- Email: [email protected]
Using Evidence-Based Practice to Improve Intrapartum Care
J OGN
N
THOUGHTS & OPRVIONS
Using Evidence-Based Practice to Improve htrapartum Care S w a n Kardong-Edgren, RNC, M S
=
The Cochrane Data Base (w.cochrane1ibrat-y. com/clibhome/clib.htm, retrieved February 23, 2001 ), a comprehensive international review of current medical and obstetric practices, demonstrates that birth outcomes improve with one-to-one labor support but not necessarily with continuous fetal monitoring. Because of a cultural bias toward technology, however, few extrinsic rewards exist for nurses who provide individualized labor support. Clinical scholarship in the obstetric setting is one way to begin changing ritualized practices, incorporating evidence-based practice, and improving nursing care. JOGNN, 30, 371-375; 2001. Keywords: Authoritative knowledge-Electronic fetal monitoring- Evidence-based practiceLabor support
Accepted: February 2001 ~
How many obstetric nurses consult A Guide to Effective Care in Pregnancy and Childbirth (Enkin et al., 2000), the affordable, smaller, and easily accessible version of the Cochrane Data Base (2001) when they want to improve their clinical practice? Although this resource has been available for 11 years, many nurses remain unaware of this text (just released in its third edition) or the larger Cochrane Data Base, the foremost authority on evidence-based practice in obstetrics that was recently highlighted in this journal (Callister & Hobbins-Garbett, 2000). In the emerging climate of evidence-based practice and nationwide best practice conferences, resistance remains to evidence-based practices to improve the care of obstetric patients. Evidence-based practice contrasts with our perhaps more familiar task-oriented approach to clinical practice, “routinized versus deliberate, mindless versus rational, habitual versus individualized,
]uly/August 2 001
and unquestioning versus evaluative” (Stetler, 1999, p. 15). In contrast, evidence-based practice is “an approach to nursing that de-emphasizes ritual, isolated and unsystematic clinical experiences, ungrounded opinions and tradition as a basis for nursing practice” (Stetler, 1999, p. 15). Nurses would be wise to remember that only 4% of medical care decisions are based on clinical research (Rooks, 1999). In fact, tradition’s ability to outweigh scientific evidence in obstetric practice so irritated Cochrane “that he awarded a wooden spoon, the British equivalent of a booby prize, to obstetrics for being the least scientific of all medical specialties” (Chase, 2000, p. 1 ) . Obstetric nursing could benefit from a concerted move toward evidence-based practice. Two examples of labor practice, continuous electronic fetal monitoring (EFM) and one-to-one labor support, will be used in this article to illustrate the value of evidence-based practice for labor and delivery nurses. These examples were chosen because intrapartum nurses are encouraged, if not required, to be certified yearly in EFM but are not required to know how to provide one-to-one labor support. Yet, one-to-one labor support is supported by research, whereas continuous EFM is not (Cochrane Data Base, 2001). According to the Cochrane Data Base records through 1999 (Cochrane Data Base, 2001), no reduction in perinatal mortality or increase in Apgar scores has occurred because of continuous EFM. However, an increase has occurred in cesarean rates in low-risk births, forceps-assisted births, and vacuum extractions. The overall risk of perinatal mortality remains unchanged (Enkin et al., 2000). According to the American College of Obstetricians and Gynecologists ( 1 9 9 9 , intermittent auscultation is equivalent to continuous fetal monitoring, yet continuous fetal monitoring is de
JOGNN 371
rigueur in most hospitals. Why? “Auscultation with stringent standards is not feasible under normal labor and delivery conditions unless a one-to-one nurse to patient ratio can be assured” (Rooks, 1999, p. 362). Nurses “may not have confidence to monitor labor by intermittent auscultation” (Enkin et al., 2000, p. 275). Enkin et al. (2000) defined one-to-one labor support as both physical comfort measures and emotional support, with the added caveat that the “laboring woman will not, at any time, be left without available support” (p. 247). Physical comfort measures are provided within culturally appropriate parameters and include massage, breathing, distraction, repositioning, assistance with bathing and showering, and provision of and assistance with hot and cold packs. Emotional support may include eye contact, verbal encouragement, explanations of procedures and examinations, and information about labor’s progress. The constant presence of a trained support person in labor “reduces the likelihood
I r
Ihis is a generation of nurses who have
practiced only in an era of fetal monitors and may not know how to provide one-to-one labor support to a laboring woman.
of medication for pain relief, cesarean delivery, operative vaginal delivery, and a 5-minute Apgar score < 7” (Enkin et al., 2000, p. 253). One-to-one labor support often is difficult to provide because of lack of staff, despite frequent admonishments that continuous fetal monitoring “should be an adjunct to, not a substitute for, personal care” (Enkin et al., 2000). Another factor is a lack of knowledge by many labor and delivery nurses about how to provide one-to-one labor support.
Background In many cases today, nursing care in a labor unit means putting a woman into bed and on a fetal monitor, waiting for her to dilate to 5 cm, then calling the anesthesiologist to administer an epidural. This is a generation of nurses who have practiced only in an era of the increased use and popularity of fetal monitors and who may not know how to provide one-to-one labor support to a laboring woman. How did this come to be? With the advent of forceps, and later, fetal monitors, modern obstetrics succumbed to technology, as has U.S. society in general. Electronic fetal monitoring transformed “the unpredictable and uncontrollable natural process of birth
372 JOG”
into a relatively predictable and controlled technological phenomenon that reinforces American society’s most fundamental beliefs about the superiority of technology over nature” (Davis-Floyd, 1992, p. 2). This seemingly human preference for technology goes back to the time of the Greeks. The tension between technology and simplicity is illustrated by the story of Hygeia, the goddess of health, and Aesclepius, the legendary first Greek physician. When Aesclepius performed the first successful surgery using a knife, the formerly dominant worship of Hygeia came to an end (Dubos, 1979). Aesclepius and his knife symbolized technology. Even in Greek times, technology held greater appeal than the unpretentious, self-reliant goddess of health. The history of obstetrics (and more recently obstetric nursing), perhaps more than that of most specialties, is the history of its technologic advances and instrumentation. Physicians first gained control over midwives and birthing women in the 18th century by stressing the risks of untrained and unschooled midwives and their lack of technology (DeVries, 1992). (Female midwives were not allowed to go to medical school at that time.) With the advent of the first reliable technologic advancement in obstetrics, the Chamberlain forceps (see Cunningham, MacDonald, Gant, Leveno, & Gilstrap, 1993), we began to routinely anticipate and expect improvements in the birthing process with instrumentation. It has been argued that “the history of obstetrics is the history of its tools and interventions . . . there are grounds to believe that without technology the specialty might never have come into existence” (Edwards & Waldorf, 1984, p. 101). This technologic transformation in obstetrics was exceptionally quick in the United States. Dick-Read, when touring a U.S. hospital in the 19@fs, noted the “trend in American obstetrics toward an element of servitude to mechanization” (Dick-Read, 1987, p. 305). In another observation, Dick-Read (1987) noted while touring a labor and delivery unit, There were syringes and needles for all manner of analgesic and anesthetic injections; some were given to desensitize the whole woman . . . others for different areas and parts of a woman. It seemed there was no possibility of an emergency arising that could not be dealt with immediately, but there was no provision for the absence of emergency or abnormality either. (p. 305)
Electronic Fetal Monitoring Electronic fetal monitoring was introduced in the United States as a new mechanical nurse that would “save three out of four babies who would have been mentally retarded and rid society of all bad boys and
Volume 30, Number 4
slow learners in school” (Edwards & Waldorf, 1984, p. 119).Nurses were instrumental in the original selling of fetal monitors to pregnant women. If the nurses were not afraid of them, many nurses being women and mothers themselves, laboring women were willing to use them. Nurses’ adoption of this technology actually subordinated nursing further to medicine, thus impeding the “development of nursing to medicine as a valued province of knowledge and practice” (Sandelowski, 1984, p. 171).Nurses were finally able to partake in the technologic aspects of birth when EFM came into vogue. The profession’s original functions and values of altruism, caring, and support became unimportant and considered low-status alternatives to modern technology (McNiven, Hodnett, & O’Brien-Pallas, 1992). Nurses’ authoritative knowledge grew with the advent of the fetal monitor, moving from caring intuitively to caring based on scientific knowledge. Fetal monitors became the nurse’s reality, not what her eyes, ears, and senses told her.
One-to-one Labor Support Obstetrics’ and subsequently obstetric nurses’ reliance on and management of fetal monitoring reflects our culture’s increasing embrace of technology. It is, therefore, not surprising that technical skills have frequently overwhelmed our supportive skills in labor. Physician-controlled functions have become the only interventions seen by nurses to significantly affect patient outcomes (McNiven et al., 1992).McNiven et al. (1992) found that supportive care, defined as reassuring touch, was provided only twice in 616 observations of nurses’ interactions with patients. Supportive patient care was provided 9.9% of the time among all other clinical duties. Leininger, a nurse anthropologist, has observed “the greater the signs of dependency upon technology to give care, the greater the signs of depersonalized human care to clients” (Alexander et al., 1989, p. 154). Reliance on fetal monitors is an accepted part of socialization into today’s role of a labor and delivery nurse. Indeed, pressure is exerted on those who d o not conform to the norm of
. . . frequent, brief visits to their patients, arranging for the epidural analgesia as soon as possible, and spending substantial periods of time with one’s colleagues at the nurse’s station. Nurses who deviate from this norm risk being shunned, set apart, and even ridiculed by their peers. (Hodnett, 1997, p. 79) Women who are given one-to-one labor support experience shorter labors, less use of epidural and other pharmacologic pain relief, less use of forceps and vacuum extraction, fewer cesarean deliveries, and greater overall satisfaction with labor (Enkin et al., 2000). J u1ylAugust 2 001
One-to-one nursing care is assumed by hospital management to be more expensive than continuous fetal monitoring. Studies of the costs of implementing oneto-one labor support versus the cost of cesarean deliveries, fetal monitors and associated training costs, and epidural monitoring are not reported in the literature. Why would some nurses resist one-to-one nursing support of laboring patients? Almost no extrinsic rewards exist for providing one-to-one labor support. Many nurses have not been socialized into a supportive labor and delivery role and d o not know how to perform this function. How many labor and delivery units build the ability to provide one-to-one nursing support in labor into a clinical ladder? H o w many units provide money for nurses to be certified in labor support? This care gap is frequently filled by doulas, who are individuals trained and certified in one-to-one labor support. Lamaze International, recognizing this lack of knowledge among labor and delivery nurses, has instituted a certification program for nurses in labor support. Some experienced labor and delivery nurses are resistant to change or implementing evidence-based practice and discourage new nursing graduates and student nurses from challenging traditional practices. Many new graduates must mimic their fellow nurses to survive after graduation. They suffer cognitive dissonance in the process, having just emerged from academia with the latest evidence-based practices fresh in their minds. “That’s what they teach in school, but this is the real world” is a familiar refrain. Hospital administrators in the United Kingdom, Canada, and the United States are becoming aware of research that demonstrates excellent birth outcomes with one-to-one labor support (Ernst, 1996). Good birth outcomes decrease overall costs. A movement is under way to hire doulas for labor support and decrease the number of labor and delivery nurses who do not know how or refuse to learn or perform labor support. There is discussion that the current generation of hightech labor and delivery nurses will not be able to socialize into a labor support role instead of a labor-monitoring role (Ernst, 1996; Hodnett, 1997). Only time will tell.
Labor and Delivery Culture in North America Our society and hospitals have millions of dollars invested in fetal monitor technology. The equipment must now be used to get a return on the investment. Monitors have become a cultural norm, and women expect to be placed on them while in labor. Technology in our culture produces authoritative knowledge: We believe machines are smarter than people. Electronic fetal monitoring has symbolic, if not proven, scientific value. Electronic fetal monitoring reinforces technolo-
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gy’s control over life (Jordan, 1993). Our entire U.S. culture is biased toward ever more upscale technology. Indeed, it is hard to resist when the next fetal monitor upgrade arrives with the company representative and a free lunch. This bias toward technology is “an ongoing social process that builds and reflects power relationships within a practice community” (Jordan, 1993, p. 152). Why do we, as nurses, like fetal monitors? They reinforce our position over the patient, at one with or slightly below the physician in power and knowledge over the woman. Indeed, EFM forced intrapartum nurses “to become more knowledgeable about biophysical, psychological, and engineering sciences” (Sandelowski, 1984, p. 170). Increasingly, technical birth reinforces the social norm of doctors and nurses continually upgrading their certifications. A vicious circle is created. Interpretations of fetal monitor tracings have acknowledged interrater and intrarater reliability issues. After 1 5 years of studies that demonstrated no improvement in fetal outcomes with fetal monitoring, researchers have developed standardized and consistent definitions for fetal heart monitor tracings “to improve communication, reliability and collaboration in future research” (Schmidt & McCartney, 2000, p. 302). The technology itself has not been questioned; it must be the interpretation of the technology that is at fault.
Increasingly, technical birth reinforces the social norm of physicians and nurses continually upgrading their monitor certifications.
Some Proposed Solutions A way out of ritualized practice and the technologic quagmire is a move toward clinical scholarship in the obstetric setting. Clinical scholarship is about inquiry and implies a willingness to scrutinize our practice, even if it means challenging the theories and procedures that we learned and practiced. It is looking for a different and better way to nurse and refusing to accept anything just because that’s the way in which it always has been done. (Dreher, 1999, p. 29) Continuous fetal monitoring and one-to-one labor support were used as examples for this article. However, multiple labor and delivery practices could benefit from research-based evaluations. Some examples 374 JOG”
include nutrition during labor, walking during labor, and second-stage perineal management. Evidence-based practice topic-of-the-month discussions in labor and delivery units could be instituted. Information and articles about the practice to be discussed or commented upon could be kept a t the nurses’ station or posted in the change room. A comments section should be included so that concerns about changes can be expressed and addressed. An annual review of labor and delivery practice protocols, incorporating practices from the Cochrane Data Base (2001), could enhance an obstetric unit’s professionalism and improve patient outcomes. Labor and delivery units often have William’s Obstetrics (Cunningham et al., 1993) and multiple fetal monitoring books in their unit libraries, but no copy of the Guide to Effective Care in Pregnancy and Childbirth (Enkin et al., 2000). This book is a smaller, printed version of the 1,500-page Cochrane Data Base that evaluates practices and research gathered from 60 journals from the 1950s to the present. Routine obstetric practices are supported, questioned, or refuted by wellreferenced clinical studies. Emotional debate is moot, along with discussion of regional and customary practices. Another excellent resource for beginning discussions about evidence-based clinical practices is Obstetrical Myths Versus Research Realities (Goer, 1995). An involved and motivated unit manager with collaboration and team-building skills may be necessary to implement change. Even the Association of Women’s Health, Obstetric and Neonatal Nurses’ research utilization project on second-stage labor practices was sabotaged by informal nurse leaders who continued to rely on anecdotal experiences and unit tradition rather than evidence-based practice (Niesen & Quirk, 1997). Some informal nurse leaders did not agree that evidencebased practice was a better method for providing quality nursing care. Indeed, they had difficulty explaining new techniques because they could not understand them. Changing the focus of apparently emotionally charged buzzwords such as research utilization to quality improvement may make a difference in how a staff perceives and responds to change (Niesen & Quirk, 1997). Researchers are demonstrating measurable clinical improvements in birth outcomes when one-to-one supportive care is provided to laboring women. A growing body of research does not show support for the use of continuous EFM during labor and delivery. Thus, “the challenge for modern obstetric care is to combine the benefits of properly applied technology with those that the presence of a birth attendant provides” (Bowes, 1992, p. 39). Intrapartum caregivers should consider one-to-one labor support an integral part of obstetric service. Certification in labor support techniques should be required at least as often as certification for EFM. In Volume 30, Number 4
addition, research comparing the cost-benefit ratio of all the costs of EFM, maintenance, purchase, a n d training of staff should be compared with the costs incurred a n d savings derived from one-to-one labor support. We hold o u r profession back when w e do n o t use o u r o w n specialty’s research.
k e r t i f i c a t i o n in labor support techniques should
be required at least as often
as certification for EFM.
T h e obstetric part of the Cochrane D a t a Base online may be accessed at www.cochranelibrary.com/clibhome/ clib.htm by starting at “Cochrane Library” a n d moving through the following: “Abstracts of the Cochrane Library a r e available without charge and c a n be browsed a n d searched,” “Search the abstracts of Cochrane Reviews,” “Abstracts listed by Cochrane Collaborative Review Groups,” a n d “Cochrane Pregnancy a n d Childbirth Group.” Some sample listings of abstracts discuss women’s position during the second stage of labor, caregiver support for w o m e n during labor, epidural versus nonepidural analgesia for pain relief in labor, a n d continuous electronic fetal heart rate monitoring for fetal assessment during labor.
REFERENCES Alexander, J., Beagle, C., Butler, P., Douerty, D., Robards, K., & Velotta, C. (Eds.). (1989). Madeline Leininger. St. Louis, MO: Mosby. American College of Obstetricians and Gynecologists. (1995). Fetal heart rate patterns: Monitoring, interpretation, and management (ACOG Technical Bulletin No. 207). Washington, DC: Author. Bowes, W. (1992). Labor support: Many unanswered questions remain. Birth, 19(1),38-39. Callister, L., & Hobbins-Garbett, D. (2000). Cochrane pregnancy and childbirth database: Resource for evidencebased practice. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 29, 123-128. Chase, M. (2000, March 30). A commonly used aid to childbirth faces doubts about benefits. The Wall Street Journal, p. 1. Cochrane Data Base [Online]. Retrieved February 23, 2001. Available: http://www.cochranelibrary.com/clibhome/ clib.htm. Cunningham, F., MacDonald, P., Gant, N., Leveno, K., & Gilstrap, L. (1993). William’s obstetrics (19th ed.). Norwalk, CT: Appleton and Lange.
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Davis-Floyd, R. (1992). Birth as an American rite ofpassage. Los Angeles: University of California Press. DeVries, R. (1992). Barriers to midwifery: An international perspective. Journal of Perinatal Education, 1 , 1-10. Dick-Read, G. (1987). Childbirth without fear (5th ed.). Toronto: Fitzhenry and Whiteside. Dreher, M. (1999). Clinical scholarship: Nursing practice as an intellectual endeavor. Clinical Scholarship White PaperlSigma Theta Tau International, 1 (l),29-36. Dubos, R. (1979). The mirage of health: Utopias, progress and biological change (Vol. 22). New York: Harper and Rowe. Edwards, M., & Waldorf, M. (1984). Reclaiming birth: History and heroines of American childbirth reform. Trumansburg, NY: Crossing Press. Enkin, M., Keirse, M., Neilson, J., Crowther, C., Dudley, L., Hodnett, E., & Hofmeyer, J. (2000). A guide to effective care in pregnancy and childbirth (3rd ed.). New York: Oxford University Press. Ernst, E. (1996). Midwifery, birth centers, and health care reform. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 25, 433-439. Goer, H. (1995). Obstetrical myths versus research realities: A guide to the medical literature. Westport, CT: Bergin & Garvey. Hodnett, E. (1997). Are nurses effective providers of labor support? Should they be? Can they be? Birth, 24(2),7880. Jordan, B. (1993). Birth in four cultures (4th ed.). Prospect Heights, IL: Waveland. McNiven, P., Hodnett, E., & O’Brien-Pallas, L. (1992). Supporting women in labor: A work sampling of the activities of labor and delivery nurses. Birth,’l9(3),3-8. Niesen, K., & Quirk, A. (1997). The process for initiating nursing practice changes in the intrapartum: Findings from a multisite research utilization project. Journal of obstetric, Gynecologic, and Neonatal Nursing, 26, 709-717. Rooks, J. (1999). Evidence-based practice and its applications to childbirth care for low risk women. Journal of Nurse-Midwifery, 44(4), 355-369. Sandelowski, M. (1984). Pain, pleasure, and American childbirth: From the twilight sleep to the Read method, 1914-1 960. Westport, CT: Greenwood. Schmidt, J., & McCartney, P. (2000). History and development of fetal heart assessment: A composite. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 29, 295-305. Stetler, C. (1999). Clinical scholarship exemplars: The Baystate Medical Center. Clinical Scholarship White Paper, Sigma Theta Tau International, 1 (l),15-16.
Swan Kardong-Edgren is an instructor at the University of Texas at Arlington School of Nursing. Address for correspondence: Suzan Kardong-Edgren, RNC, MS, Box 19407, University of Texas at Arlington School of Nursing, Arlington, ?nx 76019. E-mail: [email protected].
iOGNN 375
N
THOUGHTS & OPRVIONS
Using Evidence-Based Practice to Improve htrapartum Care S w a n Kardong-Edgren, RNC, M S
=
The Cochrane Data Base (w.cochrane1ibrat-y. com/clibhome/clib.htm, retrieved February 23, 2001 ), a comprehensive international review of current medical and obstetric practices, demonstrates that birth outcomes improve with one-to-one labor support but not necessarily with continuous fetal monitoring. Because of a cultural bias toward technology, however, few extrinsic rewards exist for nurses who provide individualized labor support. Clinical scholarship in the obstetric setting is one way to begin changing ritualized practices, incorporating evidence-based practice, and improving nursing care. JOGNN, 30, 371-375; 2001. Keywords: Authoritative knowledge-Electronic fetal monitoring- Evidence-based practiceLabor support
Accepted: February 2001 ~
How many obstetric nurses consult A Guide to Effective Care in Pregnancy and Childbirth (Enkin et al., 2000), the affordable, smaller, and easily accessible version of the Cochrane Data Base (2001) when they want to improve their clinical practice? Although this resource has been available for 11 years, many nurses remain unaware of this text (just released in its third edition) or the larger Cochrane Data Base, the foremost authority on evidence-based practice in obstetrics that was recently highlighted in this journal (Callister & Hobbins-Garbett, 2000). In the emerging climate of evidence-based practice and nationwide best practice conferences, resistance remains to evidence-based practices to improve the care of obstetric patients. Evidence-based practice contrasts with our perhaps more familiar task-oriented approach to clinical practice, “routinized versus deliberate, mindless versus rational, habitual versus individualized,
]uly/August 2 001
and unquestioning versus evaluative” (Stetler, 1999, p. 15). In contrast, evidence-based practice is “an approach to nursing that de-emphasizes ritual, isolated and unsystematic clinical experiences, ungrounded opinions and tradition as a basis for nursing practice” (Stetler, 1999, p. 15). Nurses would be wise to remember that only 4% of medical care decisions are based on clinical research (Rooks, 1999). In fact, tradition’s ability to outweigh scientific evidence in obstetric practice so irritated Cochrane “that he awarded a wooden spoon, the British equivalent of a booby prize, to obstetrics for being the least scientific of all medical specialties” (Chase, 2000, p. 1 ) . Obstetric nursing could benefit from a concerted move toward evidence-based practice. Two examples of labor practice, continuous electronic fetal monitoring (EFM) and one-to-one labor support, will be used in this article to illustrate the value of evidence-based practice for labor and delivery nurses. These examples were chosen because intrapartum nurses are encouraged, if not required, to be certified yearly in EFM but are not required to know how to provide one-to-one labor support. Yet, one-to-one labor support is supported by research, whereas continuous EFM is not (Cochrane Data Base, 2001). According to the Cochrane Data Base records through 1999 (Cochrane Data Base, 2001), no reduction in perinatal mortality or increase in Apgar scores has occurred because of continuous EFM. However, an increase has occurred in cesarean rates in low-risk births, forceps-assisted births, and vacuum extractions. The overall risk of perinatal mortality remains unchanged (Enkin et al., 2000). According to the American College of Obstetricians and Gynecologists ( 1 9 9 9 , intermittent auscultation is equivalent to continuous fetal monitoring, yet continuous fetal monitoring is de
JOGNN 371
rigueur in most hospitals. Why? “Auscultation with stringent standards is not feasible under normal labor and delivery conditions unless a one-to-one nurse to patient ratio can be assured” (Rooks, 1999, p. 362). Nurses “may not have confidence to monitor labor by intermittent auscultation” (Enkin et al., 2000, p. 275). Enkin et al. (2000) defined one-to-one labor support as both physical comfort measures and emotional support, with the added caveat that the “laboring woman will not, at any time, be left without available support” (p. 247). Physical comfort measures are provided within culturally appropriate parameters and include massage, breathing, distraction, repositioning, assistance with bathing and showering, and provision of and assistance with hot and cold packs. Emotional support may include eye contact, verbal encouragement, explanations of procedures and examinations, and information about labor’s progress. The constant presence of a trained support person in labor “reduces the likelihood
I r
Ihis is a generation of nurses who have
practiced only in an era of fetal monitors and may not know how to provide one-to-one labor support to a laboring woman.
of medication for pain relief, cesarean delivery, operative vaginal delivery, and a 5-minute Apgar score < 7” (Enkin et al., 2000, p. 253). One-to-one labor support often is difficult to provide because of lack of staff, despite frequent admonishments that continuous fetal monitoring “should be an adjunct to, not a substitute for, personal care” (Enkin et al., 2000). Another factor is a lack of knowledge by many labor and delivery nurses about how to provide one-to-one labor support.
Background In many cases today, nursing care in a labor unit means putting a woman into bed and on a fetal monitor, waiting for her to dilate to 5 cm, then calling the anesthesiologist to administer an epidural. This is a generation of nurses who have practiced only in an era of the increased use and popularity of fetal monitors and who may not know how to provide one-to-one labor support to a laboring woman. How did this come to be? With the advent of forceps, and later, fetal monitors, modern obstetrics succumbed to technology, as has U.S. society in general. Electronic fetal monitoring transformed “the unpredictable and uncontrollable natural process of birth
372 JOG”
into a relatively predictable and controlled technological phenomenon that reinforces American society’s most fundamental beliefs about the superiority of technology over nature” (Davis-Floyd, 1992, p. 2). This seemingly human preference for technology goes back to the time of the Greeks. The tension between technology and simplicity is illustrated by the story of Hygeia, the goddess of health, and Aesclepius, the legendary first Greek physician. When Aesclepius performed the first successful surgery using a knife, the formerly dominant worship of Hygeia came to an end (Dubos, 1979). Aesclepius and his knife symbolized technology. Even in Greek times, technology held greater appeal than the unpretentious, self-reliant goddess of health. The history of obstetrics (and more recently obstetric nursing), perhaps more than that of most specialties, is the history of its technologic advances and instrumentation. Physicians first gained control over midwives and birthing women in the 18th century by stressing the risks of untrained and unschooled midwives and their lack of technology (DeVries, 1992). (Female midwives were not allowed to go to medical school at that time.) With the advent of the first reliable technologic advancement in obstetrics, the Chamberlain forceps (see Cunningham, MacDonald, Gant, Leveno, & Gilstrap, 1993), we began to routinely anticipate and expect improvements in the birthing process with instrumentation. It has been argued that “the history of obstetrics is the history of its tools and interventions . . . there are grounds to believe that without technology the specialty might never have come into existence” (Edwards & Waldorf, 1984, p. 101). This technologic transformation in obstetrics was exceptionally quick in the United States. Dick-Read, when touring a U.S. hospital in the 19@fs, noted the “trend in American obstetrics toward an element of servitude to mechanization” (Dick-Read, 1987, p. 305). In another observation, Dick-Read (1987) noted while touring a labor and delivery unit, There were syringes and needles for all manner of analgesic and anesthetic injections; some were given to desensitize the whole woman . . . others for different areas and parts of a woman. It seemed there was no possibility of an emergency arising that could not be dealt with immediately, but there was no provision for the absence of emergency or abnormality either. (p. 305)
Electronic Fetal Monitoring Electronic fetal monitoring was introduced in the United States as a new mechanical nurse that would “save three out of four babies who would have been mentally retarded and rid society of all bad boys and
Volume 30, Number 4
slow learners in school” (Edwards & Waldorf, 1984, p. 119).Nurses were instrumental in the original selling of fetal monitors to pregnant women. If the nurses were not afraid of them, many nurses being women and mothers themselves, laboring women were willing to use them. Nurses’ adoption of this technology actually subordinated nursing further to medicine, thus impeding the “development of nursing to medicine as a valued province of knowledge and practice” (Sandelowski, 1984, p. 171).Nurses were finally able to partake in the technologic aspects of birth when EFM came into vogue. The profession’s original functions and values of altruism, caring, and support became unimportant and considered low-status alternatives to modern technology (McNiven, Hodnett, & O’Brien-Pallas, 1992). Nurses’ authoritative knowledge grew with the advent of the fetal monitor, moving from caring intuitively to caring based on scientific knowledge. Fetal monitors became the nurse’s reality, not what her eyes, ears, and senses told her.
One-to-one Labor Support Obstetrics’ and subsequently obstetric nurses’ reliance on and management of fetal monitoring reflects our culture’s increasing embrace of technology. It is, therefore, not surprising that technical skills have frequently overwhelmed our supportive skills in labor. Physician-controlled functions have become the only interventions seen by nurses to significantly affect patient outcomes (McNiven et al., 1992).McNiven et al. (1992) found that supportive care, defined as reassuring touch, was provided only twice in 616 observations of nurses’ interactions with patients. Supportive patient care was provided 9.9% of the time among all other clinical duties. Leininger, a nurse anthropologist, has observed “the greater the signs of dependency upon technology to give care, the greater the signs of depersonalized human care to clients” (Alexander et al., 1989, p. 154). Reliance on fetal monitors is an accepted part of socialization into today’s role of a labor and delivery nurse. Indeed, pressure is exerted on those who d o not conform to the norm of
. . . frequent, brief visits to their patients, arranging for the epidural analgesia as soon as possible, and spending substantial periods of time with one’s colleagues at the nurse’s station. Nurses who deviate from this norm risk being shunned, set apart, and even ridiculed by their peers. (Hodnett, 1997, p. 79) Women who are given one-to-one labor support experience shorter labors, less use of epidural and other pharmacologic pain relief, less use of forceps and vacuum extraction, fewer cesarean deliveries, and greater overall satisfaction with labor (Enkin et al., 2000). J u1ylAugust 2 001
One-to-one nursing care is assumed by hospital management to be more expensive than continuous fetal monitoring. Studies of the costs of implementing oneto-one labor support versus the cost of cesarean deliveries, fetal monitors and associated training costs, and epidural monitoring are not reported in the literature. Why would some nurses resist one-to-one nursing support of laboring patients? Almost no extrinsic rewards exist for providing one-to-one labor support. Many nurses have not been socialized into a supportive labor and delivery role and d o not know how to perform this function. How many labor and delivery units build the ability to provide one-to-one nursing support in labor into a clinical ladder? H o w many units provide money for nurses to be certified in labor support? This care gap is frequently filled by doulas, who are individuals trained and certified in one-to-one labor support. Lamaze International, recognizing this lack of knowledge among labor and delivery nurses, has instituted a certification program for nurses in labor support. Some experienced labor and delivery nurses are resistant to change or implementing evidence-based practice and discourage new nursing graduates and student nurses from challenging traditional practices. Many new graduates must mimic their fellow nurses to survive after graduation. They suffer cognitive dissonance in the process, having just emerged from academia with the latest evidence-based practices fresh in their minds. “That’s what they teach in school, but this is the real world” is a familiar refrain. Hospital administrators in the United Kingdom, Canada, and the United States are becoming aware of research that demonstrates excellent birth outcomes with one-to-one labor support (Ernst, 1996). Good birth outcomes decrease overall costs. A movement is under way to hire doulas for labor support and decrease the number of labor and delivery nurses who do not know how or refuse to learn or perform labor support. There is discussion that the current generation of hightech labor and delivery nurses will not be able to socialize into a labor support role instead of a labor-monitoring role (Ernst, 1996; Hodnett, 1997). Only time will tell.
Labor and Delivery Culture in North America Our society and hospitals have millions of dollars invested in fetal monitor technology. The equipment must now be used to get a return on the investment. Monitors have become a cultural norm, and women expect to be placed on them while in labor. Technology in our culture produces authoritative knowledge: We believe machines are smarter than people. Electronic fetal monitoring has symbolic, if not proven, scientific value. Electronic fetal monitoring reinforces technolo-
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gy’s control over life (Jordan, 1993). Our entire U.S. culture is biased toward ever more upscale technology. Indeed, it is hard to resist when the next fetal monitor upgrade arrives with the company representative and a free lunch. This bias toward technology is “an ongoing social process that builds and reflects power relationships within a practice community” (Jordan, 1993, p. 152). Why do we, as nurses, like fetal monitors? They reinforce our position over the patient, at one with or slightly below the physician in power and knowledge over the woman. Indeed, EFM forced intrapartum nurses “to become more knowledgeable about biophysical, psychological, and engineering sciences” (Sandelowski, 1984, p. 170). Increasingly, technical birth reinforces the social norm of doctors and nurses continually upgrading their certifications. A vicious circle is created. Interpretations of fetal monitor tracings have acknowledged interrater and intrarater reliability issues. After 1 5 years of studies that demonstrated no improvement in fetal outcomes with fetal monitoring, researchers have developed standardized and consistent definitions for fetal heart monitor tracings “to improve communication, reliability and collaboration in future research” (Schmidt & McCartney, 2000, p. 302). The technology itself has not been questioned; it must be the interpretation of the technology that is at fault.
Increasingly, technical birth reinforces the social norm of physicians and nurses continually upgrading their monitor certifications.
Some Proposed Solutions A way out of ritualized practice and the technologic quagmire is a move toward clinical scholarship in the obstetric setting. Clinical scholarship is about inquiry and implies a willingness to scrutinize our practice, even if it means challenging the theories and procedures that we learned and practiced. It is looking for a different and better way to nurse and refusing to accept anything just because that’s the way in which it always has been done. (Dreher, 1999, p. 29) Continuous fetal monitoring and one-to-one labor support were used as examples for this article. However, multiple labor and delivery practices could benefit from research-based evaluations. Some examples 374 JOG”
include nutrition during labor, walking during labor, and second-stage perineal management. Evidence-based practice topic-of-the-month discussions in labor and delivery units could be instituted. Information and articles about the practice to be discussed or commented upon could be kept a t the nurses’ station or posted in the change room. A comments section should be included so that concerns about changes can be expressed and addressed. An annual review of labor and delivery practice protocols, incorporating practices from the Cochrane Data Base (2001), could enhance an obstetric unit’s professionalism and improve patient outcomes. Labor and delivery units often have William’s Obstetrics (Cunningham et al., 1993) and multiple fetal monitoring books in their unit libraries, but no copy of the Guide to Effective Care in Pregnancy and Childbirth (Enkin et al., 2000). This book is a smaller, printed version of the 1,500-page Cochrane Data Base that evaluates practices and research gathered from 60 journals from the 1950s to the present. Routine obstetric practices are supported, questioned, or refuted by wellreferenced clinical studies. Emotional debate is moot, along with discussion of regional and customary practices. Another excellent resource for beginning discussions about evidence-based clinical practices is Obstetrical Myths Versus Research Realities (Goer, 1995). An involved and motivated unit manager with collaboration and team-building skills may be necessary to implement change. Even the Association of Women’s Health, Obstetric and Neonatal Nurses’ research utilization project on second-stage labor practices was sabotaged by informal nurse leaders who continued to rely on anecdotal experiences and unit tradition rather than evidence-based practice (Niesen & Quirk, 1997). Some informal nurse leaders did not agree that evidencebased practice was a better method for providing quality nursing care. Indeed, they had difficulty explaining new techniques because they could not understand them. Changing the focus of apparently emotionally charged buzzwords such as research utilization to quality improvement may make a difference in how a staff perceives and responds to change (Niesen & Quirk, 1997). Researchers are demonstrating measurable clinical improvements in birth outcomes when one-to-one supportive care is provided to laboring women. A growing body of research does not show support for the use of continuous EFM during labor and delivery. Thus, “the challenge for modern obstetric care is to combine the benefits of properly applied technology with those that the presence of a birth attendant provides” (Bowes, 1992, p. 39). Intrapartum caregivers should consider one-to-one labor support an integral part of obstetric service. Certification in labor support techniques should be required at least as often as certification for EFM. In Volume 30, Number 4
addition, research comparing the cost-benefit ratio of all the costs of EFM, maintenance, purchase, a n d training of staff should be compared with the costs incurred a n d savings derived from one-to-one labor support. We hold o u r profession back when w e do n o t use o u r o w n specialty’s research.
k e r t i f i c a t i o n in labor support techniques should
be required at least as often
as certification for EFM.
T h e obstetric part of the Cochrane D a t a Base online may be accessed at www.cochranelibrary.com/clibhome/ clib.htm by starting at “Cochrane Library” a n d moving through the following: “Abstracts of the Cochrane Library a r e available without charge and c a n be browsed a n d searched,” “Search the abstracts of Cochrane Reviews,” “Abstracts listed by Cochrane Collaborative Review Groups,” a n d “Cochrane Pregnancy a n d Childbirth Group.” Some sample listings of abstracts discuss women’s position during the second stage of labor, caregiver support for w o m e n during labor, epidural versus nonepidural analgesia for pain relief in labor, a n d continuous electronic fetal heart rate monitoring for fetal assessment during labor.
REFERENCES Alexander, J., Beagle, C., Butler, P., Douerty, D., Robards, K., & Velotta, C. (Eds.). (1989). Madeline Leininger. St. Louis, MO: Mosby. American College of Obstetricians and Gynecologists. (1995). Fetal heart rate patterns: Monitoring, interpretation, and management (ACOG Technical Bulletin No. 207). Washington, DC: Author. Bowes, W. (1992). Labor support: Many unanswered questions remain. Birth, 19(1),38-39. Callister, L., & Hobbins-Garbett, D. (2000). Cochrane pregnancy and childbirth database: Resource for evidencebased practice. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 29, 123-128. Chase, M. (2000, March 30). A commonly used aid to childbirth faces doubts about benefits. The Wall Street Journal, p. 1. Cochrane Data Base [Online]. Retrieved February 23, 2001. Available: http://www.cochranelibrary.com/clibhome/ clib.htm. Cunningham, F., MacDonald, P., Gant, N., Leveno, K., & Gilstrap, L. (1993). William’s obstetrics (19th ed.). Norwalk, CT: Appleton and Lange.
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Davis-Floyd, R. (1992). Birth as an American rite ofpassage. Los Angeles: University of California Press. DeVries, R. (1992). Barriers to midwifery: An international perspective. Journal of Perinatal Education, 1 , 1-10. Dick-Read, G. (1987). Childbirth without fear (5th ed.). Toronto: Fitzhenry and Whiteside. Dreher, M. (1999). Clinical scholarship: Nursing practice as an intellectual endeavor. Clinical Scholarship White PaperlSigma Theta Tau International, 1 (l),29-36. Dubos, R. (1979). The mirage of health: Utopias, progress and biological change (Vol. 22). New York: Harper and Rowe. Edwards, M., & Waldorf, M. (1984). Reclaiming birth: History and heroines of American childbirth reform. Trumansburg, NY: Crossing Press. Enkin, M., Keirse, M., Neilson, J., Crowther, C., Dudley, L., Hodnett, E., & Hofmeyer, J. (2000). A guide to effective care in pregnancy and childbirth (3rd ed.). New York: Oxford University Press. Ernst, E. (1996). Midwifery, birth centers, and health care reform. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 25, 433-439. Goer, H. (1995). Obstetrical myths versus research realities: A guide to the medical literature. Westport, CT: Bergin & Garvey. Hodnett, E. (1997). Are nurses effective providers of labor support? Should they be? Can they be? Birth, 24(2),7880. Jordan, B. (1993). Birth in four cultures (4th ed.). Prospect Heights, IL: Waveland. McNiven, P., Hodnett, E., & O’Brien-Pallas, L. (1992). Supporting women in labor: A work sampling of the activities of labor and delivery nurses. Birth,’l9(3),3-8. Niesen, K., & Quirk, A. (1997). The process for initiating nursing practice changes in the intrapartum: Findings from a multisite research utilization project. Journal of obstetric, Gynecologic, and Neonatal Nursing, 26, 709-717. Rooks, J. (1999). Evidence-based practice and its applications to childbirth care for low risk women. Journal of Nurse-Midwifery, 44(4), 355-369. Sandelowski, M. (1984). Pain, pleasure, and American childbirth: From the twilight sleep to the Read method, 1914-1 960. Westport, CT: Greenwood. Schmidt, J., & McCartney, P. (2000). History and development of fetal heart assessment: A composite. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 29, 295-305. Stetler, C. (1999). Clinical scholarship exemplars: The Baystate Medical Center. Clinical Scholarship White Paper, Sigma Theta Tau International, 1 (l),15-16.
Swan Kardong-Edgren is an instructor at the University of Texas at Arlington School of Nursing. Address for correspondence: Suzan Kardong-Edgren, RNC, MS, Box 19407, University of Texas at Arlington School of Nursing, Arlington, ?nx 76019. E-mail: [email protected].
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