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Keywords:

  • birthing experience;
  • nursing care;
  • normal birth

ABSTRACT

  1. Top of page
  2. ABSTRACT
  3. Background
  4. Methods
  5. Findings
  6. Discussion
  7. Implications for Practice
  8. Limitations
  9. Conclusion
  10. Acknowledgment
  11. REFERENCES
  12. Biographies

Objective

To explore the nature of birthing in United States (U.S.) hospitals from 1973–2007 and to explicate and interpret common, often overlooked, birthing experiences and nursing care.

Design

A Heideggerian phenomenological approach utilizing in-depth interviews.

Setting

Participants’ homes in Washington, Idaho, and Oregon.

Participants

A purposive sample of grand multiparaes (N = 14).

Methods

Data were collected via open conversational interviews of 60–90 minutes recorded on digital media and completion of a demographic and birth attribute form. Field notes and interpretive commentary were used as additional data sources and were analyzed using an established Heideggerian approach.

Results

The participants came from diverse religious and ethical backgrounds and experienced 116 births (8.29 births per woman, 79% unmedicated), a Cesarean rate of 6%, and a breastfeeding rate of 99% with a mean duration of 12 months. Two overarching patterns emerged: pursuing the “‘good birth”: a safe passage for baby and being in-and-out of control: body, technology, others. Each pattern subsumed several overlapping themes. The first pattern revealed that women often desire a good birth in the safety of a hospital by navigating their options prior to and during the birth. The second pattern revealed a common, yet often unachievable, desire by all of those involved in the process to control birth.

Conclusion

Harmonizing an exchange of ideas in a technologically advanced environment prevalent in hospitals today can increase the quality of intrapartum care. Encouraging anchored companions and promoting normal physiological birth will make hospitals places where women can experience a good birth and feel safe.

The procedure-intensive labor and delivery environment of U.S. hospitals needs attention in the current health care culture of evidence-based, cost-effective care. Birth is a poignant personal and societal experience. Health care surrounding birth has escalated into a multimillion dollar industry, and care providers and citizens are invested financially and emotionally in how birth occurs. We conducted this study to uncover meaning for a particular group, grand multiparous mothers, so as to provide insights for interpretive examination of the evolving experiences of birthing in hospitals. During the natural childbirth movement of the 1960s and 1970s, U.S. hospital personnel were receptive to making constructive changes to birthing rooms. It was years before practitioners accepted changes such as labor-delivery-recovery (LDR) birthing rooms (Fleming, Smart, & Eide, 2011). Although changing the physical environment to support relaxed birthing has evolved, what continues is an increasingly, medically intensive milieu that treats birth as an illness and can leave mothers frightened and apprehensive (Walsh, 2010). Women's experiences need to be better understood.

Grand multiparae are an excellent group for collecting data about the evolving birth experience in U.S. hospitals over the past three decades. Like the average American woman giving birth in U.S. hospitals, they were once primiparous women. As their births became more current, they experienced an increase in inductions and other birthing technologies that are reflective of the current obstetrical practice (Declercq, Sakala, Corry, & Applebaum, 2006; Zwelling, 2008). What sets the grand multiparae apart from average American women is their experience of more births over time. We investigated the compelling birthing stories of 14 grand multiparae over several decades and interpreted these experiences in an evolving, increasingly technological hospital environment. Implications for nurses are derived from these findings.

Background

  1. Top of page
  2. ABSTRACT
  3. Background
  4. Methods
  5. Findings
  6. Discussion
  7. Implications for Practice
  8. Limitations
  9. Conclusion
  10. Acknowledgment
  11. REFERENCES
  12. Biographies

Intrapartum care in U.S. hospitals is procedure intensive and highly technological, creating new challenges for the intrapartum nurse. As the implementation of technology during labor in birthing suites increases, there is a corresponding decrease in labor support (emotional and physical comfort measures) administered by nurses (Declercq et al., 2006; Zwelling, 2008). Intrapartum nurses are increasingly called upon to manage technology, such as interpreting fetal monitors from a distant centralized location to manage several laboring women. This results in decreased time available to provide one-to-one labor support to the individual laboring woman (Fleming et al., 2011). Numerous experts in the health care disciplines assert that technology is a dehumanizing aspect of the natural birth experience (Hodnett, Gates, Hofmeyer, & Sakala, 2007; Romano & Lothian, 2008; Sauls, 2006; Zwelling).

Intrapartum nurses can be trusted anchored companions for childbearing women and provide a setting where women can relax and respond to their own body cues.

The highly technological hospital birthing environment is common in the United States (a 34% induction rate, 94% fetal monitoring rate, and a 76% epidural analgesia rate) (Declercq et al., 2006). Considerable hospital care has moved to outpatient settings over the past 20 years, however, this has not been true for maternal/newborn care. By 2008, 6 of the 10 most common hospital procedures performed, including prophylactic vaccinations, Cesarean, repair of obstetric laceration, circumcision, fetal monitoring, and artificial rupture of the fetal membranes, were related to maternal/newborn care. Cesarean, listed as the most frequent operating procedure, was performed on 1.4 million women of the 4.2 million births in 2008 (Wier et al., 2010). The evidence suggests that when these invasive procedures become routine, there are adverse outcomes (Lothian, 2004). This raises the question as to how technological advances support or impede delivery and thus affect the childbirth experience.

Increasing technology is associated with increasing cost and presents a burden to the U.S. economy. In 2008, maternal and newborn care were two of the most expensive hospital conditions billed to Medicaid ($41 billion) and to private insurance ($50 billion) (Wier et al., 2010). If health care costs are to be effectively managed and technology is used appropriately, maternity care practices need to be addressed.

Methods

  1. Top of page
  2. ABSTRACT
  3. Background
  4. Methods
  5. Findings
  6. Discussion
  7. Implications for Practice
  8. Limitations
  9. Conclusion
  10. Acknowledgment
  11. REFERENCES
  12. Biographies

A Heideggerian phenomenological approach was used to interpret the meaning of experience (Diekelmann & Magnussen Ironside, 1989). Heidegger advocated for an ontological stance by using an interpretive lens to guide the researcher in all aspects of study. Thus, the researcher remains open to information that shows itself and makes interpretations with a critical eye to what is known and newly uncovered (Heidegger, 1962).

The research question “What is the nature of childbirth in U.S. hospitals as experienced by grand multiparous women?” guided the interviews, and the specific aim was to explicate and interpret common birthing experiences and nursing care in U.S. hospitals over the past three decades. Institutional Review Board exempt status was obtained.

Sample and Setting, Data Collection, & Data Analysis

Sample and Setting

A purposive sampling of 14 grand multiparae, having a total of 116 childbirths, was conducted in the fall of 2010 (see Table 1). Eligibility criteria required five or more birthing experiences with at least four births delivered in a U.S. hospital setting, with at least one birth before and one after 1996 (representing the start of a 12-year consecutive increase in cesarean births nationwide) (Hamilton, Martin, & Ventura, 2010). The interviews were conducted in a self-selected place, usually the woman's home, in Washington, Oregon, and Idaho.

Table 1. Grand Multiparae Descriptive Summary
 Participants
Note
  1. a

    Mother and father couples (n = 19), 21% (n = 4) were interracial.

  2. b

    Native American was reported as trace and all other ethnic groups were reported as primary.

  3. c

    All participants (n = 14) reported 100% (n = 111) vaginal intent (excluded planned (n = 5) Cesarean).

  4. d

    All participants (n = 14) reported 99% (n = 115) babies were breastfed.

Number (n)14
Age (mean)45.86 (Range 34–54)
Religious backgroundLatter Day Saints, Catholic, Muslim, Pentecostal, Seventh Day Adventist and Unaffiliated
Ethnic backgroundaWestern European American, Slavic American, African American, Tongan American, & Native Americanb
Marital Status (n)
 Married13
 Never married1
Age (mean)45.86 (Range 34–54)
Vaginal intent (n)c14
Breast feeding (n)d14
 Duration (Mean)12 months
Data Collection

Data were collected via open, unstructured, one-to-one interviews with the participant guiding the storytelling and the researcher clarifying messages that were unclear (Munhall & Chenail, 2008). Audio-recorded interviews were 1 to 2 hours, or as long as the women had something to share. Interviews were recorded on digital media and transcribed verbatim by a professional transcriptionist. Participants self-selected pseudonyms, allowing them to represent themselves in ways meaningful to them. The initial interview question was “I am interested in the nature of childbirth in U.S. hospitals; tell me about your birthing experiences. Is there a situation that you can recall?” This critical incident approach oriented the participants to salient experiences that represented meaning over cognitive or affective responses (Benner, 1994). Field notes and demographic information added to the data.

Data Analysis

An interpretive phenomenological analysis was conducted (Crist & Tanner, 2003; Diekelmann & Magnussen Ironside, 1989; Vandermause, 2011). Each transcript was carefully read from start to finish followed by an additional rereading of the text. A comprehensive list of notes and observations was generated and reviewed, with astute attention to frequency of related ideas, position in text, response to interview questions, style of response (halting, stuttering, slang, affect conveyed), and implied content. A rudimentary list of emerging ideas was formulated. Finally, a summary of the transcript was written with detail and textual support. These summaries were merged and revised as interpretations with supporting commentary were generated. The interpretive research team (four content and/or methodology experts) met bimonthly for several months and engaged in reading across one another and across summaries and interpretations (see Table 2). Naming and revising patterns and themes, or recurring, overlapping ideas, became part of the iterative process (Vandermause, 2008).

Table 2. Patterns, Themes, and Exemplars Related to Grand Multiparae Birthing in U.S. Hospitals
PatternsThemesExemplarsa
Note
  1. a

    Exemplars represent hundreds of experiences revealed in the data.

Pursuing the “good birth”: a safe passage for babyReadying for birth“If you haven't had any preparation and a nurse is suggesting you do something, it's hard to focus on it if you're in a lot of pain.”
  “I'd taken a Lamaze class with the first one only. I never took any others. So I kind of did the Lamaze, a lot of breathing, a lot of focusing.”
 Suffering for baby and me“If I could be patient, not have a C-section and if I was sure the baby's life was not in danger, I would do whatever I needed to do to have it natural.”
 Settling the course“Yeah. He (anesthesia) can wait outside the door. If I need him, he's there. I tell the nurse, ‘No way he's coming to the party.’ Politely.”
Being in-and-out of control: body, technology & otherEmbodiment of pregnancy, birthing, and feeding“I felt myself have this baby. You know, I felt him come totally out of the birth canal. You know? It was a total burning birth.”
  “I thought if I could breathe while I was pushing, I was doing it right. But if I held my breath, it didn't have the same effect. I do remember that.”
 Being with interventions, medicines, and machines“They went ahead and put Pitocin in that IV without telling me (after the delivery). I'd never had Medicines and Pitocin before (4th) baby. All of a sudden, I had these huge, huge pains to contract that uterus, and it really took away from the enjoyment of my new baby.
 Birthing with others“I really learned from my (new) husband. Number six (6) … him looking at me saying, ‘This is your body and this is your baby and this is your experience.’ I went, ‘Really? Really?’”
  “I look to the nurses to being that liaison between me and the doctor and to tell me what's happening and what's going on, it's gonna be okay.”

Validity was established through the primary criteria of credibility, authenticity, criticality, and integrity. Credibility addresses the question “Are the results believable?” Authenticity addresses the question “Are the individual voices of the participants being heard?” Criticality addresses the question “Are ambiguities recognized and are interpretations based on evidence?” Integrity addresses the questions “Does the research reflect recursive and repetitive checks of validity as well as humble presentation of findings? Are the investigators self-critical?” (Whittemore, Chase, & Mandle, 2001, p. 534). These criteria were the standards that upheld and represented the truthfulness of the findings. The secondary criteria of explicitness, vividness, creativity, thoroughness, congruence, and sensitivity provided the research team with supplementary guiding principles (Whittemore et al.).

Findings

  1. Top of page
  2. ABSTRACT
  3. Background
  4. Methods
  5. Findings
  6. Discussion
  7. Implications for Practice
  8. Limitations
  9. Conclusion
  10. Acknowledgment
  11. REFERENCES
  12. Biographies

We addressed the common, evolving birthing experiences of 14 grand multiparae in U.S. hospitals, not their 116 isolated birthing events. None of these births occurred in a vacuum but were influential in shaping future decisions about birthing. Two overarching, nonmutually exclusive, patterns emerged: pursuing the “good birth”: a safe passage for baby and being in-and-out of control: body, technology, others. Common themes were subsumed in these patterns. However, it is important to recognize that these excerpts represent hundreds of experiences and led to the interpretive findings. These findings are not intended to be scientifically generalized to groups, but they should resonate with practitioners and mothers in ways that increase understanding and affect practice and experience. This study provided a mothers’ perspective of childbirth and can increase our “optimal grip” of birthing in contemporary United States (Merleau-Ponty, 1962).

Pursuing the “Good Birth”: A Safe Passage for Baby

The participants described their desire for a “good birth” and to provide a “safe passage” for their infants. They described safety as their motivation for giving birth in a hospital. Mother-of-the-Ark (15 vaginal births) described her first birth experience, which was frightening and uncomfortable:

Very scared actually. I wouldn't say kind of. I really was … nervous and very frightened. I can remember when they put your legs up in the stirrups. In those days, you went into an actual delivery room from the labor room. I loved it when they started just leaving me in one room. I went to move one of my legs because I was getting a charley horse. She kind of gave me this lecture about leaving my legs up there and she strapped them in. I remember when [baby] was born, laying on the delivery table thinking, “I'm never doing this again!”

Several of the mothers experienced uncomfortable practices, such as tying women's legs and/or arms to the birthing table, with their earlier births. A combination of evolving intrapartum birthing practices and their increasing assertiveness and practical wisdom eventually led these women “good births.” Mother-of-the-Ark stated:

It was just like I had learned to relax. I'd learned to breathe and to just experience the whole experience. I remember thinking when he was born that, okay, now that's the way birth should be. Then from there on, they pretty much were that way. I just had learned enough about my body and myself and the experience to just relax and let my body do what it needed to do. I didn't have to tense up. I didn't have to fight against anything. Just work with it. It just was a marvelous experience. It really was, and for me I needed that safety of the hospital.

The first pattern subsumed three overlapping themes: readying to birth, suffering for baby and me, and settling the course.

Readying to Birth

Like most primiparous women of their time, nearly every one of the participants of this study had prepared for their first births by attending childbirth classes or reading books, such as those originating from Lamaze or Bradley or by listening to friends, talking to their providers, and/or experiencing another's birthing. When they entered the hospital with their earlier births, they were often presented with a stressful predicament. Frequently it was not what they expected or was not welcoming of their desires. Often they were subject to procedures they perceived as intensive. Several of the women said they were more frightened after their first births.

Bobbie (five vaginal births) had spent 12 weeks in class preparing for her first birth, a natural childbirth using the Bradley Method. She stated:

They were still very much into the – we're going to give you an epidural. We're going to do this. Procedure. When I came in with my first daughter, I had been laboring quite a while. I had opted not to have an IV, which was very strange for them. So they were just kind of watching me. I guess they got to a point where they felt like the baby was a little bit in distress, so I asked them to get me a pushing bar or a squatting bar. They were not really used to that either. I remember the OB doctor was there, but he stood against the wall and he watched me deliver this baby … it was a very, stressful delivery … he kind of chewed me out at the end of the delivery. He was a partner of the doctor that I had chosen. He says, “Well, you did just like we talked about.”

Bobbie found the hospital was not prepared or did not support her choice to have a natural birth. With her second birth, Bobbie was able to find a practitioner and a hospital that would support her delivery choices.

Suffering for Baby and Me

Every one of the participants spoke of the pain of childbirth. Along with pain, these women were often frightened. These grand multiparae initially wanted to deliver naturally in the hospital and avoid a Cesarean birth. Frequently, birthing naturally gives rise to suffering. However, women often stated they were able to endure suffering by giving it meaning, which was to bring new life forth in a healthful way, free of medications, interventions, or procedures.

Rachel (nine vaginal births) stated that her desire throughout her birthing years was to avoid Cesarean. She “suffered” to avoid a Cesarean birth:

If I was sure the baby's life was not in danger, I would do whatever I needed to do to have it natural. And so, you know, I would ask the doctor, “Is the baby's – you know, is there some problem for the baby?” And if he said no, then I'd say, “Okay. Then I'll just suffer until I have the baby.”

Settling the Course

These participants had to settle or reach an agreement over their birthing plans between their providers and themselves by adapting, accepting, negotiating, demanding, avoiding, confronting, or conforming to the hospital environment, even if this meant changing their initial birthing plans. During Rachel's (nine vaginal births) early birthing experiences, the doctor was reluctant to use a birthing room even when one was available. Rachel attempted to negotiate the place of her birth with her physician but she was unsuccessful:

The birthing rooms were brand new then … and they did have one in the hospital, but my doctor did not want to use it. … ‘cause I told him I really want the birthing room… He just said, “This is the way we have to do it.”

In many instances women had to change their desires to accommodate providers and give birth without conflict in hospitals.

Being In-and-Out of Control: Body, Technology, Others

The second pattern of this study reflected the participants’ desire to control their birthing experiences, often by attempting to control their bodies, birthing technologies, and/or others. However, it was often their bodies, the technologies or others controlling the births. Tina (15 vaginal births, one Cesarean) had her first nine births in Europe. When asked about her birth experiences, she recalled the latter seven births in the United States and answered, “Giving birth is like, when I come to the hospital, I always come late. I always did like that … ‘cause I didn't like to stay with IV in the bed. I like to move.” Tina described her ability to control a part of her birth before she relinquished control of her body to the technology and the people in the U.S. hospital. Tina's insights illuminated the nature of delivering in U.S. hospitals.

The second pattern subsumed three overlapping themes: embodiment during pregnancy, birthing, and feeding; being with interventions, medicines, and machines; and birthing with others.

Embodiment during Pregnancy, Birth, and Feeding

As the pregnancy progressed the embodied experience was evident. During labor, medicated or unmedicated, the participants were not able to appreciate the embodied experience of birth unless they were relaxed. If they had selected an epidural, embodiment took on a new alteration.

Bobbie (five vaginal births) always wanted a natural birth in the right conditions with the right provider and the right place. She was finally able to achieve this vision. Bobbie described a euphoric experience when she could engage in physical control, and she was keenly aware of what was happening outside and as inside her body:

You know, listening inside the body, too. So I was able to sense what muscles to use and when to use them. When the doctor said, “Stop pushing,” you always lean your head back and count ceiling tiles … you have control over that … I liked the feeling of being in control of the birth… ‘Cause I could feel the baby pushing off my uterus to push itself out. The baby and I would work together.

The description of embodiment during birth is absent in the extant literature occurring in hospital settings (Walsh, 2010). This study uncovered many accounts of euphoric experiences, which were always unmedicated and in a relaxed setting.

Being with Interventions, Medicines, and Machines

All of the women talked about the birthing technology that surrounded them during their births. Initially, they were grateful to see the use of uncomfortable interventions (e.g., tying women's legs) dwindle. However, as the stories progressed, so did the technology. Technology was being used to manage the distress caused by another technology: epidurals to ease the pain of synthetic oxytocin inductions. Jill (nine vaginal births) experienced five vaginal births naturally and felt birthing was a very easy process. Like several of the other women, her earlier births were quick and unmedicated, though overdue. However, being overdue was becoming a new issue for the women and their providers. They were offered inductions to initiate the birthing process. Jill's described her sixth birth, which was induced:

By this time, I'd walk in and an hour later I'd have the baby. Three pushes and they're out … this one was different. I was overdue. So we scheduled to induce me. They used Pitocin. I was having contractions, but like before where the contractions were actually doing something, my uterus wasn't responding like it had in the past … they had to start cranking up the Pitocin.

Unlike her previous pregnancies where she would go to the hospital and deliver within hours, this one was taking time and the contractions were not effective. She stated:

They had the fetal monitor, and her heart rate would go down. She was in distress. The doctor thought, we'll just give you a whiff and you'll just take off … they had to turn back the amount of Pitocin because the baby was going into distress. I actually got a little scared because the heart rate went down, 7-1/2 minutes to get the baby stable … they gave me oxygen. They had my leg lifted up in the air. The cord was caught around her neck – it was strangling – it was choking her. I'm looking at the monitor, and I know the numbers aren't good … by now, they're going to turn it around so I can't see what the numbers look like.

A cesarean was considered.

So now I'm kind of panicked … they called my doctor in. He said, “Don't worry. We will schedule a C-section.” The nurse said, “We've got everything ready if you need it.” The doctor stood there, and it seemed like forever. He was trying to decide what to do. He said, “You know, your body has done this so much before. I think – I think it's going to go ahead and happen naturally.” And I'm thinking to myself, “Are you kidding me?”

Jill delivered vaginally in one hour and reported that the staff watched her baby closely. Jill was extremely grateful that she did not end up with a Cesarean and the recovery associated with having one. Her eighth and ninth baby were also scheduled for inductions, but her body initiated labor on its own.

Birthing with Others

None of these women wanted to experience birthing alone and found themselves agreeing, conforming, negotiating, or even demanding that they experience birthing with others. This often led to compromise superseded by clinical events. Initially, women made it a priority to avoid epidurals, which they felt could lead to cesarean.

Childbearing women need to be informed that with the use of oxytocin, nonpharmological pain relief techniques might be ineffective in managing pain.

Colleen (nine vaginal births), like most of participants, spoke of the importance for them and/or their husbands (or partner) to connect with the nurse:

So I really look to the nurses to being that liaison between me and the doctor and tell me what's happening and what's going on … it's gonna be okay … keeping me informed, I do like to know what's going on. I feel more in control … in one way, they were an advocate, but also they were the information person. My flow of information came from them. ‘Cause they're the ones that are there. They're the ones that have their name on the board. Hello. I'm your nurse whose in today.

The intrapartum nurse was a vital link between the childbearing women and the hospital staff and/or routine. Mothers in this study who felt connected to their nurse spoke of favorable birthing experiences for themselves as well as their husbands (or partners).

Jill's ninth birth is a paradigm example. This birth was scheduled for an induction, however, labor quickly commenced on its own. Not only had the women gained practical wisdom, so did some of the fathers. Jill described her husband's announcement as they entered the hospital:

“Ninth baby. In transition,” They were just on it. It was like everybody … 15 minutes…. It was like a football team. They were just right in position, took over, and it was done. Everyone knew what they were doing. “We got this covered, honey. Don't worry.” It was the nurses that did most of the job. The doctor had his pajamas on still. I was like, “I barely made it here myself.”

The collaborative activity of this birth, initiated by a husband's experienced direction, was a favorable example of how birthing with others could be done well.

Discussion

  1. Top of page
  2. ABSTRACT
  3. Background
  4. Methods
  5. Findings
  6. Discussion
  7. Implications for Practice
  8. Limitations
  9. Conclusion
  10. Acknowledgment
  11. REFERENCES
  12. Biographies

The aims of this study were to explicate and interpret common birthing experiences and nursing care in U.S. hospitals over the past three decades. It was anticipated that the women would have many stories on nursing care. However, the data were more reflective of care in general. All of the women described pursing a “good” birth regardless of whether that was achievable. In addition, they often spoke of the safety that a hospital can offer. Interestingly, in a recent study women described safety as their motivation for delivering at home (Boucher, Bennett, McFarlin, & Freeze, 2009). There are extensive arguments surrounding safety for both hospital and home births. But a “good birth” meant comfort as well as safety to these participants.

Nearly all of the participants of this study attested to the importance of the teachings from their childbirth classes or readings. Most often they attended non-hospital-affiliated classes such as Lamaze or Bradley. These classes promote natural birthing practices and encourage women to trust their own powers and decisions. They are often described as confidence building for childbearing women (Lothian & DeVries, 2005). Conversely, hospital-affiliated birthing classes usually do not promote a preference between natural or medicated births. Rather, they present options for birth, which include routines of their hospitals. These routines often deemphasize natural birthing. Both of these types of classes have advantages as well as their own self-proclaimed agendas. Regardless, women need and desire to be educated in anticipation of their births, particularly their first birth.

Today, pregnant women list books as their most important source of information for pregnancy and birthing Even the Internet is listed as a more important source than childbirth classes. If these contemporary sources of birthing information are randomly selected, mothers may be subject to being misinformed and more fearful of birthing (Day, 2007; Declercq et al., 2006). In the Listening to Mothers II study, 68% of pregnant women watched birthing reality shows and reported the shows, “helped me understand what it would be like to give birth” (Delecerq et al., p. 24). In their content analysis of 85 reality based television shows in the United States, Morris and McInerney (2010) found women giving birth in hospitals were typically displayed as incapable of birthing without a medical intervention, which was seldom based on evidence. This present-day trend of passively watching reality-based birthing shows, which may be more entertaining than educative, can encourage American women to accept increasing medical interventions during birth.

All of the participants reported the ability to relax, whether natural or with an epidural, was essential in experiencing a “good birth.” The participants stated that this is only possible under the right conditions, with the right provider (either a doctor or midwife), and in the right setting in which they could relax. The ability to relax is often underemphasized in medical education. When a childbearing women is subject to dystocia medical school textbooks focus on mechanical aberrations where one or more of the three Ps is/are not operational. The three Ps are powers (quality of contractions and ability of expulsion), passenger (fetal size and position of presenting part), and pelvis (size and shape of the pelvis). Dystocia is the most common indication for a Cesarean (Cunningham et al., 2010; Vandevusse, 1999). This objectified view of the pregnant woman's body aligns with the empirical science of Cartesian duality where there is a mind/body split. Simkin and Ancheta (2000) added two additional Ps, which are psyche (emotional and anxiety of the woman) and pain (the ability to experience and cope with the pain). The addition of these two Ps allows for a holistic view of the pregnant woman's body. The participants of the current study shared numerous experiences indicating that their emotional stability and the ability to cope with the pain was of primary importance when giving birth. This study points to the need for the addition of another P, which is participation. With participation, the participants said that what constituted a relaxing birth was one where they were deeply involved and contributed to their birthing experience.

Control is a noteworthy issue for childbearing women, and the ability to control a birth is desirious (Namey & Lyerly, 2010). Namey and Lyerly interviewed 101 multiparaes on a “good birth” and then set out to deconstruct the meaning of control for childbearing women. Their five distinct domains of control—self-determination, respect, personal security, attachment and knowledge—fit well with the findings of this study. In addition to these five domains, this study revealed another behavior women used to express control, which was avoidance. For example, in an attempt to control their ability to freely move, they might arrive at the hospital late. Romano and Lothian's (2008) six evidence-based care practices that promote physiological birth, avoiding medically unnecessary induction of labor, allowing freedom of movement for the laboring woman, providing continuous labor support, avoiding routine interventions and restrictions, encouraging spontaneous pushing in nonsupine positions, and keeping mothers and babies together after birth without restrictions on breastfeeding were plentiful in these women's stories. However, it was often a struggle to keep them in play during birth as birthing technology began to take precedence.

Most of the participants, many who succumbed to inductions, ended their birthing journey with a near miss or actual Cesarean. The American College of Obstetricians and Gynecologists (2009) recommended not inducing prior to 39 weeks. Clark and colleagues (2009) of Hospital Corporation of America (HCA), the largest private health care organization in the United States representing 220,000 births annually (5% of the nations births), have been studying maternal care practices within their own health care system. They conducted a prospective observational study in 27 hospitals (17,794 deliveries) over a course of 3 months in 2007 and found that neonatal morbidity is significantly increased when babies are born at even 37- or 38-weeks gestation as opposed to 39-weeks gestation. In addition, they suggested women beyond 39 weeks with an unfavorable cervix should be counseled that they are at increased risk of Cesarean birth (Clark et al.). ACOG (2009) recommended not electively inducing labor prior to 39 weeks.

This study identifies an additional risk of using oxytocin, which is pain. Childbearing women should be informed that when oxytocin is used, nonpharmological pain relief techniques might be ineffective managing pain. However, the participants did talk about poor outcomes following inductions compared to their normal physiological births. This raises the question as to whether some technological interventions carry greater risks than births without such interventions and calls us to examine the use of all interventions more carefully.

Grand multiparae who have delivered primarily in hospitals can increase our understanding of where technology and nursing care intersect.

In summary, the technological advances in intrapartum care need to be carefully scrutinized, as these advances have not resulted in better outcomes, lower costs, or higher satisfaction in birthing outcomes. To improve this condition, it is important to understand the nature of the hospital environment, where technology and nursing care intersect. Multiparaous women, with their wealth of childbirth experience over time, offer much needed insight into the current state of intrapartum care in U.S. hospitals today.

Implications for Practice

  1. Top of page
  2. ABSTRACT
  3. Background
  4. Methods
  5. Findings
  6. Discussion
  7. Implications for Practice
  8. Limitations
  9. Conclusion
  10. Acknowledgment
  11. REFERENCES
  12. Biographies

This study illuminated birthing in hospitals from the 1970s, when physiological birthing was desired, to the present day, when there is a perceived need for technology to provide safe care (Zwelling, 2008). Nearly all of these participants had the privilege of a caring companion in the room, however, their companions entered a setting and routine unfamiliar to them. The need for an anchored companion (Lundgen, 2004) an intrapartum nurse providing one-to-one care, to support a woman's unique desires and ability to relax is vital. This could be implemented along with AWHONN's new 2010 staffing guidelines that recommend one nurse to one woman for women choosing to labor with minimal to no pharmacologic pain relief or medical interventions or for women receiving oxytocin for labor induction or augmentation. Both of these scenarios are prevalent in hospital births. Furthermore, one-to-one staffing could allow for normal physiological birthing to transpire. Intermittent auscultation allows women to walk and move, which helps her to respond to the needs of the fetus rather than simply maintaining the integrity of the monitor strip. Nurses need to look for opportunities to increase confidence and encourage women to access their own powers to birth. A menu of meaningful nursing labor support activities and interventions that are evidence based can be helpful if this aligns with the women's beliefs and expectations (Adams & Bianchi, 2008; Enkin et al., 2000; Lothian & DeVries, 2005; Sauls, 2006; Simkin, 2002; Simkin & Ancheta, 2000; Simkin & O'Hara, 2002; Zwelling, 2010, see Table 3). Hospitals that implement AWHONN's 2010 staffing guidelines need to be commended.

Table 3. Suggested Clinical Implications
Supportive 
ThemeSuggested Clinical Implicationsa
Note
  1. a

    These implications can promote normal physiological labor if desired and deemed appropriate.

Readying for birth• Encourage her to participate in prepared childbirth classes.
 • Welcome evidence-based care she suggests that was taught in hospital and non-hospital-based classes.
 • Connect with local hospital and nonhospital educators. Invite them to meetings to share evidence-based practices taught in their classes.
Suffering for baby and• Encourage her to relax and suggest how that can transpire.
me• Discuss with her pharmacological and nonpharmacological modes of pain relief.
 • Educate women that epidural pain relief may not be instantaneously available and they may need to self-manage their pain until this service is rendered.
 • Negotiate postdelivery oxytocin administration to allow her pain-free time to bond with her baby.
Settling the course• Read the birth plan aloud with her and identify any barriers or conflicts.
 • Meet her and get to know her and her desires before proceeding to your algorithmic admission form.
 • Discuss your hospital menu of meaningful labor support activities that align with her beliefs.
Embodiment of pregnancy birthing and• Promote normal physiological labor and identify nurses who are competent and enjoy working with these births.
feeding• Provide in-services for intermittent auscultation techniques and other interventions that promote physiological birthing.
Being with interventions, medicines, and machines• Reevaluate routine interventions and identify and modify those that conflict with the evidence.
 • Question elective inductions prior to 39 weeks gestation.
 • Implement intermittent fetal monitoring (electronic or manual) from the bedside when appropriate.
Birthing with others• Don't leave her alone; provide relief for her support person.
 • Be an “anchored companion” and a link to hospital and staff.
 • Provide one-to-one care with all unmedicated or with use of synthetic oxytocin births.
 • Be present: let her know where you are going and when you'll be back.

AWHONN's 2010 and ACOG's 2009 guidelines, extant literature, and the findings of this study call for a change in culture, which is to reinstitute and promote normal physiological labor in hospital settings. Changing staffing ratios alone will not be sufficient. Currently, most national intrapartum nursing care competencies and educational programs focus on skills related to electronic fetal monitoring prior to and during labor and not labor support. This can reinforce to nurses the vital importance of electronic fetal monitoring while overlooking labor support care. This dichotomy may contribute to nurses viewing the childbearing woman's body as incapable of birthing and in the need of constant surveillance. As suggested by the extant literature, a balanced education of technological support as well as professional labor support would enhance intrapartum care (Adams & Bianchi, 2008; Enkin et al., 2000; Fleming et al., 2011; Kardong-Edgren, 2001; Sauls, 2006; Simkin, 2002; Walsh, 2010; Zwelling, 2008, 2010). This paradigm shift calls for the need to reinstitute childbirth classes, where evidence-based teachings and birth plans will be welcomed in the intrapartum setting. All of these changes will call for additional research to explore the phenomenon of physiological birth. These changes can encourage cost effective high-quality care, which can result in better outcomes for childbearing women and newborns

Limitations

  1. Top of page
  2. ABSTRACT
  3. Background
  4. Methods
  5. Findings
  6. Discussion
  7. Implications for Practice
  8. Limitations
  9. Conclusion
  10. Acknowledgment
  11. REFERENCES
  12. Biographies

Participants in this study were limited to a geographical range of a group of willing participants. Most of the interviews took place where the women resided, which was Washington, Idaho, or Oregon, though the births took place in a range of places (Washington, Oregon, Utah, Nevada, Idaho, Arizona, California, Nebraska, Ukraine, Estonia, and Italy). This sample should be expanded and diversified.

Conclusion

  1. Top of page
  2. ABSTRACT
  3. Background
  4. Methods
  5. Findings
  6. Discussion
  7. Implications for Practice
  8. Limitations
  9. Conclusion
  10. Acknowledgment
  11. REFERENCES
  12. Biographies

A Heideggerian hermeneutic approach was used to explicate and illuminate common birthing experiences of 14 grand multiparae in hospitals over the past three decades. This allowed us to identify and examine overlooked nursing care practices. Two overarching patterns, pursuing the “good birth”: a safe passage for baby and being in-and-out of control: body, technology, others led to a greater understanding of the nature of the hospital birth environment, where technology and nursing care intersect. Intrapartum nurses and childbirth educators can be instrumental in promoting congruence among childbirth nurses, educators, and providers. Making changes in hospitals that encourage anchored companions and promote normal physiological births will make hospitals places where women can experience a “good birth” and “feel safe.”

Acknowledgment

  1. Top of page
  2. ABSTRACT
  3. Background
  4. Methods
  5. Findings
  6. Discussion
  7. Implications for Practice
  8. Limitations
  9. Conclusion
  10. Acknowledgment
  11. REFERENCES
  12. Biographies

Supported by the HRSA Nursing Faculty Loan Repayment Program and the Carl M. Hansen Foundation. Interpretive analysis by Billie Severtsen, Erla Champ-Gibson. Carrie Holliday-Santucci.

REFERENCES

  1. Top of page
  2. ABSTRACT
  3. Background
  4. Methods
  5. Findings
  6. Discussion
  7. Implications for Practice
  8. Limitations
  9. Conclusion
  10. Acknowledgment
  11. REFERENCES
  12. Biographies

Biographies

  1. Top of page
  2. ABSTRACT
  3. Background
  4. Methods
  5. Findings
  6. Discussion
  7. Implications for Practice
  8. Limitations
  9. Conclusion
  10. Acknowledgment
  11. REFERENCES
  12. Biographies
  • Susan E. Fleming PhD, RN, is a clinical assistant professor in the College of Nursing, Washington State University, Spokane, Spokane, WA.

  • Roxanne Vandermause, PhD, is an assistant professor in the College of Nursing, Washington State University, Spokane, Spokane, WA.