An interpretive qualitative study to explore midwives experiences of influencing fetal position in labour Sue Thornber Research Midwife Central Manchester NHS Foundation Trust Master of Science in Midwifery The University of Salford
Introduction Key drivers for maternity care • To encourage normality in births by reducing interventions (DoH 2007) • To focus on normal birth and reducing caesarean section rates (DoH 2012)
Focus of Literature Review
Summary of Literature Review • “Mechanism of Labour” used to describe the rotation and descent of the presenting part of the fetus • Fetus in occiput anterior position most effective passage through the pelvis • Fetus in occiput posterior position a malposition and associated with increased rates of intervention and fetal and maternal morbidity
Summary of Literature Review • Correct identification of • Influence of senior staff fetal position by can invoke obedience abdominal palpation was and conformity low Hollins Martin & Bull (2005) Hunter (2005) Webb et al (2011) & Ramphul et al (2012) • Upright maternal • Culture and context of positions utilising the birth environment are benefits of gravity may important determinants influence the passage of of midwifery confidence the fetus through the and practice pelvis Bedwell et al (2015) Gupta et al (2012)
Study objectives • To explore whether midwives endeavour to influence fetal position in labour for women with low risk pregnancies • To compare and contrast the challenges midwives may face in the hospital and home birth environments • To identify how midwives might indirectly influence fetal position Influencing fetal position in labour: what are midwives’ experiences?
Methodology • Semi structured • Purposeful sample of interviews used to guide, seven midwives recruited make sense of and to achieve information- interpret midwives rich cases for in-depth experiences. understanding and analysis • Draft guide used to ensure all topics explored with each participant
Key themes from interviews
Assessment of fetal position Midwife D “Sometimes I still get stumped (with palpations) and that’s not just in labour, I can’t always be 100% sure of what I’m feeling” Midwife B “I think with experience you can look at a woman and more or less see which way the baby’s laying”
Adverse effects of abdominal palpation All the midwives described how assessing fetal position involved the women laying semi-recumbent: Midwife A “Once they’ve got into that position, they don’t want to move” Midwife C “Some ladies don’t want to move too much in labour” Midwife F “They don’t want to move, no matter what you do…that’s a real challenge”
Actions to influence fetal position Midwife E Midwife F “I always try and grab a birth “I’d always be thinking about ball and I usually get the it from the minute they walk women to stand up or lean into the labour room…I’m over the bed, or sit on the always thinking of ways to birth ball…any position keep it (the fetus) away from that’s not on the bed, the back (posterior position) anything that’s not semi - and slowing labour”. recumbent for me”.
Influence of models of care and other people Midwife B “There’s always someone asking questions of you as a midwife; ‘what’s she doing in there ?’ ‘where are you up to in there ?’ …they are asking you about progress and there is an expectation… …you’re under more scrutiny when you are here (labour ward) than when you are at home”.
Influence of models of care and other people Midwife C “ Sometimes doctors influence how you are doing things, even if things are happening normally… …you are having to act as an advocate for the woman and say, “No, this is actually normal, we are going alright, so I think it is ok”.
Influence of partners Midwife A “I don’t think that I’ve ever seen a partner watching TV at a home birth…they are usually supporting their partner in different positions and being involved, rather than sitting in a corner”. Midwife D “Partners’ relax more than anybody, because they’ve got little jobs to do….they can go and make a cup of tea or something, so I think that has a knock on effect with the mums, it’s about being relaxed”.
Influence of the birth environment Midwife A “The language changes and the attitude’s change in the different environments…In hospital it’s the midwife who is ruling the roost, it’s her territory, so the women ask permission to eat or drink or move about … …they ask, ‘Can I?’ ‘Am I allowed to?’” Midwife F “I just find the home environment is more natural and they tend to not look to you so much for guidance, they tend to do the natural thing, the rocking, leaning over the partner, leaning over the settee”.
Influence of the birth environment Home environment Hospital environment Midwife A Midwife F “It’s like they are both taking “They walk into the labour room and they don’t know responsibility for the woman’s labour, birth and where they are. position of the baby…as a They feel totally confident midwife I’m just there to help at home, whereas in them”. hospital they don’t know what they want to do, they don’t know what they can and can’t do. They are just like a fish out of water in hospital”.
The bed Midwife B “I’ve said: ‘there’s the bed, that’s to put your bags on… we’re not going to use that unless we need to’, but the bed has a massive influence on labour…it’s always there in the middle of the room…we’ve tried putting it up against the walls but it never seems to stay there, it always seems to end up back in the middle of the room again”.
The ball Midwife C “if they are on the bed the temptation is to watch the telly… most are supportive, but only at arm’s length… …when the ladies are on the ball or when they are stood up and holding and hugging the husbands can be more supportive, holding their hands.”
Conclusions • Midwives in this study described their attempts to influence maternal and fetal position in labour • The metaphor, “like a fish out of water” was used to describe how an unfamiliar environment can adversely affect maternal position and indirectly affect fetal position • Midwives described how women appeared to “relinquish responsibility” for their own mobility and positions in labour, which could indirectly influence fetal position • The culture and context of the birth setting appeared to influence maternal and partner behavior, and midwifery practice and confidence
Acknowledgements • Supervisors Professor Alison Brettle and Dr Jeanne Lythgoe • The midwives who so generously participated in the study, without their contribution this research would not have been possible
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