“First know what is normal. Expect what is normal and do not intervene when the state is normal! If a pathological condition develops, choose the correct intervention to bring the mother and baby back to normal state and apply it. Every intervention has a powerful impact and sometimes that impact may lead to the development of further pathologies, moving the situation further away from normality. Extra caution and care is advised when choosing which intervention to apply!” [1, 13].
There have been important changes in the management of birth over the last 30 years. One trend is toward more natural childbirth, emphasizing the human emotional aspects of labor and delivery and seeing the mother as an active participant in the birth process rather than a baby-producing machine [2]. In addition to paying attention to the wellbeing of mother and child, an attempt is made to decrease unnecessary interventions at birth, protect mothers’ choices during the process, and reduce the cost of care [2, 4]. In Turkey, however, it has been reported that routine interventions, especially those used to accelerate the birth, are over-utilized [11, 14]. In the present study, two out of every three women were administered an enema, underwent elective induction, continuous EFM, had the fetus’ heart sounds listened to with Doppler/fetoscopy, experienced frequent vaginal examinations, had restrictions in intravenous fluids and nutrients and other intrapartum interventions in the first stage of labor. Almost one out of every three women experienced perineal shaving, palpation of contractions on the fundus, movement restrictions, amniotomy, and the administration of analgesics for pain control. These women however did not display satisfaction with these interventions. Similarly, 92.7% of the women in another study in Chile experienced medically augmented labor (artificial rupture of the membranes, continuous fetal monitoring, no oral hydration, while almost all received intravenous hydration, oxytocin, epidural analgesia, episiotomy, and most delivered in the lithotomy position). One-third of the women reported dissatisfaction with the care they received [4]. However, international organizations and evidence-based studies suggest that there is no need to restrict water and nutrient intake during labor at non-risk births [15, 16], no routine perineal shaving [17, 18], and enema should be applied at birth [19], delivery pain should be relieved [20, 21], intravenous fluids are not beneficial or harmful at birth [22, 23], women should be encouraged to take the position they are most comfortable during the birth, they should be allowed to move freely and their upright positions should be supported [24], vaginal examinations at 4-h intervals in the first stage of labor are adequate [25] and induction without indication and early amniotomy should not be applied as they would cause serious complications [26,27,28,29]. However in this study, surprisingly, 31.9% of the women who participated in the study and received amniotomy were found to be satisfied with the practice. It is thought that women’s satisfaction with this practice has to do with midwives/nurses telling women they are performing amniotomy “to speed up the child’s delivery.”
In the present study, one reason for continuous EFM or frequent monitoring of the fetal heart beat with Doppler/fetoscopy may be tied to the fact that in Turkey gynecologists and obstetricians are the group, after general practitioners, that receive the greatest number of complaints of malpractice and therefore this group of specialists prefers to apply this practice to avoid complaints and paying costly compensation amounts [30]. Evidence-based studies, ACOG and NICE suggest that continuous EFM not be used in low-risk pregnancies and even that intermittent auscultation is a “convenient and safe alternative” [31,32,33]. In fact, palpation of contractions on the fundus is not a common practice that is used by midwives/nurses in normal birth management because of the widespread use of continuous EFM. However, those who are new to the profession and student midwives/nurses perform it to hone their skills and gain experience.
In this study, a large majority of the women in the 2nd stage of labor underwent an episiotomy, performed Valsalva pushing, received fundal pressure, vaginal irrigation with chlorhexidine, were offered perineal protection with a “hands on” technique, had the umbilical cord clamped early and were not exposed to skin-to-skin contact at an early stage. These interventions proved to have a negative impact on the women’s maternal satisfaction. However, evidence-based studies and available data do not provide any convincing evidence to support intrapartum vaginal irrigation with chlorhexidine to reduce the risk of maternal and neonatal infection [34] and the ideal clinical practice is to support spontaneous pushing and to encourage women to choose their own pushing techniques [35], intact perineal ratios are high and anal sphincter tears are frequently seen in women under fundal pressure [36], using limited episiotomy (mediolateral) when needed, reporting that routine episiotomy does not prevent pelvic floor injury [37,38,39], the perineum should not be touched during the second stage of birth until crowning [40], and umbilical cord be clamped not too soon (approximately at minutes 1–3, after the cord pulse stops) in terms of achieving positive neonatal outcomes, and that the maternal-infant relationship should be started as early as possible [41,42,43].
In this study, more than half of the women in the 3rd stage of labor had the placenta removed with controlled cord traction, bleeding control was achieved in the early postpartum period, and one-third were administered uterine massage. It was however found that women who experienced the removal of the placenta by controlled cord traction displayed a low level of maternal satisfaction. Evidence based studies, the routine performed of controlled umbilical cord traction by experienced health professionals using uterotonics, such as oxytocin [44, 45], and postpartum uterine massage performed every 10 min for a duration of 60 min reduced blood loss and the need for additional uterotonics, reducing the number of women experiencing more than 500 ml of blood loss by 50% [46, 47]. It is assumed that women are not satisfied with the practice because of the pain and sensitivity created by the pressure on the fundus during controlled cord traction.
Birth and maternal satisfaction in this period, which is seen as a very important experience in a woman’s life, is of the utmost importance in terms of the woman’s own health, the baby’s health and a positive family relationship [48]. Giving birth safely by receiving adequate and effective medical assistance is the principal expectation of a woman [47]. For this reason, unless there is a serious problem, most women do not want medical interventions that are performed to accelerate or facilitate the birth such as oxytocin, induction, enema, amniotomy, vacuum, fundal pressure, etc. [14]. It is therefore thought that interventions at birth affect childbirth satisfaction. However, findings in this study showed that despite recommendations provided by WHO in 1985 and further confirmed in 2015 by the most important related international associations, obstetric procedures are still over-utilized [12, 44]. Such interventions and restrictions cause women to have limited mobility, restricting their freedom of movement, making them feel less comfortable and experiencing more pain and anxiety because of not being able to direct their attention to other things other than lessening the impact of contractions. These procedures disrupt the hormonal balance of birth, protract the labor process, wear down the mother, cause the baby distress, increase the likelihood of an interventional birth, turn childbirth into a distressing experience, and reduce maternal satisfaction. The literature also supports the theory that obstetric intervention is linked with reduced birth satisfaction [6, 11, 14, 49]. Although maternal satisfaction is influenced by many factors, the prevailing view is that having a sense of control over the process, labor pain, personal support, expectations about childbirth, and medical interventions play a key role in maternal satisfaction [50]. It is especially having that sense of control over the birth process that determines maternal satisfaction levels. However, administering medications and excessive routine interventions cause women to lose all sense of control over the process, resulting in maternal dissatisfaction and postpartum complications [51]. The study conducted in accordance with the current literature found that the average satisfaction score for women who underwent routine interventions was 139.59 ± 29.02, which is low. That is to say, the women were not satisfied with induction, EFM, palpation of contractions on the fundus, movement restrictions, frequent vaginal examinations, lack of labor pain relief interventions, IV fluid infusions, fundal pressure, episiotomy, delayed cord clamping, removal of the placenta with controlled cord traction, and delayed skin-to-skin contact. Similarly, Binfa et al. [3] reported that although the majority of perceptions of wellbeing during labor was adequate or optimum, it is concerning that almost 1 out of every 4 mothers reported their general wellbeing as poor. It is remarkable that in Brazil, where unnecessary interventions are less applied, women have a higher and optimum level of birth satisfaction. The findings from this study are aligned with many of the categories of mistreatment identified in a systematic review of the global literature on mistreatment of women during labor and childbirth [52]. Chalmers and Dzakpasu [53] reported that among women having vaginal births, fewer interventions during labour was significantly associated with higher overall satisfaction with the labour and birth experience (ranging from 75% of women having no interventions to 46.4% having eight or more interventions rating their experiences as ‘very postive’). The WHO affirms that disrespectful treatment violates the rights of women and also infringes on their health, bodily integrity, right to life and freedom from discrimination. In this context, instead of traditional care services focusing on morbidity and mortality, efforts to provide women in participatory models of antenatal care are recommended to promote women-centered care in accordance with the WHO guidelines. This approach requires respect and familiarity for the childbearing woman and her family’s psychological, social, and cultural needs. Therefore, the focus and evaluation of care must be centered on emotional, social, and cultural aspects, rather than solely on the physical dimension [12, 33].
Limitations
Several limitations of this study should be noted. First, the present findings are based on a cross-sectional survey. Second, the fact that the results are representative only for the institutions in a province of Turkey where the study was conducted was accepted as the limitation of the study. Third, iIn this study almost every woman was intervened at least once, so each intervention was compared with the general satisfaction status. Finally, further multivariate analyses are needed, and planned, to explore whether the observations emerging from this analysis of independent “Interventions during labor and maternal satisfaction” variables are robust or influenced by more complex associations in the data.
