Re: length of labour

Just to add to this - Ive just returned from doing some workshops on ways of maximising normal birth with some wonderful midwives in Hong Kong (following on from some similar workshops there by Paul Lewis and Cathy Warwick), and the participants were very clear that they routinely did not undertake VE's if they thought women were approaching full dilation, because, once confirmed, the second stage was strictly time limited - so they delayed as long as possible in making the confirmation. As we discussed in the workshops, this practice protects the individual woman from intervention to some extent, but skews the recorded 'norms' for length of second stage for the population of women, as Chris has noted in an earlier posting.I think this is probably a fairly universal practice? This is why Im hoping to do some work with women having truly spontaneous labours in a case-holding setting to see what the norms are! in that circumstance, following on from the work of Leah Albers, but also taking into account that labour is unlikely to be a linear process (ie progressing at any specific number of centimetres per hour). I'm also interested in correlations between maternal and sibling labour patterns on that of a currently labouring woman, particularly when she enters the realm of 'unusual normal'. It might be good to try to do some cross cultural work on this if anyone out there is interested, or to join you if you are doing it currently...?

Hello Chris, Billie and everyone - yes, I am keen to join in the discussion! As you mentioned, Chris, I am currently writing up my PhD which focuses on power and power relationships within the context of vaginal examination in labour. During interviews, all the midwife participants acknowledged that there is sometimes a discrepancy between what they feel on vaginal examination, and what they actually record in the notes. This happens most often when the midwife cannot feel any cervix (i.e. full dilatation) but states in the records that it is 8 or 9cm dilated. The rationale for doing this (and midwives were very clear on this) was that they were protecting the woman from the threat of perceived, unnecessary intervention. As the participants said, once they record full dilatation 'the clock starts ticking'.

I think this is an intriguing example of the ways in which midwives use their own midwifery knowledge to subvert the dominant discourse which is, of course, based on Friedman's curve. I'm not for a minute trying to suggest it is good practice - far from it - but I think it is interesting that midwives have developed this strategy and that it appears to be so widely used.

As I am writing-up at the moment I can get very, very boring on the subject but will stop here ... However, the findings throw up all sorts of interesting questions and dilemmas about how we assess cervical dilatation as well as ''normal' length of labour etc.

Best wishes to all - Mary

From: A forum for discussion on midwifery and reproductive health research. on behalf of Chris McCourt
Sent: Thu 15/02/2007 13:42
To: [log in to unmask]
Subject: Re: length of labour

good points Billie

there is also the issue of what or how professionals choose to measure
and record and why

Mary Stewarts's doctoral work highlighted, and we noticed the same
phenomenon (and commented on it briefly in an article) that midwives
tend to manipulate records in response to various agenda. Delaying
recording their assessments or amending the observations they record
can, they feel, give them and the woman more time in which to allow
labour to progress. This needs to be taken into account by anyone
researching labour duration using casenote audit.

If anyone is interested in this further, our article was:

Beake S, McCourt C, Page L. The use of clinical audit in evaluating
maternity services reform: a critical reflection. Journal of Evaluation
in Clinical Practice 1998.

can't remember Mary's title now, but maybe she'll respond!

Chris

-----Original Message! -----
From:   A forum for discussion on midwifery and reproductive health
research. on behalf of Hunter, Billie
Sent:   Wed 14-Feb-07 5:34 PM
To:     [log in to unmask]
Cc:
Subject:        Re: length of labour

Hi Chris and other interested list members

I've been following this discussion with interest. It seems that another
relevant issue is likely to be how labour duration is measured, in
particular what the start point is considered to be ( the end point
being fairly clear!) This may be something that has shifted over time.
For example, there are new developments which aim to differentiate
between 'active' and 'latent' phases of labour (the All Wales Clinical
Pathway for Normal Labour that I have recently been researching is one
of these). If labour is not considered to have started until a woman is
in ac! tive labour ( as defined by her attendants), this will clearly
impa ct on the length of labour that is officially recorded (though this
may not necessarily reflect the length of labour as experienced by the
woman herself!) This issue could be compounded in units where women are
encouraged to stay at home until they are in established (active)
labour, so that the experiences of the woman prior to admission become
invisible. This would seem to have all sorts of implications for labour
duration norms - and also for the experiences of women. (I am also
interested in how it may affect the work of midwives - so that only
caring women in active labour is seen as 'real work')

Billie

Billie Hunter
Professor of Midwifery
Centre for Midwifery and Gender Studies
School of Health Science
Floor 2, Vivian Tower
University of Wales Swansea
Swansea SA2 8PP
01792 518584
email: [log in to unmask]

-----Original Message-----
From: A forum for discussion on midwifery and reproductive h! ealth
research. [[log in to unmask]">mailto:[log in to unmask]] On Behalf Of Chris
McCourt

Sent: 12 February 2007 17:05
To: [log in to unmask]
Subject: length of labour

dear all

I'm interested to know whether there is any written or research evidence
on whether norms of the length of labour have changed in the recent
past. I'm aware of the impact of Friedmans work on practices in labour
wards, but am wondering whether there is anything to suggest further
trends in what is seen as a 'normal' length of labour (and by
association, whether this could be related, in either direction, to
rising intervention rates)

all ideas on relevant evidence sources, or personal/professional
observations welcome

Chris

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