Obstetric Interventions Explained

Also by Andrea Robertson Book: The Midwife Companion Book: Preparing for Birth: Mothers Book: Preparing for Birth: Fathers Book: Your Childbirth Education Classes: Finding Clients Weblog: Andrea's Diary On the same subject Andrea's Papers Childbirth Education Birth Intervention

by Andrea Robertson
		Andrea Robertson is a Consultant in Childbirth Education from Sydney, Australia. Her books include Preparing for Birth, Making Birth Easier, Empowering Women, and The Midwife Companion. As the Principal of Associates in Childbirth Education, an independent training organisation, she oversees the world's first Graduate Diploma in Childbirth Education, and presents highly acclaimed training workshops for midwives and educators on teaching and practical midwifery, within Australia, and in many overseas countries.

One of the most important functions fulfilled by prenatal education programs is to offer parents information about the many options and choices available to them during pregnancy and birth. In an age when "informed choice" are current buzz words and litigation is rampant, someone must ensure that parents are fully aware of the benefits and effects of treatments they are being offered and that someone may well be the prenatal educator, given that she spends considerable time with parents in a designated learning setting.

Tackling the subject of obstetric interventions is a crucial part of this role. Since birth is a normal process, any interventions must be undertaken with caution and the ramifications made clear to parents as well as health professionals. How can this be done effectively during the prenatal period?

First, let's take an overview of the topic and consider general strategies that may affect your success.

• You must know your facts. This means keeping up to date with the current research, but also being aware of the research that was done in the past. In addition, you must look beyond the randomised controlled trials - there are few of these (sometimes none) and some of the best research has used other methodologies. Some starting points for your investigations are at the end of this article. Remember that just because there is no research does not mean there may be no problems - it just means that we don't know the answers, or haven't looked for possible effects.
  
  
• Parents have a right to know all the facts, not just those that sit comfortably with the educator, health professional or management. Be aware of your own biases here, and make sure you are not editing, filtering or censoring the information according to your own views. Stick to the facts, even those that are unpalatable or uncomfortable for you personally. Let the parents decide for themselves how they view the information in the light of their own circumstances.
  
  
• Have copies of references articles available to back up your information and to give to parents who seek more detail. Since there is limited time for all topics in a class series, providing additional reading material can enable parents to explore further in their own time. Preparing for Birth: Mothers and the MIDIRS Informed Choice leaflets are useful resources.
  
  
• The subject matter is often complicated, technical and unfamiliar, so pay attention to your language. Translate the jargon into plain English and check that your clients have understood (asking them directly may not tell you this - you'll need to use non verbal indicators and other feedback measures). Avoid using emotive words and check your own non-verbal behaviour for cues that may accidentally convey your personal opinions.
  
  
• Look for suitable teaching aids, but be careful not to create anxiety through using graphic diagrams and pictures. Treat videos with caution here as they have the greatest impact. Avoid using actual equipment such as forceps - parents can find these quite disturbing, especially if presented gratuitously as part of a teaching session. Reserve these props for those who actually ask to see them and who are therefore ready to deal with what they see.
  
  
• Make sure that these technical topics don't overwhelm your other content and overshadow the normalcy of birth. If one of your teaching outcomes is to promote midwifery and normal birth, then the bulk of the time in class should be spent on related topics, keeping the drugs and obstetric interventions to about 20% of the program. Avoid having the local anaesthetist or doctor present this material as this will give it undue importance. You also have no control over the presentation style of these professionals, leaving your group vulnerable to bias, emotive language and outright "selling" by professionals with vested interests.
  
  
• Develop a presentation outline that helps you to remember all the details you want to include: using sub-headings such as "what it is", "when is it necessary", "how it is done", "effects on the mother" and "effects on the baby" will help you keep on track. Don't forget the baby - women are highly motivated to care for their babies and avoiding an unnecessary intervention is the best way to keep the baby healthy. The effects of obstetric procedures on the unborn and newborn baby are often overlooked by health professionals, yet producing a healthy baby is central in the whole process.
  
  
• Don't make assumptions about what parents want to know and how they will react to your information. Educators sometimes worry that they will create anxiety or frighten parents, so restrict their content to relative "safe" areas. No-one can predict how anyone will react to your message and all you can assume is that there will be a reaction of some kind and be ready to deal with it. In my experience, first time parents want all the information (even the scary statistics) and may become quite angry if you try to "protect" them. Parents who have had children (and health professionals who work with them) have had experience with birth which colours their perceptions and discussion about side effects or potential problems can create guilt and anxiety. If this does happen, appropriate counselling may be necessary and should be sought/provided. Parents must be encouraged to decide for themselves what risks they are prepared to take in relation to accepting obstetric interventions and as educators, our role is to ensure they have the vital facts necessary for complete consideration of these issues.

Teaching strategies

These topics are often presented in a didactic teaching structure. The problem with this approach is that the session tends to information-laden, technical and hard to remember. You can increase the level of understanding and involvement of clients through interactive presentation methods:

• Make a set of cards showing the advantages and disadvantages of the interventions you want to discuss. Following a general introduction describing how and when they are used, ask group members to select a card (or some cards, according to the size of the group and number of cards). Place a set of "heading cards" on the floor e.g. "Forceps", "vacuum extraction" "Caesarean section" and then ask the participants to lay their cards in a line under the heading where they think it belongs. Once all the cards are on display, review each topic, going through each of the cards determining if they are in the correct place or where they should go. A variation is to line them up in two columns according to whether the attribute could be considered positive or negative (you may want to include a third category of "neutral") as this offers an interesting visual comparison of the facts. This activity gives an opportunity to review the information and discuss the ramifications of the procedures, but can only be done once group members have enough background details (perhaps gleaned from handouts) to enable them to participate.
  
  
• The "cascade of intervention" game works well to demonstrate in a visual way how one intervention can flow on to another. You will need a set of cards naming the various interventions, a ball of wool and a pair of scissors. Deal out the cards and ask the participants to lay them on the floor, starting with "induction" and ending with "birth". Spread them out with plenty of space in between over a wide area. Pass the wool and scissors around the group, and invite each person to cut a length of wool to link up two of the cards, explaining why they have chosen the connection. Keep going until you have made links from all the cards - you will have a "spaghetti" effect of wool that creates a clear picture of how one intervention leads to another and also how unpredictable the outcome can be. Follow this with a general discussion about what they have discovered and how they feel about it. You can use the diagram in "Preparing for Birth: Mothers" as a guide to the base cards you need.

These are just two suggestions for making this topic more interesting and memorable. Further ideas will be covered in a later article on teaching about drugs and epidurals during labour and birth.

References

[1] Enkin M, Kierse M, Renfrew M, Neilson J, "A Guide to Effective Care in Pregnancy and Childbirth", Oxford University Press, 1995.

[2] Wagner M. "Pursuing the Birth Machine - the search for appropriate birth technology", ACE Graphics, Sydney, 1994.

[3] WHO,"Care in Normal Birth - a practical guide", WHO Geneva, 1996.

[4] Robertson A. "Preparing for Birth: Mothers", ACE Graphics, Sydney, 1999.

[5] MIDIRS "Informed Choice Leaflets", MIDIRS, Bristol, 1997.