Abstract: Background: Slow progress of labour (SPL) occurs in 3-37% of all labours. It constitutes the main cause of primary caesarean section (CS) and is associated with operative births, maternal and foetal morbidity, and a negative birthing experience. SPL is also the principal reason for the transfers of women from midwife-led units (MLUs) or their home, to hospitals. The current standard medical management of SPL, including intravenous administration of synthetic oxytocin and artificial rupture of membranes (ARM), has been increasingly questioned and the need for alternatives recommended. A midwifery approach to SPL represents a possible important alternative. However, contemporary literature shows a surprising dearth of research concerning midwives’ approaches to SPL. Birth centres appear ideal settings for exploring a midwifery approach to SPL, given the strong midwifery philosophy and the relevance of SPL reported in these contexts.
Aim: To explore midwives’ approaches to SPL in birth centres, focusing in particular on midwives’ understanding of the phenomenon, diagnostic process, clinical management and decision-making.
Methods: A qualitative multiple case study, underpinned by a critical realist perspective. Midwives’ approaches to SPL represented the ‘case’ of interest; an Italian alongside- (AMU) and an English freestanding- (FMU) midwifery units were purposively selected as case-sites. Data was collected between November 2012 and July 2013, after obtaining all necessary ethical approvals. An inductive reasoning, and triangulation logic characterised data collection. Multiple methods were adopted including individual semi-structured interviews, focus groups, observations and document reviews. Practising midwives, midwife managers and two lead obstetricians were included as participants after obtaining written informed consent. Data was analysed at two levels, within-case and cross-case, using a thematic analysis. Findings from the cross-case analysis supported the development of assertions and final conceptualisation regarding midwives’ approaches to SPL in birth centres.
Findings: At the Italian site, midwives identified SPL as the problem of their care in the AMU. They perceived the process of recognition of this phenomenon as an engaging challenge and attempted to untangle the main cause amongst the many intertwined ones, in order to tailor their approach. Dealing with SPL represented a struggle; midwives adopted several different interventions and their decisions appeared enabled or constrained by numerous factors, especially the problematic relationship with the hospital staff. At the English site, SPL was not considered an issue, midwives were keen in looking at diagnostic and causal factors of SPL within a bigger picture. Midwives’ interventions aimed at giving women the best chance to overcome SPL and give birth in the FMU. The several influential factors were managed by many midwives through experience.
Across cases, midwives’ understanding of SPL varied. SPL was acknowledged to result from a complex interaction of causes. Early labour was considered a critical stage for the development of SPL. The process of recognition of SPL appeared a dynamic one and aimed at reaching an objective diagnosis. Distinguishing whether SPL represented a physiological rest or arrest of labour progress represented an emerging dilemma. Midwives tailored interventions to single situations. Some interventions appeared to be fundamental to midwifery care, whilst others depended on various factors. Midwives’ relationships with all factors in the context appeared to be pivotal for both performing interventions and decision-making.
Conclusion: This is the first case study exploring midwives’ approaches to SPL in birth centres, in both an English and an Italian context. This research outlines midwives’ approaches to SPL as a result of a complex and dynamic system. Midwives’ understanding, identification, clinical management of SPL and decision-making represents a multifaceted and stratified reality. The individual characteristics of the women, the birth attendants, the midwife, and colleagues, as well as the relationships occurring in this context, represent the main factors whose variable interactions may result in variable manifestations of the midwifery approach. On the basis of the findings of this research, recommendations are made for midwifery practice, education and research.