![]()
1 Labour and normal birth
Cathy Charles
Introduction
The birth environment
Signs that precede labour
First stage of labour
Second stage of labour
Pushing
The birth
Third stage of labour
After the birth
Summary
Useful contacts and information
References
Introduction
âUndisturbed birth âŚis the balance and involvement of an exquisitely complex and finely tuned orchestra of hormonesâ (Buckley, 2004a).
The most exciting activity of a midwife is assisting a woman in labour. The care and support of a midwife may well have a direct result on a womanâs ability to labour and birth her baby. Every woman and each birthing experience is unique.
Many midwives manage excessive workloads and, particularly in hospitals, may be pressured by colleagues and policies into offering medicalised care. Yet the midwifery philosophy of helping women to work with their amazing bodies enables many women to have a safe pleasurable birth. Most good midwives find ways to provide good care, whatever the environment, and their example will be passed on to the colleagues and students with whom they work.
Some labours are inherently harder than others, despite all the best efforts of woman and midwife. A midwife should be flexible and adaptable, accepting that it may be neither the midwifeâs nor the motherâs fault if things do not go to plan. The aim is a healthy happy outcome, whatever the means.
This chapter aims to give an overview of the process of labour, but it is recognised that labour does not simplistically divide into distinct stages. It is a complex phenomenon of interdependent physical, hormonal and emotional changes, which can vary enormously between individual women. The limitation of the medical model undermines the importance of the midwifeâs observation and interpretation of a womanâs behaviour.
Facts and recommendations for care
- Women should have as normal a labour and birth as possible, and medical intervention should be used only when beneficial to mother and/or baby (DoH, 2004, 2007).
- Midwife-led care gives the best outcomes worldwide: more spontaneous births, fewer episiotomies, less use of analgesia, better breastfeeding rates. Women use less analgesia, and report that they feel more in control of their labour (Hatem et al., 2008).
- Women should be offered the choice of birth either at home, in a midwife-led unit or in an obstetric unit (NICE, 2007), although only 83% report being offered any sort of choice (CQC, 2010). While an obstetric unit may be advised for women with certain problems, up to two thirds of women are suitable for midwife-led units or home birth (DoH, 2007), and the woman has a right to choose where she gives birth.
- Women should be offered one-to-one care in labour (NICE, 2007). The presence of a caring and supportive caregiver has been proved to shorten labour, reduce intervention and improve maternal and neonatal outcomes (Green et al., 2000; Hodnett et al., 2011).
- Increasing numbers of women rate midwifery support as positive (CQC, 2010), although a few midwives are regarded as âoff-handâ, âbossyâ or âunhelpfulâ (Redshaw et al., 2007).
- 5â6% of mothers develop birth-related post-traumatic stress disorder (Kitzinger and Kitzinger, 2007).
- Over two-thirds of Heads of Midwifery report they have insufficient midwife numbers to cope with their unit workload (RCM, 2009) which impacts on the quality of midwifery care women receive, reducing the chance of one-to-one care.
- The attitude of the caregiver seems to be the most powerful influence on womenâs satisfaction in labour (NICE, 2007).
- 89% of fathers attend the birth (Redshaw and Heikkila, 2010) but there are other relationships e.g. lesbian couples, who have been less closely studied.
Mode of delivery statistics
- The normal birth rate for England was 63% in 2010/11; in 2009/10 it was 60% in Scotland, 61% in Wales and 56% in Northern Ireland (BirthChoice UK; ESRI, 2011; ONS, 2012)
- The instrumental delivery rate was 12.5% for NHS hospitals in 2010/11; 16.7% in Northern Ireland (ESRI, 2011; ONS, 2012)
- The episiotomy rate for England is 8.3% for a normal birth; almost 20% overall (BirthChoice UK; ONS, 2012).
- The caesarean section (CS) rate for England in 2010/11 is around 25% (ONS, 2012).
The birth environment
In what kind of surroundings do people like to make love? A brightly lit bare room with a high metal bed in the centre? Lots of background noise, with a series of strangers popping in and out to see how things are going? The answers to these questions may seem obvious. If we accept that oxytocin levels for sexual intercourse are directly affected by mood and environment, why is it that women in labour receive less consideration? The intensely complex relationship between birth and sexuality is an increasing source of study and reflection by birth writers (Buckley, 2010).
Once women gave birth where and when they chose, adopting the position they wanted, using their instinctive knowledge to help themselves and each other. Recently birth has become more medicalised, and the place of birth more restricted. No-one would deny that appropriate intervention saves lives. For some women an obstetric unit is the safest choice, and for others it feels like the safest, so that makes them feel happier. But does it have to be the choice for everyone?
The clinical environment and increased medicalisation of many birth settings directly affects a womanâs privacy and sense of control (Walsh, 2010a). Hodnett et al. (2010) have demonstrated that home-like birthing rooms (âalternative settingsâ) even within an obstetric unit, lead to increased maternal satisfaction, reduced intervention and satisfactory perinatal outcomes. This may be due partly to the fact that women simply feel more relaxed at home, or in a home-like setting. However, simply changing the curtains and hiding the suction machine does not always mean a change of philosophy of care. A more telling factor may be that the type of midwives who choose to work in the community or birth centre, or who gravitate towards more home-like rooms, are those with a less interventionist approach.
Women should be able to choose where to give birth; it would be still more wonderful if women could simply decide in labour whether they wish to stay at home, or go to a birth centre or an obstetric unit, and indeed if they could change their mind during labour. Such choices do exist, but UK service provision is patchy, and in many countries women have little or no choice.
Whilst it has been estimated that at least two thirds of women are suitable for labour at home or a midwife-led birthing centre (DoH, 2007), for many reasons the majority of mothers and midwives in the UK will still meet in labour in an acute hospital setting. It is incumbent on all midwives to make the environment for a woman in labour, irrespective of its location, warm, welcoming and safe. Always remember that the quality of the caregiver in labour is the thing that most strongly influences a womanâs satisfaction with her labour (NICE, 2007).
The Royal College of Midwives Campaign for Normal Birth has produced ten top tips to enhance womenâs birth experience: see Box 1.1.
Box 1.1 Ten top tips for normal birth (RCM, 2010).
(1) Wait and see The single practice most likely to help a woman have a normal birth is patience. In order to be able to let natural physiology take its own time, we have to be very confident of our own knowledge and experience.
(2) Build her a nest Mammals try to find warm, secure, dark places to give birth â and human beings are no exception.
(3) Get her off the bed Gravity is our greatest aid in giving birth, but for historical and cultural reasons (now obsolete) in this society we make women give birth on their backs. We need to help women understand and practise alternative positions antenatally, feel free to be mobile and try different positions during labour and birth.
(4) Justify intervention Technology is wonderful, except where it gets in the way. We need to ask ourselves âis it really necessary?â And not to do it unless it is indicated.
(5) Listen to her Women themselves are the best source of information about what they need. What we need to do is to get to know...
