Thursday, September 08, 2011

Living with uncertainty

I arrived at the home of a woman in labour, and everything I saw and knew about this woman and her baby told me that the birth was imminent. After greeting her - she was in the shower - I went through the routine setting out of my equipment in readiness and connecting the oxygen cylinder to the flow meter.

Three hours later, there was no baby. No apparent problem with either mother or baby. A rim of cervix, an undescended fetal head, ... Mother asked me if I had brought my knitting. No - I really didn't expect to be waiting around long enough. It's a second baby, after all.


Six hours later, still no baby. Still a rim of cervix, and no discernable progress in the station of the head.

Readers will be pleased to know that this mother did give birth spontaneously to a healthy baby, about nine hours after I had thought the birth was imminent.
Did I get it wrong?
Or was there really a major stalling of progress late in first stage?
Why would that happen?

There are many questions in my mind as I reflect on this experience, and on the comments of both mother and father, as we chatted about the labour and birth.

I would like to draw readers' attention to a paper exploring the impact of the attitude of the obstetrician on outcomes. This paper has valuable insght into any practitioner's (including a midwife's) clinical reasoning in the face of uncertainty. The title of the paper is: Evidence based-practice and Affect: The impact of Physician attitudes on outcomes associated with clinical reasoning and decision-making1 DUNPHY ET AL. Australian Journal of Educational & Developmental Psychology. Vol 10, 2010, pp56-64. Click here for full paper.
ABSTRACT The relationship between obstetrician attitudes and patient outcomes from intrapartum care was examined. Obstetrician attitudes were assessed utilizing a newly-designed pilot 35-item obstetrician attitude questionnaire (OAQ). Twelve obstetricians completed the OAQ, who provided intra-partum care to 4,149 women. Outcome measures included delivery mode and intrapartum asphyxia. Analysis was carried out using logistic regression. A number of OAQ items were significantly associated with outcome. The significance of some of these items may be explained by past clinical experience and attitudes toward certain aspects of clinical care including acceptable intervention rates and risk of patient harm associated with certain procedures. However, the importance of other attitudes was less predictable including an increased incidence of normal delivery associated with a stronger belief in the art of clinical practice (not the evidence-based nature of practice), openness to considering the wishes of the woman in labour was associated with less neonatal asphyxia, and attitudes toward the impact of sleep deprivation on decision making were associated with intervention rates. In conclusion, obstetrician attitudes appear to have a significant impact on maternal and neonatal outcomes from intrapartum care. Clinical and theoretical implications of the findings are discussed, and further development of the OAQ is recommended.
It's a paper worth reading and reflecting upon. There is much in childbirth that requires a delicate balance of clinical reasoning, judgment, and skill. There is so much in childbirth that cannot and probably will never be simplified and codified into practice guidelines. The authors of this paper have drawn attention to the reality that in childbirth obstetricians are required "to confront ineliminable fear and uncertainty."
That's what midwives do too, as we draw from knowledge as well as the art of our profession.
That's what women giving birth do, when they surrender all control of their bodies and allow birth to do its work.

1 comment:

Carolyn Hastie said...

Great paper Joy! Thanks for the link. I'm intrigued as to what the woman and her partner had to say about the labour. I too have worked with labouring women who 'circled' in labour and either during that time or after the birth in conversation, something that was bothering them at the time would emerge and until the woman was able to let go of the preoccupying 'bother' labour would go into a 'holding pattern'. Always fascinating and deeply moving to work with women in labour. Lovely to see a conversation about the variations in women's expressions of labour. I love that old (mid)wives saying that 'women labour as they live' I've found that to be so true.