Abstract
Midwifery is built on the foundations of evidence based practice, however guidelines on one of the fundamental skills of midwifery, intermittent auscultation (IA), appears to be based on limited research and expert opinion. Discussion in the literature around intermittent auscultation tends to concentrate on comparing it to other types of monitoring such as continuous monitoring (CTGs). There is a paucity of discussion that critically looks at the use of IA in its own right, and there are no trials comparing IA with no FHR auscultation during labour. Women’s experiences of IA have also gained little attention in research, therefore this research proposal aims to use a phenomenological approach to gain a deeper understanding of women’s experiences of IA during labour.
Literature Review
A literature search was undertaken using the electronic databases of the Cochrane Library, Medline, CINAHL, Maternity and Infant Care (MIDIRS), Google Scholar. Search terms used were: intermittent auscultation, fetal heart rate monitoring, fetal surveillance, intrapartum care, informed choice, women’s experiences, interrupting birth, free birth, hypnobirthing and these were not limited by publication date. The search was refined by the use of truncated wording and the application of Boolean logic. Literature that only related to electronic fetal monitoring, was excluded. The review was restricted to literature available in English. All identified documents were examined and those that were relevant were retrieved for inclusion in the review. Reference lists of retrieved documents were then scanned to identify any additional articles of interest. Grey literature such as practice guidelines from New Zealand, Australia, United States of America (USA), United Kingdom (UK), and Canada were also appraised. In order to order my thoughts once the literature was reviewed, I used a conceptual framework as suggested by Maxwell (2012) (Appendix 1).
Fetal Heart Rate Monitoring
To place IA in context, it is pertinent to include a history of FHR monitoring. Records dating back to the 1800’s document listening to the fetal heart (Goodwin, 2000; Maude, Lawson and Foureur, 2010), however it wasn’t until the first half of the 20th century that assessment of the fetal heart throughout labour became standard practise (Martis et al, 2017). It is now seen as a fundamental midwifery skill and viewed as a central component of modern midwifery care (Maude, Skinner and Foureur, 2014; Lewis, Downe and Panel, 2015). Monitoring of the fetal heart rate (FHR) during labour aims to assess fetal wellbeing, and identify those at risk of developing hypoxaemia during labour (Altaf et al, 2006; Lewis, Downe and Panel, 2015; Martis et al, 2017). Today, monitoring the fetal heart during labour, by one method or another, appears to have become a routine part of care during labour, however access to such care, varies across the world (Alfirevic et al, 2017).
The two main methods of fetal heart monitoring in labour are; intermittent and continuous. Continuous FHR monitoring consists of the continuous and simultaneous monitoring of the FHR and maternal uterine contractions onto a paper tracing called a cardiotocograph (CTG) (Martis et al, 2017). Intermittent auscultation (IA) involves listening to the fetal heart beat periodically with a pinard, fetal stethoscope or hand-held Doppler device and recording a single measure of the heart rate at that time (Martis et al, 2017). The method of IA promotes frequent contact between healthcare professionals and the laboring woman, offering the opportunity for social and clinical support (Lewis, Downe and Panel, 2015). Continuous support is associated with less use of pharmacological analgesia, fewer operative births and fewer reports of dissatisfaction with birth (Hodnett et al, 2013). Lewis, Downe and Panel (2015) also note that IA facilitates other assessments such as maternal skin tone, temperature, breathing patterns, direct palpation of fetal movements, and maternal contractions.
Methods of FHR Monitoring
CTG
The use of continuous external fetal monitoring, usually with a CTG, has become common place in maternity settings, in high income countries, since its introduction in 1960’s (RCM, 2012). The aim of the CTG was to reduce the number of babies born with cerebral palsy, however since its introduction, these numbers have remained static (Hindley, Hinsliff and Thomson, 2006). Two Cochrane systematic reviews (Neilson, 2015; Alfirevic et al, 2017) have been conducted looking at the use of CTG’s in labour. These reviews indicated that the use of continuous CTG monitoring during labour was associated with a reduction in neonatal seizures, but without a significant difference in cerebral palsy, infant mortality or Apgar scores. There was however, an increase in caesarean sections and instrumental vaginal births (Alfirevic et al, 2017). Therefore, for women with no risk factors for fetal hypoxia in normal labour, intermittent auscultation is the method of choice because of the increased level of intervention associated with electronic fetal monitoring (Alfirevic et al. 2006; NICE 2007).
Fetal electrocardiogram (ECG) for fetal monitoring during labour
An ECG measures the heart’s electrical activity and the pattern of the heart beats by passing an electrode through the woman’s cervix and attaching it to the baby’s head (Neilson, 2015). Hypoxaemia during labour can alter the shape of the fetal electrocardiogram (ECG) waveform, notably the relation of the PR to RR intervals, and elevation or depression of the ST segment. Technical systems have therefore been developed to monitor the fetal ECG during labour as an adjunct to continuous electronic fetal heart rate monitoring with the aim of improving fetal outcome and minimising unnecessary obstetric interference (Neilson, 2015). The modest benefits of fewer fetal scalp samplings during labour (in settings in which this procedure is performed) and fewer instrumental vaginal births have to be considered against the disadvantages of needing to use an internal scalp electrode, after membrane rupture, for ECG waveform recordings.
Pinard / Fetoscope
The pinard is a trumpet shape, with a flat end which is placed on the practitioner’s ear while the horn part is placed on the pregnant mother’s abdomen (Martis, 2017). The belled tube creates an amplification chamber for sound waves that are transmitted from the fetal heart to the examiner’s ear (Lewis, Downe and Panel, 2015). The fetoscope is shaped like the stethoscope and uses the practitioner’s forehead to conduct sound. Two tubes extend out of the main long plastic tube which are inserted into the practitioner’s ears. The other end of the fetoscope is similar to the Pinard and fans out into a bell/horn shape that is placed on the mother’s abdomen (Martis et al, 2017). The benefit of both these devices, is that they will only pick up the fetal, rather than the maternal heart rate (Chapman and Charles, 2013). However the disadvantages are that women may find the pressure required for a good pinard/fetoscope auscultation, uncomfortable (Chapman and Charles, 2013), and it may be difficult to use in certain maternal positions (Lewis, Downe and Panel, 2015). These devices also do not give the mother the reassurance that is gained from hearing the heart beat (ARM, 2000).
Handheld Doppler
Auscultation with the hand held Doppler uses ultrasound to detect motion of the fetal heart valves or walls and converts this information into a sound that is heard or displayed as a representation of the fetal cardiac cycle (RCM, 2012). The advantages of the handheld Doppler are that it can be more comfortable for the woman, and it can be used in various maternal positions, including in the water (Lewis, Downe and Panel, 2015). This aids mobilising in labour, which has been shown to benefit the progress of labour (Lawrence et al, 2013). The FHR can also be heard by the woman and her partner which could provide reassurance (Lewis, Downe and Panel, 2015). The disadvantages of this device is that does not transmit the actual sound produced by the fetal heart, but rather a representation of this, based on ultrasound-detected movements of fetal cardiac structures, that are then subject to signal modification and autocorrelation (Lewis, Downe and Panel, 2015). As a result, it is also recognised that as the Doppler converts movement of the heart into sound there is potential for this to be inaccurate and misinterpreted (RCM, 2012).
Comparison of the Effectiveness of IA Tools
A recent Cochrane systematic review (Martis et al, 2017) attempted to evaluate the effectiveness of different tools for intermittent auscultation (IA) of the fetal heart rate (FHR) during labour including frequency and duration of auscultation (Martis et al, 2017). The review concluded that when compared to routine Pinnard monitoring, using a hand-held (battery and wind-up) Doppler and intermittent CTG with an abdominal transducer without paper tracing for IA in labour was associated with an increase in caesarean sections due to fetal distress (Martis et al, 2017). No clear differences in neonatal outcomes (low Apgar scores at five minutes after birth, neonatal seizures or perinatal mortality) were found and long-term outcomes for the baby (including neurodevelopmental disability and cerebral palsy) were not reported (Martis et al, 2017). The quality of the evidence was assessed as moderate to very low and several important outcomes were not reported which means that uncertainty remains regarding the use of IA of FHR in labour (Martis et al, 2017).
IA Guidelines, Frequency and Timing
Traditionally, the frequency of monitoring by midwives has been determined according to the stage of labour, with the frequency of IA increasing when the woman is in advanced labour (Chapman and Charles, 2013). Of the various guidelines that have been reviewed, the recommended frequency of IA during labour, is listening to the fetal heart every 15 to 30 minutes, before and/or during, and/or immediately after a contraction in the first stage of labour, increasing to every 5 minutes in the second stage (NICE ,2014; ACOG, 2009; Liston, 2007; RANZCOG, 2014). Although there are only slight variations in the guidance that have been reviewed, the evidence supporting them is weak. There have been no randomised or non-randomised clinical trials, recommending any particular frequency or duration of IA but instead, guidelines are based on medical expert committee opinion (Sholapurkar, 2010; Chapman and Charles, 2013; Alfirevic et al, 2017; Martis et al, 2017). Lewis, Downe and Panel (2015) recognise that recommendations for the scheduling of intermittent auscultation are based only on expert opinion, however argue that standardisation of procedures is important for planning of health care and for medical and legal purposes.
Whilst not insignificant, the incidence of moderate/severe birth asphyxia is very low in the absence of risk factors, or an acute intrapartum adverse event (Sholapurkar, 2015). An example of how some IA policies are accepting of this risk, is in the Netherlands, where there are no structured guidelines for IA at homebirths, and as a convention the FHR is auscultated every 2 h or so in the active first stage (de Jonge et al, 2015). Sholapurkar (2010) questions the feasibility of adhering to current guidance, highlighting that that many of the IA guidelines are likely to be heavily influenced by obstetricians, who understandably, have little practical experience of IA. Midwives have also expressed concerns about the frequency of intermittent auscultation in the first stage of labour as being difficult to achieve in practice, and during the second stage of labour viewed as being too intrusive for women (Spiby, 2001; Beech Lawrence, 2001). Morrison et al (1993) noted in a prospective study, that the stringent evaluation and recording frequency of IA was only carried out in 3% of cases. Lack of one-to-one care and not being logistically feasible, were given as the most common reasons for non-compliance with the guidelines (Morrison et al, 1993). Compliance with these guidelines is also discussed by Alfirevic et al (2017) commenting that compliance with these guidelines, whilst maintaining contemporaneous records, poses a significant challenge for caregivers during labour who usually have multiple tasks to fulfil simultaneously.
A recent Cochrane systematic review (Martis et al, 2017) attempted to evaluate the frequency and duration of auscultation, however, disappointingly, the studies reviewed failed to report on these outcomes. Walsh (2008) argues that without any good evidence from trials to recommend any particular frequency, it is more a ‘custom and practice’ than ‘evidence-based’ process.
Women’s Experiences of FHR Monitoring and Informed Consent
One of the key principles of woman centred care is choice (Pope et al, 2001). For a woman to make decisions about her care, she needs to be fully informed of the choices available to her. Lack of informed choice denies a woman her right to be in control of her birth experience, and is in opposition to a woman’s right to autonomy and self-determination (Heelan, 2013) . Hersh, Megregian and Emeis (2014) maintain that heart rate monitoring is too often used routinely, without discussion of the benefits and limitations of either methods. For women to make true choice, any discussion must include the choice of no intervention, along with the acceptation of the potential harms and benefits of this option (Hersh, Megregian and Emeis, 2014). Thacker (1997) suggests that ideally, an antenatal discussion about fetal monitoring should take place prior to the onset of labour, and if it has not taken place when the woman arrives at hospital, it should form part of the initial discussion as part of her birth plan.
There is a limited amount, of mostly dated research, which explores women’s experiences of informed choice and fetal monitoring (Garcia et al, 1985b; O’Cathain et al, 2002; Hindley, Hinsliff and Thomson, 2008). In a qualitative study, Rattray et al (2011) used a grounded theory approach to explore midwife’s decision making in fetal monitoring for low risk women. Semi-structured interviews with five midwives revealed that there was an unexpected lack of involvement of the woman in the decision making process. Midwives described women as passive and non-participatory in the decision making process, which they put down to as a result of high levels of trust in health professionals (Rattray et al, 2011). Rattray argued that throughout the decision-making pathway, trust and consent were inferred by the woman, allowing the midwife to apply the belts and monitoring devices. The midwives did not describe the women being actively involved in the decision-making process, nor did they talk about offering a woman the choice of declining fetal monitoring (Rattray et al, 2011).
In a quantitative study, using postal questionnaires across 12 maternity units in Wales, O’Cathain (2002) aimed to describe women’s perceptions of informed choice across all maternity services. O’Cathain (2002) found that 54% of women perceived that they exercised informed choice overall, however perceptions changed by decision point, varying between 31% for fetal heart monitoring during labour and 73% for the screening test for Down’s syndrome and spina bifida in the baby. While this study adds to the findings regarding informed choice and FHR monitoring, the use of a qualitative approach, does not enable the researchers to provide any understanding as to why only a third of women feel they do not have informed choice when making decisions about FHR monitoring. Other studies looking at women’s preferences for fetal heart monitoring, found that the support that women received from staff and labour companions was more important to them than the type of monitoring used (Garcia et al, 1985a; Killien and Shy, 1989). It is clear that there is a lack of informed consent with FHR monitoring in labour, with the use of IA is seen as a routine procedure rather than individualised care that is adapted to meet the needs of the woman (Baston, Hall and Henley-Einion, 2009).
The Effects of IA on the Birth Environment and Disrupting Birth
The birthing environment has been widely discussed in literature as an important factor in the facilitation of a normal birth (Chenery-Morris and McLean, 2012; Walsh, 2012)(Hodnett, 2009) Kitzinger (2000). Buckley (2010) purports that for birth to proceed optimally, this part of the brain must take precedence over the neocortex, or rational brain. This shift can be helped by an atmosphere of quiet and privacy, with, for example, dim lighting and little conversation, and no expectation of rationality from the labouring woman. Under thse optimal conditions, a woman will intuitively choose the movements, sounds, breathing and positions that will birth her baby most easily (Buckley, 2010). In contrast to this, researchers have questioned the effect on women’s labours when this optimal environment is disturbed. Martis (2013) writes anecdotally about how a woman she was caring for felt certain that the constant interruptions in the labour ward made her labour so much longer. Leap (2010) also claims that disrupting women’s instinctive behaviours can interfere with the physiology of labour. In a qualitative study, using narrative enquiry, Reed (2016) explored midwifery practice during physiological birth from the perspective of ten midwives and ten mothers. Reed (2016) found that assessments such as auscultation of the FHR during labour, disturbed the birthing woman by having to change women’s positions to intermittently auscultate, and in doing so took them out of ‘that zone’ (Reed, Rowe and Barnes, 2016). Martis (2013) describes the dilemma of a professional obligation to assess fetal wellbeing, while trying not to disturb the labouring woman, and recounts one woman’s experience of IA as ‘being regularly ripped away from my peaceful place’. Other studies have also have also highlighted how clinical assessments could disturb the labouring woman and interfere with the birth process (Anderson, 2010; Blix, 2011; Leap, 2010). In a qualitative study, on women’s experiences of the second stage of labour, Anderson (1997) discussed the effect of clinical assessments on women in labour (Anderson, 1997; cited in Anderson, 2010). Midwives found that carrying out clinical assessments to confirm normality, such as FH monitoring, caused concern for women, and interfered with their ability to ‘let go’ during labour (Anderson, 2010).
Walsh, discusses the importance of ‘being with’ not ‘doing to’ (2012, p. 53) labouring women, which supports the works carried out by other midwifery writers who discuss the role of the midwife as ‘being invisible’ (Nightingale, 2013, p.17), ‘drinking tea intelligently’ (Anderson, 2004, cited in Walsh 2012. P.53) and ‘the less we do the more we give’ (Leap, 2000b, p.17). However, none of these midwifery thinkers offer thoughts on how this can be achieved when midwives are obliged to follow guidelines and trust policies and IA every 15 minutes. (Reed, 2013) suggests that the practice of IA should be done in a more woman-centred way, with a discussion antenatally on method of FHR monitoring, preferences on the use of Doppler or pinnard, along with an explanation that she can change her mind at any time during labour about when and how to monitor the FHR. Reed, also suggests minimising interruptions by fitting the timing of IA around the woman’s preferences and avoiding stimulating her neocortex by asking ‘can I listen in?’. Reed recommends having a prior agreement with the woman, to gently move towards her with the doppler/pinnard, and she can move away or push you away if she doesn’t want you to listen (Reed, 2013).
Chandraharan (2012) outlines a holistic approach to assessing fetal well-being which includes an understanding of the normal physiology of fetal heart rate changes during labour and recognition of factors that influence it. The RCM (2012) state that continuous assessment should include factors such as the progress of labour, maternal hydration, fetal activity, uterine stimulation and the use of opioid’s. Martis (2013) goes a step further and debates whether there is actually a place for IA in normal labour, suggesting that observations such as regular strong contractions, normal blood pressure readings, clear liquor and an oxytocin ‘spaced out’ mother could be clear indications of fetal well-being.
Gaskin (2010) suggests looking at the animal kingdom to explore how the human mind can interfere with the birth process. Gaskin reasons, that without an understanding of how an intervention can the result in complications in birth and labour, the intervention will not stop. In essence, it is apparent that the use of IA is not necessarily an innocuous midwifery practice, but an intervention that has the potential to interrupt both the birth environment and the birthing woman.
The Fetal Heart Rate Monitoring Paradox
While NICE (2014) guidelines state that FHR auscultation should begin when women are in established labour, not all women will be in hospital at this point. Indeed, women who are classed as ‘low risk’ are encouraged to stay at home for as long as possible when the onset of labour begins (Low and Moffat, 2006; Eri et al, 2010; Rota et al, 2017). This advice is motivated by research that has shown that women that attend hospital in the latent phase of labour have an increased risk of intervention compared to woman that are admitted in the active phase of labour (Eri et al, 2010). However, this advice could mean that women are labouring at home without the fetal heart rate being monitored. When discussing the use of IA in normal labour, Martis (2013) questions how many babies are born before they arrive at the intended place of birth, without having had any auscultation. Thus, women are faced with the paradox of being encouraged to stay at home without any fetal monitoring when in labour, then when they arrive at hospital are intermittently auscultated every 15 minutes in the first stage of labour. Reed, Rowe and Barnes (2016) describes how midwives acknowledge how labour can be unpredictable and difficult to assess, so one could question, why, when telephone triaging women, aren’t midwives concerned that the FHR is not being monitored. The protective mechanisms of hospitals and health departments (Walsh, 2012) could be the reason for this, with the need to have documented evidence of fetal wellbeing via the FHR once confirmation of established labour and when on hospital premises.
Are we losing the skill of IA?
In recent years maternity services have faced substantial scrutiny, with the publication of the Kirkup Report (2015) focussing on safety within maternity services, and the subsequent launch of the ‘Each Baby Counts’ programme from the RCOG. It is perhaps not surprising in this climate, that fetal heart rate monitoring and intermittent auscultation has not gone without criticism. As part of the RCOG ‘Each Baby Counts’ review, there were a number of cases that highlighted IA as a significant contributing factor in the outcome (RCOG, 2015). However on further analysis, it was not the IA that resulted in poor outcome but rather the decisions that were made when deviations from the norm were identified. Sholapurkar (2015) has also suggested that the timing and frequency of IA needs further investigation after noting that asphyxiated infants were delivered despite rigorously performed and documented IA compliant with the guidelines. Sholapukar also notes how health care professionals have reported cases where women had normal IA, but were found to have pathological FHR pattern (especially late decelerations) as soon as they were placed on CTG (Sholapurkar, 2015). Poor neonatal outcomes were reported despite prompt delivery, leading to a speculation that an abnormal FHR pattern may have been missed for quite some time in those labours (Sholapurkar, 2015).
The introduction of electronic fetal monitoring has had a significant effect on the IA skills of midwives (Heelan, 2013; Maude, Skinner and Foureur, 2014). Maude, Skinner and Foureur (2014) argue that IA is a skill that is rapidly disappearing from midwifery practice because midwives and other clinicians prefer the application of an electronic and continuous means of listening to the fetal heart using a cardiotocograph (CTG) machine. The RCM (2012) also note that within todays modern practice, the use of the Pinard stethoscope appears to be a dying skill, despite the fact that it is specifically included within the standards of for pre-registration midwifery education. Smith et al (2012) postulates the reason for this preference in the context of litigation. Smith claims that IA potentially exposes clinical staff to criticism and litigation, claiming that when an adverse outcome occurs, proof is not achievable especially when compared to the hard copy of evidence produced by a CTG machine.
Thus it is evident that a potential training deficit has been identified in the literature. One of the recommendations of the ‘Each Baby Counts’ report was to ensure all staff tasked with CTG interpretation should have documented evidence of annual training. It could, be argued that this should be extended to IA too.
Conclusion
There is a plethora of research comparing CTG and IA, but despite being regarded as a fundamental midwifery skill, IA in its own right is inadequately researched. Data regarding the benefit or burden to women is limited (Hersh, 2014) and women’s experiences of IA are also poorly understood. Given that IA is regarded as the method of choice when monitoring the fetal heart rate in labour for approximately 45% of women (Tanjay, 2014), it is timely that research is undertaken to understand women’s experiences of this practice.
Research Proposal
Research design
Methodology
A qualitative study using a phenomenological approach
Philosophy
My study seeks to understand a phenomenon from a women’s point of view, which lends itself to a qualitative approach.
To obtain a deeper understanding of women’s lived experiences of IA during labour, I have chosen to use the methodology of phenomenology. Phenomenology permits in depth exploration of a phenomena, and allows the researcher the ability to delve into, and gain an understanding of an otherwise poorly understood phenomena (Cluett and Bluff, 2006). A phenomenological approach is ideally suited to midwifery research because the underpinning philosophies of midwifery are congruent with that of phenomenology (Harvey and Land, 2017). Phenomenology like midwifery, places emphasis on the importance of being person centred and holistic, requiring excellent communication, observation and interpersonal skills (Murtagh and Folan, 2014). Examples of midwifery researchers using phenomenology are bountiful (Cluett and Bluff, 2006). Thelin, Lundgren and Hermansson (2014) used a phenomenological approach to obtain a deeper understanding of midwives’ lived experience of caring during childbirth, whilst Murtagh and Folan (2014) investigated women’s experiences of induction of labour and how it impacts on their experience of childbirth. These examples emphasise the strength of phenomenology in uncovering often sensitive and unexplored phenomenon.
Sample size and timescale
A sample size of six participants will be recruited by purposive sampling. Phenomenological studies require the use of in-depth interviews and allow the sample size to be small and selective (Cluett and Bluff, 2006; Mapp, 2008). Random sampling is inappropriate in qualitative research due to the specific and identified phenomena needing to be analysed and therefore purposive sampling is well suited to phenomenology (Cluett and Bluff, 2006). The strength of purposive sampling is that it allows the selection of individuals whose qualities or experiences permit and understanding of the phenomenon in question and are therefore invaluable (Patton, 2002).
Braun and Clarke (2013) claim that one of the hardest parts of qualitative research is timetabling and keeping it on track. As an undergraduate proposal, I aim for my study to be carried out over a period of 8 months, however this is subject to change and dependant on time taken for ethical approval. A proposed timetable is suggested in Appendix X.
Ethical Approval
When carrying out research there is a potential for harm, stress, anxiety and series of other negative consequences for participants (Robson and McCartan, 2016). This can be exacerbated when the topic of research is sensitive. Ethics refers to rules of conduct, typically conforming to a code or a set of principles (Israel, 2014). Like most health research, my research proposal will apply ethical principles on the basis of autonomy, non-maleficence, beneficence and justice (Beauchamp and Childress, 2013). In order to make an autonomous choice about whether to participate in the study, participants should be provided with clear, comprehensive and accurate information about the study (Slowther, Boynton and Shaw, 2006). In this study each participant will receive a participant information sheet (PIS) (Appendix X), detailing what the research is, what is involved by taking part and making it clear that they are free to withdraw from the research at any point. Informed consent from participants will be demonstrated by using a tailored consent form (Appendix X). The PIS will be attached to the consent form, as a permanent record for the participant, as suggested by Boynton (2005), and given to each participant a minimum of 24 hours before taking part, to enable time for reflection on participation (Boynton, 2005). Due to the potential sensitive nature of the topic, a support mechanism for debriefing will be included within the study design. Agreement will be sought with the Consultant Midwife within the Trust, for referral of participants should the need arise.
All materials used for the research, participant information sheet, consent forms, interview schedule and recruitment posters, will be presented to the research ethics committee, and ethical approval will be sought via the Integrated Research Application System (IRAS). Confidentiality will be maintained by the removal of identifiers and the use pseudonyms for all participants thus protecting their identity. Data recording and any transcripts will be stored in a locked cabinet and electronic versions will be stored on a password protected computed.
Data Collection
I intend to recruit my participants in the post-natal period using a purposive sampling method, because it selects individuals who will have knowledge of the phenomena concerned (Mapp, 2008) . Braun and Clarke (2013) suggest identifying key people who can be used to help recruit participants, in my case these are midwives on the Midwifery Led Unit (MLU) and community midwives at my local NHS trust. Flyers and posters will be left in the MLU and also given to community midwives who will be asked to give them to women who fit the inclusion criteria. I intend to approach MLU and community midwives, and brief them on my research project, recruiting them to access women in the postnatal period. Once women had been identified and agreed to participate, I would contact them one week later and confirm their willingness to participate.
Semi structured interviews, using open ended questions (Appendix X) will be carried out as my method of data collection, which is a common method of choice when using a qualitative approach (Robson and McCartan, 2016). Semi-structured interviews enable the researcher to answer the ‘how’s?’ and ‘what’s?’ and are ideally suited to the experience-type research questions (Braun and Clarke, 2013). A well prepared interview guide is the key to a successful interview (Braun and Clarke, 2013). The interview guide will be developed by listing key questions or issues in the form of headings or themes (Cluett and Bluff, 2006) that have been derived from the literature review of the topic and from professional knowledge and experience. The guide will then be tested out on experts in the field to ensure the questions answer the research question (Braun and Clarke, 2013). The interview will take place at a location convenient for the participant, either in a private room in the hospital or at their own home. Interviews will be recorded and transcribed verbatim.
The data collection process will begin with a small pilot, interviewing one participant to test out the interview guide. A pilot is a useful way of determining whether the questions are generating the kind of data needed to address the question (Braun and Clarke, 2013). As a novice researcher, the pilot will also give me the opportunity to hone my interview skills.
Inclusion criteria: Women over the age of 18, that are categorised as ‘low risk’ and eligible for IA throughout labour. IA must have been used in the first and second stage of labour, however they will not be excluded if monitoring is switched to continuous CTG at some point in the second stage.
Exclusion criteria: Women under the age of 18, non-English speaking, ‘high risk’ and continuously monitored throughout the first and second stage of labour. Women who have a stillbirth, neonatal death or have a baby on the neonatal until will be excluded from the study.
Data Analysis
The method for data analysis will be thematic analysis (TA) as outlined by Braun and Clarke (2006). TA is the process of identifying patterns or themes within qualitative data and Braun and Clarke (2006) provide a useful framework which uses a six step guide (Figure 1) for conducting TA (Maguire and Delahunt, 2017). The steps are not necessarily linear and it may be necessary to move between them a number of times, particularly if dealing with a lot of complex data (Maguire and Delahunt, 2017). The software package Nvivo 11 will be used throughout this process to organise the data generated.
Figure 1: Braun ; Clarke’s six-phase framework for doing a thematic analysis
Step 1: Become familiar with the data
Step 4: Review themes
Step 2: Generate initial codes
Step 5: Define themes
Step 3: Search for themes
Step 6: Write-up
The main strength of this method is its flexibility, and is well suited to phenomenology, developing a detailed account or aspect of a phenomenon (Braun and Clarke, 2013). TA is also an excellent method for those new to qualitative research as it offers the chance to learn basic handling and coding skills without having to delve into theoretical constructs (Braun and Clarke, 2013). Trustworthiness and credibility of the data will be enhanced by carrying out member checks, by providing participants with the interview transcripts to confirm my interpretation of their data (Cluett and Bluff, 2006).
Limitations
As with many methodologies there are potential criticisms. Phenomenology is theoretically complex (O’Leary, 2004) and was born out of philosophy rather than research methodology. According to Snow (2009), this is likely to be the root cause of the controversy when applying phenomenology within midwifery. Many authors suggest midwives should leave phenomenology alone, due to the difficulties in faithfully applying philosophical principles to research methods (Snow, 2009).
By carrying out the research in one maternity unit in the North West of England, the findings may not be generalizable to other maternity units. However, according to Guba (Guba and Lincoln, 1981)(1981), the idea of fittingness may be more appropriate to consider. Fittingness alludes to how transferable the data is when the practitioner applies the findings to their own experiences (Sandelowski, 1986).
Gathering data through interviews can be time consuming and labour intensive (Robson and McCartan, 2016), and requires the interviewer to be highly skilled (Parahoo, 2014). However, Robinson (2006) suggests that midwives are equipped with the appropriate communication skills to conduct interviews using a phenomenological approach. Interviews also risk interviewer bias, where the interviewer in some way influences the responses (Cluett and Bluff, 2006). As a student midwife as the interviewer, there is a risk the interviewee may respond to questions in more ‘socially desirable’ way than they would if the researcher was completely independent of the research subject (Mitchell and Jolley, 2012). Braun and Clarke (2013) state that it is not possible or desirable to minimise the effect of the interviewer and instead the interviewer should be reflexive, noting throughout how their practice and values may have shaped the data.
Dissemination of results
Reporting on the findings of research is an essential part of the research process, and ethically it is the researchers responsibility to ensure that the results of a study get into the ‘public domain’ (Robson and McCartan, 2016). I intend on disseminating my research results in a variety of ways such as presentation to staff at the local hospital trust, a poster presentation to academic conferences, paper to academic journal and also provide copies of the final report to the participants in an appropriate format using lay terms.
Implications for practice.
This study has the potential to increase knowledge and understanding of women’s lived experience of IA during labour and therefore has implications for practice, education, and research. By providing a window to view women’s unique experiences of childbirth, which would otherwise not be known can facilitate improvement in practice. The use of a phenomenological approach has the capability of making practitioners more empathetic through insight into other peoples’ experiences which in turn also enriches their own experiences (Snow, 2009). This research proposal provides the opportunity for women’s experiences, of what is a fundamental skill in midwifery, to be highlighted and ultimately pave way for more research in the future.
Costing
The costs of the research project will be small, involving printing flyers, consent forms, potential room hire for interviews if not in interviewees home, travel, purchase of recording equipment. Transcription, analysis and writing up of the results will be carried out by myself as part of my undergraduate degree. I will approach the research midwives at the local hospital trust to fund any costs of the research, and other funding avenues could also be explored, such as the National Institute for Health Research (NIHR) and the Medical Research Council.
Conclusion
IA is a fundamental midwifery skill and is relevant for almost half of women in labour (Tanjay, 2014). The IA guidelines reviewed in the literature review are based on low quality evidence and expert opinion. Women’s experiences of IA in labour have largely been ignored and research that does exist, highlights women’s lack of informed choice and consent. Therefore, this phenomenological study will attempt to redress this balance, enabling midwives and other clinicians to understand women’s lived experiences of IA, and thus influence practice and future research.
