In the meantime, President Bola Akma Tinnabu has taken a firm stand against the unjust stereotyping of Nigerians as inherently corrupt. He expressed his view during the public engagement on youth religion and fight against corruption organized by the Economic and Financial Crimes Commission, EFCC, the event which also marks the launch of an interfaith manual and fraud risk assessment project for MDAs, took place in Abuja this Wednesday. Tinnabu, represented by Vice President Kashim Shetema, commended the EFCC for serving as a moral compass and persistently awakening the nation's conscience. He went on to stress the unfairness of labelling all Nigerians based on the actions of a few, emphasizing that Nigeria is her home to diligent and honest people. While highlighting the global contributions of Nigerians in significant fields such as their official intelligence and in medicine, he emphasized that such gross misrepresentation fails to reflect the truer sense of a nation composed of diverse and resilient people. So, Paso Olukoe, the religious man, please try and salvage our religious leaders and religious institutions. One person that I am always embarrassing him at all public functions is Issa Olukoe, the registrar of JAP. Over 40 years, the highest that JAP had humiliatively sent to the federal account was less than 100 million dollars. Issa Olukoe, the two-chance, had reneged over 50 billion Naira. He has redefined the meaning and concept of modern leadership. He's a steady in courage, he's a profile in courage. He has out promoted the operations. And this is exactly what the current city of Posoms is doing. Automating the system and increasing the revenue profile of the nation. Finally, I want to reassert your excellencies, your eminences, ladies and gentlemen. What buys us together surpasses whatever that device has. And as you might as a people, to pace our forward challenges.


University of Western Sydney. Allie currently lives just outside of Canberra on a small rural property and her current work is at the University of Canberra teaching Bachelor of Midwifery students. In her early career, she worked in a variety of midwifery-led models of care, birth centers, publicly funded centers, home birth and in new models of midwifery care. More recently, she's had the opportunity to support the establishment of new models of midwifery care in a variety of settings and in a variety of leadership and policy development roles. She's sharing with her a study for her PhD towards her PhD degree that explores the quality of midwifery care and the issues attached to that. So I will give the floor to you now, Allie. Thank you so much for presenting tonight. Great, thank you. Can you hear me okay? Right, good morning, good afternoon, good evening, wherever you are. I thank you for this opportunity to be able to speak to an international forum. It's a wonderful opportunity. It's also a privilege for me to be here today as I was called in at the last minute. To start with, I'd like to acknowledge the traditional owners of this land, both past and present, on which I sit today, the Nungan War people. These are the local indigenous Aboriginal people of the area around Canberra. Today I will be talking about the midwives and women's interaction study, which we commonly call the Maui study. It's a study where we've explored the interactions between midwives and women in antenatal appointments using a feminist ethnographic approach. This study is still in progress and part of it has become my PhD. Firstly, I'd like to acknowledge the research team that I'm involved with. That's Professor Hannah Darlin, Professor Virginia Schmead, Dr. Nikki Leap, and midwife colleagues Julie Swain, Donna Garland and Kate Lamb. They've all provided wonderful guidance and support so far. And also to thank my doctoral supervisory team, which is Hannah and Virginia and Nikki. My apologies if this presentation is a bit disjointed, but I only had a short time to get it together. And as people know, I'm not the speediest writer in the world. So here we go. Midwifery Continued Care or CARER. As we know, there are many studies, including randomized control trials and Cochrane reviews, that demonstrate improved clinical outcomes for women when they have a known midwife who cares for them throughout their childbirth experience. This is particularly evident in models of care that are midwifery-led and offer continuity of midwifery-career. We also know that women report satisfaction with this model of care, where they're able to develop a relationship with their midwife who is available for them throughout their childbirth or childbirth experience. What we don't know is what happens in the antenatal appointment that creates this relationship. So we talk about the relationship and the wonderments of the relationship. But what are the nuts and bolts that make up this relationship? So within this study, we're exploring the interactions between midwives and women in an antenatal appointment. We're wanting to understand what the good things are. As you all are aware, there's been many changes and redesign of maternity care over the past 300 years in the Western world. This has resulted in an increased reliance on medical technology and the sighting of most of our midwifery-care within the acute care hospital system. This has taken the focus away from the midwife-woman relationship and placed value on output and clinical outcomes and not the needs of the individual women or the individual needs of the midwives. With this study, we're attempting to do, what we're attempting to do with this study is to return to the fundamentals of midwifery-care and understand how the relationship developed over a childbirth experience manifests. This is in order to understand and articulate why the relationship-based continuity of care works. So we have started with the antenatal period where the relationship is constructed. To do that, we need to look at the force within the... To do this, we need to look at the force within the interaction between people. So today's presentation, I'm going to be talking to you a bit about the study progress and a bit about storytelling. The thing that's happened within this study is that storytelling has raised itself as being something significant. And as I've begun coding and getting on with analysis, I've found out more and more about storytelling. So here's just a little 101 on storytelling. As we know, storytelling is an age-old tradition and is an interactive process of sharing stories with others. It's an integral and it's an interactive process between the teller and the listener of the story. What it does is that it establishes common experiences or similarities between teller and listener and has the potential to develop connection, trust and empowerment. It provides a way to articulate our hopes, fears and dreams and to deal with uncertainty. And it is also purported to build resilience. It is argued that storytelling empowers people by revealing their experience and lives of other people, which enables people to have clearer picture of their situation options available to them. We learn from stories and much of what we do relates to how we listen and how we understand stories, which are important factors to think about as a health practitioner or a midwife. My apologies if there's an echo. I'm having problems with my headset. So I might be having a relay between the computer microphone and the headset. Now, specifically, the aim of the MAUI study is to explore how the relationship between the midwife and the woman in continuity of care manifests and how it affects the woman and the midwife. To do this, we have studied and explored interactions in both standard midwifery or maternity care where the midwife and woman have no relationship and also midwifery continuity of carer, such as midwifery group practice or caseload, where the midwife and the woman have developed a relationship over the course of anti-natal appointments in pregnancy care. This is involved observing and filming anti-natal appointments to explore current practices and languages used by midwives and also their communication ways and wherefores. This is involved exploration also of the perceptions, beliefs and expectations of anti-natal care from women, midwives and their managers. To do this, we've also undertaken focus groups and interviews for the staff at two hospitals involved in the study and interviews with women. A quick bit on the progress of the study. This study commenced in mid-2012 with ethics and recruitment occurring in that year. Data collection was undertaken in 2013 at the two hospitals. Now, the two hospitals are metropolitan hospitals in the western suburbs of Sydney, New South Wales, Australia, and they cater between 3,000 and 5,000 births. The data collected was observation data, which was of these anti-natal appointments and involves filming and audio transcripts. We were able to observe 19 appointments in outpatient departments of the hospitals, a local community health centre and women's homes. 16 of these appointments were at late pregnancy appointments between 36 and 38 weeks. And three were at 26 to 28 weeks. The original plan or intent of the study was to have 20 late pregnancy appointments observed, but time issues, midwife preference to be filmed at a particular appointment and recruitment error hindered several of these. In addition to these observations, we had six focus groups. These included midwives from both models of care at both sites and managers from both sites. In all, we had 40 focus group participants. And these participants also included a mix of midwives who'd been filmed in the observation and midwives who'd chosen not to be filmed as part of the study. Their managers, their midwifery consultants, multicultural workers and one lone student midwife. We interviewed 10 women and in their early postnatal period, which was roughly between 9 and 14 weeks. And we also had an opportunistic interview with a woman who had received care from both models of care within the previous three years. And we also interviewed two midwives who had also been filmed and who we wanted to explore more of what they had to say after they'd been part of focus groups. Over the past year and a half, I've been going through analysis and this has been a slow and steady process, probably a little too slow for my supervisors. Now, the analysis framework has grown and evolved as any good ethnographic study does. The first-age analysis has involved thematic analysis of the interviews and focus group data. This early process was able to inform us of some health-enhancing perspectives that the midwives and women were thinking of. This is really important when we're looking at this study from a feminist perspective and also looking at it from an ethnographic perspective. We looked at these transcripts and focus groups and interviews and explored the participants' own comments on what they viewed as positive about midwifery care. This process explored components of antinatal care that were seen or described affirming and meaningful and relevant to midwifery care and also what the women and the midwives felt. This positive and affirming framework was based on theories such as solitagenesis, a strengths-based approach, appreciative inquiry and feminism. Now, a rationale for the focus group and interview data was also to analyse this early on to have a standpoint perspective as well, so a standpoint from the people who'd participated in the study. This involved getting perspectives of the participants to inform or frame the analysis of the observation data. This was not only to come to the analysis from a feminist perspective that is inclusive and respectful to those being researched, but also to balance out the biases I, as a researcher, bring to the study. As you would have heard with my bio, I have a long history with midwifery continuity of care models, and so my bias is pretty much towards continuity of care. So with the standpoints of both the midwives and women, I've been able to pull that bias back to some extent. Now, with the video observations, we found that there are multi-layered and quite complex bits of data to analyse, and this is why my analysis has been taking so long. I've moved around different processes of analysis. I've looked at interaction analysis. I've looked at thematic analysis, and I'm also now looking at storytelling analysis. But what we've been able to pull out of this analysis of the video data and the transcribed words from that video data is that there's themes coming out, and there's also a lot of information coming out around the stories that are being shown in some of these observations. With the video data, we're looking at interactions as well. So we're looking at the midwife and the woman, and the midwife and the computer, the woman and the computer, and also some interaction with the support person if they're there. Other interactions or parts of the film that we're looking at is where was the film taken? Was the observation of an anti-natal appointment in a busy outpatient department, or was it in a community health centre, or was it in a woman's home? So we've taken this all into context. We've seen that this contextual way of analysing is really important for the video data because it tells us a lot of information. It also informs what we're seeing on the written page when we're looking at the transcribed words. And what we're doing with the transcribed words is looking at storytelling, sort of trying to pull that out, but also understanding the purpose and the content of what the conversations are in the appointments and what the storytelling purpose and content is. So it's quite complex, but also very interesting and also very challenging. So if we look at this slide, this slide's showing some data that I have been developing since mid-last year, and I've sort of pulled it out from last year's data just to inform why we're going down the storytelling path today. As you can see, there's many pieces of data, concepts, and early themes that have pulled out of here. So the major meta theme is communication skills within anti-natal care. This is by the midwife. But also, there's some smaller themes which feed into communication, and that's addressing anxiety, compassionate, and also looking at more nuts and bolts stuff like body language. It's interesting that these bits of information that I have coded and beginning to theme has come from the three participants groups. So if you look at what I've pulled up here, with the midwives' comments, they are in the purple boxes. The managers are in green, and the women are in pink. So if you look at the midwives, they talk about not having a ticker box approach. Things come up. We can talk freely. Body language is important, and identifying the woman's issues is important. Managers talk about compassionate care, being engaged with the woman. And then the women talk about how they feel about their care. She was like, pregnancy and labour is not the same for every woman, so it's individualising their care. Chit-chat and sharing of self. Now, this chit-chat and sharing of self is what's coming into the storytelling. They're not just concentrating on my stomach. They socialise too. Really important factors. The other things you can see is how they talk and how they relate to the women. Being so lovely and warm, these were important factors that the women talked about. Okay, facilitators and barriers. So if we get back to the idea and the concept that we're talking about today with today's presentation, is looking at storytelling. And so one of the main ideas of this study was to explore facilitators and barriers of midwifery care and the anti-natal appointment. And so what we found is that there's some facilitators and barriers to the way in which the midwives communicate in the anti-natal appointment. And they seem to be lumped under three large themes, which are environment, time and model of care. This is the way that they communicate. It appears to... The way that the individual midwives communicate appears to stretch from one aspect of the scale, being closed to questions and, you know, one-word answers from women, right across to shared storytelling experiences with another midwife and woman and another anti-natal appointment. This is what we've observed. So if you look at environment, we've found that environment, when we've analyzed the data, seems to influence the number of communication moments occurring in the observations, which are of the anti-natal appointment. And it also seems to influence how positive and affirming those communication moments are. Now, with the environment being a factor, we found that there was a greater number of social storytelling events where the midwife and woman were showing stories of self and an understanding of the others when it was in the midwife... midwifery group practice model and when it was in the woman's home. And this was in comparison to the outpatient department and the standard midwifery care model. The majority of the appointments observed had stories that shared clinical and health information and system information. That was in all of them. But it was the appointments in the woman's homes and with the midwifery group practice midwife that the stories of self were seen. And this was from both midwife and woman. You know, often in these observations, I would see women sharing of themselves, but it wasn't every occasion that women... that midwives were sharing of themselves. And that's where the little flag-raising moment was me, the aha moment, this midwife's giving of herself. It appeared to be a way that the midwife was trying to connect and trying to demonstrate her understanding of the woman's experience. So, as you can see, this slide is quite bland, but I've got a snapshot of a couple of the observations. One is in an anti-natal clinic room in the outpatient department and it's fairly standard clinic room. The other one is of midwife and woman talking in a woman's home. And at the moment that I snapped this was when they were having a great joke. Now, just some quotes that I just wanted to pull out. I was probably sick of listening to my words, so I thought I'd pull out some of the participants' words. So this was from a focus group with the midwifery group practices at one of the hospitals. And it's about environment. I don't know. I feel like because the women are in their own environment, they feel a lot more comfortable, somebody else says. You know more about them when you see them at home. Then somebody else said in the focus group, yeah, and I feel like the clock's not ticking as well at home, whereas in the hospital we're limited to time. Now an interview with one of the women. There, it's almost like the RTA office. And you know, when you've got your numbers flashing up, you're waiting for your number to be called. There's no interaction with anyone. You have no idea how long you're going to wait or how long it's going to take or how long it's going to be. So for most people in Australia, they would understand the RTA office to be the Roads Traffic Society office. So it's an office or waiting room where you go and you take your number and you sit and wait to be told when to go to the counter with the plus your number. So this is how this woman interpreted her experience of waiting for her antenatal appointment in the hospital at the outpatient department. Then if we look at the concept of time, it has influence and appears to be linked to the length of appointment and flexibility of time for the midwives and when the appointments are out of the hospital. There's comments from the focus groups and the interviews highlight the flexibility that the women and the midwives have at home and in the community centre and the control that they have over these appointments and when they are and who's at them compared to when they're in the hospital. So this is interesting that we've got the agency and autonomy of the midwives and women coming up with appointments outside of the hospital but once you step into the hospital system it seems to be lost within the constraints and confines of hospital process. And here is what some of the midwives and women said about time. Interview, I didn't feel like she was in a rush. Not having a ticker box approach means communication flows freely, things come up. So this was a woman talking about her understanding. Then we had manager's focus group. You can't create the trust and the relationship. It's not just the information, it's the relationship. You can't create the same depth of it without having the time. So once again you've got this connection between environment and time and also the model. Focus group, midwifery group practice. But I think like it's like with any relationship when you see and know somebody obviously there's more opportunities for that to happen. I think as soon as women actually realise that this service is all about, it's almost like they have permission to talk about more personal stuff because you're not rushed. I explored the length of the appointments in the descriptive process as well and this showed that at one hospital the median difference in length of appointment was five minutes. So 26 minutes when it was in hospital and 31 minutes when it was at the home. Then at the other hospital there was an 18-minute difference with the median length. So within the hospital and the standard maternity care midwifery model it was 19 minutes and at home with the midwifery group practice it was 37 minutes. So there's some issue there around time constraints as well. The majority of the standard midwifery care appointments were within the outpatient department apart from one in the community health centre. And then if you look at the midwifery group practice appointments observed, most of them are in the woman's home and with one of them in a specifically allocated clinic room for the midwifery group practice midwives which is not situated near the outpatient department. So it's this system that seems to be controlling time that seems to have a negative influence. And then if we look at model of care the focus group with midwives again from midwifery group practice, here's what one of them said. Look, I've had continuity of care clinic in the clinic for three years before I started this. This has been as her work in midwifery group practice. It was the only continuity of care in our hospital. So I was trying to do similar things in the clinic but I tell you that this is very different still. It's so different when you work from the beginning to the end. It's so not just about seeing the same patients. So this midwife's talking about her experience of working in an antenatal clinic in a hospital where she provided a midwifery clinic for women but she then would only work in that environment and didn't provide on-call support for labor and birth and postnatal. So her experience of going on to a midwifery continuity of care model, midwifery group practice, she found that her going from the beginning, so from antenatal care to the end, so labor and birth and postnatal care had so much influence. So there's some sort of connection and continuity there that's so important. Observation A15, so this is from a video. Midwife talking to the woman's partner, okay. That's good. Well, who wouldn't not get on with her? She's so nice. We clicked like that, didn't we? So she was talking about her relationship with the woman that was sitting with her to a partner. And then the midwife said later, yeah, that's a woman's thing. We're all like that. I think I was eight weeks. I'm like, right, we've got to get the spare room clean now. We have to get rid of that car. So once again, she's aligning herself with how the woman's feeling and what she's voicing in that appointment. Now, what I've done with this presentation is that I've kept it to as small as possible, so I've taken out the video. So I'm just going to share with you the words that were shown with this excerpt of this appointment. And it's just talking about when I had the aha moment with the storytelling thought. Here we go. Pregnant woman, that's what it's the time. I think I'm much more conscious, even just in the planning of it. I'm so much more conscious of everything. I don't even remember any really of the others. You know, unless it was the drip or this or that, you don't really remember. And that's why I want photos of that as well. Midwife. So we actually get there when you look at a pregnant woman. I can't be in that. Go back to that space, yeah. Midwife. Well, I hope that you get that. I think when I look at my own birth, the third birth, the third baby I had, I should remember him being born, like that moment of him coming out of me and me giving birth to him, pregnant woman. Yes, I don't remember that with the others. Midwife. It's just the most amazing, like I mean, he's now 21, but I still remember that moment and I don't have recollection of that with the other two. Like I remember having the birth, but I so hope you get that, pregnant woman. Yeah, I think I will this time. As you can see from this excerpt, there's storytelling and the woman is showing her own vulnerability by sharing a story about an issue that's very important to him. And then the midwife has listened to that story and she's telling her own story and she's used her midwifery knowledge, skill and experience of the woman's previous history to individualise a positive message. She's also shared a story of herself which is really significant, highlighting her personal aspiration for the woman to have a positive birth and demonstrating her understanding of connection and compassion to this woman's situation. She's really putting herself out there. So these are the concepts that I'm looking at with storytelling. It's about compassion. It's about connection. It's about hope. It's about being positive and listening. Listening seems to be a very important factor. Now, this slide contains some of the comments that come mostly from the focus groups and interviews from the midwives, the managers and the women again.  I asked her in the interview what was so important about her midwife, who she'd had continually care with and that's what she said. And then another midwife talked, sorry, another woman who's the pink square at the top talks about being protected or something. It's like being protected or something. And this woman didn't have midwifery continuity of care. She was in the standard midwifery care model within the outpatient department. But we were talking about the one observation I'd had with one of the midwives. And there was a lot of storytelling and sharing of information in that appointment. But the storytelling wasn't so much of the midwife sharing of herself. But she was sharing a lot of information to that woman to reassure her about what was going to be happening. So there's something about the storytelling of trying to allay uncertainty as well. And so just with closing, I just wanted to tell you some quotes from other focus groups and interviews as well around this idea of connection and compassion. Interview one. They're not just concentrating on my stomach, they socialize too. So it's just not a clinical appointment. There's some camaraderie, there's some chats. There's a social aspect to the appointment. And this is what I found that there's three main themes of discussion in the appointments. There's the clinical discussion, there's the social-personal discussion. And then there's a discussion about how to manage the system. And it seems to be that the social-personal discussion is more intense and more obvious in the appointments when the midwives and women know each other. Observation A-15. Midwife. I love those nails. Pregnant woman. Thanks, I looked at yours when I walked in and I went, okay, midwife, I'm not meant to have nails. Pregnant woman, aren't you? But if you know what you're doing with them, you can't even, midwife, yes, I'm really clean. Pregnant woman, yeah. Midwife, I like them. Are they pregnant women? No, I was going to get them, but they didn't have the green. So I was like, no, I'll pass this time, midwife. Now, green is my favorite color, pregnant woman. It's mine, you can't see them. Green is my favorite color, too, midwife, as she finishes off. A lot of people don't like green, but I do. So once again, the midwives finding a connection with this woman, which is really, really interesting because this midwife really focuses on how she finds it really important to have connection with the women she's looking after. And she's one of the midwives working in standard care who takes the time to storytell and share to get that connection. Observation A8, this is a midwifery group practice appointment. Midwife, right, the 22nd, Wednesday at 2.30, pregnant woman. See how much I find rules in my life? It really does, midwife, yeah, I know. What did we ever do without them? Pregnant woman, I don't know, I wasn't, oh, okay, midwife. Pregnant woman, going to get one because I really, I wasn't going to get one because I was really against it. But yeah, I ended up getting one and I can't live without it now. I've got Facebook 24-7, oh my God, I'm addicted, midwife. Here, especially when you're sitting there, you're not doing anything and then you just go, I'll just have a look at Facebook. Then an hour later, I'll just look on Facebook, hopeless. Pregnant woman, I know. It really is, luckily I don't have a reception at work, otherwise I'd just be doing it 24-7. Once again, they're sharing themselves. Observation A9, this is the midwife and I'm actually recorded in this observation as the researcher. They included me in part of their discussion, midwife. The girls will tell you, Allie, that I have a chatty thing that I do and she laughs. Me, that's okay, midwife. I'm a bit of a talker. We talk a lot, don't we? And then the pregnant woman says, yeah, it's good. Yeah, I like to know everything. I like the talking bit. So you can see these midwives and women are sharing of themselves and trying to really find a point where they connect. And this connection seems to be enhanced by environment and time. And also by the fact that in a continuity of care model, the midwives and women are able to re-engage with this story from one appointment to the other. One of the last factors was with asking a midwife, asking a woman about what she found really important with continuity of care. And she said, I don't have to tell my story, the same story every visit. Each time we meet, we just build on the story. So once again, thank you for this late opportunity to come and present to you my early findings of my PhD. But I'm really enjoying this fact that I found something so rich and wonderful in storytelling. Thank you. That's wonderful, Allie. There were times when I just had flashbacks of interactions with clients. And thank you so much for sharing. Does anyone have any questions? Maybe I could just read through the chat bar a little bit or if someone wants to raise their hand to just pose any questions to Allie. It seems as though we're getting a lot of agreement in everyone's comments. Getting lots of chatter, hey? Typical midwives we like to talk. I think someone is talking about just the inner strength and just some of the feelings that are evoked when they hear some of these quotations. And I think it's the motivation that keeps us all going. What was it that led you to choose this as your doctoral thesis?  So, Colin, you're asking me what led us to doing the study? Motivated. It actually came out of I was working as a midwife in the New South Wales Health Department, so a state health department in Australia. And there was a grant that was coming up. And I'd heard that nobody had applied for it. So Hannah Darlan and I decided to design a grant that explored what happens in antinatal appointments to get more clarity around with your continuity of care. And so that's where we came up with the idea. I subsequently then left New South Wales and moved into state to just near Canberra, which isn't really far. It's only about three and a half hours away, but I changed jobs. And then Hannah said, oh, look, we've got the grant. And I said, oh, great, I'm not living there anymore. And she said, why don't you do it as your PhD? So it sort of came around in a sort of a circumvent sort of way that led us to explore something that was very close to our hearts, but was only through a process of work that we thought we could do this. So I'm very privileged. Well, all benefits from all of the findings. That's wonderful. And noticing some other comments here. Yeah, people from Canada could have the autonomy to have longer appointments and really listen to the woman. A few comments of people who are in obstetrical services where it's the obstetrician run office. And they're being cautioned not to take longer than 10 minutes or 30 minutes, seems like a luxury. Any other comments? So true. When I first started, I was speaking to Professor Darlin, Hannah Darlin the other day. And I said, when I first started doing anti-natal care, I'd be standing up and we had a 10-minute slot. So these women were very much processed and there was no chitchat. There was no storytelling. And it's just lovely to see over the last 15, 20 years that that's really changed. And now we are having more time to spend with women. But I think still that time needs to be extended more, particularly for women who have high vulnerability needs, as a lot of the women do that we're caring for. Now does Melissa have a question? Go ahead, Melissa. We'll have to press the green button. The top microphone button will turn green when you press it. Perfect, we can hear you a little bit louder. OK. I was wondering if you had found any negative feedback from any women regarding this process? I purposely didn't ask the women too many negative aspects. I particularly was looking at the positives. But I myself, when I was observing some of the appointments, I did see some negative things that were happening, which was opposite to refreshing. It was sort of very unnerving that I was sitting there with a camera rolling in an antenatal appointment and these things were happening. But most often the women were very generous and were very keen to share what was good. One of the women, the woman that was interviewed who had experienced both models of care, talked a lot about the midwives just doing their job and that they didn't really have a say in what happened and that often in situations midwives weren't skilled enough to be able to communicate in the best way. So there's still some work to be done around supporting, but I think midwives in situations where it's stressful or there's a disagreement between midwife and woman and how the midwife best is able to manage that. Any other comments? I'm noticing in the chat bar a few concerns about just the way you're expected to act or the professional demeanor that some offices are expecting and then for certain high-risk clinics or working with teens, there's some comments about that as well and then trying to run a large volume antenatal clinic. How do you make the care caring and the needs of these women? Sometimes the stories are, I guess, shared while you're doing a fundamental height, while you're physically doing something you're also talking and managing the time. Any other comments that anyone wanted to share? Finding it difficult to hear me. The comments I was just describing that were written in the chat were the challenges of running a high-volume clinic or a high-risk clinic or a clinic with vulnerable clients such as teenagers and how you would like to be able to have more time, but some of the constraints of the clinic itself make it difficult. And I don't know if you wanted to speak to that, Ali, just how sometimes it's necessary to multitask and give a caring touch while you're actually trying to listen and work with your hands at the same time. It's interesting that there was one midwife that really stood out for me in the standard model and she was the one that I took the excerpt around the green nail polish discussion. And she said it was about putting yourself into your work and making sure that you align yourself with what the women need. She was very proud of the fact that she grew up in the community where the hospital was situated and she was very proud of the fact that she was a poor woman alongside these poor women. So she said that she would always spend a lot of time... Well, not a lot of time, but she would always make the effort to make little things important and being able to nurture and care for the woman. So she also ran a clinic for early pregnancy situations where there may have been a miscarriage or early bleeding and the woman wasn't certain if their pregnancy was going to last.  I know I'm not supposed to have my burner in here, but nobody seems to notice. And she said, oh, we've put a fish tank in the room and we've painted it. And she said... And that stuff, she said just the little things, taking the time to invest in how you come across to the public is really important. That's lovely. Thank you so much, Allie. I'm just going to tie things up now so we can prepare for our next speaker. I'm just turning off our recording.


Good day everybody. My name is Dr. Sanjay Sanyal, Professor Department Chair. This dissection demonstration is going to be mostly on the distribution of the common fibular division of the sciatic nerve right from its origin to its domination of its branches. So if we go to start from the public ear foster, this is the common fibular nerve which runs under the cover of the biceps femoris. This was the tibial nerve. The common fibular nerve, it goes behind the head of the fibula and then it winds around the neck of the fibula which is located here and under the origin of the fibularis longus, it passes and it divides into two divisions. One is the superficial fibular division, the other is a deep fibular division. Let's trace them right from their beginning. This is the superficial fibular nerve and you can see when I exert traction here it pulls on this. So this is the superficial fibular nerve. It is running in the lateral compartment of the leg and the lateral compartment as we know consists of two muscles, the fibularis longus and under that the fibularis brevis. The superficial fibular supplies the fibularis longus and the fibularis brevis and immediately thereafter as we can see here it pierces through the deep fascia that is the cruel fascia and it becomes cutaneous and we can see several of these cutaneous branches which were running in the superficial fascia. These cutaneous branches they cross superficial to the extensor retiniculum which is located deep here and then the superficial fibular nerve supplies most skin of the dorsum of the foot. So therefore the superficial fibular nerve after supplying the muscles supplies the skin of the antrolateral aspect of the lower one-third of the leg and the skin of most of the dorsum of the foot except the portion which is supplied by the deep fibular nerve which I'm going to mention just after this. One important clinical correlation pertaining to the superficial fibular nerve is that if a person suffers repeated inversion injuries it can produce attraction neuropathy of the superficial fibular nerve. Now let's take the next division of the common fibular and that is this division here. This is the deep fibular nerve. All these divisions are taking place deep to the attachment of the fibularis longus muscle. The deep fibular nerve runs in the anterior compartment and we can see this is the deep fibular nerve and when we exert traction here we can see it is pulling here. This is the deep fibular nerve. So the deep fibular nerve runs in the anterior compartment it runs essentially between the tibialis anterior and the extensor halosus longus along with the anterior tibial artery and both of them we can see clearly here. The deep fibular nerve supplies the muscles of the anterior compartment and after it runs all the way down the deep fibular nerve then runs under the extensor retinoculum and we can see the extensor retinoculum which I have opened up here and we can see the deep fibular nerve is running under the extensor retinoculum and it comes on the dorsal aspect of the foot and when I exert traction here we can see it is pulling on the deep fibular nerve as well as the anterior tibial artery which now has become the dorsalis pgis artery. The deep fibular nerve once it has crossed under the extensor retinoculum it then continues and supplies intrinsic muscles in the dorsal of the foot namely the extensor halosus brevis and the extensor digitalum brevis and after it has supplied all these muscles the deep fibular nerve then continues and it becomes cutaneous and it supplies the skin of the first interdigital cleft on the dorsum of the foot namely the space between the great toe and the second toe. So this is the only portion of the skin which is supplied by the deep fibular nerve. If the deep fibular nerve is injured or even if the common fibular nerve is injured which is quite likely if there's a fracture of the fibular neck here then the muscles of the anterior compartment are paralyzed and the most notable deficit that can happen when there's an injury to the deep fibular branch or to the common fibular is paralysis of the tibialis anterior and paralysis of the tibialis anterior which is the most powerful dorsiflexor of the foot leads to a very severe disability known as foot drop. That is one important clinical correlation. The next important clinical correlation is when the deep fibular nerve is passing under the extensor retinoculum here. It can get entrapped in a condition known as ski boots syndrome. Those who put the boot laces tightly while skiing it compresses the deep fibular nerve and it can lead to entrapment neuropathy of the deep fibular nerve under the extensor retinoculum and ski boots syndrome. The point to be noted is that the muscles of the anterior compartment are spared because the anterior compartment muscles have all been supplied. The symptoms are perceived mostly on the foot. There'll be numbness, palesthesia and tingling of the first interdigital cleft and there will be weakness of the muscles on the dorsal compartment of the foot. So this is about the deep fibular nerve and the superficial fibular nerve. Now let's focus on one small nerve which I have preserved here. We can see that it is starting from the lateral side of the foot and it is this nerve here. This is the sural nerve. The sural nerve actually was formed by the union of two branches. One from the common fibular and one from the tibial and the two of them united and they formed the sural nerve which of course has been removed in the rest of the place. The sural nerve supplies the skin of the back of the leg, lower one-third of the leg and then it continues and supplies this little bit of the skin of the lateral side of the foot and we can see a little bit of the sural nerve and this notable point to be remembered is that the sural nerve is accompanied by this superficial vein that we can see here which is opening into the propitial vein and if we put them together we find that they are running parallel to each other. This is an important anatomical relationship. Surgical practice we use the sural nerve for nerve grafting. We use the short saphenous vein as our landmark. We can see the short saphenous vein and immediately adjacent to that we look for the sural nerve. We can use it for nerve grafting. Before I conclude there's one more thing I wanted to show you. This again is the common fibular nerve. It is giving a branch shift. This is the lateral sural cutaneous nerve which is a cutaneous branch from the common fibular which supplies the skin of the back of the leg. So these are the complete distribution of the common fibular and all its branches, its cutaneous supply, its muscular supply and its clinical correlations. Thank you very much for watching ladies and gentlemen. Dr. Sanjay Sanyal signing out. If you have any questions or comments put them in the comment section below. Have a nice day. Hey guys make sure you subscribe and like this video.