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I have chosen to use Gibbs’ Reflective Cycle (1988), as I am most challenged and I find this a useful way of learning. I have
familiar with this model. To maintain confidentiality, all names enjoyed good relationships with both midwifery and medical
used are pseudonyms. staff, and have always found them receptive to questions
about decisions or aspects of care. On this occasion my
Description questions about up-to-date research regarding rates of
I was assigned to care for Joanne, a primigravida in cervical dilatation were dismissed, and for the first time I
spontaneous labour at term, who arrived on delivery suite was personally aware of the theory-practice gap. I was also
using TENS and mobilising well. On vaginal examination aware that Joanne’s informed consent was not sought for the
(VE) the cervix was 7 cm dilated. Three hours following interventions, although this is not the focus of this reflection.
admission, Joanne was behaving ‘transitionally’ and having The two key issues from this experience that I need to
some urges to push. On VE, I found a rim of cervix and the reflect on are my understanding of acceptable progress in
fetal head had descended well into the pelvis. I reassured labour, and the lack of empowerment I experienced in my
Joanne that she was making good progress. However, my role as a junior and unqualified team member.
mentor advised that Joanne would require Syntocinon
augmentation based on the required progress of 1 cm per Analysis
hour not being met. When I challenged her, she sought the Progress in Labour
support of the registrar on duty who confirmed that this was Cervical dilatation is caused by contraction and retraction
unit policy. of uterine muscle fibres, which cause the cervix to shorten
Joanne was given Syntocinon augmentation and (efface) and open (dilate) (Walsh 2004). It is a key factor in
continuous monitoring until she gave birth soon after. diagnosing and tracking progress in labour, and is complete
when 10 cm dilatation is reached (Walsh 2004).
Feelings Various obstetricians have defined acceptable rates of
I was excited to be caring for Joanne who was keen progress in labour, the best known being Friedman and
on having a natural labour and birth. Having spent time Philpott (Walsh 2004). Friedman (1954) plotted a graph
observing her behaviour and contractions, I was confident of primiparous labour, defined latent and active phases,
that Joanne’s labour was progressing well and thought my VE and reported an average length of ‘active’ labour (3.5 cm
confirmed this. I provided emotional support to Joanne and –10 cm dilatation) of 4.4 hours. Methodological flaws are
the feeling in the room was one of positive anticipation. numerous in this study due to the inclusion of breech,
This changed significantly when my mentor entered. multiple gestations, induced/augmented labours, liberal use
Joanne became distressed because her labour wasn’t of sedation, 99% episiotomy rate and a 68% forceps delivery
progressing. I felt a whole host of emotions and feelings. rate (Friedman, 1954).
I was disappointed for Joanne that she was not going to Philpott developed the first ‘partogram’, a graphical
achieve the birth she had wanted, and also for myself. I felt record of labour with ‘alert’ and ‘action’ lines, based on
that my judgment had been undermined and I was angry studies of African women (Studd 1973). Studd adapted this
with my mentor for the manner in which she brought about for the UK, producing a 1cm/hr labour curve with a 2-hour
a drastic change in this labour. I was quite shocked at her action line. Despite these early partograms having 2-hour
attitude towards Joanne and me. action lines, supporters of ‘active management’ policies
I began to doubt my own knowledge – the registrar was advocate intervention as soon as a woman’s labour deviates
adamant that this labour needed augmentation. from the 1cm/hour ‘norm’ (Akoury et al, 1988, O’Driscoll
My confidence levels dropped, and I felt self-conscious and Meagher 2003). It is apparent that the registrar and
supporting Joanne through the rest of her labour with my midwife involved in this scenario both supported active
mentor watching over me. Afterwards I was disappointed in management, even though such a policy does not exist in
myself because I had been unable to advocate for Joanne – I our unit. Some authors suggest that clinical decisions are
felt that I had let us both down. influenced by factors outside the woman’s clinical picture,
with pressure for bed space and fear of litigation being cited
Evaluation (Lowe, 2007).
This scenario began very positively for me – the Whilst partograms can be useful tools in documenting
opportunity to care for a low risk woman wanting an labour, strict adherence to action lines reduces scope for
unmedicated labour does not come along often. I was decision making – midwives in Lavender and Malcomson’s
pleased to be able to observe Joanne’s labour and find ways (1999) survey felt that action lines threatened their
of supporting her that are not applicable to other scenarios autonomy. The midwives also felt that partograms relate
(for example, women labouring under epidural anaesthesia). to obstetrics, not midwifery, and that progress in labour
As a student, I have become used to having my practice should not be judged on cervical dilatation alone (Lavender