124 Chapter 5 ‘In our practice we say ‘the less you do, the more beautiful the birth will be’. It’s a kind of conscious choice […] It’s also very clearly written in the Lancet series. A lot of midwives use amniotomy to accelerate labour, and then you think: ‘why would you want to do that?’ […] Eventually, it becomes evident that it does not help at all.’ (Midwife 1) In addition, midwives in the group that utilize low rates of interventions as part of their clinical practice described how they question assumptions and generate knowledge through reflection. ‘Ultrasounds are absolutely interventions. Enormous interventions, based on which, care pathways can go in all directions. You should be very careful with the use of them. Not a standard thirty-week fetal growth scan […]. I also don’t understand that colleagues go along with this. If you think about it carefully and read all the evidence about it.’ (Midwife 10) In contrast, none of the midwives in the group that utilize high use of childbirth interventions as part of their clinical practice gave examples of using scientific literature in their clinical decision-making process. They reported how they often align with local protocols and do not use national guidelines. They accommodated to the local agreement to use these protocols, which were different from the national guidelines, often leading to a more interventionist approach. Overall, midwives described that the formal midwifery education program is an important source of knowledge. In addition, midwives with a low use of interventions clearly described how they have extended their knowledge, and the application of knowledge by reflecting on experiences and evidence. This extended knowledge through reflection influenced their clinical decisionmaking. In contrast, midwives with a high use of interventions did not mention this reflection, but described how they adhere to local protocols for their decision-making. 3.2 Critical thinking skills – advanced knowledge in context All midwives felt competent to perform interventions, such as vaginal examination or amniotomy. A difference seemed to exist in the process leading up to the use of these interventions; a difference in the reflective process involving critical thinking skills to make well-founded decisions during midwifery care. Midwives who utilize low rates of interventions as part of their clinical practice spoke about how they continuously reflect on the ongoing situation and constantly ask themselves if it is necessary to intervene. Such reflective moments seem to contribute to less standardized application of interventions compared to the group midwives with a high use of childbirth interventions who did not mention reflective moments.
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