influencing fetal position in labour Sue Thornber Research Midwife - - PowerPoint PPT Presentation

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

• Upright maternal

positions utilising the benefits of gravity may influence the passage of the fetus through the pelvis

Gupta et al (2012)

• Influence of senior staff

can invoke obedience and conformity

Hollins Martin & Bull (2005) Hunter (2005)

• Culture and context of

birth environment are important determinants

• f midwifery confidence

and practice

Bedwell et al (2015)

• Correct identification of

fetal position by abdominal palpation was low

Webb et al (2011) & Ramphul 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

interviews used to guide, make sense of and interpret midwives experiences.

• Draft guide used to

ensure all topics explored with each participant

• Purposeful sample of

seven midwives recruited to achieve information- rich cases for in-depth understanding and analysis

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 “I always try and grab a birth ball and I usually get the women to stand up or lean

• ver the bed, or sit on the

birth ball…any position that’s not on the bed, anything that’s not semi- recumbent for me”. Midwife F “I’d always be thinking about it from the minute they walk into the labour room…I’m always thinking of ways to keep it (the fetus) away from the back (posterior position) and slowing labour”.

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 Midwife A “It’s like they are both taking responsibility for the woman’s labour, birth and position of the baby…as a midwife I’m just there to help them”. Hospital environment Midwife F “They walk into the labour room and they don’t know where they are. They feel totally confident at home, whereas in 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

• f 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