Women and Birth
Volume 20, Issue 1 , Pages 11-15, March 2007

Enhancing the midwife–woman relationship through shared decision making and clinical guidelines

  • Lesa M. Freeman

      Affiliations

    • Faculty of Nursing and Midwifery, The University of Sydney, Sydney, NSW, Australia
    • Corresponding Author InformationCorresponding author. Tel.: +61 2 9351 0530.
    • ,
  • Kate Griew

      Affiliations

    • Faculty of Nursing and Midwifery, The University of Sydney, Sydney, NSW, Australia
    • Royal Prince Alfred Women and Babies (SSWAHS), Sydney, NSW, Australia

Accepted 12 October 2006.

Article Outline

Summary 

The active and passive voice allocated to women within maternity service guidelines helps construct the nature of decision making. The aim of this paper is to demonstrate that by allocating women an active voice within practice guidelines serves the interest of all parties within the health care relationship. Clinical guidelines were reviewed, and electronic databases and text were searched. The findings of this paper support that applying the principles of a shared decision making framework, within clinical practice guidelines, can assist the development of a partnership relationship between midwives and women.

Keywords: Decision making, Partnership, Clinical guidelines, Risk assessment, Waterbirth

 

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Introduction 

Health professionals, including midwives, are increasingly recognising the importance of comprehensive clinical guidelines in developing and promoting quality and effectiveness in clinical practice. The evolution of clinical guidelines has been driven largely by institutional agendas, focusing on adherence, safety and risk management. Workforce and skill mix issues have also informed the development of clinical guidelines. Thus, guidelines have served the needs of the hospital and practitioners. However, the role or needs of the ‘patient’, in this case pregnant women, have been conspicuously absent in the body of most clinical guidelines.

The aim of this paper is to show that the allocation of an active voice to the woman within practice guidelines serves the interest of all parties within the health care relationship. The authors apply a conceptual framework that includes definitions of low, medium and high-risk decisions and suggest roles for both individuals to work together to achieve a partnership relationship. The effective use of these features will be illustrated by applying the conceptual framework to a clinical practice guideline developed for the ‘Use of the Bath in Labour and Birth’ at a large tertiary referral hospital in Sydney, Australia. These guidelines and shared decision making conceptual framework can be used independently, or in combination, to achieve improved satisfaction for health care providers and the women for whom care is provided.

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Background 

Advocated within a woman-centred approach to midwifery care is shared decision making.1 Within the shared decision making model the woman's values and preferences, together with information from the clinical assessment, are taken into account to help her stay in control of decisions regarding her care. Negotiation and choice are pivotal concepts within this approach to care.2 Trnobranski2 points out that an important factor influencing the process of negotiation is the balance of power and control between the health care professional and the client.

A small exploratory study (n=15) undertaken by Harding1 to determine how midwives experience and implement shared decision making in midwifery practice, identified that the majority of midwives perceived that women preferred to work collaboratively and considered the midwife–client relationship to be the foundation of a shared decision making process. When asked to estimate the proportion of women they believed wished to take a primary and directive role in decision making, the midwives estimated between 10% to 25% and 0% to 15%, respectively. Several midwives highlighted, however, that the implementation of hospital guidelines could lead women to give up their autonomy and control.

Guidelines, also referred to as practice guidelines, policies and protocols, are systematically developed statements that assist practitioners and patients in making decisions.3 This review included clinical guidelines sourced from large maternity hospitals in Australia and New Zealand, and textbooks and references were obtained through database searches utilising CINAHL, MEDLINE and MIDIRS. The database searches used combinations of the following keywords: risk assessment, decision making, waterbirth, midwife–woman relationship and partnership.

The central focus of this review was to illustrate women's involvement in decision making within a clinical practice guideline the ‘Use of the Bath in Labour and Birth’. Consequently, data related to maternal and newborn clinical outcomes of waterbirth has been excluded from this discussion.

Findings 

The majority of protocols reviewed from large maternity hospitals did not provide clarity regarding the woman's role in decision making or in what constituted low, medium and high risk decisions. These protocols did not take into account women's preferences or needs1 but instead assumed that women will accept the outlined treatment and procedures. This represents a flagrant contrast to the rhetoric of the partnership model promoted in contemporary midwifery literature.4

Shared decision making 

Developing guidelines that reflect the shared decision making model (see Fig. 1)5 encourages a collaborative style in decision making that is currently not evident in the majority of institutional protocols. Some midwives may not view developing this type of guideline as necessary, perceiving instead that by providing women with information sheets and an explanation of the procedures women are able to make an informed decision. However, this process of sharing information may not necessarily accomplish a successful partnership.

In this model of shared decision making partnership is conceptualised as ‘a shared endeavour’. The midwife and the woman both contribute to the relationship by discussing and agreeing on individual and mutual responsibilities within the decision making process.

This shared decision making model concurs with the criteria set out in Timperley and Robinson's6 partnership framework. Within this model the midwife and the woman are provided with an opportunity to create an agreement on what they wish to achieve whilst working towards the same aim. This process then provides an opportunity for both the midwife and the woman to clearly define their roles, and identify influences that may affect their responsibilities. As the midwife and the woman seek and share information about their aims and beliefs they are able to learn each other's perspectives. Responsibility is determined within the relationship as the midwife and the woman negotiate the decision making to meet their defined aims.

Use of the bath in labour and birth policy 

One example of a protocol that aligns with this conceptual model is the Royal Prince Alfred (RPA) Women and Babies ‘Use of the Bath in Labour and Birth’ policy.7 This policy is based on the understanding that immersion in water during labour and birth can alleviate pain, decrease maternal anxiety, promote a sense of relaxation and control, allow the uterus to contract more efficiently whilst providing another choice for birthing women.8, 9, 10, 11, 12, 13 The use of the bath during labour is accepted as a safe and viable alternative when the woman is happy with its use and there are no concerns regarding maternal and foetal wellbeing.14, 15, 16, 17, 18

Within this policy, criteria for the use of the bath in labour is initially established on an individual basis, contingent on a woman's desire to enter the bath, and subject to an assessment of risk. The woman's planned place of birth is then discussed. Prior to the woman entering the bath, a verbal agreement is negotiated that the woman may be asked to leave the bath at any time if the midwife has concerns regarding foetal or maternal wellbeing. Contained in the policy is the identification of both the woman's and the midwife's areas of responsibility. The woman is encouraged to remain well hydrated, leave the bath regularly to urinate, and Entonox is made available on request as long as it is properly supervised. The midwife is responsible for providing evidence informed care and safely assisting the woman to give birth in the bath, if that is chosen by the woman. Examples of the midwife's responsibilities include taking and interpreting the maternal and foetal observations, water temperature and quality, co-ordinating the woman's use and supervision of Entonox, and addressing the issue of place of birth in a timely way. Synthesis of such information assists the midwife and woman in discussion and decision making as the labour progresses.

The above protocol has identified how the midwife and the woman can develop a working relationship based on a shared understanding of what they wish to achieve. Their roles and responsibilities have been clearly defined and, through negotiation in decision making power has been shared.

Effects of policy 

Since the introduction of the ‘Use of the Bath in Labour and Birth’ policy in 2003 a quality assurance document has been completed at RPA Women and Babies on every woman who has had a waterbirth and many women who have laboured in the bath. The information collected within this document includes data on the clinical outcomes and an opportunity for the women and the midwives to provide feedback on their experiences. Whilst there are no questions aimed specifically at gaining material on how women and midwives experience the process of decision making, the comments sections provide indirect insight.

No concerns were raised by either the women or the midwives with the decision making process. A high degree of satisfaction for the women, their significant others, and the midwives undertaking their care was reported, and four women who found their first waterbirth satisfying have since negotiated a second waterbirth.

These excerpts encapsulate the experiences of the women:

“I felt more in control, more able to cope.”

“It was a great experience.”

“My partner was very happy.”

and the midwives:
“The woman could tell me where the baby's head was in relation to her perineum, able to be really aware.”

“It is nice to be quiet, not so busy talking.”

The following account by a midwife identifies the strength of including the woman in this shared decision making process:

A 16 year old woman requested to have a water birth after using the bath earlier in the labour. She had previously left the bath (following discussion with the midwife) because the contractions had become spaced apart and irregular. She re-entered the bath when her cervix was 7cm dilated and went on to have the baby there.

The woman was able to use her awareness of her body and together with the midwife's observation and guidance was able to determine where she laboured and birthed. In partnership, the pair navigated a number of decisions involving differing levels of risk in achieving the outcome that was desired by the woman.

Low, medium and high risk decision making 

Literature tends to discuss risk in terms of risk assessment whereby individual women are classified into different categories to predict perinatal outcomes and to plan their care. Protocols generally outline procedures and interventions in relation to the level of perceived risk. Literature and protocols were reviewed to determine what constituted a high and a low risk decision. No reference was made to either of these in the literature or protocols. This concept becomes important when considering the role that women and midwives play in creating a functional relationship in planning care.

To this end low risk decisions have been defined as decisions that are unlikely to affect the physical outcome for the woman or the baby. These include decisions that are made as part of the activities of daily living; for example, the consumption of food and fluids, positioning for comfort and rest, maintaining hygiene and elimination needs. In the ‘Use of the Bath in Labour and Birth’ protocol examples of low risk decisions that a woman will be responsible for include; maintenance of hydration, emptying her bladder or choosing to use ‘Entonox’. If all is going well she may then choose to continue her labour in the bath when birth becomes imminent, in consultation with a midwife who discusses the appropriateness of this course.

Medium risk decisions have been defined as decisions that may affect the outcome to both the woman and her baby because of side effects that could occur. These are not decisions that have to be made in an emergency situation and, therefore, can be taken at a slightly more leisurely pace. An example of a medium risk decision may include the woman and the midwife discussing an alternative method of pain relief from that which was originally in the woman's ‘ideal’ birth plan. Examples in the ‘Use of the Bath in Labour and Birth’ policy include decisions about timing of entry into the bath, the woman choosing a water temperature that is outside Duley's19 recommended range of 36–37°C, a decision to birth in water following receipt of a dose of narcotic analgesia, or pre-emptive decision making regarding the third stage of labour.

High risk decisions have been determined as decisions that can impact on the outcome for the woman and her baby. These high risk decisions are based on complex analysis of data that can generally best be achieved through education, training or extensive experience. They are often the type of decisions that have to be made in emergency situations. These include decisions that are made, for example, on feeling a cord pulsating during a vaginal examination, or seeing no movement following the slow birth of a baby's head which then seems to retract backwards into the woman's perineum. In the context of the ‘Use of the Bath in Labour and Birth’ policy these decisions generally relate to the situations that cause the midwife to ask the woman to exit the bath. Shoulder dystocia during the birth, or serious concern regarding the foetal wellbeing, make expeditious exit from the bath appropriate. Similarly, concern regarding the ability of the midwife and woman to achieve a safe birthing outcome. Examples of this are where language incompatibilities and/or restlessness become exaggerated as a labouring woman reaches transition, jeopardizing the physical safety of the woman in the bath or the baby during birth.

It is important to take into account both the nature of the decision and the individual person with whom it is being made. For example, eating in labour may appear low risk, but if during labour a woman has become more at risk of requiring a caesarean section the decision to eat large amounts of food during labour may no longer be low risk.20

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Discussion 

Differentiation of risk in decision making can assist in the challenge of achieving partnership through exploration of the conceptual framework. Negotiation with the woman regarding who assumes responsibility for what level of decision making means that the process is transparent. Discussion regarding the responsibilities that each partner has in the process clarifies the roles adopted by each participant.

Within the ‘Bath in Labour and Birth’ policy when a woman wishes to use the bath, she and her midwife discuss any contra-indications to the use of the bath at her stage of labour. The woman enters the bath with the understanding that she may be asked to leave if any complications arise. This identifies that there are potential risks in some situations if labour and birth occur in the bath, and that the midwife will be vigilant about these situations. The midwife and the woman discuss any concerns as they arise and negotiate a path of action. The woman's responsibilities (low risk decisions) at this point are to ensure that she remains hydrated and urinates regularly, activities that the midwife will assist her with as necessary.

As labour progresses the midwife continues to monitor and encourage the woman with her progress. The midwife will reiterate that if any circumstances occur which lead to a change to the woman's ideal birth plan that these will be individually negotiated as they work together to achieve the birth (medium risk decisions). When the second stage or birth is imminent, the midwife and woman will discuss their assessment of the situation and clarify whether the woman chooses to remain in the bath for the birth.

At any time, if concerns arise the midwife will raise these with the woman outlining perceived risks and possible outcomes. This may be emergent and therefore rapid. The midwife will suggest exit from the bath if more invasive monitoring and/or interventions are required; or in the event of the woman removing herself from the bath after delivery of the head but prior to birth of the baby's body (high risk decisions). The fact that negotiation occurs prior to the emergent event, and there are clearly defined roles and responsibilities, means that these situations can be managed expeditiously. Having clarity regarding these situations of high risk decision making allows both parties to fulfill their roles in the decision making process and their responsibilities to the functional partnership.

The utilisation of this shared decision making model should circumvent Edward's21 account of women who experienced policies as inflexible and not accounting for their individual needs. The women in Edward's21 study reported that as part of the risk assessment process in planning a home birth they were measured against a set of abstract norms. When there was a difference of opinion between themselves and their midwives about risk, the women perceived they did not feel supported in their decision making, which led them to feel distanced from their midwives. The inclusion of an active voice for women in clinical guidelines may avoid this unpleasant experience.

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Conclusion 

In reviewing clinical guidelines it became apparent that few guidelines include active participation of women in their text, particularly in relation to decision making. This omission potentially affects the nature of the relationships that is created between women and their caregivers. The inclusion of an active voice to women in clinical guidelines influences both the relationships that are established and institutional norms. Incorporation of an active voice for women provides institutional encouragement for midwives and support for women when negotiating working partnerships. Guidelines which include an active voice for women are consistent with the ideals of woman-centred maternity care, promoting choice and control. Acknowledging that there are situations where a woman will rely on the clinical and educational experience of her midwife encourages both the woman and the midwife to be specific about how they will deal with the challenges of creating their working partnership.

Developing clinical guidelines such as the ‘Use of the Bath in Labour and Birth’ policy which reflects the illustrated shared decision making model, health care providers and women are able to work together to achieve the same aim, define their roles and responsibilities to each other and by sharing power in decision making achieve a relationship of partnership.

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References 

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PII: S1871-5192(06)00093-X

doi:10.1016/j.wombi.2006.10.003

Women and Birth
Volume 20, Issue 1 , Pages 11-15, March 2007

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