ic2 English midwives' views and experiences of intrapartum fetal heart rate monitoring in women at low obstetric risk: conflicts and compromises
- Hindley, Carol
- Hinsliff, Sophie Wren
- Thomson, Ann M
Background:
In direct contradiction of the evidence, midwives in the UK continue to use routine electronic fetal monitoring (EFM) for women at low obstetric risk. The number of operative deliveries continues to rise in the UK, to the extent that childbirth intervention rates now match those in the USA. The continued widespread, indiscriminate use of EFM has been implicated in the unacceptably high rates of intervention in the UK. A midwife's decision to implement evidence-based practice is influenced by the individual's perception of their role, professional power and related organisational culture. There is little published data about midwives' attitudes to EFM and the use of EFM on women at low obstetric risk. The discrepancy between practice and best evidence merits further investigation.
Objective:
To evaluate midwives' attitudes and experiences about the use of fetal monitoring for women at low obstetric risk.
Design:
A qualitative study using semi-structured interviews as a component of the second part of a two part study which also included a survey of childbearing women. Part one involved a quality appraisal of intrapartum fetal monitoring guidelines from 24 hospitals in the region. The whole study was carried out over three years.
Setting:
Two hospitals in the north of England. Centre A- was designated ‘partially evidence-based’,. Centre B- designated ‘not at all evidence-based’. Patterns of care delivery were similar and each centre provided maternity services for a similar urban population and ethnic mix.
Participants:
There were 58 midwives in total; 28 midwives were recruited from Centre A and 30 midwives were recruited from Centre B. The only criterion for participation was experience in the use of intermittent auscultation (IA) and EFM. Midwives varied widely in their range of experience and clinical areas.
Results:
General thematic analysis revealed similarities and contradictions in midwives' views about fetal monitoring. A separate researcher reviewed a random selection of transcriptions and validated the four identified themes: — views of IA, views of EFM, fear of litigation, and informed choice for women. Conclusions about midwives' views and experiences of fetal monitoring were generated. This paper reports midwives' views on the themes of IA and EFM. Midwives preferred IA to EFM. They identified the liberating effect of using IA in women's freedom of movement and believed its use promoted the philosophy of normal birth. They enjoyed the positive impact using IA had upon the relationship between a woman and her midwife. Midwives and women became closer. In contrast, midwives viewed EFM as being restrictive and having an oppressive effect on women's labours. Women needed pharmacological and regional analgesia sooner and more frequently. Despite their dislike of EFM, they also acknowledged that it was used as a ‘midwife by proxy’ during busy shifts, regardless of a woman's risk status. Overall though, midwives found EFM intrusive and disliked having to shift their attention from the woman to the machine when they used it. Interestingly, they did not identify themselves as the administrators of the technology imposing the restriction.
Implications:
Despite their belief the IA was preferable, midwives were frightened using it in case they missed some pathological event in the fetal heart rate in between. They were over-reliant on the technology of EFM and felt vulnerable when they did not use it. The translation of best evidence, such as national guidelines, into best practice requires an institutional culture and the resources to support it, alongside practitioners who are willing and able.