A national survey of obstetric early warning systems in the United Kingdom: five years on.

The Confidential Enquiries into Maternal Deaths in the UK have recommended obstetric early warning systems for early identification of clinical deterioration to reduce maternal morbidity and mortality. This survey explored early warning systems currently used by maternity units in the UK. An electronic questionnaire was sent to all 205 lead obstetric anaesthetists under the auspices of the Obstetric Anaesthetists' Association, generating 130 (63%) responses. All respondents reported use of an obstetric early warning system, compared with 19% in a similar survey in 2007. Respondents agreed that the six most important physiological parameters to record were respiratory rate, heart rate, temperature, systolic and diastolic blood pressure and oxygen saturation. One hundred and eighteen (91%) lead anaesthetists agreed that early warning systems helped to prevent obstetric morbidity. Staffing pressures were perceived as the greatest barrier to their use, and improved audit, education and training for healthcare professionals were identified as priority areas.

Using a birth ball to reduce pain perception in the latent phase of labour: a randomised controlled trial.

BACKGROUND: Admission in the latent phase of labour is associated with higher rates of obstetric intervention. Women are frequently admitted due to pain. This study aimed to determine whether using a birth ball at home in the latent phase of labour reduces pain perception on admission. METHOD: A prospective, pragmatic randomised controlled trial of 294 low risk pregnant women aged 18 and over planning a hospital birth. An animated educational video was offered at 36 weeks' gestation along with a birth ball. The primary outcome was pain on a Visual Analogue Scale on admission in labour. Participants who experienced a spontaneous labour were invited to respond to an online questionnaire 6 weeks' postpartum. RESULTS: There were no differences in the mean pain scores; (6.3 versus 6.5; 90%CI -0.72 to 0.37 p = 0.6) or mean cervical dilatation on admission (4.7 cm versus 5.0 cm; 95% CI -1.1 to 0.5 p = 0.58). More Intervention participants were admitted in active labour (63.6% versus 55.7%; p = 0.28) and experienced an unassisted vaginal birth (70.3% v. 65.8%; p = 0.07) with fewer intrapartum caesarean sections (7.5% v. 17.9%; p = 0.07) although the trial was not powered to detect these differences in secondary outcomes. Most participants found the birth ball helpful (89.2%) and would use it in a future labour (92.5%). CONCLUSION: Using the birth ball at home in the latent phase is a safe and acceptable strategy for labouring women to manage their labour, potentially postpone admission and reduce caesarean section. Further research is warranted.

The RETHINK Study: Could pain catastrophising explain why some women are more likely to attend hospital during the latent phase of labour.

OBJECTIVE: To examine the prevalence of pain catastrophising and identify whether it impacts on the timing of hospital admission when in labour. METHODS: A longitudinal cohort study. Nulliparous women, experiencing an uncomplicated pregnancy in England, were recruited between 25 and 33 weeks gestation. Participants completed two online questionnaires, (1) on recruitment, including the Pain Catastrophizing Scale (PCS) and the Wijma Delivery Expectancy Questionnaire (WDEQ-A) (2) at three weeks postnatal. RESULTS: A total of 389 eligible participants entered the study. The percentage of women who were pain catastrophisers (PCS ≥ 20) was 28.1 %, while 7.6 % had a high pain catastrophising score (PCS ≥ 30). There was no association between pain catastrophising and the timing of hospital admission. The percentage of women reporting fear of childbirth (WDEQ-A score of ≥ 85) was 10.6 %. Fear of childbirth was highly associated with PCS scores (p <.001) at both the lower (≥20) and higher (≥30) thresholds. CONCLUSION: Although not statistically significant, there was a tendency for women who pain catastrophise to present to hospital in the latent phase. The highly significant association between PCS and WDEQ-A scores has implications for the identification of these women and suggests that the PCS can be used as a screening tool to identify those women who have heightened fear around pain and who may also go on to develop clinically relevant fear of childbirth. Further studies are needed to confirm the acceptability of the PCS as a screening tool with women.

Should oral misoprostol be used to prevent postpartum haemorrhage in home-birth settings in low-resource countries? A systematic review of the evidence.

BACKGROUND: Using misoprostol to prevent postpartum haemorrhage (PPH) in home-birth settings remains controversial. OBJECTIVES: To review the safety and effectiveness of oral misoprostol in preventing PPH in home-birth settings. SEARCH STRATEGY: The Cochrane Library, PubMed, and POPLINE were searched for articles published until 31 March 2012. SELECTION CRITERIA: Studies, conducted in low-resource countries, comparing oral misoprostol with a placebo or no treatment in a home-birth setting. Studies of misoprostol administered by other routes were excluded. DATA COLLECTION AND ANALYSIS: Data were extracted by two reviewers and independently checked for accuracy by a third. The quality of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Data were sythesised and meta-analysis was performed where appropriate. MAIN RESULTS: Ten papers describing two randomised and four non randomised trials. Administration of misoprostol was associated with a significant reduction in the incidence of PPH (RR 0.58, 95% CI 0.38-0.87), additional uterotonics (RR 0.34, 95% CI 0.16-0.73), and referral for PPH (RR 0.49, 95% CI 0.37-0.66). None of the studies was large enough to detect a difference in maternal mortality, and none reported neonatal mortality. Shivering and pyrexia were the most common side effects. AUTHOR'S CONCLUSIONS: The finding that the distribution of oral misoprostol through frontline health workers is effective in reducing the incidence of PPH could be a significant step forwards in reducing maternal deaths in low-resource countries. However, given the limited number of high-quality studies in this review, further randomised controlled trials are required to confirm the association, particularly in different implementation settings. Adverse effects have not been systematically captured, and there has been limited consideration of the potential for inappropriate or inadvertent use of misoprostol. Further evidence is needed to inform the development of implementation and safety guidelines on the routine availability of misoprostol.

Writing an abstract for a scientific conference.

For most students and junior researchers, writing an abstract for a poster or oral presentation at a conference is the first piece they may write for an audience other than their university tutors or examiners. Since some researchers struggle with this process we have put together some advice on issues to consider when writing a conference abstract. We highlight a number of issues to bear in mind when constructing one's abstract.

Effects of slow and deep breathing on reducing obstetric intervention in women with pregnancy-induced hypertension: a feasibility study protocol.

Objective: To evaluate whether a slow and deep breathing (SDB) intervention is acceptable to pregnant women. Methods: The trial aims to recruit 67 pregnant women who have developed pregnancy-induced hypertension (clinicaltrials.gov: NCT04059822). SDB will be undertaken daily for 10 min using a video aid and women will self-monitor blood pressure (BP) daily. At 36-weeks gestation women will complete an online questionnaire. Adherence, recruitment rates, and acceptance of the intervention will be evaluated. Conclusion: The findings from this trial will evaluate if women accept SDB as a treatment method. Initial analysis will evaluate if BP and/or obstetric interventions reduce following SDB intervention.

Design errors in vital sign charts used in consultant-led maternity units in the United Kingdom.

BACKGROUND: Paper-based charts remain the principal means of documenting the vital signs of hospitalised pregnant and postnatal women. However, poor chart design may contribute to both incorrect charting of data and clinical responses. We decided to identify design faults that might have an adverse clinical impact. METHODS: One hundred and twenty obstetric early warning charts and escalation protocols from consultant-led maternity units in the United Kingdom and the Channel Islands were analysed using an objective and systematic approach. We identified design errors that might impede their successful use (e.g. generate confusion regarding vital sign documentation, hamper the recognition of maternal deterioration, cause a failure of the early warning system or of any clinical response). RESULTS: We found 30% (n=36/120) of charts contained at least one design error with the potential to confuse staff, render the charts difficult to use or compromise patient safety. Amongst the most common areas were inadequate patient identification, poor use of colour, illogical weighting, poor alignment and labelling of axes, and the opportunity for staff to 'game' the escalation. CONCLUSIONS: We recommend the urgent development of an evidence-based, standardised obstetric observation chart, which integrates 'human factors' and user experience. It should have a clear layout and style, appropriate colour scheme, correct language and labelling, and the ability for vital signs to be documented accurately and quickly. It should incorporate a suitable early warning score to guide clinical management.

Slovenian midwives' and nurses' views on post-natal depression: an exploratory study.

BACKGROUND: Post-natal depression affects approximately 10-15% of women. The literature suggests that midwives and nurses are key professionals in dealing with post-natal mood disorders. However, this would be a new role in Slovenia for which it is not clear whether midwives and nurses are prepared. AIM: This study explored Slovenian midwives' and nurses' knowledge of, and attitudes towards, post-natal mood disorders. METHODS: Two focus groups were conducted, each with five participants, working in the maternity hospital and in the community centre in Postojna. FINDINGS: Data were grouped into three main themes--knowledge of post-natal mental health disorders, role in the management of these issues, and perceived problems and possible solutions in the health care of post-natally depressed women. Participants lacked knowledge on post-natal mental health and did not consider its management to be their role. They saw the main obstacle to caring for these women as being a lack of continuity of carer. CONCLUSION: Slovenian midwives and nurses should be appropriately educated regarding this subject in order to become more capable of managing post-natal mental health. Continuous relationships with women should be encouraged. LIMITATIONS: Further investigation is required and a questionnaire survey involving a larger sample of midwives and community nurses is planned on the basis of the findings of this study.

Vital signs and other observations used to detect deterioration in pregnant women: an analysis of vital sign charts in consultant-led UK maternity units.

BACKGROUND: Obstetric early warning systems are recommended for monitoring hospitalised pregnant and postnatal women. We decided to compare: (i) vital sign values used to define physiological normality; (ii) symptoms and signs used to escalate care; (iii) type of chart used; and (iv) presence of explicit instructions for escalating care. METHODS: One-hundred-and-twenty obstetric early warning charts and escalation protocols were obtained from consultant-led maternity units in the UK and Channel Islands. These data were extracted: values used to determine normality for each maternal vital sign; chart colour-coding; instructions following early warning system triggering; other criteria used as triggers. RESULTS: There was considerable variation in the charts, warning systems and escalation protocols. Of 120 charts, 89.2% used colour; 69.2% used colour-coded escalation systems. Forty-one (34.2%) systems required the calculation of weighted scores. Seventy-five discrete combinations of 'normal' vital sign ranges were found, the most common being: heart rate=50-99beats/min; respiratory rate=11-20breaths/min; blood pressure, systolic=100-149mmHg, diastolic ≤89mmHg; SpO2=95-100%; temperature=36.0-37.9°C; and Alert-Voice-Pain-Unresponsive assessment=Alert. Most charts (90.8%) provided instructions about who to contact following triggering, but only 41.7% gave instructions about subsequent observation frequency. CONCLUSION: The wide range of 'normal' vital sign values in different systems suggests a lack of equity in the processes for detecting deterioration and escalating care in hospitalised pregnant and postnatal women. Agreement regarding 'normal' vital sign ranges is urgently required and would assist the development of a standardised obstetric early warning system and chart.

Sustainable maternity services in remote and rural Scotland? A qualitative survey of staff views on required skills, competencies and training.

OBJECTIVES: To explore staff views on their roles, skills and training to deliver high quality and local intrapartum services in remote and rural settings against national recommendations. DESIGN: Interview and postal survey. SETTING: A stratified representative sample of remote and rural maternity units in Scotland (December 2002 to May 2003). PARTICIPANTS: Staff proportionally representative of professional groups involved in maternity care. RESULTS: Staff interviews took place at 11 units (response rate 93%). A subsequent postal survey included the interview sample and staff in a further 11 units (response rate 78%). Medical specialisation, workforce issues, and proposed regulatory evaluation of competencies linked to throughput raised concerns about the sustainability and safety of services, particularly for "generalists" in rural maternity care teams and for medical cover in small district general hospitals with large rural catchments. Risk assessment and decision making to transfer were seen as central for effective rural practice and these were influenced by rural context. Staff self-reported competence and confidence varied according to procedure, but noted service change appeared to be underway ahead of their preparedness. Self-reported competence in managing obstetric emergencies was surprisingly high, with the caveat that they were not independently assessed in this study. Staff with access to video conference technology reported low actual use although there was enthusiasm about its potential use. CONCLUSIONS: Considerable uncertainties remain around staffing models and training to maintain maternity care team skills and competencies. Further research is required to test how this will impact on safety, appropriateness, and access and acceptability to rural communities.

Decision making with respect to diagnostic testing: a method of valuing the benefits of antenatal screening.

This paper outlines a model for valuing the benefits of antenatal screening based on the analysis of individual decision making with respect to consequent diagnostic testing. Central to the model is the idea that the benefits of screening can be measured by valuing the improved information generated from screening. The model is developed in the context of antenatal carrier screening for cystic fibrosis (CF). Benefits are assessed by surveying women in the general population in order to establish their preferences for two alternative methods of CF carrier screening-stepwise and couple screening. Preferences are elicited using standard-gamble questions in which women from a population-based random sample are asked to trade off risk of fetal loss with improved information from diagnostic testing. A series of standard-gamble questions is employed to elicit utility values for each of the possible information outcomes from screening. The expected utilities of both screening methods are calculated at both individual and group levels. The results suggest that the use of individual decision making with respect to diagnostic testing as a means of valuing the benefits of screening may have wide applications.

Cord-care practice in Scotland.

OBJECTIVE: To identify the range of policies, practices and rationale for umbilical-cord stump care in the NHS in Scotland. DESIGN: A postal questionnaire survey completed in two stages. The first stage elicited the views of Heads of Midwifery/Senior Midwives, and the second stage the views of midwives, enrolled nurses and nursery nurses. SETTING: NHS units in Scotland providing intrapartum care. They were separated into large and small units with small units having < or = 1000 deliveries per year (n = 178), and large units > 1000 deliveries per year (n = 300). PARTICIPANTS: The Heads of Midwifery/Senior Midwives from the 51 units were invited to participate in the study and 49 (96.1%) replied. In stage two 512 maternity unit employees were sent questionnaires and 390 (76.2%) replied. These were six enrolled nurses, 20 nursery nurses and 360 midwives and four respondents of unspecified occupation. MEASUREMENTS: The existence of cord-care policies and their rationale. FINDINGS: About half of the units that responded had a written policy. Large units were four times more likely than small units to have a written policy. Both managers and staff reported that the most common policy/agreed practice was no specific care (cord observed and only cleaned if soiled). Where a written policy existed, less than one-half of the Heads of Midwifery/Senior Midwives and less than one third of the staff reported that the basis for this policy was research. KEY CONCLUSIONS: Units with a written policy are in the minority and small units are far less likely to have such a policy. Wide variation exists in policy, practice and rationale. Diversity within and between units creates anxiety and disillusionment for practitioners. It may also cause confusion for patients who are exposed to different cord-care practices either as these change over time or because they use different units. IMPLICATIONS FOR PRACTICE: The midwifery profession must examine this area of practice and determine how to address this lack of evidence. Further research is required to determine the most effective method of cord care and how best to put the findings into practice. Outstanding questions which beg further investigation are: How do cords heal and separate and what bacteria are naturally involved in this process? What constitutes an infected cord as opposed to a colonised cord?

Can anxiety in pregnant women be measured using the State-Trait Anxiety Inventory.

OBJECTIVE: To explore the stability of the State-Trait Anxiety Inventory (STAI), which was used to explain shifts in women's priorities for intrapartum care. DESIGN: A comparative survey of women's priorities for intrapartum care, using a self-complete questionnaire at two intervals, 34 weeks gestation and 10 days postpartum. The questionnaire incorporated the full 40 item STAI. SETTING: Aberdeen, Scotland. PARTICIPANTS: 217 women presenting at Aberdeen Maternity Hospital at 34 weeks gestation who were 'booked' for delivery within the hospital, and who lived within Aberdeen city. One hundred and thirty-six were expecting their first baby and 81 were expecting their second. MEASUREMENTS: Women's priorities for intrapartum care as ascertained at 34 weeks gestation and 10 days postpartum; shifts in priorities observed during this time period; and factors, such as anxiety (measured by the STAI), which could explain these shifts. FINDINGS: Regardless of parity, women had significantly lower A-Trait scores postnatally than antenatally, when compared over a relatively short time period. Differences between nulliparous and parous women were found where the time lapse, between completion of the scales, was more than 45 days. For nulliparous women significant differences in A-Trait scores were still evident in the 45-56 day interval, but not in the later interval of 57-91 days. Parous women appeared to follow the opposite trend, however the numbers were considerably smaller. CONCLUSION: The findings reported in this paper are derived from a study assessing women's priorities for intrapartum care. Anxiety was not a primary outcome measure in this study, but rather a factor which was measured as a possible explanation for shifts in priorities. However, the findings suggest that the STAI may not be stable around the time of delivery. In particular, the test-retest reliability of the STAI A-Trait scale appears to be quite low. IMPLICATIONS: The study reported here raises the need for further research in this area and cautions against the unqualified use of this tool until its performance, specifically in the context of pregnant or recently-delivered women, has been thoroughly assessed.

A comparison of data obtained from service providers and service users to assess the quality of maternity care.

OBJECTIVE: to compare data obtained from two sources, service providers and service users, regarding the maternity services in Scotland. DESIGN: an audit of maternity services involving site visits, staff interviews and a cross-sectional survey of service users. PARTICIPANTS: lead professionals in every consultant-led maternity unit in Scotland and all 1639 women giving birth in Scotland during a ten-day period. DATA COLLECTION: structured group interviews with service providers and a questionnaire survey of recently delivered women. DATA ANALYSIS: professionals' and women's responses were cross-tabulated and differences in proportions were tested for statistical significance using the chi-square test. FINDINGS: a total of 1137 women completed the questionnaire (response rate 69%). Overall, there was good agreement between professionals' and women's perceptions of the aspects of care studied. However, there were disparities in some areas. For example, staff in eight units reported mechanisms to ensure early distribution of a free national pregnancy book; however, in six of these units less than 75% of women actually received this book prior to their first hospital visit. Eighteen units reported that they offer a postnatal 'reunion meeting'; in ten of these units, less than 50% of women were aware of the reunion meeting. Eighteen units reported a policy of each woman having a lead professional or care co-ordinator; in three of these units, less than 50% of women perceived that they had a care co-ordinator and for most women, the profession (midwife, general practitioner or obstetrician) of their perceived co-ordinator differed from that expected on the basis of staff reports. There was some evidence overall that unit policies had a direct influence on women's responses. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: this study demonstrates the importance of using a range of complementary methods of data collection and of ascertaining both service users' and providers' views when assessing the quality of care. Further research is required to explore differences in service provider's and women's perceptions and how this information can be used to improve the quality of maternity care. The finding that service provision may influence women's preferences has important implications for service planning, in particular the introduction of new models of care, and this needs further exploration.

A national survey of women's views of their maternity care in Scotland.

OBJECTIVE: A survey of women's views of their care was undertaken as part of a national audit of maternity services in Scotland. The overall aim of the audit was to determine the extent to which recommendations from recent national policy documents had been adopted in practice. DESIGN: A cross-sectional study seeking the views of all women giving birth throughout Scotland during a 10-day period in September 1998. PARTICIPANTS: All women giving birth in Scotland within the survey period were eligible to participate in the study. Women unable to complete the questionnaire in English, women for whom the midwife deemed it inappropriate, and women who delivered but no longer resided in Scotland by their 10th postnatal day were excluded. DATA COLLECTION: A self-complete questionnaire given to the woman by her community midwife for completion on her 10th postnatal day. DATA ANALYSIS: Analysis was carried out using the statistical package SPSS for Windows. Descriptive statistics were produced for all variables. Statistical tests of significance were not used, as this was primarily a descriptive survey. FINDINGS: Of the 1152 questionnaires returned, 1137 were suitable for analysis. This gave a response rate of 69% of the eligible population (1639). Most women (80%) had the majority of their antenatal care in the community but only one third had a choice about this. Sixty-nine per cent of women received care from one or two people. However, only 37% had a choice about who these people were. The majority of women gave birth in hospital (99%). Sixty-one per cent felt that they had a choice about where they could have their baby. However, fewer women had a choice about having a home birth (41%) or a DOMINO delivery (23%). Just over half the women felt that it was important to be cared for by a midwife that they had met during pregnancy but only 12% of women achieved this. Sixty-two per cent of women had talked to a health professional about what happened during labour and delivery but less than half had spoken with a professional who was present during her labour or birth. CONCLUSIONS: Considerable efforts have been made to improve information and choice for women. However, it is clear that further work is needed if women are to be offered informed choice in the provision of their maternity care.

Costs of intrapartum care in a midwife-managed delivery unit and a consultant-led labour ward.

OBJECTIVE: to investigate whether there are differences between the cost of intrapartum care for women at low obstetric risk in a midwife-managed labour and delivery unit and that in a consultant-led labour and delivery ward. DESIGN: cost analysis based on the findings of a randomised controlled trial comparing two alternative types of intrapartum care. SETTING: Aberdeen Maternity Hospital, Grampian. SUBJECTS: the number of women 'booked' for care in the Midwives' Unit in a standard year and a comparable group of women cared for in the consultant-led labour ward. PRIMARY OUTCOME MEASURE: the cost 'outcome' is the extra (or reduced) cost per woman resulting from the introduction of a midwife-managed delivery unit. FINDINGS: the baseline extra cost of the introduction of the Midwives' Unit was found to be 40.71 pounds per woman. Depending on the scenario used, this ranged from a cost saving of 9.74 pounds per woman to an additional cost of 44.23 pounds per woman. CONCLUSIONS: this study has shown that, in terms of costs incurred during the intrapartum period, the marginal cost of caring for women at low obstetric risk alongside women at high obstetric risk in a standard labour ward is small. However, the impact of establishing a separate midwife-managed delivery unit, requiring an increase in midwifery staffing levels, can be significant.

Satisfaction and continuity of care: staff views of care in a midwife-managed delivery unit.

OBJECTIVE: to examine whether there are differences in the midwife's role in, and satisfaction with, intrapartum care and delivery of women at low obstetric risk in a midwife-managed delivery unit compared to a consultant-led labour ward. DESIGN: a pragmatic randomised controlled trial. Subjects were randomised in a 2:1 ratio between the midwives' unit and the labour ward. SETTING: Aberdeen Maternity Hospital, Grampian, UK. SUBJECTS: midwives within the delivery suite who cared for the 2844 women at low obstetric risk receiving care in a pragmatic randomised controlled trial of the two delivery areas. PRIMARY OUTCOME MEASURES: continuity of carer and midwife satisfaction. FINDINGS: midwives looking after women in the midwives' unit group were significantly more likely to be of a higher grade, more qualified and have a longer length of experience than those in the labour ward group. There was greater continuity of carer both during labour and after delivery in the midwives' unit group. Despite a small but statistically significant difference in overall satisfaction between the groups, area of 'booking' or area of delivery were not important in predicting midwife satisfaction. Autonomy and continuity of carer were the best predictors of midwife satisfaction. CONCLUSIONS: midwife-managed intrapartum care increases continuity of carer and, therefore, midwife satisfaction. Extending this outside the delivery suite requires a system of care that is acceptable to midwives as well as women. Such systems will depend to a large extent on geography, consumer demand and availability of resources. However, midwife satisfaction should also be considered. In order to do this further research is required to fully evaluate the effect these systems have on the midwives working in them.

Midwife managed delivery unit: a randomised controlled comparison with consultant led care.

OBJECTIVE: To examine whether intrapartum care and delivery of low risk women in a midwife managed delivery unit differs from that in a consultant led labour ward. DESIGN: Pragmatic randomised controlled trial. Subjects were randomised in a 2:1 ratio between the midwives unit and the labour ward. SETTING: Aberdeen Maternity Hospital, Grampian. SUBJECTS: 2844 low risk women, as defined by existing booking criteria for general practitioner units in Grampian. 1900 women were randomised to the midwives unit and 944 to the labour ward. MAIN OUTCOME MEASURES: Maternal and perinatal morbidity. RESULTS: Of the women randomised to the midwives unit, 647 (34%) were transferred to the labour ward antepartum, 303 (16%) were transferred intrapartum, and 80 (4%) were lost to follow up. 870 women (46%) were delivered in the midwives unit. Primigravid women (255/596, 43%) were significantly more likely to be transferred intrapartum than multi-gravid women (48/577, 8%). Significant differences between the midwives unit and labour ward were found in monitoring, fetal distress, analgesia, mobility, and use of episiotomy. There were no significant differences in mode of delivery or fetal outcome. CONCLUSIONS: Midwife managed intrapartum care for low risk women results in more mobility and less intervention with no increase in neonatal morbidity. However, the high rate of transfer shows that antenatal criteria are unable to determine who will remain at low risk throughout pregnancy and labour.

Decision making about mode of delivery among pregnant women who have previously had a caesarean section: A qualitative study.

OBJECTIVE: To explore prospectively women's decision making regarding mode of delivery after a previous caesarean section. MAIN OUTCOME MEASURES: The evolution of decision making, women's participation in decision making, and factors affecting decision making. DESIGN AND METHODS: A qualitative study using diaries, observations and semi-structured interviews. Data were analysed thematically from both a longitudinal and a cross-sectional perspective. SETTING: An antenatal unit in a large teaching hospital in Scotland and participants' homes. SAMPLE: Twenty-six women who had previously had a caesarean section for a nonrecurrent cause. RESULTS: Women were influenced by their own previous experiences and expectations, and the final decision on mode of delivery often developed during the course of the pregnancy. Most acknowledged that any decision was provisional and might change if circumstances necessitated. Despite a universal desire to be involved in the process, many women did not participate actively and were uncomfortable with having responsibility for decision making. Feelings about the amount and quality of the information received regarding delivery options varied greatly, with many women wishing for information to be tailored to their individual clinical circumstances and needs. In contrast to the impression created in the media, there was no evidence of clear preferences or strong demands for elective caesarean section. CONCLUSION: Women who have had a previous caesarean section do not usually have firm ideas about mode of delivery. They look for targeted information and guidance from medical personnel based on their individual circumstances, and some are unhappy with the responsibility of deciding how to deliver in the current pregnancy.