The fear factor of risk - clinical governance and midwifery talk and practice in the UK

Objective: Through the critical application of social theory, this paper will scrutinise how the operations of risk management help to constitute midwives’ understandings of childbirth in a particular way. Design and setting: Drawing from rich ethnographic data, collected in the southeast of England, the paper presents empirical evidence to critically explore how institutional concerns around risk and risk management impact upon the way midwives can legitimately imagine and manage labour and childbirth. Observational field notes, transcribed interviews with various midwives, along with material culture in the form of documentary evidence will be used to explore the unintended consequences of clinical governance and its risk management technologies. Key conclusions: Through this analysis the fear factor of risk in midwifery talk and practice will be introduced to provide an insight into how risk management impacts midwifery practice in the UK

The discourse of breech as a paradigm shift

Management of breech births is the subject of much controversy. Thomas Kuhn's theory of paradigm shifts shows how professional knowledge is never fixed. A selection of professional practice texts ranging the last 30 years was analysed using a discourse analysis approach. Breech as an obstetric emergency discourse is prevalent across a range of professional text sources, predominately in the instructive genre following formal and authoritative discourse styles. Physiological breech birth first appears in the discursive fringes of the breech debate, finding space in social action group publications and lower impact journals. As the discourse of physiological breech gains authority its advocates should be mindful that an authoritative discourse, no matter how new, provides convenient mechanisms through which they can disregard discursive resistance

Childbirth Within the Risk Society

Despite the fact that the speciality of obstetrics is considered to be a high risk area, indeed it is estimated that in the UK, maternity services account for massive 60% of all the NHS litigation claims burden; scholarly activity in childbirth performance as part of the risk society is relatively underdeveloped when compared to other areas of health. It is the extent of the influence of risk upon the maternity services that makes this underdevelopment especially striking. In an effort to present childbirth as a worthwhile site for empirical investigation and theoretical discussion, this paper attempts to review the sociology of childbirth and to consolidate some of the multidisciplinary contributions made to date on childbirth within the risk society

Innovation in preregistration midwifery education: Web based interactive storytelling learning.

BACKGROUND: through a critical description of the implementation of a web based interactive storytelling learning activity introduced into an undergraduate, preregistration midwifery education programme, this paper will explore how low-cost, low-fidelity online storytelling, designed using Moodle, can be used to enhance students' understanding of compassion and empathy in practice. SAMPLE: cross sectional sample of first year undergraduate Midwifery students (n111) METHOD: drawing from both research and audit data collected in an Higher Education Institution in London England, the paper presents the case for using web based technology to create a sustainable model for midwifery education. FINDINGS: initial results indicate that it is both the low cost and positive student evaluations of web based interactive storytelling, which make this approach to preregistration midwifery education which suggests that this approach has significant potential for learning and teaching in midwifery education in diverse settings around the world. Or how about: global relevance

Fateful moments and the categorisation of risk: Midwifery practice and the ever-narrowing window of normality during childbirth

In this article, we examine the ways in which risk is categorised in childbirth, and how such categorisation shapes decision-making in the risk management of childbirth. We consider the ways in which midwives focus on and highlight particular adverse events that threaten the normality of childbirth and the life of the mother and/or her baby. We argue that such a focus tends to override other elements of risk, especially the low probability of such adverse events, resulting in 'an ever-narrowing window of normality' and a precautionary approach to the management of uncertainty. We start our analysis with a discussion of the nature of childbirth as a fateful moment in the lives of those involved, and consider the ways in which this fateful moment is structured in contemporary society. In this discussion, we highlight a major paradox; although normal childbirth is both highly valued and associated with good outcomes in countries like the UK, there has been an apparent relentless expansion of 'the birth machine' whereby birth is increasingly defined through the medicalised practices of intensive surveillance and technocratic intervention. We explore the dynamics that create this paradox using ethnographic fieldwork. In the course of this work, the lead author observed and recorded midwives' work and talk in four clinical settings in England during 2009 and 2010. In this article, we focus on how midwives orientate themselves to normality and risk through their everyday talk and practice; and on how normality and risk interact to shape the ways in which birth can be legitimately imagined. We show that language plays a key role in the categorisation of risk. Normality was signified only through an absence of risk, andhad few linguistic signifiers of its own through which it could be identified and defended. Where normality only existed as the non-occurrence of unwanted futures, imagined futures where things went wrong took on a very real existence in the present, thereby impacting upon how birth could be conceptualised and managed. As such midwifery activity can be said to function, not to preserve normality but to introduce a pathologisation process where birth can never be categorised as normal until it is over

Deliberate acquisition of competence in physiological breech birth: A grounded theory study

Problem Research suggests that the skill and experience of the attendant significantly affect the outcomes of vaginal breech births, yet practitioner experience levels are minimal within many contemporary maternity care systems. Background Due to minimal experience and cultural resistance, few practitioners offer vaginal breech birth, and many practice guidelines and training programmes recommend delivery techniques requiring supine maternal position. Fewer practitioners have skills to support physiological breech birth, involving active maternal movement and choice of birthing position, including upright postures such as kneeling, standing, squatting, or on a birth stool. How professionals learn complex skills contrary to those taught in their local practice settings is unclear. Question How do professionals develop competence and expertise in physiological breech birth? Methods Nine midwives and five obstetricians with experience facilitating upright physiological breech births participated in semi-structured interviews. Data were analysed iteratively using constructivist grounded theory methods to develop an empirical theory of physiological breech skill acquisition. Results Among the participants in this research, the deliberate acquisition of competence in physiological breech birth included stages of affinity with physiological birth, critical awareness, intention, identity and responsibility. Expert practitioners operating across local and national boundaries guided less experienced practitioners. Discussion The results depict a specialist learning model which could be formalised in sympathetic training programmes, and evaluated. It may also be relevant to developing competence in other specialist/expert roles and innovative practices. Conclusion Deliberate development of local communities of practice may support professionals to acquire elusive breech skills in a sustainable way

Standards for maternity care professionals facilitating planned upright breech births: a Delphi consensus technique study

Objective: to establish a consensus of opinion on standards of competence for professionals attending upright breech births. Design: a three-round Delphi e-survey. Setting: multi-national. Participants: a panel of thirteen obstetricians, thirteen midwives and two user representatives. Clinicians had attended >20 upright breech births, or >10 upright among >40 total breech births. Mean level of experience = 135 breech births, median = 100 breech births. Methods: an initial survey contained open-ended questions. Answers were coded and amalgamated to form 164 statements in the second round and 9 further statements in the third round. Panellists were asked to evaluate their agreement with each statement using a 5-point Likert scale. The pre-determined level of consensus was 70% of respondents indicating agreement or strong agreement with the statement. Results: the panel returned a consensus-level agreement on 63 statements under the theme, 'Standards of Competence.' Panellists supported teaching breech as a 'normal' skill rather than an emergency, including optimal mechanisms and breech-specific progress measures, upright variations of classical manoeuvres, the initiation of resuscitation with the umbilical cord intact, birth videos as learning tools, and the development of breech teams to support the wider team in all maternity care settings. Conclusions: while every health professional should maintain basic competence to assist unanticipated breech births, establishing enhanced training and standards for those who support planned breech births may help protect users and providers of maternity services, while introducing greater choice and flexibility for women seeking the option of vaginal breech birth