Oxford Handbook of Midwifery (52 page)

CHAPTER 11
Normal labour: first stage

206

• Provide an efficient communication network so that the woman can phone and obtain advice regarding her progress and concerns during this phase.
  
• In some areas vaginal examination to assess progress may initially be undertaken at home by the community midwife, so that unnecessary visits to hospital are minimized and the woman remains in a non- threatening environment.
  
• Provide antenatal health promotion that focuses on clear explanations of the latent phase and spurious labour, so that women adopt a more realistic notion of what labour involves.
  

  

  1. Gurewitsch E, Diament P, Fong J,
     et al
     . (2002). The labour curve of the grand multipara: Does progress of labour continue to improve with additional childbearing?
     American Journal of Obstetrics and Gynaecology
     186
     , 1331–8.
     
  2. Lauzon L, Hodnett E (2006). Labour assessment programs to delay admission to labour wards (Cochrane Review), In:
     Cochrane Library
     , Issue 1. Chichester: John Wiley and Sons Ltd.
     
  3. Rahnama P, Ziaei S, Faghihzadeh S (2006). Impact of early admission in labour on method of delivery.
     International Journal of Gynaecology and Obstetrics
     92
     (3), 217–20.
     

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  CHAPTER 11
  Normal labour: first stage
  

  208‌‌
  

  Support for women in labour
  

  Research has shown that where women are supported through their birth experience by midwives in birth units or midwife-led areas there is:
  

• Less intervention—induction of labour, caesarean section, forceps, ventouse, and artificial rupture of the membranes
  ¹
  
• Less pharmacological analgesia
  
• Fewer episiotomies
  
• Less immobility during birthing and labour
  
• Less external fetal monitoring
  
• Fewer fetal heart abnormalities. In addition:
  
• There are more normal, spontaneous births
  
• Women experience greater satisfaction with their care
  
• Midwives express greater job satisfaction
  
• There is no difference in perinatal mortality or morbidity rates compared with births in other units.
  

  These outcomes rely on the following aspects relating to care.
  

• Informational support
  : full, accurate, and individualized information is provided about progress and procedures. There is a two-way process of information and communication between mother and partner and midwife.
  
• Physical support
  : physical activity is encouraged, tactile support is provided for some women, non-pharmacological means are provided to help women to cope better, e.g. warm baths, massage, freedom
  

  of movement, optimal positioning.
  ²
  Reassurance is provided about physical changes and symptoms that occur during labour, e.g. show, rupture of membranes, feeling nauseated.
  

• Emotional support
  : it is important that the midwife appreciates the range of emotional feelings and behaviour that may be expressed during labour and birth:
  
  • Fear: of failure, pain, the unknown; perhaps influenced by a previous negative obstetric experience
    
  • Hostility: due to poor previous relationships with health professionals; a defence mechanism for unexpressed anxiety; unwanted pregnancy
    

    • Resentment: due to personal circumstances and difficult relationships
    

  • Positive emotions: excitement, confidence, fulfilment, etc.
    
  • Unrealistic expectations
    
  • Awareness of fears and anxieties of partner.
    

    Unrealistic expectations are addressed with sensitivity. Relaxation techniques, breathing awareness, and dialogue are encouraged to help allay fears.
    

• Advocacy and empowerment
  :
  
  • Birth and labour are viewed as a partnership within a social, cultural, and biophysical model of care.
    
  • The midwife acts as an intermediary for the woman when she may feel undermined by the environment of a hospital, experiences loss
    

    SUPPORT FOR WOMEN IN LABOUR
    

    209
    

    of personal identity or loss of assertiveness to express her needs and anxieties.
    

    • Empowerment is encouraged by assisting women with decision- making that reflects their needs and care plans.
      
    • Facilitate choice and control for women.
      
    • Respect is shown for women’s ability to verbalize their wishes and requirements freely.
      

• Women are encouraged to adopt upright/alternative positions and freedom of movement.
  
• Appropriate props are provided: birthing balls, beanbags, easy chairs, stools, music, etc.
  
• Low lights and low noise levels.
  
• Creation of a home-from-home environment within a hospital setting: medical apparatus is removed or hidden, pleasant furnishings are provided, etc.
  
• Complementary therapies are used, e.g. massage, aromatherapy.
  
• Privacy is provided.
  
• Key carers only are involved in care: continuous support from a midwife has been shown to be associated with less use of pharmacological analgesia and epidurals. Attendance of a birth
  

  supporter (partner, friend, sister, mother) has been shown to result in shorter labours and less intervention.
  ^1,2
  

Providing the opportunity to discuss the woman’s labour afterwards, to clear up any concerns or confusion.

1. Hodnett ED, Gates S, Hofmeyr GJ, Sakala C (2003). Continuous support for women during childbirth.
   Cochrane Database of Systematic Reviews
   3
   , CD003766.
   
2. Simkin P, O’Hara M (2002). Non-pharmacological relief of pain during labour: systematic review of five methods.
   American Journal of Obstetrics and Gynaecology
   1
   86
   , S131–S59.
   
3. Walsh D (2006). Subverting assembly-line childbirth: childbirth in a free-standing birth centre.
   

   Social Science and Medicine
   26
   (6), 1330–40.
   

   CHAPTER 11
   Normal labour: first stage
   

   210‌‌
   

   High- and low-risk labour
   

   Determining whether a woman falls into a high- or low-risk category for labour is dependent on her previous medical and obstetric history. This will have been recorded in her notes at the booking visit, and recommen- dations made for her care in labour. For a list of these, b see Screening for risk in pregnancy, p. 56.
   

   Sometimes a woman may have had a theoretical risk factor during pregnancy which may have been resolved, e.g. a fetal abnormality which has been investigated and all is normal, or a woman with active herpes which has been treated and is not active when she presents in labour. Therefore, there may be overlapping situations where decisions are not verified until a woman commences labour.
   

   Take a full and detailed account of the woman’s current obstetric and medical health when she presents in labour.
   

   In addition to the antenatal risk factors, circumstances may occur in the current pregnancy and early labour stage that will require high-risk care:
   

   • Antepartum haemorrhage
     
   • Breech presentation
     
   • Malpresentation of the fetal head
     
   • Preterm labour
     
   • Premature rupture of the membranes
     
   • Multiple pregnancy
     
   • Placenta praevia
     
   • Pre-eclampsia
     
   • Pregnancy-induced hypertension
     
   • Severe anaemia
     
   • Renal conditions associated with pregnancy, such as pyelonephritis
     
   • Abnormalities of the genital tract, such as bicornate uterus and female genital mutilation
     
   • Intrauterine growth retardation
     
   • Acute fetal distress
     
   • Cord presentation or prolapse
     
   • Maternal anxiety.
     

A low-risk labour may be viewed as one where the woman commences labour having experienced an uneventful pregnancy, is in good physical

health, and has no known risk factors that would interfere with the normal physiological course of labour and birth.

Always discuss, and take into account, the woman’s individual needs and choices before making decisions about care in labour.

PRINCIPLES OF CARE FOR LOW-RISK WOMEN

211‌‌

Principles of care for low-risk women

Since the inception of medically managed care for labour and birth, there has been a steep rise in intervention and assisted birth, among a popula- tion of women who invariably have uncomplicated pregnancies. In view of the evidence to support midwives managing low-risk women in labour, it is important that the midwife is confident in all aspects of midwifery care to support women’s choices and to enhance normal physiological principles.
¹

The midwife needs to assess suitability for low-risk care based on individual needs and predisposing conditions.

Assessment