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Gould identifies the need for midwives to understand the meaning of normal labour in order to fulfil their statutory duty.

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Gould argues that the failure of midwives to define normality on their own terms contributes to the dominance of a medicalised, technologically-driven, interventionist birthing culture. Evidence indicates that physiological birth is supportive of the health and well-being of mother and child Carolan-Olah et al for example, promoting mother-baby bonding and successful initiation and continuation of breastfeeding Moore et al In the long term neonates experiencing impaired remodelling may be at risk of problems of metabolism such as type 1 diabetes and obesity Taylor Midwifery support for normal birth would seem, therefore, to have considerable potential for supporting the health of current and future generations thereby relieving financial pressure on the NHS.

Scientific knowledge based on technological output, such as continuous monitoring of the fetal heart rate FHR , was privileged over body knowledge and intuition and the midwife-mother relationship was interrupted by a task-driven labour ward culture. All of the ten midwives interviewed drew strength and inspiration from colleagues modelling the facilitation of physiological birthing. How a midwife responds to an uncertainty in a low-risk labour, such as the presence of meconium in late second stage, becomes a defining characteristic of that labour, in terms of normality.

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It shows in addition, therefore, that identifying deviation from normal is not a simple response to a cut and dried event as regulatory standards suggest NMC Normal birth perspective Student midwives, when asked for their understanding of NB, identified a woman working to birth her baby without pharmacological pain relief or intervention as representing an ideal of NB Gilkison et al Furthermore, Anderson found that students regarded NB as the unfolding of a physiological process without disturbance. They identified hospital policies as a barrier to NB because they were valued over autonomous practice in the birthing culture.

Students in both studies Gilkison et al , Anderson concluded that you could classify normal as what happened regularly which, in an obstetric-led unit, could involve a number of interventions in the birthing process. Some of the students who talked to Gilkison et al felt very strongly that normality could, in fact, only be defined by the birthing woman. However, it is reasonable to infer that for some women giving birth is a profound experience which, for those who felt in control of the process, engendered a sense of health and well-being that benefitted their parenting.

Conversely, women who felt that they had not experienced NB, and this was related to interventions during labour and mode of birth, suffered physical, mental and emotional morbidity that compromised their transition to parenthood. Hunter found, by contrast, that positive birth experiences enjoyed by women she talked to were not dependent on mode of birth, setting for birth, or model of care experienced. Positivity was dependent on mutually trusting relationships with health professionals and a strong sense of labour and birth as an embodied experience that they controlled.

It can be seen, therefore, that the journey for student midwives to qualification as practitioners who are confident and skilful in the Indeed, a student midwife who does not recognise that the topic of NB raises questions around epistemological understanding, ethical practice, advocacy and mutually respectful multiprofessional working, may lack competence as an autonomous practitioner. A midwife needs to recognise and guard normality because, as a specialist, she knows that undisturbed, physiological birthing supports safety and satisfaction for mother and baby.

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Perhaps this is because NB, as a social construct, built by individuals and communities from ideas, values, interests, experience and cultural influences, is a chimera. Different definitions of NB are informing models of care that are in competition with one another for status and resources, and there may be tensions for midwives attempting to reconcile conflicting values systems in order to meet the individual needs of labouring women.

Educators, therefore, need to identify ways of facilitating learning that encourage depth and breadth of exploration so that the gap between theory and practice around NB can be bridged.


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Why enquiry-based learning? EBL, sometimes also called inquiry-based learning in the literature, and PBL overlap in terms of pedagogical philosophy and educational method Savery Schmidt et al emphasise, however, that it is the combination of self-direction and group-working that gives PBL its potency as a means of learning. Facilitators are not characterised as fonts of knowledge but as guides to learning Hmelo-Silver A multifaceted topic like NB has to be unpacked and, therefore, needs students to feel that they share in the midwifery discourse and can contribute to it by full and frank discussion.

Hmelo-Silver and Schmidt et al say that the PBL process encourages students to develop higher-order thinking skills such as analysis and evaluation because they are looking for meaning and so identify patterns and connections at micro and macro levels.


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Figure 1 below describes the EBL process that first year midwifery students follow at the University of Worcester. Introduction of enquiry trigger by tutor.

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Cohort has tutor learning outcomes. Tutor present as facilitator. Cohort breaks into designated EBL groups for initial identification of focus of interest. Group nominates chairperson and scribe. Group identifies a key question or a learning outcome. Each EBL group feeds back its findings to the cohort. All students participate. Verbal feedback from tutor. Written feedback from tutor to each group regarding identification of chosen topic, quality of evidence identified, style of presentation. In terms of NB students may, for example, identify factors that facilitate it, and those that restrain it, leading to consideration of labour ward culture, evidence-based practice, defensive practice, professional identity, the medicalisation of birth as a feminist issue, and so on.

If students qualify feeling confident in their ability to question and analyse usual practice around NB then they will be the autonomous, evidence-based practitioners constituted by statutory regulation. Enquiry-based learning can be transformative learning as described by Mezirow cited by Illeris Illeris has extended this cognitive transformation to encompass the emotional and social aspects of learning by proposing a concept of identity as a term suggestive of the totality of an individual. This is particularly important when students are exploring NB because, as discussed earlier in this paper, its promotion and facilitation is strongly influenced by the motivations and values of individual midwives.

Nairn et al assert that nurse education often fails to support students to achieve deep reflection that is transformative because it pays too little attention to the influence on reflection of individual and communal values systems. Bourdieu cited by Nairn et al identified an internalisation by the individual of the values systems of particular milieux that he called habitus.

Hobbs , researching seven newly qualified midwives, questioned whether they internalised the labour ward habitus or were able to restructure it to more closely resemble their ideal of midwifery practice. Furthermore, Hobbs attributed their ability to resist conforming to established practice that compromised normality to their exposure as undergraduates to higher-order thinking, such as that involved in reflexivity.

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It is essential for midwives that they appreciate the impact of their own values on NB, and those of the organisation within which they are working, in order to reconcile tensions between woman-centred care giving and task-driven practice that may do labouring women a disservice. Barry et al identified stages that newly graduated midwives move through during their first six months in practice before arriving at a more comfortable place where they can put women first and practice autonomously. The new midwives displayed considerable resilience, and made sophisticated use of communication and relationships to promote the primacy of their midwifery values in caring for women.

Russell found that midwives working in obstetric units where the culture was hierarchical, task-driven and interventionist used tactics, such as underestimating cervical dilatation, to protect normal labour from disturbance. These midwives had been qualified for between two and more than 15 years but were being strategic to support NB rather than acting as agents to change labour ward culture.

It may be that university-educated midwives Hobbs , Barry et al , Anderson , and particularly those who have acquired their professional identity through EBL, have the confidence and the cognitive and interpersonal skills to unpick the workplace culture and remake it in favour of supporting NB. Summary This paper demonstrates that NB is a nebulous concept that has different meanings for childbearing women, midwives, obstetricians, health regulators and funders of maternity services.

Midwives need to recognise it because they have a professional duty to promote and facilitate it and it marks the boundary of their specialist area of autonomous practice. Women need it because physiological birthing protects the health and well-being of mothers and babies. This is recognised by organisations concerned with health, both in the United Kingdom and internationally, as society struggles to meet the cost of medical intervention in birth, and a rising caesarean section rate.

The values systems of birth workplaces and of individual midwives have a significant impact upon NB. Educators of midwifery students are also midwives with the same responsibility for guardianship of normality as is incumbent upon their Midwife tutors have a duty to ensure that, at the point of registration students can promote and facilitate NB, and so need to identify pedagogical approaches that inspire deep learning capable of transfer from theory to practice.

Enquirybased learning is both an educational philosophy, and a teaching method that can be effective in helping students to become self-directed and reflexive with effective cognitive skills and a strong sense of professional identity. Newly qualified midwives need these attributes if they are to be agents of change for the promotion of woman-centred NB and have the potential to become consultant midwives who can inspire others and lead service development that offers the best possible experience to birthing women.


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References Anderson G Evidence Based Midwifery 13 2 Newly-graduated midwives transcending barriers: mechanisms for putting plans into actions. Normal childbirth: evidence and debate. Edinburgh: Churchill Livingstone: Midwifery 31 1 Effects of tutor-related behaviours on the process of problem-based learning. Fisher M, Moore S Enquiry-based learning links psychology theory to practice.

British Journal of Midwifery 13 3 Understanding student learning. A handbook for teaching and learning in higher education. Abingdon: Routledge: Defining normal birth: a student perspective. Illeris K Transformative learning and identity. Journal of Transformative Education 12 2 International Confederation of Midwives International code of ethics for midwives. International definition of the midwife. Understanding enquiry-based learning. Handbook of enquiry and problem based learning: Irish case studies and international perspectives. Consensus statement from the Maternity Care Working Party: our shared views about the need to recognise, facilitate and audit normal birth.

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Back to normal: a retrospective, cross-sectional study of the multi-factorial determinants of normal birth in Queensland, Australia. Midwifery 31 8 Early skin-toskin contact for mothers and their healthy newborn infants.

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Reflexivity and habitus: opportunities and constraints on transformative learning. London: NICE. Standards for competence for registered midwives. Page M, Mander R Intrapartum uncertainty: a feature of normal birth, as experienced by midwives in Scotland. Rothman BK The social construction of birth. Midwives and normal birth in obstetric led units. A structural-equations modeling approach to learning in problem-based curricula.

Academic Medicine 70 8 The process of problem-based learning: what works and why. Medical Education 45 8 Smyth C Midwives back down on natural childbirth. Taylor PD Midwifery 31 3 The influence of tutoring competencies on problems, group functioning and student achievement in problem-based learning. Medical Education 40 8 Mason L. Every year, the Office for National Statistics records around , live births in England and Wales, and about a third of these women will experience some sort of vaginal leakage.

In most cases, it is harmless, resulting from urinary incontinence or changes to the vaginal secretions. It is also not unusual for hormonal changes during pregnancy to increase the amount of mucous and moisture in the vagina, which might be mistaken for something more serious. Mild infections, such as thrush or bacterial vaginosis may also mimic amniotic rupture.

Although dampness may indicate a rupture of the membranes, it is important to promptly rule out other causes. Others may dismiss it, assuming it to be a normal part of pregnancy, possibly only mentioning it in passing. This presents midwives with a tough challenge as without invasive intervention, it can be difficult to tell whether it is urine, vaginal discharge or leaking amniotic fluid.