It is estimated that approximately 350 000 women in the UK will experience some degree of perineal trauma during childbirth, and 75% of these will require suturing (Kettle et al, 2002; Thiagamoorthy et al, 2014). Failure to accurately assess and repair perineal trauma can result in significant maternal morbidities including pain, infection, dyspareunia and incontinence. Women may also report psychological sequelae (Salmon, 1999; East et al, 2012).
Skilled repair of first- or second-degree perineal trauma is considered a core midwifery competency and it is imperative that midwives can undertake this accurately, to reduce adverse outcomes (National Institute for Health and Care Excellence (NICE), 2015). Research suggests, however, that many midwives lack confidence in this skill, claiming dissatisfaction with their level of training, experience or support in perineal assessment and repair (Selo-Ojeme et al, 2015; Campbell, 2016).
In line with European standards for midwifery (Keighley, 2009), the Nursing and Midwifery Council (NMC) does not require student midwives to demonstrate clinical competency in perineal repair at point of registration (NMC, 2009) and pre-registration training in perineal assessment and repair varies widely between UK universities (Bick et al, 2012; Selo-Ojeme et al, 2015). Furthermore, while the NMC ‘strongly recommends’ that newly-qualified midwives undertake a period of post-registration preceptorship (NMC, 2006), this remains a non-statutory requirement. Despite recommendations for best practice (NICE, 2015) and training programmes such as PeARLS (Ismail et al, 2013), there remains no nationally-accredited standard of competency in the UK and no international equivalents.
The assessment and management of perineal trauma after vaginal birth has been reported as a source of anxiety for midwives (Campbell, 2016). However, the factors that underlie these concerns have not been fully explored. The aim of this study was to explore the experiences that early-career midwives (defined as less than 5 years from qualification) had of perineal repair, to inform the development of effective training or education initiatives for midwives.
Methods
This study adopted an interpretative phenomenological analysis approach to data collection and analysis. This is a qualitative research methodology that focuses on the examination of little-known phenomena (Smith et al, 2009) and attempts to describe and interpret a participant's lived experience with a view to illuminating it for others.
Sampling
A purposive sampling method was used to identify participants who were familiar with the phenomenon of study and most likely to provide rich data for analysis (Smith et al, 2009). Four participants were recruited via post-qualification modules at the researcher's university, with a further two participants recruited via snowballing methods (Flick, 2014).
Ethical approval
Ethical approval was gained from the researcher's university ethics committee. Copies of the study information sheet and the researcher's contact details were distributed so that interested participants could contact the researcher in their own time. To minimise bias, participants who had been taught or mentored by the researcher were excluded from the study.
Inclusion criteria
The study aimed to examine the experiences of midwives who had performed perineal assessment and repair in practice but would also be able to reflect on current midwifery education. The following inclusion criteria were therefore applied:
Data collection
Data were collected via in-depth, semi-structured, one-to-one interviews. A pilot interview was undertaken with the assistance of a midwifery colleague not involved with the study. The interviews were audio-recorded in the researcher's office with prior consent from the participants.
Rigour and reflexivity
As a midwife and teacher of student midwives, the researcher was aware of the impact that her own experiences may have had on the process of data collection and analysis. A reflective diary was kept throughout the process to enable the researcher to acknowledge and explore any personal preconceptions on the subject of perineal repair that might bias the research process (Smythe, 2011; Berger, 2013). Participant details were protected by pseudonyms when reporting the data.
Data analysis
Data analysis followed guidelines developed by Smith et al (2009). The researcher manually transcribed the recorded data in order to promote greater familiarity with the text. After several re-readings, initial notes were made on emergent themes. Two superordinate themes developed which were then subdivided into four constituent themes.
Findings
All six participants were band 6 midwives who had been qualified for fewer than 5 years. Each participant worked in large London teaching hospitals, in either a labour ward or community caseload role.
Two superordinate themes emerged from the analytical process. Each theme had four constituent themes. The first, ‘working and learning in an imperfect environment’ concerned the way in which midwives developed the skill of perineal assessment and suturing, in relation to the organisations in which they worked. The second theme ‘Knowing myself, understanding my women’ reflected midwives' reactions to learning these skills..
Working and learning in an imperfect environment
Expectations unmet
All the participants characterised their pre-registration training as poor preparation for perineal repair in practice, and noted that the teaching of relevant skills had a low priority on the curriculum:
‘It was a very rushed day … they said, “Oh I'm really sorry but we haven't got time for this, you're going to have to do it on your own”… they just didn't have time for it.’
Once qualified, midwives found that their preceptorship programmes often did not accommodate their expectations. The experience of getting timely support for skills practice was a difficult one:
‘The lovely practice development midwife said, “Whenever you want [help with] suturing, come and find us.” Well, that's so much easier said than done. Like, “Oh yeah, you're there in the middle of the night!” … I didn't feel very supported.’
Standing up for yourself
Competing priorities and heavy workloads were identified as barriers to skills development:
‘I've had times when I've not even delivered the placenta and I've been given another labouring woman to look after. How can you possibly learn suturing at that point?’
Some of the midwives felt that they could only get experience by prioritising their own learning over the perceived needs of the service. However, the ability to push oneself forward did not come easily to all participants and labour ward hierarchies often affected skills development:
‘I said, “I've not done it before so could someone come and observe me?” And they were kind of like, “Well, we don't have time.” And then one of the consultants said, “Actually my junior needs to do it, so he's going to go in, you can get all the paperwork done and we'll observe the doctor doing it!” I probably should've been like, “Can someone not watch me instead?’”
Progression vs. stagnation
Regular opportunities to suture were identified as important in maintaining a midwife's confidence in their skills. However, training opportunities or study days often occurred when, due to clinical rotations, midwives had no chance to undertake the skill in practice. Acquisition of skills was regarded as time-sensitive, leading to anxiety:
‘You almost get to the stage where it's like, “I'm never going to learn. It's been two years now, is it ever going to happen?” The more qualified you are, the more people judge: “Well, why can't you suture?”’
The fairy godmother
Attitudes of colleagues played a significant role in midwives' experiences. Five participants identified one specific midwife in their practice environment who had made a positive impact and to whom they owed a debt of gratitude in building their confidence and understanding:
‘The first time, there was this really nice midwife … she watched me all the way through and she goes, “That was absolutely fine, you just need to practise”… I think the penny dropped then.’
‘Knowing myself, understanding my women’
The second theme focused on the ways in which the performance of perineal assessment and repair influenced midwives' understanding of their role and their professional self-image.
Being the whole package
All participants identified the concept of ‘being whole’, relating this to both their client's physical state and their own scope of practice. The midwives' views of themselves as competent professional practitioners were strongly influenced by their self-assessed abilities:
‘[Being unable to suture] makes me feel a bit incompetent … the woman's now going to think, “Oh, is this woman actually a midwife or has she just wandered in off the street and delivered my baby?”’
The weight of responsibility
All participants articulated a clear sense of personal responsibility for women's wellbeing with regard to perineal suturing. For some, these feelings were intensified by their own personal experiences:
‘I think originally it goes back to my mum … she had an episiotomy and it was sutured by a student and it was done really badly … so I was like, “Oh my god, I'm going to ruin all these women's perineums!” And now I still feel like that.’
However, all participants were highly conscious of the long-term physical and emotional effects on women of poor perineal repair:
‘I think it's the one thing we do that leaves them with a physical reminder of what you've done to them.’
The shock of reality
The reality of performing perineal assessment and repair in practice, as opposed to simulated learning, was present in many of the participants' experiences. Their descriptions of being confronted with ‘real life’ perineal trauma were often emotionally charged:
‘You're putting a needle into someone's perineum … they always react when that happens and that's terrifying … that's really, that's horrible, that's a horrible, horrible thing to do.’
Is this what a midwife does?
The participants strongly identified with an image of midwives as caring and nurturing practitioners. This meant that they found the possibility of inflicting pain on women during assessment and repair deeply problematic:
‘I feel like I'm doing something wrong here, because I'm causing pain to a woman and that's distressing for me … but you have to override that with a cognitive awareness that you are doing a service to the woman. But there's a … disjoint? They're two totally contradictory things.’
This ‘disjoint’ was also apparent as participants identified a difference between perineal suturing and other aspects of ‘normal’ midwifery care:
‘There's so much focus on normal birth, natural birth, and it's something kind of outside of that … but then it's also a midwifery skill that you should have.’
‘There's something about it which is quite surgical … well, it is surgical, isn't it? You are suturing, it is surgery!’
Discussion
This study is one of the first to examine, in depth, recently qualified midwives' perceptions of undertaking perineal assessment and repair. One of the primary findings of this study was that all participants characterised their pre-registration education provision as inadequate, with suturing skills given a low priority in the curriculum. However, this was in stark contrast to practice, where the ability to undertake perineal repair was regarded as of clear benefit to women, and a part of normal birth.
This study's findings echo those of other UK and international studies, including Campbell (2016) and Selo-Ojeme et al (2015), in positioning perineal repair as an essential midwifery skill for normal birth and therefore arguably something to be embedded at the pre-registration stage. In addition, several participants in the current study recalled that they had asked for extra teaching or had sought out extra-curricular study days at their own expense to mitigate the lack of formal curriculum provision. It can be argued that undergraduates in any discipline should expect to be proactive in developing their own knowledge and understanding beyond the curriculum. Equally, as 50% of midwifery student learning takes place in practice, it could be considered unreasonable to expect all these learning needs to be met in a university environment. Modern midwifery curricula are crowded, and educators may struggle to incorporate sufficient teaching and learning opportunities without sacrificing other priorities (Arias and Coxon, 2018). Nevertheless, these participants clearly articulated a significant theory-practice gap, whereby they felt that their learning needs went unmet.
On qualification, midwives lose the ‘protected’ status afforded to them as a student, while the imperative to develop their clinical skills quickly increases. However, this study suggests that learning opportunities were frequently sacrificed to the demands of an overstretched service and labour ward hierarchies. Participants were often ‘competing’ with other, more senior midwifery colleagues or doctors in a situation which Wilson (2012) has described as ‘fighting for experience’. These findings are also supported by Bick et al (2012), Selo-Ojeme (2015) and Campbell (2016), who highlighted the difficulty of midwives gaining support for skills development on the labour ward. Midwives who were naturally more assertive were sometimes able to move their learning forward despite the alternative priorities of senior midwives or obstetric colleagues (Young, 2012). However, for some this was more difficult, and appeared to mean a choice between personal development and professional relationships.
These findings also support recent work by Campbell (2016) and Clements et al (2013) who found that the hierarchy of the labour ward frequently affected whether or not learning needs were fulfilled. It also resonates with the work of Hunter (2004), who suggested that competing ideologies on the labour ward led to midwives absorbing personal responsibility for systemic issues; and that of Reiger (2008), who found that midwives' learning needs were marginalised in favour of their obstetric colleagues. The recurring motif of the ‘fairy godmother’ in the participants' stories appears at first to be a positive counterpoint to this. However, it may also suggest that support for skills development was not embedded in the day-to-day workplace environment and depended on midwives' individual ability to locate role models for themselves in the face of inadequate formal provision.
Wilson (2012) emphasised the importance of autonomous practitioners identifying and taking responsibility for their own skills development. The will to do this is evident in participants' responses; however, analysis of the data presented here suggests that the pressures of the transitional preceptorship period often hindered the ability to learn new skills or consolidate under-developed ones.
It is equally important to note that midwives in this study experienced perineal assessment and repair not simply within the context of clinical skills development but also, at times, from a deeply personal perspective. While Dahlen and Homer (2008) and Campbell (2016) found that continuity was the major motivating factor for midwives to become competent in perineal repair, the evidence presented here suggests that there may also be other, more complex issues at stake. These findings suggest that the ability to competently undertake perineal repair was intimately connected to both professional and personal self-image. Despite evidence of systemic barriers to skills consolidation, midwives in this study still sometimes regarded themselves as ‘incompetent’ or ‘inadequate’. This sense of inadequacy suggests a frustrated desire to provide an authentic and holistic experience that prioritises women's wellbeing, but that also promotes midwives' own sense of professional and personal satisfaction (Hunter, 2004; Dahlen and Homer, 2008; Campbell, 2016). The demands of an over-stretched service, and the persistence of labour-ward hierarchies, coupled with the participants' deep identification with the women that they cared for, suggests that at times significant emotion work was being done by midwives in this study to maintain a positive self-image.
This study also suggests a further dimension to the experience of perineal repair as related to midwifery identity. Campbell (2016) found that midwives had difficulty in handling suturing instruments and did not always view perineal repair as a midwifery skill. In this study, participants understood perineal repair as a core skill for normal birth, but characterised many aspects of suturing practice as surgical and therefore outside the scope of midwifery practice. Performing repair was also associated with causing pain to women, separating it yet further from participants' views of themselves as caring and nurturing midwives. This suggests a cognitive dissonance that may perhaps contribute to lack of confidence in skills development. Previous qualitative studies have suggested that midwives ‘distance’ themselves from the emotions associated with causing pain to women, by placing the responsibility for staying pain-free in the woman's hands (Briscoe et al, 2015) but it could be suggested that these early-career midwives have not yet reached this point of disassociation. Hobbs' (2012) study on the assimilation of newly-qualified midwives into their professional role described how registrants must learn to juggle both the midwifery and medical models, and some of the participants in this study clearly took pride in their achievement of such a ‘technical’ skill. However for others, this positioning of perineal repair between midwifery and surgical care was problematic, and reinforced their uncertainty around the procedure. Reiger (2008) discussed the historical positioning of midwifery as the ‘warm and fuzzy’ alternative to the technical dominance of obstetrics. For midwives in the present study, the reality of perineal repair could be said to occupy a contested space, wherein desire to provide skilled, holistic, nurturing midwifery care was at odds with the performance of a ‘surgical’ procedure for which they often felt ill-equipped.
Strengths and limitations
This study has very limited generalisability due to its small, homogeneous sample. However, it is the first study to address this question in depth, and many of the findings are consistent with other related research. It employed a methodology that elicited the development of rich and illuminating data, adding to the growing body of evidence around midwives' skills in perineal repair.
Conclusions and recommendations for practice
This study adds to the body of evidence that suggests that midwives need and want to learn skills such as suturing, but too often they struggle with acquiring and maintaining appropriate knowledge and ability. The findings here, and in other similar studies, suggest that midwives' true scope of practice may be limited by ambivalence in curriculum planning, a lack of robustness in some preceptorship programmes and competing priorities in practice. While this argument might be made about many areas of practice, the findings of this study suggest that skills of perineal repair may be particularly vulnerable to the pressures of an over-stretched and under-resourced service.
To address this, training in assessment and repair could be embedded earlier and more comprehensively in pre-registration education, so that the preceptorship period is one of consolidation and development, not of learning a complex skill anew. New NMC standards for pre-registration midwifery education may be an opportunity to address this issue. Midwives may benefit from training opportunities that are scheduled during intrapartum care rotations, and there may be a role for maternity unit ‘champions’ who could take a special interest in the training and development of midwives in-situ and as required (Campbell, 2016). Increased interprofessional education can be an important tool to mitigate issues around competing midwifery/obstetric priorities.
Midwives are highly sensitive to the needs of the women in their care and while this can lead to powerfully effective midwife-mother relationships, this study suggests that practitioners' empathetic reactions to the physical realities of pain and trauma might also be experienced as negative. Training and education could therefore incorporate a reflective or debriefing element that allows midwives to explore their own concerns before they obstruct learning and development.