Introduction

From its introduction in 1989, various authors have researched a variety of

pregnancy outcomes after LETZ. From a quality of research perspective, the various choices of statistical tests are worrying. Tests usually used in randomised control studies are used, without taking note of the type of data they are analysing. Most studies investigate both mothers having their first baby and mothers having other births. Although all emphasise the need to include both groups and cite the

differences in the pattern and progress of labour in these groups as justification, only Cruikshank, Flannelly, Campbell and Kitchener (1995) do any sub-analysis by parity. They find no difference in pregnancy outcomes, or the length of the 1^st stage of labour, which is that part which involves the cervix. The study that plans, at the outset, an analysis by parity groups is long overdue.

Chapter 2 LETZ and progress in labour

The previous studies vary in methodology, and therefore it is difficult to aggregate them. Indeed, their results vary and therefore the evidence to date is equivocal until the recent research by Kyrgiou, Koliopoulos, Martin-Hirsch, Arbyn, Prendiville and Paraskevaidis (2006) and Bruinsma, Lumley, Tan and Quinn (2007). None of the published research in the literature review into the effects of LETZ took cognisance of the woman‟s experience during labour. Although the exact process of ripening and dilation of the cervix is still unknown, LETZ is not thought to alter this process in labour. There is little work on which to base this assumption. The study seeks to provide the evidence that there is an association between LETZ and progress in labour. It seeks to use these results to change the expectation that the labours of women after LETZ conform to the „normal‟ pattern. The study‟s results, once disseminated, will improve the quality of care for these women.

Measurement of the dilatation of the cervix is a relatively modern phenomenon.

Obstetricians dislike uncertainty; therefore, division of labour into discrete parts, division of the interplay of forces in labour into three physical parameters and the definition of an active phase at 3cm dilatation, all reassure that labour can be controlled. Although medical education, and medical textbooks, strive to ensure evidence-based practice in medicine, with a low value on authority, and a high value on evidence in decision making; practice is often still based on authority or „expert opinion‟, what experts think is right will be right (Peterson, Meikle et al. 1999). The definition of normal labour varies throughout maternity units in the UK, and indeed throughout nations of the world (Gould 2000), providing strong indications that these definitions are not evidence based. Vaginal examinations, that are unpleasant for women, are used unnecessarily when there are no problems in labour, and are a very imprecise measurement of progress; the exact flaw obstetricians use to dismiss midwifery methods of assessment. This reliance on VE disadvantages women who have LETZ as their cervix does not dilate in the „normal‟ manner.

If labour onset and progression is a seamless transition from pregnancy, which involves a cascade of events that culminate in birth, it seems self-evident that there are multiple control mechanisms and „fail-safe‟ pathways, as is the case in other complex biological systems. Although there is increasing knowledge about uterine function and the processes of labour, precise mechanisms remain obscure and incomplete. This leads to the conclusion that, physiologically, there is no distinction

Chapter 2 LETZ and progress in labour

between passive and progressive phases, and that the demarcation point is based on observed events and experience (Cluett 2000). A comprehensive approach to care during labour that considers women's situations and their individual desires, acknowledges that birth is complex. This acknowledgement is particularly relevant to women after LETZ. This enables care for women to be holistic (Vande-Vusse

1999a).

The language used in labour, when their bodies do not „perform‟ in the way the medical establishment has decreed as „normal‟ affects women negatively. They are made to feel a failure and powerless. When they are supported to give birth

naturally, the results are different. If birth really unfolds the way a woman wants, this is not so much a „nice‟ experience as a profound one. It increases their self-esteem and confidence, they find the natural process of birth empowering and this seems to last long term (Davis-Floyd 1990; Edwards 1997b).

Definition of a pattern of labour after LETZ will alert both clinicians and women to their „normal‟ pattern and perhaps remove unnecessary interventions from their care. However contrived demarcation of labour into various stages is, it has to be acknowledged that to change practice, it is necessary to abide by the terms that are used by the dominant hegemony i.e. obstetrics. From the pilot study, BS of 11 is more often associated with 4cm dilatation and as vaginal examinations are subjective assessments, 4cm is taken as the starting point for the progressive phase, in the Quantitative part of the study.

Chapter 3 Pilot study

Chapter 3

Pilot study

Chapter 3 Pilot study

3.1 Introduction

Chapter 2 discusses how LETZ became the dominant treatment for CIN and the variety of outcomes in previous research. It describes research looking at all the three stages of labour, when the cervix is the main component of the 1^st stage only, and the lack of distinction between the parity of women. The previous Chapter also reviews progress in labour and the ways this is measured, together with the

assessment and management of progress in labour via the conflicting paradigms. It examines the views of midwives and concludes by describing and discussing the resulting effects on women when their births do not conform to the „normal‟ pattern.

Chapter 3 discusses the pilot study conducted before the main study. As Teddlie and Tashakkori (2009) state, pilot studies are a useful way of developing research questions in an emergent design, demonstrating the feasibility of the study to others, and validating research instruments. A pilot study was necessary in order to

determine if the 1^st stage of labour could be isolated. It also determined if

retrospective delivery notes could be used, to examine the differences in the pattern and progress of the 1^st stage of labour, between women who had previous LETZ treatment for abnormal smears of the cervix and women who had not. It was used to establish the types of data that were available for analysis and provided a guide as to expected size of differences, to enable power and sample size calculations to be made for the main study.

Although there had been earlier research into the effect of LETZ on labour, as was illustrated previously in Chp. 2; Section 2.2, p.35, most of the research did not concentrate on the 1^st stage. No previous study was found that suggested expected outcomes, to enable calculation of size of difference, power and sample size. This Chapter illuminates the research questions that the pilot study sought to answer. It describes the design and methodology of the pilot study and the methods of data collection. The pilot study raises some interesting points that this Chapter discusses, including the differences between time in the 1^st stage of labour, type of delivery of baby and dilatation at admission, some of which contradict the results of previous studies

Chapter 3 Pilot study