Factors influencing midwives’ views and decisions about outpatient induction of labour with vaginal dinoprostone

Abstract

The research presented in this thesis explores midwives’ views and decisions about outpatient induction of labour to avoid prolonged pregnancy using vaginal dinoprostone (prostaglandin E2). Over 33 per cent of pregnant women underwent induction of labour in England and Wales in 2019/20 – an increase of 60 per cent over the past 10 years. The resultant demands on capacity or inpatient care have led many Trusts to implement outpatient induction of labour (OPIOL). The limited evidence available suggests women are highly satisfied with this approach although others express ambivalence about going home and prefer inpatient management. Staff also influence uptake of any intervention yet there is a dearth of evidence that considers their views and decisions about OPIOL. Critical realist discourse analysis was used to explore aspects of physical and social reality that mediate midwives’ views and decisions about OPIOL within a large teaching hospital in the South of England. Descriptive statistics were used to contextualise OPIOL outcomes within overall induction of labour activity. Semi-structured interviews were then used to explore midwives’ views and decisions about OPIOL. The findings demonstrate that few women had the opportunity to experience OPIOL and women eligible for the intervention were not offered it routinely. While midwives’ talk orientated towards choice and personalisation and normalising birth discourses, risk and safety discourses featured heavily in their talk. Midwives sought sanctuary in the safety net of their organisational guideline to determine women’s eligibility for outpatient management but remained uneasy about the possibility of uterine hyperstimulation and lack of surveillance at home. Some midwives were also uncertain about how to interpret the significance of earlier assessments for reduced fetal movements in pregnancy even when findings had been normal. This small, local study contributes to a wider body of literature about risk work tensions in maternity care decision-making. A deeply pernicious fear of adverse outcomes exists amongst staff, and they are rightly cautious when undertaking any risk assessments. Increasing fetal surveillance is seen as a way to provide assurance of fetal wellbeing. The findings of this study provide support for an induction of labour team, to enhance familiarity and confidence around decision-making about OPIOL with vaginal dinoprostone. Midwives may also benefit from additional multi-professional support when making decisions. Alternatively, catheter balloon induction may be preferable to staff as the risk of uterine hyperstimulation is minimised.

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ORCID for Lisa Smith: orcid.org/0000-0003-0724-289X

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