By Caroline Flint

Does it matter how many episiotomies, inductions or Caesarean sections are performed in your delivery unit? Caroline Flint argues that midwives can easily carry out this type of research locally, and that this could ultimately affect obstetric practice

What is really happening to the women midwives are looking after? What affects them`? What affects their care? Is the care we are giving the most appropriate? The most needed or the most desired?

Is midwifery care based on the wishes of each individual woman, or is it based on a scientific and reasonable assessment of the needs of this particular woman, her baby and her partner? Or does her outcome depend on the time of day, the day of the week, or even on who is on duty?

Midwives are in a unique position to find out the answers to hundreds of questions affecting women. There is a great deal of research they can do easily, cheaply, with little effort and which may influence midwifery and obstetric practice and what happens to women.

Midwives are there - there in the antenatal clinic, in the labour ward, in the postnatal ward and in the community. Midwives actually see what is happening and they have a special opportunity to report it to their colleagues.

There are several questions worth asking. For example, does the Caesarean section rate in your delivery suite go up every Tuesday evening because a certain doctor is on duty? Is this useful or helpful to the women'? Could you look back in the birth register and work out the numbers of Caesarean sections performed each day and point out how it increases when Dr X is on duty? Perhaps the birth register will show that in fact the Caesarean section rate on Tuesday evenings is no different from any other day. Perhaps

If you show that Dr X does more Caesareans than average and if you alert him to this fact, perhaps he will be more circumspect in his practice in the future. This will help him and will be beneficial to the women coming to your hospital.

If you show that Dr X does less than or the same proportion of Caesareans as the average it is a chance for you to revise your opinion of Dr X.

The birth register is the easiest of all research tools, enabling you to do research with no extra equipment, no searching for notes, no literature searches and no expense. Kept on every labour ward, the birth register can answer so many questions and those answers can make such a difference to the way women are treated in a unit.

Traditionally, we have thought that women aged under 18 and over 35 are at a higher risk during pregnancy than those who are between those ages. But is this still true? Can you find out what birth outcomes women in these two categories have in your unit? Will it benefit anyone if you do?

If you find out that these women fare exactly the same as anyone else then probably they will be deemed suitable for a midwife's care during more of their pregnancy and labour. But if you find out that these women fare worse than other women, you have accentuated the known body of knowledge and your work will ensure that these women have more medical care than they otherwise would.

How many episiotomies are carried out in your unit? Valerie Wilkerson found that one midwife in her unit performed episiotomies on 92.8 per cent of women having a first baby, while another midwife carried out this procedure on only 12.5 per cent of these women.' Is this what happens in your unit? Does the episiotomy depend on the midwife supervising the delivery rather than on fetal distress, old scar tissue or an impending large tear?

What proportion of women in your unit are induced? Is it ten per cent or 45 per cent? Does it matter whether they are induced or not? Sheila Kitzinger, in her report to the DHSS in 1975 and 1978 quotes a higher rate of instrumental deliveries in women having induced births, higher levels of analgesia, babies with more respiratory depression and more babies admitted to the special care baby unite

Again, if you proved this to be wrong in your unit you would have scotched a myth. If you proved it to be correct you would have alerted your obstetric colleagues to the hazards of being induced in your unit and you would have helped countless women to avoid unnecessary intervention. Read these paragraphs again but for induction substitute acceleration.

As midwives we have a duty to the women and families in our care to ascertain that they are having the care that is most appropriate and desirable for them. As we become more aware of quality control we shall be providing figures to our general managers and ultimately to our clients, with information on what they can expect in our unit compared with St Nibs down the road. If midwives can be one jump ahead here we shall be doing mothers and their families a good turn. So come on - get cracking!

Wilkerson, V. (1984). `The use of episiotomy

in normal delivery.' Midwives Chronicle and Nursing Notes April, pp. 106-110. Kitzinger, S. (1978). Some Mothers' Experiences of Induced Labour. London: The National Childbirth Trust.

May 22 1985