Back to Basics
An exploration into midwives' use of active labour and birth techniques in a tertiary setting
Michelle Newton,A Della Forster,B,C Wendy Linford,D Gemma Wills,D Kim ConguesD
A Division of Nursing & Midwifery, La Trobe University; B Mother and Child Health Research, La Trobe University; C Royal Women's Hospital; D Mercy Hospital for Women
Why 'Back to Basics'?
Despite evidence on the benefits of being active during labour and birth, it appears that many women still labour and give birth in bed, not taking advantage of the possible benefits of being more active.
In order to provide safe care for women in labour it is essential that midwives providing that care are as skilled as possible. Fundamental skills include a thorough knowledge of, and ability to practice, 'the basics'. This includes skills such as: assessing progress of labour; abdominal palpation; vaginal examination; an understanding of the course of normal labour; how best to support women in labour; the benefits of being active in labour; and non-pharmacological methods of pain relief in labour.
We designed an education program for midwives to re-visit these skills - 'Back to Basics' (B2B).
Aims of the study:
Our aim was to introduce and evaluate an education program focused on the basic skills involved in caring for a woman in labour and the benefits of 'active birth', for midwives working at Mercy Hospital for Women, Melbourne.
The aim of the evaluation was to:
- Assess changes in knowledge and views of midwives regarding basic skills in care of women in labour before and after the introduction of the education program
- Audit changes in clinical practice observed after the introduction of B2B.
What study design was used?
A before and after design was used to evaluate the effect of introducing B2B. Data were collected from both of these sources before and after the intervention: a survey of all midwives working with birthing women or providing childbirth education, exploring their views on active birth and perceptions of basic midwifery skills; and an audit of charts of labour care and outcomes of women presenting with a singleton pregnancy, cephalic presentation in spontaneous, term labour.
Based on hospital reports, 70% of women having normal vaginal births gave birth lying down. To see a reduction to 50% (with 95% confidence and 80% power) we needed to audit the outcomes of 103 women presenting in normal labour before and after the intervention. Given that a percentage of those who present in normal labour would not have a normal vaginal birth, we planned to audit 150 charts at each time point.
We offered all midwives working with birthing women or providing childbirth education the opportunity to participate in the survey. Response rates were 54% and 65% for before and after the education strategy.
- Baseline data:
- Survey of midwives (n=38)
- Practice audit (n=158)
- Intervention:
- Education program
- Information for women on birth choices
- Evaluation of effect:
- Survey of midwives (n=62)
- Practice audit (n=153)
The intervention
A twelve-month education strategy was implemented, initially targeting midwives who worked with labouring women or provided childbirth education. Four one-hour interactive in-service sessions covered key concepts and evidence around care in normal labour, based on adult learning principles and using a learner-centred approach. Evidence based references supported the education program.
Our participants
From the introduction of the education program in November 2003 until November 2004, 140 midwives participated in the program. The breakdown of session attendance is represented below.
Outcomes:
Primary Outcome:
Position of birth
There was no difference before or after the intervention in the position of birth for women who had a spontaneous vaginal birth.
Secondary outcomes:
Use of active birth techniques:
reported versus actual
All the midwives surveyed after B2B (100% ) and 94% surveyed before stated that they used 'active birth' methods in normal labour management. There were no differences between the groups in the use of any listed active birth methods (Table 1).
| Group One n=37 before B2B |
Group Two n=59 after B2B |
|
|---|---|---|
| Position Change | 97% | 98% |
| Shower | 97% | 92% |
| Bean Bag | 95% | 94% |
| Walking | 95% | 90% |
| Birth Ball | 89% | 95% |
| Birth Mat | 82% | 76% |
| Hot / Cold Pack | 82% | 79% |
| Bath | 79% | 73% |
| Rocking | 76% | 68% |
| Massage | 74% | 60% |
| Relaxation | 55% | 56% |
There was evidence from the practice audit that women used active birth techniques in labour but on a far lesser scale than reported in the midwives survey. Again there was little increase in active labour techniques used between groups before and after the intervention (Table 2).
| Group One n=158 before B2B |
Group Two n=153 after B2B |
|
|---|---|---|
| Position Change | 45% | 41% |
| Walking | 30% | 31% |
| Hot Packs | 27% | 14% |
| Massage | 20% | 20% |
| Rocking | 18% | 20% |
| Shower | 16% | 21% |
| Bean Bag | 14% | 6% |
| Relaxation | 14% | 17% |
| Birth Ball | 13% | 15% |
| Stroking | 8% | 9% |
| Birth Mat | 6% | 9% |
In a comparison of the top five active birth techniques reported (from the midwives survey) and actual (from the practice audit) showed a considerable contrast (Figure 3).
Midwifery skills: competence
A major focus of the survey was the midwives self-rated confidence and competence around monitoring progress of labour. They were asked about a range of clinical skills related to this. When calculated using a two-sample test of proportions there was a significant increase in self-reported competence in assessing the progress of labour by abdominal palpation and vaginal examination after B2B.
| Group One n=38 before B2B |
Group Two n=60 after B2B |
p= | |
|---|---|---|---|
| Abdominal Palpation * | 92% | 100% | 0.026 |
| Vaginal Examination (VE) * | 71% | 95% | 0.002 |
| Fetal position on VE | 66% | 60% | 0.632 |
| Using clinical signs | 61% | 65% | 0.816 |
| Women's behaviour | 62% | 75% | 0.298 |
| Verbal cues | 44% | 41% | 0.859 |
| Type of contractions | 29% | 27% | 0.916 |
Midwifery skills: opportunity
Aside from competence and confidence, we wanted to understand the opportunities that midwives had to use these clinical skills. Using a two-sample test of proportions there was a significant increase in the proportion of midwives who felt they had the opportunity to utilise their skills in vaginal examination and assessing fetal position on vaginal examination after B2B.
| Group One n=38 | Group Two n=60 | p= | |
|---|---|---|---|
| Abdominal Palpation | 100% | 100% | |
| Vaginal Examination (VE) * | 71% | 98% | <0.001 |
| Fetal position on VE * | 71% | 92% | 0.01 |
| Other skills * | 85% | 100% | <0.001 |
Accoucheur:
The profession of the accoucheur in spontaneous vaginal births was of interest to the research team. Midwives were the accoucheur in the majority of spontaneous vaginal births (65% before & 52% after). However, when taking into account the number of births where both midwife and student assumed the role of accoucheur we can determine that midwives alone or working with students are responsible for a high proportion of these births (71.5% before and 86.9% after B2B p=0.003). This may have been influenced by the number of student midwives on placement in birth suite at the time of the second audit as well as a push for more midwifery led births in the B2B program.
Conclusions
The Back to Basics program appears to have been implemented as we intended, and was well attended. Although there was no change in our primary outcome measure of position of birth, nor in the proportion of women using active birth techniques during labour, we did see changes in the self-reported skills of midwives in undertaking and feeling competent with key aspects of monitoring progress of labour. The outcomes of this project have given us a basis with which to move forward, and has provided a focus for further clinical research in the form of audit of specific birthing suite practices; Weighing up Evidence in Birthing Suite (WEBS).
The B2B team would like to acknowledge and thank:
The members of the original research team including Jennifer Stevenson, Cheryl Prentice, Megan Burgmann; the midwives who gave of their expertise to facilitate the training including Bernadette Reynolds,
Caprice Gellman, Leanne Plush and Tracy Henderson; for the ongoing support of this and many other projects, Denise Patterson
and finally to all the midwives who participated in the project and were willing to take the time to examine their own practice.
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