Fetal monitoring — midwifery attitudes

Fetal monitoringmidwifery attitudes Susan L. Dover and Susan M. Gauge

Objective: to survey midwives' attitudes

Susan L. Dover BAppSci, RM, ADM, PGCEA, Midwife Teacher, Birmingham and Solihull College of Nursing and Midwifery, Thorne House College Centre, I 13- I 15, Anderton Park Road, Moseley, Birmingham. BI3 9DQ, UK Susan M. Gauge RN, RM, ONC, ADM, Clinical Midwife Education and Professional Development, Birmingham Maternity Hospital, Birmingham, UK

(Requests for offprints to SLD) Manuscript accepted 15 December 1994

and practices related to intrapartum fetal monitoring. Design: descriptive correlational study. Setting: regional and district maternity unit and related community area within one health authority. Participants: all midwives were invited to participate. Two hundred and forty two questionnaires were administered and I 17 were returned (48% response rate). Measurements and findings: in the questionnaire information was collected on professional/demographic details, education and practices related to intrapartum fetal monitoring, together with a 20-item attitude scale which encompassed attitudes towards fetal monitoring and related issues. As expected, the findings suggest that midwives' preferred methods of fetal monitoring varied with the client's risk category. However, midwife preference did not necessarily match actual choice of method. There are many factors influencing choice, not least of which is confidence in ability. Significant differences were found between midwives. Key conclusions and implications for practice: the findings highlight some of the issues relating to individual confidence. 97% of the midwives felt they would benefit from in-service training in CTG interpretation. The findings support the development of continuing in service education programmes for midwives.

INTRODUCTION In the Western world, continuous electronic fetal heart rate (FHR) monitoring is currently the most widely used technique for assessing

Midwifery (1995) I I, 18-27 © 1995PearsonProfessionalLtd

fetal status during labour (Quirk & Miller 1986). The first commercially produced electronic fetal monitor became available in 1968. Since then, further technological advances have resulted in highly sophisticated monitors being commonly used in clinical practice. Unfortunately, continuous electronic F H R monitoring has not lived up to early hopes and expectations. Unequivocal classification of normal and abnormal F H R patterns have not evolved. This failing is said to be not so much the fault o f the equipment, but rather a reflection on the abilities of the users (Gibb & Arulkumaran 1992). Early detection of fetal distress via continuous electronic F H R monitoring was seen as an important development in the reduction of perinatal mortality and morbidity (Anthony & Levene 1990). However, other factors which may have contributed, such as improved antenatal and neonatal intensive care, were not taken into account (Prentice & Lind 1987). The largest randomised controlled trial ofintrapartum fetal monitoring to date, showed no statistical difference in outcome o f those low risk fetuses monitored continuously (electronically) during labour, compared with those monitored by intermittent auscultation. (MacDonald et al 1985). Analysis of the fetal heart recording (CTG) is open to differing interpretations. For example, in some cases it can lead to actions not being taken when indicated; alternatively, it can lead to interventions occurring when not necessary (Grant 1989). This variation in interpretation could have affected the findings of many studies (Grant 1989). Despite its well documented limitations (MacDonald et al 1985, Howie 1986, Prentice & Lind 1987), continuous electronic F H R monitoring has become an accepted routine component ofintrapartum care (Neilson 1993). For some women problems occur during pregnancy and labour placing them in a high obstetric risk category. However, for the majority childbirth is a normal physiological event, not requiring intervention. Nevertheless, interventions such as internal electronic fetal heart monitoring do occur during labour, without obvious indications. Although there is no conclusive evidence from controlled trials that it is beneficial this practice has been introduced (Holmes-Syndal 1988, Colditz & Henderson-Smart 1990). Midwives and women have repeatedly expressed their concerns about routine electronic F H R monitoring (Garcia et al 1985, Cooke 1992, Evans 1992, Miller 1993). Concerns about continuous electronic F H R monitoring have not been confined to its efficacy as a screening method. Other aspects

Fetal monitoring- midwiferyattitudes 19 which have been studied include its effect on maternal psychological parameters such as satisfaction, control and anxiety (Hodnett 1982, Jackson et al 1983, Morgan et al 1984, Jacoby 1987). The reviewed literature concerned with the psychological effects of continuous electronic (FHR) monitoring has been equivocal about its positive and negative impact. Contributing factors such as expectations (midwives and women), staffbehaviour, the degree of preparation and explanation, and locus o f control have all been highlighted. It appears that the support women in labour receive from staff or companions is more important than the method of fetal monitoring (Garcia et al 1985). Midwives are the professionals with w h o m w o m e n have the most contact throughout pregnancy. As such, they are best placed to assist women in reaching decisions regarding the care and management they will receive during the antenatal, intranatal and postnatal periods (UKCC1994). This includes the method of fetal monitoring during labour. T h e assertion that midwives are autonomous, independent practitioners is not new (Mander 1993), nor is the exhortation that midwives are experts in the field o f normal midwifery (Flint 1986). Maintaining traditional skills such as intermittent auscultation of the fetal heart (using Pinards fetal stethoscope or its electronic equivalent) is desirable and achievable, although concerns have been voiced that midwives using this method may not be capable of monitoring women in labour who are at low obstetric risk (Hillan 1991, MurphyBlack 1991). Research evidence supports the use of intermittent auscultation as a reliable method of monitoring the fetal heart when caring for women at low obstetric risk (Enkin et al 1989). This conclusion does not appear to be supported in clinical practice. Increasingly, placement evaluations from student midwives (who gain their experience in the hospitals participating in the survey) reflect their anxieties that they have never cared for a woman in labour who was not continuously electronically monitored. The majority professed to being completely inexperienced in the use of intermittent auscultation as a means of fetal heart monitoring. An examination of the participating regional maternity unit's statistics revealed that for the year ending 31 March 1993, 83% of women were continuously electronically monitored during their labour. O f these women, 48% were monitored using fetal scalp electrode. Concerns relating to methods of FHR. monitoring and cardiotocograph (CTG) interpretation are not confined to student midwives. Anxieties about trace interpretation were commonly expressed by the recently

qualified midwives at their support group meetings. More experienced midwives rotating back to the delivery suite also appeared keen to update their skills. The activities o f a midwife are clearly defined in the European Community Midwives Directive (80/155/EEC Article 4), and are included in the Midwife's Code of Practice ( U K C C 1994. p4-6). Activity 5.5. reads: To care for and assist the mother during labour, and to monitor the condition o f the fetus in utero by the appropriate clinical and technical means. A number of questions arise from the literature and current clinical midwifery practice and training reports. For example, are midwives prepared and indeed skilled to care for women in labour at low obstetric risk by intermittently auscultating the FH1K? Or do we have a situation where under evaluated technology has replaced what used to be a basic skill (Hillan 1991, Murphy-Black 1991)? Have midwives become so dependent upon FH1K monitors that their skills in auscultation of the fetal heart with Pinards stethoscope have been lost (Cooke 1992)? Since monitoring the fetal condition is fundamental to midwifery practice, it is worrying that a number of midwives may be feeling less than confident in this area. These issues have obvious implications for education and training. This survey was undertaken to find out how midwives carried out intrapartum fetal heart rate monitoring.

METHODS The purpose of the study was exploratory and broadly three-fold: 1. What were the midwives' preferred methods of fetal monitoring? 2. What factors influenced midwives' choice of methods? 3. What are the educational implications?

Sample and setting Because midwifery students gained their clinical experience in different hospitals, the study was designed to sample all midwives working at the regional maternity unit, the district maternity unit, and the related community district. T w o maternity units and the related c o m m u nity district within the same health authority were sampled. Unit One is a teaching hospital and regional referral centre with approximately 4800 deliveries per annum. The unit covers a

20 Midwifery wide area and takes 'bookings' from within the region. The following are available: 95 obstetric beds; 10 transitional care beds; 20 beds in delivery suite and 32 neonatal cots. The client group served is approximately 70% Caucasian and 30% Asian, Afro-Caribbean and other ethnic groups with a mixed social group. Unit Two is a smaller unit with approximately 2500 deliveries per annum, a significant proportion being women at low obstetric risk. The client group is approximately 60% Asian and Afro-Caribbean, the Asian population being more dominant, 40% Caucasian, with a mixed social group. The following are available: 53 obstetric beds; 10 beds in delivery suite and 18 special care baby unit cots. The community district served both maternity units. Midwives work in geographical teams and are required to update their hospital based experience on an annual basis. Since completion of the study, Unit T w o has closed. A descriptive correlational study using a questionnaire was designed to collect the data. The questionnaire was modified and finally developed after expert review by ten senior midwives, most o f w h o m were midwife teachers. A number of them were experienced in the research process and offered valuable criticism. A psychologist with a strong research background and a statistician also guided the development o f the questionnaire. Pilot testing of the questionnaire with a random sample of midwives also provided invaluable feedback and necessary changes were made as a result. The questionnaire was finally administered with what was felt to be a much improved face and content validity. The questionnaire was divided into three parts. In Section A information on professional and demographic details was collected. This section was completed by the respondents ticking the appropriate boxes. In Section B information related to F H R monitoring was collected. The respondents were asked to describe any formal/informal training they had received in C T G interpretation. They were then requested to acknowledge which of the described guidelines most resembled their unit's policy/guidelines in practice. The extent to which they agreed or disagreed with their unit's policy/guidelines was also asked. This section concluded with the midwives being asked to place in rank order their preferred methods o f monitoring women at low obstetric risk and women at high obstetric risk. Confidence in each method's accuracy was then scored on a five point ordinal scale. N o differentiation was made between the first and second stages o f labour. Section C was designed to collect relevant information about midwives' attitudes towards fetal monitoring in general,

and related issues concerned with midwifery practice, and educational preparation for practice. This section was included because it was necessary to attempt to identify factors which might be related to differences in midwifery practice, as well as simply describing those differences. A 20-item Likert type attitude scale was finally developed after item analysis (Fig. 1). Due to researcher error the test-retest reliability o f items was not completed prior to administering the finalised questionnaire. Seven discriminating statements were included with 13 others which had not been found to be discriminating, but were felt to be useful for audit purposes. It was felt possible that midwives, answering with professionally desirable responses, may have resulted in some items being found to be non-discriminating. They were included because it was felt that self disclosure might be more forthcoming if the questionnaire was administered to a larger sample. Positive and negative statements were included and each scored on a five point scale - strongly agree to strongly disagree. The scoring of the scale was arranged so that the higher the total score, the more positive the attitude generally to practice. Permission to undertake the study was obtained from the relevant senior midwifery management. Local Research Ethics Committee approval was not considered to be necessary. A personally addressed envelope containing the unmarked questionnaire and covering explanatory letter was left for each midwife in her clinical area. Participation in the study was voluntary and anonymous. C o m pleted questionnaires were left in designated places in each clinical area, and collected at regular intervals by the researchers. Follow-up by personal visit and telephone calls to clinical areas helped to maintain interest in the study. Final collection of the questionnaires took place 6 weeks after the original administration. Data were processed by computer using the Statistical Package for the Social Sciences (SPSS). A statistician undertook the data analysis which included frequencies, cross tabulation, correlation, chi square, t-test and analysis of variance (ANOVA). A total o f 242 questionnaires were administered in the following proportions: regional maternity u n i t - 135; district maternity unit 58; community - 49.

FINDINGS O f the 242 questionnaires distributed, 117 were returned in the following proportions: regional maternity unit - 62 (46%); district

Fetal m o n i t o r i n g -

m i d w i f e r y attitudes

21

I. Pregnancy and childbirth should only be considered normal in retrospect. 2. I feel prepared to assume complete responsibility for women at low obstetric risk in normal labour. 3. As a student midwife I ought to have had more classroom input on FHR monitoring. 4. I do not feel research findings influence my preferred method of intrapartum fetal monitoring for women at low obstetric risk. 5. When staffing levels are poor, I feel the method of FHR monitoring chosen is more likely to be continuous electronic, 6. I do not feel I am capable of deciding the most appropriate method of intrapartum FHR monitoring. 7. I believe continuous electronic FHR monitoring is safer than intermittent auscultation. 8. I do not feel that the increase in awareness re litigation should influence the policies determining the methods of FHR monitoring in labour. 9. I feel my midwifery training adequately prepared me theoretically to assume complete responsibility for women at low obstetric risk in normal labour. I 0. All women in labour should be considered high risk. I I. I feel confident to monitor women at low obstetric risk using intermittent auscultation of FHR as my main method. 12. I do not feel my midwifery training adequately prepared me practically to assume complete responsibility for women at low obstetric risk in normal labour. 13. I feel I was adequately prepared by my midwifery training to competently monitor FHR using all the available methods. 14.

feel my midwifery practice is negatively influenced by my concerns about litigation.

15.

do not feel confident interpreting CTG traces.

16.

do not believe continuous electronic FHR monitoring is more reliable than intermittent auscultation.

17.

feel midwives would benefit from in-service training in the interpretation of CTGs.

I B. 19.

enjoy being totally responsible for the low obstetric risk women I care for in labour. am influenced by the mother's preferences when deciding the appropriate method of FHR monitoring in labour.

20. Modern methods of fetal monitoring are not always the best. Fig. I Attitude scale items (1-20).

maternity unit - 34 (59%); community - 21 (43%). The overall response rate was 48%.

Sample characteristics There were equal numbers of E and F grade midwives, more G grades, and a few H grades. The majority o f midwiyes worked full-time, and had completed an 18-month training. Length of experience ranged from less than 1 year to more than 21 years, with the majority having six or more years of clinical experience (Table 1). 73% (n = 86) of the respondents were in the 25-40 age group. The greater proportion of midwives (73%, n = 85) had past delivery suite experience and 51 (43%) were presently allocated to this area. Less than half (36%, n = 42) the midwives either had, or were, studying for some sort of relevant continuing education qualification. An equivalent number were planning to study, or were wanting to study (36%, n = 42). The remainder either had no continuing education qualifications or had no intentions to proceed to further study (28%, n = 33) (Table 2).

Intrapartum fetal monitoring opinions and practice In Section B of the questionnaire information

about midwifery practice related to FH1K monitoring was collected. O f the respondents, 52% (n = 61) indicated that apart from their midwifery education course, they had received no instruction in methods of fetal monitoring, either formally or informally. More specifically, 59% (n = 69) of the sample had not received

N

%

Clinical Grade E F G H

35 35 43 4

30 30 37 3

Length of course Part I and 2 12 months I B months 3 years

25 25 65 2

2I 2I 56 2

75 42

64 36

3 14 21 34 30 12

3 12 18 29 26 II

Type of work Full-time Part-time

Lengthof experience Less than I year Between I and 2 years Between 3 and 5 years Between 6 and I 0 years Between I I and 20 years Over 21 years

22

Midwifery

!i!i!i~i~i~i~i~i~i!iiiiiiiiii:i:i:i:i:i:i:i:i:i:i:i:i:!:~:!:~:i:i:~:i:i:~:~:~:~:~:~:~:~:~:~:~:~:~:!:!:!:!:!:i:!:!::!:!:!:~:!:!:!:!81:~:~:i:i:i:i:i:i:i:i:i:i:i:i:i:i:i:!:i:~:i:!:T:~:!:~:~:~::::::::::::::::::::::::::::!:! midwives'

Yes - undertaken No - but plan to/would like to No No - a n d no intention to Unknown/blank

N

%

42 42 20 II 2

36 36 17 9 2

N

Midwives discretion completely Obstetricians discretion completely Baseline CTG on admission, then regular intermittent CTG during labour Continuous electronic FHR monitoring for all women in labour Continuous electronic FHR monitoring for women at high obstetric risk, otherwise midwives' discretion Baseline CTG on admission, then intermittent auscultation unless otherwise indicated Other combination of above Blank/not mentioned

personal beliefs about what constituted the policy. The accuracy o f their belief was not verified. W h e n monitoring w o m e n at high obstetric risk, 55% (n = 64) ranked continuous internal electronic F H R monitoring as their first choice; 56% (n = 66) ranked continuous external electronic F H R as their second choice; 73% (n = 86) chose intermittent external electronic F H R as their third choice and 84% (n = 98) ranked intermittent auscultation as their fourth choice o f method (Table 4). W h e n indicating preferences for w o m e n designated to be at low obstetric risk, 55% (n = 64) chose intermittent auscultation as their first choice. Second choice was intermittent external electronic F H R monitoring (55%) (n = 64). 72% (n = 84) chose continuous external monitoring as their third choice and the fourth choice was continuous internal electronic monitoring (79%, n = 93) (Table 4). The final question in this section asked midwives to score, on a five point scale, their level o f confidence in each method's ability to m o n itor the fetal heart accurately (Table 5).

%

4 I

3 I

26

22

9

8

57

49

8 5 7

7 4 6

Attitudes

any formal (organised) education in C T G interpretation. In the response to the question asking midwives to indicate the intrapartum fetal monitoring policy most closely resembling their unit's in practice (Table 3), 49% (n = 57) chose continuous electronic F H R monitoring for w o m e n designated to be at high obstetric risk, otherwise midwives' discretion. This choice accurately reflected the policy at the time. The next question asked midwives if they agreed with their unit's policy. 62% o f the sample agreed (n = 72), 22% (n = 26) were undecided, 9% (n = 11) disagreed and 7% (n = 8) did not answer. This response reflected the

to practice

The 20-item attitude scale had a maximum possible score o f 100, a possible m i n i m u m o f 20 and a true mean o f 60. The sample mean was 72.9 and the standard deviation was 9.9. There were no significant differences in mean scores between units. The seven discriminating items were also inspected separately. The maximum score for these items was 35, and the m i n i m u m seven (true mean = 21). The sample mean was 22.58 with a standard deviation o f 4. Throughout the data analysis, the attitude score findings for the complete, 20-item scale, were consistently reflected in the scores o f the seven discriminating items (identified after item analysis during development o f the question-

{i i{N ii !ii i i !i !i ii !iiii!!!i!!i!iiiiiii!!iiiiiiiii!i!iiiii!i!iiiiiiiiiiiiiiiiiiiiii iiiiiiiiiiiiiiiiiiiii i i iii i iiii{ii!iii!i!iiiiiii i!i i i!iii iiiii i iiiiiiii iiiiiiiiiii i i iiiii iiiii i %

I st

No

%

2nd

No

%

3rd

No

%

4th

No

Blank % No

Women who are considered high obstetric risk Continuous internal electronic Continuous external electronic Intermittent external electronic Intermittent auscultation

55 35 5 I

64 41 6 I

28 56 5 0

33 66 6 0

8 I 73 2

9 I 86 3

I I 3 84

I I 3 98

8 7 14 13

10 8 16 15

Women who are considered low obstetric risk Continuous internal electronic Continuous external electronic Intermittent external electronic Intermittent auscultation

2 4 37 55

2 5 44 64

I 8 55 25

I 9 64 30

4 72 I 8

5 84 I 9

79 2 I 4

93 3 I 5

14 14 6 8

16 16 7 9

Fetal monitoring- midwifery attitudes

23

iiiiiii ii i i i i!ii iii i i i !i !iiiiiiiiiiiiii!iiiiiiiiiiiiiii i i i iii iiiii iiiiiiiiii!iiiiiiiiiiiiii!iii!iiiiiii i i iii i i i i iiii!ii!iiiiiiiiiiiiiiii i!iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiili i i i i i!iiiii!i!!!i iii!i!i!iiiii!i!iiiiiiiiiiii!iiiiiiiiiiiii ili i ili !i!i i i ii!iiiiiiiiii i !i i i iiiiii!iiiiii!i!iii ililili i i i i i li!i i i!i i i i i i i

:::::::::::::::::::::::::::::::: :::::::::::::::::::::: :::::::::::::::::::::: ~i~:::::::::::::::::::::::::::::::: :~i :::::::::::::::::::::::::::::::::::: :::::::::::::::::::::::::::::::::::::::::::::::::::::::: :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: :::::::::::::::::::::::::: ~:~!:::.:::.!ii::ii ::i::i::::.i:.:ii:.:~ili~z:i:~~:i:~:.)i:i~: ~:~:i::i:: ::~if:.i:::::::::::::::::::::::::::::::::::::::::::::::::: ::.:: ii:.::!!~;i)::i:;~i ~:i~::~~i:~~::i:: i:~~::i::i:: ii~::i:i:::!:.!::#i::!i .~:.~:.i:#~:~i.~~i;:.~ :.~i~~:.i~i:.i~~i~i~ii~i!~! ii!i!i! ii!i!::!::! !::i~:.:i~:.~:.~U~i:;~: ~:.~~:. i~il~i::..i~ili~i~ii!:. i~i!!:.!!:i:. !:.!!i!:.i :.i:.~:.~:~:.~i~~i!~i:.~!:.~i !:.~~:.~:.~i~:.i~~ii~i~~!~!iii! i i!i!i! i!:.!~::.:.!.~!:.i:.i I % Intermittent auscultation Intermittent external electronic Continuous external electronic Continuous internal electronic Scale -

I

=

not all confident - - 5

2 No

0 I I I =

3

4

5

%

No

%

No

%

No

%

No

%

14 0 0 0

16 0 0 0

33 28 I0 3

38 32 12 4

30 45 51 40

35 53 59 47

20 23 35 52

24 27 41 60

3 3 3 4

Blank No 4 4 4 5

very confident

naire). T h e discrimination o f the attitude scale was further checked by calculating t-test for scores on each o f the 20 items for groups o f respondents whose total attitude scores fell into the highest and lowest quartile o f the distribution. This analysis revealed that 17 items did discriminate, and three items did not discriminate. As a result, the findings presented relating to attitude score are those o f the 2 0 - i t e m scale. C r o n b a c h ' s alpha and Guttman's split-half reliability coefficient were calculated on the sample's attitude score data. For all 20 items, Guttman's split-half coefficient equalled 0.716 and C r o n b a c h ' s alpha coefficient equalled 0.635. Certain individual statements within the attitude scale elicited strong responses. 72% (n = 84) o f the sample agreed or strongly agreed that the m e t h o d o f F H R m o n i t o r i n g chosen was more likely to be continuous electronic w h e n staffing levels were poor. 92% (n = 108) o f midwives felt they were capable o f deciding the most appropriate m e t h o d o f fetal m o n i t o r ing. W h e n asked if they were confident to m o n i t o r w o m e n at low obstetric risk using intermittent auscultation o f F H R as their main method, 85% (n = 100) responded positively. The majority (76%, n = 89) felt adequately prepared by their midwifery education to assume complete responsibility for w o m e n at low obstetric risk in normal labour. This figure increased to 92% (n = 108) for current enjoyment o f complete responsibility for practice. 72% o f midwives (n = 84) felt confident interpreting C T G traces. W h e n asked if midwives w o u l d benefit from in-service education in C T G interpretation, 97% (n = 113) o f the m i d wives agreed or strongly agreed.

Inter-relating

factors

Significant (but not unexpected) correlations were found b e t w e e n certain items m a k i n g up the attitude score. Midwives w h o believed childbirth to be prospectively normal, and that w o m e n in labour should not be routinely c o n sidered at high obstetric risk, did not agree that continuous electronic F H R m o n i t o r i n g was a

safer m e t h o d than intermittent auscultation ( r = 0 . 3 1 0 7 , p = 0 . 0 0 1 ) . T h e y were also confident to m o n i t o r w o m e n at l o w obstetric risk using intermittent auscultation as their main m e t h o d (r = 0.2391, p < 0.05). Items relating to confidence in ability, willingness to assume responsibility and e n j o y m e n t o f responsibility also correlated ( r = 0 . 2 9 3 6 , p = 0 . 0 0 1 , and r = 0.2263, p < 0.05). Place o f w o r k figured significantly for a n u m b e r o f variables. Midwives w o r k i n g at the regional maternity unit were significantly more likely to choose continuous internal electronic F H R m o n i t o r i n g as their first choice for m o n i toring w o m e n at high obstetric risk c o m p a r e d with midwives w o r k i n g at the district unit or in the c o m m u n i t y (F(2,104)=7.8989, p < 0 . 0 5 ) . C o n t i n u o u s external electronic F H R m o n i t o r ing was the preferred m e t h o d for midwives at the district unit, whereas it was second choice for midwives at the regional unit (F(2,106)= 4.3115, p < 0.05). Midwives w o r k i n g in the c o m m u n i t y scored themselves as less confident interpreting C T G traces than those midwives w o r k i n g at the regional unit (F(2,112) = 3.307, p < 0.05). Confidence in C T G interpretation was also less in those midwives w h o had not undertaken any form o f continuing education since qualification and w h o had no intention o f doing so (F(3,110) = 4.4906, p < 0.05). L o w e r attitude scores were achieved by midwives w h o ranked continuous internal electronic F H R m o n i t o r i n g as their first choice o f m e t h o d for w o m e n at high obstetric risk (F(3,103) =5.5507, p < 0.05). W h e n m o n i t o r i n g w o m e n at low obstetric risk, midwives w h o chose intermittent auscultation as their first or second choice achieved higher attitude scores than those w h o ranked the m e t h o d as third or fourth choice (F(3,104)=4.6913, p < 0 . 0 5 ) . H i g h e r attitude scores were also achieved by the midwives w h o felt they were confident or very confident using this m e t h o d , c o m p a r e d with those w h o were not (F(3,109)=6.5312, p < 0.05). Length o f education course p r o v e d significant with regard both to beliefs about the normality o f

24 Midwifery pregnancy and childbirth, and whether adequate preparation for the care of women in labour had been provided. Midwives who had undertaken an 18-month course were more positive in the belief that pregnancy and childbirth were prospectively normal (F(3,108) =3.9668, p < 0.05). However, those midwives who had undertaken a 12-month or part 1 and 2 course felt better practically prepared by the course to assume complete responsibility for the care of women at low obstetric risk (F(3,111)= 4.9834, p < 0.05). Significant differences were found between midwives who worked full-time and those who worked part-time. Midwives working part-time held fewer continuing education qualifications and had less intention o f further study ()~2=13.605, df=3, p<0.01). Part-time midwives were also less likely than their full-time colleagues to have received any instruction in fetal monitoring methods (X2=4.962, d f = l , p<0.05). They were also significantly less confident monitoring the fetal heart using Pinards or Sonicaid than those midwives working full time (Z2=11.892, df=3, p < 0.01). Significant relationships were found between items relating to fetal monitoring in the attitude scale and midwives preferred choice of, and confidence, in methods. Midwives who preferred to use continuous internal electronic monitoring were more likely to believe that continuous electronic monitoring was a safer and more reliable method than intermittent auscultation (F(3,103)=6.7622, p<0.05) and (F(3,103)= 7.8135, p < 0.05). Midwives who preferred to use intermittent auscultation for monitoring women at low obstetric risk O) and who were confident doing so (2), were less likely to believe that continuous electronic monitoring was a safer or more reliable (3)method (1.F(3,104)=4.1760; 2.F(3,109) =5.4856; 3.F(3,109)=6.1342, all at p<0.05). Midwives who ranked intermittent auscultation first as their preferred method for monitoring women at low obstetric risk were significantly more confident using the method than those who ranked it second, third or fourth choice. Midwives who ranked it as their second choice were also more confident than colleagues who ranked it their third or fourth choice (F(3,104) = 12.3579, p < 0.05). Those midwives ranking intermittent auscultation first or second choice were also significantly more positive in their enjoyment o f being responsible for care (F(3,104)= 6.6032, p<0.05). Midwives very confident in this method also felt more capable of deciding the most appropriate method ofintrapartum monitoring (F(3,109)=13.3215, p < 0.05).

DISCUSSION O f the 242 questionnaires distributed 117 were returned, an overall response rate of 48%. The return was somewhat disappointing in view of the follow-up, but perhaps reflective o f a generally low morale at that time. The district maternity unit was due to close and major changes were taking place in each of the units sampled. However, it is interesting to note that the most returns were received from the midwives working in the unit about to close. The low response rate makes it unwise to generalise the findings to all the midwives currently working in the units which were sampled. However, enough information was obtained to answer the research questions with reference to the respondents. It is not unreasonable to suppose that the findings are illustrative. The attitude scale developed and used in the survey is moderately reliable and as such, probably sufficient for making group-level comparison, 'The more homogenous the sample, the lower the reliability coefficient will be' (Polit & Hungler 1991, p374). There is a school of thought, however, which believes that highly reliable tests only measure a narrow variable of little variance (Kline 1986). The scale developed for the survey attempted to encompass attitudes to childbirth, midwifery education and midwifery practice. As such, the scale probably incorporated concepts which should have been measured separately. As expected, midwives' preferred methods ofintrapartum fetal monitoring varied with the woman's risk category. The majority of midwives preferred continuous electronic monitoring (internal or external) to monitor women designated to be at high obstetric risk. This is an expected finding, but some interesting details have emerged in relation to these data. Midwives who ranked continuous internal electronic monitoring as their first choice tended tO be those working at the regional unit. Even though the attitude scores were generally high, these midwives' scores were lower than those of their colleagues. Regional units, by nature of their purpose, care for a large number of high risk women. It is not surprising to find that those midwives more involved with caring for women at high obstetric risk are more likely to prefer a method viewed as more consistently reliable. What is interesting is the apparent willingness of the same groups of midwives to forego continuous electronic monitoring when caring for women at low obstetric risk. The majority of midwives chose intermittent auscultation or intermittent external electronic monitoring for this category of women.

Fetal monitoring- midwifery attitudes As one would expect, these midwives achieved higher attitude scores than their colleagues. Apart from overall attitude scores, however, there few other significant relationships found for this variable. There was nothing to suggest that these midwives worked in a different unit, were a different age group or had received a different education. W h y then, when most of the midwives acknowledged a unit policy that either allows midwife discretion, or at least baseline and intermittent C T G during labour, were the majority (83%) of women at the regional unit, continuously electronically m o n itored? Regional units also provide intrapartum care for a large number o f women at low obstetric risk. It would seem that the willingness demonstrated to monitor these women via a less invasive method for some reason does not actually extend to practice. In her study o f midwives and the factors influencing their decision to rupture the membranes, Henderson (1984) highlighted the differences between written and unwritten policy. The importance o f the hidden agenda should not be overlooked, especially when it appears to be generated from a more powerful position than one's own. In her article describing midwives' attitudes to research Hicks (1993) also discusses the discrepancy between private opinion and public practice. She raises several points which are equally relevant to midwives' attitudes to fetal monitoring. The first is that questions can be answered by midwives as they desire them to be. That is, responses may be biased by 'social and professional desirability factors rather than real, privately-held views...' (Hicks 1993, p58). Secondly, organisational/structural inhibitors may result in environmental constraints which account for the attitude/behaviour discrepancy. One of the difficulties of attributing meaning to some of our findings is the inability to interpret findings in relationship to accurate clinical statistics. It was not easy obtaining information about fetal monitoring methods for intrapartum w o m e n at both the regional and district units. This was not because o f a lack of willingness by either unit representative(s) to provide the information, but rather because of problems accessing the information. The district unit did not keep collated contemporaneous records o f their intrapartum monitoring methods, and 'patient' records were not transferred on to a computer database. Time limitations precluded a manual search. Anecdotal information, obtained through general discussion, suggested that the minority of w o m e n were continuously electronically monitored. Tills is in keeping with the midwives' rank ordering of preferred methods and the unit's

25

remit of providing care for women at low obstetric risk in the majority. However, it has already been highlighted that actual behaviour may not match attitudes relating to that behaviour. The lack of available information about intrapartum monitoring methods implies a possible shortcoming with regard to audit o f related midwifery and obstetric practice. It was possible to identify the proportion of w o m e n who were continuously electronically monitored in labour from the regional unit's computer database. Unfortunately, this information was not able to be cross tabulated with the risk category of the w o m e n monitored. N o r was it possible to isolate events which may have affected the monitoring decision. Again, time constraints made it impossible to screen individual's records. So although it is possible for midwives at the regional unit to obtain collated information about intrapartum practices generally, it requires more effort to be able to ascribe meaning to the available statistics. This difficulty has been previously identified: 'The possession of a computerised obstetric data base is not an automatic entry to effective audit' (Barron 1991 p.1065). If the quality of health care can be assessed by providers, purchasers and consumers then whatever system developed to judge such quality, needs to consider all three viewpoints (Paterson et al 1991). If midwives are to audit their practice efficiently and effectively, information systems must be user-friendly. However, midwives must be better prepared to utilise what is readily available. Audit of midwifery care should be ongoing and so much a part of professional practice as to be difficult to separate from it. The information obtained from audit could support our efforts to be better recognised and rewarded as autonomous, accountable practitioners. Downe (1994) describes the successful development of a maternity audit project led by midwives. Improvements in service have followed. It seems reasonable to suppose that purchasers might be influenced by desirable results. Clinical audit is certainly an area which requires care and attention, especially in light o f the Cumberlege Report (Doll 1993). It is important that data relevant to audit o f midwifery practice(s) do not become unrecognisable within whichever information system is used. A number of factors influencing practice clearly emerged from the data analysis. Place of work, and consequently associated policies and philosophies of care in relation to client groups, will clearly have an effect on the attitudes and professional behaviour of midwives. One o f the most influential factors affecting choice o f monitoring method is confidence.

26

Midwifery That is, confidence in one's own ability to choose the appropriate method, to use the method, and to support the choice of method. Confidence in the equipment being used is also an important factor. A number of midwives qualified their ranking of methods with comments referring to equipment reliability. Many expressed dissatisfaction with the available monitors, citing poor trace quality as a reason for progressing on to internal electronic from external electronic monitoring. Equipment failure should not be the cause of more invasive methods needing to be used. Confidence in practice can be either boosted or undermined by managers .and medical staff who exert their own influences on midwifery practice (Henderson 1984). Proof of monitoring in the form of a C T G printout appears to be an important requirement for many midwives. Whether for their own benefit or as a requirement of the unit in which they work, it suggests a lack of confidence by the policy makers within the system and all those who are part of the system. More so, if the majority of midwives were prepared to agree that poor staffing levels resulted in more continuous electronic monitoring. There were some interesting discrepancies in the data analysed. W h e n scoring the attitude responses, most midwives agreed they were confident using intermittent auscultation as their main method for women at low obstetric risk. However, this confidence was not as evident when methods were ranked. N o r was it as evident in midwives' beliefs that the method was accurate. Beliefs about a method's accuracy or safety were certainly factors influencing individual choice. The generally high attitude scores for the sample are gratifying in that they indicate that most of the midwives hold positive attitudes towards childbirth and midwifery practice. If midwives are to assume more professional responsibility for care within the maternity services, then it is important that these positive attitudes are nurtured. Confidence in one's own ability and the enjoyment of responsibility seem to go hand in hand. It is not surprising that the degree to which these feelings are enjoyed is related in some way or another to educational preparation for practice. Despite overall higher attitude scores, midwives who had completed an 18month course felt less well prepared practically to assume complete responsibility for the care of women at low obstetric risk than those midwives who had undertaken a 12-month or Part 1 and 2 course. W h y should this be, when a longer theoretical and practical education has been completed and supposedly more experienced gained? Are the majority of student mid-

wives undertaking their education in high tech units, exposed more to obstetric intervention than midwifery care? It is likely to be not only a reflection o f education and training shortcomings, but also a result of major changes in approaches to the delivery o f care. This is an area which requires further examination before any conclusions are drawn. It was not surprising to find that community midwives were less confident interpreting CTGs than their colleagues working in the regional unit. However, providing intrapartum care on a more frequent and regular basis is likely to result from the increasing demand for D O M I N O care. Community midwives must not be overlooked when in-service education programmes are being planned. It was not only community midwives who, as a group, were less confident in C T G interpretation. Midwives who had not gained any continuing education qualification(s) and who had no intention of doing so, were also less confident than their colleagues. Part-time midwives were more likely to belong to this group and also more likely to be less confident using intermittent auscultation as a method. It follows that full-time midwives are exposed more frequently to these practices. It could also be that full-time midwives have received more instruction in fetal monitoring methods. This is to be expected as midwives working full-time will have more access to available educational opportunities. It is worrying, though, that after completion of midwifery education over half the sample had received no instruction in fetal monitoring methods or C T G interpretation. More so when one realises that electronic fetal monitoring was not available when some o f these midwives qualified. Despite the generally very positive scoring of attitude statements relating to confidence in ability, decision making and enjoyment of practice, the majority of respondents (97%) still felt that midwives would benefit from inservice education in C T G interpretation. It also appears that midwives would value more experience using intermittent auscultation as a method of intrapartum fetal monitoring. Perhaps Murphy-Black (1991) is right to be concerned about midwives being capable of utilising this low tech approach. So even if midwives felt well prepared and confident to practice, they believed that most would derive benefit from further in-service training. An educational need has clearly been identified. Fetal monitoring is integral to midwifery practise and midwives should feel confident in their ability to utilise appropriately all the methods available to them. There are good reasons for the differences in what midwives do, and what they feel they should do, not least of

Fetal monitoring- midwifery attitudes 27 which is their vulnerability to the threats and realities of litigation. This vulnerability can be diminished if midwives are as well prepared to monitor fetal condition as they should be. They should also be supported in their practice by their peers, managers and medical staff, as well as by appropriate protocols, thus allowing the growth of confidence and professional development. Practices change and skills become redundant and it is therefore important that support is provided by appropriate ongoing education. Continuing professional education should be regarded as a necessity which must be afforded rather than a luxury.

REFERENCES Anthony M, Levene M 1990 An assessment of the benefits ofintrapartum fetal monitoring. Developmental Medicine and Child Neurology 32:547-553 Barton S L 1991 Audit in obstetrics. British Journal of Obstetrics and Gynaecology 98 (11): 1065-1072 Colditz P, Henderson-Smart D 1990 Electronic fetal heart rate monitoring during labour. Does it prevent perinatal asphyxia and cerebral palsy? The Medical Journal of Australia 153:71-88 Cooke P 1992 Fetal monitoring a questionable practice. Modern Midwife 12 (2): 8-11 Departnmnt of Health 1993 Changing Childbirth, Part 1. Report of the Expert Maternity Group. HMSO, London Downe S 1994 Maternity audit in practice. British Journal of Midwifery 2 (2): 77-81 Enkin M, Keirse M J N C, Chalmers I 1989 A guide to effective care in pregnancy and childbirth. Oxford University Press, Oxford Evans S 1992 The value of cardiotocograph monitoring in midwifery. Midwives Chronicle 105 (1248): 4-10 Flint C 1986 Objections overruled. Nursing Times 82 (14): 22 Garcia J, Corry M, MacDonald D et al i985 Mothers' views of continuous electronic fetal heart rate monitoring and intermittent auscultation in a randomised controlled trial. Birth 12:79-85 Gibb D, Arulkumaran S 1992 Fetal monitoring in practice. Butterworth-Heinemann Ltd, Oxford Grant A 1989 Monitoring the fetus during labour. In: Chahners I, Enkin M, Keirse M (eds) Effective care in pregnancy and childbirth. Oxford University Press, Oxford Henderson C 1984 Influences and interactions surrounding the decision to rupture the membranes by the midwife. Unpublished MA dissertation. Universitw of Warwick

Hicks C 1993 A survey of midwives' attitudes to, and involvement in, research: the first stage in identifying needs for a staff development programme. Midwifery 9:51 62 Hillan E 1991 Electronic fetal monitoring - more problems than benefits. MIDIRS Midwifery Digest 1 (3): 249-251 Hodnett E 1982 Patient control during labour. Effects of two types of fetal monitors. Journal of Obstetrics, Gynecological and Neonatal Nursing 11:9a~99 Holmes-Syndal S 1988 Methods of fetal heart rate monitoring during labour, a selective review of the literature. Journal of Nurse Midwifery 33 (1): 4-14 Howie P W 1986 Fetal monitoring in labour (editorial). British Medical Journal 2 9 2 : 4 2 7 4 2 8 Jackson J, Vaughan M, Black P e t al 1983 Psychological aspects of fetal monitoring: maternal reaction to the position of the monitor and staffbehaviour. Journal of Psychosomatic Obstetrics and GynaecologT 2 (2): 97-102 Jacoby A 1987 Women's preferences for and satisfaction with current procedures in childbirth. Findings from a national study. Midwifery 3:117-124 Kline P 1986 A Handbook of Test Construction. Introduction to Psychometric Design. Methuen & Co Ltd, London MacDonald D, Grant A, Sheridan-Pereira et al 1985 The Dublin randomised controlled trial ofintrapartum F H R monitoring. American Journal of Obstetrics and Gyr~ecology 152: (5): 524-539 Mander 1K 1993 Autonomy in midwifery and maternity care. Midwives Chronicle 106 (1269): 369-374 Miller S 1993 Continuous Assessment. Nursing Times 89 (23): 48 49 Morgan B M, Bulpitt J, Clifton P e t al 1984 Consumers' attitudes to obstetric care. British Journal of Obsterics and Gynaecology 91:624-628 Murphy-Black T 1991 Fetal monitoring during labour. Nursing Times 87 (28): 58-59 Neilson J P 1993 Cardiotocography during labour. British Medical Journal 306:347-348 Paterson C M, Chapple J C, Beard R W e t al 1991 Evaluating the quality of the maternity services - a discussion paper. British Journal of Obsterics and Gynaecology 98 (11): 1073-1078 Polit D F, Hungler B F 1991 Nursing Research Principles and Methods (4th ed). J B Lippincott Company, Philadelphia Prentice A, Lind T 1987 Fetal heart rate monitoring during labour - too frequent intervention, too little benefit? The Lancet 2 (8572): 1375 1377 Quirk J, Miller F 1986 FHR tracing - characteristics that jeopardise the diagnosis of fetal well-being. In Pitkin R M (ed) Clinical Obstetrics and Gynaecology 29 (1): 12-21 U K C C 1994 The Midwife's Code of Practice. UKCC, London