Holly Priddis

What are the facilitators, inhibitors, and implications of birth positioning? A review of the literature.

BACKGROUND From the historical literature it is apparent that birthing in an upright position was once common practice while today it appears that the majority of women within Western cultures give birth in a semi-recumbent position. AIM To undertake a review of the literature reporting the impact of birth positions on maternal and perinatal wellbeing, and the factors that facilitate or inhibit women adopting various birth positions throughout the first and second stages of labour. METHODS A search strategy was designed to identify the relevant literature, and the following databases were searched: CINAHL, CIAP, the Cochrane Database of Systematic Reviews, Medline, Biomed Central, OVID and Google Scholar. The search was limited to the last 15 years as current literature was sought. Over 40 papers were identified as relevant and included in this literature review. RESULTS The literature reports both the physical and psychological benefits for women when they are able to adopt physiological positions in labour, and birth in an upright position of their choice. Women who utilise upright positions during labour, have a shorter duration of the first and second stage of labour, experience less intervention, and report less severe pain and increased satisfaction with their childbirth experience than women in a semi recumbent or supine/lithotomy position. Increased blood loss during third stage is the only disadvantage identified but this may be due to increased perineal oedema associated with upright positions. There is a lack of research into factors and/or practices within the current health system that facilitate or inhibit women to adopt various positions during labour and birth. Upright birth positioning appears to occur more often within certain models of care, and birth settings, compared to others. The preferences for positions, and the philosophies of health professionals, are also reported to impact upon the position that women adopt during birth. CONCLUSION Understanding the facilitators and inhibitors of physiological birth positioning, the impact of birth settings and how midwives and women perceive physiological birth positions, and how beliefs are translated into practice needs to be researched.

Women's experiences following severe perineal trauma : a meta-ethnographic synthesis

Aims This article presents a meta-ethnographic synthesis of studies on womens experiences of sustaining a third or fourth degree tear during childbirth. Background It has been reported that for women who sustain third or fourth degree perineal tears (severe perineal trauma) some may experience extensive physical and psychological outcomes. Design A meta-ethnographic synthesis. Data sources The CINAHL, PubMed, Scopus, MD Consult, and SocIndex with Full Text databases were searched for the period January 1996–June 2011. Out of 478 papers retrieved four met the review aim. Review methods A meta-ethnographic synthesis approach was undertaken using analytic strategies and theme synthesis techniques of reciprocal translation and refutational investigation. Quality appraisal was undertaken using the Critical Appraisal Skills Programme (CASP) tool. Findings Four qualitative papers were included, with three major themes identified: ‘I am broken and a failure’, ‘Dismissed, devalued and disregarded’, and ‘The practicalities of the unpredictable perineum’. Conclusion There is evidence to suggest that for women who experience severe perineal trauma during childbirth the physical and psychological outcomes can be complex, with some women experiencing social isolation and marginalization due to their ongoing symptomatology. Severe perineal trauma appeared to affect not only physiological and psychological well-being but also altered the womens understanding of their identity as sexual beings. Health professionals should be mindful of the language that they use and their actions during suturing and the postpartum period to avoid causing unnecessary distress.

Trends and risk factors for severe perineal trauma during childbirth in New South Wales between 2000 and 2008: a population-based data study

Objectives To determine trends and risk factors for severe perineal trauma between 2000 and 2008. Design This was a population-based data study. Setting New South Wales, Australia. Participants 510 006 women giving birth to a singleton baby during the period 2000–2008. Main outcome measures Rates of severe perineal trauma between 2000 and 2008 and associated demographic, fetal, antenatal, labour and delivery events and factors. Results There was an increase in the overall rate of severe perineal trauma from 2000 to 2008 from 1.4% to 1.9% (36% increase). Compared with women who were intact or had minor perineal trauma (first-degree tear, vaginal graze/tear), women who were primiparous (adjusted OR (AOR) 1.8 CI (1.65 to 1.95), were born in China or Vietnam (AOR 1.1 CI (1.09 to 1.23), gave birth in a private hospital (AOR 1.1 CI (1.03 to 1.20), had an instrumental birth (AOR 1.8 CI (1.65 to 1.95) and male baby (AOR 1.3 CI (1.27 to 1.34) all had a significantly higher risk of severe perineal trauma. Only giving birth to a male baby, adjusted for birth weight (AOR 1.5 CI (1.44 to 1.58), remained significant, when women with severe perineal trauma were compared with all other women not experiencing severe perineal trauma. This association increased over the study period. Conclusions To our knowledge, this is the first time that having a male baby has been found to exert such a strong independent risk for severe perineal trauma and the increasing significance of this in recent years needs further exploration.

Women's experiences following severe perineal trauma: a qualitative study

BackgroundLiterature reports that the psychological impact for women following severe perineal trauma is extensive and complex, however there is a paucity of research reporting on women’s experience and perspective of how they are cared for during this time. The aim of this study was to explore how women experience and make meaning of living with severe perineal trauma.MethodsA qualitative interpretive approach using a feminist perspective guided data collection and analysis. Data were collected through semi-structured face to face interviews with twelve women in Sydney, Australia, who had experienced severe perineal trauma during vaginal birth. Thematic analysis was used to analyse the data.ResultsThree main themes were identified: The Abandoned Mother describes how women feel vulnerable, exposed and disempowered throughout the labour and birth, suturing, and postpartum period and how these feelings are a direct result of the actions of their health care providers. The Fractured Fairytale explores the disconnect between the expectations and reality of the birth experience and immediate postpartum period for women, and how this reality impacts upon their ability to mother their newborn child and the sexual relationship they have with their partner. A Completely Different Normal discusses the emotional pathway women travel as they work to rediscover and redefine a new sense of self following severe perineal trauma.ConclusionHow women are cared for during their labour, birth and postnatal period has a direct impact on how they process, understand and rediscover a new sense of self following severe perineal trauma. Women who experience severe perineal trauma and associated postnatal morbidities undergo a transition as their maternal body boundaries shift, and the trauma to their perineum results in an extended physical opening whereby the internal becomes external, and that creates a continual shift between self and other.

Severe perineal trauma is rising, but let us not overreact

Severe perineal trauma (SPT) experienced during childbirth is a serious morbidity for women, impacting on short and long-term physical and psychological wellbeing (Signorello et al., 2001; Macarthur and Macarthur, 2004; Priddis et al., 2013; H. Priddis et al., 2014). SPT is defined as a third degree tear, which involves injury to the perineum involving the anal sphincter complex; or a fourth degree tear, which involves injury to the perineum involving the external, internal and epithelium of the anal sphincter (Royal College Obstetricians and Gynaecologists, 2007). It does appear that severe perineal trauma is rising in several developing nations; including Australia (Kettle and Tohill, 2008; Baghestan et al., 2012; Dahlen et al., 2013) (Fig. 1) and this should be a concern to health practitioners. It is important that thoughtful, appropriate and co-ordinated multidisciplinary action is taken and that this action is based on high level evidence, and most importantly is acceptable to women. Overreacting, or reacting without a full understanding of the problem at hand should never be acceptable in today’s enlightened, evidence based health care environment. Consideration of possible unintended consequences and acceptability to women is most important when making major changes in clinical practice.

Juggling Instinct and Fear: An Ethnographic Study of Facilitators and Inhibitors of Physiological Birth Positioning in Two Different Birth Settings

BACKGROUND: Although there is evidence to support the benefits for women of using a variety of birth positions, particularly upright birth positions, there is limited research into practices that facilitate or inhibit physiological birth positioning. AIM: To explore how physiological birth positioning is facilitated by midwives and experienced by women in two main settings in New South Wales (NSW), Australia (birth center and delivery ward). METHOD: An ethnographic approach guided data collection and analysis in this study. Data was collected using observation of women in the second stage of labor, focus groups with midwives, and interviews with women. RESULTS: Women were more likely to assume upright birth positions in the birth center setting (81.84%) than in the delivery ward setting (24.47%). They also instinctively wanted to lean forward during labor and birth. Midwives and women constantly “juggle instinct and fear” as they work to adapt to the birth environment, and this impacts physiological birth positioning. CONCLUSION: Women are more likely to adopt physiological birth positions during the first and second stage of labor in a birth center setting compared to a delivery ward setting. The birth center setting acts as a facilitator for physiological birth positions by providing a buffer from medicalized care. CLINICAL IMPLICATIONS: An in-depth exploration into facilitators and inhibitors of physiological birth positioning in two different birth settings provided new insights. Findings from this study have the potential to inform clinical practice through the design of birth environments and models of care that are available to women.

“A patchwork of services” – caring for women who sustain severe perineal trauma in New South Wales – from the perspective of women and midwives

BackgroundCurrent research into severe perineal trauma (3rd and 4th degree) focuses upon identification of risk factors, preventative practices and methods of repair, with little focus on women’s experiences of, and interactions with, health professionals following severe perineal trauma (SPT). The aim of this study is to describe current health services provided to women in New South Wales (NSW) who have experienced SPT from the perspective of Clinical Midwifery Consultants (CMC) and women.MethodsThis study used a descriptive qualitative design and reports on the findings of a component of a larger mixed methods study. Data were collected through a semi-structured discussion group using a variety of non-directive, open-ended questions leading CMCs of NSW. A survey was distributed prior to the discussion group to collect further information and enable a more comprehensive understanding of services provided. Data from individual interviews with twelve women who had experienced SPT during vaginal birth is used to provide greater insight into their interactions with, and ease of access to, health service providers in NSW. An integrative approach was undertaken in reporting the findings which involved comparing and analysing findings from the three sets of data.ResultsOne overarching theme was identified: A Patchwork of Policy and Process which identified that current health services operate in a ‘patchwork’ manner when caring for women who sustain SPT. They are characterised by lack of consistency in practice and standardisation of care. Within the overarching theme, four subthemes were identified: Falling through the gaps; Qualifications, skills and attitudes of health professionals; Caring for women who have sustained SPT; and Gold standard care: how would it look?ConclusionThe findings from this study suggest that current health services in NSW represent a ‘patchwork’ of service provision for women who have sustained SPT. It appeared that women seek compassionate and supportive care based upon a clear exchange of information, and this should be considered when reflecting upon health service design. This study highlights the benefits of establishing multi-disciplinary collaborative specialist clinics to support women who experience SPT and associated morbidities, with the aim of providing comprehensive physiological and psychological support.

Autoethnography and severe perineal trauma—an unexpected journey from disembodiment to embodiment

BackgroundThere is a lack of research reporting on the physical and emotional experiences of women who sustain severe perineal trauma (third and fourth degree tears). When the researcher identifies with the group being researched, autoethnography can allow an insight into the experiences of the marginalised group through the telling of a personal story. The aim of this paper is to share the journey travelled by an autoethnographer who on examining the issue of severe perineal trauma came to understand the challenges and rewards she experienced through this reflective and analytic process.MethodsA transformative emancipatory approach guided the design, data collection and analysis of findings from this study. For this paper, a multivocal narrative approach was taken in presenting the findings, which incorporated the words of both the autoethnographer and the twelve women who were interviewed as a component of the study, all of whom had sustained severe perineal trauma.ResultsAs an autoethnographer, being a member of the group being researched, can be confronting as the necessary reflection upon one’s personal journey may lead to feelings of vulnerability, sadness, and emotional pain. The transformation from disembodied to embodied self, resulted in a physical and emotional breakdown that occurred for this autoethnographer.ConclusionAutoethnographers may experience unexpected emotional and physical challenges as they reflect upon their experiences and research the experiences of others. When incorporating a transformative emancipatory framework, the hardships are somewhat balanced by the rewards of witnessing ‘self-transformation’ as a result of the research.