European Journal of Obstetrics & Gynecology and Reproductive Biology 206 (2016) 204–207

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European Journal of Obstetrics & Gynecology and

Reproductive Biology
journal homepage: www.elsevier.com/locate/ejogrb

Medical students learning experiences of the labour ward: a qualitative

research study
Danielle Cottera,b , Michael J. Turnerb , Fionnuala M. McAuliffea , Mary F. Higginsa,*
a
UCD Obstetrics and Gynaecology, School of Medicine and Medical Sciences, University College Dublin, National Maternity Hospital, Dublin 2, Ireland
b
UCD Center for Human Reproduction, Coombe Women and Children’s University Hospital, Dublin 8, Ireland

A R T I C L E I N F O A B S T R A C T

Article history: Objective: To study the educational value to medical students of a labour ward rotation.
Received 17 July 2016 Design: Qualitative research study was performed in two tertiary level obstetric hospitals attached to a
Received in revised form 4 September 2016 large medical school in Dublin. Medical students attending a six-week rotation in Obstetrics and
Accepted 13 September 2016
Gynaecology in University College Dublin were invited to participate. As part of this rotation, students
spend one week as part of the clinical team working on the labour ward. Focus groups were held in order
Keywords: to identify common themes and experiences of medical students during this labour ward week.
Medical students
Grounded theory with thematic analysis was used. The main outcome measures were the educational
Labour ward
Experience
experience and value of a labour ward rotation to medical students.
Education Results: Five distinct themes developed from the focus groups of 19 students. A high value was placed on
patient centred bedside teaching. Midwives were identified as excellent teachers and facilitators of
learning. There was a clear sense of teamwork and belonging by the students. However, students reported
frustration with unclear learning objectives. Students identified extra pre-learning with pre-specified
learning aims before the labour ward week as being important.
Conclusion: Bedside teaching was highly valued as it advanced student’s knowledge of obstetrics theory
and improved communication skills. In general, medical students reported a positive experience from
working in the labour word but there is scope for improvement.
ã 2016 Elsevier Ireland Ltd. All rights reserved.

Introduction
The safe delivery of a mother and baby is a joy. Spending time
on a labour ward as a medical student introduces doctors-to-be
to normal labour, and to the privilege of being involved in a
woman’s care at one of the most special time in her life. After
years of teaching by scientists and medical academics, it is often
the first time that the students are taught directly by midwives,
who work as independent practitioners and teach students the
normal and abnormal variants of labour. Much of the research
in this area focuses on midwives experiences of teaching
medical students, or patient’s perceptions [1–4]. A successful
teaching strategy should also involve the experiences of medical
students, including determining whether learning objectives
were achieved.
* Corresponding author at: UCD Obstetrics and Gynaecology, National Maternity
Hospital, Holles Street, Dublin 2, Republic of Ireland.
E-mail address: mary.higgins@ucd.ie (M.F. Higgins).
The aim of this study was evaluate medical student’s experience
of both the labour ward placement and the teaching they
experienced.
Materials and methods
Medical students in University College Dublin study Obstetrics
and Gynaecology throughout medical college, but concentrate
their learning in a six-weeks hospital based rotation, normally
occurring within the last 18 months of medical school. The first day
of the rotation consists of an orientation to the six weeks, including
a brief orientation to the labour ward. Further orientation is
provided by both written documentation, online documentation
and staff support.
The rotation comprises of over sixty lectures, including three
video linked teaching sessions per day, bedside tutorials, ward
rounds, attendance at antenatal and gynaecological clinics and at
multidisciplinary weekly clinical meetings. Crucial to this teaching
of the art of obstetrics is a mandatory one-week rotation on the
labour ward where they work within the clinical team under the
supervision of the midwifery staff. During this time students are

http://dx.doi.org/10.1016/j.ejogrb.2016.09.022
0301-2115/ã 2016 Elsevier Ireland Ltd. All rights reserved.
 D. Cotter et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 206 (2016) 204–207 205

expected to fully integrate into the clinical team working in each
eight-hour shift on the ward (including nights), and to assist the
midwifery staff to care for women in labour and after delivery.
Students are also expected to complete anonymous summaries of
six women in labour for discussion at the end of the six-weeks
rotation. At the end of the six-weeks each student meets with a
member of staff to provide feedback on both the positive and
negative aspects of the entire six-weeks module. In addition, an
external assessor reviews the course content and interviews
students on a yearly basis to provide a written external assessment
of the module.
For this study, following completion of the one-week labour
ward rotation, students were invited to give feedback of their
experiences as medical students on the labour ward. Consenting
students attended a focus group that aimed to obtain a more in-
depth representation of student’s experiences. A medical student
with a background in psychology (DC) led the focus group. DC was
a member of the previous student group and students attending
the focus group were unknown to her. While this was not meant to
be an assessment of teaching, suggestions aimed to improve the
experience for other students were welcomed. Grounded theory
was used, with thematic analysis. Multiple focus groups were
planned until saturation of data. An interview schedule with
twelve baseline questions was developed (defined in Table 1) and
led by a facilitator. Positive and negative aspects of the experience
were discussed followed by a recommendation of various
approaches that could be used to improve learning experiences.
Each group session lasted approximately 45 min.
The settings were the two tertiary level university hospitals
with 9000+ deliveries per annum, the National Maternity
Hospitaland the Coombe Women’s and Children’s University
Hospital. Both hospitals are associated with University College
Dublin and provide undergraduate teaching to medical, midwifery
and nursing students from the university. Formal approval of the
project was obtained from Ethics Committee of University College
Dublin.
Results
Nineteen students were interviewed in focus groups until
thematic saturation was reached. No differences were identified
between males and female students, nor between the students
attending different hospitals.
Five distinct themes were identified—the value of patient
centred care in education, midwives as excellent teachers and
facilitators, a feeling of teamwork and belonging, the frustration of
unclear learning goals and a wish for specific pre-rotation learning
interventions.
Students placed a high value on bedside teaching as it advanced
both their knowledge of obstetrics as well as their communication
skills. “Everyone felt like they got a lot out of it . . . it was helpful for
reinforcing knowledge, being there and seeing it”. Some practiced
their practical skills “You got to practice things like taking a blood
pressure”. For others, a particular topic pertaining to a patient
augmented their education “Everyone learns something different
from their patient—like the patient I was with had gestational
diabetes . . . when you go to study a topic later its already in your
head”. Notably, because the care was patient centred, and the
students stayed with the patient for the duration of the patients
time on the labour ward (or duration of the students shift,
whichever was shorter), the students believed that their commu-
nication skills improved “At the start I was very nervous being with
one couple for a time, but it was fine!” “Good for learning how to
communicate with patients”.
Midwives were respected as both excellent teachers and
facilitators of learning. Students’ comments included that
“ . . . the midwives were very willing to teach medical students as
they are used to students on the labour ward”. Equally midwives
were conscious of the limited time the medical students had on the
labour ward. “They were understanding of time constraints of the
labour ward, putting you with a multiparous women or calling you
out to see other deliveries”.

Table 1
The interview schedule for the focus groups consisting of twelve baseline questions, with supported talking points and probing questions.

Engagement question
1. What was your general impression of the labour ward? Enthusiastic teachers, patients? What might have contributed to this atmosphere

Exploration questions
2. What were you expectations of the labour ward?
3. How were your expectations met?
4. How could they be better met?
5. How useful did you find your time on the labour ward?
a. What specific skills, abilities or experiences did you gain?
6. What was your favourite part of the week?
7. What are the strengths of placement?
8. What are the disappointments/weaknesses of the week on the labour ward?
9. How can we improve the time on the labour ward for medical students?
10. If you could change anything about your week on the labour ward what would it be?

Exit questions
11. Is there anything else you would like to say about your experience on the labour ward? (Why you liked/disliked it?)
12. Of all things discussed today, what do you think is most important?
.... Have we missed anything?

Other talking points

 Attendance through the whole week versus how they felt it benefited them?
 Any pre-learning that was done and how they feel it benefited them? E.g. labour ward on week 1 versus labour ward on week 6?

Probes
 Can you talk more about that?/Please tell me more about that
 Help me understand what you mean by that . . .
 Can you give an example of that
 Could you explain what you mean by that
 Can you tell me something else about that
206 D. Cotter et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 206 (2016) 204–207
There was a clear feeling for the students of both teamwork and
belonging. Several students described being apart of the team
during their week. “There is a sense of belonging to the team”; “They
make sure you get your break and you feel like you belong” as well as
the value of the work “My favorite part of the week was getting hands
on experience”. Others suggested having a tour of the ward prior to
starting the rotation, to have a better orientation in order to be
more useful to the team.
Students reported unclear learning objectives. Providing a list of
tasks outlining the role of the medical student would be very
valuable, enabling students to perform more hands-on work. “If
you had a list of things to do and knew what was expected of you, you
can rise to those expectations”. “It could be improved if they got us to
do more hands-on work . . . I know some people got to do it but only if
they were keen”. There were some expressions of regret, of missed
opportunities. “If I could change anything about the week, I would ask
about getting hands on experience”, “I got no hands on experience, I
wished I had asked” “should have been told in the beginning, don’t be
afraid to ask about hands on”.
Pre-learning before the labour ward was thought to be
beneficial. “I would suggest that one of the first lectures of the year
should go through a normal delivery from start to finish including
interventions . . . . I personally had a hard time understanding what
was normal for a while and didn’t know when interventions were
meant to be implemented”. This was especially noted as important
for students that were assigned to labour ward in the first week of
the rotation.
Discussion
Main findings
This research indicates the beneficial value of integrated
teaching between midwives and medical students, with concrete
feelings of team membership and fulfilment reported by the
students, as well as defined recommendations for future teaching
programmes.
The respect shown by the students towards the midwives in
this study is especially important as in a previous publication from
another centre nearly half of nurses and midwives (43.9%) reported
that their contributions to medical education was unrecognized by
the doctors and students that they taught [2].
Other studies in this area have investigated the attitudes of
patients, midwives and midwifery students towards medical
students working on the labour ward. Attitudes and expectations
towards medical students in the literature are varied. Some
have reported negative attitudes of pregnant patients towards
students that can impact negatively on a student’s experiences.
They are less likely to allow a medical student to assist with their
care [3,5].
Midwifery students have been reported to feel in competition
with medical students for patients, in one study midwifery
students did not identify a role for medical students in performing
a normal birth, neonatal assessment or providing advice on
breastfeeding [6].
A reduced ‘hands-on’ approach of medical students on the
labour ward has been identified previously. While students
referred to the labour ward experience as “the most exciting part
of the attachment” there is a reduced expectation that students
perform deliveries by themselves, with no set number of deliveries
to be experienced by the medical students in some medical
schools, and one school not making labour ward experience
compulsory [5]. The National Undergraduate Curriculum for
Obstetrics and Gynaecology in the United Kingdom has called
for all undergraduate students to have delivery suite experience,
stating that “witnessing the birth of a baby gives students exposure
to a unique event, where they will learn the importance of patient-
focused care, including communication skills, dealing with pain,
team working and the importance of patient choice” [7]. It is
interesting to note that even though orientation to the labour ward
includes strong encouragement by faculty that this is “hands on”
learning, medical students in these groups still needed further
encouragement during their week.
Despite suggestions of negative attitudes towards medical
students, although not specific to labour ward, studies have
shown a positive assessment of an inter-professional ward
placement. An improvement in attitudes towards future working
relationships can be enhanced by opportunities to learn together
and allow a better understanding of another professional role
[8,9].
Integrated teaching between different teams has proven
beneficial. There is recognition of the value the teacher brings
and reports of positive clinical learning experiences [10]. In joint
psychological and obstetric teaching ward rounds for medical
students integrated session reported students being better
prepared for the psycho-social aspects of obstetrics [11]. The
same hypotheses applied to the interdisciplinary teaching between
midwives and medical students and found that interdisciplinary
teaching can improve communication skills, improve teamwork
and expand clinical perspectives. It is likely a positive experience
from teaching – how obstetricians, midwives nurses and
anaesthetists all work together with common goals – will be
carried into practice when medical students graduate [1]. This
should also serve as strong examples of the value of true
multidisciplinary team working and mutual respects for each
person’s strengths and training. As well as appreciation for the
strengths of all members of the multidisciplinary team, these
positive experiences can also result in career choices, as a
successful undergraduate attachment is a significant factor for
graduates who are considering obstetrics and gynaecology as a
career [5].
A key issue emerging from the study is a perceived lack of
clear learning objectives. Many midwives (>97%) who teach have
more than five years clinical experience, with nearly three
quarters having more than five years experience teaching
medical and midwifery students [12]. It is acknowledged that
many academic practices are moving towards collaborative
interdisciplinary teaching models [10]. At present midwives
can teach medical students but there are no national standards or
expectations. The negative impact of unclear learning goals was
highlighted when a difference of learning expectations between
midwives and medical students contributed to student dissatis-
faction with their obstetric learning experience [4]. A teaching
role specific to medical curriculum can help to facilitate teaching
efforts [12].
So how should medical students be best taught in order to
maximize learning objectives and experiences on the labour ward?
Despite the perception of faculty that orientation had been
provided in several ways, it was disappointing that the students
still perceived that the goals of the rotation were uncertain. In
order to overcome this the faculty have developed a specific online
module providing orientation to the labour ward, including the
professional behaviour expected by the students as the goals to be
achieved during their time on rotation, as well as an overview of
labour specifically orientated to those students starting the labour
ward week early in the rotation.
A strength of the study was that this was a student led study,
derived, developed and ran by a student (DC) with the support of
faculty. While the small number of participants may initially be
seen as a limitation, thematic saturation was achieved very quickly
and higher numbers were not required. In addition, very few
negative comments were made, suggesting either that the
 D. Cotter et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 206 (2016) 204–207
students had mostly positive experiences or those who had
negative experiences did not consent to join the focus groups.
Conclusion
Medical students showed respect for the excellent teaching of
midwives on the labour ward with a clear sense of teamwork and
belonging by the students after only one week of placement on the
ward. Though this study was not meant to be an assessment of
teaching, the faculty has identified negative aspects such as
unclear learning objectives as priority items for future educational
programmes. In particular, a suggestion of pre-learning before the
labour ward week was considered to be potentially beneficial. This
study shows that the long tradition in Dublin of respecting the
value of bedside teaching continues on [13]. Though Graves and
Corrigan brought students out of the lecture theatre and into the
wards well before Osler, both would well appreciate his quote
“have no teaching without a patient for a text, and the best
teaching is that taught by the patient himself”, a principle which
we believe should remain core to teaching the Art of Obstetrics
[14].
Disclosure of interests
None.
Contribution to authorship
DC, MT, FMcA and MH made substantial contributions to
conception and design, DC acquired, analysed and interpreted
data; DC, and MH drafted the article; DC, MT, FMcA and MH
revised it critically for important intellectual content; DC, MT,
FMcA and MH gave final approval of the version to be published;
DC, MT, FMcA and MH agree to be accountable for all aspects of
the work in ensuring that questions related to the accuracy or
integrity of any part of the work are appropriately investigated
and resolved.
Ethical approval
This study was approved by the Ethics Committee of University
College Dublin.
207
Funding
Not applicable.
Acknowledgements
With thanks to the excellent midwives working in both the
National Maternity Hospital and the Coombe Womens and
Childrens University Hospital—as ever, a pleasure to work with
you.
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