Norwegian midwives’ perception of the labour admission test

The social organisation of decision-making about intrapartum fetal monitoring: An Institutional Ethnography

BACKGROUND

International guidelines recommend intrapartum cardiotocograph (CTG) monitoring for women at risk for poor perinatal outcome. Research has not previously addressed how midwives and obstetricians enable or hinder women's decision-making regarding intrapartum fetal monitoring and how this work is structured by external organising factors.

AIM

To examine impacts of policy and research texts on midwives' and obstetricians' work with labouring women related to intrapartum fetal monitoring decision-making.

METHODS

We used a critical feminist qualitative methodology known as Institutional Ethnography (IE). The research was conducted in an Australian tertiary maternity service. Data collection included interviews, observation, and texts relating to midwives' and obstetricians' work with the fetal monitoring system. Textual mapping was used to explain how midwives' and obstetricians' work was organised to happen the way it was.

FINDINGS

CTG monitoring was initiated predominantly by midwives applying mandatory policy. Midwives described reluctance to inform labouring women that they had a choice of fetal monitoring method. Discursive approaches used in a national fetal surveillance guideline, a Cochrane systematic review, and the largest randomised controlled trial regarding CTG monitoring in labour generated and reproduced assumptions that clinicians, not labouring women, were the appropriate decision-maker regarding fetal monitoring in labour.

DISCUSSION AND CONCLUSION

Guidelines structured midwives' and obstetricians' work in a manner that undermined women's participation in decisions about fetal monitoring method. Intrapartum fetal monitoring guidelines should be critically reviewed to ensure they encourage and enable midwives and obstetricians to support women to make decisions about intrapartum care.

Shared decision-making and maternity care in the deep learning age: Acknowledging and overcoming inherited defeaters

In recent years there has been an explosion of interest in Artificial Intelligence (AI) both in health care and academic philosophy. This has been due mainly to the rise of effective machine learning and deep learning algorithms, together with increases in data collection and processing power, which have made rapid progress in many areas. However, use of this technology has brought with it philosophical issues and practical problems, in particular, epistemic and ethical. In this paper the authors, with backgrounds in philosophy, maternity care practice and clinical research, draw upon and extend a recent framework for shared decision-making (SDM) that identified a duty of care to the client's knowledge as a necessary condition for SDM. This duty entails the responsibility to acknowledge and overcome epistemic defeaters. This framework is applied to the use of AI in maternity care, in particular, the use of machine learning and deep learning technology to attempt to enhance electronic fetal monitoring (EFM). In doing so, various sub-kinds of epistemic defeater, namely, transparent, opaque, underdetermined, and inherited defeaters are taxonomized and discussed. The authors argue that, although effective current or future AI-enhanced EFM may impose an epistemic obligation on the part of clinicians to rely on such systems' predictions or diagnoses as input to SDM, such obligations may be overridden by inherited defeaters, caused by a form of algorithmic bias. The existence of inherited defeaters implies that the duty of care to the client's knowledge extends to any situation in which a clinician (or anyone else) is involved in producing training data for a system that will be used in SDM. Any future AI must be capable of assessing women individually, taking into account a wide range of factors including women's preferences, to provide a holistic range of evidence for clinical decision-making.

Midwives must, obstetricians may: An ethnographic exploration of how policy documents organise intrapartum fetal monitoring practice

BACKGROUND

The capacity for midwifery to improve maternity care is under-utilised. Midwives have expressed limits on their autonomy to provide quality care in relation to intrapartum fetal heart rate monitoring.

AIM

To explore how the work of midwives and obstetricians was textually structured by policy documents related to intrapartum fetal heart rate monitoring.

METHODS

Institutional Ethnography, a critical qualitative approach was used. Data were collected in an Australian hospital with a central fetal monitoring system. Midwives (n=34) and obstetricians (n=16) with experience working with the central fetal monitoring system were interviewed and observed. Policy documents were collected and analysed.

FINDINGS

Midwives' work was strongly structured by policy documents that required escalation of care for any CTG abnormality. Prior to being able to escalate care, midwives were often interrupted by other clinicians uninvited entry into the room in response to the CTG seen at the central monitoring station. While the same collection of documents guided the work of both obstetricians and midwives, they generated the expectation that midwives must perform certain tasks while obstetricians may perform others. Midwifery work was textually invisible.

DISCUSSION AND CONCLUSION

Our findings provide a concrete example of the way policy documents both reflect and generate power imbalances in maternity care. Obstetric ways of knowing and doing are reinforced within these documents and continue to diminish the visibility and autonomy of midwifery. Midwifery organisations are well placed to co-lead policy development and reform in collaboration with maternity consumer and obstetric organisations.

Recommendations for intrapartum fetal monitoring are not followed in low-risk women: A study from two Norwegian birth units

OBJECTIVE

International and national intrapartum fetal monitoring guidelines recommend intermittent auscultation in low-risk women, and admission cardiotocography and continuous cardiotocography in high-risk women. The present study aimed to investigate fetal monitoring practices for low- and high-risk women in two hospitals in Norway, and if practice were according to national and international guidelines.

STUDY DESIGN

To this cross sectional study, data on methods of fetal monitoring and women's risk status were collected from the patient journals of 998 women with intended vaginal birth in 2017 and 2018.

MAIN OUTCOME MEASURES

Type of fetal monitoring related to risk status.

RESULTS

On admission, 401 (40%) of the women were classified as low-risk and 597 (60%) as high-risk. An admission cardiotocography was reported for 327 (82%) low-risk women and 554 (93%) high-risk women. Of the low-risk women, 187 (47%) remained low-risk throughout labor. During labor, 99 (53%) of the women that remained low-risk were monitored with intermittent auscultation, 62 (33%) with cardiotocography, 24 (13%) with partial cardiotocography, and two (1%) had no monitoring documented. In the high-risk women, intermittent auscultation was used for 11 (2%) during labor, cardiotocography for 544 (91%), partial cardiotocography for 35 (6%), and seven (1%) women had no monitoring documented.

CONCLUSIONS

The majority of low-risk women had an admission cardiotocography and during labor many low-risk women were monitored with continuous cardiotocography. This is not in accordance with guidelines which recommend intermittent auscultation. In addition, almost one-tenth of high-risk women were not monitored with continuous cardiotocography, as recommended.

Experiences and views of midwives performing antenatal cardiotocography in Dutch primary care: A qualitative study

OBJECTIVE

In the current Dutch maternity care system, pregnant women who have an indication for an antenatal cardiotocography (CTG) to be undertaken need to be referred from primary midwife-led care to secondary obstetric-led care. Within three different regions in the Netherlands independent primary care midwives perform antenatal CTG in primary care, introduced as a pilot project. The aim of this study was to evaluate the experiences and views of primary care midwives who perform antenatal CTG in primary care.

DESIGN

Using a qualitative approach data were collected by seventeen in depth semi-structured interviews. The interview recordings were transcribed verbatim and analysed using thematic coding.

SETTING

Three regions in the Netherlands where midwives carry out antenatal CTG in primary care during this pilot project.

PARTICIPANTS

Seventeen primary care midwives were interviewed between July and November 2017.

FINDINGS

In general, midwives were satisfied with performing antenatal CTG and felt it contributed positively towards the midwife-client relationship. However, midwives experienced an increased workload, partly due to time-consuming technical difficulties. Furthermore, mixed feelings existed on whether antenatal CTG contributes to a more physiological or to a more pathological approach in midwifery practice. Most midwives believed that performing antenatal CTG contributes to the physiological process: strengthening of their gate-keeper role, increased confidence of their clients and improved midwife-client relationship. In contrast, some midwives believed it contributes to a pathological process: medicalization and relying too much on technical devices.

KEY CONCLUSIONS

This study showed an overall positive attitude of primary care midwives towards performing antenatal CTG when required, in primary midwife-led care. However, performing the antenatal CTG can be a challenge for midwives, as midwifery care within this setting is often for healthy women who have a straightforward pregnancy. For some midwives, providing antenatal CTG monitoring in the primary care setting may be seen as using a pathological approach to midwifery care.

IMPLICATIONS FOR PRACTICE

There seems to be a place for antenatal CTG in primary midwife-led care. However, further research is needed before this practice can be implemented widely.

Admission Test and Pregnancy Outcome

BACKGROUND

The admission test (AT) has been carried out for many years, but there are still debates about the prognostic value of the test. Therefore, we aimed to examine the value of the AT in predicting the adverse outcome in neonates.

METHODS

In this cross-sectional study, 425 pregnant women with normal vaginal delivery were studied between2009 and 2014at Vali-e-Asr Hospital. Based on the results, the women were divided into 2groups of normal and abnormal ATs. All the patients were followed up until the birth of their baby, when the status of mother and neonate was determined. The main outcomes of the study were cesarean rate, neonatal intensive care unit (NICU) admission, fetus demise, neonatal acidosis, and Apgar score. The independent t-test, chi-square test, Fisher exact test, and logistic regression were used for statistical analysis. The data were analyzed using SPSS (version 17).

RESULTS

Of 425 pregnant women studied, 142 (33.4%) had abnormal ATs with a mean age of 29 (±4.5) years. Multivariate analysis showed that an abnormal AT was able to predict the incidence of cesarean section, intrauterine growth restriction, turned cord, and Apgar<7, but it could not predict neonatal death and hypoxia.

CONCLUSION

The AT was shown to be a useful screening test with risk factors such as oligohydramnios, bloody amniotic fluid, meconium amniotic fluid, intrauterine growth restriction, and turned cord. Additionally, the test was also able to predict NICU admission and the need for cesarean section, but it could not predict the occurrence of neonatal death.

Professionals' views of fetal monitoring during labour: a systematic review and thematic analysis

Background

Current recommendations do not support the use of continuous electronic fetal monitoring (EFM) for low risk women during labour, yet EFM remains widespread in clinical practice. Consideration of the views, perspectives and experiences of individuals directly concerned with EFM application may be beneficial for identifying barriers to and facilitators for implementing evidence-based maternity care. The aim of this paper is to offer insight and understanding, through systematic review and thematic analysis, of research into professionals’ views on fetal heart rate monitoring during labour.

Methods

Any study whose aim was to explore professional views of fetal monitoring during labour was considered eligible for inclusion. The electronic databases of MEDLINE (1966–2010), CINAHL (1980–2010), EMBASE (1974–2010) and Maternity and Infant Care: MIDIRS (1971–2010) were searched in January 2010 and an updated search was performed in March 2012. Quality appraisal of each included study was performed. Data extraction tables were developed to collect data. Data synthesis was by thematic analysis.

Results

Eleven studies, including 1,194 participants, were identified and included in this review. Four themes emerged from the data: 1) reassurance, 2) technology, 3) communication/education and 4) midwife by proxy.

Conclusion

This systematic review and thematic analysis offers insight into some of the views of professionals on fetal monitoring during labour. It provides evidence for the continuing use of EFM when caring for low-risk women, contrary to current research evidence. Further research to ascertain how some of these views might be addressed to ensure the provision of evidence-based care for women and their babies is recommended.

Foetal monitoring: a woman-centred decision-making pathway

PROBLEM

Many midwives continue to use continuous foetal monitoring on low risk women in labour, despite evidence based clinical guidelines to the contrary. Continuous foetal monitoring has been linked to increased rates of medical intervention during labour and birth with no improvement in long term neonatal outcomes.

PARTICIPANTS

Midwives who used continuous foetal monitoring on low risk women in labour at two regional Queensland hospitals.

METHODS

This Grounded Theory study explored midwives' decision-making processes related to the use of continuous electronic foetal monitoring on low risk labouring women. Primary data were gathered in semi-structured interviews with five purposively selected midwives and concurrently analysed using Grounded Theory techniques of theoretical sampling and constant comparison.

FINDINGS

The midwives made the decision that led to continuous electronic foetal monitoring on low risk women at two key decision points during labour care; the first during the midwives' initial assessment of the woman and foetus, and the second when the midwives categorised the women as high or low risk. However, various factors impacted on these decisions including trust and staff workloads within a context of risk management and medical dominance. There was limited opportunity for women to be involved in the decision-making process about foetal monitoring and only partial information was provided prior to cardiotocography.

CONCLUSIONS

Consistent with current clinical guidelines which recommend open, consultative discussion with the woman about foetal monitoring and a partnership approach towards decision-making following informed choice, a woman-centred foetal monitoring decision-making pathway is proposed. This pathway is applicable in midwifery education, research and clinical practice to promote both evidence based practice and woman-centred decision-making.