Understanding factors influencing safety and team functionality at operative vaginal birth through multidisciplinary perspectives: A mixed methods study.

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Sasha Skinner, Eleanor Kippen, Daniel Rolnik, Peter Neil, Ryan Hodges, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5321816/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 21 Jan, 2025 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted 12 You are reading this latest preprint version Abstract Background: Operative vaginal birth (OVB) relies on effective teamwork to optimise outcomes. This study aims to explore providers’ perspectives of factors influencing safety and team functionality at OVB. Methods: This mixed methods study involved four maternity sites at Monash Health, Australia. Surveys sent to healthcare providers invited quantitative and qualitative appraisal of safety and team functionality at OVB. Semi-structured interviews further explored themes emerging from survey responses. Categorical survey data were compared between staff roles using Pearson’s chi-squared tests. Thematic analysis of free-text survey responses and interviews identified themes influencing safety and team functionality at OVB. Findings: We received 100 survey responses from obstetric (n=41), midwifery (n=52) and paediatric (n=7) staff, including senior (n=49) and junior (n=51) roles. Overall, 99% thought team communication should improve and 82% had witnessed practices outside protocol. Obstetric versus midwifery or paediatric staff were less likely to rate communication as low or very low quality (5% vs. 29%, p=0.010). Reporting being extremely or very confident to escalate concerns was more likely in obstetric versus midwifery or paediatric staff (49% vs.12%, p=0.003) and senior versus junior staff (44% vs. 10%, p=0.008). Five overarching themes impacted on team functionality at OVB; (1) Calibre of communication, (2) Preparation and risk assessment, (3) Leadership and interpersonal dynamics, (4) Transfer from Birth Unit to Operating Theatre, (5) Variation in clinical practice. Discussion: Some care providers perspectives of team functionality at OVB differed, with midwifery and paediatric staff more likely to report challenges with communication and were less empowered to escalate concerns. Training in factors impacting team functionality at OVB should be considered. Operative vaginal birth instrumental birth communication team functionality human factors Background Operative vaginal birth (OVB) accounted for 12% of all births in Australia 2021, and one in four births of first-time mothers. 1 OVB may be considered in the second stage of labour to expedite birth for maternal and/or fetal wellbeing, as an alternative to fully dilated caesarean section (FDCS). However, both OVB and FDCS are associated with increased risks of neonatal and maternal morbidity and mortality. In 2019, the Consultative Council on Obstetric and Paediatric Mortality and Morbidity (CCOPMM), a Victorian advisory body to the Minister of Health, reported that cases of poor outcomes resulting from OVB demonstrated similar themes of breakdown in team communication, loss of situational awareness, lack of escalation, and inadequate safety systems. 2 This report recommended a formal team time-out to improve situational awareness and decision-making in OVB, as well as ensuring staff were knowledgeable of current safety guidelines and avoided excessive traction to achieve vaginal birth. The “role and value of the whole healthcare team” alongside structured processes to assess and consider safety factors were emphasised. The importance of human factors in healthcare to improve patient safety is increasingly recognised. 3 – 5 In maternity care, failure of human factors such as teamwork, communication and situational awareness, is responsible for over 70–80% of sentinel adverse events. 6 , 7 Provision of safe and holistic intrapartum care relies on effective and respectful collaboration between members of the multidisciplinary team, as well as with the birthing woman and support person. In this high-acuity setting, decision-making is often time-critical and multifactorial, balancing the needs of mother and neonate, which may be conflicting. In this context, situational awareness involves the capacity to accurately identify, assess and anticipate multiple risks and events occurring in real-time, to therefore provide appropriate and timely care. 7 When performing technically complex births, such as OVB, clinicians can become task-focussed and thus susceptible to loss of situational awareness. 8 This may potentially lead to practices outside accepted safety guidelines, including excessive attempts at vaginal birth resulting in significant trauma to the mother and neonate, or limited capacity to anticipate and recognise complications. 2 , 9 A team “time-out” refers to a pre-procedural safety checklist involving the healthcare team and patient which aims to introduce the team, summarise the planned procedure, identify any safety concerns, anticipate possible complications and outline escalation pathways. Safety checklists have been shown to improve team communication, adherence to safety guidelines and safety culture in many areas of medicine, including in maternity care. 10 – 15 Improving communication and collaboration of the healthcare team, the birthing woman and support person, has been shown to prevent adverse obstetric outcomes and improve maternal birth experience. 16 – 18 Enhancing team functionality at OVB is proposed to improve situational awareness, anticipation of potential complications, utilisation of available resources and adherence to safety guidelines. 9 , 19 However, there is limited qualitative inquiry into the factors that impact teamwork and safety of OVB from healthcare workers perspectives. Methods Aim This study aims to evaluate how team functionality and safety of OVB can be optimised through the perspectives of healthcare providers. In this study, team functionality refers to how healthcare staff perceive the dynamics, collaboration and performance of the multidisciplinary team present at an OVB, with particular attention to team communication, escalation, and adherence to safety guidelines, considering the 2019 CCOPMM recommendations. Study design This study design is based on a pragmatist paradigm, in which multidimensional methods are encouraged in order to achieve the desired research objective whilst ensuring the research is contextually relevant to the subjects of its inquiry. 20 Pragmatism allows scope for the pluralist understanding of multiple truths, acknowledging that individuals can experience reality differently. 21 This framework enables a nuanced understanding of the different perspectives of healthcare providers involved in an OVB, within the complex and dynamic social systems in which they work, including perspectives that are both congruent and conflicting. This is especially important when considering potential influences on team functionality, where it is necessary to understand multiple perspectives and how they relate to each other. We employed a mixed methods convergent sequential study design. First, to quantify the diversity of perspectives amongst a large cohort of staff involved in OVB, we utilised electronic surveys with both Likert-scale and free-text style questioning relating to OVB (Supplementary Material 1). An interview guide (Supplementary Material 2) was then developed based on responses from the surveys and in collaboration with researchers of obstetric and midwifery clinical backgrounds. Semi-structured interviews were then performed to further explore emerging themes and nuances of contributory factors identified by staff. Team reflexivity The diversity of our research team assists in maximizing data analysis credibility. SS, the primary author, is an obstetric trainee and concurrently completing a Doctor of Philosophy degree in obstetrics. EK is a junior midwife with four years’ experience in maternity care, and NM a senior midwife with more than 20 years’ experience. DR, RH, PN, BM and AK are consultant obstetricians with extensive experience in obstetrics academic and research design. Setting This study was performed at Monash Health encompassing four metropolitan public hospitals in Victoria, Australia, including one tertiary and three secondary sites. Monash Health is the largest maternity and perinatal provider in Victoria, providing care for over 10,000 births annually, of which 10.5% of births are assisted with forceps and 5% with ventouse. Obstetric staff must either be themselves credentialed or supervised by a credentialed practitioner to perform OVB. Midwives do not perform OVB, but do have an essential role in supporting the birthing woman as well as the obstetric accoucheur, including preparing equipment and medications, receiving the neonate, managing complications and facilitating appropriate escalation as needed. The local protocol indicates that all OVB are attended to by a paediatric staff member to care for the neonate. The local OVB protocol gives recommendations regarding appropriate indications, prerequisites, precautions and contraindications, procedural limits, escalation pathways, complications and post birth cares for OVB with reference to international college guidelines. This protocol applies for all four maternity sites. Data collection occurred from October to November 2021 at Monash Medical Centre, Dandenong and Casey Hospitals and then at Sandringham Hospital in from March to May 2023 when this service joined the Monash Health network. Participants and recruitment Participants were healthcare providers including junior and senior midwifery, obstetric and paediatric staff. Senior and junior midwifery staff were defined as those with more than or less than five years clinical experience respectively. Senior obstetric or paediatric staff were defined as specialist consultants, with junior obstetric and paediatric staff being doctors in training who had not yet obtained their specialty certification. Anonymous survey links were distributed via staff e-mail addresses to all midwifery, obstetric and paediatric staff, as well as in the maternity newsletter through convenience sampling. Following survey data collection and development of the interview guide, invitations to participate in interviews were similarly distributed to all maternity and perinatal staff via staff e-mail addresses. We utilised a mixture of convenience and purposive sampling for interviews, whereby recruitment continued until representation of senior and junior, obstetric and midwifery staff was achieved. Ethics The study received ethical approval from the hospital Human Research Ethics Committee as a low-risk project. Participants gave informed and verbal consent to participate in the study. Survey responses were anonymous, and interview transcriptions were deidentified to maintain confidentiality. Data collection Anonymous survey data were collected electronically from all four hospitals and completed independently by responders without assistance of research staff. Interviews were performed by authors SS and AK to further explore themes emerging from analysis of survey responses and involved five participants with representation of senior and junior midwifery and obstetric staff. Given surveys were anonymous, researchers were not aware of whether interview participants had responded to the survey. Participants were aware of the research aims prior to consenting to be interviewed. Interviews were conducted via video conferencing and audio recorded. The interview started by asking open-ended questions about participants’ roles at an OVB and factors they identified influencing team functionality and safety of OVB. As the interviews were semi-structured, the direction of the interview was guided by the participants, with a focus on exploratory enquiry. The interview guide (Supplementary Material 2) covered topics such as communication, teamwork, clinical practice in the context of recommended guidelines and escalation. The interview concluded by asking participants to share any suggestions they had to improve the physical or psychological safety of OVB for birthing women and their neonates. Interviews ranged from 20 to 28 minutes in duration. Interviews were transcribed verbatim, and transcriptions were checked for accuracy by one of the authors (SS) with the assistance Otter.ai software. Data analysis Likert-scale survey responses were collated and compared between obstetric and midwifery or paediatric staff, as well as between junior and senior staff, using Pearson's chi-squared test or fisher exact test for questions with less than five counts for any of the response options. The grouping of obstetric compared to midwifery and paediatric staff was chosen to reflect the perspectives of staff performing the OVB procedure (obstetric staff) compared to those present supporting the procedure and receiving the neonate (midwifery and paediatric staff). Statistical significance was defined as a p value < 0.05. Deidentified interview transcriptions and free-text survey responses were thematically analysed per Braun and Clarke 6-step process. 22 , 23 The data were read multiple times by authors SS, AK and EK, initially to gain familiarity and later to inductively and independently code the data, ensuring each transcript was reviewed by at least two researchers. In the first round of analysis, initial codes were agreed upon by the researchers and in subsequent rounds emerging themes were developed. Ongoing analysis and refinement of themes was performed to ensure themes applied to the entire dataset. Final themes and interpretations of the findings, in context of the research question, were agreed upon by the authors. Results We received 100 responses to the survey. Of those, 41 were from obstetric, 52 midwifery, and seven from paediatric staff. There was an even distribution of responses from senior (n = 49) and junior staff (n = 51). The clinical roles of respondents are summarised in Table 1 . Table 1 Clinical roles of respondents Midwifery or Paediatric staff n = 59 (%) Obstetric Staff n = 41 (%) Senior midwives 25 (42) Obstetric consultants 14 (34) Junior midwives 27 (46) Obstetric senior registrars 4 (10) Paediatric consultants 6 (10) Obstetric junior registrars 16 (39) Paediatric registrars 1 (2) Obstetric residents 7 (17) Junior Staff n = 51 (%) Senior Staff n = 49 (%) Obstetric junior registrars 16 (32) Obstetric consultants 14 (29) Obstetric residents 7 (14) Obstetric senior registrars 4 (8) Junior midwives 27 (53) Senior midwives 25 (51) Paediatric registrars 1 (2) Paediatric consultants 6 (12) Data are presented as absolute numbers (n) and proportions (%). Junior and senior midwives were defined as less than or greater than five years’ experience, respectively. Comparing responses from obstetric vs. midwifery and paediatric staff, obstetric staff were more likely to rate communication as high quality (56% vs. 29%, p = 0.010) and more likely to be very or extremely confident raising concern if they observed practices outside protocol (49% vs. 12%, p = 0.003). Compared to senior staff, junior staff were more likely to report never conducting or observing a team time-out prior to OVB (53% vs. 29%, p = 0.023) and less likely to be very or extremely confident raising concern if they observed practices outside protocol (10% vs. 45%, p = 0.008). Overall, 99% of healthcare staff thought communication at OVB could improve, with the majority (58%) reporting it should improve “a lot” or “a great deal”. Only 21% of staff reported that concerns would be raised by staff “usually” or “always” if practices outside protocol were observed. Likert-scale survey responses are summarised in Table 2 . As there were relatively few responses from paediatric staff, we conducted a sensitivity analysis excluding paediatric staff responses with similar results (Supplementary Material 3). Table 2 Perspectives of maternity and perinatal staff on team functionality at operative vaginal birth Overall (n = 100) Midwifery or Paediatric staff (n = 59) Obstetric staff (n = 41) p-value Junior staff (n = 51) Senior staff (n = 49) p-value Currently, how effectively do you believe teams communicate during attempted OVB? Very high quality 2 (2) 2 (3) 0 (0) 0.010 0 (0) 2 (4) 0.289 High quality 40 (40) 17 (29) 23 (56) 20 (39) 20 (41) Neither high nor low quality 39 (39) 23 (39) 16 (39) 19 (37) 20 (41) Low quality 18 (18) 16 (27) 2 (5) 12 (24) 6 (12) Very low quality 1 (1) 1 (2) 0 (0) 0 (0) 1 (2) Do you think team communication at OVB could improve? A great deal 24 (24) 16 (27) 8 (20) 0.452 14 (28) 10 (20) 0.282 A lot 34 (34) 20 (34) 14 (34) 20 (39) 14 (29) A moderate amount 28 (28) 13 (22) 15 (37) 10 (20) 18 (37) A little 13 (13) 9 (15) 4 (10) 7 (14) 6 (12) None at all 1 (1) 1 (2) 0 (0) 0 (0) 1 (2) How often have you observed or conducted a team 'time out' prior to attempted OVB? Always 0 (0) 0 (0) 0 (0) 0.139 0 (0) 0 (0) 0.023 Usually 10 (10) 6 (10) 4 (10) 2 (4) 8 (16) Sometimes 20 (20) 8 (14) 12 (29) 11 (22) 9 (18) Rarely 29 (29) 16 (27) 13 (32) 11 (22) 18 (37) Never 41 (41) 29 (49) 12 (29) 27 (53) 14 (29) Have you witnessed OVB practices that are outside protocol? A great deal 3 (3) 2 (3) 1 (2) 0.513 2 (4) 1 (2) 0.035 A lot 6 (6) 5 (8.5) 1 (2) 1 (2) 5 (10) A moderate amount 28 (28) 19 (32) 9 (22) 21 (41) 7 (14) A little 45 (45) 25 (42) 20 (49) 18 (35) 27 (55) Not at all 11 (11) 5 (8.5) 6 (15) 5 (10) 6 (12) I am unsure of the Monash Health OVB protocol 7 (7) 3 (5) 4 (10) 4 (8) 3 (6) When you have observed OVB practices that are outside protocol, how often are concerns raised by other members of the team? Always 4 (4) 1 (2) 3 (7) 0.220 3 (6) 1 (2) 0.561 Usually 17 (17) 10 (17) 7 (17) 5 (10) 12 (25) Sometimes 35 (35) 23 (40) 12 (29) 20 (40) 15 (31) Rarely 24 (24) 17 (29) 7 (17) 13 (26) 11 (22) Never 4 (4) 1 (2) 3 (7) 2 (4) 2 (4) I am unsure of the Monash Health OVB protocol 9 (9) 4 (7) 5 (12) 4 (8) 5 (10) I have not observed OVB practices that are outside protocol 6 (6) 2 (3) 4 (10) 3 (6) 3 (6) No response 1 1 0 1 0 When you observe OVB practices that are outside protocol, how comfortable do you feel about raising concern? Extremely confident 12 (12) 3 (5) 9 (22) 0.003 1 (2) 11 (22) 0.008 Very confident 15 (15) 4 (7) 11 (27) 4 (8) 11 (22) Somewhat confident 21 (21) 14 (24) 7 (17) 13 (26) 8 (16) Not so confident 34 (34) 24 (41) 10 (24) 20 (40) 14 (29) Not at all confident 9 (9) 8 (14) 1 (2) 6 (12) 3 (6) I am unsure of the Monash Health OVB protocol 6 (6) 3 (5) 3 (7) 4 (8) 2 (4) I have not observed OVB practices that are outside protocol 2 (2) 2 (3) 0 (0) 2 (4) 0 (0) No response 1 1 0 1 0 Data are presented as absolute numbers (n) and proportions (%). p-values obtained using Chi-squared of Fisher’s Exact tests. OVB = Operative Vaginal Birth NB. Eleven of the eighteen survey responders who reported being unsure of the protocol or having not observed OVB practices outside protocol, then answered one of the follow-up questions relating to raising concern when such practices were observed, which was inconsistent with their prior response. Qualitative analysis of free-text survey responses and semi-structured interviews identified five overarching themes impacting team functionality at OVB; (1) Calibre of communication, (2) Preparation and risk assessment, (3) Leadership and interpersonal dynamics, (4) Transfer from Birth Unit to Operating Theatre and (5) Variation in clinical practice. These themes closely related to our research enquiry into communication, escalation and adherence to safety guidelines. Themes, subthemes and representative quotes are summarised in Table 3 . Table 3 Themes Theme Subtheme Illustrative quotes (1) Calibre of communication Indirect communication “We can sort of guess what might be happening, but it's definitely not discussed with us…nobody actually tells you specifically, you just sort of overhear it.” (MW2, junior midwife) “Simply talk to one another and describe the degree of concern for the baby.” (PED4, paediatric consultant/fellow) Unclear reasoning for decision-making “I think a lot of women are confused and are unsure of what happened and why. And I think the midwives probably are too.” (MW1, senior midwife) “I don't know necessarily why we choose to go down to theater for a trial of forceps versus or forceps in the room” (MW2, junior midwife) Manner of communication impacting team performance “This belittling and demanding communication can make junior staff, in particular, become frazzled and feel a great deal of pressure. This can lead to lack of ability to speak up or ask questions to put into documentation. It can also make the woman feel more concerned and uncomfortable.” (MW11, junior midwife) “Just more communication from O&G to midwifery, and not to get too upset if TXA [Tranexamic acid] and Augmentin [Amoxycillin-Clavulanic acid antibiotic] aren't in the room straight away. It takes time and rapport to set up effectively for an instrumental by midwifery team and it can be so tough when communication isn’t effective.” (MW21, junior midwife) “I think they [the midwifery team] are just really good communicators… it's a very open and very friendly environment.” (OB2, obstetric registrar) Inadequate consent “I often feel women are inadequately counselled to make an informed decision” (MW42, senior midwife) “You might get a doctor sitting on the end of the bed talking to the woman saying, you know, you've been pushing for an hour, we haven't seen much progress, we just need to "help your baby out" without actually necessarily saying what that is, or what that looks like, or the risks of that as well.” (MW2, junior midwife) “Communication to the woman is mostly inadequate.” (MW19, Senior midwife) (2) Preparation and risk assessment Understanding capabilities of the team and role allocation “It feels like no one really checks in... turns around and makes sure, Okay, who have we got in the room? We've got a really junior midwife. That's it. Like, that's probably not a good time to start the procedure.” (MW1, senior midwife) “Waiting until paediatrician arrives before delivery.” (MW17, junior midwife) “That would be my biggest suggestion…to make sure that all the right people are there. Explain what's about to happen briefly. Make sure everyone knows that their roles are clearly defined. Make sure we have someone documenting, someone drawing up drugs, someone making sure all the equipment is present, making sure that the paediatrician was on the way or that some sort of person is there for the baby.” (MW1, senior midwife) Transparency of decision making and risk assessment “More clear communication between obstetric and neonatal staff, particularly if there have been concerns about fetal wellbeing during labour” (PED1, paediatric consultant/fellow) “I feel more confident when I've seen the doctor use that ultrasound prior to confirm position.” (MW1, senior midwife) “I don't know, I haven't had my hands inside the woman so I don't know where the head is at …sometimes it can feel like decisions are made. And then if a woman asked you when you're in recovery, why did that happen? I wouldn't necessarily know the answer to that” (MW2, junior midwife) Pain relief “I think there is often a lack of opportunity for any type of pain relief as well which can be super traumatic for the women…they often ask us afterwards why they had no pain relief!” (MW14, junior MW) “I feel the only analgesia appropriate for trial of forceps is epidural/spinal to reduce the trauma women often describe.” (MW19, senior midwife) (3) Leadership and interpersonal dynamics Involvement of senior clinicians “The seniority of the people in the room, that's when I would be less confident, if particularly more junior doctors were the ones performing the instrumental.” (MW1, senior midwife) “Discuss with senior doctors prior to performing procedure and the consultant should provide a second opinion in Birth Suite and not book a trial of instrumental in Operating Theatre if procedure can be carried out on the ward.” (MW8, junior midwife) “They [the obstetric team] feel more comfortable, because if we go to Theatre, then they have a more senior person present.” (MW1, senior midwife) Interprofessional relationships and working with a familiar team “I think it would depend on the situation for sure, and my relationship with a doctor. Like, some doctors, you know, you definitely feel much more comfortable with” (MW1, senior midwife) “I think maybe the hardest bit comes from because our doctors sort of cycle through and by the time we're finally used to them, and what they do and how they communicate, they leave, and a new lot comes.” (MW2, junior midwife) Hierarchy and empowerment to escalate “It doesn't feel like you can necessarily say anything in that moment, particularly if it's a consultant, obviously, doing the procedure, rather than like one of our registrars or something” (MW2, junior midwife) “I don't feel like there's a great level of maybe confidence of the midwives. I know I probably wouldn't feel comfortable making those calls.” (MW1, senior midwife) “I feel least confident commenting to obstetric team as the paediatrician regarding number of pulls that should/shouldn’t be done.” (PED6, paediatric consultant/fellow) “Everyone follows the hierarchy, they know when to escalate.” (OB1, senior obstetrician) (4) Transfer from Birth Unit to Operating Theatre Change in team dynamics “All healthcare workers in the theatre should provide a positive environment. As a midwife I often feel like an outsider which can make the experience awkward. We are all a team even if we are from different departments.” (MW5, junior midwife) “In Theatre… that's obviously a very different experience, because Theatre is very in control of that space. But when they do happen upstairs [referring to Birth Suite], I think there's enough people around, and I think we've got enough support.” (MW2, junior midwife) Difficulty communicating urgency “But whenever we go down to Theatre for a trial of instrumental, it's mainly the Theatre issue… it's sometimes difficult to get things done quickly. It's difficult to just get them on the same page…communication with the Theatre team is challenging” (OB1, senior obstetrician) “The hardest part communication wise is getting down there and reinforcing the importance of why you need to be there…It makes it quite difficult for you to communicate how quickly you need to do something.” (OB2, obstetric registrar) Poor patient experience in theatre “I think once you're down in Theatre, there becomes this weird disconnect between the patient and what you're doing… I think that change of venue sometimes messes with how clinicians might communicate with them.” (MW2, junior midwife) “A trial of forceps is a stressful and overwhelming experience for the woman and partner and midwife.” (MW19, senior midwife) (5) Variation in clinical practice Variation in clinician practice “Sometimes there's doctors that you know, this person is always going to go to Theatre, this person never goes to Theatre, which I don't understand whether it's just like a personal preference.” (MW1, senior midwife) “Each time is with a different consultant with a different method. It's hard to get in consistent practice. To be honest, it's hard to apply the protocol because you just do what the consultant says.” (OB10, obstetric registrar) “There is a lot of variation in practice, for example with number of pulls with a vacuum delivery.” (PED7, paediatric consultant/fellow) “There is also sometimes an inconsistency in where we do an OVB – Birth Suite or Operating Theatre. There needs to be a clearer policy as it appears to be based on the doctor’s experience as opposed to the clinical picture.” (MW41, senior midwife) Availability and clarity of guidelines and protocols “I think it would definitely be worthwhile getting more information and education on the guidelines … so that we can identify if something hasn't been done up to standard and can escalate that to whoever else. But yeah, I feel like I definitely don't have that knowledge behind me.” (MW2, junior midwife) “I think everyone knows that there's a certain amount of pulls or a certain amount of pop offs and all of those kinds of things. But I don't think everyone knows exactly what that is.” (MW1, senior midwife) “Make it clearer and shared with paeds [the paediatric team] officially what actually one pull is defined as…Also how many pulls are allowed needs to be clearer as well.” (PED2, paediatric registrar) “I feel if we have a proper guideline, it would really be very helpful.” (OB1, senior obstetrician) Themes and subthemes with examples of illustrative quotes from survey and interview data. Seniority and clinical role of staff providing quotes given in parenthesis. (1) Calibre of communication Healthcare providers described the importance of direct communication and clear reasoning for risk assessment and decision-making between the accoucheur and supporting staff. Indirect communication led to significant confusion for both staff and patients. “We can sort of guess what might be happening, but it's definitely not discussed with us…nobody actually tells you specifically, you just sort of overhear it.” (MW2, junior midwife) The manner of communication was reported as an important factor that impacted team performance. Unclear or disrespectful communication was perceived to create a lack of understanding and/or disconnect between healthcare staff as well as with the patient, which impacted the dynamics of the team and safety of the procedure. “This belittling and demanding communication can make junior staff, in particular, become frazzled and feel a great deal of pressure. This can lead to lack of ability to speak up or ask questions to put into documentation. It can also make the woman feel more concerned and uncomfortable.” (MW11, junior midwife) Communication with birthing woman was repeatedly identified as an important aspect of optimal care. Concern was raised about challenges in obtaining adequate consent for the procedure in an emergency setting or using language that “downplayed” significant risks. “I often feel women are inadequately counselled to make an informed decision” (MW42, senior midwife) Conversely, obstetric staff were more likely to perceive the current calibre of communication at OVB as effective, as reflected in quantitative analysis. “I think they [the midwifery team] are just really good communicators… it's a very open and very friendly environment.” (OB2, obstetric registrar) (2) Preparation and risk assessment The next theme, related to both communication and escalation, was the need to adequately prepare for the birth, including being aware of the capabilities and limitations of the team, accurately assessing risks and anticipating potential complications. Participants spoke about appropriate allocation of roles and ensuring all necessary members of the team were present for the birth, in particular awaiting arrival of someone adequately skilled to care for the neonate. This process was reliant on multidisciplinary communication. “It feels like no one really checks in... turns around and makes sure, Okay, who have we got in the room? We've got a really junior midwife. That's it. Like, that's probably not a good time to start the procedure.” (MW1, senior midwife) “More clear communication between obstetric and neonatal staff, particularly if there have been concerns about fetal wellbeing during labour” (PED1, paediatric consultant/fellow) Use of ultrasound to confirm fetal head position was noted to increase objectivity of risk assessment, which increased the confidence of staff. “I feel more confident when I've seen the doctor use that ultrasound prior to confirm position.” (MW1, senior midwife) Ensuring adequate pain relief was also highlighted as an important aspect of preparation for an OVB. “I think there is often a lack of opportunity for any type of pain relief as well which can be super traumatic for the women…they often ask us afterwards why they had no pain relief!” (MW14, junior MW) (3) Leadership and interpersonal dynamics A key theme related to escalation in the context of team functionality and safety, was the role of leadership and interpersonal dynamics of the team. Higher seniority of staff present at the birth was noted to improve confidence of the team, ensure appropriate decision-making and readily available support in case of complication. “The seniority of the people in the room, that's when I would be less confident, if particularly more junior doctors were the ones performing the instrumental.” (MW1, senior midwife) On the other hand, higher seniority of involved staff and the team's hierarchical structure were identified as barriers impacting confidence to escalate. Midwifery and paediatric staff interviewed expressed that they would not feel comfortable escalating if they had concerns about the birth. “It doesn't feel like you can necessarily say anything in that moment, particularly if it's a consultant, obviously, doing the procedure, rather than like one of our registrars or something” (MW2, junior midwife) Conversely, senior obstetric staff reported feeling more comfortable with existing escalation pathways. “Everyone follows the hierarchy, they know when to escalate.” (OB1, senior obstetrician) The familiarity of the team was also a key factor reported to impact staff confidence and comfort to escalate concerns, with challenges noted with constant rotation of staff through the service. “I think maybe the hardest bit comes from because our doctors sort of cycle through and by the time we're finally used to them, and what they do and how they communicate, they leave, and a new lot comes.” (MW2, junior midwife) (4) Transfer from Birth Unit to Operating Theatre The Operating Theatre environment was noted to be a particularly challenging setting to optimise team functioning, particularly regarding communication and escalation. The sudden change in the team was acknowledged as disruptive to interdisciplinary communication and team cohesion. “All healthcare workers in the theatre should provide a positive environment. As a midwife I often feel like an outsider which can make the experience awkward. We are all a team even if we are from different departments.” (MW5, Junior midwife) Obstetric staff noted that it was challenging to escalate and communicate their concerns about the urgency of the birth with theatre staff. “But whenever we go down to Theatre for a trial of instrumental… it's sometimes difficult to get things done quickly. It's difficult to just get them on the same page…communication with the Theatre team is challenging” (OB1, senior obstetrician) Conversely, some staff felt more comfortable in the Operating Theatre, as this meant there was more senior obstetric support available. “They [the obstetric team] feel more comfortable, because if we go to Theatre, then they have a more senior person present.” (MW1, senior midwife) Healthcare staff reported births in the Operating Theatre to be particularly stressful for the birthing woman and support person. This more medicalised environment could lead to a greater disconnect between the birthing woman and the healthcare team, with less focus on communication and rapport in the context of increased clinical acuity. “I think once you're down in Theatre, there becomes this weird disconnect between the patient and what you're doing… I think that change of venue sometimes messes with how clinicians might communicate with them.” (MW2, junior midwife) (5) Variation in clinical practice The final overarching theme was most strongly related to our exploration of adherence to accepted safety guidelines. Healthcare staff noted variation in clinical practice, particularly regarding the indication for transferring to the operating theatre, the methods of expediting birth and the number of tractions acceptable to perform. This was noted to depend on the clinician attending the birth, the location of the birth and clinical context. Such variation made the reasoning of decision-making unclear and unpredictable, potentially limiting their capacity to apply protocol or optimally support the accoucheur. “Each time is with a different consultant with a different method. It's hard to get in consistent practice. To be honest, it's hard to apply the protocol because you just do what the consultant says.” (OB10, obstetric registrar) Guidelines and policies were seen as useful tools to assist this and improve safety of OVB, but were thought to be currently lacking or not accessible. Healthcare staff sought education and transparency around accepted safety guidelines and shared terminology, such what constitutes one “pull”. “I think it would definitely be worthwhile getting more information and education on the guidelines … so that we can identify if something hasn't been done up to standard and can escalate that to whoever else. But yeah, I feel like I definitely don't have that knowledge behind me.” (MW2, junior midwife) “Make it clearer and shared with paeds [referring to the paediatric team] officially what actually one pull is defined as…Also how many pulls are allowed needs to be clearer as well.” (PED2, paediatric registrar) Discussion This study provides insight into the perspectives of healthcare staff on the factors impacting safety and team functionality at OVB. Prominent themes included the calibre of communication, preparation and risk assessment, leadership and interpersonal dynamics, transfer from Birth Unit to the Operating Theatre and variation in clinical practice. The themes identified had clear interplay with our study enquiry into factors of communication, escalation and adherence to safety guidelines. Variation in perspectives of different members of the healthcare team were congruent in the quantitative and qualitative analysis, particularly regarding quality of communication and capacity to escalate. All healthcare providers acknowledged the importance of optimising communication at OVB, both within the healthcare team and with the birthing woman. However, concerns with communication were more likely to be highlighted by midwifery and paediatric staff. In particular, staff reported that inadequate communication between the accoucheur and other attending staff limited awareness of clinical risk assessment, reasoning behind decision-making or required roles and expectations, leading to confusion and inability to optimally support the accoucheur or provide an explanation to the birthing woman. Communicating the needs and limitations of the team is particularly important in maternity care, where teams are dynamic with frequently rotating rosters, and thus involve members with variable experiences and capabilities. 9 The manner of communication was also perceived as important in getting optimal team performance and outcomes. This is supported by a recent retrospective cohort study 16 which found that interprofessional communication training could significantly reduce adverse obstetric events. Concerns were also expressed regarding communication with the birthing woman, a fundamental member of the team at an OVB. In particular, responders reflected on the challenges in obtaining adequate consent from a birthing woman in an emergency situation, such as OVB. This is in keeping with previous studies, 24 which highlight factors impacting intrapartum consent, such as pain and the emergency nature of decision-making. Dedicated efforts to involve birthing women in decision-making and supporting their autonomy was recognised by staff as a crucial influence on psychological safety. Previous studies 25 , 26 have demonstrated increased risk of negative birth experience and development of post-traumatic stress disorder with emergency operative birth, including OVB. However, a recent qualitative analysis of women who had an OVB, identified that being part of the team and feeling empowered were key to facilitating a positive birth experience. 18 Confidence of staff and perceived functioning of the team at OVB were related to leadership and interpersonal relationships. Greater seniority of the accoucheur improved perceived team confidence and safety, but was also a significant barrier to staff feeling empowered to escalate concerns. Additionally, poorly developed relationships within the team and lack of awareness of existing best practice guidelines reduced staff confidence to escalate. Midwifery and paediatric or junior staff were less likely to feel empowered to escalate, compared to obstetric and senior staff. These contrasting perspectives likely reflect differences in power dynamics associated with the traditional hierarchical structure of the team. A recent study 6 acknowledged that care is more effective and coordinated, particularly in a crisis situation, in teams where leaders “flatten the hierarchy to promote information exchange”. Many responders acknowledged additional challenges in communication, escalation and team cohesion at OVB performed in the Operating Theatre. Some staff felt like “outsiders” or found it challenging to be “on the same page” in the Operating Theatre, reflecting a deterioration in interprofessional relations and team dynamics. The introduction of new team members, change in environment and loss of additional midwifery support contributed to this fragmentation. The change in location was noted to be stressful and overwhelming for both staff and patients, with one staff member describing greater “disconnect” with the patient in the more medicalised environment. It was acknowledged that births in the Operating Theatre were typically more high-risk which contributed to stress of the team. Conversely, some staff reported that the additional senior obstetric support present at births in the Operating Theatre was reassuring and improved confidence. Variations in clinical practice contributed further to uncertainty amongst the team, particularly relating to risk assessment or reasoning for management. Factors influencing variation in practice included clinician preferences and skill, differences in hospital policy, location of the attempted OVB and the clinical context of the birth. This theme was strongly related to adherence to safety guidelines, with staff universally advocating for the development of clear and accessible guidelines and policies as well as shared understanding of terminology, as these were recognised as useful tools to support consistency of safe practice. An important limitation of this study is that it was performed at one healthcare network, which may limit generalisability. However, it did include staff across multiple hospital campuses with differing levels of clinical acuity. Whilst this study obtained relatively balanced representation of senior and junior staff, as well as of staff performing and supporting OVB, there were relatively few paediatric staff who participated in the study increasing the risk of bias and reducing generalisability of those responses. Whilst this study focussed on healthcare staff perceptions of team functionality and safety of OVB, it is crucial that future research include the perspectives of birthing women. This study highlights the importance of behavioural skills to support team functionality and safety of OVB, in keeping with previous studies 27 , 28 identifying the crucial role of behavioural skills in OVB competency. Healthcare staff in this study called for increased clarity of multidisciplinary communication and transparency in risk assessment, prioritising involving and engaging the birthing women, fostering positive interdisciplinary relationships especially in the context of OVB in the Operating Theatre and greater access to safety guidelines. Further research should explore methods to improve behavioural skills, such as those identified in this study, and assess the potential to improve the physical and psychological safety of OVB. Our findings suggest that this is likely to require a multimodal approach with incorporation of education, skills training, guideline accessibility, systems changes and cultural transformation. Conclusion Healthcare providers identified multiple factors that they perceived to impact team functionality and patient safety at OVB. Perspectives on communication and empowerment to escalate differed between members of the team. Acknowledging the perspectives of all staff members and how they may differ is a crucial first step to understand key factors to target in order to comprehensively improve team functionality and safety at OVB. Improved training in behavioural skills, alongside procedural technique, should be considered to ensure psychical and psychological safety through excellence in team-based care. Abbreviations CCOPMM Consultative Council on Obstetric and Paediatric Mortality and Morbidity FDCS Fully dilated caesarean section OVB Operative vaginal birth Declarations Ethics approval The study received ethical approval from the hospital Human Research Ethics Committee (HREC ref. number QA/76336/MonH-2021-265279(v1)). Consent to participate Participants indicated their consent to participate through completion of anonymous surveys. Written informed consent was obtained for semi-structured interviews. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors report no competing interest. Funding Author SS was supported by The Australian Government Research Training Program Scholarship. The funding sources were not involved in the study design; collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the article for publication. Authors' contributions SS is the primary author who was involved in concept design, data collection, data analysis, and manuscript preparation. AK was involved in concept design, review of survey and interview guide, co-interviewer, data coding and thematic analysis. EK was involved in data coding and thematic analysis. RH, PN, NM, BM and DR were involved in concept design. All authors were involved in review of themes, manuscript editing and approval of the final manuscript. Acknowledgements We acknowledge the time and expertise of our participants. References Australian Institute of Health and Welfare. Australia's mothers and babies. Australian Government. 2024. Accessed 20th August, 2024. https://www.aihw.gov.au/reports/mothers-babies/australias-mothers-babies/contents/labour-and-birth/method-of-birth Victoria’s Mothers, Babies and Children 2019 (Consultative Council on Obstetric and Paediatric Mortality and Morbidity) (May 2021). Patrick W, Ken C. Human factors in healthcare: welcome progress, but still scratching the surface. BMJ Quality & Safety . 2016;25(7):480. doi:10.1136/bmjqs-2015-005074 Hughes AM, Gregory ME, Joseph DL, et al. Saving lives: A meta-analysis of team training in healthcare. J Appl Psychol . Sep 2016;101(9):1266-304. doi:10.1037/apl0000120 Keebler JR, Rosen MA, Sittig DF, Thomas E, Salas E. Human Factors and Ergonomics in Healthcare: Industry Demands and a Path Forward. Human Factors . 2022/02/01 2022;64(1):250-258. doi:10.1177/00187208211073623 Guise JM, Segel S. Teamwork in obstetric critical care. Best Pract Res Clin Obstet Gynaecol . Oct 2008;22(5):937-51. doi:10.1016/j.bpobgyn.2008.06.010 Hinshaw K. Human factors in obstetrics and gynaecology. Obstetrics, Gynaecology & Reproductive Medicine . 2016/12/01/ 2016;26(12):368-370. doi:https://doi.org/10.1016/j.ogrm.2016.09.002 The Royal College of Obstetricians and Gynaecologists. Each Baby Counts: 2019 Progress Report . 2020. https://www.rcog.org.uk/media/qhzlelnc/each-baby-counts-2019-progress-report.pdf Young P, Maclennan K. Human factors in obstetrics. Anaesthesia & Intensive Care Medicine . 2022/08/01/ 2022;23(8):467-471. doi:https://doi.org/10.1016/j.mpaic.2022.05.002 Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. New England Journal of Medicine . 2009;360(5):491-499. doi:10.1056/NEJMsa0810119 Hullfish KL, Miller T, Pastore LM, et al. A checklist for timeout on labor and delivery: A pilot study to improve communication and safety. Article. Journal of Reproductive Medicine . 2014;59(6):579-584. Treadwell JR, Lucas S, Tsou AY. Surgical checklists: A systematic review of impacts and implementation. Review. BMJ Quality and Safety . 2014;23(4):299-318. doi:10.1136/bmjqs-2012-001797 Mohammed A, Wu J, Biggs T, et al. Does use of a World Health Organization obstetric safe surgery checklist improve communication between obstetricians and anaesthetists? A retrospective study of 389 caesarean sections. Article. BJOG: An International Journal of Obstetrics and Gynaecology . 2013;120(5):644-648. doi:10.1111/1471-0528.12041 Tscholl DW, Weiss M, Kolbe M, et al. An Anesthesia Preinduction Checklist to Improve Information Exchange, Knowledge of Critical Information, Perception of Safety, and Possibly Perception of Teamwork in Anesthesia Teams. Anesthesia & Analgesia . 2015;121(4) True BA, Cochrane CC, Sleutel MR, Newcomb P, Tullar PE, Sammons JH. Developing and Testing a Vaginal Delivery Safety Checklist. Journal of Obstetric, Gynecologic & Neonatal Nursing . 2016/03/01/ 2016;45(2):239-248. doi:https://doi.org/10.1016/j.jogn.2015.12.010 Hüner B, Derksen C, Schmiedhofer M, et al. Reducing preventable adverse events in obstetrics by improving interprofessional communication skills – Results of an intervention study. BMC Pregnancy and Childbirth . 2023/01/23 2023;23(1):55. doi:10.1186/s12884-022-05304-8 Cass GKS, Goyder K, Strachan B, Bahl R. Can we improve women's experience of operative vaginal birth? Eur J Obstet Gynecol Reprod Biol . Sep 2020;252:424-430. doi:10.1016/j.ejogrb.2020.07.021 Sjödin M, Rådestad I, Zwedberg S. A qualitative study showing women's participation and empowerment in instrumental vaginal births. Women Birth . Jun 2018;31(3):e185-e189. doi:10.1016/j.wombi.2017.09.006 Brogaard L, Rosvig L, Hjorth-Hansen KR, et al. Team performance during vacuum-assisted vaginal delivery: video review of obstetric multidisciplinary teams. Front Med (Lausanne) . 2024;11:1330457. doi:10.3389/fmed.2024.1330457 Clarke E, Visser J. Pragmatic research methodology in education: possibilities and pitfalls. International Journal of Research & Method in Education . 2019/10/20 2019;42(5):455-469. doi:10.1080/1743727X.2018.1524866 Kelly LM, Cordeiro M. Three principles of pragmatism for research on organizational processes. Methodological Innovations . 2020;13(2):2059799120937242. doi:10.1177/2059799120937242 Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology . 2006/01/01 2006;3(2):77-101. doi:10.1191/1478088706qp063oa Braun V, Clarke V. Toward good practice in thematic analysis: Avoiding common problems and be(com)ing a knowing researcher. International Journal of Transgender Health . 2023/01/25 2023;24(1):1-6. doi:10.1080/26895269.2022.2129597 Nicholls J, David AL, Iskaros J, Lanceley A. Patient-centred consent in women’s health: does it really work in antenatal and intra-partum care? Article. BMC Pregnancy and Childbirth . 2022;22(1)156. doi:10.1186/s12884-022-04493-6 Viirman F, Hesselman S, Wikström A-K, et al. Negative childbirth experience – what matters most? a register-based study of risk factors in three time periods during pregnancy. Sexual & Reproductive Healthcare . 2022/12/01/ 2022;34:100779. doi:https://doi.org/10.1016/j.srhc.2022.100779 Carter J, Bick D, Gallacher D, Chang YS. Mode of birth and development of maternal postnatal post-traumatic stress disorder: A mixed-methods systematic review and meta-analysis. Birth . Dec 2022;49(4):616-627. doi:10.1111/birt.12649 Feeley C, Crossland N, Betran AP, Weeks A, Downe S, Kingdon C. Training and expertise in undertaking assisted vaginal delivery (AVD): a mixed methods systematic review of practitioners views and experiences. Reproductive Health . 2021/05/05 2021;18(1):92. doi:10.1186/s12978-021-01146-3 Bahl R, Murphy DJ, Strachan B. Non-technical skills for obstetricians conducting forceps and vacuum deliveries: qualitative analysis by interviews and video recordings. Eur J Obstet Gynecol Reprod Biol . Jun 2010;150(2):147-51. doi:10.1016/j.ejogrb.2010.03.004 Additional Declarations No competing interests reported. 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13:10:58","extension":"docx","order_by":7,"title":"","display":"","copyAsset":false,"role":"supplement","size":25290,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterial3.docx","url":"https://assets-eu.researchsquare.com/files/rs-5321816/v1/332c47202b47da69224534fa.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Understanding factors influencing safety and team functionality at operative vaginal birth through multidisciplinary perspectives: A mixed methods study.","fulltext":[{"header":"Background","content":"\u003cp\u003eOperative vaginal birth (OVB) accounted for 12% of all births in Australia 2021, and one in four births of first-time mothers.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e OVB may be considered in the second stage of labour to expedite birth for maternal and/or fetal wellbeing, as an alternative to fully dilated caesarean section (FDCS). However, both OVB and FDCS are associated with increased risks of neonatal and maternal morbidity and mortality. In 2019, the Consultative Council on Obstetric and Paediatric Mortality and Morbidity (CCOPMM), a Victorian advisory body to the Minister of Health, reported that cases of poor outcomes resulting from OVB demonstrated similar themes of breakdown in team communication, loss of situational awareness, lack of escalation, and inadequate safety systems.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e This report recommended a formal team time-out to improve situational awareness and decision-making in OVB, as well as ensuring staff were knowledgeable of current safety guidelines and avoided excessive traction to achieve vaginal birth. The \u0026ldquo;role and value of the whole healthcare team\u0026rdquo; alongside structured processes to assess and consider safety factors were emphasised.\u003c/p\u003e \u003cp\u003eThe importance of human factors in healthcare to improve patient safety is increasingly recognised.\u003csup\u003e\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e In maternity care, failure of human factors such as teamwork, communication and situational awareness, is responsible for over 70\u0026ndash;80% of sentinel adverse events.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Provision of safe and holistic intrapartum care relies on effective and respectful collaboration between members of the multidisciplinary team, as well as with the birthing woman and support person. In this high-acuity setting, decision-making is often time-critical and multifactorial, balancing the needs of mother and neonate, which may be conflicting. In this context, situational awareness involves the capacity to accurately identify, assess and anticipate multiple risks and events occurring in real-time, to therefore provide appropriate and timely care.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e When performing technically complex births, such as OVB, clinicians can become task-focussed and thus susceptible to loss of situational awareness.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e This may potentially lead to practices outside accepted safety guidelines, including excessive attempts at vaginal birth resulting in significant trauma to the mother and neonate, or limited capacity to anticipate and recognise complications.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e A team \u0026ldquo;time-out\u0026rdquo; refers to a pre-procedural safety checklist involving the healthcare team and patient which aims to introduce the team, summarise the planned procedure, identify any safety concerns, anticipate possible complications and outline escalation pathways. Safety checklists have been shown to improve team communication, adherence to safety guidelines and safety culture in many areas of medicine, including in maternity care.\u003csup\u003e\u003cspan additionalcitationids=\"CR11 CR12 CR13 CR14\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Improving communication and collaboration of the healthcare team, the birthing woman and support person, has been shown to prevent adverse obstetric outcomes and improve maternal birth experience.\u003csup\u003e\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e Enhancing team functionality at OVB is proposed to improve situational awareness, anticipation of potential complications, utilisation of available resources and adherence to safety guidelines.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e However, there is limited qualitative inquiry into the factors that impact teamwork and safety of OVB from healthcare workers perspectives.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eAim\u003c/h2\u003e \u003cp\u003eThis study aims to evaluate how team functionality and safety of OVB can be optimised through the perspectives of healthcare providers. In this study, team functionality refers to how healthcare staff perceive the dynamics, collaboration and performance of the multidisciplinary team present at an OVB, with particular attention to team communication, escalation, and adherence to safety guidelines, considering the 2019 CCOPMM recommendations.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy design\u003c/h3\u003e\n\u003cp\u003eThis study design is based on a pragmatist paradigm, in which multidimensional methods are encouraged in order to achieve the desired research objective whilst ensuring the research is contextually relevant to the subjects of its inquiry.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e Pragmatism allows scope for the pluralist understanding of multiple truths, acknowledging that individuals can experience reality differently.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e This framework enables a nuanced understanding of the different perspectives of healthcare providers involved in an OVB, within the complex and dynamic social systems in which they work, including perspectives that are both congruent and conflicting. This is especially important when considering potential influences on team functionality, where it is necessary to understand multiple perspectives and how they relate to each other.\u003c/p\u003e \u003cp\u003eWe employed a mixed methods convergent sequential study design. First, to quantify the diversity of perspectives amongst a large cohort of staff involved in OVB, we utilised electronic surveys with both Likert-scale and free-text style questioning relating to OVB (Supplementary Material 1). An interview guide (Supplementary Material 2) was then developed based on responses from the surveys and in collaboration with researchers of obstetric and midwifery clinical backgrounds. Semi-structured interviews were then performed to further explore emerging themes and nuances of contributory factors identified by staff.\u003c/p\u003e\n\u003ch3\u003eTeam reflexivity\u003c/h3\u003e\n\u003cp\u003eThe diversity of our research team assists in maximizing data analysis credibility. SS, the primary author, is an obstetric trainee and concurrently completing a Doctor of Philosophy degree in obstetrics. EK is a junior midwife with four years\u0026rsquo; experience in maternity care, and NM a senior midwife with more than 20 years\u0026rsquo; experience. DR, RH, PN, BM and AK are consultant obstetricians with extensive experience in obstetrics academic and research design.\u003c/p\u003e\n\u003ch3\u003eSetting\u003c/h3\u003e\n\u003cp\u003eThis study was performed at Monash Health encompassing four metropolitan public hospitals in Victoria, Australia, including one tertiary and three secondary sites. Monash Health is the largest maternity and perinatal provider in Victoria, providing care for over 10,000 births annually, of which 10.5% of births are assisted with forceps and 5% with ventouse. Obstetric staff must either be themselves credentialed or supervised by a credentialed practitioner to perform OVB. Midwives do not perform OVB, but do have an essential role in supporting the birthing woman as well as the obstetric accoucheur, including preparing equipment and medications, receiving the neonate, managing complications and facilitating appropriate escalation as needed. The local protocol indicates that all OVB are attended to by a paediatric staff member to care for the neonate. The local OVB protocol gives recommendations regarding appropriate indications, prerequisites, precautions and contraindications, procedural limits, escalation pathways, complications and post birth cares for OVB with reference to international college guidelines. This protocol applies for all four maternity sites. Data collection occurred from October to November 2021 at Monash Medical Centre, Dandenong and Casey Hospitals and then at Sandringham Hospital in from March to May 2023 when this service joined the Monash Health network.\u003c/p\u003e\n\u003ch3\u003eParticipants and recruitment\u003c/h3\u003e\n\u003cp\u003eParticipants were healthcare providers including junior and senior midwifery, obstetric and paediatric staff. Senior and junior midwifery staff were defined as those with more than or less than five years clinical experience respectively. Senior obstetric or paediatric staff were defined as specialist consultants, with junior obstetric and paediatric staff being doctors in training who had not yet obtained their specialty certification. Anonymous survey links were distributed via staff e-mail addresses to all midwifery, obstetric and paediatric staff, as well as in the maternity newsletter through convenience sampling. Following survey data collection and development of the interview guide, invitations to participate in interviews were similarly distributed to all maternity and perinatal staff via staff e-mail addresses. We utilised a mixture of convenience and purposive sampling for interviews, whereby recruitment continued until representation of senior and junior, obstetric and midwifery staff was achieved.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eEthics\u003c/h2\u003e \u003cp\u003e The study received ethical approval from the hospital Human Research Ethics Committee as a low-risk project. Participants gave informed and verbal consent to participate in the study. Survey responses were anonymous, and interview transcriptions were deidentified to maintain confidentiality.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eAnonymous survey data were collected electronically from all four hospitals and completed independently by responders without assistance of research staff. Interviews were performed by authors SS and AK to further explore themes emerging from analysis of survey responses and involved five participants with representation of senior and junior midwifery and obstetric staff. Given surveys were anonymous, researchers were not aware of whether interview participants had responded to the survey. Participants were aware of the research aims prior to consenting to be interviewed. Interviews were conducted via video conferencing and audio recorded. The interview started by asking open-ended questions about participants\u0026rsquo; roles at an OVB and factors they identified influencing team functionality and safety of OVB. As the interviews were semi-structured, the direction of the interview was guided by the participants, with a focus on exploratory enquiry. The interview guide (Supplementary Material 2) covered topics such as communication, teamwork, clinical practice in the context of recommended guidelines and escalation. The interview concluded by asking participants to share any suggestions they had to improve the physical or psychological safety of OVB for birthing women and their neonates. Interviews ranged from 20 to 28 minutes in duration. Interviews were transcribed verbatim, and transcriptions were checked for accuracy by one of the authors (SS) with the assistance Otter.ai software.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eLikert-scale survey responses were collated and compared between obstetric and midwifery or paediatric staff, as well as between junior and senior staff, using Pearson's chi-squared test or fisher exact test for questions with less than five counts for any of the response options. The grouping of obstetric compared to midwifery and paediatric staff was chosen to reflect the perspectives of staff performing the OVB procedure (obstetric staff) compared to those present supporting the procedure and receiving the neonate (midwifery and paediatric staff). Statistical significance was defined as a p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003cp\u003eDeidentified interview transcriptions and free-text survey responses were thematically analysed per Braun and Clarke 6-step process.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e The data were read multiple times by authors SS, AK and EK, initially to gain familiarity and later to inductively and independently code the data, ensuring each transcript was reviewed by at least two researchers. In the first round of analysis, initial codes were agreed upon by the researchers and in subsequent rounds emerging themes were developed. Ongoing analysis and refinement of themes was performed to ensure themes applied to the entire dataset. Final themes and interpretations of the findings, in context of the research question, were agreed upon by the authors.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eWe received 100 responses to the survey. Of those, 41 were from obstetric, 52 midwifery, and seven from paediatric staff. There was an even distribution of responses from senior (n\u0026thinsp;=\u0026thinsp;49) and junior staff (n\u0026thinsp;=\u0026thinsp;51). The clinical roles of respondents are summarised in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical roles of respondents\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMidwifery or Paediatric staff\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;59 (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eObstetric Staff\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;41 (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSenior midwives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eObstetric consultants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (34)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJunior midwives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eObstetric senior registrars\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePaediatric consultants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eObstetric junior registrars\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (39)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePaediatric registrars\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eObstetric residents\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (17)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eJunior Staff\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;51 (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eSenior Staff\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;49 (%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObstetric junior registrars\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eObstetric consultants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (29)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObstetric residents\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eObstetric senior registrars\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJunior midwives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSenior midwives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 (51)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePaediatric registrars\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePaediatric consultants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eData are presented as absolute numbers (n) and proportions (%).\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eJunior and senior midwives were defined as less than or greater than five years\u0026rsquo; experience, respectively.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eComparing responses from obstetric vs. midwifery and paediatric staff, obstetric staff were more likely to rate communication as high quality (56% vs. 29%, p\u0026thinsp;=\u0026thinsp;0.010) and more likely to be very or extremely confident raising concern if they observed practices outside protocol (49% vs. 12%, p\u0026thinsp;=\u0026thinsp;0.003). Compared to senior staff, junior staff were more likely to report never conducting or observing a team time-out prior to OVB (53% vs. 29%, p\u0026thinsp;=\u0026thinsp;0.023) and less likely to be very or extremely confident raising concern if they observed practices outside protocol (10% vs. 45%, p\u0026thinsp;=\u0026thinsp;0.008). Overall, 99% of healthcare staff thought communication at OVB could improve, with the majority (58%) reporting it should improve \u0026ldquo;a lot\u0026rdquo; or \u0026ldquo;a great deal\u0026rdquo;. Only 21% of staff reported that concerns would be raised by staff \u0026ldquo;usually\u0026rdquo; or \u0026ldquo;always\u0026rdquo; if practices outside protocol were observed. Likert-scale survey responses are summarised in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. As there were relatively few responses from paediatric staff, we conducted a sensitivity analysis excluding paediatric staff responses with similar results (Supplementary Material 3).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePerspectives of maternity and perinatal staff on team functionality at operative vaginal birth\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverall\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;100)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMidwifery or Paediatric staff\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;59)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eObstetric staff (n\u0026thinsp;=\u0026thinsp;41)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eJunior staff\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;51)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSenior staff\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;49)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003eCurrently, how effectively do you believe teams communicate during attempted OVB?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery high quality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003e0.010\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.289\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh quality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 (40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23 (56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20 (39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e20 (41)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeither high nor low quality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39 (39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e19 (37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e20 (41)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow quality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12 (24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6 (12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery low quality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1 (2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003eDo you think team communication at OVB could improve?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA great deal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.452\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e14 (28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10 (20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.282\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA lot\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20 (39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e14 (29)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA moderate amount\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10 (20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e18 (37)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA little\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7 (14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6 (12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone at all\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1 (2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003eHow often have you observed or conducted a team 'time out' prior to attempted OVB?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlways\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.139\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003e0.023\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUsually\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8 (16)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSometimes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11 (22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9 (18)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRarely\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11 (22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e18 (37)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e27 (53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e14 (29)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003eHave you witnessed OVB practices that are outside protocol?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA great deal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003e0.513\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003e\u003cb\u003e0.035\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA lot\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (8.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5 (10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA moderate amount\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e21 (41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7 (14)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA little\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 (45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20 (49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e18 (35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e27 (55)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot at all\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (8.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5 (10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6 (12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI am unsure of the Monash Health OVB protocol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4 (8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3 (6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003eWhen you have observed OVB practices that are outside protocol, how often are concerns raised by other members of the team?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlways\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003e0.220\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3 (6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003e0.561\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUsually\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5 (10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e12 (25)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSometimes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20 (40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e15 (31)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRarely\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13 (26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e11 (22)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2 (4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI am unsure of the Monash Health OVB protocol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4 (8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5 (10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI have not observed OVB practices that are outside protocol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3 (6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3 (6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNo response\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e1\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e1\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e1\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003e0\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003eWhen you observe OVB practices that are outside protocol, how comfortable do you feel about raising concern?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExtremely confident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003e\u003cb\u003e0.003\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e11 (22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003e\u003cb\u003e0.008\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery confident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4 (8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e11 (22)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSomewhat confident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13 (26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8 (16)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot so confident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20 (40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e14 (29)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot at all confident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6 (12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3 (6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI am unsure of the Monash Health OVB protocol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4 (8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2 (4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI have not observed OVB practices that are outside protocol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNo response\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e1\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e1\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e1\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003e0\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003eData are presented as absolute numbers (n) and proportions (%). p-values obtained using Chi-squared of Fisher\u0026rsquo;s Exact tests.\u003c/p\u003e \u003cp\u003eOVB\u0026thinsp;=\u0026thinsp;Operative Vaginal Birth\u003c/p\u003e \u003cp\u003e\u003cem\u003eNB. Eleven of the eighteen survey responders who reported being unsure of the protocol or having not observed OVB practices outside protocol, then answered one of the follow-up questions relating to raising concern when such practices were observed, which was inconsistent with their prior response.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eQualitative analysis of free-text survey responses and semi-structured interviews identified five overarching themes impacting team functionality at OVB; (1) Calibre of communication, (2) Preparation and risk assessment, (3) Leadership and interpersonal dynamics, (4) Transfer from Birth Unit to Operating Theatre and (5) Variation in clinical practice. These themes closely related to our research enquiry into communication, escalation and adherence to safety guidelines. Themes, subthemes and representative quotes are summarised in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThemes\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTheme\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSubtheme\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIllustrative quotes\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e(1) Calibre of communication\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIndirect communication\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;We can sort of guess what might be happening, but it's definitely not discussed with us\u0026hellip;nobody actually tells you specifically, you just sort of overhear it.\u0026rdquo; (MW2, junior midwife)\u003c/p\u003e\u003cp\u003e\u0026ldquo;Simply talk to one another and describe the degree of concern for the baby.\u0026rdquo; (PED4, paediatric consultant/fellow)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUnclear reasoning for decision-making\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;I think a lot of women are confused and are unsure of what happened and why. And I think the midwives probably are too.\u0026rdquo; (MW1, senior midwife)\u003c/p\u003e\u003cp\u003e\u0026ldquo;I don't know necessarily why we choose to go down to theater for a trial of forceps versus or forceps in the room\u0026rdquo; (MW2, junior midwife)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eManner of communication impacting team performance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;This belittling and demanding communication can make junior staff, in particular, become frazzled and feel a great deal of pressure. This can lead to lack of ability to speak up or ask questions to put into documentation. It can also make the woman feel more concerned and uncomfortable.\u0026rdquo; (MW11, junior midwife)\u003c/p\u003e\u003cp\u003e\u0026ldquo;Just more communication from O\u0026amp;G to midwifery, and not to get too upset if TXA [Tranexamic acid] and Augmentin [Amoxycillin-Clavulanic acid antibiotic] aren't in the room straight away. It takes time and rapport to set up effectively for an instrumental by midwifery team and it can be so tough when communication isn\u0026rsquo;t effective.\u0026rdquo; (MW21, junior midwife)\u003c/p\u003e\u003cp\u003e\u0026ldquo;I think they [the midwifery team] are just really good communicators\u0026hellip; it's a very open and very friendly environment.\u0026rdquo; (OB2, obstetric registrar)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInadequate consent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;I often feel women are inadequately counselled to make an informed decision\u0026rdquo; (MW42, senior midwife)\u003c/p\u003e\u003cp\u003e\u0026ldquo;You might get a doctor sitting on the end of the bed talking to the woman saying, you know, you've been pushing for an hour, we haven't seen much progress, we just need to \"help your baby out\" without actually necessarily saying what that is, or what that looks like, or the risks of that as well.\u0026rdquo; (MW2, junior midwife)\u003c/p\u003e\u003cp\u003e\u0026ldquo;Communication to the woman is mostly inadequate.\u0026rdquo; (MW19, Senior midwife)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e(2) Preparation and risk assessment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUnderstanding capabilities of the team and role allocation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;It feels like no one really checks in... turns around and makes sure, Okay, who have we got in the room? We've got a really junior midwife. That's it. Like, that's probably not a good time to start the procedure.\u0026rdquo; (MW1, senior midwife)\u003c/p\u003e\u003cp\u003e\u0026ldquo;Waiting until paediatrician arrives before delivery.\u0026rdquo; (MW17, junior midwife)\u003c/p\u003e\u003cp\u003e\u0026ldquo;That would be my biggest suggestion\u0026hellip;to make sure that all the right people are there. Explain what's about to happen briefly. Make sure everyone knows that their roles are clearly defined. Make sure we have someone documenting, someone drawing up drugs, someone making sure all the equipment is present, making sure that the paediatrician was on the way or that some sort of person is there for the baby.\u0026rdquo; (MW1, senior midwife)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTransparency of decision making and risk assessment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;More clear communication between obstetric and neonatal staff, particularly if there have been concerns about fetal wellbeing during labour\u0026rdquo; (PED1, paediatric consultant/fellow)\u003c/p\u003e\u003cp\u003e\u0026ldquo;I feel more confident when I've seen the doctor use that ultrasound prior to confirm position.\u0026rdquo; (MW1, senior midwife)\u003c/p\u003e\u003cp\u003e\u0026ldquo;I don't know, I haven't had my hands inside the woman so I don't know where the head is at \u0026hellip;sometimes it can feel like decisions are made. And then if a woman asked you when you're in recovery, why did that happen? I wouldn't necessarily know the answer to that\u0026rdquo; (MW2, junior midwife)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePain relief\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;I think there is often a lack of opportunity for any type of pain relief as well which can be super traumatic for the women\u0026hellip;they often ask us afterwards why they had no pain relief!\u0026rdquo; (MW14, junior MW)\u003c/p\u003e\u003cp\u003e\u0026ldquo;I feel the only analgesia appropriate for trial of forceps is epidural/spinal to reduce the trauma women often describe.\u0026rdquo; (MW19, senior midwife)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e(3) Leadership and interpersonal dynamics\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInvolvement of senior clinicians\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;The seniority of the people in the room, that's when I would be less confident, if particularly more junior doctors were the ones performing the instrumental.\u0026rdquo; (MW1, senior midwife)\u003c/p\u003e\u003cp\u003e\u0026ldquo;Discuss with senior doctors prior to performing procedure and the consultant should provide a second opinion in Birth Suite and not book a trial of instrumental in Operating Theatre if procedure can be carried out on the ward.\u0026rdquo; (MW8, junior midwife)\u003c/p\u003e\u003cp\u003e\u0026ldquo;They [the obstetric team] feel more comfortable, because if we go to Theatre, then they have a more senior person present.\u0026rdquo; (MW1, senior midwife)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInterprofessional relationships and working with a familiar team\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;I think it would depend on the situation for sure, and my relationship with a doctor. Like, some doctors, you know, you definitely feel much more comfortable with\u0026rdquo; (MW1, senior midwife)\u003c/p\u003e\u003cp\u003e\u0026ldquo;I think maybe the hardest bit comes from because our doctors sort of cycle through and by the time we're finally used to them, and what they do and how they communicate, they leave, and a new lot comes.\u0026rdquo; (MW2, junior midwife)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHierarchy and empowerment to escalate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;It doesn't feel like you can necessarily say anything in that moment, particularly if it's a consultant, obviously, doing the procedure, rather than like one of our registrars or something\u0026rdquo; (MW2, junior midwife)\u003c/p\u003e\u003cp\u003e\u0026ldquo;I don't feel like there's a great level of maybe confidence of the midwives. I know I probably wouldn't feel comfortable making those calls.\u0026rdquo; (MW1, senior midwife)\u003c/p\u003e\u003cp\u003e\u0026ldquo;I feel least confident commenting to obstetric team as the paediatrician regarding number of pulls that should/shouldn\u0026rsquo;t be done.\u0026rdquo; (PED6, paediatric consultant/fellow)\u003c/p\u003e\u003cp\u003e\u0026ldquo;Everyone follows the hierarchy, they know when to escalate.\u0026rdquo; (OB1, senior obstetrician)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e(4) Transfer from Birth Unit to Operating Theatre\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eChange in team dynamics\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;All healthcare workers in the theatre should provide a positive environment. As a midwife I often feel like an outsider which can make the experience awkward. We are all a team even if we are from different departments.\u0026rdquo; (MW5, junior midwife)\u003c/p\u003e\u003cp\u003e\u0026ldquo;In Theatre\u0026hellip; that's obviously a very different experience, because Theatre is very in control of that space. But when they do happen upstairs [referring to Birth Suite], I think there's enough people around, and I think we've got enough support.\u0026rdquo; (MW2, junior midwife)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDifficulty communicating urgency\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;But whenever we go down to Theatre for a trial of instrumental, it's mainly the Theatre issue\u0026hellip; it's sometimes difficult to get things done quickly. It's difficult to just get them on the same page\u0026hellip;communication with the Theatre team is challenging\u0026rdquo; (OB1, senior obstetrician)\u003c/p\u003e\u003cp\u003e\u0026ldquo;The hardest part communication wise is getting down there and reinforcing the importance of why you need to be there\u0026hellip;It makes it quite difficult for you to communicate how quickly you need to do something.\u0026rdquo; (OB2, obstetric registrar)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePoor patient experience in theatre\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;I think once you're down in Theatre, there becomes this weird disconnect between the patient and what you're doing\u0026hellip; I think that change of venue sometimes messes with how clinicians might communicate with them.\u0026rdquo; (MW2, junior midwife)\u003c/p\u003e\u003cp\u003e\u0026ldquo;A trial of forceps is a stressful and overwhelming experience for the woman and partner and midwife.\u0026rdquo; (MW19, senior midwife)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e(5) Variation in clinical practice\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVariation in clinician practice\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;Sometimes there's doctors that you know, this person is always going to go to Theatre, this person never goes to Theatre, which I don't understand whether it's just like a personal preference.\u0026rdquo; (MW1, senior midwife)\u003c/p\u003e\u003cp\u003e\u0026ldquo;Each time is with a different consultant with a different method. It's hard to get in consistent practice. To be honest, it's hard to apply the protocol because you just do what the consultant says.\u0026rdquo; (OB10, obstetric registrar)\u003c/p\u003e\u003cp\u003e\u0026ldquo;There is a lot of variation in practice, for example with number of pulls with a vacuum delivery.\u0026rdquo; (PED7, paediatric consultant/fellow)\u003c/p\u003e\u003cp\u003e\u0026ldquo;There is also sometimes an inconsistency in where we do an OVB \u0026ndash; Birth Suite or Operating Theatre. There needs to be a clearer policy as it appears to be based on the doctor\u0026rsquo;s experience as opposed to the clinical picture.\u0026rdquo; (MW41, senior midwife)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAvailability and clarity of guidelines and protocols\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e \u0026ldquo;I think it would definitely be worthwhile getting more information and education on the guidelines \u0026hellip; so that we can identify if something hasn't been done up to standard and can escalate that to whoever else. But yeah, I feel like I definitely don't have that knowledge behind me.\u0026rdquo; (MW2, junior midwife)\u003c/p\u003e\u003cp\u003e\u0026ldquo;I think everyone knows that there's a certain amount of pulls or a certain amount of pop offs and all of those kinds of things. But I don't think everyone knows exactly what that is.\u0026rdquo; (MW1, senior midwife)\u003c/p\u003e\u003cp\u003e\u0026ldquo;Make it clearer and shared with paeds [the paediatric team] officially what actually one pull is defined as\u0026hellip;Also how many pulls are allowed needs to be clearer as well.\u0026rdquo; (PED2, paediatric registrar)\u003c/p\u003e\u003cp\u003e\u0026ldquo;I feel if we have a proper guideline, it would really be very helpful.\u0026rdquo; (OB1, senior obstetrician)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cem\u003eThemes and subthemes with examples of illustrative quotes from survey and interview data. Seniority and clinical role of staff providing quotes given in parenthesis.\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e(1) Calibre of communication\u003c/h2\u003e \u003cp\u003eHealthcare providers described the importance of direct communication and clear reasoning for risk assessment and decision-making between the accoucheur and supporting staff. Indirect communication led to significant confusion for both staff and patients.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We can sort of guess what might be happening, but it's definitely not discussed with us\u0026hellip;nobody actually tells you specifically, you just sort of overhear it.\u0026rdquo; (MW2, junior midwife)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe manner of communication was reported as an important factor that impacted team performance. Unclear or disrespectful communication was perceived to create a lack of understanding and/or disconnect between healthcare staff as well as with the patient, which impacted the dynamics of the team and safety of the procedure.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;This belittling and demanding communication can make junior staff, in particular, become frazzled and feel a great deal of pressure. This can lead to lack of ability to speak up or ask questions to put into documentation. It can also make the woman feel more concerned and uncomfortable.\u0026rdquo; (MW11, junior midwife)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eCommunication with birthing woman was repeatedly identified as an important aspect of optimal care. Concern was raised about challenges in obtaining adequate consent for the procedure in an emergency setting or using language that \u0026ldquo;downplayed\u0026rdquo; significant risks.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I often feel women are inadequately counselled to make an informed decision\u0026rdquo; (MW42, senior midwife)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eConversely, obstetric staff were more likely to perceive the current calibre of communication at OVB as effective, as reflected in quantitative analysis.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I think they [the midwifery team] are just really good communicators\u0026hellip; it's a very open and very friendly environment.\u0026rdquo; (OB2, obstetric registrar)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e(2) Preparation and risk assessment\u003c/h2\u003e \u003cp\u003eThe next theme, related to both communication and escalation, was the need to adequately prepare for the birth, including being aware of the capabilities and limitations of the team, accurately assessing risks and anticipating potential complications. Participants spoke about appropriate allocation of roles and ensuring all necessary members of the team were present for the birth, in particular awaiting arrival of someone adequately skilled to care for the neonate. This process was reliant on multidisciplinary communication.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;It feels like no one really checks in... turns around and makes sure, Okay, who have we got in the room? We've got a really junior midwife. That's it. Like, that's probably not a good time to start the procedure.\u0026rdquo; (MW1, senior midwife)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;More clear communication between obstetric and neonatal staff, particularly if there have been concerns about fetal wellbeing during labour\u0026rdquo; (PED1, paediatric consultant/fellow)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eUse of ultrasound to confirm fetal head position was noted to increase objectivity of risk assessment, which increased the confidence of staff.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I feel more confident when I've seen the doctor use that ultrasound prior to confirm position.\u0026rdquo; (MW1, senior midwife)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eEnsuring adequate pain relief was also highlighted as an important aspect of preparation for an OVB.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I think there is often a lack of opportunity for any type of pain relief as well which can be super traumatic for the women\u0026hellip;they often ask us afterwards why they had no pain relief!\u0026rdquo; (MW14, junior MW)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e(3) Leadership and interpersonal dynamics\u003c/h2\u003e \u003cp\u003eA key theme related to escalation in the context of team functionality and safety, was the role of leadership and interpersonal dynamics of the team. Higher seniority of staff present at the birth was noted to improve confidence of the team, ensure appropriate decision-making and readily available support in case of complication.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The seniority of the people in the room, that's when I would be less confident, if particularly more junior doctors were the ones performing the instrumental.\u0026rdquo; (MW1, senior midwife)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOn the other hand, higher seniority of involved staff and the team's hierarchical structure were identified as barriers impacting confidence to escalate. Midwifery and paediatric staff interviewed expressed that they would not feel comfortable escalating if they had concerns about the birth.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;It doesn't feel like you can necessarily say anything in that moment, particularly if it's a consultant, obviously, doing the procedure, rather than like one of our registrars or something\u0026rdquo; (MW2, junior midwife)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eConversely, senior obstetric staff reported feeling more comfortable with existing escalation pathways.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Everyone follows the hierarchy, they know when to escalate.\u0026rdquo; (OB1, senior obstetrician)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe familiarity of the team was also a key factor reported to impact staff confidence and comfort to escalate concerns, with challenges noted with constant rotation of staff through the service.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I think maybe the hardest bit comes from because our doctors sort of cycle through and by the time we're finally used to them, and what they do and how they communicate, they leave, and a new lot comes.\u0026rdquo; (MW2, junior midwife)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e(4) Transfer from Birth Unit to Operating Theatre\u003c/h2\u003e \u003cp\u003eThe Operating Theatre environment was noted to be a particularly challenging setting to optimise team functioning, particularly regarding communication and escalation. The sudden change in the team was acknowledged as disruptive to interdisciplinary communication and team cohesion.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;All healthcare workers in the theatre should provide a positive environment. As a midwife I often feel like an outsider which can make the experience awkward. We are all a team even if we are from different departments.\u0026rdquo; (MW5, Junior midwife)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eObstetric staff noted that it was challenging to escalate and communicate their concerns about the urgency of the birth with theatre staff.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;But whenever we go down to Theatre for a trial of instrumental\u0026hellip; it's sometimes difficult to get things done quickly. It's difficult to just get them on the same page\u0026hellip;communication with the Theatre team is challenging\u0026rdquo; (OB1, senior obstetrician)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eConversely, some staff felt more comfortable in the Operating Theatre, as this meant there was more senior obstetric support available.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;They [the obstetric team] feel more comfortable, because if we go to Theatre, then they have a more senior person present.\u0026rdquo; (MW1, senior midwife)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHealthcare staff reported births in the Operating Theatre to be particularly stressful for the birthing woman and support person. This more medicalised environment could lead to a greater disconnect between the birthing woman and the healthcare team, with less focus on communication and rapport in the context of increased clinical acuity.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I think once you're down in Theatre, there becomes this weird disconnect between the patient and what you're doing\u0026hellip; I think that change of venue sometimes messes with how clinicians might communicate with them.\u0026rdquo; (MW2, junior midwife)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e(5) Variation in clinical practice\u003c/h2\u003e \u003cp\u003e The final overarching theme was most strongly related to our exploration of adherence to accepted safety guidelines. Healthcare staff noted variation in clinical practice, particularly regarding the indication for transferring to the operating theatre, the methods of expediting birth and the number of tractions acceptable to perform. This was noted to depend on the clinician attending the birth, the location of the birth and clinical context. Such variation made the reasoning of decision-making unclear and unpredictable, potentially limiting their capacity to apply protocol or optimally support the accoucheur.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Each time is with a different consultant with a different method. It's hard to get in consistent practice. To be honest, it's hard to apply the protocol because you just do what the consultant says.\u0026rdquo; (OB10, obstetric registrar)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Guidelines and policies were seen as useful tools to assist this and improve safety of OVB, but were thought to be currently lacking or not accessible. Healthcare staff sought education and transparency around accepted safety guidelines and shared terminology, such what constitutes one \u0026ldquo;pull\u0026rdquo;.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I think it would definitely be worthwhile getting more information and education on the guidelines \u0026hellip; so that we can identify if something hasn't been done up to standard and can escalate that to whoever else. But yeah, I feel like I definitely don't have that knowledge behind me.\u0026rdquo; (MW2, junior midwife)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Make it clearer and shared with paeds [referring to the paediatric team] officially what actually one pull is defined as\u0026hellip;Also how many pulls are allowed needs to be clearer as well.\u0026rdquo; (PED2, paediatric registrar)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study provides insight into the perspectives of healthcare staff on the factors impacting safety and team functionality at OVB. Prominent themes included the calibre of communication, preparation and risk assessment, leadership and interpersonal dynamics, transfer from Birth Unit to the Operating Theatre and variation in clinical practice. The themes identified had clear interplay with our study enquiry into factors of communication, escalation and adherence to safety guidelines. Variation in perspectives of different members of the healthcare team were congruent in the quantitative and qualitative analysis, particularly regarding quality of communication and capacity to escalate.\u003c/p\u003e \u003cp\u003eAll healthcare providers acknowledged the importance of optimising communication at OVB, both within the healthcare team and with the birthing woman. However, concerns with communication were more likely to be highlighted by midwifery and paediatric staff. In particular, staff reported that inadequate communication between the accoucheur and other attending staff limited awareness of clinical risk assessment, reasoning behind decision-making or required roles and expectations, leading to confusion and inability to optimally support the accoucheur or provide an explanation to the birthing woman. Communicating the needs and limitations of the team is particularly important in maternity care, where teams are dynamic with frequently rotating rosters, and thus involve members with variable experiences and capabilities.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e The manner of communication was also perceived as important in getting optimal team performance and outcomes. This is supported by a recent retrospective cohort study\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e which found that interprofessional communication training could significantly reduce adverse obstetric events.\u003c/p\u003e \u003cp\u003eConcerns were also expressed regarding communication with the birthing woman, a fundamental member of the team at an OVB. In particular, responders reflected on the challenges in obtaining adequate consent from a birthing woman in an emergency situation, such as OVB. This is in keeping with previous studies,\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e which highlight factors impacting intrapartum consent, such as pain and the emergency nature of decision-making. Dedicated efforts to involve birthing women in decision-making and supporting their autonomy was recognised by staff as a crucial influence on psychological safety. Previous studies\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e have demonstrated increased risk of negative birth experience and development of post-traumatic stress disorder with emergency operative birth, including OVB. However, a recent qualitative analysis of women who had an OVB, identified that being part of the team and feeling empowered were key to facilitating a positive birth experience.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eConfidence of staff and perceived functioning of the team at OVB were related to leadership and interpersonal relationships. Greater seniority of the accoucheur improved perceived team confidence and safety, but was also a significant barrier to staff feeling empowered to escalate concerns. Additionally, poorly developed relationships within the team and lack of awareness of existing best practice guidelines reduced staff confidence to escalate. Midwifery and paediatric or junior staff were less likely to feel empowered to escalate, compared to obstetric and senior staff. These contrasting perspectives likely reflect differences in power dynamics associated with the traditional hierarchical structure of the team. A recent study\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e acknowledged that care is more effective and coordinated, particularly in a crisis situation, in teams where leaders \u0026ldquo;flatten the hierarchy to promote information exchange\u0026rdquo;.\u003c/p\u003e \u003cp\u003eMany responders acknowledged additional challenges in communication, escalation and team cohesion at OVB performed in the Operating Theatre. Some staff felt like \u0026ldquo;outsiders\u0026rdquo; or found it challenging to be \u0026ldquo;on the same page\u0026rdquo; in the Operating Theatre, reflecting a deterioration in interprofessional relations and team dynamics. The introduction of new team members, change in environment and loss of additional midwifery support contributed to this fragmentation. The change in location was noted to be stressful and overwhelming for both staff and patients, with one staff member describing greater \u0026ldquo;disconnect\u0026rdquo; with the patient in the more medicalised environment. It was acknowledged that births in the Operating Theatre were typically more high-risk which contributed to stress of the team. Conversely, some staff reported that the additional senior obstetric support present at births in the Operating Theatre was reassuring and improved confidence.\u003c/p\u003e \u003cp\u003eVariations in clinical practice contributed further to uncertainty amongst the team, particularly relating to risk assessment or reasoning for management. Factors influencing variation in practice included clinician preferences and skill, differences in hospital policy, location of the attempted OVB and the clinical context of the birth. This theme was strongly related to adherence to safety guidelines, with staff universally advocating for the development of clear and accessible guidelines and policies as well as shared understanding of terminology, as these were recognised as useful tools to support consistency of safe practice.\u003c/p\u003e \u003cp\u003eAn important limitation of this study is that it was performed at one healthcare network, which may limit generalisability. However, it did include staff across multiple hospital campuses with differing levels of clinical acuity. Whilst this study obtained relatively balanced representation of senior and junior staff, as well as of staff performing and supporting OVB, there were relatively few paediatric staff who participated in the study increasing the risk of bias and reducing generalisability of those responses. Whilst this study focussed on healthcare staff perceptions of team functionality and safety of OVB, it is crucial that future research include the perspectives of birthing women.\u003c/p\u003e \u003cp\u003eThis study highlights the importance of behavioural skills to support team functionality and safety of OVB, in keeping with previous studies\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e identifying the crucial role of behavioural skills in OVB competency. Healthcare staff in this study called for increased clarity of multidisciplinary communication and transparency in risk assessment, prioritising involving and engaging the birthing women, fostering positive interdisciplinary relationships especially in the context of OVB in the Operating Theatre and greater access to safety guidelines. Further research should explore methods to improve behavioural skills, such as those identified in this study, and assess the potential to improve the physical and psychological safety of OVB. Our findings suggest that this is likely to require a multimodal approach with incorporation of education, skills training, guideline accessibility, systems changes and cultural transformation.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eHealthcare providers identified multiple factors that they perceived to impact team functionality and patient safety at OVB. Perspectives on communication and empowerment to escalate differed between members of the team. Acknowledging the perspectives of all staff members and how they may differ is a crucial first step to understand key factors to target in order to comprehensively improve team functionality and safety at OVB. Improved training in behavioural skills, alongside procedural technique, should be considered to ensure psychical and psychological safety through excellence in team-based care.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCCOPMM\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Consultative Council on Obstetric and Paediatric Mortality and Morbidity\u003c/p\u003e\n\u003cp\u003eFDCS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Fully dilated caesarean section\u003c/p\u003e\n\u003cp\u003eOVB \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Operative vaginal birth\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study received ethical approval from the hospital Human Research Ethics Committee (HREC ref. number\u0026nbsp;QA/76336/MonH-2021-265279(v1)).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants indicated their consent to participate through completion of anonymous surveys. Written informed consent was obtained for semi-structured interviews.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors report no competing interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthor SS was supported by The Australian Government Research Training Program Scholarship. The funding sources were not involved in the study design; collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the article for publication.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSS is the primary author who was involved in\u0026nbsp;concept design, data collection, data analysis, and manuscript preparation. AK was involved in concept design, review of survey and interview guide, co-interviewer, data coding and thematic analysis. EK was involved in data coding and thematic analysis. RH, PN, NM, BM and DR were involved in concept design. All authors were involved in review of themes, manuscript editing and approval of the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe acknowledge the time and expertise of our participants.\u0026nbsp;\u003c/p\u003e"},{"header":"References ","content":"\u003col\u003e\n\u003cli\u003eAustralian Institute of Health and Welfare. Australia\u0026apos;s mothers and babies. Australian Government. 2024. Accessed 20th August, 2024. https://www.aihw.gov.au/reports/mothers-babies/australias-mothers-babies/contents/labour-and-birth/method-of-birth\u003c/li\u003e\n\u003cli\u003eVictoria\u0026rsquo;s Mothers, Babies and Children 2019 (Consultative Council on Obstetric and Paediatric Mortality and Morbidity) (May 2021).\u003c/li\u003e\n\u003cli\u003ePatrick W, Ken C. 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Toward good practice in thematic analysis: Avoiding common problems and be(com)ing a knowing researcher. \u003cem\u003eInternational Journal of Transgender Health\u003c/em\u003e. 2023/01/25 2023;24(1):1-6. doi:10.1080/26895269.2022.2129597\u003c/li\u003e\n\u003cli\u003eNicholls J, David AL, Iskaros J, Lanceley A. Patient-centred consent in women\u0026rsquo;s health: does it really work in antenatal and intra-partum care? Article. \u003cem\u003eBMC Pregnancy and Childbirth\u003c/em\u003e. 2022;22(1)156. doi:10.1186/s12884-022-04493-6\u003c/li\u003e\n\u003cli\u003eViirman F, Hesselman S, Wikstr\u0026ouml;m A-K, et al. Negative childbirth experience \u0026ndash; what matters most? a register-based study of risk factors in three time periods during pregnancy. \u003cem\u003eSexual \u0026amp; Reproductive Healthcare\u003c/em\u003e. 2022/12/01/ 2022;34:100779. doi:https://doi.org/10.1016/j.srhc.2022.100779\u003c/li\u003e\n\u003cli\u003eCarter J, Bick D, Gallacher D, Chang YS. Mode of birth and development of maternal postnatal post-traumatic stress disorder: A mixed-methods systematic review and meta-analysis. \u003cem\u003eBirth\u003c/em\u003e. Dec 2022;49(4):616-627. doi:10.1111/birt.12649\u003c/li\u003e\n\u003cli\u003eFeeley C, Crossland N, Betran AP, Weeks A, Downe S, Kingdon C. Training and expertise in undertaking assisted vaginal delivery (AVD): a mixed methods systematic review of practitioners views and experiences. \u003cem\u003eReproductive Health\u003c/em\u003e. 2021/05/05 2021;18(1):92. doi:10.1186/s12978-021-01146-3\u003c/li\u003e\n\u003cli\u003eBahl R, Murphy DJ, Strachan B. Non-technical skills for obstetricians conducting forceps and vacuum deliveries: qualitative analysis by interviews and video recordings. \u003cem\u003eEur J Obstet Gynecol Reprod Biol\u003c/em\u003e. Jun 2010;150(2):147-51. doi:10.1016/j.ejogrb.2010.03.004\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Operative vaginal birth, instrumental birth, communication, team functionality, human factors","lastPublishedDoi":"10.21203/rs.3.rs-5321816/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5321816/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Operative vaginal birth (OVB) relies on effective teamwork to optimise outcomes. This study aims to explore providers’ perspectives of factors influencing safety and team functionality at OVB.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This mixed methods study involved four maternity sites at Monash Health, Australia. Surveys sent to healthcare providers invited quantitative and qualitative appraisal of safety and team functionality at OVB. Semi-structured interviews further explored themes emerging from survey responses. Categorical survey data were compared between staff roles using Pearson’s chi-squared tests. Thematic analysis of free-text survey responses and interviews identified themes influencing safety and team functionality at OVB.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFindings:\u003c/strong\u003e We received 100 survey responses from obstetric (n=41), midwifery (n=52) and paediatric (n=7) staff, including senior (n=49) and junior (n=51) roles. Overall, 99% thought team communication should improve and 82% had witnessed practices outside protocol. Obstetric versus midwifery or paediatric staff were less likely to rate communication as low or very low quality (5% vs. 29%, p=0.010). Reporting being extremely or very confident to escalate concerns was more likely in obstetric versus midwifery or paediatric staff (49% vs.12%, p=0.003) and senior versus junior staff (44% vs. 10%, p=0.008). Five overarching themes impacted on team functionality at OVB; (1) Calibre of communication, (2) Preparation and risk assessment, (3) Leadership and interpersonal dynamics, (4) Transfer from Birth Unit to Operating Theatre, (5) Variation in clinical practice.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion:\u003c/strong\u003e Some care providers perspectives of team functionality at OVB differed, with midwifery and paediatric staff more likely to report challenges with communication and were less empowered to escalate concerns. Training in factors impacting team functionality at OVB should be considered.\u003c/p\u003e","manuscriptTitle":"Understanding factors influencing safety and team functionality at operative vaginal birth through multidisciplinary perspectives: A mixed methods study.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-06 13:10:53","doi":"10.21203/rs.3.rs-5321816/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-12-03T07:12:37+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-12-01T14:47:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"38954883903568607221793806777284453145","date":"2024-11-10T20:12:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"299130338999682592959848413194092602206","date":"2024-11-09T19:43:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"324999199430709023916459330754944777115","date":"2024-11-09T14:24:00+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-09T00:58:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"90267458341429753977158735287839761530","date":"2024-11-08T23:55:19+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-11-06T20:40:36+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-10-29T06:49:55+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-28T04:41:14+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-28T04:39:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2024-10-24T01:05:54+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fa25294f-9dec-4b6b-901b-d2e68fc7f2d4","owner":[],"postedDate":"November 6th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-01-27T16:06:32+00:00","versionOfRecord":{"articleIdentity":"rs-5321816","link":"https://doi.org/10.1186/s12884-024-07075-w","journal":{"identity":"bmc-pregnancy-and-childbirth","isVorOnly":false,"title":"BMC Pregnancy and Childbirth"},"publishedOn":"2025-01-21 15:57:46","publishedOnDateReadable":"January 21st, 2025"},"versionCreatedAt":"2024-11-06 13:10:53","video":"","vorDoi":"10.1186/s12884-024-07075-w","vorDoiUrl":"https://doi.org/10.1186/s12884-024-07075-w","workflowStages":[]},"version":"v1","identity":"rs-5321816","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5321816","identity":"rs-5321816","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}