When labour slows down either the first or second stage of labour the midwives need to make sense of the change and decide whether or not it is safe to stay in the rural area. This can involve a gradual mind shift from doing everything to promote a normal birth experience to having to voice their concern to the woman about the possibility of transfer; for example in the scenario below.
The other thing is women who have little bits of bleeding when they are in labour and you are thinking is that just the cervix dilating and the show, or is this the start of something more sinister? You think well if I transfer now then everything can be dealt with there and if I don’t, am I putting everyone at risk? (m/4/11)
The midwives in this study describe this ‘tipping point’ of movement from normal to possibly abnormal labour, and how this realization is often complicated by tiredness.
Our focus is normal and we are willing it to happen and it is very difficult to make that mind shift ourselves as well. OK I need to stop here and often that is the time we need each other’s support to find out, and maybe [for our colleague] to say well I really do think you have to make a decision here. And we do sometimes come across as the meanie to the family doing that but it is the need to see clearly in the situation which must be the midwives challenge really when they have been up for hours and hours. (m/5/6)
I think the challenge here for me is finding the balance and working out when the normal becomes the abnormal and what perhaps could have been prevented. That is the other challenge for rural midwifery. (m/5/3)
The midwife describes her dilemma: “…is this normal or am I keeping this normal or am I normalizing something that is abnormal? Or other way around abnormalising what is normal”. (m/5/15)
To describe the decision making process in regard to slow labour, the midwives resorted to stories from their practice. The reconstructions of the labour events demonstrate how the midwives ‘made sense’ of what was happening and how the decision to stay or transfer was arrived at. In the following situation a midwife describes her vacillation over the decision to transfer for slow progress; this decision complicated by fatigue.
Our decision was intermittent because there [were] some changes and she was standing and it looked like there was some progress and we are definitely going to transfer. So it was an oscillation of progress there was no head at all above the brim, it was a big baby good OA [occipito-anterior] position so we were trying to persuade her to keep going and we felt she could do it. But it was the early hours of the morning or was it late at night. I can’t remember, I had been up for several hours and I asked [my colleague] for support as we had decided to go to [hospital]. (m/5/4-5)
Critical for this midwife was having colleagues available who could help put the events into perspective
… when someone has been caring for someone in labour well you are very sleep deprived when you are getting into the early hours of the morning the value of them being able to call two of your colleagues in and say this is the situation and I need your input into looking objectively at where we are at, help me make some decisions. (m/5/13)
In some slow labour situations the woman’s partner plays an important role in supporting the woman to birth. In the comment below one midwife explains how she worked with the partner of a woman whose labour had stalled.
I just got her on her side as she was pushing and not getting anywhere, and I showed him how to lift her “sit bone”12 and she rolled slightly between her side and her back and she had the baby. It is something that Wintergreen, Birthing Better had shown me. And she would have done it anyway but it just made it a little quicker for her. (m/4/6)
On another occasion the partner of a woman gave the midwife a much needed rest during a long labour prior to transfer.
Had a long haul and ended up going down there at 8 centimeters and she had a Caesar. The baby was wedged in the pelvis. Honestly it was her husband who did all the work; I sat in the chair and rested while he worked. I said that man is one who should be a midwife. (m/4/3)
In rural areas the challenge of timing for transfer during slower labours involves not just the events unfolding but also forward thinking.
I have had a few [that I transferred] and I have had a few where I got very close to it. Because things start slowing down and you… the thing is you always have to be thinking ahead. When you work here you have to be thinking ‘what if’. (m/3/4)
This notion of thinking ahead and poised to intervene and transfer was voiced by others. Waiting to see if progress happened meant that if transfer needed eventually to happen then valuable time would have been wasted.
You need to be thinking well ahead you need to be very aware and keep those emergency skills really sharp and if in doubt transfer really - we haven’t got that leniency or opportunity to leave it for another hour and see what happens. (m/3/4)
12 The “sit bones” or “sitz bones” is a lay term for the swelling or tuberosity on the superior rami
Thus the challenge of a long labour can result in rural midwives getting close to, or moving beyond, where they feel comfortable.