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Is hiesho in pregnant women a risk factor for postpartum haemorrhage?

By Nakamura, S., Horiuchi, S.
on Saturday, 01 Dec 2018 in New Zealand College of Midwives Journal - Volume: 54

Background: In Japanese culture, a cold sensation known as “hie” is an important symptom in traditional medicine. Hiesho is a condition whereby the sympathetic nervous system becomes dominant, causing peripheral blood vessels to contract, impairing circulation and leading to low skin temperatures in the extremities. A link between hiesho and prolonged labour and uterine inertia, both of which are risk factors for postpartum haemorrhage (PPH), has previously been identified. Aim: The aim of this study was to analyse whether hiesho has a direct impact on PPH by comparing the outcomes for women who experienced hiesho in their pregnancies with those who did not. Methods: The study design was a retrospective cohort study conducted over 12 months, between 19th October, 2009, and 8th October, 2010, involving 2,427 women who had given birth in six hospitals in Japan. Women were excluded if they had had a caesarean section. Data were extracted from medical records and a paper questionnaire. Analysis was conducted using multiple logistic regression analysis and the Mantel-Haenszel test. Findings: Of the women, 613 experienced PPH (25.3% of the entire sample), of whom 343 (56.0%) had experienced hiesho. In the analysis of covariance, the regression coefficient for hiesho was 0.2, p=0.07, the odds ratio (OR) was 1.22, and the 95% confidence interval (CI) was 0.98-1.50. In a stratified analysis, the regression coefficient was 0.25, p=0.02, the common OR was 1.29, and 95% CI was 1.04-1.59. Thus, there was no significant link found between a woman experiencing heisho during pregnancy and having a PPH. Conclusion: Although the findings indicate that uterine inertia and prolonged labour are direct causes of PPH, hiesho may potentially have an indirect effect. Therefore, since hiesho potentially affects the occurrence of uterine inertia and prolonged labour, preventing hiesho may help avoid uterine inertia and prolonged labour and consequently PPH. For women who experience hiesho in pregnancy, lifestyle activities known to improve peripheral circulation should be promoted antenatally.

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Editorial: Consumer representation on editorial board

By Dixon, L, Neely, E, Martis, R
on Saturday, 01 Dec 2018 in New Zealand College of Midwives Journal - Volume: 54

Consumer membership and working in partnership with women are key principles of the College and the midwifery profession... The National Committee and the editorial board are pleased to announce that Eva Neely has been appointed as consumer subeditor on the Journal's editorial board.

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Bridging the theory-practice divide: Using small tutorial groups within a blended Bachelor of Midwifery programme

By Kensington, M, Davies, L, Daellenbach, R, Deary, R, Richards, J
on Friday, 01 Dec 2017 in New Zealand College of Midwives - Volume: 53

Background: In 2009 an innovative Bachelor of Midwifery programme was introduced using a blended delivery model to enable students to study and gain practice experience within their own communities. Students learn much of the theoretical content from their homes through access to online resources and virtual classrooms. In recognition for the potential of social isolation and to encourage cooperative learning between student and lecturer, a modified version of the Oxford Tutorial model was adopted. Students meet in small tutorial groups in their areas each week with a locally employed lecturer, and attend scheduled block study weeks on campus throughout the year. Aim: To critically evaluate the introduction of this programme. Method: A participatory action research methodology was used in which students’ views were gathered through anonymous questionnaires and focus group interviews. Ethics approval was gained through Ara Human Research Ethics Committee. The particular focus of this article is the students’ views in relation to the small group tutorials. Findings: We found that small group tutorials are helpful in assisting students to manage feelings of isolation and the competing demands of home life and study. Students developed a community of inquiry which was pivotal to negotiating the gap between theory and clinical practice: what they are taught and what they see in midwifery settings. Conclusion: The research found that the midwifery tutorial model is valued by all students and seen as the “hub” of the programme, effectively bridging the gap between theory and practice.

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Strategies for improving the experiences of Māori students in a blended Bachelor of Midwifery programme

By Patterson, J, Newman, E, Baddock, S, Kerkin, B, See, R
on Friday, 01 Dec 2017 in New Zealand College of Midwives Journal - Volume: 53

Introduction: The New Zealand Māori population is predicted to increase to 16.6% of the total population by 2021 and more Māori midwives are needed. Aim: The aim of this research was to ask Māori students about their experiences in the Bachelor of Midwifery programme and to identify strategies to optimise success for Māori students in becoming midwives. Method: A participant research project was designed and undertaken, on behalf of the Midwifery School at Otago Polytechnic in New Zealand, by a Māori researcher, who was guided by Tuhiwai-Smith’s seven codes of conduct. Nine of a possible 22 students who self-identified as Māori consented to participate. Ethical approval for the study was granted by the Otago Polytechnic Ethics Committee, following consultation with the Kaitohutohu’s (Māori advisor) office which provided support for the Māori researcher. Findings: The Māori students appreciated the opportunities afforded by the blended midwifery programme model, such as the range of learning modes and being able to study in their home areas. The students were challenged by aspects of the programme organisation, the learning environment, student placements and assessments, the lack of Māori visibility, and aspects of the support for Māori students. Recommendations were offered by the students for changes that would improve the learning experience for Māori. Conclusion: Incorporation of the recommended changes has the potential to improve the learning culture for Māori students in this midwifery programme. This includes changes to the programme organisation and developing a learning environment that more visibly celebrates bicultural identity; thereby decreasing the attrition rate for Māori students in the programme, increasing the number of Māori midwives registering, and contributing to the richness, success and enjoyment of the programme by all students.

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Outcomes of blood loss post physiological birth with physiological management in the third stage of labour at a maternity home in Japan

By Oishi, T, Tamura, T, Yamamoto, U
on Friday, 01 Dec 2017 in New Zealand College of Midwives Journal - Volume: 53

Background: Debate continues as to whether active or physiological management of the third stage of labour reduces the risk of postpartum haemorrhage for healthy well women. However, little attention has been paid to what volume of blood loss should be considered within normal range when the birth has been physiological, including physiological management of the third stage. At midwife-run maternity homes in Japan, midwives support physiological labour and birth, including the third stage, with protocols in place which govern when to intervene, refer and transfer to hospital obstetric care. Objectives: To describe and quantify and gauge the significance of blood loss volume following birth when labour, birth and third stage have been physiological at one Japanese maternity home. Method: Retrospective cohort study with data being extracted from the birth records of 512 women who gave birth at a maternity home between January 2007 and February 2010. Blood loss was measured up to two hours postpartum. Findings: Among the 512 births, we determined the means of parity as 2.2 (SD=0.86), blood loss up to two hours post-delivery as 608.7ml (SD=403.1), and length of the third stage of labour as 12.9min (SD=7.7). Blood losses of between 0-499ml, 500-999ml, 1000-1499ml, 1500-1999ml and ≥2000ml were 52.3%, 31.6%, 11.3%, 4.1% and 0.6%, respectively. Therapeutic intravenous uterotonics were provided to 3.1% of women when blood loss was <1000ml but given to 83.3% when blood loss exceeded 1500ml. Furthermore, 5.6% of the women received IV iron therapy when blood loss was <1000ml, while all the women did when blood loss exceeded 1500ml. Mean haemoglobin level at four days postpartum with blood loss >1500ml was 8.3 g/dl (SD=1.0) which was significantly lower than the mean of 9.8 g/dl (SD=1.2) calculated for the women who had a blood loss of 1000-1499ml and the 9.6 g/dl mean (SD=0.9) for the women with a blood loss of 500-999ml (F=27.92, p<0.001). Of those reported (n=11), mean haemoglobin levels in all groups increased to almost 11 g/dl after two weeks. Conclusion: Although these data are only from one maternity home in Japan, they clearly demonstrate that for these women, when births were physiological and the third stage was physiologically managed, blood loss during the third stage and up to two hours postpartum could be more than 500ml and may be as much as 1000ml without adversely affecting them.

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Online postgraduate midwifery education increases knowledge integration into practice: Insights from a survey of Otago Polytechnic’s postgraduate midwifery students

By Miller, S, Griffiths, C
on Friday, 01 Dec 2017 in New Zealand College of Midwives Journal - Volume: 53

Background: The Midwifery Council of New Zealand requires that registered midwives are engaged in education as one aspect of demonstrating ongoing competence. Barriers to engagement include geographical isolation, inability of workplaces to release midwives, potential for the post-registration student to be unavailable to her Lead Maternity Care clients, and financial constraints associated with travel to where the study is offered. In New Zealand, the Otago Polytechnic postgraduate midwifery programme offers a range of clinically focussed and theoretical papers that are delivered at distance in a blended model, combining online learning with synchronous and asynchronous online discussion opportunities. This model enables midwives to up-skill and build “communities of practice” regardless of their physical location, with no resultant loss of availability to their community or workplace. Aim: This research aimed to explore midwives’ perceptions of how their engagement in online postgraduate midwifery education had influenced their practice, potentially benefiting childbearing women in their care. Method: Following ethical approval, an online survey was sent to all midwives who were enrolled in postgraduate midwifery courses at Otago Polytechnic in the period 2012 to 2013. Data were collected in April 2014, from a survey that used a combination of Likert scales, yes/no responses, and provision for qualitative comments. Data were analysed using descriptive statistics and thematic analysis. Results: Fifty-five out of 117 (47%) surveys were returned. Midwife respondents practised across a range of settings from urban to remote rural locations, and midwifery care was provided at home and at primary, secondary and tertiary birth facilities. Respondents felt that participation in online postgraduate midwifery education had improved their knowledge base and their ability to practise in an evidence-informed way, and they felt connected to a community of practice in a virtual sense, gaining the benefits of support and encouragement from fellow learners and lecturers. They believed that the care they provided to women was enhanced because they had practice currency and could apply their knowledge to clinical situations with increased confidence. Conclusion: For these midwives, engagement in online postgraduate midwifery education informed their midwifery practice, and therefore the care that women received. Online postgraduate midwifery education enabled these midwives through its accessibility.

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The emotional wellbeing of New Zealand midwives: Comparing responses for midwives in caseloading and shift work settings

By Dixon, L, Guilliland, K, Pallant, J, Sidebotham, M, Fenwick, J, McAra-Couper, J, Gilkison, A
on Friday, 01 Dec 2017 in New Zealand College of Midwives Journal (epub February 2017) - Volume: 53

Background: Ensuring the psychological wellbeing of midwives is becoming increasingly recognised as an important strategy in maintaining a healthy workforce and retaining midwives within the profession. Midwives in New Zealand can choose to be self-employed and work in the community, providing continuity of care to a caseload of women (self-employed caseloading), or can be employed to work within a maternity hospital environment (generally shift work). Some choose to work in both work settings (self-employed and employed by an organisation). Aim: The overall aim of this study was to explore the emotional wellbeing of midwives in New Zealand. The first objective was to describe and compare the demographic and work-related factors of midwives who were (a) self-employed, (b) employed by an organisation or (c) both self-employed and employed. The second objective was to explore factors associated with burnout within each of the three groups. Method: Practising New Zealand midwives who were members of the New Zealand College of Midwives were invited to complete an online survey. The study package included demographic questions, the Depression, Anxiety and Stress Scale (DASS-21), the Copenhagen Burnout Inventory (CBI), Perceptions of Empowerment in Midwifery Scale (PEMS) and the Practice Environment Scale (PES). Findings: A total of 1073 midwives responded with 44% (n=473) self-employed, 42% (n=452) employed and 14% (n=148) both self-employed and employed. Employed midwives worked fewer hours (median 32hrs) than the other two groups (median 40hrs and 36hrs respectively) but had significantly higher levels of work and personal-related burnout as well as anxiety. Employed midwives also reported lower levels of autonomy, empowerment and professional recognition. Aspects of the work environment found to be associated with burnout (particularly for employed midwives) were inadequacy of resources, lack of management support, and lack of professional recognition and development opportunities. Conclusion: While levels of stress and depression were high for all midwives, self-employed midwives providing continuity of care to a caseload of women had better emotional health and less burnout than midwives working in an exclusively employed capacity.

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Individualised risks of stillbirth at advanced maternal age: A literature review of the evidence

By Weathington, M, Patterson, J, Hickey, R
on Friday, 01 Dec 2017 in New Zealand College of Midwives Journal - Volume: 53

Introduction: Women worldwide are having their babies later than in previous generations. Advanced maternal age (AMA) has been associated with adverse pregnancy outcomes, the most severe being increased risk of stillbirth. This literature review examines the evidence for risk of stillbirth at term for women aged 40 or over in high income countries, and outlines factors found in the literature that amplify or mitigate the risk. The aim is to assist New Zealand (NZ) AMA women to make informed choices around induction of labour (IOL) which is frequently recommended at 39 weeks gestation as a general district health board (DHB) guideline for women of AMA. Methods: Databases searched included Google Scholar, CINAHL, Science Direct, PubMed, ProQuest, and Cochrane. Seven papers met the inclusion criteria. Stillbirth risk was assessed against the exacerbating or mitigating factors within the individual papers and compared, if appropriate. Guideline documents regarding NZ obstetric recommendations for AMA were also hand searched. Findings: The risk of stillbirth is associated with increasing maternal age beyond age 40 with the range of adjusted odds ratios (AORs) of 1.43 to 3.04. However, absolute risk of stillbirth for Australian and NZ women over age 40 remains very low at 4.05 stillbirths/1000 undelivered pregnancies, or an absolute risk factor above a baseline rate of 3.4/1000 for stillbirths (>24wks). Further, the stillbirth risk for women of AMA may be modified by parity and general health. Conclusion: AMA is associated with increasing stillbirth rates, although the absolute rate remains low and can potentially be modified by parity and general health. Therefore, women of AMA in the NZ context have the opportunity to assess their overall risk in consultation with their maternity carer, including these factors, when making a decision about early term IOL.

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Editorial: Invisibility of midwifery

By Gilkison, A
on Friday, 01 Dec 2017 in New Zealand College of Midwives - Volume: 53

...Whether it be liaising with social services, making multiple home visits, or advocating with the consultant for a vaginal breech birth, these students did it all and in such a professional way. How lucky are the women of New Zealand to have these midwives at their sides... Yet this incredible day-to-day work of midwives in New Zealand is often invisible to all except the woman and her whanau.

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The core of the core: What is at the heart of hospital core midwifery practice in New Zealand?

By Gilkison, A, McAra-Couper, J, Fielder, A, Hunter, M, Austin, D
on Friday, 01 Dec 2017 in New Zealand College of Midwives Journal - Volume: 53

Background: New Zealand midwives who are employed by District Health Boards and are based in hospitals and maternity units are known as core midwives. Half of New Zealand midwives are employed as core midwives, performing a variety of key roles and, as such, are central to the functioning of maternity services. The sustainability of core midwifery is therefore highly significant for the future of maternity services in New Zealand. Research on sustainable midwifery practice operates as a constructive counterpoint to the growing literature on burnout and stress amongst midwives. Aim: The question this study asked is: What sustains midwives who have been in hospital practice in New Zealand for more than eight years? The findings will inform workforce planners, managers and the midwifery profession about what may well contribute to the retention of midwives who are essential to the maternity services provided in hospital settings. Methods: A qualitative descriptive study was conducted in New Zealand, recruiting and interviewing 22 core midwives with between 8 and 40-plus years’ experience. Interviews were transcribed and thematic analysis was undertaken by the research team. Analysis was done as a group in a reciprocal fashion between the individual interviews and the data as a whole. Themes were clustered into groups and excerpts from the data used to illustrate the agreed themes. Ethical approval was obtained from Auckland University of Technology Ethics Committee. Findings: This study found that core midwives sustain themselves in practice through developing significant core midwifery skills. Core midwives quickly build a partnership with women; and they are prepared to deal with everything, including unexpected and critical incidents. Core midwives often take on a managerial role in a unit and, as such, create the culture of the unit while supporting students and new graduates, as well as Lead Maternity Carers. Conclusion: Core midwives highlight the importance of effective relationships with women, whānau, colleagues and managers. Our sample displayed unique and specific skills: connecting quickly with women, anticipating ahead to keep women safe, managing complexity, being prepared for everything, managing a unit and displaying flexibility and adaptability in their work. However, these core midwives feel invisible and undervalued at times, a finding that may well shine much needed light on what threatens sustainability of the core midwifery service nationwide.

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