From the first encounter to management of childbirth - An insider action research in a labour ward world

Abstract

Childbirth leaves a lifelong memory for women and their families. How they were met and treated during labour and birth affects their experience. Therefore it is of utmost importance that childbirth care is of optimal quality in accordance with each woman´s and partner’s needs. Aim: The overall aim was to explore and improve management of childbirth on a labour ward through insider action research, beginning with the midwives first encounter when the woman and partner arrive on the labour ward. Methodology and results: As part of a local project to improve hospital based labour and childbirth care, an Insider Action Research (IAR) project was carried out. A hermeneutic reflective lifeworld research approach was used to identify and understand patterns of meaning of first time parents´ (n=65) experiences of the first encounter on a labour ward. The emerging meaning was captured as a ‘waiting to earn permission to enter the labour ward world’. It included ‘timing it right ’, ‘waiting to be informed’, ‘being in an inferior position’, and ‘facing reality with a mosaic of emotions’ (paper I). An interpretive description research approach was then used to examine midwives´ (n=37) responses to a collaboratively agreed change in the initial encounters with women in labour and their partners. The overall interpretation was ‘glancing beyond or being confined to routines’ (paper II). Being an insider action researcher as a clinical staff member and a novice doctoral student was described from a reflective lifeworld approach, and summarised as ‘learning how to clinically reflect on and to voice the tacit components of care’. This comprised: ‘to catalyse a counterbalance to the medico technical focus’, ‘to stand alone at the messy front line’, and ‘to struggle to get the organisation participative’ (paper III). An observational study ended the Action Research project by evaluating labour ward routine management of childbirth in healthy women at term over the time of the study. There was a significant reduction in duration of the admission CTG (cardiotocography), use of fetal scalp electrode and of augmentation of labour with synthetic oxytocin. The data also showed a downward trend in the numbers of amniotomy (artificial rupture of fetal membranes) (paper IV). Discussion and Conclusions: To commit to do AR in one’s own organisation is challenging. However, undertaking an insider research role to collaboratively focus on routines was an effective approach in developing care, and it may have contributed to avoidance of further increases in intervention in normal labour. From the participant parents’ point of view, expert monitoring and support was sought actively through seeking admission to the labour ward once they had an embodied sense of being in labour, as they then needed individual support. However, from the organisation’s point of view, carers focused more on observed signs of labour. Being compliant to technocratic norms, and the prioritisation of ‘getting through the work’ that midwives experience working in publicly funded settings was challenged through this action research study. The data suggest that midwives are imprisoned in a hegemonic ‘CTG faith’, and that they rely on medico technical surveillance for normal childbirth, but also that they were still able to reflect on and glance beyond inherent routines. Reducing unnecessary routine intervention in normal labour can free up time for midwives to be present with a woman in labour, and with her partner. New local knowledge derived during this AR process and was best disseminated through everyday dialogues. Further investigation on health care practices from the bottom up perspective, combined with theoretical knowledge, could improve carers competence and capacity.