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Concept analysis of watchful waiting as used by midwives and physicians in labour.

Concept analysis of watchful waiting as used by midwives and physicians in labour.

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This paper is a report of an analysis of the concept of watchful waiting. Little is known about differences between the intrapartum care processes of midwives and physicians. In this time of growing rates of surgical birth outcomes, intrapartum care processes are a key area for research and improvement. Watchful waiting is a common care plan used b...

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Context 1
... diagram of the components of the concept watchful wait- ing in a labour setting was built using themes collected from the included articles in this analysis (Figure 2). Each component of the concept is presented in the diagram and in discussion below, with themes identified for both mid- wives and physicians. ...
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... a consequence of a period of watchful waiting, intrapar- tum providers anticipate different results. From a physi- cian's perspective, watchful waiting brings the possibility of several negative and one possible positive consequence (Fig- ure 2). Physician-authors expressed concern that watchful waiting would result in healthcare inefficiency, with the related risk for more costly care stemming from surveillance costs (Driffield & Smith 2007). ...
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... factors emerged from the reviewed literature as fac- tors affecting the relationship of watchful waiting anteced- ents to the attributes and consequences (Figure 2). Medical insurance companies, liability insurance, national guidelines and other outside organizations have the potential to change the way that watchful waiting is practised in a particular community or setting (Bryers & van Teijlingen 2010, Rayment 2011, Rosenbaum 2011). ...
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... many physicians, watchful waiting is defined as a period of observation undertaken to avoid immediate surgery while active surveillance of labour progress and maternal/foetal stability is enacted. The antecedents, attributes, conse- quences and affecting factors of watchful waiting, as revealed by the scientific literature, reflect a middle-range explanatory theory of this concept in these two disciplines (Figure 2). The use of this term in the scientific literature reveals the very different underlying theories held by some midwives and physicians regarding the care of women in labour. ...


... • Develop improved diagnostic criteria for labor arrest and indications for unplanned cesarean delivery. Can we build on known clinical approaches to improve delivery outcomes and vaginal delivery rates [134]? Is watchful patience the best approach and how can we encourage this behavior from the labor and delivery attendant? ...
... Individualizing treatment based on pathophysiologic mechanisms may reduce risks, optimize care, and reduce unplanned cesareans. There are multiple treatment options for labor dystocia, including watchful waiting, symptom and pain management, and augmentation [97,134]; however, gaps in the biological/translational literature and limited assessment technologies limit current opportunities for clinical individualization. Clinical and translational research that could alter diagnosis and therapy of labor dystocia should be prioritized as part of programs to increase the rate of successful vaginal birth. ...
Abnormally prolonged labor, or labor dystocia, is a common complication of parturition. It is the indication for about half of unplanned cesarean deliveries in low-risk nulliparous women. Reducing the rate of unplanned cesarean birth in the USA has been a public health priority over the last two decades with limited success. Labor dystocia is a complex disorder due to multiple causes with a common clinical outcome of slow cervical dilation and fetal descent. A better understanding of the pathophysiologic mechanisms of labor dystocia could lead to new clinical opportunities to increase the rate of normal vaginal delivery, reduce cesarean birth rates, and improve maternal and neonatal health. We conducted a literature review of the causes and pathophysiologic mechanisms of labor dystocia. We summarize known mechanisms supported by clinical and experimental data and newer hypotheses with less supporting evidence. We review recent data on uterine preparation for labor, uterine contractility, cervical preparation for labor, maternal obesity, cephalopelvic disproportion, fetal malposition, intrauterine infection, and maternal stress. We also describe current clinical approaches to preventing and managing labor dystocia. The variation in pathophysiologic causes of labor dystocia probably limits the utility of current general treatment options. However, treatments targeting specific underlying etiologies could be more effective. We found that the pathophysiologic basis of labor dystocia is under-researched, offering wide opportunities for translational investigation of individualized labor management, particularly regarding uterine metabolism and fetal position. More precise diagnostic tools and individualized therapies for labor dystocia might lead to better outcomes. We conclude that additional knowledge of parturition physiology coupled with rigorous clinical evaluation of novel biologically directed treatments could improve obstetric quality of care.
... This approach goes hand-in-hand with the 'watchful waiting' approach to labour within the midwifery model of care, defined as 'providing calm, non-invasive therapeutic support to a woman in labour' (Carlson and Lowe, 2013). It involves very little 'talking and doing', unless this is absolutely necessary to ensure the safety and wellbeing of the birthing person and the baby. ...
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Susann Huschke discusses how communicating with birthing people in the current technocratic maternity systems in Ireland and elsewhere can inhibit the birthing person's meaningful involvement in decision-making
... Examples include perinatal care providers' approaches to antenatal decision making regarding elective cesarean birth, 43 characteristics of birth settings, 11,44 differing perinatal care models, 36,45,46 and social interaction effects that normalize intervention rates among neighboring hospitals. 47 Other aspects of birth culture known to affect the likelihood of cesarean include use of intervention during uncomplicated labors, 48 allowance of sufficient time for labor to progress, 49 use of universal electronic fetal monitoring, 50 and differences in care provided by labor and birth unit nurses. 51 As our findings suggest, differences in perinatal care providers' approaches to labor and birth management may affect cesarean birth utilization, use of labor induction, and effectiveness of trial of labor after cesarean. ...
Introduction: The Robson 10-group classification system stratifies cesarean birth rates using maternal characteristics. Our aim was to compare cesarean birth utilization in US centers with and without midwifery care using the Robson classification. Methods: We used National Institute of Child and Human Development Consortium on Safe Labor data from 2002 to 2008. Births to women in centers with interprofessional care that included midwives (n = 48,857) were compared with births in non-interprofessional centers (n = 47,935). To compare cesarean utilization, births were classified into the Robson categories. Cesarean birth rates within each category and the contribution to the overall rate were calculated. Maternal demographics, labor and birth outcomes, and neonatal outcomes were described. Logistic regression was used to adjust for maternal comorbidities. Results: Women were less likely to have a cesarean birth (26.1% vs 33.5%, P < .001) in centers with interprofessional care. Nulliparous women with singleton, cephalic, term fetuses (category 2) were less likely to have labor induced (11.1% vs 23.4%, P < .001), and women with a prior uterine scar (category 5) had lower cesarean birth rates (73.8% vs 85.1%, P < .001) in centers with midwives. In centers without midwives, nulliparous women with singleton, cephalic, term fetuses with induction of labor (category 2a) were less likely to have a cesarean birth compared with those in interprofessional care centers in unadjusted comparison (30.3% vs 35.8%, P < .001), but this was reversed after adjustment for maternal comorbidities (adjusted odds ratio, 1.21; 95% CI, 1.12-1.32; P < .001). Cesarean birth rates among women at risk for complications (eg, breech) were similar between groups. Discussion: Interprofessional care teams were associated with lower rates of labor induction and overall cesarean utilization as well as higher rates of vaginal birth after cesarean. There was consistency in cesarean rates among women with higher risk for complications.
... Midwives specialize in the management of normal birth, including watchful waiting in labor. 48 Perhaps, by incorporating maternal BMI into their labor assessments, both midwives and physicians might protect more women from cesarean birth. ...
Introduction: Maternal obesity is associated with slow labor progression and unplanned cesarean birth. Midwives use fewer medical interventions during labor, and the women they care for have lower cesarean birth rates, compared with low-risk, matched groups of women cared for by physicians. The primary aim of this study was to examine associations between midwifery unit-level presence and unplanned cesarean birth in women with different body mass index (BMI) ranges. Unit-level presence of midwives was analyzed as a representation of a unique set of care practices that exist in settings where midwives work. Methods: A retrospective cohort study was conducted using Consortium on Safe Labor data from low-risk, healthy women who labored and gave birth in medical centers with (n = 9795) or without (n = 13,398) the unit-level presence of midwives. Regression models were used to evaluate for associations between unit-level midwifery presence and 1) the incidence of unplanned cesarean birth and 2) in-hospital labor durations with stratification by maternal BMI and adjustment for maternal demographic and pregnancy factors. Results: The odds of unplanned cesarean birth among women who gave birth in centers with midwives were 16% lower than the odds of cesarean birth among similar women at who gave birth at centers without midwives (adjusted odds ratio, 0.84; 95% CI, 0.77-0.93). However, women whose BMI was above 35.00 kg/m2 at labor admission had similar odds of cesarean birth, regardless of unit-level midwifery presence. In-hospital labor duration prior to unplanned cesarean was no different by unit-level midwifery presence in nulliparous women whose BMI was above 35.00 kg/m2 . Discussion: Although integration of midwives into the caregiving environment of medical centers in the United States was associated with overall decrease in the incidence of cesarean birth, increased maternal BMI nevertheless remained positively associated with these outcomes.
This chapter provides a theoretical understanding and an overview of the meaning and implications of ‘too much too soon’ and ‘too little too late’ medicine, focusing on the medicalised, fear- and risk-based approach to care that seems conducive to practising care defensively. The author will examine an interventionist and risk-based model of care and how it applies to the healthcare system in the UK, the NHS, using examples drawn from the primary, secondary, and tertiary pathways of care, with a particular focus on maternity care. It is shown that an interventionist approach to care does not necessarily lead to high-value care but that it may instead trigger opportunist costs and low-value care. ‘Too much medicine’ does not create health for all, but it instead creates a gap in health improvements while hindering health equity. Furthermore, with a nuanced approach to the topic, it is argued that the root of a mechanistic approach to care in maternity and healthcare is generated from layers of biased decisions and wrongdoings that include single individuals as well as whole care structures. An alternative model of care will be presented and critically appraised, along with some viable solutions that could be implemented relatively swiftly.