Onset of Labour

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• Onset of Labour Recognition and Failures
• Caroline Diamond
• Supervisor of Midwives
• Lead Midwife Obstetrics and Gynaecology Causeway
  Hospital
• NHSCT

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Failures

• Failure to recognise the onset of labour has been
  a predominant failing highlighted in Coroners
  inquest and in a number of SAIs
• The ability to recognise the onset of labour is
  an essential core skill to the midwives role
• 3. Determine the onset of labour.
• (Essential Skills Clusters (ESCs) for
  pre-registration midwifery education3. NMC
  Standards for pre-registration midwifery
  education 2010).

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Recognition of labour- what is the problem?

• Diagnosis of labour can be problematic
• A workforce planning tool identified that up to
  30 of women admitted to labour wards were not in
  labour
• Women are more likely to have
• some form of medical intervention

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• ODriscoll et al (1973) asserts that recognition
  of labour is among the most important clinical
  decisions in labour care.
• The WHO (1996) states that the most important
  aspect of assessing and managing a labour is the
  diagnosis of labour onset and that women may come
  to harm if misdiagnosed.
• Despite the impact of misdiagnosis, there is a
  dearth of research on the process of
  decision-making by midwives in relation to
  diagnosis of labour

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Whats the problem?

• Midwives continue to struggle to
• articulate the nature of their expertise
• Midwives have both tacit and practical
• knowledge derived from experiential
• learning and intuition.
• Midwives use a variety of emotional,
  psychological and physical cues to diagnose
  labour onset such as a womans movements,
  breathing, conversation and emotional states.
• HOWEVER, recognition and use of these cues is
  influenced by the political and social context in
  which a midwife works.

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Why are we getting it wrong?

• Physiological criteria
• Use of vague but frequently used medical
  definitions of labour onset such as cervical
  dilatation
• Use of medical cues of labour onset- regular,
  rhythmical painful contractions and a cervical
  dilatation of 3cm, do not represent the
  experience and reality of all women
• Descriptors of false spurious and true
  labours are antiquated and imprecise

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Why are we getting it wrong?

• Physiological criteria
• Diagnosis of labour can only be made in
  retrospect
• Impossible to determine the precise moment when
  labour begins
• Inappropriate use of labels in the latent stage
  such as nigglers and gel pains if IOL
• Blurring of the Normality Boundary by induction
  agents deters the midwifes intuitive ability to
  diagnose onset of labour, revert to medical model

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What influences the decision-making

• Psychological processes
• Midwives respond to the cues presented to them
  by the use of heuristic processes
  (experience-based techniques for problem
  solving), or shortcuts to decision-making
• The more complex the clinical case, the greater
  the use of heuristics in early labour
• The use of heuristics is useful in identifying
  that unexplainable, intuitive knowledge and
  expertise.

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What influences the decision-making

• Socio-political and philosophical perspective
• Midwifery knowledge has become distorted by over
  reliance on the medical model and hospital
  routine practices
• The competing nature of explicit or technical
  knowledge versus indeterminate or intuitive
  knowledge is a challenge to midwives seeking
  autonomy in a system influenced by the scientific
  paradigm
• Midwives need to explore and understand
  midwifery ideology in order to preserve normal
  midwifery

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How do we get it right?

• Spontaneous labour
• External signs of labour i.e. vaginal discharge,
  red line, contractions with and without abdominal
  palpation
• Internal signs of labour- VE to include
  effacement, dilatation, application, consistency
  and position
• Observe subtle maternal behaviours and reactions
  i.e. nesting, bright shining eyes, excitement,
  mood, conversation

• Induction of labour
• Clear, unambiguous terminology to describe
  contractions i.e. mild, moderate, strong,
  regular, irregular and timings
• Avoid vague use of terms such as gel pains
  irritable uterus
• Perform VE as per policy or when analgesia
  requested

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In summary

• Midwives need to be vigilant that the future
  midwifery ideology is not rooted purely in the
  biomedical model
• Midwives need to clearly differentiate the normal
  pathway, spontaneous onset of labour and the high
  risk induced onset of labour
• Midwives need to be able to articulate the
  indeterminate midwifery expertise and knowledge
  with regards to diagnosis of onset of labour
• More research in the processes of diagnosing
  labour and is required

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References

• Ball Washbrook (1996). Birthrate Plus A
  Framework for Workforce Planning and Decision
  Making for Midwifery Services. Books for
  Midwives Press, London
• Burvill (2002) Midwifery diagnosis of labour
  onset. British Journal of Midwifery, Vol 10, No
  10, pp 600-605.
• Cheyne, H., Dowding, D.W., Hundely, V. (2006)
  Making the diagnosis of labour midwives
  diagnostic judgment and management decisions.
  Issues and Innovations in Nursing Practice. The
  Authors Journal compliation. Blackwell
  PUBLISJHING ltD
• ODriscoll, K., Stronge, J.M., Minogue, M.
  (1973) Active Management of Labour British
  Medical Journal 3 135-137.
• WHO (1996) Care in Normal Birth A Practical
  Guide Report of a Technical Working Group.
  Maternal and Newborn Health/ Safe Motherhood
  Unit, WHO, Geneva.