Attitudes of Swedish midwives towards management of extremely preterm labour and birth.

OBJECTIVE: the aim of the study was to ascertain the attitudes of Swedish midwives towards management of very preterm labour and birth and to compare the attitudes of midwives at university hospitals with those at general hospitals. DESIGN: this cross-sectional descriptive and comparative study used an anonymous self-administrated questionnaire for data collection. Descriptive and analytic statistics were carried out for analysis. PARTICIPANTS: the answers from midwives (n=259) were collected in a prospective SWEMID study. SETTING: the midwives had experience of working on delivery wards in maternity units with neonatal intensive care units (NICU) in Sweden. FINDINGS: in the management of very preterm labour and birth, midwives agreed to initiate interventions concerning steroid prophylaxis at 23 gestational weeks (GW), caesarean section for preterm labour only at 25 GW, when to give information to the neonatologist before birth at 23 GW, and when to suggest transfer to NICU at 23 GW. Midwives at university hospitals were prone to start interventions at an earlier gestational age than the midwives at general hospitals. Midwives at university hospitals seemed to be more willing to disclose information to the parents. KEY CONCLUSIONS: midwives with experience of handling very preterm births at 21-28 GW develop a positive attitude to interventions at an earlier gestational age as compared to midwives without such experience. IMPLICATIONS FOR PRACTICE: based on these results we suggest more communication and transfer of information about the advances in perinatal care and exchange of knowledge between the staff at general and university hospitals. Establishment of platforms for inter-professional discussions about ethically difficult situations in perinatal care, might benefit the management of very preterm labour and birth

Critical obstetric situations - obstetricians' ethical decision-making and parents' handling of threat of preterm birth

Ethical issues arise in obstetric situations and demand the obstetrician’s moral consideration for those who are involved in the actual case (Paper I). A balance between the health of the foetus and the autonomy of the woman is necessary to do the best for both the mother and her foetus/infant. Preterm birth is one of the main causes of mortality and morbidity for the child, in short and long term (Paper II). When the mother is hospitalized, a feeling of frustration can appear due to her concern for the foetus during the pregnancy and of her ability to function as a mother, wife and working woman. Fathers are worried when their partner has a threat of preterm birth. It is important for the woman and her partner to be informed and to take part in the decision-making process. The overall aim of this thesis was to illuminate and gain deeper understanding of obstetricians’ and parents’ experiences of being in a critical obstetric situation. The thesis includes two specific aims: to highlight the meaning of being in ethically difficult obstetric situations as narrated by obstetricians (Paper I) and to gain a deeper understanding of both parents’ experiences, when the mother was hospitalized due to a threat of preterm birth (Paper II). Both studies have a qualitative approach and a hermeneutic phenomenological method was used in Paper I and Grounded Theory in Paper II. Data collection was done with tape-recorded interviews in both studies. The findings in Paper I are described thematically with one overriding theme; Sympathetic responsibility in decisions of critical importance for the mother and her infant. Five themes illuminated the decision-making process which the obstetricians went through during the situations; ‘To proceed with a moral reasoning that leads to the choice of a solution’, ‘To balance one’s own medical knowledge and moral insight with the needs and requests of the parents’, ‘To know one’s medical and moral responsibility in the relation to the decision made’, ‘To experience the ability to take action and to make and carry out difficult and important decisions for the health of the mother and her infant’ and ‘To reflect on a given situation in a manner leading to a rational acceptance of one’s own conduct’. The parents’ main concern is shown through the concepts of the parents’ experiences of threat of preterm birth (Paper II). This included the core category “Inter-adapting” followed by three categories with six related subcategories; Interacting (‘Communicating with the professional caregivers’, ‘Keeping the family together through a stressful situation’, ‘Seeking empowerment during labour and birth’), Reorganizing (‘Arranging for a new family situation’) and Caring (‘Accepting the restrictions for the sake of the health of the foetus’, ‘Reaching out to the infant and taking part in the care’). “Inter-adapting” is a new concept and was interpreted as a mutual adaptation between the actors involved in the situation. The theoretical model “Inter-adapting to Threat of Preterm Birth” was developed and named the ITPB-model. In conclusion, sympathetic responsibility is present during the obstetricians’ decision-making process and includes a moral reasoning while balancing their medical knowledge against the woman’s autonomy and the health of the foetus/infant. Emotional strain for the obstetricians could appear during the situation. Their decision-making was aimed at obtaining the best possible outcome for both mother and infant (Paper I). The concern of the foetus/infant made the parents accept the hospitalization. Reorganizing their work situation and home responsibility was important to enable the family to function. When ‘‘Inter-adapting” occurred between the parents and the actors involved, the parents were able to manage the situation (Paper II). Implications for care could be formal meetings with different professionals to discuss ethically difficult situations. This could lead to a deeper understanding and co-operation between colleagues and professions (Paper I). To strengthen and support the parents during hospitalization and decrease the feeling of separation by integrating the different wards involved, could help the family manage their situation (Paper II)

Decision-making in critical situations during pregnancy and birth

The overall aim of this thesis was to describe the experiences of obstetricians and parents and the attitudes of midwives in relation to critical situations during pregnancy and birth. The data collection (Paper I and II) started in year 2000 with interviews with obstetricians (n=14) concerning the meaning of being in ethically difficult situations. During 2002 to 2004 interviews with parents (n=23) about handling preterm labour and birth were performed. The quantitative studies had a cross-sectional method and a descriptive (Paper III and IV) and comparative (Paper III) design. The data collection was performed during 2007 to 2008, using a structured, anonymous and self-reported questionnaire for midwives (n=259). The midwives’ attitudes about very/extremely preterm labour and birth (Paper III) and towards a woman’s refusal of emergency cesarean section (CS) or request of CS without any medical indication (Paper IV) were investigated. The tape-recorded interviews with obstetricians were analysed using the hermeneutic-phenomenological method and with the parents the Grounded theory method was used. Descriptive and analytic statistics was used to analyse the data of the quantitative studies. The overriding theme in Paper I was “Sympathetic responsibility in decisions of critical importance for the mother and her baby” (Paper I). Together with the five subthemes this illuminated the decision-making process, which the obstetricians went through during the situations. The parents’ main concern is shown through the core category “Inter-adapting” followed by three categories; Interacting, Reorganizing and Caring. “Inter-adapting” is a new concept and was interpreted as a mutual adaptation between the actors involved in the situation (Paper II). The midwives’ attitudes in relation to very/extremely preterm labour and birth, was that midwives at university hospitals were more likely to agree on to start interventions at an earlier gestational age than midwives at general hospitals. Obstetricians seemed to be more active in management than midwives, though midwives seemed to be more willing to disclose information to the parents (Paper III). In a conflict of interest concerning a woman’s refusal of an emergency CS for fetal distress, the midwives thought that the obstetrician should try to persuade the woman to accept the recommended CS. If a woman requests a CS without medical indication, the midwives thought that the obstetrician should comply with the woman’s’ request if she had had previous maternal or fetal complications. The reason for supporting the woman’s choice was mostly out of respect for the woman’s autonomy, although midwives at university hospitals were significant less willing to do so (Paper IV). In conclusion this thesis revealed that the obstetricians respected the autonomy of the woman during the decision-making process (Paper I). Inter-adapting strategies were used to achieve the best possible outcome for the fetus/infant (Paper II). Midwives and obstetricians with experience of handling preterm births at 21 – 28 GW develop a positive attitude to interventions at an earlier gestational age as compared to midwives without such experience (Paper III). The main focus of midwives seems to be the baby’s health and a positive birth experience for the woman and therefore they do not always agree to the woman’s refusal or request of cesarean section (Paper IV)

Sympathetic responsibility in ethically difficult situations*.

Background. Ethical issues arise in many obstetric situations and demand constant consideration by obstetricians. The aim of this study was to highlight the meaning of being in an ethically difficult situation as narrated by obstetricians. Methods. A descriptive design with a qualitative approach using a hermeneutic phenomenological method for analysis. Interviews were performed with 14 obstetricians working in a Swedish hospital setting. Results. The overriding theme was Sympathetic responsibility in the decisions of critical importance for the mother and her infant. Five related themes were to: (i) proceed with a moral reasoning that leads to the choice of a possible solution; (ii) balance one's own medical knowledge and moral insight with the needs and requests of the parents; (iii) be aware of one's medical and moral responsibility in relation to the decision made; (iv) experience the ability to take action and to make and carry out difficult and important decisions relating to the health of the mother and infant; and (v) reflect on a given situation in a manner leading to a rational acceptance of one's own conduct. Conclusions. Sympathetic responsibility is the structure of the meaning of the obstetricians' lived experience, which means that the obstetricians with the help of their medical knowledge and their desire to support the mother's autonomy do what is best for the mother and her infant. Implications include that an exchange of ethical thoughts and moral reasoning should lead to a higher degree of mutual understanding between colleagues and between the different professionals. Co-operation is important to achieve the best outcome for the mother and her infant

A theoretical model of parents' experiences of threat of preterm birth in Sweden.

Objective: to gain a deeper understanding of both parents' experiences during the mother's stay in hospital for threat of an early delivery and eventual preterm birth. Design: explanatory design with separate interviews for mothers and fathers using the grounded theory method. Setting: University Hospital in southern Sweden. Participants: 17 mothers and six fathers, who had experienced a threat of early delivery and eventual preterm birth, while the mother was in hospital. Findings: the core category 'inter-adapting' and the following three categories and six subcategories emerged: interacting (communicating with the professional caregivers; keeping the family together through a stressful situation; seeking empowerment during tabour and birth); reorganising (arranging for a new family situation); and caring (accepting the restrictions for the health of the fetus; reaching out to the baby and taking part in the care). Key conclusions: during the mothers' stay in hospital, the most stressful issues experienced were the parents' concern for the baby and the separation from the family. Parents are able to manage the situation by mutually adapting to each other, family members, significant others and caregivers. A new concept 'inter-adapting' therefore emerged. Implications for practice: for perinatal care, feelings of separation can be reduced and family bonds strengthened through integrating the different wards involved

The meaning of problem solving in critical situations

The objective was to explore the meaning of the phenomenon of problem solving in midwifery when the midwife is faced with a critical situation in the absence of an obstetrician or any physician. A qualitative method was used and critical incidents from delivery wards and/or antenatal clinics in the south of Sweden were narrated by midwives and transcribed verbatim. The interwievs were then analysed using a phenomenological method. Seven midwives, all with at least five years working experience of both antenatal and delivery ward work participated. Problem solving in midwifery showed itself to be a multifaceted phenomenon. Some of the facets were to listen, to assess, to make fast decisions, to possess knowledge and experience, to use intuition,to be able to identified a problem and find a solution, cooperation, engagement, purposefulness, concentration, euphoria, consideration and control. Knowledge about the meaning of problem solving in midwifery can influence the working team to su

Attitudes of Midwives in Sweden Toward a Woman's Refusal of an Emergency Cesarean Section or a Cesarean Section on Request.

Background: A woman's refusal or request for a cesarean section can be a problem for midwives and obstetricians working in maternity units. The objective of this study was to describe the attitudes of midwives in Sweden toward the obstetrician's decision making in relation to a woman's refusal of an emergency cesarean section and to a woman's request for a cesarean section without a medical indication. Methods: The study has a cross-sectional multicenter design and used an anonymous, structured, and standardized questionnaire for data collection. The study group comprised midwives who had experience working at a delivery ward at 13 maternity units with neonatal intensive care units in Sweden (n = 259). Results: In the case of a woman's refusal to undergo an emergency cesarean section for fetal reasons, most midwives (89%) thought that the obstetrician should try to persuade the woman to agree. Concerning a woman's request for a cesarean section without any medical indications, most midwives thought that the obstetrician should agree if the woman had previous maternal or fetal complications. The reason was to support the woman's decision out of respect for her autonomy; the midwives at six university hospitals were less willing to accept the woman's autonomy in this situation. If the only reason was "her own choice," 77 percent of the midwives responded that the obstetrician should not comply. Conclusions: The main focus of midwives seems to be the baby's health, and therefore they do not always agree with respect to a woman's refusal or request for a cesarean section. The midwives prefer to continue to explain the situation and persuade the woman to agree with the recommendation of the obstetrician. (BIRTH 38:1 March 2011)