Chapter Seven: Authoritative Knowledge and Power: The Second OptiBIRTH Antenatal Class
7.4 Induction and Power
While the main aim of the second antenatal class was to give information and
confidence to women about labour management and birth, other issues arose in the class regarding the management of labour by the OOL. This was in relation to the induction of labour (IOL).
IOL is the process whereby labour is started artificially involving the administration of certain drugs so that this will encourage the cervix to soften and dilate. IOL is “an intervention to initiate the process of labour by artificial means and is the term used when initiating this process in pregnancies from 24 weeks‟ gestation” (Fraser & Cooper, 2009, p.558). The use of IOL occurs if the woman has a prolonged pregnancy (exceeds 42 weeks), intrauterine growth restriction (the foetus is compromised if the pregnancy continues) and maternal request among several reasons.
With regards to inducing a woman that has had a previous CS, the literature is ongoing with many countries examining the risks of inducing after a CS. The HSE guidelines (2013) on delivery after a previous CS state that, with an induction of labour there is an
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increased with UR and that caution should be used. Similar thoughts exist in the ACOG (2010) guideline whereby the risk of IOL is associated with UR and these sentiments are echoed by the RCOG (2015). As well as these guidelines, there has been research into the use of IOL and VBAC (Kweeet al, 2007; Landon et al, 2005; Guise et al, 2003). Srinivas et al (2007), in their retrospective cohort study of 13,706 women who attempted VBAC, found that IOL was one of the largest factors concerning VBAC with 3,988 of the cohort being induced and, of these, 1,349 had a failed VBAC. Similarly, Sims et al (2001), in their analysis of 505 women attempting a VBAC, the success rate for VBAC was significantly lower in women who had their labour induced than women with spontaneous labour (57.9% and 77.1% respectively). On the other hand, Agnew & Turner (2009), investigating the use of induction after a previous CS found that, of the 1,818 women who achieved a VBAC, 421 had an induced labour. Of these, 421 however, 331 (76%) achieved a VBAC. The authors thus recommended that induction can be used and that it
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is important to know not only the risk of uterine rupture but also, the likelihood of a successful vaginal delivery” (Agnew& Turner, 2009, p.210). The evidence suggests, however, that the subject of inducing a woman that has a previous CS and would like to try for a VBAC is a complicated issue.Yet, I must state that it is not my place to deem whether IOL for VBAC is considered a right or wrong thing to do, even more-so because I am not a healthcare professional. As an ethnographer looking at the OptiBIRTH intervention, I am simply trying to
understand the elements of the intervention and whether introducing this intervention effected cultural change in the field site. The literature and clinical guidelines on IOL
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that I have described are presented to give you some context on the medical aspect of induction, rather than presenting an opinion on VBAC and IOL. I am simply conveying what occurred and the implications of giving the women this information to use when they are considering how they would like to birth in their current pregnancy.
From the very beginnings of the second class, induction came up in conversation with the OOL, with him bringing up the case and his reasoning for induction after a previous CS. Many of these conversations centred on his practice around induction (e.g. giving the women “1/2 a gel15”) and that his colleagues in the hospital did not believe in induction in women who had a previous CS. In fact, at one of the classes that he attended, he told women when the subject of induction arose “I always get into a bit of trouble for saying this at this talk” (Field-note, 8th October 2014)
. This type of thinking and telling women this information, I suggest, is related to the concept of authoritative knowledge and power. The women are hearing about induction after a previous CS from a highly qualified consultant in the field-site who believes whole-heartedly in VBAC and, with this knowledge and confidence in the OOL, they are given the information for them to use in the clinic and labour ward.
This culminated in two of the OptiBIRTH women asking their doctor in the antenatal clinic to be induced so that they could be given the fullest chance in achieving a VBAC (One of the women did go on to have a VBAC while the other women had a repeat CS).
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What the OOL is referring to is Prostaglandin, a drug that is used to induce labour. Prostaglandin is hormone that is produced in the body to induce labour naturally. However, if spontaneous labour does not occur, synthetic Prostaglandin is “generally given by the vaginal route because of the relative lack of side- effects from this route. It is used for the induction of labour and acts on the cervix and myometrium (middle layer of the uterine wall)” (Fraser &Cooper, 2009, p.913).
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Throughout my time observing the classes, it was constantly stated to the women by the OLs that “the best scenario for you is to go into spontaneous labour” (Field-note, August 2014) and the conversation then moved towards induction and why it happens.
The issue of talking about induction and the OLs telling the women that the OOL for this field-site is the only clinician in the field-site that will induce a woman that has had a previous CS can be linked to a control and power issue; control in that the OOL has control over the woman attempting the VBAC rather than leaving it to his colleagues, and power in that he is exhibiting power over his colleagues and showing the women in the class that he may be their best chance of having a VBAC because he induces labour.
By the OOL telling women of his use of IOL brings about the conversation of power and the use of power in the second antenatal class. He states to the class that the subject of inducing a woman that has had a previous CS is “quite controversial” and saying that he is a “control freak so I know what is happening” (Field-note, 8th October 2014). In another class, when induction came up, the women were told that the OOL was in favour of induction but not the rest of the doctors in the hospital and that the induction would be in a “controlled environment” and that potentially, by the woman not being given the chance to attempt the VBAC, “someone else will section her” (Field-note, 12th November 2014) . By stating this to the women in the intervention, he is demonstrating power over his fellow clinicians in the field-site and creating the idea that he is the only person that, if left to the later stages of pregnancy, will allow them the chance to attempt a VBAC through controlled induction. It is this presence of power in the second antenatal class that is presented by the OOLs that I will now move on to discuss.
176 7.4.1 Power and Control
The concept of power has been explored for decades in anthropological works of various settings, from gender studies to governance and political power. When looking at power in anthropological and sociological terms we can refer back to the theoretical writings of Michel Foucault (1926-1984) and Pierre Bourdieu (1930-2002). Power in sociological writings as also been described as „authority‟ which perceives power be a legitimate entity by the social structure.
Applying the concept of power and authority to this second antenatal class, the OOL constantly referred back to the practices of his colleagues, stating that “not all colleagues are open-minded” (Field-note, June 20th 2014) and mentioned educating his
colleagues around the subject of giving women the chance to try for a VBAC by making the decision with them. From this, the women see the OOL as the main clinician in power when it came to the decision around them trying to achieve a VBAC and would ask in the class if they could refer back to his opinion when discussing their option for VBAC with their doctors at their clinic appointments if they feel the need to. They could rely on him to ensure their best interests in achieving a VBAC were at the
forefront. By using induction with a woman who has had previous CS, he is telling them he will give them a chance and how he does it for “[the OOLs] women. I give the gel the night before they are booked in for a section. We give a run for it and if they are not ripe then we can go for the section” (Field-note, January, 2015).
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Control on the part of the OOL could be seen when it came to the conversation around induction, from both his control over the way the woman would birth and control over his colleagues. When discussing induction in the class, he would tell them that he uses induction as a means of “controlling it [labour] and watching it like a hawk” (Field-note, January 2015) and that “personally I‟ll give my ones a chance” (Field-note, February, 2015)
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7.4.2 Contrasting Opinions
The subject of induction appears to portray contrasting opinions between the OLs. An example of this is when the OOL had not arrived to the class and the MOL was discussing induction:
“[The MOL] constantly throughout the class emphasised the benefits of VBAC,
especially the recovery aspect, telling the women that „you can go home after 24 hours‟. [The MOL] then moves on the best scenario for the women and that is coming into the hospital in spontaneous labour. Then one of the women asks [the MOL] about drugs and induction. She tells the class that „we don‟t do that routinely‟ and if they did, she reassured them that it would be done in a safe environment and they would have on-to- one care. [The MOL] then emphasised to the class that it is „the last step on the ladder getting the gel‟ and that „not everyone would be suitable for it‟. The women are nodding along when they are listening to [the MOL]” (Field-note, 17th August 2014).
I then supplemented this in my diary when I observed this contrasting opinion on induction and giving this information to the women in the class:
“[The MOL] does not seem to share the same opinion about induction as [the OOL]. She seems to play down the availability of being induced when the woman comes in not in labour but wants to try for a VBAC. [The OOL] proposes to the women in every class that induction is available to them and that he would even seem to advocate using induction as a regular method for this group of women. It was interesting to see that [the MOL] does not show her feelings about induction (that it would essentially be a last
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resort) to [the OOL] and looks to be quietly trying to push the play the idea of induction down when [the OOL] cannot be a greater influence than herself, like this class when she had full control of the information that was being given to the women” (Diary Entry, 17th August, 2014).
Throughout the intervention, the opinions around the use of induction between the OLs did not change and the interactions that I describe above were present in the majority of the antenatal classes.
As discussed in Chapter Two (see section 2.7.2), this contrasting opinion may be due to the contrasting philosophies between midwifery and obstetrics. In the class, when induction comes up in the conversation, the MOL stresses to them that if they are induced “it will not be the case of having multiple gels” and consistently tells the women that it is only the OOL that will induce a woman: “[The OOL] is the only one, for the last chance to try and have it” (Field-note, April 2015)
. However, if the OOL does not attend the class, the MOL will tell the participants that the OOL does induce but “you would want to be quite favourable” (Field-note, May 2015)
.
As well as showing power through the use of IOL after a previous CS, the OOL with the support of the MOL created the notion of a „VBAC clinic‟ in the field site.