Epidurals during normal labour and birth — Midwives’ attitudes and experiences

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Epidurals during normal labour and birth — Midwives ’ attitudes and experiences

Ingvild Aune

^a,

*, Siri Brøtmet

^b

, Katrine H. Grytskog

^c

, Eldri B. Sperstad

^d

aMidwiferyEducation,FacultyofMedicineandHealthSciences,DepartmentofClinicalandMolecularMedicine,NTNU—NorwegianUniversityofScience andTechnology,OlavKyrresgate11,7006Trondheim,Norway

bAkershusUniversitetssykehus,Sykehusveien25,1478Lørenskog,Norway

cKristiansundsykehus,HermanDøhlensvei1,6508Kristiansund,Norway

dSt.OlavsHospital,OlavKyrresgate11,7006Trondheim,Norway

ARTICLE INFO

Articlehistory:

Received1April2020

Receivedinrevisedform13August2020 Accepted13August2020

Keywords:

Epidural Attitudes Experiences Midwife

Qualitativemethod

ABSTRACT

Background: Midwives have their own beliefs and values regarding painduring childbirth. Their preferencesconcerninglabourpainmanagementmayinﬂuencewomen’schoices.

Aim:Togainadeeperunderstandingofmidwives’attitudesandexperiencesregardingtheuseofan epiduralduringnormallabour.

Methods:Aqualitativeapproachwaschosenfordatacollection.Tenin-depthinterviewswereconducted withmidwivesworkinginthreedifferentobstetricunitsinNorway.Thetranscribedinterviewswere analysedusingMalterud’ssystematictextcondensation.

Findings:Theanalysisprovidedtwomainthemes:“Normalchildbirthasthegoal”and“Challengestothe practice,knowledge,philosophyandexperienceofmidwives”.Distinctivedifferencesinexperiencesand attitudeswerefound.Theworkplacecultureintheobstetricunitsaffectedthemidwives’attitudesand theirmidwiferypractice.Howtheyattendedtowomenwithepiduralalsodiffered.Anepiduralwasoften usedasasubstituteforcontinuoussupportwhentheobstetricunitwasbusy.

Discussion: Midwives estimate labour paindifferently, and this might impact themidwifery care.

However,midwives’interestsandpreferencesconcerninglabourpainmanagementshouldnotinﬂuence women’schoices.Midwivesareaffectedbythesettingwheretheywork,andresearchhighlightsthatan epiduralmightleadtoafocusonmedicalproceduresinsteadofthenormalityoflabour.

Conclusion:Midwivesshouldbeawareofhowpowerfultheirpositionisandhowtheworkplaceculture mightinﬂuencetheirattitudes.Thefocusshouldbeon“workingwith”womentopromoteanormalbirth process,evenwithanepidural.

Statementofsigniﬁcance

Problem

Midwiveshavetheirownbeliefsandvaluesregardingpain duringchildbirth.Theirpreferencesandinterestsconcerning labourpainmanagementmayinﬂuencethewomen’schoice Whatisalreadyknown

Anepiduralleadstothemedicalizationofnormalbirthsand the birth transforms from a physiological process to a medicalprocedure.Ingeneral,thereisahigherfrequencyof epidural use in obstetric units compared to units with midwife-ledcare.Midwives’attitudesmaybeaffectedbythe attitudesofotherhealthpersonnelatthelabourward.

Whatthispaperadds

The distinctive differences in experiences and attitudes towardsepiduralinanormalbirthprocessisaninteresting ﬁnding.Theworkplacecultureintheobstetricunitsaffected themidwives’attitudesandtheirmidwifery practice.How midwivessupportedwomenwithepiduralsalsodifferedand whentheobstetricunitwasbusy,anepiduralwasoftenused asasubstituteforcontinuoussupport.

Introduction

Unlikeothertypesofpain,labourpainisnotassociatedwith tissue damage but is a natural partof childbirth[1,2]. Several factors,suchasmobility,anxietyandsupportreceivedinﬂuence thewomen’spainperception[1].Epiduralisthemostinvasivetype

*Correspondingauthor.

E-mailaddress:ingvild.aune@ntnu.no(I.Aune).

http://dx.doi.org/10.1016/j.wombi.2020.08.001

creativecommons.org/licenses/by/4.0/).

ContentslistsavailableatScienceDirect

Women and Birth

j o u r n a l h o m e p a g e : w w w . e l s ev i er . c o m / l o c a te / w o m b i

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ofpainmanagement[2]whereamixtureoflocalanaestheticand opioid is given continuously into the epidural space [3]. An epidural is effective in reducing pain during labour and birth.

Researchhasshownthatwomenwhohaveanepiduralreportless pain comparedto womenthat have noanalgesia orparenteral opioids[1,4].InNorway,anepiduralwasusedin34%oflaboursin 2018.Thehospitalwiththehighestrateusedit43%ofthetime[5].

Researchsuggeststhatthefrequencyofepiduraluseinlabouris stillincreasing,both in Norwayandin otherwestern countries [2,5].

Studies have shown a signiﬁcant increase in instrumental vaginal births when an epidural is used [1,4]. A recent study showedthatwomenwhoreceiveepiduralanalgesiahavefourto ﬁvetimesincreasedriskofvacuumextraction[6].Thereisalsoan increasedrisk of oxytocicuse, longer birth phase, hypotension, urinaryretention,fever,motorblockade[1,4]andanincreasedrisk of having a less positive birth experience [7,8]. The National InstituteforHealthandCareExcellence(NICE)[9],Jonesetal.[1]

andLindholmandHildingsson[8]emphasizethatmidwivesmust informwomenabouttherisksandbeneﬁtsofhavinganepidural andhowthismightaffectherlabour.

The International Confederation of Midwives (ICM) [10]

supportsthefollowingdeﬁnitionofnormalbirth:“Normalbirth iswherethewomancommences,continuesandcompleteslabour withtheinfantbeingbornspontaneouslyatterm,inthevertex positionatterm,withoutanysurgical,medical,orpharmaceutical intervention”.ICMhighlightsthatpromotingnormalbirthsisan importantstrategyinwhichmidwivesplayacentralrole.Oneof theWorld Health Organization’s (WHO) principles of perinatal careis the demedicalizationof normal births[11]. An epidural leads to the medicalization of normal births and the birth transformsfromaphysiologicalprocesstoamedicalprocedure.

Itrequires technologicalequipment andtrained personnel[12].

Thismightaffectthemidwiferycarebecausethefocusismoved fromthenormalityoflabourtomedicalprocedures[2,7].Wherea woman in Norway gives birth is thoroughly selected after considerationoftheriskfactors.Obstetricunitshaveresponsibility forwomenwithbothhighand lowrisksduringpregnancyand birth[13].Ingeneral,thereisahigherfrequencyofepiduraluse andotherinterventionsinobstetricunitscomparedtounitswith midwife-ledcare[8,14].Ithasbeenshownthatmidwiveshavea greaterpersonalpreferenceforphysicalandpsychosocialmethods of pain relief, while obstetricians have a greater personal preferenceforpharmacologicalmethods,suchasepidurals[15].

Midwives’ attitudes may be affected by the attitudes of other healthpersonnelatthelabourward[16].TheNationalInstitutefor HealthandCareExcellence (NICE)[9] pointsoutthatmidwives must be awareof theirown beliefs and values regarding pain during childbirth. The midwives’ preferences and interests concerning labour pain management should not inﬂuence the women’schoice[8].

Theaimofthisstudywastoinvestigatemidwives’attitudesand experiencesregardingtheuseofepiduralsduringnormallabour.

Method Datacollections

A qualitative approach is suitable for gaining knowledge of subjectiveexperiencesandattitudes.Thismethodallowspartic- ipants to speak freely in safe surroundings and is suitable for gaining a deeper understanding of midwives’ experiences and thoughtsregardingtheuseofanepiduralduringnormalchildbirth [17]. Individual in-depth interviews were conducted for data collection.

Participants

Theinclusioncriteriaweremidwiveswhowerepermanentlyor temporallyemployedatthehospitalandhadaminimumoftwo yearsofexperiencefromthelabourandbirthward.Theyhadto workdirectlywithlabouringwomenintheircurrentjob.Thehead midwivesofthreeobstetricunitsindifferentpartsofNorwaywere contacted by e-mail and telephone. At one of the clinics, the researchersshoweduppersonallytogiveinformationaboutthe study A total of ten midwives were recruited, four from one hospitalandthreefromeachoftheotherhospitals.Themidwives had from four to over 30 years of experience and were from approximately30–60yearsofage.Theyhaddifferentexperiences;

somehadworkedinbothlargeobstetricunitsandsmallmidwife led-units, and some had also worked in antenatal care. An interviewguidewithﬁveopen-ended questionswas developed (Table 1) and was used in all the ten interviews to keep the conversation onthe chosen topic[17]. Theindividual in-depth interviews were conducted at the participant’s workplace and lasted about 30 45min. When necessary, follow-up questions wereasked,toclarifyandelaboratetheanswers.Themidwives spokefreely,andthedatacollectedwasrichincontent.Afterten interviews,datasaturationwasachieved.

Ethicalstatement

ThestudywasapprovedbytheNorwegianCentreforResearch Data(ref.no.54601).Themidwivesvolunteeredtoparticipatein thestudyafterreceivingwrittenandoralinformationaboutthe study.Theywereinformedaboutconﬁdentiality,andtheirrightto withdraw from the study at any time. Written consent was collected.

Dataanalysis

Theinterviewsweretape-recordedandtranscribedverbatim.

The transcribedinterviews wereanalysed usingsystematic text condensation,whichisanexplorativeanddescriptivemethodfor the analysis of qualitative data. This is a four-step method developedbyMalterud[17],inspiredbyGiorgi’s[18] phenome- nologicalanalysis.Malterud’sfourstepswereasfollows:(1)The authorsreadallthedatacollectedtoobtainageneralimpression.

Theresearcherslookedforthemesthatrepresentedthemidwives’ experiences and attitudes regarding epidural during normal labour.(2)Thematerialwassystematicallyreviewedandmeaning unitswereidentiﬁedand coded.(3)Thecoded subgroupswere condensed, abstracted and summarised. (4) The fundamental aspects ofeach codegroupweresynthesized intothemeswith descriptions of the midwives’ experiences and attitudes. To enhanceinternalvalidity,alltheauthorsparticipatedinthewhole process of analysis. Aneffortwas made tobrackethypotheses, preconceptionsandthetheoreticalreferenceframework.Decon- textualisationallowspartsofthesubjectmattertobeinvestigated moreclosely,together withotherelementsacrossthematerial.

Table1 Interviewguide.

1.Canyoutellusaboutyourexperienceswithpainmanagementduringlabour?

2.Canyoutellusaboutyourexperienceswithanepiduralasapainrelief methodduringanormallabour?

3.Canyoudescribewhathappensafterthewomanreceivesanepidural?

4.Reﬂectaroundwomen’sknowledgeandattitudesregardingpain managementduringlabour

5.Reﬂectaroundmidwives’knowledgeandattitudesregardingpain managementduringlabour

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Recontextualisationwillmake sure that thepatternsstill agree withthecontextfromwhichtheywerecollected[17].Quotesfrom theinterviewswereusedtosupporttheﬁndingsinthisstudy.To ensureconﬁdentialityandanonymity,pseudonymswereused.

Findings

Fromthe ﬁndings in this study, twomain themesemerged:

“Normalchildbirthasthegoal”and“Challengestothepractice, knowledge,philosophyandexperienceofmidwives”.Fromthese mainthemes,foursub-themesunfolded.

Normalchildbirthasthegoal

Thisthemeconcernsthemidwives’attitudestolabourpainand epidurals,inadditiontohowanepiduralinﬂuencesthecourseof labour.

Attitudestolabourpain

Alltheparticipantsagreedthatanepiduralprovidesgoodpain relief and is especially beneﬁcial for exhausted women with prolonged labour and for women who are frightened. Some midwivesemphasizedtheimportanceofunderstandingpainasa normal part of labour, and that it is a positive pain. They highlightedthat midwives shouldbe awareof this and notbe afraid of beingwith women in pain. Theyshould “work with” womentocopewithpain,insteadofjustusingmedicalpainrelief.

Itwaspointedoutthatalmostallwomenwantanepiduralwhen theyareseventoninecentimetresdilated,includingwomenwho originallywanttogothroughlabourwithoutanepidural.Itwas highlightedthatmidwivescouldbemoreawareoftheirimpacton the motivation of women during labour and how this might inﬂuencetheirneedforanepidural.Severaloftheparticipantssaid thatwomenhaveindividualneedsforpainmanagementduring labour,andyouhavetogiveadvicebasedonthewomanandher situation.Theyhighlightedthatpainmanagementshouldbeon thewoman’spremisesandnotbecausethemidwifethinksitisa challengingsituation.

“Wehavequitealotofpowerinourposition.Manytimes,itisa bitdangeroustopushthemtoomuch,becauseitisnotalways the case that the woman and the midwife have the same experience.”

MidwifeElida

Manyofthemidwivesdidnotseewhywomenshouldbeinpain whentheyhavetheopportunitytogivethemanepiduralforpain relief. It was pointed out that an epidural could be a good alternativeifthe midwiveshaveknowledge aboutthepossible consequencesitcanleadtoandhavethisinmindwhenpromoting anormallabour.Severalmidwivesthoughtthatanepiduralcould beincludedinthedeﬁnitionofanormalbirth.Thiswasbasedon theattitude that having an epiduralis easy and commonplace nowadays. Other midwives thought that an epidural was an invasiveprocedurethatcouldnotbeincludedinthedeﬁnitionofa normalbirth.Theypointedouttheimportanceofbelievingina woman’s ability to give birth without any interventions. Even thoughtheysawanepiduralasanintervention,somemidwives saidtheydidnotseeanydisadvantages.

“Wehavealmostcometobelievethatitisnormalbothtohave an epiduraland tostimulate a birth medically.Butit is not normal. I think that a normal birth is a birth without interventions.”

MidwifeIngrid

“Afterallitisalsoapartofourjob,tocontributekeepingbirths normal.”

MidwifeShelley

Mostoftheparticipantssaidthatintheirexperience,labouring womenlistenedtothemidwives’advice.Theypointedoutthat womenareinavulnerablepositionandthereforeareresponsiveto advice. Some also said that the midwives’ experiences and attitudesimpactwhatkindofpain reliefthewomenreceive.It was emphasized that the midwives have a central role in promotingnon-medicalpainreliefandkeepinglabournormal.

“Butitisobvious,ifyouinformherwellenoughyoucangether todoalmostanything”.SosometimesIofferanepiduralsimply toreachthegoal.”

MidwifeCarina

Many of the participantsemphasized that after the woman receivedanepidural,therewasacalmandgoodatmosphereinthe birth room. The woman was happy and able to relax. It was explained thatan epiduralcouldtakethewomen’sfocus away from thebirthing process, and it was questionedwhetherthis coulddisturbtheprocess.Someof theparticipantspointedout thatgivingthewomananepiduralforpainreliefmightleadtoa positive birth experience. Othermidwiveshad experienced the opposite,thatwomenwhoreceivedcontinuoussupportandhad beenmotivatedbythemidwifetomakeitthroughlabourwithout anepiduralhadagoodbirthexperience.

“Itisnotuptometodecidewhatagoodbirthis,anepidural birthcanbeagoodbirthformany.”

MidwifeIngrid

Theinﬂuenceonthecourseoflabour

Severalmidwiveshadexperiencedthattheuseofanepidural could shortenthe durationof labour duetothe woman being more relaxed. Other midwives experienced that an epidural prolonged the course of labour and often led to more inter- ventionssuchasoxytocin,themonitoringofmotherandbaby, andoperativedeliveries.Itcanalsoleadtourineretention,which leads to more catheterization during and after labour. Several midwives pointed out that women with epidurals were less mobileandstayedinbed.Thewomenwerethereforenotableto use theirnatural bodymovements to promote a normal birth process. The midwives also mentioned thatan epidural could preventthewomen’snaturalurgetopush.Severalbelievedthat theymightbeaffectedbyaworkplaceculturewheretheyexpect progressinlabour,andthatthismightleadthemtointervenein thenormallabour.Theyexplainedhowtheyareusedtopathology inobstetricunits,whichresultedinmedicalisationofbirthwith moreepidurals,oxytocinandfoetalmonitoring,eveninnormal labour.

“Itisquestionablewhetherwemanagetokeepnormalbirths normal,whenweare usedtoworking inaward whereitis commontojustgiveanepidural,breakthewater,giveoxytocin andsoon.”

MidwifeMelia

Some of the midwives emphasized the importance of mobilizationafterwomenhad receivedanepidural,topromote anormalbirthprocess.Theparticipantsexplainedthatwomenare moreimmobile,andthefoetusoftendoesnotrotateaswellasit should. It is therefore essential that the midwives know the positionofthefoetus,sotheycanhelpthewomentomobilizeina waythatpromotes normalrotationand progressinlabour. The midwiveshighlightedthatifwomenarenotabletostandontheir feet,themidwivesshouldnotgiveup onmobilizing them,but mustworkactivelyandusetheirknowledgetohelpthemchange positionsinbed.Othermidwivesdidnotfocusontheimportance ofactivityforwomenwithepidurals.Theysaidthatwomenoften stayinbedandthatthefocusisfrequentlyrestandnutrition.The midwives also explained that the labour often becomes more passive,forbothwomanandmidwife.

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“ThatiswhereIthinkwegowrongwhenwegiveanepidural.

Everythingseemsgood,themotherisrelaxinginbed,andwe forgetthatwehavetowork.”

MidwifeElida

Challengestothepractice,knowledge,philosophyandexperienceof midwives

Thismainthemeinvolveshowthemidwivesexperiencedan increasedcustomerfocusduringlabour,andthatanepiduralmade iteasierforthemnottobecontinuouslypresent.

Fulﬁllingthewoman’swishesandneeds

Somemidwiveshadexperiencedachangeinattitudetowards labourandlabourpainamongwomen.Theydescribedhowinpast yearslabourpainwasconsideredpositive,but nowwomenare morescaredandexpecttobeinaslittlepainaspossible.

“Theyareallawareofthatmedicalpainreliefexist,sotheywant tobewithoutpain.Aseasyaspossible.”

MidwifeGyda

During the interviews, two typesof labouring women were presented. Somewomen had an open attitude toseeing what labourbroughtandothersweresetonhavinganepidural.Itwas emphasizedthatthis couldleadtoacustomerfocuswhere the midwifesimplyfulﬁlsthewomen’swishes.Someofthemidwives saidthattheyhadliberalattitudestomedicalpainrelief,suchasan epidural.Thiswasbecausetheythoughtitwasuptothewomento decidewhattheywant,andiftheywantanepiduralthemidwives wouldgivethemthatwithoutfurtherquestioningorinformation.

Othermidwivessaidthattheyalwaysinformedwomenaboutthe risksandbeneﬁtsofanepiduraltobecertaintheyhaveenough informationbeforemakingadecision.Itwashighlightedthatitis oftendifﬁcultandeventoolatetoinformwomenwhentheyarein labour pain. However, some had an experience of how good informationhadledtowomenwantingtocontinuelabourwithout anepidural.

“Whentheysaytheywantanepidural,IdowhateverIcanto fulﬁlthatwish.”

MidwifeMelia

The participants experienced different levels of knowledge amongwomenandthatabigpartoftheinformationwasreceived throughnon-medicalwebpagesand persons.Nearly allwomen knewaboutthegoodpainreliefofanepidural,butmanyhadalack ofknowledgeaboutrisksandcomplications.Theyalsomentioned thatmanywomendidnothaveknowledgeregardingnon-medical painrelief.Itwasemphasizedthatmidwiferyisaprofessionandin manycases,midwiveshavemoreknowledgethanwomenabout when different pain methods work best. Several participants believed that some midwives are afraid of not supporting the womaninherchoicesifthewomanwantsanepiduralanddoesnot getit.Theyemphasizedthatitisimportanttorememberthatitis thewoman’slabour,andthatthemidwifeshouldworktogether withthewoman.

“Butsometimestherearealternativesthatmightbebetter,and youmustdaretopresentthem.”

MidwifeShelley

“Ihaveadutyinmyprofession.Itshouldnotbeaneasysolution to give her an epidural because it makes it easier for me.

Becauseitdoesnothavetogeteasierforher.” MidwifeAase

Substituteforcontinuoussupport

Severalmidwivessaidthatanepiduralaffectedtheirroleasa midwife,andthattheirfocusbecamemoremedicallycentred.It washighlightedthatmidwivesdidnothavetofocusasmuchon

“workingwith”thewomeniftheyhadanepidural.Theyfeltthat

women were calmer and in control of the situation, and they believedthatanepiduralreducedtheneedforcontinuoussupport.

Othermidwivespointedoutcontinuoussupportasanimportant methodtohelpwomenthroughlabour,andthatthiscouldaffect theirneedformedicalpainrelief,suchasanepidural.

“Ifyougiveanepidural,youdonotneedtoworkthatactive,asa midwifeeither.”

MidwifeAase

Severalparticipantspointedoutthatmidwiferyisademanding profession.Theyhighlightedthatasamidwifeyouhaveto“work activelywith”thewomen,andthatthiswasespeciallychallenging duringnightshifts.Themidwivesexpressedthatwhenitwasbusy andduringnightshiftsmorewomenhadanepidural.Somealso saidthattheymoreoftenofferedandpresentedanepiduralasa goodoptionattimeslikethis.Theparticipantssaidthatitiseasier to“worktogetherwith”womenwho haveanepiduralbecause they are calmer. Some of the participants highlighted the importanceofcontinuoussupport,butduetotimepressurethis wasnotalwaysachievable.Theyalsofeltthattheycouldleavethe birthroomtodootherworktasksifthewomanhadanepidural.

“Youmightofferanepiduralearlierbecauseyoudonothavethe timetobethere.Weknowthatweshouldhurryupandﬁnish, sowecansupportotherwomen.”

MidwifeIngrid Discussion

Allthemidwivesinthisstudyagreedthatanepiduralprovides goodpainrelief,whichotherresearchalsosupports[4,19].Despite this,themidwiveshaddifferentattitudestotheuseofanepidural innormallabourandwhetheranepiduralcouldbeincludedinthe deﬁnition of normal labour. It was emphasizedthat having an epiduraliscommonandseveralmidwivesdidnotseewhywomen shouldbeinpainwhenanepiduralisavailable.Othershighlighted painasanormalpartoflabourandthatmidwivesshouldbelievein women’sabilitytogivebirthnormally.ICM[10]statesthatmedical orpharmaceuticalinterventionisnotincludedinthedeﬁnitionof normalbirth.Theparticipantssaidthatmidwiveshaveto“work with”women andtheirindividualneedsinorder topromotea normallabourwithoutmedicalpainrelief.Itwasmentionedbythe midwivesthatanepiduralisaninvasiveprocedure,soitcouldbe helpfulforthemidwivestohaveknowledgeaboutthepossible consequences it can lead to,so they have this in mind when promotinganormalbirthprocess.SandersandLamb[2]highlight thatmidwiveshaveacentralroleinhelpingwomentocopewith pain and help them make individual choices regarding pain management.Todoso,midwivesneedknowledgeaboutnormal painresponsesinlabourandmustworkinaholisticandwoman centredway[2,7].

A recurring themeduringtheinterviews was themidwives’ impactonwomenduringlabour.Theparticipantsemphasizedthat women are in a vulnerable position, and that midwives can persuadethemtodoalmostanything.Pairman[20]describesthat traditionally, therelationship betweenhealth professionals and clients is hierarchical, where the health professional is the

“expert”.Theprofessionalroleofbeingamidwifeisapowerful oneandthemidwifemustbeawareofthisandnotmisuseit.She furtherpresentsthatmidwivesandwomenshouldbeviewedas equal individuals with equal power, and they should work in partnership. ICM[21] highlights in their“International Code of Ethics forMidwives”thatmidwivesshouldwork inpartnership withwomen.Theparticipantsinthepresentstudybelievedthat midwives’experiencesandpreferencescouldimpactthewoman’s choiceofpainrelief.Itwashighlightedthatthemidwivesshould notbeafraidtoworkwithwomaninpainandanepiduralshould not be used because the midwife thinks it is a challenging

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situation. Midwives estimate labour pain differently, and this mightimpactthemidwiferycare[22].LindholmandHildingsson [8]highlightthatmidwives’interestsandpreferencesconcerning labourpainmanagementshouldnotinﬂuencewomen’schoices.

Midwivesmustsupportwomen’schoicesandbeawareof their own values and beliefs regarding labour pain [9] and pain management during birth [7]. Based on thepresent study and the material presented above [7–9,20,22] it is important that midwivesareawareoftheirownattitudesandhowtheymight impactwomen’schoicesregardingpainreliefduringlabour.

Someofthemidwivesexpressedthatanepiduraloftenledto prolonged labourand an increased risk of interventions.These experiencescorrespondwiththeﬁndingsinseveralstudies[1,4,6].

Howthemidwiveswereaffectedbytheworkplaceculturewasa recurring theme during the interviews. Wiklund et al. [16]

concludethatmidwivesmaybeaffectedbytheattitudesinthe obstetricunitwheretheyworkanddemonstratesthatmidwives workinginlow-riskunitshaveagreaterbeliefinnormallabour andthatprimiparascangivebirthwithoutanepidural.Another Swedishstudy showed a higher frequency of epiduraluse and otherinterventionsinlargerclinicscompared tomidwifery-led units [8]. The midwives in the present study represented a workplaceculturewhere theyexpectedprogressin labour and where interventions were frequently used, including normal labours. It was questioned whethera culture like this lead to unnecessaryinterventionsandpreventedthemfrommaintaining anormalbirth.Hunter[23]arguesthatmidwivesareaffectedby thesettingwheretheywork,andthatworkinginahospitalsetting oftenconsistsofmedicalproceduresandafocusonefﬁciency.The WHO [12] states that epidurals lead to the medicalization of normal births and requires technological unit and trained personnel. The WHO’sprinciple of demedicalizationof normal birth[11]maybechallengingtoadheretoinamedicallyoriented culture. During the interviews, it was pointed out that the midwives’focusbecamemoremedicallycentredwhenthewoman hadanepidural.Researchhighlightsthatanepiduralmightleadto afocusonmedicalproceduresinsteadofthenormalityoflabour andwillthereforeinﬂuencethemidwiferycare[2,7].

The participants described how women oftenbecome more immobileafter receivingan epiduraland both thewoman and midwifeareoftenlessactiveinpromotinganormallabourand birth. Research has shown that an epidural might lead to a prolongedlabourandmotorblockade[1,4].Desseauveetal.[24]

explainthatmotorblockadeisafrequentandfrequentlyignored consequenceof an epidural, and due tothis, women often lie horizontallyin bed. Nevertheless, the midwives at one of the obstetric units in the present study in particular stressed the importanceofmobilizationtopromoteanormalbirthforwomen withanepidural.Theparticipantsatthis clinicemphasizedthe importanceofknowledgeaboutthebabies’positionandthatthe midwiveshave to work actively with mobilizationto promote progress in birth. A Cochrane review concluded that upright positionsandwalkingshortens theduration oflabour[25].The WHO[12] explainsthatmidwivesshould encouragewomen to experimentwithdifferentpositionsratherthanlyinginasupine positionoveralongperiodoftime.

The midwives in this study had experienced a change in attitudetolabourpainamongwomen.Theparticipantspresented anincreasingcustomerfocus,wherethemidwives’jobistofulfil thewomen’swishes. Someparticipantsbelievedthat midwives mightbeafraidofnotdoinga goodjobifthey donotfulfilthe women’swish for an epidural.It was also highlighted that an epiduralcouldleadtoapositivebirthexperience.Thisdoesnot correspondwithresearchwhichhasshownthatwomengivenan epiduralhadasignificantlyincreasedriskofhavingalesspositive birthexperience,independentlyofherpreferencestowardstheuse

ofepidurals[7,8].Theparticipantsinthepresentstudyarguedthat midwiferyisaprofessionwithconsiderableknowledgeaboutpain management, and midwives should not beafraid of using this knowledgeandtheirexperiencetoworkinwomen’sbestinterests.

In ICM’s [26] deﬁnition of the midwife, they highlight that a midwifeshouldworkinpartnershipwithwomenandgiveadvice duringpregnancyandlabour.

Thepregnantandlabouringwomen’slackofknowledgeabout therisksandcomplicationsofanepiduralwasarecurringthemein this study. Some midwives highlighted the importance of information so the women could make an informed decision.

Otherssaidtheygaveanepiduralwithoutfurtherquestioningor information, because they thoughtit was upto thewomen to decide. Both research[1,8] and NICE’s[9] guideline statesthat midwives must informwomen about the risks and beneﬁts of having anepidural andhow this might affecttheirlabour. The midwives emphasized the difﬁculties of giving information to womeninpainduringlabourandhighlightedthatitwasoftentoo latetogiveinformationwhentheyarrivedatthelabourward.This is supported by Sanders and Lamb [2], who noted that during labour, thewoman mightbein suchpain thatsheis notin an emotionalstatetounderstandtheprosandconsofdifferentpain reliefmethods.Withthisinmind,itisimportanttohaveagreater focusoncopingwithlabourpainanddifferentpainreliefmethods, bothmedicallyandnon-medicallyinantenatalcare.

Thisstudydemonstratesthatmostofthemidwivesfoundit easiertoleavethebirthroomtodootherworktaskswhenthe womenhadanepidural.Themidwivesbasedthisupontheirbelief and experiencethat womenarecalmer andthereforehaveless need for continuous support. Payant et al. [27] examined the determinantsofintentionstopracticecontinuouslaboursupport.

Theauthorsconcludedthattheintentionstoprovidecontinuous supportarelowerforwomenreceivingepiduralanalgesiaandare inﬂuencedbytheperceivedsocialpressureontheirunit.Therewas anexpectation not tostay inthe woman’sroomonceshewas comfortablewithanepiduralbutbeavailabletohelpwithother tasks.Thispracticedoesnotcorrespondwithotherresearchthat pointsoutthatepiduralsareassociatedwithalackofcontrolfor women[28]andthatcontinuoussupportisespeciallyimportant fortheﬁrstonetotwohoursafteranepiduralisactivated[7].In contrast, a Cochrane Review concluded that women receiving continuoussupportaremorelikelytohaveaspontaneousvaginal birth,positivebirthexperienceandlessuseofregionalanalgesia [29].Inthepresentstudy,someofthemidwiveshighlightedthe importanceofcontinuoussupport,butduetotimepressurethis wasnotalwaysachievable.Mostofthemidwivesmentionedthatit wasoftenverybusyattheobstetricunitandthatnightshiftswere particularlydemanding.Attimeslikethis,thereseemedtobea higheruseofepiduralsandsomemidwivesalsosaidtheyofferedit more often because of the increasedworkload. The WHO [12]

states that pharmacological pain relief should never replace midwives’supportin labour and TheNorwegian Directorateof Health [13] recommendscontinuoussupport fromthemidwife duringactivelabour.Basedonthepresentstudy’sﬁndings,these recommendationsaredifﬁculttoachievewhentheobstetricunitis busy, and the midwives use an epidural as a substitute for continuoussupportincertainsituations.Auneetal.[30]alsofound thatthemidwivesdidnotalwayshavetimetoprovidecontinuous supportandthatanepiduralwasgivenasasubstitute.

Limitations

Inthisstudy,theexperiencesandattitudesofasmallgroupof midwivesworkinginNorwegianobstetricunitswereinvestigated.

Thisisaqualitativestudywithalimitednumberofparticipants.

However,the midwivesworked atdifferentobstetric unitsand

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theygaverichanddetaileddescriptionsoftheirexperiences.For thisreason,theﬁndingsshouldbeconsideredrelevant.

Conclusion

This study has provided some insight regarding midwives’ experiences and attitudes towards epidurals in a normal birth process.Distinctivedifferencesinexperiencesandattitudeswere found.Theworkplacecultureintheobstetricunitsinﬂuencesthe midwives’attitudesandtheirmidwiferypractice.Somemidwives didnotseewhythewomenshouldbeinpainwhenanepidural wasavailable,while otherssawitasanintervention.Howthey supportedwomenwithepiduralsalso differed.Somemidwives focused on working actively with mobilization to promote a normalbirthprocess,whileotherssaidtheybecomemorepassive andmedicalcentred.Whentheobstetricunitwasbusy,anepidural wasoftenusedasasubstituteforcontinuoussupport.Midwives should be aware of the power in their position and how the workplaceculture might inﬂuence theirattitudes. They should

“workwith”womentopromoteanormalbirthprocess,evenwith anepidural.Thisresearchindicatesthatthereshouldbeagreater focusaroundorganisationalfactorsandworkplaceculturesthat leadtothe offerand uptake of intrapartumepiduralanalgesia.

Althoughthisstudyissmall-scaleitshouldformthestartingpoint forfurtherandmorewidespreadinvestigationintothistopicand itsrelevanceformidwiferypracticeandmidwiferyeducation.

Ethicalstatement

ThestudywasapprovedbytheNorwegianCentreforResearch Data(ref.no.54601)June23,2019.

ConﬂictofInterest

Thereisnoconﬂictofinterest Acknowledgements

The authors would like to thank the ten midwives who participatedinthisstudy.

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