Becoming Redundant: women’s experience of unwanted scheduled caesarean section - a grounded theory study

Currently, one third of Australian childbearing women per annum have a caesarean section. Evidence strongly indicates, however, that most women enter into pregnancy expecting and wanting to give birth naturally. While a body of research exists that accounts for some aspects of how women experience caesarean section, the phenomenon has not previously been described in depth. The purpose of this study was to uncover and theorise how women processed and experienced a first caesarean recommended in pregnancy for a health reason.This Western Australian investigation was conducted using the Glaserian version of Grounded Theory methodology. Twenty-eight pregnant women who had been anticipating giving birth naturally, but were advised during pregnancy that they would need to give birth by caesarean section, agreed to participate in the study. Five sets of data were collected. The first comprised semi-structured in depth interviews with the 28 women both before and after the birth of their baby. Non-participant observations of women’s behaviours and interactions whilst they were in the operating theatre, including situation maps, written notes and pencil sketches, formed the second data set. The third and fourth sets of data consisted of semi-structured interviews held with participating women’s partners and with maternity health care professionals. Field notes formed the final set.The Grounded Theory that emerged was labelled Becoming Redundant. The theory comprises the core problem that anticipating and experiencing a scheduled caesarean section posed for women, namely Being Made Redundant, and the psychosocial process they undertook to manage it, labelled Regrouping. In total, eight major categories were identified. The four categories that contributed to the core problem were labelled Being robbed, Becoming a ‘persona non grata’, Off everyone’s radar and Left wanting. The categories in the regrouping process were labelled Trying to make it feel real, Travelling a new path blindly, Striving to be included whilst trying to behave and Treading water. In addition, four factors emerged from the data that moderated, or limited, women’s regrouping endeavours. These were titled Expecting birth would be natural, Hurtling towards ‘D-day’, The green drape and Caesarean section is hospital not women’s business.For 25 of the 28 women, needing and having a caesarean section was frightening, disempowering, distressing and in complete contrast with how they had expected and wanted their baby’s birth to be. The childbirth expectations of these 25 women were shattered as the hospital effectively took over their baby’s birth, and they were left with feelings of loss, grief and, in some cases, symptoms of emotional trauma. In response, women set about trying to accommodate the personal losses they incurred, and to transition to their ‘new reality’. The effect of the moderating factors, however, was to thwart women’s adaptation efforts. Consequently, when they were interviewed between 10 and 14 weeks after their caesarean section, these 25 women reported feeling cognitively and emotionally ‘stuck’ in their childbearing experience. They also described spending considerable energy and attention on trying to work out what had happened to them rather than focusing on their new baby.The remaining three women either experienced or responded to their scheduled caesarean section differently to the other 25; this was because of the absence of one or more of the moderating factors. Ultimately, however, only one of the women was left feeling positive, emotionally on a ‘high’ and free of regret after her baby’s birth.This Western Australian research highlights significant new findings about women who require a caesarean section for a health reason. The work makes an important and original contribution not only to the maternity literature, but to the body of knowledge concerning grief, traumatic stress and dissociation, and change transition. The theory of Becoming Redundant provides maternity care professionals, academics and consumers with previously unknown information about how women might experience, manage and be affected by unforeseen and unwelcome change during the childbearing episode, and has direct and important implications for the care of childbearing women. The disappointment, grief and/or traumatic stress that is likely to arise for a woman when her childbearing expectations can no longer be fulfilled must be anticipated, recognised, acknowledged and forestalled where possible. For women to integrate and move on from their childbirth experience and become fully engaged in motherhood, those who have had to ‘change track’ must be afforded the time, space and support to explore the meaning of the change, to fully mourn what they lose because of it, and to recapture their losses to the greatest extent possible

Factors that enable midwives to stay in the profession : Why do midwives stay in midwifery?

Background: There is a global awareness regarding the challenges facing midwives to remain in the profession. Aim: The aim of this study was to understand why Western Australian (WA) midwives chose to remain in the profession. Methods: This study was undertaken using grounded theory (GT) methodology. Semi-structured interviews were conducted with 14 midwives working in the clinical area. Participants were interviewed about why and how they remain in the midwifery profession. Data were collected from December 2017 to November 2018 and were generated through open-ended semi-structured interviews, together with memos and field notes. The interviews were digitally recorded, transcribed verbatim and analysed and interpreted with the guidance of Glaser and Strauss’ (1967) coding stages. Ethical approval for this study was granted by the Human Research Ethics Committee at Edith Cowan University (record 18747) on 23 November 2017. Findings: The core category derived from the data was labelled: ‘I love being a midwife; it’s who I am’. The contextual factors that underpin the core category are labelled: ‘My rosters provide me with good work–life balance’; ‘You never know what’s going to happen [but] I can deal with the bad days because the good days outweigh them’; ‘I like my practice environment’; ‘It’s a juggling act but the women’s appreciation is worth it’ and ‘By looking after myself I’m a good midwife’. Bronfenbrenner’s (1997) theory was applied to the findings in the process of developing them into a middle-range theory of the phenomenon of interest. Conclusion: The findings of this study provide new insights into workplace and personal factors that contribute to enabling midwives to remain in their profession. Although this study represents midwives in only one geographical context it will be of value to professional and health care leaders

Australian midwifery students’ views about profession-specific peer mentoring

Midwifery is one of the most demanding professions there is, and midwifery students can find coping with the practice aspect of their course difficult. Mentoring is one way of supporting health clinicians’ emotional wellbeing; to date however, there is little research on mentoring for midwifery students. In this study, the aim of which was to discover midwifery students’ views of profession-related peer mentoring, qualitative and quantitative data were collected from 21 midwifery students at one Australian university. Analysis of the data revealed that most participants felt they would benefit from and would like to know more about mentoring. The qualitative themes, ‘Support’ and ‘Knowledge and Guidance’, convey the challenges to being mentored in the clinical area as well as participants’ ‘ideal mentor’ profile. Further work to conceptualise and test a robust clinical mentorship matrix for midwifery students is required

Convalescent plasma in patients admitted to hospital with COVID-19 (RECOVERY): a randomised controlled, open-label, platform trial

SummaryBackground Azithromycin has been proposed as a treatment for COVID-19 on the basis of its immunomodulatoryactions. We aimed to evaluate the safety and efficacy of azithromycin in patients admitted to hospital with COVID-19.Methods In this randomised, controlled, open-label, adaptive platform trial (Randomised Evaluation of COVID-19Therapy [RECOVERY]), several possible treatments were compared with usual care in patients admitted to hospitalwith COVID-19 in the UK. The trial is underway at 176 hospitals in the UK. Eligible and consenting patients wererandomly allocated to either usual standard of care alone or usual standard of care plus azithromycin 500 mg once perday by mouth or intravenously for 10 days or until discharge (or allocation to one of the other RECOVERY treatmentgroups). Patients were assigned via web-based simple (unstratified) randomisation with allocation concealment andwere twice as likely to be randomly assigned to usual care than to any of the active treatment groups. Participants andlocal study staff were not masked to the allocated treatment, but all others involved in the trial were masked to theoutcome data during the trial. The primary outcome was 28-day all-cause mortality, assessed in the intention-to-treatpopulation. The trial is registered with ISRCTN, 50189673, and ClinicalTrials.gov, NCT04381936.Findings Between April 7 and Nov 27, 2020, of 16 442 patients enrolled in the RECOVERY trial, 9433 (57%) wereeligible and 7763 were included in the assessment of azithromycin. The mean age of these study participants was65·3 years (SD 15·7) and approximately a third were women (2944 [38%] of 7763). 2582 patients were randomlyallocated to receive azithromycin and 5181 patients were randomly allocated to usual care alone. Overall,561 (22%) patients allocated to azithromycin and 1162 (22%) patients allocated to usual care died within 28 days(rate ratio 0·97, 95% CI 0·87–1·07; p=0·50). No significant difference was seen in duration of hospital stay (median10 days [IQR 5 to >28] vs 11 days [5 to >28]) or the proportion of patients discharged from hospital alive within 28 days(rate ratio 1·04, 95% CI 0·98–1·10; p=0·19). Among those not on invasive mechanical ventilation at baseline, nosignificant difference was seen in the proportion meeting the composite endpoint of invasive mechanical ventilationor death (risk ratio 0·95, 95% CI 0·87–1·03; p=0·24).Interpretation In patients admitted to hospital with COVID-19, azithromycin did not improve survival or otherprespecified clinical outcomes. Azithromycin use in patients admitted to hospital with COVID-19 should be restrictedto patients in whom there is a clear antimicrobial indication

Communication surrounding initiation and withdrawal of non-invasive ventilation in adults with motor neurone disease

Background: Motor neurone disease causes respiratory weakness that can lead to death. While non-invasive ventilation relieves symptoms, there are complex issues to consider prior to commencement. Aim: To identify what is known and understood about the clinician communication of non-invasive ventilation by people with motor neurone disease. Method: The Joanna Briggs Institute approach to systematic reviews was followed for literature retrieval and selection. Data sources: Research literature published between 1990-2019 in English from the Medline, CINAHL, ProQuest Research Library and the Cochrane Library of Systematic Reviews databases were used. Results: A total of two themes emerged: communication challenges doctors face when discussing non-invasive ventilation withdrawal, and the importance of well-timed, effective communication by clinicians-specifically the influence clinicians have on family decision-making. Conclusions: Guidance on communications around palliative care, non-invasive ventilation introduction and withdrawal exist, however implementation is often not straightforward. Research into the communication surrounding non-invasive ventilation from those living with motor neuron disease, their families and clinicians is required to inform guideline implementation and practice