Data analysis and research rigour
Theoretical perspectives: The institution and the ‘medical gaze’
Organizational technology: The Journey Board as surveillance
The board is displayed at the back of the midwives’ desk… Up the top is the shift coordinator’s name, and a key of symbols, e.g. ‘seen’, ‘needs to be seen’, ‘CTG [cardiotocograph]’, etc. At the left hand side is the midwife allocated to care for the woman, the bed number, then the woman’s full name, type of labour/birth (IOL [induction of labour], SOL [spontaneous onset of labour], LSCS [lower segment caesarean section]), gestation, membranes (time, intact, ARM [artificial rupture of membranes], SRM [spontaneous rupture of membranes], colour), Cx [cervix] (dilatation and time), next exam due, CTG (yes/no), GBS [group B streptococcus] status, Group & Save (yes/no), Syntocinon, analgesia, remarks (e.g. postdates, allergies, GD [gestational diabetes], Rh neg). (Field notes 2/5/12).
The doctors stand there and look at the board. If they’re 3 cm [dilated] they want them to be seven in four hours. If they [women] don’t [dilate fast enough], then they start talking about ARM, Synt (MW2).
I hate examining them. You know, ‘cause once they’re fully [dilated], then the doctors put a time limit on. The registrars, I know most of them, and they trust my judgement, but then they report to the consultants who don’t know the women, and want everything to follow a protocol (MW4).
The reality that escaping surveillance may facilitate non bureaucratic ways of achieving goals reinforces Foucault’s concept of panopticism and its constraining effects. By being outside the ‘gaze’, the staff experienced a freedom that, for them, was extremely creative (p. 1336) .
The ‘board’ appears to be the main focus of attention in the ward. Team leaders, doctors, midwives who come out to the desk, periodically throughout the shift, come and stare at the board. There is discussion about who is doing what, who is coming in, how long they will be here for etc. It seems to be a process of organising…Discussion at the board between T/L [shift team leader] and clinical midwife: ‘Let’s try and get one delivered, then we’ll be ok [staffing and bed numbers]. We’ll target room seven’ (Field notes 2/5/12).
I spoke to a midwife who was on the late [shift] last night. After I left it got messy. They had two MET [Medical emergency team] calls. One for the woman who came in by ambulance yesterday. She had a fainting episode, and ‘looked like she was abrupting.’ The other [MET call was for] a woman with a massive PPH. These high-risk episodes are surely the kinds of events that cause the ‘risk aversion’ behaviours previously mentioned (Field notes 21/6/12).
I have been thinking about the staffing issues, and how they affect the way that things happen here. They don’t want women here who don’t need to be here (eg early labourers) and like to keep things moving along simply so that the labour ward doesn’t fill up. It is a safety issue (Field notes 21/6/12).
The board is full. Two women of 30 weeks gestation are in labour, and another woman who is 35 weeks. There is a woman being induced for epilepsy. Two postnatal women on MgSO4 for pre-eclampsia, there are two women having elective CS, and one woman due to have a CS for two previous CS has come in contracting. Another woman who is scheduled for a CS later in pregnancy with twins has come in with a query of ruptured membranes. The T/L goes through it all with the consultant, then, as there is a mix up with who is covering labour ward that day, goes through it all again with a registrar. If someone else comes in labour, there will be no bed for her (Field notes 11/7/12).
As the night progresses, the monitoring system is observed, the board attended to, updates given. T/L: ‘The woman in Rm four is fully, at spines, should have a baby in there soon.’ Obstetric registrar ‘Oh good’ [pause] ‘The trace looks beautiful doesn’t it?’ (Field notes 31/5/12).
[There is a] registrar standing at the board with [a group of] new students or RMOs explaining how it works: ‘Green is postnatal. They don’t cause much trouble, so I like to see a Green board’ (Field notes 2/5/12).
Playing for time
The most frustrating thing about working here is you just want to slow everything down. I mean, just give her a chance, you know? (MW50).I do a lot of nights because then I can just do my job. It’s hard because you have to fit into the institutional constraints (MW4).It’s frustrating you know, day in, day out. It depends on the doctor. Some are just worse than others. They jump in too quickly. They don’t give them a chance (MW43).
The other thing I’ve noticed is they do an ARM here, and they’ll want to put Synt up in the next hour. And I’m like ‘Why?’ But no-one gives me an answer. I have a feeling it’s about beds, but that’s not right. That woman deserves to be given that space for labour. If we do an ARM, she’s most likely going to go into labour, she just needs time (MW34).
A midwife comes out to discuss the progress of the woman she is caring for in labour with the registrar. She wants to know whether or not Syntocinon will be required and if so, when. The woman has had an epidural in since 9 am. The midwife has done a vaginal examination (VE) and the woman is 7–8 cms dilated. There is discussion about the contractions. The midwife explains they feel a little less strong than before the epidural but still 3: 10.Moderate? Asks the registrar.Midwife35: Umm yep.Registrar: Well, she is a primip, so…let’s give her some more time if she is contracting well.Midwife35: So when shall I reassess her?Registrar: Well, in four hours.Midwife35: Ok, great [lets T/L know].T/L (to registrar): Good decision.
The consultant came and overrode the registrar’s decision and wanted a VE in 2 h (from the 7–8 cms).T/L: Oh, she’s written ‘consider’ here [ie consider another VE in 2 h] as a compromise. But Dr [consultant] comes in and she wants, you know, it all to happen, to be fully in 2 h (Field notes 11/7/12).
8 am doctors round [standing at board]. The consultant is pleased that the registrar has begun the inductions. Registrar: ‘Well, that’s what we used to do at hospital X. ARM and Syntoed [commenced a Syntocinon infusion] them all overnight [early hours of morning] and then they’d all be ‘going’ when the morning staff came on’ (Field notes 10/5/12).This accentuates the difference in philosophy between midwifery and medicine around birth. There was an understanding between these two doctors that a reduction in workload for the oncoming doctors was a good thing. It also keeps within the lines of the functioning hospital idea, where women left to their own devices are seen as displeasing to medical staff, as if they are making the place untidy (Analytic memo 10/5/12).
A key element in this organisation is keeping up the throughput of women and, whatever the rhetoric may be about individual choice, the bottom line is to ensure that the individual woman does not upset the system with her own demands or reactions to handling labour…Under such circumstances it is immensely useful to the obstetric system to draw on variants of its own historically grounded argument about the natural unreliability of the female body in labour (p. 42) .
‘Yes’, says the T/L, ‘I used to do that in birth centre, and we didn’t do hourly blood sugars’. In fact, this woman shouldn’t even be induced – that’s what the consultant said when she came on this morning: ‘Why is she being induced? It’s not necessary. She’s 39 weeks and has diet-controlled GD?’T/L: ‘It would be different if she was on insulin, then she should be induced at 38 weeks. But oh well, it happens here all the time’ (Field notes 10/5/12).
In handover I hear: ‘She’s a time bomb waiting to happen. There’s no point sitting on her’ (Previous CS, scar dehiscence, other issues) (Field notes 25/7/12).