During the process, eleven women were invited to an interview. Ten agreed to participate. One woman refused because her husband declined. Interviews lasted around 30 minutes and took place 4–15 weeks after delivery.
Dialectical Birth Process
The core category was named Dialectical Birth Process. It emerged for the first time after interview 3 and was reassured continuously by identical or new codes and categories during the rest of the interviews and analyses. In total, 677 codes were found and condensed into 28 sub-categories. These were reduced into 7 categories and 3 main categories. An example is given in Table .
An example of analysis and development of categories (Inerviewee 9)
The concept "Dialectical Birth Process" was based on the 3 main categories: Balancing natural and medical delivery, Losing and regaining control and Interacting. The birth process included experience of a dialectical conflict between wishing for a natural delivery and accepting a medical delivery. Acceptance and satisfaction was expressed as a feeling of reconciliation after having struggled hard with physical and mental challenges.
"I have had this basic attitude that it should all be natural [laughs]. I didn't want any intervention. I had the opinion that this was something the body would manage in its own way and in the best way. There is a reason for the body to do as it does, so I said "No thanks" [to the drip] in the beginning - - - - - - She asks me 3 or 4 times and eventually I agreed and it was a good decision, I delivered within 20 minutes [laughs]" (Interviewee 1).
The concept "Dialectical Birth Process" comprises what happens in the time span from onset of labour until the establishment of augmentation and delivery. In this process several dialectically interwoven factors were identified and eventually a synthesis seemed to occur. The dialectically interwoven factors were positive and negative interaction with the midwife and the partner, experience of coherence and separation between mind and body, and losing and regaining control. Embedded in the feelings and experiences of control were in addition, positive and negative experience of pain and pain relief, participation and non- participation in decision-making regarding augmentation and pain relief. A synthesis in the process by way of reconciliation was identified. The dialectical birth process is illustrated in Figure . In the time span from delivery until the day of the interview reasons for non-progressive labour and future mode of delivery were considered by the participants and the perception of the birth was undergoing a change over time towards a more positive view of the overall birth experience.
Figure 1 The dialectical birth process. The dialectical birth process comprising contrasting feelings and experiences. The two areas in the inner circle represent varying degrees of interacting and being in control. Progress of the delivery towards a natural or (more ...)
Balancing natural birth and medical birth
At onset of labour the women's desire for a delivery without medical or instrumental interaction and with as little medical pain relief as possible was pronounced. During labour this was challenged and the women faced the necessity of balancing this wish against the need for augmentation.
The process was initiated by the experience of non-progressive labour. This was expressed as a feeling of "never getting any further", a feeling of being let down by the body, being exhausted; being in severe pain and doubting that the baby would ever arrive. The feeling that the body did not help the mind and that the mind was on its own in dealing with the hard work was described vividly. The mind desired the labour to progress, but the body did not co-operate.
"I didn't have much help from my body. I didn't have the urge [to push]. That was something I had to pull myself together to do, and so I did as good as I could" (Interviewee 4).
When augmentation had been established, feelings of confusion, worry and ambivalence were described along with feelings of relief and satisfaction.
"So I had the drip and it worked well because she increased it slowly - - - I could keep pace with it and that was in fact very nice" (Interviewee 5).
Feelings of ambivalence were expressed, especially if an epidural was administered simultaneously. Some decisions for augmentation were closely related to the decision to have an epidural. This was a cause of concern and worry for some women.
"I was thinking a lot about that one should not push the body, - - - I mean maybe one should listen to the body, if it doesn't want to make contractions. Especially if the body has been working well for some time and then it stops. Then it might be unnatural for the body to be pushed like that, because you give the body a heavy load of contractions at the same time as you anaesthetise it and how on earth does that affect the child, one can consider" (Interviewee 8).
A wish that labour and delivery would have taken another course was indicated. Although augmentation was accepted and appreciated, some women had doubts.
"Eventually, I appreciated that drip, and I feel sorry that it has a bad reputation, that's a pity [laughs]. But I think the delivery could have taken another course - - - I should have refused to have my waters broken. I think there must be a reason why the water didn't come by itself. If I hadn't had the waters broken and I had waited 11/2 hour, he might have rotated and I might have delivered easier, a little faster and without that drip - - - It is easy to be wise after the event [laughs]" (Interviewee 1).
Reflections on reasons for non-progressive labour were expressed as a part of the women's views on the overall experience of labour.
"I have been thinking that it might be because I was so tired - - -actually, I think I have been doing all the right things during pregnancy, - I have done some physical exercising, I have had wholesome food, I have stopped smoking, - - so I don't know - - - the only thing that went wrong was that I was so tired" (Interviewee 1).
Other reasons reflected upon by the women were overwhelming pain, the epidural or the Entonox, no help from the body, feeling insecure and unsafe or not having a good contact with the midwife. Hypothetical considerations on the possibility of another course of labour and delivery were also expressed along with reasons for non-progression.
"My conclusion is that it [the non-progressive labour] had to do with my feeling of being insecure or unsafe - - - Had I only felt "on top" and felt that "this is totally ok, as it should be", and had I not needed to doubt if I had made a wrong decision concerning the epidural - - - - maybe things would have gone the way they should have gone" (Interviewee 2).
Decision-making was interwoven with acceptance and was also seen as a heavy responsibility to bear. The level of confidence in the midwife's assessment was expressed along with doubts of the necessity of the augmentation. Decision-making was mostly conducted in co-operation between the woman and the midwife. Not being involved in the decision-making was also mentioned, but did not appear to be a problem.
"It was explained to me what the disadvantages could be. It could provoke severe pain, but I had the epidural, and just because I had that, I don't think they made a big deal of explaining to me - - - but well - It [the drip] was installed and - - I wanted the drip" (Interviewee 10).
At the time of the interview the overall perception of the birth experience was positive. This was expressed as a motion over time. The feeling of acceptance of the need for augmentation occurred during the course of labour. Immediately after labour a feeling of satisfaction was prevalent and eventually at the time of the interview an overall feeling of reconciliation was achieved. For some it had made sense to consider a future mode of delivery, for instance elective caesarean delivery and home delivery.
"Well I think of it in a different way now - - - -Immediately after birth I thought that it was the worst thing I had ever experienced, I didn't see any positive conditions at all. But now I find something positive, retrospectively. There are things that I find more positive in retrospect" (Interviewee 2).
A couple of women described that they had no experience of non-progression or exhaustion. They mentioned that the midwife assessed the labour to be non-progressive and that they were surprised that the drip was a treatment for non-progressive labour.
Losing and regaining control
The feeling of being in control was crucial. The women stated that they had a feeling of being in control at the onset of labour and at admission to hospital.
"At the beginning, I felt that everything was just fine, I had been nervous for the delivery and for the pain, but in fact I handled the pain very well and I had a lot of self-confidence and felt rather strong" (Interviewee 9).
Losing control was related to feeling exhausted, insecure, unsafe, afraid and scared. Feeling overwhelmed by severe pain, not knowing what was going to happen or losing confidence in the midwife was also related to losing control. A perception of separation between mind and body leaving the mind incapable of controlling what happened in the body was a source of frustration.
"I got scared because I could not control what was happening in my body. I was so tensed, my legs and arms were shivering and - - when I was speaking, my voice was trembling. One gets so frightened for something you're not able to control I think, – so that's what is happening. And furthermore, one doesn't know what is going to happen, – because anything and everything can happen. It is the unforeseeable one gets frightened for" (Interviewee 5).
Regaining control was related to sufficient pain relief, being able to rest, feeling well informed and being respected for subjective signs and perceptions.
"It worked [the epidural] and that was fantastic ...I was so tired. It was an extreme relief to get rid [of the pain] and also stop vomiting. It really was wonderful ------ and I felt so optimistic. It came back when I had that epidural" (Interviewee 7).
Losing as well as regaining control was closely related to interaction with the midwife.
"She had a conflict with the doctor. I clearly sensed that. She was kind of surprised or frightened, when I asked, what that was about? The conflict was evident to me. And because you try to stick to someone that you can trust and rely on, I got lost when she kind of got frustrated" (Interviewee 8).
The category is closely connected to the category "Losing and regaining control", as interaction between the woman and the midwife influences the woman's experience of control. A positive interaction included that the midwife acted as a coach and guided the woman, respecting her wishes and subjective perceptions, but also demonstrating that she, (the midwife) was the one who ultimately knew what was the best.
"She looked at me and said: You don't look like someone, who should be sent back home, – and she was right, I really shouldn't be sent back home - - - I found that she was incredibly good at guiding me. I needed guidance and pushing a little bit all the time, but at the same time I was allowed to decide what I wanted" (Interviewee 7).
The midwife's professional skills, and the way she demonstrated these, were of importance for a positive interaction, which was obvious when the midwife radiated security, confidence, empathy, and commitment and when she was calm, kind and informative, also towards the husband/partner.
"They were very kind, the three midwives that I had. They were sweet, helpful, assisting and understanding. - - - - When I should have the epidural, I remember that she was very empathic. She was looking at me, and I must have had a strange look on my face, which also she had herself indeed, and afterwards she said that she suddenly had doubts whether it was the right thing for me to have the epidural" (Interviewee 10).
It was stated that the most important relation and interaction was the one between the woman and the midwife, when this interaction was positive. Elements in a negative interaction with the midwife were the midwife being "invisible", uninformative, not being in control of the situation and not listening to the woman's wishes or showing her respect.
"I felt deceived by her. I wanted to deliver standing upright next to the bed but I don't think she had ever tried that and she wasn't very happy about it. But we had agreed on it earlier - - - but then she asked me to lie on hands and knees and suddenly she asked me to turn around, - - and there I was lying on the bed although I had pointed out that I did not want to lie on my back. But then she said that I couldn't push properly if I wasn't lying in this way and that was that. It ended up like that" (Interviewee 9).
Experience of positive interaction included the partner's ability to offer caring and loving support, not needing support from the woman, and also being able to actively advocate for the woman's point of view. When the interaction with the midwife was negative the partner was the emotional centre point. Overall the women were satisfied with the interaction with their partner. One partner's impatience and desire for augmentation and instrumental delivery was mentioned but did not create a problem for the couple.
"C (partner) was fantastic he was really good. He took it as a man. Yet I remember feeling that he was impatient. He kept on saying: " Shouldn't we increase the drips" [laughs] ----- He also said: "Shouldn't we use the vacuum" But then I told him off [laughs]" (Interviewee 2).
Outline of a theoretical model
Two central issues emerged during data collection and analyses. The first one had its origin in expectations of a natural delivery and experience of a non-progressive labour with augmentation and, for some, also an instrumental delivery. Feelings of disappointment and frustration were expressed. The second issue appeared when a perception of the body having its own will was expressed. It was voiced that "the body can manage this", "my body would not - -" and "I didn't have any help from my body". These two issues were intermediate steps between codes and categories and were repeated and strengthened by the progressing categorisation. Eventually they contributed to the category Balancing natural and medical delivery and through this category they constituted the basis for an outline of a theoretical model that includes all the final three main categories and can be presented as follows: Having expectations of a natural delivery is, among other factors, based on a fundamental confidence that the body will be able to manage the physical demands of labour and delivery. During labour the body is seen as being separated from the mind and this dualism creates a conflict that makes the woman in labour feel let down by her body when her labour is non-progressive. She perceives her mind as "me" or "I" whilst her body is outside "me" or "I". Accordingly she must balance her body, which is not interacting with her mind, to her mind, which is disappointed that the expectation of a natural delivery is not being met.
In this situation the woman faces the impact of the process of Interacting with the midwife and the partner and the impact of the process of Losing and regaining control. Both of these processes hold possibilities of dialectical interplay with the potential to create reconciliation. Reconciliation is seen as a mentally healthy synthesis in the dialectical process. For the women in this study, reconciliation was the end point in an emotional motion initiated by acceptance of the need for augmentation and potential subsequent interventions, i.e. a medical delivery. A feeling of satisfaction followed acceptance immediately after the delivery and eventually reconciliation was expressed as a present feeling at the time of the interview. The midwife's handling of inter personal interaction with the woman and support of the woman's feeling of being in control has a major impact on whether a dialectical birth process will include reconciliation or not. Figure illustrates the dialectical birth process that this outline of a theoretical model is based upon.