HESAV PPT Générique IN - HES-SO

Transcription

MIDWIVES’ EXPERIENCES AND
PERCEPTIONS IN RELATION TO
BIRTH-POSITIONING IN
MATERNITY HOSPITALS IN
WESTERN SWITZERLAND
SILVIA AMMANN-FIECHTER
MSC MIDWIFERY
Haute Ecole de Santé Vaud
European MSc Midwifery Presentation, September 2nd, 2013,
HESAV, CH-Lausanne
PLAN
1. Introduction
2. Literature review
3. Methodology and research methods
4. Findings and discussion of results.
5. Conclusions and Recommendations
2
HESAV, CH-Lausanne
1. INTRODUCTION
• Background
- MSc Midwifery Dissertation, Glasgow Caledonian
University
- Summary
• Rationale
- Personal Interest (Practice, Literature)
- Professional (Students, Ethics, Regulations)
- Theory-practice gap
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HESAV, CH-Lausanne
2. LITERATURE REVIEW
• Search strategy
• Definitions
- Midwifery
- Birthing positions and second stage of labour (views)
- Specific birthing positions (lack of universally agreed
definitions → limitations)
•Anatomo-physiological interplay of the
pelvis, the foetus and its relationship to
birth-positioning
- movement, positions, rotation of femur, angle femurspine → variations in pelvic shapes, sizes and diameters
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HESAV, CH-Lausanne
• History of birthing positions
- upright positions until 18th century
- western obstetrics forced women to lie supine
based on no evidence and reflection on birth
physiology
- most caregivers have been trained delivering a
baby in supine position
- today?
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• Evidence based literature and
international recommendations
- methodological limitations
- discourage women from lying supine and semisupine
- encourage comfortable and upright positions
(WHO 2006, NICE 2008, RCM 2008, MIDIRS 2008)
-”best results”: all fours/kneeling and side-lying
- back-lying positions: ↑ labour time, ↑assisted
deliveries, ↑episiotomies, ↑pain
(Gupta et al 2004, de Jonge et al 2004).
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• Women’s views on birth-positioning
- inconclusive
- women lack information about options for birthing positions
- expect midwives to give them relevant information
• Midwives’ views in relation to birthpositioning
- are aware of their influence on the choice of birthing
positions
- adapt to positions women adopt or desire
- practice influenced by their views, experiences,
exposure and relevant obstetric factors
→Literature scarce and inconclusive, no local
studies
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3. METHODOLOGY AND RESEARCH METHODS
• Aim and objectives
To explore midwives’ experiences and perceptions in relation
to birth-positioning (BP) in maternity hospitals in Western
Switzerland
- To describe midwives’ experiences in relation to BP
- To understand midwives’ rationale for their practice in
relation to BP
- To explore factors which influence midwives’ practice in
relation to BP
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• Research approach
Exploratory, qualitative methodology, under
a phenomenological umbrella
- Qualitative research perspective
→
to understand respondents and the social
and cultural context within which they live (Myers
1997), a perspective that values respondent’s views
and seeks to understand their world (Parahoo 2006))
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• Research approach
- Phenomenology
→only those who experience phenomena are capable of
communicating them to others, researchers’ observations
are limited in terms of understanding people’s experiences
and perceptions (Parahoo 2006)
- General qualitative exploratory methodology
→to reach a better understanding of how people think
and behave, to understand the underlying processes
influencing their thoughts and behaviour
(Flick 2009,Parahoo, 2006, Beyea and Nicoll 1997)
→flexible, not replicable, leads to initial exploration only
(Lamnek 2010, Wood and Ross-Kerr 2006)
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•Methods
- Study population and sample, site access
and
management approval
- Purposive sampling, midwives working in birth units in
Western Switzerland
- Institutional management approvals
- Ethics committee approval, ethical principles
- Information to head midwives – staff meeting, e-mails
- Seven volunteer midwives
- Personal contact, information letter, consent form
- No details, anonymity
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• Data collection
- audio-recorded, semi-structured face-to-face interviews
following an interview-guide, duration 45-90 minutes,
verbatim transcription, pilot study, Microsoft-Word
• Data analysis
- Thematic analysis following Braun and Clark (2006)
1. Familiarize yourself with your data
2. Generate initial codes
3. Search for themes
4. Review themes
5. Define and name themes
6. Produce the report
- Issues of rigor: credibility, fittingness, auditability
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4. FINDINGS AND DISCUSSION OF RESULTS
1. “Listening to the woman”
2. “The health of the woman and the baby
comes first”
3. “I do what I am familiar with”
4. “ Too many opinions”
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• “Listening to the woman”
- Cathy: …what I really and truly think is that you really have to
listen to the woman. (C 3.7)
- Marie: I am with her wherever she is…. ….wanting to move, to
stay in bed….you see, I am with her wherever she is. (M.1.0)
- Lisa: Often they (the women) tell me, oh normal, just normal..... And
normal means on the back, often people tell me that. (L 5.0)
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• “Listening to the woman”
- Julie: If you take the body of women without epidural, they naturally do
their own thing, in most cases I just don’t say anything, I follow, I
deliver babies in all positions, 360°.....I adapt to the woman. (J 1.4)
- Emilie: With epidural it’s me who suggests to the women that they
change position …..it’s like they let themselves go…, we ask them how
are you more comfortable, what would you like.... they don’t know
anymore.... they say it’s you who knows best.... (E 1.4)
- Viola: Information is of primary importance in how things develop and
in the desire that the women have to move. (V 1.3)
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“The health of the woman and the baby comes
first”
- Cathy: ...for me it’s the health of the mother and the baby first, this is for
sure,….after comes the rest….(C 7.6)
- Marie: ...if it takes too long ….I will change positions more frequently….to try to
see if at the level of the pelvis, this can help the baby to progress more
quickly.. (M 3.9)
- Emilie: If I have a suspect EFM in right side-lying, I will change her to the left
side or the back or sitting or squatting or in all-fours; in fact I will try to find the
right position for the EFM and generally if the EFM is improving, the baby will
descend. (E 4.3)
- Lisa: …..the all-fours ……with posterior presentation, I do this systematically,
this 17works extremely well.(L 1.8)
“The health of the woman and the baby comes
first”
Lisa: A shoulder dystocia is always easier to resolve on
leg holders….and you never know, in the case…, you are
already ready for an eventual intervention….(L1.5)
Viola: Macrosomia is not a reason to put her on the back;
it’s rather to position her on all-fours…. I think it is
on all-fours that there is less risk of having a problem
with shoulder dystocia, because we have a very, very good
flexion of the pelvis and we find ourselves in a pseudo Mc
Roberts…… (V3.0)
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• “I do what I am familiar with”
- Milly: …what I really want to say in relation to positioning, it is really moving, to
change positions, different positions, not static. (Mi 10.4)
- Julie: ….I never keep one position for good, unless it is magical and the baby
progresses, but otherwise, I vary. (J.3.3)
- Emilie: … I had this woman on her back with a suspicious EFM….. then I
turned her into all-fours with her upper body on the ball, she was moving with her
pelvis……..and she was feeling very well like this…..and what I found
incredible, the EFM improved, it turned out perfectly physiologically. (E 4.8).
-Viola: I use different varieties of the all-fours position….sometimes it is more like
kneeling……..I can see it practically….women who are agitated when they were
in another position, often they manage better their contractions and at the same
time the baby descends….and what is also extremely important, the head
descends well. (V2.2).
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• “I do what I am familiar with”
- Cathy: I quite often do it on the left side, well just because it works better, and
it is better for the baby too ….you can see the difference at the perineal level,
the perineum adapts differently and all this, it’s true, in the end it is positive at
the final…(C1.9).
- Viola: …. well giving birth on the birthing stool is OK if you install them right
at the end, just for the expulsion, because of the risk of oedema in the perineal
region…..(V 3.6)
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•“I do what I am familiar with”
- Milly: I have the impression that in our institution it’s mostly on the back…I just
lower the lower part of the bed, I nearly always do like that. (Mi 8.4, 6,3)
- Lisa: For a first baby, sometimes I adapt a little, but principally for a first one on
leg holders, in the normal position, the one I learned from the beginning, and
then I am very flexible…..but for a first I believe that you have a better control
over the perineum. (L1.9, 2.8)
- Viola: It’s excluded that I position a woman on her back, absolutely excluded…
she is generally very uncomfortable, it’s often more painful, often she can’t bear
this position and in any case, regarding obstetric mechanics, it’s absolutely
against anatomy and physiology. (V1.8)
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•“I do what I am familiar with”
-Viola: Well, I adapt the gynaecological position……..I put two rolled towels
under the buttocks, just in order to liberate the sacrum and the coccyx, so the
nutation movement is possible…..I turn the leg holders……….so I can position
the knees in internal rotation, this opens the ischial tuberosities and
consequently the lower pelvis.….. (V6.5)
- Julie: …sitting, yes I adapt the sitting position…which helps the verticality and
descent of the baby ……the most difficult thing is to position her in order that the
coccyx can move and she can move ……….(J5.9)
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•“ Too many opinions”
- Milly: What is difficult sometimes is that the doctors always assist the births
and there are interferences …..doctors give their opinion, different people give
their opinion and this creates a climate of stress and there are birthing positions
you do not dare use because this or that person will be present and making
comments on the birthing position or not agree with its use. (M5.1)
- Emilie: …. I am clearly not working the same (in relation to birth-positioning), in
fact I know in advance when I start my shift, depending on who is in charge, how
I will manage my birth….it’s as if I prepare myself and the couple for the fact
that we won’t be able to do everything we would like. (E3.7)
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- Emilie: …sometimes I realise that I have the anatomical knowledge but not an
excellent vision of the space and sometimes I do not know how to position a
woman in order to open the pelvis, especially under epidural, sometimes I don’t
know. (E 1.7)
- Julie: Well, I have a lot of problems……to see those absurd birth
positions…..well installed in gynaecological position, with legs in external rotation,
feet turned outwards, ……a sacrum pulled against the bed……..a monitoring
which is getting worse and nobody moves……..I should then say if you continue
this way we will finish in forceps…… the young doctors lack knowledge and some
midwives lack knowledge. (J7.1)
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- Julie: …we would not leave a young midwife or a student midwife to deliver in
any other position than supine, in fact it is really a pity as the student midwife
often would like to try and at the same time we would not let her, we would not
permit her…..well in fact it’s a pity as we are not passing on this art at the
moment…(J5.0)
- Viola: Well, with the young, the young assistant doctors, I explain to them why
and well if you explain things to them well, all of a sudden there are no more
problems. It is not just because I want to de-medicalise birth, well, the proof is
clearly there, it works better. (V5.6)
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5. CONCLUSION AND RECOMMENDATIONS
• Overall all four themes highlight the fact
that profound
knowledge in birth-positioning, based on
anatomophysiological and evidence-based
knowledge,
improves the health and wellbeing of
mother and baby.
• Very complex subject, influenced by many
different
factors relating to the woman, the
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• Limitations of the study
- Participants volunteers and most special
interest in
BP – not representative of whole
population
- Themes can only be considered emerging
themes
- Definitions
- Personal experience and perception
- No claim of completeness
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• Implications for midwifery practice
- Well designed implementation project
- Antenatal education
•Implications for midwifery education
-Stronger theory-practice collaboration
-Collaboration between midwifery and medical
education
•Recommendations for further research
-Collection of further data
-Focus on institutional factors
-Define common definitions and classifications for BP
-Conduct research combining mobility and BP
-Conduct research in order to confirm or expand
anatomo-physiological empirical knowledge
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Women and babies deserve the best possible care.
This study’s findings highlight the fact that birth-positioning practice which
is based on a woman’s needs, the specific obstetrical situation and
evidence-based and anatomo-physiological knowledge improves the
health of the mother and the baby. This study indirectly detected a lack of
knowledge among midwives and medical staff on best practice in birthpositioning. This needs addressing at the level of midwifery and medical
practice, education and research.
29
European Master of Science in Midwifery

HESAV PPT Générique IN - HES-SO

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