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Clamping the umbilical cord straight after birth is bad for a baby’s health

 

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Umbilical cord clamps.
KANOWA/Shutterstock.com

Sally Pezaro, Coventry University

Clamping and cutting a baby’s umbilical cord as soon as it is born can be bad for its health. The World Health Organisation advises that clamping should be delayed for two to three minutes after the baby has been born, and the UK watchdog NICE advices midwives and obstetricians not to clamp the cord earlier than one minute after the birth. But in nearly a third of cases, this doesn’t appear to be happening.

In a survey of 3,500 parents whose children were born in the UK between 2015 and 2017, 31% said that their baby’s cord was clamped less than a minute after they were born. One in five said that their baby’s cord was cut immediately following the birth.

Life support

The umbilical cord consists of a vein and two arteries, which are surrounded by a gelatinous substance called Wharton’s jelly. A membrane, called the amnion, holds the whole thing together.

During pregnancy, the umbilical cord vein carries oxygen-rich blood and nutrients from the placenta to the baby, and the arteries return deoxygenated blood and waste products, such as carbon dioxide, to the placenta.

A baby’s blood supply is independent of its mother’s, and remains within this closed circuit throughout pregnancy, labour and birth. As the baby is squeezed through the birth canal or an abdominal incision (if it’s a caesarean birth), a lot of the baby’s blood is pushed back into the placenta. But as the baby emerges, the umbilical cord – if left to pulsate – returns all of this blood to its rightful owner in a few minutes.

The cord continues to act as the baby’s only oxygen supply until the baby starts to breathe, before the placenta becomes detached. So, even when a baby needs help to breathe, the cord should ideally remain intact as the baby is resuscitated at the bedside. If the umbilical cord is cut too early, the baby can be deprived of oxygen, 20-30% of its blood volume and 50% of its red blood cell volume.

Baby with a clamped umbilical cord.
Wikimedia Commons

This shortage of blood will leave up to 30% of babies with iron-deficient anaemia. A review of 27 studies involving six to 24-month-old babies found that babies with iron-deficient anaemia have significantly poorer brain, physical, social and emotional functioning. Iron deficiency has also been linked to recurring infections, autism and learning difficulties.

A few minutes makes a big difference

Aside from reducing the risk of iron-deficiency anaemia, delaying clamping by a few minutes has a range of other health benefits, including: a reduced lifetime risk of developing chronic lung disease, asthma, diabetes, epilepsy, cerebral palsy, Parkinson’s disease, infection and abnormal tissue growths; a reduced risk of bowel infections, death in premature babies,sepsis and brain haemorrhage in very premature babies; and an increased likelihood of being more sociable and better behaved at age four.

Babies who have delayed cord clamping also enjoy higher birth weights, compared with babies who have their cords clamped immediately.

The ConversationUltimately, immediate cord clamping disrupts the natural birth process and may cause harm to some babies by depriving them of essential blood and stem cells. Waiting until the umbilical cord is empty of blood before clamping it is the way to go.

Sally Pezaro, Midwife, Lecturer and Researcher, Coventry University

This article was originally published on The Conversation. Read the original article.

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7 things you probably didn’t know about midwives

Oh baby: seven things you probably didn’t know about midwives

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Vasiuk Iryna/Shutterstock

Sally Pezaro, Coventry University

The term “midwife” can conjure up images of a stern matron, iron pressed and ready for some no-nonsense birthing, or, in the more modern era, a back-rubbing, hand-holding, motivational cheerleader who can make or break the birthing experience. Midwives are so much more than those two stereotypes. Here are a few things you may not know about the profession.

1. The word “midwife” means “with woman”, although in France, where the midwife is a “sage femme”, it means “wise woman”.

2. Some people think that midwifery is simply another branch of nursing. Midwifery is, in fact, one of the oldest professions in the world, one that is thought to have arrived prior to the nursing and medical professions.

Midwifery is not a branch of nursing.
Kzenon/Shutterstock

3. Midwives make up 36% of the midwifery-service workforce, according to a survey of 73 countries. Other professional members of the team may include auxiliaries, nurse-midwives, nurses, associate clinicians, general physicians, obstetricians and gynaecologists. Yet, as midwives can perform most essential maternal and newborn care, future investment in midwives could free up these other professionals to focus on other health needs around the world.

4. Midwives are among the few healthcare professionals that don’t generally care for the sick. Although they are trained to manage emergency situations, midwives are the experts in normal childbearing.

5. Midwives don’t just catch babies. There are a number of specialist roles that a midwife can fulfill. Such specialist roles may include sonography (ultrasound scanning) during pregnancy as well as safeguarding – where a midwife works to protect vulnerable families. Midwives can also work in management, commissioning, education, policy, quality assurance, inspection, and research.

Midwives also do ultrasound scanning.
GagliardiImages/Shutterstock

6. Along with the decline of women’s social status during the middle ages, midwives (almost always female) were denounced as witches by doctors (always male) who felt threatened professionally. Yet, while doctors were trying to catch up to midwives in learning about physiology in childbirth, women were unable to train as doctors. So, despite their wealth of professional experience, midwives were pushed out as the less desirable choice in childbearing.

In medieval times, midwives were denounced as witches.
Wikimedia Commons

7. During the 19th and early 20th centuries, doctors ran campaigns to socially stigmatise midwifery and make the ancient practice illegal in some places. This was largely done for economic reasons, but also to increase the status of the predominantly male medical profession.

The ConversationIt worked, as the care of physicians in childbirth during this time became the popular choice for upper-class women. Now, in the 21st century, midwives continue to reclaim their position as respected experts in childbirth, working in partnership with doctors, multidisciplinary teams, mothers and families to achieve the best outcomes in childbirth around the world.

Sally Pezaro, Midwife, Lecturer and Researcher, Coventry University

This article was originally published on The Conversation. Read the original article.

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19 Things That Show Workplace Compassion for Healthcare Staff

We are all well aware of how the wellbeing of healthcare staff can affect the quality and safety of care. I have also talked at length about the wellbeing of health care staff and the theories surrounding work-related psychological distress. But do we really have any concrete idea of what shows workplace compassion for healthcare staff?

My research published in collaboration with Dr. Wendy Clyne, Dr. Karen Deeny and Dr. Rosie Kneafsey asked Twitter users to contribute their views about what activities, actions, policies, philosophies or approaches demonstrate workplace compassion in healthcare using the hashtag #ShowsWorkplaceCompassion. It can be cited as follows:

Clyne W, Pezaro S, Deeny K, Kneafsey R. Using Social Media to Generate and Collect Primary Data: The #ShowsWorkplaceCompassion Twitter Research Campaign. JMIR Public Health Surveill 2018;4(2):e41. DOI: 10.2196/publichealth.7686. PMID: 29685866

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The results of this study outlined 19 things or ‘Themes’ in relation to what shows workplace compassion for healthcare staff as follows…

  Leadership and Management
1 Embedded organizational culture of caring for one another
2 Speaking openly to learn from mistakes
3 No blame/no bullying management
4 Inspiring leaders and collective leadership
5 Financial investment in staff
6 Recognize humanity and diversity
  Values and Culture
7 Common purpose in a team
8 Feeling valued
9 Being heard
10 Enjoying work
11 Being Engaged at work
12 Use of caring language
  Personalized Policies and Procedures
13 Recognition of the emotional and physical impact of healthcare work
14 Recognition of non-work personal context
15 Work/life balance is respected
16 Respecting the right to breaks
17 Being treated well when unwell
  Activities and Actions
18 Small gestures of kindness
19 Provision of emotional support

How will you implement these things within your healthcare workplace? I would love to hear your thoughts on this…

If you would like to follow the progress of my work going forward..

Follow me via @SallyPezaroThe Academic MidwifeThis blog

Until next time…Look after yourselves and each other 💚💙💜❤

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How to publish your PhD thesis in 6 easy steps

Whilst I am sure that there are many reputable companies who will publish your thesis out there, I wanted to share with you all how I published mine.

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First of all, I believe that if you have a PhD then your work must be adding some original knowledge to the world. That means that your work is of value, and should therefore be published and disseminated widely. This is also true for students, whose work is of great value to the academic community.

See my post here about ‘Why Midwifery and Nursing Students Should Publish their Work and How’

But here, I wanted to map out one way to publish your thesis. It is the way I published mine.

Step one…

Publish background literature reviews to outline how you arrived at your research questions. Much of this work will summarize the first chapters of your thesis. It will also help you refine your ideas if you publish as you write.

My initial chapters were published as follows:

Pezaro, S The midwifery workforce:  A global picture of psychological distress – Article inMidwives: Official journal of the Royal College of Midwives (2016): 19:33

Pezaro S Addressing psychological distress in midwives. Nursing Times (2016): 112: 8, 22-23.

Pezaro, S., Clyne, W., Turner, A., Fulton, E. A., & Gerada, C. (2015). ‘Midwives overboard! ‘Inside their hearts are breaking, their makeup may be flaking but their smile still stays on. Women and Birth 29.3 (2016): e59-e66.

Step two…

Publish your ideas around the theories used in your work.

I did this by publishing a blog on theories of work-related stress. I also published a paper exploring the ethical considerations of what I was trying to do entitled ‘Confidentiality, anonymity and amnesty for midwives in distress seeking online support – Ethical?’. Opening this up for discussion meant that my thesis was much stronger overall.

Step three…

Publish your methods via research protocols.

Not only does this mean that you have claimed the idea for yourself in the academic world, but you also then get the benefit of a wider peer review of your work. I published the protocol of my Delphi study as follows:

Pezaro, S, Clyne, W (2015) Achieving Consensus in the Development of an Online Intervention Designed to Effectively Support Midwives in Work-Related Psychological Distress: Protocol for a Delphi Study. JMIR Res Protoc 2015 (Sep 04); 4(3):e107

Step four…

Publish each chapter of your work as you go.

Again, this gives your work added peer review in the process of developing your thesis. I published the two largest pieces of research in my thesis as follows:

Pezaro, S, Clyne, W and Fulton, E.A  “A systematic mixed-methods review of interventions, outcomes and experiences for midwives and student midwives in work-related psychological distress.” Midwifery (2017). DOI: http://dx.doi.org/10.1016/j.midw.2017.04.003

Pezaro, S and Clyne, W “Achieving Consensus for the Design and Delivery of an Online Intervention to Support Midwives in Work-Related Psychological Distress: Results From a Delphi Study.” JMIR Mental Health3.3 (2016).

Step five…

Publish summaries of your work for different audiences

Once you begin to pull together your entire thesis, you will begin to discuss the findings and arrive at certain conclusions. You can summarise these in a series of blogs and papers as you go. I published the following summary papers to reach both national and international audiences.

Pezaro, S (2018) Securing The Evidence And Theory-Based Design Of An Online Intervention Designed To Support Midwives In Work-Related Psychological Distress (Special Theme on Women in eHealth). Journal of the International Society for Telemedicine and eHealth. Vol 6, e8. 1-12.

Pezaro, S “The case for developing an online intervention to support midwives in work-related psychological distress.” British Journal of Midwifery 24.11 (2016): 799-805.

Step six…

Use info graphics to map out key points in your thesis

Once complete, your thesis will be published in full. Mine can be accessed here via the British Library and via Coventry University’s open collections. But it’s a mighty big document. Therefore, I produced the following infographic to map out my PhD journey for those looking for a shorter, yet engaging summary.

PhD infographic

…and there you have it. A fully published PhD thesis via a variety of avenues. I hope that you enjoy publishing your PhD thesis, and that publishing it helps you to defend it.

Also…If you need a co-author, let me know!🎓😉

If you would like to follow the progress of my work going forward..

Follow me via @SallyPezaroThe Academic MidwifeThis blog

Until next time…Look after yourselves and each other 💚💙💜❤

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The pregnant midwife: A personal reflection on having a baby as a midwife

I have always had a passion for matters around pregnancy, birth and babies. For years I have enjoyed being a midwife, clinically in research and in teaching. My passion started at around 4 years old when my brother was born. Mesmerized by a growing belly and the fact that another human was coming in to the world, I read my mother’s antenatal books from cover to cover. Having just experienced the birth of my own baby, I felt compelled to write my own reflections and experiences down….

Please note: For personal reasons I would request that close family members do not read any further.

*Long post alert*

What happens when the midwife has a baby? We are people just like any other having a baby…right?…probably. Did I know too much?…Did that affect my choices? did I have a better choice and/or experience because I had ‘insider knowledge’?… One thing is certain. Having a baby as a midwife was unique for me.

The stick turned blue

Yes, our little Autumn baby was planned….and thankfully, we had no trouble conceiving our little darling, who was due to arrive conveniently after I had  been awarded my PhD. But my period being late and the pregnancy tests showing up negative confused me. This was my first experience of feeling as though ‘I should have known better’! … Of course, though I knew that all I was looking for was a little Human chorionic gonadotropin (hCG), the cheap sticks I had bought clearly were not sensitive enough to detect it…it took a friend to prompt me to spend a bit of extra cash on the test. Of course a fancy pants digital stick did the trick….Silly me. The midwife should have known better (was one of my first thoughts… and a recurrent theme throughout my pregnancy)! The pressure was on!

Of course when the stick did officially ‘turn blue’ my heart jumped into my mouth, knowing that this was an ‘oh sh*t’ moment. No take backsies. Yet, I have no idea why I panicked …it was planned after all! Perhaps it was because..

  1. My parents would know for sure that I was sexually active (ridiculous I know…especially as my husband and I have been together 18 years)!
  2. I really would need to finish my PhD in time
  3. Life was about to change for ever
  4. I think this pregnancy is a good thing (probably)

My unicorn was on her way..

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Choosing my care givers

Unlike many women who my just meet the nearest or most convenient midwife. I had the luxury of knowing a myriad of great midwives who could provide great care for me and my baby. I also had the luxury of knowing how and who to ask directly for what I wanted. I felt spoilt. This felt like a luxury that many women don’t have…but it was also a perfectly reasonable thing to be able to do. I was able to chose a midwife who I knew was ‘on the same page’… and who would care for me continuously throughout…Do all women get this opportunity?

Pregnancy symptoms

For years I have been caring for women with ligament pain, pelvic pain, odd sensations and physical stresses and strains. Being pregnant myself meant that I could finally feel what I had been describing… ‘Ahh…that’s what hey mean by feeling a ‘twang”

One great benefit of being a pregnant midwife is also knowing what symptoms to worry about and what symptoms not to worry about. I imagine that this may have enabled me to experience somewhat less worry than others experiencing such things for the first time….In the beginning anyway!

To tell or not to tell…that is the question

Other than the midwives I knew, there were other care givers throughout my pregnancy who were meeting me for the first time. They all began with the usual spiel about risks/benefits/routine and procedure. The question is (or was).. do I let them go on talking like I know nothing.. or do I let them know that I am a midwife who is used to spouting this spiel myself.

In not telling them, I felt like a fraud.. Like I was making a fool of them… But in telling them of my profession, I felt as though I would be giving up my status as a ‘regular’ maternity service user. My cover would essentially be blown.

A desire for honesty got the better of me. I told all new care givers that I was a midwife. The following happened:

  1. Clinicians dropped any facade of being ‘ultra professional’ – They became more friendly… like we were ‘on the same team’.
  2. I was told frequently ‘Well you know all of this already so I won’t repeat it’

As they did this, I felt a mix of emotions. On the one hand…I felt truly part of the team…a sense of power and autonomy…On the other hand… I felt like I no longer had the safety net of being ‘nurtured’ through my pregnancy. Was I missing out?..I’m not sure. But I was no longer treated as a ‘regular pregnant woman’.

Choosing my own care pathways

In my experience as a midwife, I have seen how some professionals can dismiss the thoughts, feelings and desires of women wanting to make decisions in relation to their own care pathways. For more on this, please see Michelle Quashie @QuashieMichelle 

As such, I sometimes had to fight hard to make sure that the women in my care got what they wanted. I was expecting to have the same fight.

However, I found that once people realised that I was a midwife, they were more willing to trust that my own decisions were informed decisions. They seemed less intent on trying to persuade me one way or another. They seemed to respect and accept my choice more than I had seen some maternity staff respect the choices of other women.

For me this highlighted issues around respecting women’s choice. When do we feel that women can make their own choices without question?…and when do women’s choices cause clinicians concern?….

Whatever the opinion of others… I, as a midwife could seemingly make any choice I wanted with ease…. Is this the same for all? I think not.

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Birth choices

I have actually known what my own birth choice would be for a long time now. My main fear was that my choice would be made unavailable to me. Pre-conceptually I had consulted the obstetric team to discuss my birth choices…Would they be facilitated? because if not…did I really want to get pregnant in the first place?… the answer was ‘Let’s wait and see once you get pregnant’…Damn. I was really looking for a signed deal beforehand.

Once I became pregnant of course, they held all of the cards. I was pregnant…. trapped… The baby had to come out somehow, but I was beholden to them.. as they were the ones who would decide whether or not to facilitate my choice. This also altered the power balance and really made me feel vulnerable… at the mercy of those with the power to say yes or no. It was not a nice place to be.

My midwife, and my consultant midwife were 100% supportive of my decision, but they were not in a position to sign on the dotted line. I wanted a beautiful planned cesarean section. Something which goes against the grain for some.

When it came to meeting the consultant team, I was nervous about what they would ‘allow’. Now… I hate the word ‘allow‘ in maternity services, but this is how it felt. I was asking permission to have this… asking them to facilitate this. They had the power to say no. As a midwife, I believe I knew the right things to say to maximize my chances of them agreeing to my birth choice. I also had all of the up to date guidelines and research to back up my arguments should I need them. I was still nervously holding my breath.

There was some resistance, I had some extra appointments and some hoops to jump through, but with some firm words and some strong midwifery back up, I was able to get my birth choice ‘agreed’ or ‘allowed’.  Though the clinical reasons for my birth choice are too complex to explain here, it felt as though my decision making was not so trusted by other professionals in this case. I also had to repeatedly sit and listen to the list of risks involved, and be repeatedly asked if I had wanted to change my mind. Would this be the case if I had chosen a vaginal birth?

The sense of relief was immense…I could finally start to look forward to the birth and enjoy my pregnancy!

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Though this relief could have come much earlier for me… having the obstetric team on board pre-conceptually would have made my experience so much better!

What I really wanted to do was have my birth choice go unquestioned. I wanted to know all of the facts and then be trusted to make my own decision. Doesn’t every person want this?…

A “good birth” goes beyond having a healthy baby…

But I felt as though I may be denied my choice if it did not conform with what the health professional believed was the ‘right’ decision… This was utterly terrifying. The consequences of my choice being denied would literally mean that I would have less control over what would happen to my body. This was a horrifying thought. I would literally be forced to have a vaginal birth against my will. This is literally how the reality  felt.

For more information around birth rights see: @birthrightsorg

These experiences in relation to birth choices got me thinking about ‘informed’ choice in maternity care…

Everyone is ever so concerned about gaining ‘informed’ consent (and rightly so)… but is it disconcerting that we forever talk about the risks of Cesarean section and rarely the benefits? Equally…do we (as healthcare professionals) inform women of the risks of a vaginal birth? or a hospital birth? Wouldn’t that be ‘true’ informed consent?

As a midwife, I have to admit that my favorite type of birth to be in attendance of is an uninterrupted home birth….they are fab!… but that is my preference as a midwife. My preference as a mother was a cesarean section, and I have to ensure that I remain objective in respect to all women’s choices regardless of these facts.

At the end of the day.. a baby is coming out of you. There are a variety of ways in which this can happen. Should there be a default or ‘preferred’ way? or is this ‘preferred’ way subjective to each and every woman? If so then we must stop talking about the ways in which we might prefer women to give birth…and instead celebrate women’s choice in pursuit of their own subjective ‘positive birth’.

See here about the myths associated with positive birth

In my case, I felt a solidarity with Helen George from Call the Midwife, who was shamed for choosing to have a cesarean section. I also identified with some of the reasons she gave for her very personal choice. Of course there are many other reasons why women may choose a cesarean section. Some have been explored in the following paper:

Why do women request an elective cesarean delivery for non-medical reasons? A systematic review of the qualitative literature

From my perspective…the ‘rights’ and ‘wrongs’ of one’s birth choices are too subjective to ever cast judgment upon.

Challenging poor practice

The care I received from the English maternity services in my area was fantastic….For the most part. Unfortunately I did encounter one incidence of poor practice. Sadly this episode warranted escalation.

As a midwife, I know my duty is to take further action (escalate) mistakes in practice where appropriate. However, as a mother, I was nervous about escalating the poor practice of someone whom I relied on for my care (and to facilitate my birth choices). Would they take revenge? would I loose my place of birth? or would my birth choices be taken from me?…It was a very vulnerable position to be in.

“After all…If you complain to the chef..they may spit in your food.”

Thankfully, with the support of my midwife, I am now working with the General Medical Council (GMC) to ensure that other mothers and babies can be protected from the same actions being repeated.

Aside from this… as a midwife, I feel highly privileged that I was able to spot this poor practice and call it out. Another pregnant woman (non-midwife) may not have spotted this poor practice, and been put at risk unknowingly. This highlights how vulnerable women may be, as they trust us all with their (and their babies) lives. Here the role of the midwife as an advocate becomes even more important for those who cannot always safeguard their own care.

Patient & Public Involvement in research

INVOLVE briefings state that there is an important distinction to be made between the perspectives of the public and the perspectives of people who have a professional role in health and social care services. As midwives are not considered to be patients under this guidance, I have felt unable to participate in Patient and Public Involvement (PPI) activities during my pregnancy. This was difficult, as I would have loved to have participated in PPI whilst pregnant in order to contribute to the improvement of maternity services from a user perspective. This issue is worthy of further discussion… after all, health professionals can be ‘patients’ too right?

Antenatal education

My husband is surely sick of my chums and I always talking pregnancy and birth…and of course passion for the profession can get a little sickly for some. So, I wanted the father of my baby to hear what I already knew from someone other than me. I didn’t want him to rely on me for information…after all, I may come across as a know it all rather than an equal partner in his parenting journey. So we went to NCT classes.

The classes were great and the information was sound….Yet, as a midwife… I could feel myself wanting to ‘approve’ of the information given out to the group.

During the challenges set out for us as a group, I was anxious. What if I got a question wrong? or stuck an anatomy sticker in the wrong place?

oh the shame!

Thankfully, I made no mistakes and my midwifery knowledge held strong. Yet again, I felt compelled to disclose my profession to the group. Not to do so felt dishonest somehow, like I was tricking them into thinking I was new to pregnancy and birth from all perspectives…and not just from a parental one. As such, I was relied upon at times for the lived experience of maternity services. People were also generally glad to have me on their ‘team’ during group challenges.

At the end of the course, I think my husband was glad to learn from someone perhaps more objective than myself. I also think that hearing the facts from another birth educator strengthened my husbands faith in what I had been saying all along…For example.. he now trusts that it is indeed OK to have a glass of wine whilst breastfeeding (Very important)!

And just like any other mum of course… I needed to meet other people sharing the same journey as I was.

And so little ‘Loveday Alice Pezaro’ came into the world. I had the perfect ‘positive’ birth (for me).. The breastfeeding is going wonderfully…and we are now knee deep in baby sensory groups and Costa Coffee chats. This experience from the other side of the fence has provided me with more empathy for women and more passion for womens rights in childbirth. The journey was less scary than I thought it might be. But…………………

What if I can’t breastfeed?

This was another real fear for me…having supported so many other women to breastfeed… what if I couldn’t do it myself? I mean… if the midwife can’t do it…What hope is there? 😮😨😩

These types of fears and anxieties resonate with other midwives who find themselves becoming mothers…In fact, the very pertinent research of my friend and mentor Dr. Sarah Church demonstrates how;

“a reliance on professional knowledge may create opportunities for choice and increased autonomy in some situations, although the need for intervention during childbirth, for example, may challenge the degree of autonomy exercised by midwives and the choices available to them. As knowledgeable experts, midwives demonstrate a very different understanding of risk and safety in relation to their own experiences of childbirth. Professional knowledge may increase their anxieties which may not be addressed appropriately by caregivers due to their professional status. The use of knowledge in this way highlights potential conflict between their position as midwives and their experience as mothers, illustrating that midwives’ ability to exercise agency and autonomy in relation to their pregnancy and childbirth experiences is potentially problematic.”

Final thoughts and reflections

  • Being pregnant as a midwife increased both my anxieties and my autonomy.
  • My professional knowledge impacted significantly upon my own perceptions around risk and safety in maternity
  • As a midwife I knew how to best ‘get’ my birth choices.
  • I felt vulnerable at times, especially in calling out poor practice.
  • I felt as though I was treated differently because of my professional background
  • The pressure to ‘get it right’ was always on.

In conclusion, the whole experience of childbearing was much better than I thought it would ever be. I feared much more than I needed to, and in retrospect, I had a wonderful experience. If only I could have anticipated such good outcomes in advance…the fear of the ‘worst’ happening may have never been an issue. One thing is for sure. My experience of being on the other side of the fence will enrich my midwifery practice forever.

On another note..There are so many wonderful midwives and initiatives out there making births better for women and their babies…There are not enough words to mention all of their wonderful work in this single blog. But I would urge further reading around the following groups:

@birthrightsorg

@MatExpBazaar

@NatMatVoicesorg

@BirthChoiceUK 

@birthpositive 

…and Many more (happy to add to this list if suggestions are given)!

My baby ❤️ ‘Loveday Alice’

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If you would like to follow the progress of my work going forward..

Follow me via @SallyPezaroThe Academic MidwifeThis blog

Until next time…Look after yourselves and each other 💚💙💜❤

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10 Top tips for caring for women with Hypermobile Ehlers-Danlos Syndrome in pregnancy for International Day of the Midwife #IDM2018 & #EDS awareness month

 or ‘International Day of the Midwife’ falls on May the 5th of every year. The theme for 2018 in three languages is…

  • Midwives leading the way with quality care
  • Sages-femmes, ouvrons la voie avec la qualité des soins
  • Matronas liderando el camino con un cuidado de calidad 

Also… Every May is Ehlers-Danlos Syndrome (EDS) awareness month around the world.

As such….for , and EDS awareness month… I shared 10 top tips for caring for women with hypermobile Ehlers Danlos Syndrome (hEDS) during pregnancy birth and beyond. These tips come from my latest paper, authored in partnership with Dr. Gemma Pearce (@GemmaSPearce) and Dr. Emma Reinhold (@DrEReinhold ), entitled …

Hypermobile Ehlers-Danlos Syndrome during pregnancy, birth and beyond

Here, we present care considerations for midwives and the multidisciplinary team caring for this unique subgroup of childbearing women. However, we hope that women with hEDS will also benefit from this paper, as they make decisions in partnership with their professional health care teams. You can read the press release from this paper here.

I would personally like to thank the board members of the British Journal of Midwifery for making this article FREE for all to read. I would also like to thank the Royal college of Midwives for sharing news of the article here…and the Nursing Times for sharing further news here.

So what can midwives do to maximize the quality of care given to women with hEDS throughout pregnancy birth and beyond?…First of all….Know the facts…

  • There have been no prevalence studies since EDS received a major reclassification in 2017
  • Earlier estimates from 2006 suggest a prevalence rate of 0.75-2% for hyper mobile EDS
  • hEDS is the most common form of EDS
  • Up to 78% of women with hEDS could also have a diagnosis of Postural Orthostatic Tachycardia Syndrome (POTS)
  • POTS predominantly occurs in women of childbearing age
  • EDS is considered to remain largely under diagnosed.

Tips for midwives

  1. Discuss individual needs with women, as no two cases will be the same. Do this early, and always in partnership with the woman and the wider multidisciplinary healthcare team.
  2. Consider early referral to obstetric, physiotherapy and anaesthetic teams in partnership with the woman.
  3. Consider the need for alternate maternal positioning during pregnancy, birth and beyond. To minimise the risk of injury, positioning should be led by the mother.
  4. As wound healing can be problematic, the use of non-tension, non-dissolvable, deep double sutures, left in for at least 14 days is advisable.
  5. Wait longer for local anaesthetics to take effect and consider giving maximum dosage. Always be led by the mother on whether pain relief is sufficient
  6. Always consider the significance of a routine observation in light of existing POTS and/or EDS symptoms
  7. Promote spontaneous pushing rather than directed pushing during birth
  8. Promote effective pain management and the use of therapeutic birthing environments to promote reductions in stress
  9. Consider additional joint support for newborns suspected of having hEDS
  10. Document all joint dislocations and bruising marks on the newborn from birth to avoid misdiagnosis and/or wrongful accusations of mistreatment.

Research into EDS and childbearing is in it’s very early stages. We hope to build on this work to make a difference for all women with hEDS during pregnancy, birth and beyond.

pregnant belly

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2

Theories of work-related stress

There are many theories of work stress and general stress theories. I have been trying to get my head around just a few, and so I thought I would share them here for future reference on work stress theory. Perhaps these will help you in your job and career?…or perhaps help you as a leader or manager to support your employees. In any case, please share your top workplace tips for working productively…. I would love to see these theories used to make your workplace a happier one ❣

worked

Transactional theories of work-related stress

The most commonly used transactional theory suggests that stress is the direct product of a transaction between an individual and their environment which may tax their resources and thus threaten their wellbeing (Lazarus 1986, Lazarus and Folkman 1987). Yet a more recent version of this theoretical model suggests that it is the appraisal of this transaction that offers a causal pathway that may better express the nature of the underlying psychological and physiological mechanisms which underpin the overall process and experience of stress (Lazarus et al. 2001).

In this sense, any aspect of the work environment can be perceived as a stressor by the appraising individual. Yet the individual appraisal of demands and capabilities can be influenced by a number of factors, including personality, situational demands, coping skills, pervious experiences, time lapse, and any current stress state already experienced (Prem et al. 2017). One multidisciplinary review provides a broad consensus that stressors really only exert their effects through how an individual perceives and evaluates them (Ganster and Rosen 2013).

As such, the experience of workplace stress according to the transactional theory, is associated with exposure to particular workplace scenarios, and a person’s appraisal of a difficulty in coping. This experience is usually accompanied by attempts to cope with the underlying problem and by changes in psychological functioning, behaviour and function (Aspinwall and Taylor 1997, Guppy and Weatherstone 1997). In order to recognise these external and internal elements of workplace stress, Cox (1993) outlined another modified transactional theory. This theory represented the sources of the stressor, the perceptions of those stressors in relation to his/her ability to cope, the psychological and physiological changes associated with the recognition of stress arising, including perceived ability to cope, the consequences of coping, and all general feedback that occurs during this process.

Yet, as with all transactional theories of work-related stress, it is the concept of appraisal that has been criticised for being too simplistic and for not always considering an individuals’ history, future, goals and identities (Harris, Daniels and Briner 2004). Additionally, in his later works, Lazarus stressed that his transactional theories of stress failed to acknowledge the outcomes associated with coping in specific social contexts and during interpersonal interactions (Lazarus 2006a).

cooperate

Interactional theories of stress

Interactional models emphasise the interaction of the environmental stimulus and the associated individual responses as a foundation of stress (Lazarus and Launier 1978). For instance, the Effort-Reward Imbalance (ERI) theory posits that effort at work is spent as part of a psychological contract, based on the norm of social reciprocity, where effort at work is remunerated with rewards and opportunities (Siegrist 1996). Here, it is the imbalance in this contract that can result in stress or distress. Yet in contrast to transactional theories of stress, this imbalance may not necessarily be subject to any appraisal, as the stressor may be an everyday constant occurrence.

The Person-Environment Fit theory is one of the earliest interactional theories of work-related psychological distress, suggesting that work-related stress arises due to a lack of fit between the individual’s skills, resources and abilities, and the demands of the work environment (Caplan 1987, French, Caplan and Van Harrison 1982). Here, interactions may occur between objective realities and subjective perceptions and between environmental variables and individual variables. In this case, it has been argued that stress can occur when there is a lack of fit between either the degree to which an employee’s attitudes and abilities meet the demands of the job or the extent to which the job environment meets the workers’ needs (French, Rodgers and Cobb 1974).

Yet the Job Demand-Control (JDC) theory supposes that work-related stress can result from the interaction between several psychological job demands relating to workload such as cognitive and emotional demands, interpersonal conflict, job control relating to decision authority (agency to make work-related decisions) and skill discretion (breadth of work-related skills used) (Karasek Jr 1979). The JDC model is concerned with predicting outcomes of psychological strain, and workers who experience high demands paired with low control are more likely to experience work-related psychological distress and strain (Beehr et al. 2001).

However, the original concept of job demand and control was expanded in 1988 to become the Demand Control Support (DCS) theory, describing how social support may also act as a buffer in high demand situations (Johnson and Hall 1988). As social support as a coping mechanism can moderate the negative impacts of job stress, another later version of the JDC theory was developed to suggest that it is those individuals who experience high demands paired with low control and poor support who are most at risk of work-related psychological distress (Van der Doef and Maes 1999). These later versions of the JDC theory were developed, as earlier versions were considered to be too simplistic and ignorant of the moderating effects of social support upon the main variables. However, the perceived job demands and decision autonomy outlined in the JDC theory have been acknowledged as being key factors in determining the effects and outcomes of work on employees’ health (Cox, Griffiths and Rial-González 2000).

Allostatic Load Model of the Stress Process

Early psychological models of stress may be suitable for describing how environmental events generate stressful appraisals for individuals. Yet another theoretical model, devised via a multidisciplinary review of Work Stress and Employee Health identifies the intervening physiological processes that link stress exposure to health outcomes (Ganster and Rosen 2013). This Allostatic load model of the stress process builds on earlier cognitive appraisal models of stress and the work of Seyle (Seyle 1983) to describe the developments of allostasis in the process of stress. Allostasis is the process of adjustment for an individual’s bodily systems that serve to cope with real, illusory, or anticipated challenges to homeostatic (stable) bodily systems. This model proposes that continued overstimulation leads to dysregulation, and then to poor tertiary health outcomes. However, the sequence of this model has proven difficult to validate empirically. Additionally, this research is concerned with the psychological rather than the physical outcomes of work-related stress.

Allostatic Load Model of the Stress Process

Allostatic Load Model of the Stress Process

Another model of work stress has been developed in response to the Health and Safety Executive’s (HSE) advice for tackling work-related stress and stress risk assessments (Cousins* et al. 2004, HSE 2001). This model, developed by Cooper and Palmer underpins the theory and practice advocated by the HSE (Palmer, Cooper and Thomas 2003). This model explores the stress-related ‘hazards’ or sources of stress facing employees in the workplace. The acute symptoms of stress are also set out, and these symptoms relate to the organisation, as well as the individual. The negative outcomes are outlined for both an individual’s physical and mental health, however beyond this, outcomes are presented as financial losses for both the individual and the organisation.

Cooper and Palmer’s model of work stress

Cooper and Palmer_s model of work stress

Another model of work stress developed by Cooper and Marshall sets out the sources of stress at work, factors which determine how an individual may respond to such stressors, go on to experience acute symptoms, and eventually go on to reach the chronic disease phase affecting one’s physical and/or mental health (Cooper and Marshall 1976). This model is concerned with the long-term consequences of work-related stress, as well as the acute symptoms of, sources of, and the individual characteristics associated with work-related stress.

Cooper and Marshall’s model of work-related stress

Cooper and Marshall_s model of work-related stress

The Conservation of Resources (COR) Model

The above models all outline potential stressors or hazards relating to the workplace. Yet work-related stressors cannot always remain separate from general life stressors. Illustrating this, the Conservation of Resources (COR) Model, an integrated model of stress looks to encompass several stress theories relating to work, life and family (Hobfoll 1989). According to this theory, stress occurs when there is a loss, or threat of loss of resources. This is because individuals ultimately seek to obtain and maintain their resources, loosely described by the authors as objects, states, conditions, and other things that people value. Some of these stressors may relate to resources such as one’s home, clothing, self-esteem, relationship status, time and/or finances. In this context, work/relationship conflicts may result in stress, because resources such as time and energy are lost in the process of managing both roles effectively (Hobfoll 2001). This may in turn result in job dissatisfaction and anxiety, although other resources such as self-esteem may moderate such conflicts and stress (Hobfoll 2002). Such a model would be useful in the development of resource-focused interventions which aim to make changes in employees’ resources and subsequent outcomes (Halbesleben et al. 2014).

Understanding the Role of Resources in Conservation of Resources Theory

Basic Tenets of Conservation of Resources Theory

Principle 1 Resource loss is more salient than resource gain.

Principle 2 People must invest resources to gain resources and protect themselves from losing resources or to recover from resource loss.

Corollary 1 Individuals with more resources are better positioned for resource gains. Individuals with fewer resources are more likely to experience resource losses.

Corollary 2 Initial resource losses lead to future resource losses.

Corollary 3 Initial resource gains lead to future resource gains.

Corollary 4 Lack of resources leads to defensive attempts to conserve remaining resources.

(Halbesleben et al. 2014)

A Sample of Psychological Resources

Objects/ Conditions: Job Security Constructive Rewards, Reinforcement Contingencies, Inducements

Constructive: Autonomy, Decision Authority, Skill Discretion, Control Participation in Decision Making Opportunities for Professional Development Resilience

Social Support: (supervisor, coworker, organization, spousal, customer, etc.)

Energies: Time Away from Work, Recovery Experiences

Key: Self-Esteem, Self-Efficacy, Locus of Control, Core Self-Evaluation Conscientiousness, Emotional Stability

Macro: Family-Friendly Workplace Policies

(Halbesleben et al. 2014)

The Revised Transactional Model of Occupational Stress and Coping

One model combines both Lazarus’ transactional theory of stress and coping (Lazarus 1986) and Karasek’s JDC theory (Karasek Jr 1979) is the revised transactional model of occupational stress and coping presented by Goh and colleagues (Goh, Sawang and Oei 2010). This model demonstrates how individuals appraise, cope with and experience occupational stress. This process involves an individual firstly encountering a potential stressor and appraising their experience of it. Subsequently, this model demonstrates how the individual then goes on to a secondary phase of risk appraisal, where coping strategies are initiated in response to the individuals experience of the initial stressor. The model also outlines how immediate outcomes and outcomes after 2 to 4 weeks are involved throughout this process of stress and coping.

In this case, the model demonstrates a direct link between the primary appraisal of the stressor and primary stress outcomes, and also a direct link between the primary and secondary stress outcomes. This process demonstrates how the appraisals of stressful events can significantly impact on an individual’s experience of stress and its associated outcomes. This model also provides support to the effect of emotions on a person’s choice of coping strategy (Ficková 2002). Notably, this model posits that the experience of stress, coping and the development of negative outcomes can occur at different points in the process of occupational stress and coping, and can be triggered by both psychological and behavioural coping factors.

The Revised Transactional Model of Occupational Stress and Coping

This model is my personal favourite as it explains the process and experience of stress and appraisal, along with the outcomes of stress. Here, we can also see how each component relates to one another. These are just a few of the stress models out there. Some can be applied to life, and some to areas of the workplace. Are the two ever really separate?…If you have any more you would like me to add then please let me know. I hope these few give us all something to think about in the field of work-related stress research and practice.

If you would like to follow the progress of my work going forward..

Follow me via @SallyPezaroThe Academic MidwifeThis blog

Until next time…Look after yourselves and each other 💚💙💜❤

References

Aspinwall, L. G. and Taylor, S. E. (1997) ‘A Stitch in Time: Self-Regulation and Proactive Coping.’. Psychological Bulletin 121 (3), 417

Beehr, T. A., Glaser, K. M., Canali, K. G., and Wallwey, D. A. (2001) ‘Back to Basics: Re-Examination of Demand-Control Theory of Occupational Stress’. Work & Stress 15 (2), 115-130

Caplan, R. D. (1987) ‘Person-Environment Fit Theory and Organizations: Commensurate Dimensions, Time Perspectives, and Mechanisms’. Journal of Vocational Behavior 31 (3), 248-267

Cooper, C. L. and Marshall, J. (1976) ‘Occupational Sources of Stress: A Review of the Literature Relating to Coronary Heart Disease and Mental Ill Health’. Journal of Occupational Psychology 49 (1), 11-28

Cousins*, R., Mackay, C. J., Clarke, S. D., Kelly, C., Kelly, P. J., and McCaig, R. H. (2004) ‘‘Management Standards’ Work-Related Stress in the UK: Practical Development’. Work & Stress 18 (2), 113-136

Cox, T., Griffiths, A., and Rial-González, E. (2000) ‘Research on Work-Related Stress: European Agency for Safety and Health at Work’. Luxembourg: Office for Official Publications of the European Communities

Cox, T. (1993) Stress Research and Stress Management: Putting Theory to Work.: HSE Books Sudbury

Ficková, E. (2002) ‘Impact of Negative Emotionality on Coping with Stress in Adolescents.’. Studia Psychologica

French, J. R., Caplan, R. D., and Van Harrison, R. (1982) The Mechanisms of Job Stress and Strain.: Chichester [Sussex]; New York: J. Wiley

French, J. R., Rodgers, W., and Cobb, S. (1974) ‘Adjustment as Person-Environment Fit’. Coping and Adaptation, 316-333

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Johnson, J. V. and Hall, E. M. (1988) ‘Job Strain, Work Place Social Support, and Cardiovascular Disease: A Cross-Sectional Study of a Random Sample of the Swedish Working Population’. American Journal of Public Health 78 (10), 1336-1342

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Lazarus, R. S., Cohen-Charash, Y., Payne, R., and Cooper, C. (2001) ‘Discrete Emotions in Organizational Life’. Emotions at Work: Theory, Research and Applications for Management 4584

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Lazarus, R. S. and Launier, R. (1978) ‘Stress-Related Transactions between Person and Environment’. in Perspectives in Interactional Psychology. ed. by Anon: Springer, 287-327

Palmer, S., Cooper, C., and Thomas, K. (2003) ‘Revised Model of Organisational Stress for use within Stress Prevention/Management and Wellbeing programmes—Brief Update’. International Journal of Health Promotion and Education 41 (2), 57-58

Prem, R., Ohly, S., Kubicek, B., and Korunka, C. (2017) ‘Thriving on Challenge Stressors? Exploring Time Pressure and Learning Demands as Antecedents of Thriving at Work’. Journal of Organizational Behavior 38 (1), 108-123

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