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Authors: Janet Medforth,Sue Battersby,Maggie Evans,Beverley Marsh,Angela Walker

Oxford Handbook of Midwifery (56 page)

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Usually women like to vacate the pool for the third stage of labour. If active management of the third stage is chosen, then this should be undertaken out of the pool.
If the woman chooses to stay in the pool, then a physiological third stage is the only option. Ensure that the woman is aware of this before she makes the decision to stay in the pool.
Keep the mother and baby warm by submerging the baby’s body under the water and draping a towel over the woman’s shoulders.
Blood loss may not be easy to assess. Normal amounts of bleeding associated with separation of the placenta will sink to the bottom of the pool. However, if the bleeding appears to be diffusing very quickly through the water, and there is any doubt, it is best to ask the woman to vacate the pool so that more accurate assessment of bleeding can be established.
In the event of bleeding, administer an oxytocic drug when the mother has vacated the pool.
Carry out examination of vaginal trauma as in normal labour.
After use, empty the pool and decontaminate according to local policy. Thorough cleaning of the pool after use is essential.
⁴Some units use a new pool liner for each woman.
Recommended reading
Cluett ER, Burns E (2009). Immersion in water in labour and birth (Cochrane review). In:
Cochrane Library
, Issue 2. Oxford: Update Software.
Da Silva FMB, de Oliveira SMJV, Nobre MRC (2009). A randomized controlled trial evaluating the effect of immersion bath on labour pain.
Midwifery
25
(3), 286–94.
1. Garland D (2006). On the crest of a wave. Completion of a collaborative audit.
  MIDIRS Midwifery Digest
  :
  16
  (1), 81–5.
2. Andersen B, Gyhagen M, Neilson TF (1996). Warm tub bath during labour. Effects on labour duration and maternal infectious morbidity.
  Journal of Obstetrics and Gynaecology
  16
  , 326–30.
3. Lim SK (1994).
  A Study to Compare Midwives Visual Estimation of Blood Loss in ‘Water’ and on ‘Land
  ’. MSc Dissertation. Guildford: University of Surrey.
4. Forde C, Creighton S, Batty A, Hawdon J, Summers-Ma S, Ridgway G (1999). Labour and delivery in the birthing pool.
  British Journal of Midwifery
  7
  , 165–71.
5. Eriksson M, Mattson LA, Ladfors L (1997). Early or late bath during the first stage of labour: a randomized study of 200 women.
  Midwifery
  13
  , 146–8.
6. Charles C (1998). Fetal hyperthermia risk from warm water immersion.
  British Journal of Midwifery
  6
  , 152–6.
7. Gilbert RE, Tookey PA (1999). Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey.
  British Medical Journal
  319
  , 183–7.
  CHAPTER 11
  Normal labour: first stage
  224‌‌
  Mobility and positioning in labour
  Women should be encouraged to adopt an upright position in labour.
  ¹This works with the laws of gravity to assist labour and facilitate birth, and has been shown to have the following physiological advantages:
  - Shorter labour, bearing down easier
    ²
  - Reduced analgesia requirements
  - Less need to speed up the labour with intravenous oxytocin
  - Less intervention in labour
  - Apgar scores higher at 1 and 5min.
    Suggested positions
  - Upright, walking freely—support during contraction from partner, wall, table, or other furniture.
  - Sitting in a chair, either forward or astride, supported by pillows.
  - Use of bean bags/wedges/pillows.
  - Use of a birthing ball (pelvic rocking aids rotation).
  - Left lateral position.
    For the second stage of labour
    Positions adopted in the second stage have the potential to maximize the pelvic outlet by up to 20–30% and to influence favourably stretching of the perineum.
    ³
  - The traditional semi-recumbent position: even when well supported with pillows, there is a tendency to slide down the bed leading to compression of the vena cava. The perineum is stretched adversely sideways when the legs are bent and the knees flopped open, thus substantially reducing the pelvic outlet. Therefore this position is not recommended in current midwifery practice.
  - Left lateral position on a bed or mattress on the floor—particularly useful for when women require some temporary relief from an upright position or during a restful phase.
  - Kneeling on the floor or a bed.
  - Squatting (this is difficult to maintain without support).
  - Supported squatting (partner, chair, parallel bars, furniture). Squatting positions open up the pelvic outlet, whereas the sacrum is fixed when lying flat.
    •
    On all fours: the perineum is stretched favourably lengthways to form a
    continuation of the birth canal, maintaining flexion of the fetal head.
  - Birthing chair or stool (linked to a higher incidence of haemorrhage).
  - The laws of physics and gravity can improve the intravaginal pressures in upright and sitting positions. Sitting is 30% more effective than lateral or supine positions.
    ⁴
The choice of analgesia, electronic fetal monitoring, and intravenous infusions will impair a woman’s mobility. To make an informed choice, women need to be aware of these restrictions.
MOBILITY AND POSITIONING IN LABOUR
225
Recommended reading
Boyle M (2000). Childbirth in bed—the historical perspective.
Practising Midwife
3
(11), 21–4.
Gupta J, Hofmeyr G (2006). Position for women during second stage of labour (Cochrane review). In:
Cochrane Library
, Issue 4. Chichester: John Wiley and Sons Ltd.
Walsh D (2007).
Evidence-based Care for Normal Labour and Birth
. London: Taylor and Francis Group.
1. Deakin BA (2001). Alternative positions in labour and childbirth.
  British Journal of Midwifery
  9
  (10), 620–5.
2. De Jonge A, Largo-Janssen ALM (2004). Birthing positions. A qualitative study into the views of women about various birthing positions.
  Journal of Psychosomatic Obstetrics and Gynaecology
  25
  , 47–55.
3. Downe S, Gerrett D, Renfrew MJ (2004). A prospective randomized trial on the effect of posi- tion in the passive second stage of labour on birth outcome in nulliparous women using epidural anaesthesia.
  Midwifery
  20
  (2), 157–68.
4. Walsh D (2000). Evidence-based care. Part five: Why we should reject the ‘bed birth’ myth.
  British Journal of Midwifery
  8
  (9), 556–8.
  CHAPTER 11
  Normal labour: first stage
  226‌‌
  Nutrition in labour
  Studies regarding nutrition in labour are sourced primarily from anaes- thetics research into delayed gastric emptying.
  ¹Whenever a general anaesthetic is administered, there is a high risk of regurgitation and inha- lation of stomach contents. The lower oesophageal sphincter is often impaired during pregnancy and intragastric pressure is raised due to the gravid uterus. There is some debate regarding the more common use of spinal anaesthesia for caesarean section and the reduced risk of regurgita- tion, however, the factors below should also be considered in the overall assessment and management of eating and drinking in labour.
  - Delayed gastric emptying may be influenced by pain, anxiety, and, most significantly, the use of narcotics.
  - Consequently, there is insufficient evidence to support fasting during labour. Nor is there support for increasing the calorie intake during labour. A recent study has highlighted that consumption of a light diet during labour did not appear to influence obstetric or neonatal outcomes.
    ²
  - The body stores fat during pregnancy, which can be used as fuel in labour if required.
    ³The smooth muscle of the uterus metabolizes fatty acids/ketones as fuel. Therefore, mild acidosis is considered to be a normal, and probably beneficial, physiological state of labour.
  - In normal labour there is little evidence to suggest that fluid balance needs correcting, however there has been recent caution regarding possible risk of fluid overload where women are over-zealous to drink copious amounts of water during labour.
    ⁴The usual practice of
    sipping water between contractions should not pose a risk. IV infusions of glucose should be used sparingly, due to the risks of rebound hypoglycaemia in the newborn infant.
    In order to achieve safety and comfort for women, and not to impose a strict, unreasonable regimen for the majority, it is important to consider the risk factors and to recognize those women who may need a caesarean section. As there is scant evidence of improved outcomes for the baby and mother regarding fasting in labour, women should be informed of the choices they have, taking into account their individual situation during labour. Management will therefore depend on the risk factors present and
    maternal choice.
    Management
  - Self regulation of food intake during normal labour has been recommended. Eating and drinking may help to make a woman feel healthy and normal.
  - No restrictions of food intake after induction, prior to the onset of labour and beyond if the labour proceeds normally.
  - Drinks and light diet during early labour; established normal labour without narcotics; uncomplicated labour with an epidural.
  - Alcohol and fatty foods should be avoided at all times.