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

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

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

Principles of physiological breech birth practice: a Delphi study

Objective To establish a multi-professional consensus on shared principles underlying the practice of physiological breech birth. Design Three-round Delphi e-survey. Setting Multi-national. Participants A panel of thirteen obstetricians and thirteen midwives, experienced in facilitating physiological breech births in varied settings, and involving varied maternal birthing positions, and two service user representatives. Methods An initial survey contained open-ended questions. Answers were coded and amalgamated into 60 statements in Round 1 and a further 6 statements in Round 2. Participants considered statements in the following categories: first principles (14), maternal positioning (12), birth environment (18), fetal positions (14), safe progress (8). The panel indicated the extent of their agreement using a 5-point Likert scale. The pre-determined level of consensus was 70% of respondents indicating 4 or 5 on the Likert scale (agreement or strong agreement). Findings The panel indicated consensus on 37 of 66 proposed statements concerning 'Principles of Practice.' Negative data (29/66 statements) are also reported, highlighting areas of divergent opinions. The findings suggest a paradigm shift away from risk management strategies based on prediction and control, and towards facilitation strategies based on relationship and response. Upright positions are a tool and not a rule of physiological breech birth. Conclusion The parameters of 'normal for breech' require further exploration to support professionals working within a paradigm of complex normality. The principles articulated in this research can be used to design further research exploring the influence of physiological breech practices on neonatal and maternal outcomes, including women's experiences of maternity care

Professional symmetry in clinically based ethnographic research: an asset or liability?

Purpose: To offer methodological reflection on the complexities of being an insider ethnographic health service researcher. Methods/data: Taking ethnographic fieldnotes that describe an observed episode of midwifery care in a UK-based maternity service, the shared identity between the researcher and research participant will be explored as being at once comfortably shared, while at the same time, a source of pernicious estrangement. The methodological reflections came from a study investigating the work midwives (n32) did, in a range of intra-partum (labour and birth) settings, when making sense of the concept of risk. Data were collected during fieldwork carried out in an NHS maternity service offering intra-partum care in four distinct clinical settings: the home; freestanding midwifery-led units (n2); alongside midwifery-led units (n2); and obstetric-led units (n2). Fieldnotes were compiled over a period of 13 months. Conclusion: Detailed interrogation of the potential tensions that can arise out of a common identity shared by both the ethnographic researcher and the participant helps to expose some ethical dimensions of insider ethnographic research in clinical health care settings

Time, risk and midwife practice: The vaginal examination

In this article, we examine the impact on midwifery practice of clinical governance in the UK with its shift from individual autonomous practice based on personal experience and intuition (embodied knowledge) to the collective control of work based on guidelines and protocols (encoded knowledge) associated with the scientific-bureaucratic approach to care. We focus on the ways in which midwives use partograms and associated vaginal examinations to monitor and manage the progress of labour. The partogram represents (among other things) a timetable for dilation of the cervix during labour. Women who fail to keep up with this timetable are shifted from a low-to-high risk category and subjected to additional surveillance and intervention. In this article, we draw on empirical evidence taken from two independent ethnographic studies of midwifery talk and practice in England undertaken in 2005-2007 and 2008-2010, to describe the ways in which midwives practice of vaginal examinations during labour both complies with, while at the same time creatively subverts, the scientific-bureaucratic approach to maternity care. We argue that although divergent in nature, each way of practicing is mutually dependent upon the other: the space afforded by midwifery creativity not only co-exists with the scientific-bureaucratic approach to care, but also sustains it. © 2014 © 2014 Taylor & Francis