Reflection on Augmentation
a third year student midwife
I have chosen to use Gibbs’ Reflective Cycle (1988), as I am most
familiar with this model. To maintain confidentiality, all names
used are pseudonyms.
Description
I was assigned to care for Joanne, a primigravida in
spontaneous labour at term, who arrived on delivery suite
using TENS and mobilising well. On vaginal examination
(VE) the cervix was 7 cm dilated. Three hours following
admission, Joanne was behaving ‘transitionally’ and having
some urges to push. On VE, I found a rim of cervix and the
fetal head had descended well into the pelvis. I reassured
Joanne that she was making good progress. However, my
mentor advised that Joanne would require Syntocinon
augmentation based on the required progress of 1 cm per
hour not being met. When I challenged her, she sought the
support of the registrar on duty who confirmed that this was
unit policy.
Joanne was given Syntocinon augmentation and
continuous monitoring until she gave birth soon after.
Feelings
I was excited to be caring for Joanne who was keen
on having a natural labour and birth. Having spent time
observing her behaviour and contractions, I was confident
that Joanne’s labour was progressing well and thought my VE
confirmed this. I provided emotional support to Joanne and
the feeling in the room was one of positive anticipation.
This changed significantly when my mentor entered.
Joanne became distressed because her labour wasn’t
progressing. I felt a whole host of emotions and feelings.
I was disappointed for Joanne that she was not going to
achieve the birth she had wanted, and also for myself. I felt
that my judgment had been undermined and I was angry
with my mentor for the manner in which she brought about
a drastic change in this labour. I was quite shocked at her
attitude towards Joanne and me.
I began to doubt my own knowledge – the registrar was
adamant that this labour needed augmentation.
My confidence levels dropped, and I felt self-conscious
supporting Joanne through the rest of her labour with my
mentor watching over me. Afterwards I was disappointed in
myself because I had been unable to advocate for Joanne – I
felt that I had let us both down.
Evaluation
This scenario began very positively for me – the
opportunity to care for a low risk woman wanting an
unmedicated labour does not come along often. I was
pleased to be able to observe Joanne’s labour and find ways
of supporting her that are not applicable to other scenarios
(for example, women labouring under epidural anaesthesia).
As a student, I have become used to having my practice
10 Midwifery Matters ISSUE 129 Summer 2011
challenged and I find this a useful way of learning. I have
enjoyed good relationships with both midwifery and medical
staff, and have always found them receptive to questions
about decisions or aspects of care. On this occasion my
questions about up-to-date research regarding rates of
cervical dilatation were dismissed, and for the first time I
was personally aware of the theory-practice gap. I was also
aware that Joanne’s informed consent was not sought for the
interventions, although this is not the focus of this reflection.
The two key issues from this experience that I need to
reflect on are my understanding of acceptable progress in
labour, and the lack of empowerment I experienced in my
role as a junior and unqualified team member.
Analysis
Progress in Labour
Cervical dilatation is caused by contraction and retraction
of uterine muscle fibres, which cause the cervix to shorten
(efface) and open (dilate) (Walsh 2004). It is a key factor in
diagnosing and tracking progress in labour, and is complete
when 10 cm dilatation is reached (Walsh 2004).
Various obstetricians have defined acceptable rates of
progress in labour, the best known being Friedman and
Philpott (Walsh 2004). Friedman (1954) plotted a graph
of primiparous labour, defined latent and active phases,
and reported an average length of ‘active’ labour (3.5 cm
–10 cm dilatation) of 4.4 hours. Methodological flaws are
numerous in this study due to the inclusion of breech,
multiple gestations, induced/augmented labours, liberal use
of sedation, 99% episiotomy rate and a 68% forceps delivery
rate (Friedman, 1954).
Philpott developed the first ‘partogram’, a graphical
record of labour with ‘alert’ and ‘action’ lines, based on
studies of African women (Studd 1973). Studd adapted this
for the UK, producing a 1cm/hr labour curve with a 2-hour
action line. Despite these early partograms having 2-hour
action lines, supporters of ‘active management’ policies
advocate intervention as soon as a woman’s labour deviates
from the 1cm/hour ‘norm’ (Akoury et al, 1988, O’Driscoll
and Meagher 2003). It is apparent that the registrar and
midwife involved in this scenario both supported active
management, even though such a policy does not exist in
our unit. Some authors suggest that clinical decisions are
influenced by factors outside the woman’s clinical picture,
with pressure for bed space and fear of litigation being cited
(Lowe, 2007).
Whilst partograms can be useful tools in documenting
labour, strict adherence to action lines reduces scope for
decision making – midwives in Lavender and Malcomson’s
(1999) survey felt that action lines threatened their
autonomy. The midwives also felt that partograms relate
to obstetrics, not midwifery, and that progress in labour
should not be judged on cervical dilatation alone (Lavender
and Malcomson 1999). The concept of tracking progress
in labour based on more than just cervical dilatation
was evident in a study by Perl and Hunter in 1992. They
performed a retrospective analysis of primigravid women in
spontaneous, active labour at term. Multiples and breech
were excluded and confounding variables were analysed
– during the study period no labour management policies
were used and diagnosis of dystocia was not based on
cervical dilatation alone (Perl and Hunter, 1992). The study
found no difference in labour outcomes between women
who progressed at 0.5 cm/hr and those who progressed at
1cm/hr or more. When the rate of dilatation fell below 0.5
cm/hr the need for intervention increased.
Albers et al (1996) and Zhang et al (2002) have replicated
these findings. Results showed a substantially slower rate
of cervical dilatation and not as uniform a pattern of labour
as that published by Friedman, and with no increase in
morbidity.
Such studies have led to guidelines being amended
by both the American College of Obstetricians and
Gynecologists (ACOG) and by the National Institute for
Health and Clinical Excellence (NICE). In the most recent
ACOG guideline on managing dystocia, classification of
acceptable progress being 1.2 cm/hr dilatation was removed
(ACOG, 2004). Guidelines from NICE (2007) advise
consideration of all aspects of progress including a minimum
of 2 cm dilatation in 4 hours (0.5cm/hr); descent and rotation
of the fetal head; and the frequency, strength and duration of
contractions (NICE, 2007).
Unfortunately, this incident happened before publication
of the NICE guideline, which specifies an evidence-based
measure of progress in labour. The unit does use partograms,
but does not use action lines, so decisions regarding
management are the responsibility of the caregiver and
ideally, the woman herself.
Empowerment
Empowerment means, “to give power or authority to;
to enable or permit” (Dictionary.com, 2006). It is a phrase
often used in midwifery, both in terms of empowerment of
midwives and of women (International Confederation of
Midwives (ICM) 2005).
Lack of empowerment for nursing and midwifery students
can lead to loss of self-esteem and confidence, which can
result in students leaving (Bradbury-Jones et al 2007). Whilst
this incident did not make me consider leaving the course,
I certainly felt low on confidence following Joanne’s labour.
The theory-practice gap I experienced, along with a lack of
practice in decision making and using judgement were noted
by Begley (1999) – the phenomenological aspect of her
mixed-methods study into student midwives’ experiences
found repeated reference to these issues.
A qualitative study by Bradbury-Jones et al (2007)
using a critical incident technique with nursing students
also found that learning in practice was affected by the
lack of responsibility afforded to students. The authors
found that students often felt belittled by members of the
multidisciplinary team and unable to act as advocates for
their patients owing to a lack of power. These findings sum
up how I felt on this occasion.
The theory-practice gap is also alluded to by Ewing
(2006), who notes that midwifery tutors strive to produce
educated, professional midwives who are autonomous and
able to make evidence-based decisions. In reality, these
midwives must follow medical, locally produced guidelines
leading to erosion of the midwife’s role in normal childbirth
(Ewing, 2006). This opinion is supported by Kitzinger
(2005) who suggests that the concept of keeping birth
normal is trivialised, and that midwives are unable to
fully support women in ‘normal’ labour due to restrictive
management protocols (Kitzinger, 2005). This mirrored my
own experience – I did not feel that I had supported Joanne
properly during the latter stages of her labour.
Lack of empowerment caused by restrictive unit
protocols is a recurring theme in the literature, along with
the effect of hierarchies. In Begley’s (2002) longitudinal
cohort study of student midwives in Ireland, it was noted
that in an environment where doctors make decisions,
midwives and students suffer from a lack of confidence in
developing autonomy and professionalism. The issues caused
by hierarchical structures are not the sole fault of medical
staff, as senior midwives often reinforce the hierarchy to
junior team members (Begley, 2002).
Several papers by Hollins-Martin and Bull (2004, 2006)
reinforce Begley’s findings in relation to hierarchy. In their
studies into obedience, results showed that where midwives
did make decisions, these were influenced by obligation
to follow hospital policy and fear of consequences if they
challenged clinicians further up the hierarchy (Hollins-Martin
and Bull, 2006). A separate analysis of data found that
social relationships and the hierarchy within maternity units
affected decision making much more than training (Hollins-
Martin and Bull, 2004).
Both organisations and individuals can foster
empowerment of midwives. In the workplace, midwives need
regular skills and knowledge updates; recognition of their
role from medical staff; control over their own decisions;
and most importantly support from their colleagues and
managers (Matthews et al, 2006). On a personal level,
midwives need self-awareness, understanding their own
standards of behaviour and boundaries and what they will
tolerate from others (Hadikin 2002). In a work situation,
controlling emotional responses and taking time to respond
rather than react helps us to be assertive and become
empowered (Hadikin, 2002).
Conclusions
From reading about cervical dilatation, I have concluded
that whilst it is an important way of measuring progress
in labour, it should not be used to dictate practice as has
previously been claimed. Recent research has unanimously
found that 1 cm/hr is not an average rate of dilatation for a
primigravida, and that progress can equate to half this figure
without an adverse effect on outcomes. Original research
undertaken in the 1950s was methodologically flawed, and
clinical practice then does not relate to modern practice.
Philpott’s partograms were designed to alert caregivers in
rural Africa to potential issues in labour so women could be
transferred to hospital in good time (Studd, 1973). Even with
the adjustments made for use in the UK, partograms are still
Summer 2011 ISSUE 129 Midwifery Matters 11
open to individual interpretation and their prescriptive use in
maternity units removes individual midwives’ autonomy.
In my scenario, my mentor and the registrar would
not allow Joanne’s labour to deviate even slightly from the
1cm/hr labour curve. Had partograms with action lines been
in place, intervention would not have been indicated, and
Joanne’s labour would have been left to progress naturally. I
have also considered Lowe’s (2007) opinion that decisions
are sometimes based on pressure for beds or fear of
litigation. The unit was moderately busy on this particular
shift, but I felt no pressure to clear my room, so I doubt that
either issue was relevant on this occasion.
I do feel that the hierarchy on the unit played a big part in
what happened with Joanne. The registrar covering delivery
suite very firmly believed in the 1 cm/hr ‘rule’ regarding
labour progress. The shift co-ordinator did not offer any
support either to me or to my mentor during the shift. This
could be down to acceptance of the doctor being responsible
for decision making, regardless of Joanne’s ‘low risk’ status.
From this experience, I can see how this hierarchy blocks
midwives from being empowered, which in turn disempowers
students working with them and more importantly, the
women in their care.
Action Plan
Following this incident, I debriefed with my peers and
with my supervisor of midwives who was working the next
shift. I resolved to undertake this formal reflection as a way
to work through the issues.
Soon after, I used the opportunity of my mid-placement
interview to discuss the incident with my mentor, and I
explained how her actions had made me feel. I was able to
follow advice about controlling my emotions (Hadikin, 2002).
My mentor apologised, and we had a very constructive
discussion about the theory-practice gap and the realities of
working in a consultant led unit.
Later in my placement, I found myself in a similar situation
with a covering consultant requesting that I artificially
rupture the membranes of a lady who had just strayed off
the 1cm per hour ‘rule’. I explained why I was confident
that her labour was progressing normally (as evidenced by a
change in contractions, her behaviour and fetal descent) and
to my surprise the consultant retracted her plan and agreed
to reassessment in one hour. The unit co-ordinator was very
supportive, my confidence was restored, and the mother
enjoyed her natural birth.
I would now feel confident in challenging care plans
again if I thought they were not evidence-based or against a
woman’s wishes. Whilst I have accepted that some policies
or protocols in a consultant led unit are not supportive of
midwifery skills and attitudes, I have learnt that these can be
challenged and need not always dictate midwifery-led care.
REFERENCES
ACOG (2004). ACOG Practice Bulletin: Dystocia and
Augmentation of Labor. International Journal of Gynecology
and Obstetrics, 85, 3, 315-324.
Akoury H, Brodie G, Caddick R, McLaughin V, Pugh P (1988).
12 Midwifery Matters ISSUE 129 Summer 2011
‘Active management of labor and operative delivery in
nulliparous women’, American Journal of Obstetrics and
Gynecology, 158, 2, 255-258.
Albers L, Schiff M, Gorwoda J (1996). ‘The length of active
labor in normal pregnancies’, Obstetrics and Gynecology, 87,
3, 355-359.
Begley C (1999). ‘Student midwives’ views of learning to be a
midwife in Ireland’, Midwifery, 15, 4, 264-273.
Begley C (2002). ‘Great fleas have little fleas: Irish student
midwives’ views of the hierarchy in midwifery’, Journal of
Advanced Nursing, 38, 3, 310-317.
Bradbury-Jones C, Sambrook S, Irvine F (2007). ‘The meaning
of empowerment for nursing students: a critical incident
study’, Journal of Advanced Nursing, 59, 4, 342-351.
Dictionary.com (2006). Available online at <http://dictionary.
reference.com /search?r=2&q=empowerment> [Accessed
3rd October 2007]
Ewing A (2006). ‘Mechanical midwifery – autonomous or
automaton?’ Midwifery Matters, 111, 3-4.
Friedman E (1954). ‘The graphic analysis of labor’, American
Journal of Obstetrics and Gynecology, 68, 6, 1568-1575.
Gibbs G (1998). Learning by Doing: A guide to teaching
and learning. Further Education Unit, Oxford Brookes
University, Oxford.
Hollins-Martin CJ & Bull P (2004). ‘Does status have more
influence than education on the decisions midwives make?’
Clinical Effectiveness in Nursing, 8, 3-4, 133-139.
Hollins-Martin CJ & Bull P (2006). ‘What features of
the maternity unit promote obedient behaviour from
midwives?’, Clinical Effectiveness in Nursing, 9 (suppl 2): e221-
e231.
ICM (2006). The philosophy and model of midwifery care.
Available online at <http://www.internationalmidwives.org>
[Accessed 3rd October 2007].
Kitzinger S (2005). ‘Midwifery degraded’, The Practising
Midwife, 8, 8, 4-5.
Lavender T & Malcomson L (1999). ‘Is the partogram a help
or a hindrance?’ The Practising Midwife, 2, 8, 23-27.
Lowe N (2007). ‘A review of factors associated with dystocia
and cesarean section in nulliparous women’, Journal of
Midwifery and Women’s Health, 52, 2, 216-228.
NICE (2007). Clinical Guideline 55. Intrapartum Care: care
of healthy women and their babies during childbirth. NICE:
London.
O’Driscoll K & Meagher D (2003). Active Management of
Labour 4th Edn, Mosby, Edinburgh.
Perl F & Hunter D (1992). ‘What cervical dilatation rate
during active labor should be considered abnormal?’
European Journal of Obstetrics, Gynecology and Reproductive
Biology, 45, 2, 89-92.
Studd J (1973). ‘Partograms and nomograms of cervical
dilatation in management of primigravid labour’, British
Medical Journal, 4, 5890, 451-455.
Walsh D (2004). ‘Care in the first stage of labour’, chapter 26
in Henderson C & Macdonald S (Eds). Mayes Midwifery - A
Textbook for Midwives 13th Edn. Bailliere Tindall, Edinburgh.
Zhang J, Troendle J,Yancey M (2002). ‘Reassessing the labor
curve in nulliparous women’, American Journal of Obstetrics
and Gynecology, 187, 4, 824-828.