AGREE II instrument. Conclusions Either instrument could be used with confidence to assess the quality of CPGs. The choice of appraisal instrument depends on the needs and time of end-users. Having an alternative (rapid) critical appraisal tool will potentially encourage busy end-users to identify and use good quality CPGs to inform practice decisions.
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This discourse analytic study examines how violence can be constructed as an honourable course of action, using the example of a leaflet circulated in the loyalist Donegall Pass area of Belfast urging the removal of the minority Chinese population. Starting from the assumptions that racism is an ideological practice that naturalises social categories and devalues members of some of them so that their subjugation and exclusion is legitimised (Miles and Brown 2003; Billig 2002), and that violence is a human activity imbued with meaning through discourse, we applied guidelines set out by Parker (1992) to consider language as a social practice that achieves specific discursive effects by constructing its objects in a particular way. Two interrelated discourses were identified: a community-focused discourse construed the Chinese immigrants as morally and culturally bereft and negated their worth, while a martial discourse focused on defending the locality against foreign invasion. An examination of themes in loyalist culture revealed ways in which the text reconstructed resonant fears, and we argue that the way the in-group constructs its character defines the racist construction of the other.
The fetus, by virtue of its location, is faced with a problem of heat elimination. Sixteen acute pregnant ewe preparations were studied. Thermistors were inserted in the maternal abdominal aorta and the umbilical artery and vein. Electromagnetic flowmeters were applied to the umbilical and uterine arteries. Maternal hyperthermia was induced by radiant heat. The fetus maintained a temperature difference to the mother during the hyperthermia. The fetal-maternal difference decreased with increasing maternal temperature. With a 1.5° C. to 2.0° C. rise in maternal temperature there was an increase in umbilical blood flow (36 per cent) and a decrease in umbilical vascular resistance (40 per cent). The fetal arteriovenous temperature and O2 content difference decreased. Maternal arterial pressure did not change but respiratory rate, cardiac output, and rate of uterine blood flow increased. Maternal systemic vascular resistance decreased (20 per cent). At a maternal 2.0° C. temperature rise, maternal cardiovascular collapse occurred. At this point fetal-maternal temperature difference increased markedly. The umbilical circulation is not only a carrier of O2 and nutrients but is a major pathway for fetal heat exchange. The ability of the fetus to aliminate heat is another reflection of the adequacy of the uteroplacental circulation.
This chapter provides a brief history of water birth, reviews the research evidence to support its use, and provides practical guidance and suggestions for those who wish to begin offering this choice to women in their birthing units. The chapter describes five basic principles that underlie the positive physiologic effects of immersion in warm water: buoyancy, specific gravity and density, hydrostatic pressure, specific heat, and thermal effect. Infection, hemorrhage, emboli, and reduced strength of uterine contractions are considered theoretical risks because quality research has not demonstrated their occurrence as a result of water immersion and/or water birth. The chapter illustrates, through case studies, that water immersion and water birth are safe options that clinicians can offer to laboring women.
What is unique and exemplary about the midwifery model of care? Does exemplary midwifery care result in improved outcomes for the recipient(s) of that can? These are the questions that the profession of midwifery grapples with today within the context of a changing health care arena. Exemplary midwives, and women who had received their care, came to consensus about these issues in a Delphi study. A model of exemplary midwifery care is presented based on the identification of essential elements aligned within three dimensions: therapeutics, caring, and the profession of midwifery. Supporting the normalcy of pregnancy and birth, vigilance and attention to detail, and respecting the uniqueness of the woman, were several of many processes of care identified. The critical difference that emerged was the art of doing "nothing" well. By ensuring that normalcy continued through vigilant and attentive care, the midwives were content to foster the normal processes of labor and birth, intervening and using technology only when the individual situation required. Health care, whether in the gynecologic setting or during pregnancy, was geared to help the woman achieve a level of control of the process and outcome. The ultimate outcomes were optimal health in the given situation, and the experience of health care that is both respectful and empowering. The model provides structure for future research on the unique aspects of midwifery care to support its correlation with excellent outcomes and value in health care economics. (C) 2000 by the American College of Nurse-Midwives.