- Email: [email protected]
English Midwives’ Views and Experiences of Intrapartum Fetal Heart Rate Monitoring in Women at Low Obstetric Risk: Conflicts and Compromises
English Midwives’ Views and Experiences of Intrapartum Fetal Heart Rate Monitoring in Women at Low Obstetric Risk: Conflicts and Compromises Carol Hindley, RM, MSc, Sophie Wren Hinsliff, RM, MPhil, and Ann M. Thomson, RM, MSc, MTD Over the last 20 years in the United Kingdom, midwives have implemented the routine use of intrapartum fetal monitoring regardless of the risk status of laboring women. This practice is at odds with the published research. The discrepancy between practice and best evidence merits further investigation. A qualitative study was conducted to evaluate midwives’ attitudes and experiences about the use of fetal monitoring for women at low obstetric risk. Fifty-eight midwives working in two hospitals in the north of England were interviewed by using a semistructured approach. The taped interviews were transcribed and analyzed by using a general thematic approach. Issues included midwives’ perceptions of low-risk status, the socialization of midwives, and the loss of woman-centered care. Midwives subscribed to the notion of woman-centered care, but because of a complexity of factors experienced in their daily working lives, they felt vulnerable when attempting to implement evidence-based fetal monitoring practices. Midwives regretted the loss of a woman-centered approach to care when technologic methods of intrapartum fetal heart rate monitoring were used indiscriminately. An appreciation of the complex factors affecting the ability of midwives to implement evidence-based practice is important when attempting to facilitate the development of appropriate fetal monitoring practices for women at low obstetric risk. J Midwifery Womens Health 2006;51:354 –360 © 2006 by the American College of Nurse-Midwives. keywords: electronic fetal monitoring, intermittent auscultation, midwives, evidence-based practice
INTRODUCTION Extensive research over the last 30 years has shown that routine use of intrapartum electronic fetal monitoring (EFM) is of limited benefit for women considered to be at low obstetric risk.1 The two most often cited reasons for the widespread use of intrapartum EFM are the prevention of perinatal mortality and cerebral palsy. Yet, these have remained static over the last three decades,2 and recent evidence suggests that EFM is still not a reliable tool for the prediction of intrapartum neurologic insult to the fetus.3 A further important consideration is that the greatest negative overall consequence of routine EFM use is to the mother because women who experience continuous EFM have a higher rate of cesarean birth than do women who are not monitored continuously with EFM during labor.1 Nonetheless, midwives in the United Kingdom have continued to use EFM routinely in caring for women with uncomplicated pregnancies. This is in direct contradiction to the evidence, which states that the most appropriate method of intrapartum fetal monitoring for women at low obstetric risk is intermittent auscultation.4 The United Kingdom has unacceptably high child-
Address correspondence to Carol Hindley, RM, MSc, ADM, Cert Ed, School of Nursing, Midwifery and Social Work, University of Manchester, 5th Floor, Gateway House, Piccadilly South, Manchester M60 7LP, UK. E-mail: [email protected]
354 © 2006 by the American College of Nurse-Midwives Issued by Elsevier Inc.
birth intervention rates, and is now on equal intervention rates with the United States.5 The extensive use of EFM, regardless of obstetric risk, has been implicated in the rise in the number of operative deliveries in the United Kingdom over the last decade.1,6 The organizational culture of the practice environment profoundly affects the implementation of evidence-based practice and role definitions. Widespread professional power based on historical monopolies continues to exist in the National Health Service. For instance, the midwife’s ability to implement evidencebased care is directly influenced by her perceived professional power within a maternity system that prioritizes the power of obstetricians.7 Consequently, there may be a discrepancy between the theory and practice of appropriate intrapartum fetal-monitoring techniques. The discrepancy between midwifery theory and practice has been reported recently in a US study in which there was a lack of congruity between the ideal practices for normal birth and the actual practices that occurred.8 UK health care policy places an emphasis on the need to develop a woman-centered or consumer-oriented approach to care in the maternity services.9 The natural consequence of this policy is that by the integration of evidence-based practice, women’s needs are considered as paramount. However, the data on the use of EFM in women at low obstetric risk and on midwifery attitudes about EFM are scarce. EFM has been used indiscriminately in the United Kingdom despite evidence that states it should be used Volume 51, No. 5, September/October 2006 1526-9523/06/$32.00 • doi:10.1016/j.jmwh.2006.02.008
sparingly4; hence, this is the rationale for the present study. The full 3-year study entailed two parts. Part one involved a quality appraisal of all regional guidelines on EFM10 using a specifically developed tool.11 Part two involved surveys of childbearing women and interviews with midwives. One aspect of part two of the study intended to explore midwives’ attitudes and experiences of intrapartum fetal monitoring. METHODS Semistructured interviews were conducted with 58 midwives from two hospitals in the north of England from October 2002 to October 2003. A full description of the criteria used to identify participants is described elsewhere.10 The aim was to investigate midwives attitudes, values, and beliefs about the use of intrapartum fetal monitoring for women at low obstetric risk (i.e., normal, uneventful pregnancies without medical complications). A qualitative approach in the naturalistic paradigm was used, which is nonexperimental in design and is undertaken in naturally occurring settings.12 The emphasis of qualitative research is about communicating the meanings, experiences, and views of all the participants. Therefore, this approach was used so that a more holistic view of intrapartum fetal monitoring could be communicated.12 It is also used to expand the knowledge of midwifery practice. A semistructured interview tool derived from a literature review on intrapartum fetal monitoring was used.3 Several points emerged from the literature on fetal monitoring, which were relevant to the role of the midwife; these were incorporated into an interview schedule using open-ended questions. The interview schedule included 1) the advantages/disadvantages of intrapartum monitoring methods, 2) decisions influencing midwives’ practice in relation to choice of fetal monitoring method, 3) definition of risk status and how midwives perceived the status of childbirth, 4) the influence of fetal monitoring research on midwifery practice, 5) implementation of guidelines on intrapartum fetal monitoring, and 6) the effects of fetal monitoring technology on midwifery practice and the process of birth. Ethical approval was obtained from both the university
Carol Hindley, RM, MSc, ADM, Certified Editor, is a full-time lecturer in midwifery in the School of Nursing, Midwifery, and Social Work, University of Manchester. She devised the project, gained external funding, gathered and analyzed the data, and managed the project. Sophie Wren Hinsliff, RM, MPhil, is currently employed as a part-time clinical midwife. At the time of the project, she was the full-time research assistant who helped with data gathering and analysis. Ann M. Thomson, RM, MSc, ADM, MTD, is a professor in Midwifery in the School of Nursing, Midwifery, and Social Work, University of Manchester. Professor Thomson supervised the project and helped analyze the data.
Journal of Midwifery & Women’s Health • www.jmwh.org
and the research committees in each hospital. The purpose of the study was communicated by the researchers via seminars in each hospital, and midwives were invited to take part. Prior to undertaking the interview, each midwife was also given a cover letter explaining the purpose of the study along with a consent form. The interviews were conducted at a time and place convenient to the midwives to minimize disruption to their professional and personal lives. Each interview lasted between 30 and 60 minutes. All consenting participants were assured that all data from the interviews would be stored off hospital site and coded so that confidentiality and anonymity were ensured. Twenty-eight midwives were recruited from one hospital (Center A) and 30 midwives from another (Center B). In summary, guidelines on intrapartum fetal monitoring from 24 hospitals in the region were evaluated against criteria formulated by a multidisciplinary group. Guidelines were scored as being “totally, partially, or not at all” evidence-based. None scored in the highest category, but Center A was chosen for being partially evidence-based, and Center B was chosen as not at all evidence-based. Each center provided maternity services for a similar urban population and ethnic mix, and patterns of care delivery were similar. Midwives work in a range of settings in the United Kingdom: in consultant units, with General Practitioners in community settings, and in midwifery-led units. The sample was recruited by practitioner researchers, who are employed by a university in an academic capacity and are also Registered Midwives with the Nursing and Midwifery Council for England and Wales. The sample included midwives with a wide range of clinical experience and work environments (i.e., totally hospital-based or worked in teams that rotated from community to hospital settings). The midwives worked across a range of clinical areas, which integrated antepartum, intrapartum, and postpartum care. The only criterion for participation in the study was experience in the use of intermittent auscultation and EFM. All of the midwives had experience using intrapartum fetal monitoring techniques when delivering intrapartum care, as this is a routine practice in UK maternity units. The interviews were audiotaped and were played back to the participants with no changes. The taped interviews were transcribed verbatim, and line-by-line analysis was undertaken. A general, thematic analysis, as described by Aronson,13 was used because it facilitated a systematic consideration of the themes and associated meanings present in the data. More relevantly, because of the large amount of data generated and the time constraints of the study, thematic analysis enables researchers to quickly retrieve and collect together all the data so that they can be compared.14 During analysis, it was necessary to establish recurring 355
categories or patterns using direct quotes or paraphrasing common expressions. All data that related directly to the already classified patterns were identified, and these were combined into subthemes. The data were systematically sifted and sorted to detect and interpret thematic categorizations, looking for similarities and contradictions to generate conclusions about the midwives’ views and experiences of using fetal monitoring. Grouping the responses in this way explored the participants’ views rather than those of the researchers. The information was indexed and stored on computer. Validation of the data was required to establish that the themes were relevant to the chosen research question. Twenty randomly selected, transcribed interviews were selected and reviewed by a separate researcher. There was concordance with the identified themes; hence, the method used was deemed relevant and consistent. This is crucial to the rigor of the research, as it implies that the data are credible and that the relationship between the data and the interpretation of the findings is transparent.15 RESULTS The number of years spent in practice by the midwives ranged from 2 to 30 years, with an average of 15 years of professional practice. Several themes emerged from the data: 1) views of intermittent auscultation, 2) views of EFM, 3) a fear of litigation, and 4) informed choice for the woman. The issue of informed choice in relation to this study has been discussed elsewhere.16 Findings on chosen monitoring method and the fear of litigation generated a large amount of data and will be published separately. Therefore, the two major themes reported in this article are midwives’ views of intermittent auscultation and EFM. Intermittent Auscultation The midwives defined intermittent auscultation as auscultation of the fetal heart every 15 minutes in the first stage of labor and at least every 5 minutes or following each contraction in the second stage of labor using Pinard’s stethoscope or a mobile Doppler device.4 Categories that emerged from discussion around the use of intermittent auscultation were coded as 1) freedom/ liberating effects of intermittent auscultation for the woman, 2) closeness/proximity of the midwife, and 3) quicker progress in labor. Freedom/Liberating Effects of Intermittent Auscultation for Women The midwives preferred to use intermittent auscultation, as they reported that it encouraged freedom of movement for women because the women were not totally confined to the bed when intermittent auscultation was used: 356
“I think it gives the woman more freedom. She can mobilise. I think the labour tends to get quicker because she is not pinned to the bed in one position. She can move around, it’s more natural, it’s more normal.” “Listening in, it’s easy for her to get up and walk about, it’s easier to listen in when they’re straddling a pool or whatever, yes. Also, they don’t feel like they’re strapped down and stuck to the machine all the time.” The quotes illustrate how the midwives viewed the use of traditional skills such as intermittent auscultation as the antithesis of the usual EFM technology favored in routine, hospital labor care. The midwives also commented on the low technology focus of intermittent auscultation and that its use facilitated a more natural approach to birth. “I have worked in a regional referral unit where it was very difficult to do IA [intermittent auscultation], and I felt the midwives had lost sight of what was normal; and that’s actually the reason why I left there to come to a less medical hospital. So, I felt that the midwives were in danger. . . . I might be in danger of losing sight of what’s normal.” Others commented that intermittent auscultation was difficult to implement because active management policies in maternity units are promoted over more conservative approaches to childbirth: “Well, at the moment, it [midwifery care] is getting very interventionist. I mean, we are getting so many inductions. Why? Most of them are only post term, they have no illness, and once you induce them, you are required to use the EFM, they get ARM [artificial rupture of membranes] and often end up with an epidural. How can midwives learn IA and feel confident when this is the norm?” It was evident that the midwives perceived using intermittent auscultation as a technique that promotes a philosophy of normal birth rather than the cascade of intervention associated with EFM. Closeness/Proximity of the Midwife A further positive feature of intermittent auscultation was that it encouraged the close proximity of the midwife to the laboring woman as a direct result of auscultating the abdomen for the required period of time and, in turn, this enhanced the importance of sitting with women. “I think IA brings you closer to them, and it’s just more natural and normal, so it’s less technology that I am in favour of.” Volume 51, No. 5, September/October 2006
This point also helps to illustrate the preferences held by some midwives for a decidedly nonintervention philosophy for women with low-risk pregnancies. Quicker Progress in Labor The midwives held a strong belief system that intermittent auscultation influenced the progress of labor more efficiently than EFM. “Women said . . . ‘I was able to walk around much more this time’ You know, things like that, so they obviously weren’t on the monitor, they felt happy, ‘I used the bean bag,’ ‘I was moving around better.’ They think that’s speeded things up for them, and it probably has.” There was a clearly reported association between intermittent auscultation and efficient progress in labor, which was important for many of the midwives in the study. This was because their collective, clinical experiences demonstrated that inactivity may slow labor and increase the need for interventions to accelerate labor. Paradoxically, the positive features of intermittent auscultation were tempered quite significantly by the midwives’ fears of missing some pathologic event in the fetal heart rate in between auscultation. Electronic Fetal Monitoring It was evident that there was a paradoxical representation of the midwives’ views in relation to the use of EFM. For example, the following categories of 1) oppressive/ restrictive, 2) midwife by proxy, and 3) requirements for pain relief render the impression that the midwives were opposed to EFM. However, in reality, it was difficult for some to relinquish old routines such as electronic monitoring. Oppressive/Restrictive The midwives viewed EFM negatively, and phrases such as “pinned,” “chained,” or “tied to the bed” were used to describe its restrictive/oppressive nature. “I think a lot of the women feel really restricted by monitoring. It also means that as a midwife, your time is taken up with analysing and looking at the machine a lot of the time when you could be giving other support to the woman.” “They are tied to a bed and everything has to be so clinical then.” It is interesting to note that the machine was associated with the connotations of restriction, rather than midwives perceiving themselves as the administrators of the technology that resulted in women being “tied down.” Journal of Midwifery & Women’s Health • www.jmwh.org
Midwife by Proxy The midwives felt that the use of technology in labor had contributed to the feeling that it dehumanized the birth process by distracting the midwife away from communicating with the woman. Midwives reported that EFM had an intrusive effect on their relationships with women and their birth partners. The attention of the midwives was directed away from the woman and from aiding the woman to use her coping strategies in labor. Literally, all of the midwives’ time was taken up by the “surveillance” element involved in the use of EFM. “The machine is the centre of attention. . . . It becomes an obsession. . . . I think a lot of people find it very bare and empty if there’s no machine in the room. They come in and they instantly ask themselves, ‘Where’s the little thing that ticks along?’” Some of the midwives reported that EFM was used in the absence of a midwife during very busy shifts. The midwives freely admitted that sometimes the monitors had been attached to laboring women regardless of their perceived risk status because of staff shortages. Pain Relief The associated effects of different monitoring methods and their influence on pain relief were reported by the midwives. This was often cited as indirect references to maternal position or restricted mobility as factors affecting pain relief. The midwives discussed the influence of EFM on pain relief: “I think, especially with the monitors, they are waiting for the next pain. The focus is on the pain. Certainly, there are more epidurals as opposed to the woman who is labouring in the bath or moving about.” The direct associations made by the midwives on the method of monitoring and type of pain relief offered were a direct result of their own clinical experiences. They had little doubt that pharmacologic methods and epidural analgesia were resorted to earlier and more frequently in those women experiencing EFM. DISCUSSION The majority of pregnancies are perfectly straightforward, but it was evident that many midwives were overreliant on technologic interventions such as electronic monitoring. This study concentrated on women at low obstetric risk, as the midwife in the United Kingdom is the primary caregiver for this specific population during childbirth, and the midwives’ scope of practice is clearly defined in statute.17 In their monograph, Care in Normal Birth, the World Health Organization (WHO) 357
were seminal in defining the criteria for “normal birth” by providing a benchmark for all midwives to follow for levels of appropriate technology in childbirth.18 These factors helped to set the context for the background of our study. Many proponents of the normal model of birth support the process of active birth where a nontechnologic focus toward childbearing is deemed to confer greater benefits than an actively managed birth.19 Despite the continued promotion of a philosophy that supports limited use of technology in childbirth, EFM is an example of a technology used for laboring women that may lead to cascade effects, as described in the seminal work by Mold and Stein.20 This is relevant to our findings because the midwives reported personal experiences of the cascade effects of EFM, yet they still used it despite their espoused allegiance to a normal approach to birth. The findings from our study show how midwives view EFM, and they are aware that the traditional, watchful approach of the midwife has been devalued in favor of routine practices such as EFM. This resonates with the work of Kennedy, in that midwives still use EFM because it is deemed “scientific” and, therefore, more reliable than the midwife’s gaze or touch.21 Despite the negative connotations of EFM and its frequent use, the midwives espoused a philosophy of normal childbirth because it validated their professional ideology for a woman-centered approach to care. Both English and US data cite high rates of continuous EFM, even in women at low obstetric risk.22,23 Intermittent auscultation was particularly valued for facilitating a closer working partnership, thereby positively affecting birth experiences for women. In contrast, the midwives did not think that the use of EFM promoted the midwife’s proximity to the birthing process. Our findings in this respect concur with a previous study by Kennedy and Shannon, who reported that midwives believed in birth as a normal process, and as a consequence, their actions were specifically aimed toward the support of it as a physiologic, rather than pathologic, process.24 As in the study by Kennedy and Shannon, the proximity and continued presence of the midwife with the woman was also a strong indicator of normalcy in our study. The midwives reported that choice of monitoring method was influenced by reduced staffing during busy labor ward shift systems. This meant that in some circumstances, the monitor was used as a midwife by proxy—a substitute for the presence of the midwife who would otherwise use the clinical skills of perception, auscultation, palpation, and communication. Some of the midwives in our study recognized that this was an unacceptable but sometimes unavoidable consequence of a busy labor ward. The use of EFM as a midwife by proxy was also specifically mentioned in expert evidence given to a UK parliamentary select committee on health, 358
which commented on the national shortage of midwives.25 This use has been mentioned as well in articles on EFM from the United States, in reference to nursing shortages.26 However, it is too simplistic to suggest that the overuse of EFM is exclusively associated with reduced staffing levels. For example, it has been reported that the attitudes of professionals are just as important; that is, midwives who trust machines are more disposed to their use.27 In essence, some of the midwives used this as an opportunity to delegate their own professional skills to the machine to determine the progress of labor rather than offer personal support. Engaging on a deep and personal level with women can be physically and emotionally demanding for midwives, and this was recognized by the midwives as an important issue. As a result, some midwives did not always think that they had the emotional energy to divest in the process of sitting with the women. The importance of sitting with women has also been discussed at length by others.24,28 The numerous physical, spiritual, and emotional demands placed on midwives when delivering care in labor are often inextricably linked to the coping strategies of the women themselves. This is particularly the case for the woman’s reaction to pain in labor, and it was often easier for the midwife to “busy” herself with the monitor rather than engage on a deeper, personal level with the woman. This is interesting because the combination of inactivity and anxiety associated with EFM has been associated with an increased need for pain relief.29 EFM is associated with epidural analgesia, and recent statistics show that a third of all obstetric pain relief in the United Kingdom is administered by epidural.30 Hence, the indiscriminate use of EFM as a direct replacement for the one-to-one support of a caring midwife may have a detrimental impact on the woman’s coping strategies. This use of more invasive methods of pain relief has been cited in the literature.31 This study has some limitations. It was undertaken in only two hospitals and in one region of England. However, the profile of practice in these two settings reflects the national standards of midwifery practice, and as such, is an accurate representation of midwifery care in English maternity units. As practitioner researchers, we were also aware that our prior knowledge and preconceptions of midwifery practice may have affected the data collection process. To address this issue, the researchers completed diaries, which helped to maintain the process of reflexivity. Despite the limitations, we believe that the findings are relevant to the conduct of midwifery practice when using intrapartum fetal monitoring in women at low obstetric risk. Ultimately, our study revealed that it requires more than the availability of national guidelines from expert groups and the availability of research to translate best Volume 51, No. 5, September/October 2006
evidence into practice. The reasons why outmoded clinical practices continue are complex and have been discussed previously.32 Some midwives perceived there was a lack of institutional support when implementing intermittent auscultation for women at low obstetric risk. This was not necessarily associated with midwifery management, but rather, more with medical policies and a persistently held belief by many obstetricians that birth is inherently dangerous and should be risk managed.
Future Research
CONCLUSION
REFERENCES
It appears that midwives have positive attitudes toward intermittent auscultation and seem committed to increasing its use. They dislike EFM because of its deleterious effects on labor as the increased vigilance is focused on the machine and not the woman. The paradox is that midwives find it difficult to practice confidently without EFM, and it is doubtful that this dilemma will be resolved as the technology becomes increasingly more sophisticated. Midwifery practice over the last 30 years has undergone a metamorphosis dependent on the prevailing ideology of the time, when the midwife as expert of normal birth became defunct, and the midwife as an instrument for the active management of birth arose. However, blind acceptance of routine EFM technology for all women, regardless of risk, has not resulted in positive contributions for women and their babies. Nobody suggests it is easy for midwives, as there are complex issues influencing their practice, which undoubtedly affect the speed of change. Midwives do genuinely fear abandoning the philosophy of a technology-free birth, but the institutional culture and available resources are mitigating factors affecting the process of implementing care based on best evidence. Practice Implications Where national guidelines on the most appropriate use of EFM are available, it is useful to audit compliance with those guidelines to better implement risk management protocols. Simple strategies such as removing fetal monitors from rooms might also help the midwife to consciously question the need for EFM rather than applying it routinely, merely because it is proximal. The provision of resources for one-to-one midwifery care in labor are crucial in reducing the use of EFM as a midwife by proxy. Debate also needs to continue surrounding the routine use of active management strategies for labor such as the use of oxytocin and epidural analgesia, as guidelines may stipulate the use of EFM when either of these is used. Finally, there needs to be continued debate and discussion on the precise clinical risk indicators for the use of EFM so that midwives share a consensus of what is regarded as normal, and conversely, abnormal. Journal of Midwifery & Women’s Health • www.jmwh.org
It is important to continue to explore the complexity of issues affecting the role of the midwife and the implementation of evidence-based care. Therefore, it would be useful to undertake further research in countries where EFM is used extensively to gain an insight into midwifery attitudes and practice issues that affect the continued use of EFM.
1. Thacker SB, Stroup D, Chang M. Continuous electronic heart rate monitoring for fetal assessment during labor (Cochrane Review). Chichester (UK): The Cochrane Library, 2005(3). 2. Blair E, Stanley F. When can cerebral palsy be prevented? The generation of causal hypotheses by multi-variate analysis of a case control study. Pediatr Perinat Epidemiol 2003;7:272–301. 3. Hindley C. Intrapartum electronic fetal monitoring in lowrisk women: A literature review. J Clin Excel 2001;3:91–9. 4. Royal College of Obstetricians and Gynaecologists. The use of electronic fetal monitoring: The use and interpretation of cardiotocography in intrapartum fetal surveillance (Evidence-Based Clinical Guideline Number 8). London: Royal College of Obstetricians and Gynaecologists, 2001. 5. Young D. The push against vaginal birth. Birth Issues Perinat Care 2003, 30(3):149 –52. 6. Sinclair M. Midwives perceptions of the use of technology in assisting childbirth in Northern Ireland. J Adv Nurs 2001;36: 229 –31. 7. Rogers J. Midwife alone. Br J Midwifery 2003;11:112–5. 8. Lange G, Kennedy HP. Student perceptions of ideal and actual midwifery practice. J Midwifery Womens Health 2005;51: 71–7. 9. Department of Health. The NHS plan: A plan for investment a plan for reform. London: The Stationary Office, 2000. 10. Hinsliff S, Hindley C, Thomson AM. A survey of regional guidelines for intrapartum electronic fetal monitoring in women at low obstetric risk. Midwifery 2004;20:345–57. 11. Hindley C, Hinsliff SW, Thomson AM. Developing a tool to appraise fetal monitoring guidelines for women at low obstetric risk J Adv Nurs 2005;52:307–14. 12. Rubin HJ, Rubin R. Qualitative interviewing: The art of hearing data, 2nd edition. Thousand Oaks (CA): Sage Publishers, 2005. 13. Aronson J. A pragmatic view of thematic analysis. Qual Rep 1994;2:1– 4. 14. Ritchie J, Spencer L. Qualitative data analysis for applied policy research. In Bryman A, Burgess RD, eds. Analyzing qualitative data. London: Sage, 1994. 15. Thorne S. Data analysis in qualitative research. Evid Based Nurs 2000;3:68 –70. 16. Hindley C, Thomson AM. The rhetoric of informed choice: Perspectives from midwives on intrapartum fetal heart rate monitoring. Health Expect 2005;8:306 –14.
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17. Nursing and Midwifery Council. Midwives rules and standards 05.04. London: Nursing and Midwifery Council, 2004. 18. World Health Organisation Report. Care in normal birth: A practical guide. Geneva: World Health Organization, 1997. 19. Hunter LP. Being with woman: A guiding concept for the care of laboring women. J Obstet Gynecol Neonatal Nurs 2002; 31:650 –7. 20. Mold JW, Stein HF. The cascade effect in the clinical care of patients. N Engl J Med 1986;314:512– 4. 21. Kennedy HP. The landscape of midwifery care: A narrative study of midwifery practice. J Midwifery Womens Health 2004; 49:14 –23. 22. Williams FLR, Florey C du V, Ogston SA, et al. UK study of intrapartum care for low risk primigravidas: A survey of interventions. J Epidemiol Community Health 1998;52:494 –500. 23. Maternity Center Association. Recommendations from listening to mothers: The first national US survey of women’s childbearing experiences. Birth 2004;31:61–5. 24. Kennedy HP, Shannon MT. Keeping birth normal: Research findings on midwifery care during childbirth. J Obstet Gynecol Neonatal Nurs 2004;33:554 – 60. 25. The United Kingdom Parliament Select Committee on Health (Written Evidence). Appendix 44, memo by action for
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victims of medical accidents (MS S3) 3:10; Use and interpretation of electronic fetal monitoring. London: The Stationary Office, 2003. 26. Parer JTP, King T. Fetal heart rate monitoring: Is it salvageable? Am J Obstet Gynecol 2000;182:982–7. 27. Jackson DJ, Lang JM, Swartz WH, Ganiats TG, Fullerton J, Ecker J, Nguyen U. Outcomes, safety, and resource utilization in a collaborative care birth center program compared with traditional physician-based perinatal care. Am J Public Health 2003;93:999 – 1006. 28. Davis-Floyd RE. The technocratic, humanistic, and holistic paradigms of childbirth. Int J Gynecol Obstet 2001;75(suppl 1): S5–S23. 29. Hodnett ED. Pain and women’s satisfaction with the experience of childbirth: A systematic review. Am J Obstet Gynecol 2002;186(suppl):S160 –S72. 30. Department of Health: Statistical bulletin, NHS maternity statistics, England: 2003–2004. London: The Stationary Office, 2005. 31. Goodman P, Mackey MC, Tavakoli AS. Factors relating to childbirth satisfaction. J Adv Nurs 2003;46:212–9. 32. Retsas A. Barriers to using research evidence in nursing practice. J Adv Nurs 2000;31:599 – 606.
Volume 51, No. 5, September/October 2006
INTRODUCTION Extensive research over the last 30 years has shown that routine use of intrapartum electronic fetal monitoring (EFM) is of limited benefit for women considered to be at low obstetric risk.1 The two most often cited reasons for the widespread use of intrapartum EFM are the prevention of perinatal mortality and cerebral palsy. Yet, these have remained static over the last three decades,2 and recent evidence suggests that EFM is still not a reliable tool for the prediction of intrapartum neurologic insult to the fetus.3 A further important consideration is that the greatest negative overall consequence of routine EFM use is to the mother because women who experience continuous EFM have a higher rate of cesarean birth than do women who are not monitored continuously with EFM during labor.1 Nonetheless, midwives in the United Kingdom have continued to use EFM routinely in caring for women with uncomplicated pregnancies. This is in direct contradiction to the evidence, which states that the most appropriate method of intrapartum fetal monitoring for women at low obstetric risk is intermittent auscultation.4 The United Kingdom has unacceptably high child-
Address correspondence to Carol Hindley, RM, MSc, ADM, Cert Ed, School of Nursing, Midwifery and Social Work, University of Manchester, 5th Floor, Gateway House, Piccadilly South, Manchester M60 7LP, UK. E-mail: [email protected]
354 © 2006 by the American College of Nurse-Midwives Issued by Elsevier Inc.
birth intervention rates, and is now on equal intervention rates with the United States.5 The extensive use of EFM, regardless of obstetric risk, has been implicated in the rise in the number of operative deliveries in the United Kingdom over the last decade.1,6 The organizational culture of the practice environment profoundly affects the implementation of evidence-based practice and role definitions. Widespread professional power based on historical monopolies continues to exist in the National Health Service. For instance, the midwife’s ability to implement evidencebased care is directly influenced by her perceived professional power within a maternity system that prioritizes the power of obstetricians.7 Consequently, there may be a discrepancy between the theory and practice of appropriate intrapartum fetal-monitoring techniques. The discrepancy between midwifery theory and practice has been reported recently in a US study in which there was a lack of congruity between the ideal practices for normal birth and the actual practices that occurred.8 UK health care policy places an emphasis on the need to develop a woman-centered or consumer-oriented approach to care in the maternity services.9 The natural consequence of this policy is that by the integration of evidence-based practice, women’s needs are considered as paramount. However, the data on the use of EFM in women at low obstetric risk and on midwifery attitudes about EFM are scarce. EFM has been used indiscriminately in the United Kingdom despite evidence that states it should be used Volume 51, No. 5, September/October 2006 1526-9523/06/$32.00 • doi:10.1016/j.jmwh.2006.02.008
sparingly4; hence, this is the rationale for the present study. The full 3-year study entailed two parts. Part one involved a quality appraisal of all regional guidelines on EFM10 using a specifically developed tool.11 Part two involved surveys of childbearing women and interviews with midwives. One aspect of part two of the study intended to explore midwives’ attitudes and experiences of intrapartum fetal monitoring. METHODS Semistructured interviews were conducted with 58 midwives from two hospitals in the north of England from October 2002 to October 2003. A full description of the criteria used to identify participants is described elsewhere.10 The aim was to investigate midwives attitudes, values, and beliefs about the use of intrapartum fetal monitoring for women at low obstetric risk (i.e., normal, uneventful pregnancies without medical complications). A qualitative approach in the naturalistic paradigm was used, which is nonexperimental in design and is undertaken in naturally occurring settings.12 The emphasis of qualitative research is about communicating the meanings, experiences, and views of all the participants. Therefore, this approach was used so that a more holistic view of intrapartum fetal monitoring could be communicated.12 It is also used to expand the knowledge of midwifery practice. A semistructured interview tool derived from a literature review on intrapartum fetal monitoring was used.3 Several points emerged from the literature on fetal monitoring, which were relevant to the role of the midwife; these were incorporated into an interview schedule using open-ended questions. The interview schedule included 1) the advantages/disadvantages of intrapartum monitoring methods, 2) decisions influencing midwives’ practice in relation to choice of fetal monitoring method, 3) definition of risk status and how midwives perceived the status of childbirth, 4) the influence of fetal monitoring research on midwifery practice, 5) implementation of guidelines on intrapartum fetal monitoring, and 6) the effects of fetal monitoring technology on midwifery practice and the process of birth. Ethical approval was obtained from both the university
Carol Hindley, RM, MSc, ADM, Certified Editor, is a full-time lecturer in midwifery in the School of Nursing, Midwifery, and Social Work, University of Manchester. She devised the project, gained external funding, gathered and analyzed the data, and managed the project. Sophie Wren Hinsliff, RM, MPhil, is currently employed as a part-time clinical midwife. At the time of the project, she was the full-time research assistant who helped with data gathering and analysis. Ann M. Thomson, RM, MSc, ADM, MTD, is a professor in Midwifery in the School of Nursing, Midwifery, and Social Work, University of Manchester. Professor Thomson supervised the project and helped analyze the data.
Journal of Midwifery & Women’s Health • www.jmwh.org
and the research committees in each hospital. The purpose of the study was communicated by the researchers via seminars in each hospital, and midwives were invited to take part. Prior to undertaking the interview, each midwife was also given a cover letter explaining the purpose of the study along with a consent form. The interviews were conducted at a time and place convenient to the midwives to minimize disruption to their professional and personal lives. Each interview lasted between 30 and 60 minutes. All consenting participants were assured that all data from the interviews would be stored off hospital site and coded so that confidentiality and anonymity were ensured. Twenty-eight midwives were recruited from one hospital (Center A) and 30 midwives from another (Center B). In summary, guidelines on intrapartum fetal monitoring from 24 hospitals in the region were evaluated against criteria formulated by a multidisciplinary group. Guidelines were scored as being “totally, partially, or not at all” evidence-based. None scored in the highest category, but Center A was chosen for being partially evidence-based, and Center B was chosen as not at all evidence-based. Each center provided maternity services for a similar urban population and ethnic mix, and patterns of care delivery were similar. Midwives work in a range of settings in the United Kingdom: in consultant units, with General Practitioners in community settings, and in midwifery-led units. The sample was recruited by practitioner researchers, who are employed by a university in an academic capacity and are also Registered Midwives with the Nursing and Midwifery Council for England and Wales. The sample included midwives with a wide range of clinical experience and work environments (i.e., totally hospital-based or worked in teams that rotated from community to hospital settings). The midwives worked across a range of clinical areas, which integrated antepartum, intrapartum, and postpartum care. The only criterion for participation in the study was experience in the use of intermittent auscultation and EFM. All of the midwives had experience using intrapartum fetal monitoring techniques when delivering intrapartum care, as this is a routine practice in UK maternity units. The interviews were audiotaped and were played back to the participants with no changes. The taped interviews were transcribed verbatim, and line-by-line analysis was undertaken. A general, thematic analysis, as described by Aronson,13 was used because it facilitated a systematic consideration of the themes and associated meanings present in the data. More relevantly, because of the large amount of data generated and the time constraints of the study, thematic analysis enables researchers to quickly retrieve and collect together all the data so that they can be compared.14 During analysis, it was necessary to establish recurring 355
categories or patterns using direct quotes or paraphrasing common expressions. All data that related directly to the already classified patterns were identified, and these were combined into subthemes. The data were systematically sifted and sorted to detect and interpret thematic categorizations, looking for similarities and contradictions to generate conclusions about the midwives’ views and experiences of using fetal monitoring. Grouping the responses in this way explored the participants’ views rather than those of the researchers. The information was indexed and stored on computer. Validation of the data was required to establish that the themes were relevant to the chosen research question. Twenty randomly selected, transcribed interviews were selected and reviewed by a separate researcher. There was concordance with the identified themes; hence, the method used was deemed relevant and consistent. This is crucial to the rigor of the research, as it implies that the data are credible and that the relationship between the data and the interpretation of the findings is transparent.15 RESULTS The number of years spent in practice by the midwives ranged from 2 to 30 years, with an average of 15 years of professional practice. Several themes emerged from the data: 1) views of intermittent auscultation, 2) views of EFM, 3) a fear of litigation, and 4) informed choice for the woman. The issue of informed choice in relation to this study has been discussed elsewhere.16 Findings on chosen monitoring method and the fear of litigation generated a large amount of data and will be published separately. Therefore, the two major themes reported in this article are midwives’ views of intermittent auscultation and EFM. Intermittent Auscultation The midwives defined intermittent auscultation as auscultation of the fetal heart every 15 minutes in the first stage of labor and at least every 5 minutes or following each contraction in the second stage of labor using Pinard’s stethoscope or a mobile Doppler device.4 Categories that emerged from discussion around the use of intermittent auscultation were coded as 1) freedom/ liberating effects of intermittent auscultation for the woman, 2) closeness/proximity of the midwife, and 3) quicker progress in labor. Freedom/Liberating Effects of Intermittent Auscultation for Women The midwives preferred to use intermittent auscultation, as they reported that it encouraged freedom of movement for women because the women were not totally confined to the bed when intermittent auscultation was used: 356
“I think it gives the woman more freedom. She can mobilise. I think the labour tends to get quicker because she is not pinned to the bed in one position. She can move around, it’s more natural, it’s more normal.” “Listening in, it’s easy for her to get up and walk about, it’s easier to listen in when they’re straddling a pool or whatever, yes. Also, they don’t feel like they’re strapped down and stuck to the machine all the time.” The quotes illustrate how the midwives viewed the use of traditional skills such as intermittent auscultation as the antithesis of the usual EFM technology favored in routine, hospital labor care. The midwives also commented on the low technology focus of intermittent auscultation and that its use facilitated a more natural approach to birth. “I have worked in a regional referral unit where it was very difficult to do IA [intermittent auscultation], and I felt the midwives had lost sight of what was normal; and that’s actually the reason why I left there to come to a less medical hospital. So, I felt that the midwives were in danger. . . . I might be in danger of losing sight of what’s normal.” Others commented that intermittent auscultation was difficult to implement because active management policies in maternity units are promoted over more conservative approaches to childbirth: “Well, at the moment, it [midwifery care] is getting very interventionist. I mean, we are getting so many inductions. Why? Most of them are only post term, they have no illness, and once you induce them, you are required to use the EFM, they get ARM [artificial rupture of membranes] and often end up with an epidural. How can midwives learn IA and feel confident when this is the norm?” It was evident that the midwives perceived using intermittent auscultation as a technique that promotes a philosophy of normal birth rather than the cascade of intervention associated with EFM. Closeness/Proximity of the Midwife A further positive feature of intermittent auscultation was that it encouraged the close proximity of the midwife to the laboring woman as a direct result of auscultating the abdomen for the required period of time and, in turn, this enhanced the importance of sitting with women. “I think IA brings you closer to them, and it’s just more natural and normal, so it’s less technology that I am in favour of.” Volume 51, No. 5, September/October 2006
This point also helps to illustrate the preferences held by some midwives for a decidedly nonintervention philosophy for women with low-risk pregnancies. Quicker Progress in Labor The midwives held a strong belief system that intermittent auscultation influenced the progress of labor more efficiently than EFM. “Women said . . . ‘I was able to walk around much more this time’ You know, things like that, so they obviously weren’t on the monitor, they felt happy, ‘I used the bean bag,’ ‘I was moving around better.’ They think that’s speeded things up for them, and it probably has.” There was a clearly reported association between intermittent auscultation and efficient progress in labor, which was important for many of the midwives in the study. This was because their collective, clinical experiences demonstrated that inactivity may slow labor and increase the need for interventions to accelerate labor. Paradoxically, the positive features of intermittent auscultation were tempered quite significantly by the midwives’ fears of missing some pathologic event in the fetal heart rate in between auscultation. Electronic Fetal Monitoring It was evident that there was a paradoxical representation of the midwives’ views in relation to the use of EFM. For example, the following categories of 1) oppressive/ restrictive, 2) midwife by proxy, and 3) requirements for pain relief render the impression that the midwives were opposed to EFM. However, in reality, it was difficult for some to relinquish old routines such as electronic monitoring. Oppressive/Restrictive The midwives viewed EFM negatively, and phrases such as “pinned,” “chained,” or “tied to the bed” were used to describe its restrictive/oppressive nature. “I think a lot of the women feel really restricted by monitoring. It also means that as a midwife, your time is taken up with analysing and looking at the machine a lot of the time when you could be giving other support to the woman.” “They are tied to a bed and everything has to be so clinical then.” It is interesting to note that the machine was associated with the connotations of restriction, rather than midwives perceiving themselves as the administrators of the technology that resulted in women being “tied down.” Journal of Midwifery & Women’s Health • www.jmwh.org
Midwife by Proxy The midwives felt that the use of technology in labor had contributed to the feeling that it dehumanized the birth process by distracting the midwife away from communicating with the woman. Midwives reported that EFM had an intrusive effect on their relationships with women and their birth partners. The attention of the midwives was directed away from the woman and from aiding the woman to use her coping strategies in labor. Literally, all of the midwives’ time was taken up by the “surveillance” element involved in the use of EFM. “The machine is the centre of attention. . . . It becomes an obsession. . . . I think a lot of people find it very bare and empty if there’s no machine in the room. They come in and they instantly ask themselves, ‘Where’s the little thing that ticks along?’” Some of the midwives reported that EFM was used in the absence of a midwife during very busy shifts. The midwives freely admitted that sometimes the monitors had been attached to laboring women regardless of their perceived risk status because of staff shortages. Pain Relief The associated effects of different monitoring methods and their influence on pain relief were reported by the midwives. This was often cited as indirect references to maternal position or restricted mobility as factors affecting pain relief. The midwives discussed the influence of EFM on pain relief: “I think, especially with the monitors, they are waiting for the next pain. The focus is on the pain. Certainly, there are more epidurals as opposed to the woman who is labouring in the bath or moving about.” The direct associations made by the midwives on the method of monitoring and type of pain relief offered were a direct result of their own clinical experiences. They had little doubt that pharmacologic methods and epidural analgesia were resorted to earlier and more frequently in those women experiencing EFM. DISCUSSION The majority of pregnancies are perfectly straightforward, but it was evident that many midwives were overreliant on technologic interventions such as electronic monitoring. This study concentrated on women at low obstetric risk, as the midwife in the United Kingdom is the primary caregiver for this specific population during childbirth, and the midwives’ scope of practice is clearly defined in statute.17 In their monograph, Care in Normal Birth, the World Health Organization (WHO) 357
were seminal in defining the criteria for “normal birth” by providing a benchmark for all midwives to follow for levels of appropriate technology in childbirth.18 These factors helped to set the context for the background of our study. Many proponents of the normal model of birth support the process of active birth where a nontechnologic focus toward childbearing is deemed to confer greater benefits than an actively managed birth.19 Despite the continued promotion of a philosophy that supports limited use of technology in childbirth, EFM is an example of a technology used for laboring women that may lead to cascade effects, as described in the seminal work by Mold and Stein.20 This is relevant to our findings because the midwives reported personal experiences of the cascade effects of EFM, yet they still used it despite their espoused allegiance to a normal approach to birth. The findings from our study show how midwives view EFM, and they are aware that the traditional, watchful approach of the midwife has been devalued in favor of routine practices such as EFM. This resonates with the work of Kennedy, in that midwives still use EFM because it is deemed “scientific” and, therefore, more reliable than the midwife’s gaze or touch.21 Despite the negative connotations of EFM and its frequent use, the midwives espoused a philosophy of normal childbirth because it validated their professional ideology for a woman-centered approach to care. Both English and US data cite high rates of continuous EFM, even in women at low obstetric risk.22,23 Intermittent auscultation was particularly valued for facilitating a closer working partnership, thereby positively affecting birth experiences for women. In contrast, the midwives did not think that the use of EFM promoted the midwife’s proximity to the birthing process. Our findings in this respect concur with a previous study by Kennedy and Shannon, who reported that midwives believed in birth as a normal process, and as a consequence, their actions were specifically aimed toward the support of it as a physiologic, rather than pathologic, process.24 As in the study by Kennedy and Shannon, the proximity and continued presence of the midwife with the woman was also a strong indicator of normalcy in our study. The midwives reported that choice of monitoring method was influenced by reduced staffing during busy labor ward shift systems. This meant that in some circumstances, the monitor was used as a midwife by proxy—a substitute for the presence of the midwife who would otherwise use the clinical skills of perception, auscultation, palpation, and communication. Some of the midwives in our study recognized that this was an unacceptable but sometimes unavoidable consequence of a busy labor ward. The use of EFM as a midwife by proxy was also specifically mentioned in expert evidence given to a UK parliamentary select committee on health, 358
which commented on the national shortage of midwives.25 This use has been mentioned as well in articles on EFM from the United States, in reference to nursing shortages.26 However, it is too simplistic to suggest that the overuse of EFM is exclusively associated with reduced staffing levels. For example, it has been reported that the attitudes of professionals are just as important; that is, midwives who trust machines are more disposed to their use.27 In essence, some of the midwives used this as an opportunity to delegate their own professional skills to the machine to determine the progress of labor rather than offer personal support. Engaging on a deep and personal level with women can be physically and emotionally demanding for midwives, and this was recognized by the midwives as an important issue. As a result, some midwives did not always think that they had the emotional energy to divest in the process of sitting with the women. The importance of sitting with women has also been discussed at length by others.24,28 The numerous physical, spiritual, and emotional demands placed on midwives when delivering care in labor are often inextricably linked to the coping strategies of the women themselves. This is particularly the case for the woman’s reaction to pain in labor, and it was often easier for the midwife to “busy” herself with the monitor rather than engage on a deeper, personal level with the woman. This is interesting because the combination of inactivity and anxiety associated with EFM has been associated with an increased need for pain relief.29 EFM is associated with epidural analgesia, and recent statistics show that a third of all obstetric pain relief in the United Kingdom is administered by epidural.30 Hence, the indiscriminate use of EFM as a direct replacement for the one-to-one support of a caring midwife may have a detrimental impact on the woman’s coping strategies. This use of more invasive methods of pain relief has been cited in the literature.31 This study has some limitations. It was undertaken in only two hospitals and in one region of England. However, the profile of practice in these two settings reflects the national standards of midwifery practice, and as such, is an accurate representation of midwifery care in English maternity units. As practitioner researchers, we were also aware that our prior knowledge and preconceptions of midwifery practice may have affected the data collection process. To address this issue, the researchers completed diaries, which helped to maintain the process of reflexivity. Despite the limitations, we believe that the findings are relevant to the conduct of midwifery practice when using intrapartum fetal monitoring in women at low obstetric risk. Ultimately, our study revealed that it requires more than the availability of national guidelines from expert groups and the availability of research to translate best Volume 51, No. 5, September/October 2006
evidence into practice. The reasons why outmoded clinical practices continue are complex and have been discussed previously.32 Some midwives perceived there was a lack of institutional support when implementing intermittent auscultation for women at low obstetric risk. This was not necessarily associated with midwifery management, but rather, more with medical policies and a persistently held belief by many obstetricians that birth is inherently dangerous and should be risk managed.
Future Research
CONCLUSION
REFERENCES
It appears that midwives have positive attitudes toward intermittent auscultation and seem committed to increasing its use. They dislike EFM because of its deleterious effects on labor as the increased vigilance is focused on the machine and not the woman. The paradox is that midwives find it difficult to practice confidently without EFM, and it is doubtful that this dilemma will be resolved as the technology becomes increasingly more sophisticated. Midwifery practice over the last 30 years has undergone a metamorphosis dependent on the prevailing ideology of the time, when the midwife as expert of normal birth became defunct, and the midwife as an instrument for the active management of birth arose. However, blind acceptance of routine EFM technology for all women, regardless of risk, has not resulted in positive contributions for women and their babies. Nobody suggests it is easy for midwives, as there are complex issues influencing their practice, which undoubtedly affect the speed of change. Midwives do genuinely fear abandoning the philosophy of a technology-free birth, but the institutional culture and available resources are mitigating factors affecting the process of implementing care based on best evidence. Practice Implications Where national guidelines on the most appropriate use of EFM are available, it is useful to audit compliance with those guidelines to better implement risk management protocols. Simple strategies such as removing fetal monitors from rooms might also help the midwife to consciously question the need for EFM rather than applying it routinely, merely because it is proximal. The provision of resources for one-to-one midwifery care in labor are crucial in reducing the use of EFM as a midwife by proxy. Debate also needs to continue surrounding the routine use of active management strategies for labor such as the use of oxytocin and epidural analgesia, as guidelines may stipulate the use of EFM when either of these is used. Finally, there needs to be continued debate and discussion on the precise clinical risk indicators for the use of EFM so that midwives share a consensus of what is regarded as normal, and conversely, abnormal. Journal of Midwifery & Women’s Health • www.jmwh.org
It is important to continue to explore the complexity of issues affecting the role of the midwife and the implementation of evidence-based care. Therefore, it would be useful to undertake further research in countries where EFM is used extensively to gain an insight into midwifery attitudes and practice issues that affect the continued use of EFM.
1. Thacker SB, Stroup D, Chang M. Continuous electronic heart rate monitoring for fetal assessment during labor (Cochrane Review). Chichester (UK): The Cochrane Library, 2005(3). 2. Blair E, Stanley F. When can cerebral palsy be prevented? The generation of causal hypotheses by multi-variate analysis of a case control study. Pediatr Perinat Epidemiol 2003;7:272–301. 3. Hindley C. Intrapartum electronic fetal monitoring in lowrisk women: A literature review. J Clin Excel 2001;3:91–9. 4. Royal College of Obstetricians and Gynaecologists. The use of electronic fetal monitoring: The use and interpretation of cardiotocography in intrapartum fetal surveillance (Evidence-Based Clinical Guideline Number 8). London: Royal College of Obstetricians and Gynaecologists, 2001. 5. Young D. The push against vaginal birth. Birth Issues Perinat Care 2003, 30(3):149 –52. 6. Sinclair M. Midwives perceptions of the use of technology in assisting childbirth in Northern Ireland. J Adv Nurs 2001;36: 229 –31. 7. Rogers J. Midwife alone. Br J Midwifery 2003;11:112–5. 8. Lange G, Kennedy HP. Student perceptions of ideal and actual midwifery practice. J Midwifery Womens Health 2005;51: 71–7. 9. Department of Health. The NHS plan: A plan for investment a plan for reform. London: The Stationary Office, 2000. 10. Hinsliff S, Hindley C, Thomson AM. A survey of regional guidelines for intrapartum electronic fetal monitoring in women at low obstetric risk. Midwifery 2004;20:345–57. 11. Hindley C, Hinsliff SW, Thomson AM. Developing a tool to appraise fetal monitoring guidelines for women at low obstetric risk J Adv Nurs 2005;52:307–14. 12. Rubin HJ, Rubin R. Qualitative interviewing: The art of hearing data, 2nd edition. Thousand Oaks (CA): Sage Publishers, 2005. 13. Aronson J. A pragmatic view of thematic analysis. Qual Rep 1994;2:1– 4. 14. Ritchie J, Spencer L. Qualitative data analysis for applied policy research. In Bryman A, Burgess RD, eds. Analyzing qualitative data. London: Sage, 1994. 15. Thorne S. Data analysis in qualitative research. Evid Based Nurs 2000;3:68 –70. 16. Hindley C, Thomson AM. The rhetoric of informed choice: Perspectives from midwives on intrapartum fetal heart rate monitoring. Health Expect 2005;8:306 –14.
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17. Nursing and Midwifery Council. Midwives rules and standards 05.04. London: Nursing and Midwifery Council, 2004. 18. World Health Organisation Report. Care in normal birth: A practical guide. Geneva: World Health Organization, 1997. 19. Hunter LP. Being with woman: A guiding concept for the care of laboring women. J Obstet Gynecol Neonatal Nurs 2002; 31:650 –7. 20. Mold JW, Stein HF. The cascade effect in the clinical care of patients. N Engl J Med 1986;314:512– 4. 21. Kennedy HP. The landscape of midwifery care: A narrative study of midwifery practice. J Midwifery Womens Health 2004; 49:14 –23. 22. Williams FLR, Florey C du V, Ogston SA, et al. UK study of intrapartum care for low risk primigravidas: A survey of interventions. J Epidemiol Community Health 1998;52:494 –500. 23. Maternity Center Association. Recommendations from listening to mothers: The first national US survey of women’s childbearing experiences. Birth 2004;31:61–5. 24. Kennedy HP, Shannon MT. Keeping birth normal: Research findings on midwifery care during childbirth. J Obstet Gynecol Neonatal Nurs 2004;33:554 – 60. 25. The United Kingdom Parliament Select Committee on Health (Written Evidence). Appendix 44, memo by action for
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victims of medical accidents (MS S3) 3:10; Use and interpretation of electronic fetal monitoring. London: The Stationary Office, 2003. 26. Parer JTP, King T. Fetal heart rate monitoring: Is it salvageable? Am J Obstet Gynecol 2000;182:982–7. 27. Jackson DJ, Lang JM, Swartz WH, Ganiats TG, Fullerton J, Ecker J, Nguyen U. Outcomes, safety, and resource utilization in a collaborative care birth center program compared with traditional physician-based perinatal care. Am J Public Health 2003;93:999 – 1006. 28. Davis-Floyd RE. The technocratic, humanistic, and holistic paradigms of childbirth. Int J Gynecol Obstet 2001;75(suppl 1): S5–S23. 29. Hodnett ED. Pain and women’s satisfaction with the experience of childbirth: A systematic review. Am J Obstet Gynecol 2002;186(suppl):S160 –S72. 30. Department of Health: Statistical bulletin, NHS maternity statistics, England: 2003–2004. London: The Stationary Office, 2005. 31. Goodman P, Mackey MC, Tavakoli AS. Factors relating to childbirth satisfaction. J Adv Nurs 2003;46:212–9. 32. Retsas A. Barriers to using research evidence in nursing practice. J Adv Nurs 2000;31:599 – 606.
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