Midwives’ care on a labour ward prior to the introduction of a midwifery model of care: a field of tension

Figures & data

Text box 1. Vignette: A look into two of the birthing rooms.

The atmosphere in the birthing room during one observation was very intense, but still calm and filled with trust. The birthing woman was sitting like a queen in her bed; she had strong contractions and inhaled Entonox with silent breaths. Her mother and sister were there, holding her hands. The midwife was present at her side, occasionally listening to the baby’s heart by using a Pinard. She later described the ward as being very hectic that day, but in this room it was calm. When the researcher informed the woman that the study concerned midwives’ care, she said with a big smile that her midwife was wonderful: “You must pass her with distinction. She was breathing with me, and that made me calm”. ***** In another room, a multiparous woman had very painful contractions. The situation seemed rather chaotic, but the young midwife was calm and appeared to be in control. The woman lay in the bed, connected to a CTG monitor through a wire, and inhaled Entonox heavily. She screamed occasionally, but listened to the midwife. Her husband was at her side holding her hand, looking worried. The midwife had a plastic smock on and all the birthing utensils ready at a table. She urged the woman to try to relax and listen to her. While observing the CTG and the woman’s genitals, she asked the auxiliary nurse to call for the assisting midwife to hand her oxytocin. After a short while the baby’s head crowned. The midwife held her hands on the baby’s head and the woman’s perineum, and her face turned slightly red because of the effort. The baby was born, but didn’t cry immediately. The midwife put her hand on the baby’s chest and said everything was fine. She wiped the baby dry, soon he cried and the mother and father looked very happy. Within the next few minutes the midwife had taken care of the following duties: she took a blood test from the umbilical cord before cutting it, placed the baby onto the mother’s chest, checked the woman’s uterus by placing a hand on the abdomen, gave an injection with oxytocin, helped the placenta out, checked that the placenta was complete, and thereafter examined the woman’s genitals for possible tears. The midwife was focused and worked very quickly, but respectfully by sometimes apologising for disturbing the woman.

Text box 2. Vignette: Epidural.

One day, the following was observed at the labour ward: A woman in advanced labour who was recently admitted told her midwife that she wanted an epidural. The midwife asked her to reconsider and explained that the preparations would take much of her time, with the risk of leaving the woman alone without a midwife being at her side. Despite the midwife’s concerns, the woman chose the epidural. However, when all the preparations were completed she started to push and gave birth just a few minutes later. The midwife explained later to the ethnographer that she wanted to be honest with the woman and make sure she understood the possible consequences of her choice. The midwife’s interpretation was that the woman did not dare to give birth without the pain relief, while from her experience she knew that she as a midwife had the possibility to support and induce courage with her presence.

Text box 3. Vignette: Examples of tensions between different models of care.

A midwife and a physician had a discussion in the office concerning which method to use for inducing a woman’s labour. The midwife suggested a method having the drug already prepared in her hand. The physician instead pondered on different suggestions from colleague physicians. The discussion ended with the physician saying: “I will examine the patient and discuss the case with my colleague, and then I let you know what to do”. Despite the determined tone, the physician seemed unsure about the midwife’s suggestion and wanted to consult with a colleague, excluding the midwife from this talk. The midwives in turn tended to exclude physicians because they preferred to consult with each other before consulting the physicians. They felt that the morning rounds with physicians focused on the medical and organizational aspects of childbirth to the exclusion of midwives’ views on the normality of childbirth and caring issues. The midwives therefore discussed the need for a midwife-round before the ordinary round with the physicians where they could consider more midwifery caring issues and not just the medical and institutional aspects of childbirth as they usually did during the morning rounds.

Text box 4. Vignette: In labour or not?.

One midwife with long experience told the ethnographer how she collects information from the women. When a woman is admitted, she not only asks about her obstetrical data, but she also wants to know about the woman´s whole life. This included her mother’s and other family member’s childbirths. She listens to each woman’s individual story, collects information, and then uses this knowledge in her care. This midwife was observed when she cared for a woman having no obvious signs of labour; she had no contractions and the previous cervix status showed only a minor opening. According to the guidelines, the woman should be sent home. However, this did not concern the midwife, and after she had made her examination and observations she concluded: “This will be a good birth, the woman has the right attitude; she wants a normal birth and her mother also wanted a vaginal birth when she gave birth to her daughter. She must stay”. One hour later the woman had stronger contractions.

Data availability statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to restrictions, e.g., their containing information that could compromise the privacy of research participants.