Midwifery Care Standards for the First Stage of Labour 4. Definition of Terms 4.1 Quality Health Care □ Stage I S. 1.2 the Quantifying Phase 5.2 the Population and Sample for Peer Group Review and Validation of Standards 5.2.1 the Target Population

1. INTRODUCTION Changes in the social and political structures have brought about changing demands on the delivery of health care. The restructuring of health care under the banner of comprehensive health care has brought about a diversity of lifestyles, traditions, cultures, customs and language barriers which presently cannot be met in totality because of lack of knowledge and understanding of the above-mentioned aspects on the part of health professionals. Fathers and family members are beginning to take a more active part in child-rearing and pregnancy is becoming a family affair. Families are demanding greater involvement thus enhancing the delivery experience. The birth of a baby is one of life's most meaningful events which preferably should be shared with family members and not strangers This has lead to a shifl from hospital to natural birth se ttin g s w here the fam ily can be accommodated. The woman has a right to expect safe and competent nursing care and the midwife is ethically and legally bound to provide the best possible nursing care for her client. Parturient couples are demanding greater involvement and decision-making in the method and type of delivery, thus the midwives' dilemma is ensuring that her practice is within the ethical and legal aspects laid down by the S A.Nursing Council as v^ll as satisfying the needs of the parturient and her family. The pressures on the National Health service and changing consumer expectations have made it imperative for midwives to look critically and analytically at the quality of care being rendered and there is real need for the formulation of standards in midwifery care to ensure that the Midwife complies with these requirements. The questions which thus arise arc: 2.1 How can the midwife render quality com prehensive health care to the partunent family during the first stage of labour? 2.2 How can she render midwifery care based on scientific principles within the ethical and legal framework? 3. THE AIM OF THE STUDY The aim of the study is to formulate valid structure and process standards for improving the quality of care during the first stage of labour. Douglas and Bevis (1983:281) base quality health care on the follow ing: " safe " , " advanced " , " efficient " and " acceptable ". The quality o f care being rendered can be measured by the quality assurance process which is a process of formulating …


INTRODUCTION
Changes in the social and political structures have brought about changing demands on the delivery of health care.The restructuring of health care under the banner of comprehensive health care has brought about a diversity of lifestyles, traditions, cultures, customs and language barriers which presently cannot be met in totality because of lack of knowledge and understanding of the above-mentioned aspects on the part of health professionals.
Fathers and family members are beginning to take a more active part in child-rearing and pregnancy is becoming a family affair.Families are demanding greater involvement thus enhancing the delivery experience.The birth of a baby is one of life's most meaningful events which preferably should be shared with family members and not strangers This has lead to a shifl from hospital to natural birth se ttin g s w here the fam ily can be accommodated.The woman has a right to expect safe and competent nursing care and the midwife is ethically and legally bound to provide the best possible nursing care for her client.Parturient couples are demanding greater involvement and decision-making in the method and type of delivery, thus the midwives' dilemma is ensuring that her practice is within the ethical and legal aspects laid down by the S A.Nursing Council as v^ll as satisfying the needs of the parturient and her family.The pressures on the National Health service and changing consumer expectations have made it imperative for midwives to look critically and analytically at the quality of care being rendered and there is real need for the formulation of standards in midwifery care to ensure that the Midwife complies with these requirements.

THE RESEARCH PROBLEM
The questions which thus arise arc: 2.1 How can the midwife render quality com prehensive health care to the partunent family during the first stage of labour?
2.2 How can she render midwifery care based on scientific principles within the ethical and legal framework?

THE AIM OF THE STUDY
The aim of the study is to formulate valid structure and process standards for improving the quality of care during the first stage of labour.

DEFINITION OF TERMS
4.1 QUALITY HEALTH CARE Douglas and Bevis (1983:281) base quality health care on the follow ing: " safe" , "advanced", "efficient" and "acceptable".The quality o f care being rendered can be measured by the quality assurance process which is a process of formulating standards, evaluating performance o f current care rendered against set standards and taking remedial action to improve practice.(Jemigan & Young, 1983:9).Standards serve as a yardstick to measure the quality of care being rendered.

NURSING CARE STANDARDS
Nursing care standards are a descriptive statement of desired quality against which to evaluate nursing care rendered to a patient.

FIRST STAGE OF LABOUR
First stage of labour begins with the onset of regular contractions and is complete when the cervix is fully dilated (Jensen & Bobak, 1985:436).

DESIGN OF THE RESEARCH
In the formulation of nursing care standards a descriptive design is used to identify, describe and validate the variables of care during the first stage of labour

RESEARCH TECHNIQUE
The research technique for the formulation of standards consists of the developmental and quantifying phases respectively (Muller, 1990:12)

The developmental phase
This phase is based on a conceptual framework of care during the first stage of labour prior to formulating standards A scientific model of midvofery care is used whereby the practice of midwifery care during the first stage of labour is evaluated (Wright m Muller, 1990:12) Curalionis, Vol.18 No 4, December 1995

□ stage I
The aim of this stage was to do a literature study of care during the first stage of labour and to define core words.

□ Stage II
Concept standards were formulated with reference to the literature study.The concept standards and criteria were listed -The Midwife. -Philosophy. -Objectives.
-Policies and procedures.
-The scientific method of nursing.
-Quality care by the midwife during the first stage of labour.
These were then distributed to a peer group of experts for cognitive analysis and logical systematization.Background information on the research, instructions for the discussion of the standards, including the meaning of concepts was sent to the sample of experts.The researcher's telephone number was included for possible queries.The group of experts then met for discussion and to make recommendations.The goal of the preparation and discussion phases was to refine the standards and to reinforce the content validity of each individual standard.The necessary changes were brought about according to the recommendations of this advisory group.

S. 1.2 The quantifying phase
During this phase the statistical validity of the standards was determined (Lynn in Muller, 1990:21).
A four point ordinal Likcrt scale was used to evaluate the validity of each standard as follows: 1 irrelevant/not applicable to the first stage of labour.
2 indistinct and applicability questionable 3 applicable but needs reformulation. 4 complete, clear well formulated and high ly applicable/realistic to be used as a minimum standard in labour institutions to assu re/im p ro v e the q u ality o f midwifery care being rendered These standards were sent to midwives with expenence in different spheres of midwifery i.e. academic and clinical, in order to validate each standard.Information regarding the research, instructions for the validation of the standards were sent to the selected sample of experts.The researcher's telephone number was included for possible queries The validity o f each standard was determ ined by calculating averages and standard deviations.

The target population
Consisted of experts in different spheres of midwifery namely: -Midwives rendering care during labour at 3 public hospitals in Johannesburg.
-Midwives studying for their Master's degree in Advanced Midwifery and N eonatology at a u n iv ersity in Johannesburg.
-University lecturers who are experts in formulating standards

The sample
Goal directed sampling was used for both phases of validation.

• The developmental phase
Sisters from the labour ward unit of one of the public hospitals will be consulted in the formulation of standards.Seven midwifery experts were selected to participate in peer group discussion of the standards: • Two from a university lecturing in Midwifery education.
-One from a nursing co lleg e in Midwifery education studying for a Master's degree.
-One from nursing practice with a Honours degree.
-Three from midwifery practice each with more than eleven years clinical experience.

• The quantifying phase
Practising Midwives from the labour units and midwifery education of the three public hospitals in Johannesburg, M idwifery lecturers from a University and Colleges of Nursing in Johannesburg will be participating A sample of 30 will be selected consisting of: -Seven experts of the developmental phase.
-Twenty three practising midwives from a University, Colleges and hospitals in Johannesburg

CONTENT VALIDITY
The content validity was confirmed by the literature study as well as by the experts Content validity during the quantifying phase was determined statistically by means of a content validity index.The index is derived from rating of the content relevance of the items on an instrument using a four point ordinal rating scale, in which one indicates an irrelevant item and four an extremely relevant item.Items with an average of between 3.0 or 4.0 are considered valid (Muller, 1990:28).

RELIABILITY
The researcher attempted to control the reliability in the following manner (Muller, 1990:229): -A structured two-phase procedure was used for the validation of standards; -clear, structured written instructions were given to participants during both stages, -during the discussion of the standards the researcher gave each person an equal opportunity to give her point of view on each standard.The group was not dominated by the opinions of one specific person at any stage, -midwives from the University, Colleges and the three chosen hospitals validated the standards independently during the second stage to avoid direct influence of the researcher on the participants; -a list of definitions was included to explain some of the terminology used to avoid confusion; -the anonymity of the participants was assured in order to improve objectivity and honesty in their grading of the standards.

RESULTS
The results will be presented under the following sections:-@ BU LLET -The description of the sample.
• The interpretation of the results of the validated standards.This will be done statistically according to the content validity index (CVI) and the standard deviation (SD) level.
• The results ofthe validation of nursing care standards for the first stage of labour 6.RESULTS

Interpretation of the results of validated standards
Dunng this phase the statistical validity of all the standards were determined (Lynn in Muller, 1990:21).After refining the standards, a four point ordinal Likert scale was used to evaluate the validity of each standard The content validity is confirmed by the literature, as well as experts in the field of m idw ifery.The content validity was detcnnined statistically during the quantifying phase by means of a content validity index using a four point ordinal Likert rating scale scored as described above.A content validity index of 3.5 was used in this study as the minimum for accepting a standard\criterium (Muller, 1990in Nolte, 1990:57).A standard deviation level of 0.5 indicated consensus between the respondents.Items with a standard deviation outside this range require reformulation/ revalidation depending on the scoring of the respondents.
The results of the validity of standards/criteria w ill be presen ted as follow s: The standard/criteria are stated together.If it was accepted unchanged no result is indicated but if it required reformulation this is indicated in brackets.

A.THE MIDWIFE Principle
The midwife is one who is appropriately qualified and who continuously updates her knowledge and contributes towards quality midwifery care.

Standard
The midwife who renders care during the first stage of labour is qualified and proficient.

Criteria
• The midwife is registered with the S.A.
Nursing Council as a midwife; • it is desirable that the midwife is registered as a general nurse and community nurse in order to render com prehensive care (Reformulate); •' the midwife dem onstrates skill and competence with the changing scientific and technological advances in the first stage of labour: • she actively participates in staff development programmes, -it is desirable that the midwife be an active member of the S.A. Society for Midwives (Reformulate) • The midwife practices within the ethical and legal frame work of -the Nursing Act No 50 of 1978, as amended; -the S.A Nursing Council rules and regulations; -the midwives Scope of practice (S.A Nursing Council R2598, as amended), • other relevant health legislation.

RPHILOSOPHY
The philosophy of midwifery practice states the values and beliefs of the organization which may have an influence on the practice of the midwife.This serves as a guide and explanation for actions taken.

Standard
There is a written philosophy on care during the first stage of labour.

Criteria
• The philosophy of care during the first stage of labour is available; • the philosophy is in line with that of the profession and the controlling bodies; • the philosophy is updated and takes recent advances and scientific knowledge into consideration; • the following components are contained within the philosophy of care during the first stage of labour: -the family preparation component (Reformulate); -the extent o f family involvement (Reformulate) -the quality of the practice o f the midwife; -the role of the midwife; -the role of technology; -the approach to childbirth; -choices regarding different aspects of the first stage of labour.

COBJECTIVES Principle
Objecti ves reflect goal directed care dunng the first sUge of labour based on knowledge, skill and judgement.

Standard
The midwife formulates objectives to meet the level of care agreed upon and ensures that they are met.

Criteria
• Written long and short term objectives are available in the labour ward, • the objectives are consistent with that of the p ro fessio n , m idw ifery service and organization.
• objectives are stated in measurable, behaviourable terms and outcomes.
• objectives are attainable, realistic and allow for evaluation of outcome; • objectives state the extent o f family involvement (Reformulate); • objectives are consistent with the cultural beliefs and wishes of clients as long as fam ily m em bers are not at risk (Reformulate); • objectives allow for joint decision-making by health care providers and recipients of care (Reformulate).

Principle
Policies and procedures relating to the first stage of labour serve as a guide for the provision of midwifery care consistent with that of the profession, midwifery service and that of the organization.

Standard
C om prehensive policy statem ents are formulated and regulariy updated to serve as a guide for care during the first stage of labour.

Criteria
• Policy and procedure m anuals are available; -The Nursing Act No. 50 of 1978, as amended and its regulations; • Related S A. Nursing Council rules and regulations; -The most recent promulgated Acts and regulations pertaining to the practice of midwifery; • W ritten midwifery care policies are available and include the following: - • Positions; • Safety; • Health education (Reformulate)

Principle
The use of the scientific method of midwifery contributes to individualized goal directed quality midwifery care.

Standard
The scientific method of midwifery is utilized in accordance with the Nursing Act and scope of practice for midwives (S.A. Nursing Council R1598, as amended).

Criteria
The principle o f scientific m idw ifery (assessment, planning, intervention and evaluation) are utilized and documented for each intrapartal family from admission to the end of the first stage o f labour.

ASSESSMENT Principle
The midwife assesses the childbearing family to identify risk factors, educational needs, care needs and referral needs.

Standard
Each family's needs are assessed in totality by a registered midwife or student midwife under supervision of a registered midwife.

Criteria
• On admission to confirm the advent of labour, • Education and preparation; • Childbirth expectations and goals; • -Continuously to: -determine progress of the first stage of labour -m on ito r m aternal p hysical and psychosocial condition monitor fetal conditio -check family need for support

PLANNING Principle
The midwife establishes a care plan for the childbearing family based on the midwifery diagnosis which includes the specific goals and interventions delineating midwifery actions unique to the fam ily 's needs (Reformulate).

Standard
A registered midwife or student midwife under supervision of a registered midwife is responsible for planning the care of the family (Reformulate).

Criteria
• Data obtained from assessment form a basis for m idw ifery diagnosis and contributes to the formulation of a care plan.
• Planning ofcare is in compliance with: -the scope ofpractice for midwives (S A. Nursing Council R2S98, as amended) and its regulations; -written objectives, policies, procedures and standards of midwifery care during the first stage of labour, -the needs of the family (Reformulate); -the medical therapy as prescribed by the medical practitioner, -the therapy prescribed by other health team members (Reformulate).
• Planning of care is modified as the need arises.

Principle
The midwife implements interventions based on the developed midwifery care plan.

Standard
Implementation of care is done by registered m idw ives or student m idw ives under supervision of a registered midwife.

Criteria
• Care is facilitative and supportive • Care is continuous (Reformulate).

EVALUATION Standard
Midwives evaluate family responses to midwifery intervention and revise the midwifery diagnosis and the midwifery care plan.

Criteria
• Evaluation of goals is done continuously and at specified times; • Evaluation of goals is documented; r • Progress of labour is documented on a partogram.

Principle
All care rendered is documented on the care plan.-indicate patients' needs, problems, capabilities and limitations.

Standard
• documentation is done daily and nightly in compliance with written midwifery service policies.

F.QUALITY CARE BY THE MIDWIFE DURING THE FIRST STAGE OF LABOUR Principle
The midwife facilitates and promotes the maintenance of the health of the family.M idwifery care is based on scientific know ledge and av ailab le technology (Reformulate).

Standard
Midwifery care during the first stage of labour is directed towards the safe delivery of a live healthy infant and a fulfllling childbirth expenence for the family and the midwife.

Criteria
• The psychological environm ent is conducive to a trusting relationship between the midwife and the other health professionals (Reformulate).
• The midwife creates a positive childbirth experience by: -unconditional acceptance of the family values and beliefs (Reformulate); -welcoming the family or support person (Reformulate); -allowing the family a choice in the type of delivery experience as long as it is not detrimental to the health of the family (Reformulate); • allowing the partner/support person to be present throughout the first stage of labour if so desired; -respecting the family's dignity; -accepting and promoting the family's rights and responsibility to participate activ ely in d ecisio n m aking (Reformulate); -providing privacy; -accepting and respecting the families uniqueness; • displaying confidence in the execution of her duties -accepting and promoting the expression of positive and negative feelings; • displaying communication skills.

Standard
The facilitating function of the midwife co n sists o f g u id a n c e, support and accompaniment according to the needs of the client and family.

Criteria
• Guidance -guidance is given in the form of suggestions, direction and supervision; -guidance is given on aspects in which th e family lacks knowledge or experience; • Support -support signifies the family will not be len unattended and uncared for during the first stage of labour (Reformulate) -support will be ph ysical, em otional, spiritual and inform ative support.-The m idw ife is resp o n sib le for availability and adequacy of supplies and equipment.

CONCLUSIONS
The standards submitted for validation were acceptable on the whole.The possible lim itations identified were the lack of understanding of the definition of the family and the small number of midwives who have the qualification in community health suggesting that the mother is seen not as part of a family but as an individual entity on her own.
Each group o f standards is discussed separately below.

THE MIDWIFE
The standard and criteria in this group were accepted unchanged except for two criteria which must be reformulated.The one which proves interesting was that only four (22.2*/«) in the quantifying phase have a qualification in Community Health, thus they possibly did not see the need for the midwife to be Community Health trained as indicated by their scoring.The respondents agree on the point of remaining up to date with recent advances, but not by active involvement of the SA.Society for Midwives.Only four in the group of twenty five did not mark a score of four thus clarity does not exist whether the cnteria is impractical or needs reformulation

PHILOSOPHY
The standard and its criteria in this group were accepted unchanged except the one involving the family.The mother is not seen as part of a family but rather as an entity on her own Another possibility is the definition of the family was ambiguous; some interpreted the family as the extended family as indicated in their comments, and others as the nuclear fam ily.Thus the crite ria need to be reformulated.

OBJECTIVES
The standard as well as the criteria regarding the necessity of objectives was unchanged The objectives regarding family involvement have a SD of 0.577 and 0.554 respectively Some respondents had a problem with the definition of the family thus giving a score of two each.The criteria regarding joint decision-making between client and care providers required reformulation because of an SD o f0.554.According to the literature this is an essential objective and midwi ves must be educated regarding its importance.

POLIOES AND PROCEDURES
The standard and criteria regarding the need for policies and procedures was accepted unchanged except the ones on family involvement which required reformulation due to lack of clarity of the definition.The criteria on health education also need reformulation.Midwives need to be educated about this aspect as health education is a necessity.

THE SCIENTIFIC METHOD OF NURSING
The standard as w«ll as its criteria on the scientific method of nursing was accepted unchanged.

Assessment
The standard and its criteria on assessment w«re accepted unchanged.

Planning
The standard as well as three of its criteria were rejected and require reformulation.It is interesting to note that it is once again the ones involving the family due to lack of clarity of the definition of the family.The criteria involving other team members also required reformulation It appears as if the midwives who rejected this criteria are not ready to plan their care in conjunction with other health professionals and this in fact is a necessity in order to render comprehensive care to the client/family.

Implementation of carc
The standard as v^ll as the criteria on the implementation o f care were accepted unchanged except for one which was not completed by seven respondents because the scoring section was omitted by accident.The rest of the respondents filled it in themselves

Evaluation
The standards and all their criteria were accepted unchanged

Documentation
The standard and its criteria were accepted unchanged except the ones involving the family.

QUALITY CARE BY THE MIDWIFE DURING THE FIRST STAGE OF LABOUR
The standard regarding the family was Curationis, Vol 18 No 4, December 1995 rgected and requires reformulation due to lack of clarity of the definition of the family.The criteria on the other health professionals was rejected because some midwives are not ready to share the carc rendered with other health professionals.

Guidance
The standard and criteria on guidance were accepted unchanged.

Support
The standard on support was accepted unchanged but the one criteria needs reformulation because of lack of clarity of the definition of the family.

Accompaniment
The stan d ard and the c rite ria on accompaniment were accepted unchanged.

Safe environment
The standard and the criteria on the safety of the environment were accepted unchanged.

CONCLUSION
The standards sent in for validation on the whole were acccpted, though there were some which needed reformulation.The possible lim itations identifred were the lack of understanding of the defmition of the family and the limited number of midwi ves who have the qualification in community health.The mother is thus not seen as part of a family unit rather as a separate entity.

RECOMMENDATIONS 1. FUTURE RESEARCH
• Reformulation of the relevant standards and criteria.
• P ublication o f these standards for midwives to use as guidelines for the improvement o f the quality o f care presently being rendered.
• Development and standardization of an evaluation instrument which is based on these standards and criteria.

IN THE PRACTICAL SITUATION
• Continuing education and inservice education programmes be implemented on family centered care and comprehensive health care; the researcher found these lacking in the research.
• M idwives in hospitals use these as minimum standards of practice for the improvement of the quality of care being rendered.
• Midwives render care according to the needs of the client^family based on current research.

CONCLUSION
With the rising costs of health care it is imperative that midwives reach towards excellence in carc being rendered based on current research.To strive for the ideal the client/family must be active participants in their own health care.It is time for midwives to look at the client as a member of a family and not as an entity on her own.It must be bome in mind that, that which affects her, affects her family too.

A
ccom p anim en t will lead to independent decision-m aki ng i n order to have a creates a safe environment for the ch ild b earin g fam ily by minimizing medico-legal risks;-The midwife is familiar with the lo cation and use o f em ergency equipment and procedures;-The midwife follows the principles of aseptic technique and infection control;