The influence of the birthplace and models of care on midwifery practice for the management of women in labour

Article Outline

• Summary
• Introduction
  • Management of the first stage of labour
  • Decision making relationships
• Method
  • Recruitment
  • Data collection
  • Midwives questionnaires
    • Section one: Midwifery training
    • Section two: Management of care
  • Maternal questionnaires
    • Section one: Information about you
    • Section two: Labour and delivery of your baby
    • Section three: Reflection on your care
  • Analysis of information
• Findings
  • Demographic results
  • Midwives’ definition of labour
  • Management of labour
  • Assessment of progress of labour
    • Examination per vaginum
    • Rupture of membranes
    • Positions adopted in labour
    • Monitoring of fetal heart
    • Consumption of food and fluids
    • Pain relief
    • Enhancement of prolonged labour
    • Protocols and guidelines
    • Women's concerns when left alone
    • Decision making and partnership
• Discussion
  • Midwives’ assessment of labour
  • Midwives’ management of labour
  • Limitation of study
• Conclusion
• References
• Copyright

Summary 

This paper will examine how the settings in which midwives practice (the birthplace) and models of care affect midwives’ decision making during the management of labour. One-hundred-and-four independent, team and hospital based midwives and 100 low obstetric risk nulliparous women to whom labour care was provided were surveyed. These midwives and women resided in the Auckland metropolitan area of New Zealand. The majority of midwives who participated worked in models of care which provided women with continuity of carer and care, however, this was not found to influence the way the midwives provided labour care. Instead, practice was found to be relatively homogenous regardless of whether the midwives worked in independent, team, or hospital-based practice. The birthplace setting in which the labour care took place did influence midwifery practice. The majority of midwives provided labour care in large obstetric hospitals and identified practices dominated by the medical model of care. Practice was described as being influenced by intervention and the need for technology, however, this did not prevent the majority of women from perceiving they were actively involved in the decision making process and that they worked in partnership with their midwives. Closer examination of the midwives’ decision making processes whilst providing the labour care revealed that the midwives’ individual decisions were influenced by the needs of the women rather than the hospital protocols. What became evident was that the midwives in this study had adopted a humanistic approach to care whereby technology was used alongside relationship-centred care.

Keywords: Decision making, Labour management, Models of care

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Introduction 

Imagine that you are a midwife; you are assisting at someone else's birth. Do good without show or fuss. Facilitate what is happening rather than what you think ought to be happening. If you must take the lead, lead so that the mother is helped, yet still free and in charge. When the baby is born, the mother will rightly say: “We did it ourselves!”

Lao Tzu, The Tao of Leadership (5th century B.C.)

The style of leadership that Lao Tzu (5th century B.C.) described encompasses a facilitative approach to the woman's birth process without unnecessary intervention which leads to the empowerment of the woman. Centuries on following reforms of maternity services to more woman-centred care these same values of respecting normal birth and providing woman-centred care are espoused in what Page¹ refers to as ‘the new midwifery’. However, the environment in which a birth takes place may significantly influence midwives’ practice during the management of labour.

Management of the first stage of labour 

Labour has been defined as the presence of regular uterine contractions leading to progressive effacement and dilatation of the cervix² with at least two measurements of cervical effacement and dilatation required to ascertain labour progress.², ³ Friedman,⁴ the first to construct a cervical dilatation time curve, laid the foundations for the current monitoring of progress in labour. Friedman's curve of cervical dilatation was obtained from studying 100 primigravid women in spontaneous labour. No exclusions were made for malposition, multiple pregnancies or oxytocin infusion, and only 29 women went on to have normal vaginal deliveries. The minimum rate of dilatation Friedman expected for nulliparous women as they entered the active phase of labour was 1.2cm/h, and 1.5cm/h for multiparous women. Not surprisingly, Friedman considered cervical dilatation to be the most exact method for measuring labour progress.², ⁵ However, there have been no reported studies of either inter-observer or intra-observer reliability to confirm Friedman's beliefs, and based on personal experience Crowther et al.² report considerable variation in examinations performed by different observers in the same situation, or by the same observer in repeated examinations.

Philpott and Castle⁶ (cited in ref. 5), who have been acknowledged for the introduction of the first partogram, recommended that a straight line drawn on a cervicograph, representing a dilatation rate of 1cm/h, was a baseline of minimum dilatation that could be applied to all labours. However, to date, no researcher has statistically established the limits of biological variation within any given population.⁷ Philpott's and Castle's cervicogram was devised to ascertain the appropriate place of delivery for an African population. Studd³ (cited in ref. 7), for example, in attempting to use the cervicogram on women residing in Birmingham, England, found a need to modify the protocol to prevent inappropriate decision making occurring.

How frequently vaginal examinations are performed to assess the progress of cervical dilatation varies widely depending on the setting in which the care is provided and the literature cited.² Philpott and Castle,⁶ for example, recommended four hourly vaginal assessments, Studd³ three hourly, and O’Driscoll et al.⁸ advised two hourly examinations.

There are two commonly recognised approaches to managing the first stage of labour: the expectant approach and the active approach. The expectant approach allows labour to progress at its own rate without intervention unless problems arise.⁹ With this type of management, physical and emotional support are provided and occasional checking is undertaken to ensure the woman's labour remains uncomplicated. Conversely, the active approach requires close monitoring of the woman's rate of cervical dilatation and intervention to augment labour if it is not progressing at a determined rate.⁹ One form of the active approach known as ‘active management of labour’⁹ was pioneered in the 1960s by O’Driscoll and coworkers at the National Maternity Hospital, Dublin, Ireland. Its use was initially proposed as a strategy to lower the rate of caesarean sections performed for labour dystocia.¹⁰

Active management of labour was then implemented widely, often with apparent success in decreasing caesarean section rates.¹⁰ However, other institutions remained unconvinced, obtaining lower rates of caesarean section than O’Driscoll's active management with minimal intervention.¹¹

With these discrepancies in birth outcomes, if it is not active management of labour with its routine amniotomy and high dose oxytocin infusions that has influenced the caesarean section rate, what is it in these protocols that has?¹² In identifying the need to study hospital practices in more detail, Thomson¹³ suggested that the inter-personal aspects of care may have had an impact on the first stage of labour. Thomson's¹³ work highlighted that what the National Maternity Hospital did offer was continuous care from a midwife. Further studies are therefore needed to explore the practice of midwives, the management they provide, and the decisions they make during labour.

The available studies have, however, failed to address the opinion of the women and their choice when discussing the management of labour.⁵ To date the involvement of women and midwives in decision making about the management of labour appears to have been overlooked.

Decision making relationships 

Traditional childbirth practices involved a gathering of women to attend a labouring woman in her home. The woman looked to supporters such as family, friends and neighbours, and her midwife, to help her decide the most appropriate action if labour was not proceeding to plan. As childbirth practices in industrialised countries changed throughout the twentieth century and women moved from the community to the hospital setting to give birth, women were provided with access to different methods of pain relief and facilities. This move into a hospital setting also had consequences for midwives. Doctors took over the care of childbearing women from midwives and the decision making processes changed. What was once women-led and community-supported decision making became patriarchal and medically orientated.¹⁴, ¹⁵

This science-based medical model of care has since become so influential on society and within health care organisations that it is important to recognise this before any discussion on midwifery models of care and shared decision making can begin.¹⁴

Instead of referring to the term medical model, Davis-Floyd and Mather,¹⁶ call it the ‘technocratic model of medicine’, or the ‘technomedical model’, to make clear the connections between the model and the core values of industrialised societies organised around an ideology of technological progress. These authors explain that the main value underlying this technocratic paradigm is separation whereby ‘things’ [sic] are better understood outside of their context. Within this technocratic model, the human body is separated from the human mind and the body is defined as a machine. In order to diagnose problems and repair dysfunction, technomedicine requires that diagnosis and treatment work from an ‘outside-in approach’. Diagnosis can be achieved through the use of high-tech diagnostic machines, ranging from ultrasound scans during pregnancy to electronic fetal monitoring during labour. Treatment is also provided using this ‘outside–in approach’, for example, when a woman's labour slows, an artificial rupture of membranes is performed and an oxytocin infusion commenced.¹⁶ Concomitantly, under this technocratic paradigm individuals are subordinated to standardised institutional practices and routines such as regular vaginal examinations, electronic fetal monitoring and oxytocin are routinely given without scientific justification.¹⁶

The alternative model of pregnancy asserts that pregnancy and childbirth are natural processes and normal life-events. This model places the woman at the centre of care, rather than the obstetrician or midwife and it is the woman who makes the choices and reaches decisions regarding the type of care she would prefer.¹⁴ Midwifery care is therefore viewed as a holistic system of care where midwives and women work in partnership. The fundamental principles of this midwifery model are therefore stated by Harding¹⁵ to be: ‘continuity of care and caregiver, informed choice, shared decision making and choice of birthplace’ (p. 75).

This paper presents a description of the labour care provided by both midwives and women participating in a prospective study to answer the research question—‘How do the settings and models of care affect midwives’ decision making during the management of labour?’

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Method 

This study was designed to obtain an in-depth understanding of how the settings and models of practice affected the decision making processes used by midwives in the management of labouring women. The sample consisted of 104 midwives practising in Auckland, New Zealand, who were providing labour care to 100 nulliparous women at low obstetric risk. Ethical approval was sought and obtained concurrently from the University of Auckland Human Ethics Committee and the Health Funding Authority Ethics Committee.

Recruitment 

Presentations were made to independent, team and hospital-based midwives in the various settings in which they practised. Recruited midwives were asked to identify a low obstetric risk woman for whom they would provide labour care. To ensure the groups were balanced the midwives were grouped according to their years of experience and the settings in which they practised.

Data collection 

Midwives and women were each asked to complete questionnaires following the birth of the baby. The pre-paid self-addressed questionnaires were returned within 1–4 weeks of the baby's birth.

Midwives questionnaires 

The questionnaire comprised two sections each containing subsections. The first section requested demographic information about the setting in which the midwives practised. The second section comprised open-ended questions designed to establish a description on the labour care provided.

The type of training the midwives had undertaken, their previous experience and current work practices were addressed. Midwives who worked in independent practice or a team scheme were asked for details of the type of care they provided; midwives were then asked to provide personal definition of the terms ‘progress of labour’ and ‘established labour’. These two definitions then provided information to determine if midwives defined labour in similar terms to that of obstetrical practice.

This section asked midwives to describe the type of care provided throughout the women's labour by answering questions addressing the management of labour, birth plans, labour care, vaginal examinations, rupture of membranes, positioning, monitoring, food and fluids and pain relief. A subsection entitled ‘strategies’ asked midwives to describe what strategies they adopted if labour was identified as being prolonged or if the woman wanted different care from what the midwife had thought was indicated. A final section asked midwives to discuss any concerns they had during the woman's labour and birth and how these concerns were resolved.

Maternal questionnaires 

The questionnaire comprised three sections. The first section requested demographic information, the second a description of the labour and the care provided, and the third provided an opportunity to record reflections on the midwifery care provided and the partnership relationship experienced.

The first part of this section gathered demographic information on the women with questions ranging from ‘how old are you’ to the qualifications they held. The second part entitled ‘general feelings’, asked women to indicate how they believed the decision making in labour should occur and whether they believed it was important to have labour care from a midwife they knew. A third section on ‘care providers’ asked whether the same midwife looked after them throughout their labour and birth and if they would have liked the opportunity to know the midwife better. The fourth section addressed ‘information about pregnancy and childbirth’ and asked what type of information was made available to the women and what type of birth they were expecting.

Section two of the questionnaire requested details about the labour and delivery of their baby and the care provided. The first subsection ‘your experiences’ gathered information on the support the women had in labour; this was followed by further subsections questioning how labour commenced and progressed, the type of pain management strategies planned and used, the birth plan, the labour and delivery care provided, and information about their baby. This information was sought to gain an understanding of the woman's childbirth experience.

This last section asked women to think back over their labour and delivery and answer questions pertaining to the care they had received. Information was requested to investigate whether the women were given an active say in making decisions, were able to work in partnership with the midwife, and their perception of how their care was managed during their labour and birth.

Analysis of information 

Data management and quantitative analysis was undertaken using the Statistical Package for the Social Sciences (SPSS, Version 10). Answers to open ended questions were coded based on a thematic coding schedule developed after identifying the themes evident within the responses. Univariate analyses were undertaken and the variables were examined extensively, revealing a high consistency in all of the results. This quantitative data were used to document the practice of the midwives and provide a description of the women's satisfaction.

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Findings 

Demographic results 

Of the 104 midwives participating in this research, 47 (45%) practised in independent practice, 29 (28%) were hospital or university employed to take a caseload of women and work in a continuity of care scheme. The remaining 28 (27%) worked in a hospital setting on a shift basis staffing either delivery suite or rotating between the antenatal/postnatal wards to delivery suite.

The majority of the participating midwives had considerable midwifery experience. Ninety-one (87%) had more than 3 years, whilst eight (8%) had 1–3 years’ experience and five (5%) were new graduates with less than 1 year. Seventy-three (70%) of the midwives had more than 3 years’ delivery suite experience, 15 (14%) 1–3 years and 16 (16%) less than 1 year's experience.

The ages of the 100 women participating as clients in this study ranged between 15 and 35 years, with the largest group of women (40%) aged between 25 and 29 years. Fifty-nine percent of women were New Zealand European, 13 (13%) Pacific Islander, 11 (11%) Maori, 6 (6%) Indian, 5 Asian and 6 belonged to other ethnic groups. The majority of the women (83%) spoke English. Of the 17 women who identified that English was not their first language, 12 reported speaking English very well and 5 fairly well.

Midwives’ definition of labour 

Prior to describing the labour care, the midwives were asked to think about their midwifery philosophy of care and define progress of labour and established labour to determine what midwives used as a definition for normal labour. The two characteristics that were predominantly reported were the strength and frequency of contractions and their findings on vaginal examination. The respondents had the opportunity to report up to six characteristics that would define a woman's progress in labour. Forty-two percent reported the strength and frequency of uterine contractions and 40% findings on examination per vaginum (see Table 1).

Table 1. Midwives definition of progress of labour (n=98)

Management of labour 

Forty-seven percent of the women were in early labour, and 53% were in active labour when midwives commenced the labour care. The majority (85%) of the labour care experienced by the women was provided by midwives in a hospital setting. Eighty-six percent of the births were conducted at large maternity hospitals (between 2500 and 7500 births per annum), 11% were at small maternity units and 3% were home births. The length of labour for the women ranged from less than 3 to 72h, with half (49%) labouring between 13 and 24h.

Assessment of progress of labour 

In order to ascertain how midwives assessed progress of labour, the midwives were asked to describe the decision making criteria they used for determining that the women's labour was progressing. The midwives reported using vaginal examinations (41%), evaluation of contractions (38%), observation of the woman's behaviour (17%) and descent of the fetus on palpation (4%).

Almost all the midwives (96%) reported performing examinations per vaginum in labour primarily to confirm labour or then to assess labour progress. Eighty-percent reported performing between one and four vaginal examinations (see Table 2).

Table 2. Number of vaginal examinations performed (n=100)

For the 80 women whose membranes did not spontaneously rupture, 55 (53%) had an artificial rupture of membranes performed. The major reason given for this procedure was to augment the progress of labour.

The midwives were asked to record, in sequence, four positions that the women adopted in labour and to provide evidence regarding the decision to change position. As labour progressed it was reported that the women tended to change position: firstly from walking (39%) and standing (19%), secondly to lying on their side (27%) and sitting (20%), thirdly to hands and knees (22%), and later semi-reclined (35%). Data provided in Table 3 indicate that the women's comfort was the major determinant for these positions to be adopted. When the women were asked if they were able to move around and change position during labour, over half (55%) said yes; 33% were unable to move around because they were either attached to a monitor, an oxytocic drip, or had an epidural; and 12% said they did not want to move.

Table 3. Why these positions were adopted by women in labour

Fifty-seven percent of the midwives reported performing continuous electronic fetal monitoring during the women's labour. The design of this question precluded analysis of each individual method of fetal heart monitoring to establish why the midwives chose to monitor the fetal heart in the way that they did. However, 86 midwives (83%) provided general information on why they monitored the fetal heart (see Table 4). Hospital policy was given as a reason by only 12% of these midwives. When the women were asked if they received enough information about cardiotocograph fetal heart monitoring, 88% reported that they had been told enough about how the monitor worked and what it showed. Only 10% would have liked to have been told more.

Table 4. Evidence given by midwives for making the decision to monitor the fetal heart (n=86)

Rationale	Frequency	Percent
Low risk variables
Position/comfort	31	36.0
Hospital policy	10	11.6
Low risk	7	8.1
Spa pool	4	4.7
High risk variables
Fetal distress/wellbeing	15	17.4
Epidural	9	10.5
Syntocinon	6	7.0
Prolonged labour	3	3.5
High blood pressure	1	1.2

Eighty-two percent of midwives (n=69) provided the opportunity for food and fluids to be consumed during labour to hydrate (46%) or nourish (44%) the women, or to aid progress of labour (4%). Of the 22 midwives who said the women did not eat and drink during labour, 10 reported it was because the women declined (see Table 5).

Table 5. Why food and fluids were withheld in labour (n=22)

Excluding natural methods of pain management, midwives reported using pain relief with 76 of the 100 women (76%). The first choice of pain relief for the midwives was nitrous oxide and oxygen (55%), with epidural anaesthesia the second choice (29%), Pethidine third (12%) and transcutaneous electrical nerve stimulation (TENS) fourth (4%). Eighty-six percent of midwives reported that the pain relief options used were the options identified through preparation of the women's birth plans, commenting in 45% of cases that the birth plan was flexible. The decision on what was the most appropriate pain relief for 42% of the 59 midwives was based on the woman's birth plan. A further 49% of these midwives based their decision on the woman's level of pain; whilst 9% based their decision on either promoting the progress of labour, lowering the woman's blood pressure, or decreasing the urge to push. When these midwives were given the opportunity to report on how the decision to have pain relief was made, 44% of the 54 who provided an answer reported that it was a joint decision between themselves and the women. A further 42% identified it as the woman's decision, and in the remaining 14% of cases the midwives reported they had made the decision.

Fifty percent of the women reported that they planned to use pain relief in labour. For the 67 women who provided detail on how they decided what pain relief to use, their decisions were based on information provided by the midwife (25%), the degree of pain experienced (22%) and pain management strategies that would not affect their baby (16%) (see Table 6). Ninety-two percent of the 100 reported they were given enough information on pain relief.

Table 6. How the women decided what pain relief to use (n=67)

Sixty-nine percent of midwives reported that women in their care had a prolonged labour. The strategies identified to enhance uterine function were syntocinon augmentation 22%, upright position 20% and artificial rupture of membranes 20%.

When the midwives were asked to describe in general the protocols, guidelines or principles that they had identified to prompt their management of the women's care, over half the midwives either named a particular protocol or reported using a best practice guide. However, when all the midwives were asked to disclose why a particular decision was made for each specific care these protocols were rarely evident.

Twelve percent of women reported that they were worried when the midwife left them alone in labour. The reasons given for this concern were: because the fetal heart was dropping (n=3), they were in pain (n=5), they did not know what was happening (n=3), and the woman was pushing (n=1).

The majority of women participating in the study (91%) believed they were given an active say in making decisions during labour. A midwifery partnership was reported to have been achieved by 89% of women, a further 7% identified they were unable to, and 4% said it was not important to them.

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Discussion 

Initial examination of the findings of the midwives’ management of labour identifies practice that was relatively homogenous. It could also be argued that the practice was dominated by the biomedical model in that the majority of midwives monitored the physiological process by performing a number of vaginal examinations, and over half performed continuous electronic fetal monitoring. One-quarter of the women had their labours induced, over half the women who had an artificial rupture of membranes had this procedure performed to accelerate labour, and almost a quarter of the women had their labour augmented with an oxytocin infusion.

Midwives’ assessment of labour 

As early as the mid-1800s text books written by physicians on the management of childbirth recommended performing vaginal examinations from the onset of labour.¹⁷ How firmly ingrained this teaching has become is apparent in this study as the midwives defined progress of labour as the strength and frequency of contractions, and findings on vaginal examination. The vast experience of a number of these midwives and the various settings in which they practised did not lead the majority of midwives to describe progress of labour any differently from the early medical definitions. Although a third of the midwives reported evaluating contractions and 17% identified observing the women's behaviour, vaginal examinations predominated as the method for assessing the progress of labour.

When constructing the initial dilatation time curve Friedman⁴ considered that of ‘the major observable events’ that occur during labour in which he included frequency, strength and duration of contractions, descent of the presenting part, and cervical effacement and dilatation that only cervical effacement and dilatation could be used as an assessment in developing a graphic analysis of labour. This decision was based on Friedman's belief that cervical effacement and dilatation provided the best method to determine progress hence establishing the predominance of vaginal examination as a method of assessment during labour. Hunter¹⁸ identifies that maintaining such a belief reflects a medicalised paradigm of childbirth in that if something is measurable it is considered reliable.

Recent work by Walsh¹⁹ is, however, questioning whether the widespread practice of performing vaginal examinations on women in normal labour is protocol driven or supported by caregivers inherent distrust in women's ability to birth, and recommends that the same information could be gained from less intrusive methods. Earlier work by Crowther et al.² emphasised holistic consideration of the rate of progress of labour within the total context of a woman's wellbeing, rather than simply as a physical phenomenon. These authors suggested that abdominal palpation to determine the amount of the baby's head above the pelvic brim could avoid the need for vaginal examination, whilst Duff²⁰ recommended combining the observed behaviours of labouring women with observations of contractions and cervical dilatation recorded on the partogram.

Midwives’ documentation, within women's clinical records has, however, not been found to provide a picture of practice, as observed progress of labour and support are rarely documented.²¹ Traditionally midwifery is an oral culture²² and it remains difficult to escape from the power of the written discourses which consistently dominate the spoken. Analyses such as Fleming's²² thus providing a possible explanation for the stereotypical manner and emulation of medical records midwives have adopted when documenting their practice.

Just because something is measurable it does not necessarily guarantee reliability. Most practitioners providing labour care would have evidenced the ‘shrinking cervix phenomenon’ caused through inter-observer variability. It is therefore imperative that midwives document not only what is done during labour and delivery but also how it is done by detailing the assessments of labour behaviour that are made, the support that is given, and the decision making that occurs. If a complete picture of practice is therefore painted, practitioners may become less reliant on performing vaginal examinations and new definitions of labour can be incorporated into the medically led assessment and progress of labour that currently exists. As Walsh¹⁹ recommended in his concluding remarks until research has established their appropriate place, vaginal examinations should only be performed with clear rationale and justification, not undertaken as part of repeated routine practice. So much of the care provided by midwives during labour occurs behind closed doors out of sight from colleagues. By fully detailing care through written documentation, midwifery practice becomes more visible both to women and colleagues and provides an opportunity for all involved to learn from one another.

Midwives’ management of labour 

The use of continuous electronic fetal monitoring on low obstetric risk women by over half the midwives participating in the current study provides an example of practice that has become part of routine obstetrics, in the absence of available research evidence to support subsequent clinical decisions. Proponents of the use of electronic fetal monitoring as a screening tool hoped that continuous electronic fetal monitoring would prevent fetal compromise and decrease the rate of cerebral palsy. However, no evidence has been obtained to show that it reduces the incidence of perinatal mortality or cerebral palsy.²³ On the other hand, continuous electronic fetal monitoring has been found to decrease the woman's mobility, reduce contact between the woman and her partner and prevent the midwife working closely with the woman.²³ In addition, this procedure leads the midwife to turn her focus to monitoring and abnormality.¹⁸ Electronic fetal monitoring has also been found to significantly increase the rate of operative deliveries and the rate of caesarean section.²³ Taking into consideration this evidence, these authors recommend intermittent auscultation for women who are of low obstetric risk and further recommend that decisions about the use of continuous electronic fetal monitoring versus intermittent auscultation of the fetal heart needs to be discussed with the woman, to determine her preferences so the woman and her care provider jointly decide on the most appropriate method for her labour.²³

Artificial rupture of the membranes (amniotomy) in early labour has been found to shorten the duration of the first stage of labour by approximately 30–60min.²⁴ This method of accelerating labour has been used since the mid-1700s.¹⁷ Over half the midwives in this present study who artificially ruptured the women's membranes reported that this procedure was performed because of a long latent phase or to induce or augment labour. However, as a routine process, the consensus meeting on Appropriate Technology for Birth (ATB), in Brazil, recommended that early rupture of membranes is not scientifically justified²⁴ and should be restricted to a few complicated and serious situations. This recommendation is based on the questionable benefit of the procedure and the serious risks involved.²⁵

Recommendations were also made by the consensus meeting on ATB to limit the number of inductions of labour to specific medical indications because of the hazards known to be associated with induction.²⁴ For example, induction has been found to be associated with a woman experiencing a significant increase in pain. This heightened pain may lead to increased use of pain medication, which could result in an exhausted woman and a drugged fetus, which in turn increases the chance of an instrumental delivery or caesarean birth. Wagner²⁴ used this example to illustrate a chain of events that he reviewed as being characteristic of birth technology, whereby one intervention leads to another resulting in an escalation in the use of technology. The consensus meeting on ATB stated its belief that no geographic region should have an induction rate of over 10% of births.²⁴ However, almost 25% of the women participating in this present study reported they had an induction of labour performed either by a doctor or a midwife.

Augmentation of labour with an oxytocin infusion for slow progress was also undertaken by almost 25% of the midwives participating in the study. In providing comment for The World Health Organisation's (1992) report on the rates of oxytocin use, Keirse (cited in ref. 24) advised that there was a place for this intervention but only after more simple measures had been used, contending that allowing women the freedom to walk, eat and drink as desired were as effective as oxytocin augmentation.

The type of practice described by the midwives in this study is influenced by the need for technology and intervention which could be explained by the setting in which the majority of the midwives provided the labour care—large obstetric hospitals. However, if women's needs are subordinated because of these standardised practices¹⁶ it is difficult to understand why the majority of women participating in this study reported that they took an active role in decision making and worked in partnership with their midwives. To answer this question it is important to look at the decision making processes used by midwives in providing the women's labour care. It was not the protocols and hospital routines that were influencing the midwives’ individual decisions about care but instead the needs of the women identifying a humanistic approach to care. Davis-Floyd and Mather¹⁶ use the phrase ‘high tech, high touch’ to illustrate how humanistic midwives use technology, whilst emphasising caring and relationships alongside of it.

The majority of women participating in this study ate and drank in labour as they chose guided by their midwives’ clinical judgement which determined they were of low obstetric risk, and understood the importance of providing nourishment and hydration. This practice not only identifies a humanistic approach to care but also reflects research evidence. As recommendations have been made that if women have no risk factors for requiring an instrumental delivery or a general anaesthetic, then women should be given the opportunity to eat a light diet and drink as required.²⁶ Grant²⁶ believes that this has a physiological but also a psychological effect on women, as being able to perform everyday activities such as eating and drinking may increase women's feelings of wellbeing and reduce stress.

Women have been observed to assume positions in labour which meet the attitudes and beliefs of their care providers and the environment.²⁷ The findings of this present study displayed how midwives identified research evidence and made decisions based on the needs of women. The women in this present study were encouraged by their midwives to adopt different positions in labour. This was based mainly on the midwives attempting to find positions that were comfortable for the women and allowed the women to take control. Moving around and adopting upright positions during labour has been associated with increasing women's levels of comfort²⁸ and their sense of control.²⁹ The positions chosen by the women in this study were similar to those documented by Roberts²⁷ who noted that women tended to choose an upright position initially and then adopt lateral recumbent positions as labour became more advanced. In contrast, Seibold et al.'s research²¹ found, in some cases, that women were encouraged by midwives to labour on the bed, despite the women appearing more comfortable when they were actively moving around. These researchers believed one possible reason for this practice was the layout of the labour room. Delivery beds dominated the available space and little provision was made for equipment such as birth mats, beanbags and balls to be present, and showers were not easily accessible without the assistance of a midwife.

In this study, pain relief was administered in a similar manner to what Leap³⁰, ³¹ described as ‘the menu approach’ to pain in labour which commenced with non-pharmacological methods and worked through to epidural anaesthesia. Leap,³⁰, ³¹ asserts that offering a menu approach and the pros and cons of each method in the name of providing ‘informed choice’, creates a culture where women are supported if they want to have some form of pain relief during the birthing process. This contentious point of view may help to explain why half the women participating in the current study reported they planned to use pain relief in labour.

Where the menu approach described by Leap,³⁰, ³¹ differed from this study was in the use of the pharmacological pain relief (pethidine). Instead of pethidine following nitrous oxide and oxygen, epidural anaesthesia was the second choice for pain management. This ranking was based on the degree of pain experienced or the women's decisions to use pain management strategies that would not affect their babies. Visible within this decision making is the women's level of education and knowledge of the side-effects of pethidine; which was further reinforced by the majority of women stating that they had received enough information on pain relief from their midwives to make an appropriate informed decision. Pain management in this present research focused on providing woman-centred care. Almost half the midwives cited that the decision on what was the most appropriate pain relief was based on the women's birth plan, and that in the majority of cases either the women were the primary decision makers or a shared decision style was employed.

Pharmacological pain relief, according to Seibold et al.,²¹ is also more likely to be given to labouring women if the midwife cannot maintain sufficient or ongoing contact. Of the women participating in this present study, five reported they were worried when the midwife left them alone because they were in pain. Smythe³² raised an interesting question on this issue of support: who is responsible for the woman who is left alone—the midwife who had more urgent priorities, management who determine staffing numbers, or the funders who set limits for the possibilities of safe care?

Limitation of study 

In order to explore the effects of the birthplace and models of care, the management of labour section of the midwives’ questionnaire had a set of questions that asked ‘what’ occurred during the labour, giving the midwives the opportunity to describe the care provided. This was accompanied by a second set of questions which asked ‘why’, giving midwives the opportunity to disclose their decision making behind the care. However, it needs to be noted that the number of midwives who responded to the ‘why’ questions or provided explanations were lower than those who answered the ‘what’ questions. Fewer women also gave explanatory information in the open questions following a structured question.

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Conclusion 

Despite the model of care provided (independent, team or hospital-based) the practice of the midwives in providing the labour care was found to be relatively homogenous. The setting in which the majority of midwives practised (mainly large obstetric hospitals) disclosed a veneer of practice influenced by the medical model. Labour procedures dating back as along ago as the 1700s were still apparent despite no scientific evidence being available to support their use. The continuation of these procedures highlights how some procedures, such as amniotomy, have become so deeply rooted into practice they are difficult to break down. The same can be said for a subsequent dependence on technology. However, further analysis identified that the midwives adopted a humanistic approach in providing care whereby relationship-centred care was fostered alongside technology.

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