Avoiding unnecessary time restrictions in labour
The current practice of timing each stage of labour – especially the active second stage – refl ects the predisposing medical models of
care in operation since the early twentieth century. The aim is to reduce adverse outcomes to mother and baby by detecting early signs of deviation from the norm, which may be indicated by an unusually prolonged labour. However, there is no evidence to impose arbitrary time limits on labour or to justify intervention unless there are clear signs of fetal or maternal compromise or a lack of progress (Janni et al. 2002; cited in RCM 2005). There may, however, be an increased risk in maternal morbidity when the second stage of labour exceeds two hours (Janni et al. 2002; Myles and Santolaya 2003). The midwife must decide whether the possible risk to the mother of a prolonged second stage outweighs the pos- sible risks to the mother and baby of a curtailed second stage through the intervention of medical procedures. Recent guidelines by the National Institute for Clinical Excellence (NICE 2007) advise that normal progress in fi rst stage labour is identifi ed by cervical dilata- tion of 2 cm or more every 4 hours. Once active second stage has been identifi ed, birth should be expected within 3 hours for pri- miparous women and 2 hours for multiparous women.
Some maternity units impose strict time limits, particularly on the active second stage of labour, whilst others allow the midwife to use her discretion. An example of this might be a woman who is making steady progress, although at a slower than average rate. In this case, interventions may be withheld, providing that both mother and fetus remain well. To reduce the likelihood of intervention in the second stage of labour, the midwife can use her skills to encourage the passive descent of the presenting part, thus shortening the active pushing phase (Roberts 2002). This might include encouraging the woman to adopt different postures to reduce the urge to push or employing distraction techniques such as back massage.
Movement and posture
Case Notes
Julie arrives in the delivery suite in established labour with her fi rst baby.
She is well and there is no evidence of fetal compromise. Julie has seen babies being born on television where the woman is lying in bed. On entering the labour room, Julie automatically gets undressed and into the bed. Her partner helps her lie down and arranges pillows around her, as he has seen people do on television.
Julie’s contractions are becoming increasingly painful and she is unable to get comfortable. She is thinking about asking for an epidural.
Women, like most female mammals, are not physiologically designed to give birth in a supine position. Adopting an upright, forward- leaning posture is more natural for birthing. This allows gravity to assist with the descent and rotation of the PP and pressure on the internal cervical os to promote dilatation. There are other physiolog- ical advantages to adopting an upright posture for labour. These include a reduction in aorto-caval compression, better alignment of the fetus and an increased pelvic outlet (MIDIRS and the NHS Centre for Reviews and Dissemination 2003).
When the woman adopts an upright or forward-leaning posture with her legs slightly apart, the ligaments between the sacro-iliac joints and the pubic symphisis, already softened by the effects of the hormones progesterone and relaxin, allow the bones of the pelvis to separate slightly. This can create up to 28 per cent more space in the pelvic outlet (Robertson 2001), allowing for an easier birth. When a woman is upright, the natural tilt of the pelvis guides the fetus in a downward direction, whereas a woman in a semi-supine position must push her baby uphill. Postures which interfere with the phys- iological progress of the fetus through the pelvis are likely to lengthen labour, which in turn may lead to fetal compromise and maternal exhaustion.
An upright position in the fi rst stage of labour is associated with less need for narcotic pain relief and epidurals (Williams et al. 1980) and a shorter fi rst stage (Roberts, Mendez-Bauer and Wodell 1983).
A systematic review by Gupta and Hofmeyr (2004) showed that women who adopted upright postures for the second stage of labour tended to have shorter second stages, fewer assisted births and epi- siotomies, less severe pain and fewer fetal heart rate anomalies.
There is little evidence comparing different upright positions for giving birth. However, a study by Ragnar et al. (2006) considered sitting and kneeling postures in the second stage of labour and found that although there was no difference in the length of the second stage of labour, the kneeling position was associated with less pain and a more favourable experience for the woman.
Until the advent of modern obstetric practices, it was normal for women to give birth standing, squatting, on all fours or in some other supported upright posture (Coppen 2005). Twentieth-century hospital practices changed this in order to facilitate the midwife’s and obstetrician’s role with regard to examinations in labour. Unless the woman has an epidural block in situ or other medical impedi- ment, she should be encouraged to move freely and adopt whatever posture is comfortable. The RCM evidence-based guidelines (RCM 2005) note that women’s choice of position for labour is strongly infl uenced by what they feel is expected of them. It is therefore
incumbent on the midwife to promote the use of different positions.
It is not acceptable to impose restrictions based on the midwife’s own comfort. Even where continuous fetal monitoring is necessary, the woman need not be restricted to the bed. Unless there is a medical reason to the contrary, women should be encouraged to mobilise freely during labour.
Women giving birth at home may adapt their surroundings to suit their needs. There should be no reason why women undergoing normal labour in hospital should not be encouraged to do likewise:
hospital beds can be moved, mats or mattresses can be placed on the fl oor, a birthing ball or beanbag may be placed on the bed or the fl oor, a birthing stool may be used if available (MIDIRS and the NHS Centre for Reviews and Dissemination 2003).
Activity
Take a good look around the delivery rooms in your maternity unit.
Think about how easy it would be for women to adopt various postures in labour.
• Could the furniture be adapted or moved to facilitate upright, forward-leaning postures?
• Does the unit supply birthing balls or a birthing stool, and if so, what restrictions are there on its use?
Eating and drinking in labour
Case Notes
Julie has been in active labour for several hours. There are no complica- tions. Julie’s last full meal was at 1900 h yesterday evening and, after a restless night, she had only a cup of tea and a bowl of cereal before coming into hospital fi ve hours ago. Julie has been drinking water freely, as the Entonox makes her thirsty. She is now starting to feel very weary and a little dizzy. Her contractions have slowed down and she is begin- ning to feel discouraged.
The case note above is a typical scenario of a labouring woman who needs food.
In the latter half of the twentieth century, many maternity units imposed restrictions on eating and drinking in labour. This was
based on the principle that reduced gastric motility during labour increases the risk of vomiting. In the event of a caesarean section, acid stomach contents could be inhaled, a condition known as Mendelsohn’s syndrome (Mendelsohn 1946). However, improvements in anaesthesia in the last 50 years have seen this almost eradicated (Parsons and Nagy 2006). There is currently no good evidence to support the restriction of food and drink in labour in preventing Mendelsohn’s syndrome. Furthermore, the aspiration of undiluted, acidic gastric fl uids is far more dangerous than when diluted by food or drink (Parsons and Nagy 2006). It is common practice on labour wards to give antacids to all labouring women. However, there is no strong evidence to suggest that this has any effect on maternal mortality and morbidity (Pengelley 2002).
Narcotic drugs used in labour have the effect of delaying gastric emptying time (Broach and Newton 1988). If these are used, the woman should be advised to have sips of water only, otherwise, there is no evidence that withholding food and drink is benefi cial and indeed this practice is likely to be harmful (Broach and Newton 1988). If a woman is allowed to remain hungry, her blood glucose level will fall, leading to ketosis, which, combined with starvation and fatigue, may lead to reduced uterine action and therefore the likelihood of medical intervention. In addition, hunger may adversely affect the woman’s sense of well-being and mood.
Current evidence suggests that labouring women who feel hungry should be encouraged to eat as their appetite dictates, providing there is no likelihood of their needing general anaesthesia (Baker 1996).
The above notwithstanding, there are some simple precautions which the woman should be advised of to limit the risk of nausea and vomiting. Although vomiting is common in labour, it is unpleas- ant for the women who experience it. Examples of suitable foods and drinks include low-residue, low-fat, easily absorbed foods such as bananas, ‘smoothies’, cereal bars, toast, yogurts or isotonic sports drinks. Foods which are high in fat or energy content tend to slow gastric emptying (Micklewright and Champion 2002) and may increase nausea.
Whilst most women appreciate the option of eating and drinking in labour (Newton and Champion 1997) some will neither wish nor need to do so. If this is the case, she should not be enticed to eat against her will. Odent (1994) notes that once in active labour, most women choose not to eat. In short, the labouring woman’s appetite is usually the best judge of whether or not she needs to eat in labour.
Support in labour
Activity
Read the literature on Mendelsohn’s syndrome.
Find out what your local maternity unit policy says about eating and drinking in labour.
Case Notes
A midwife is giving an antenatal class about labour. Several of the women present have asked who they can have as their birth partner.
Some want to have their mother present as well as their husband or partner. One woman wants to bring her doula (a non-medical assistant, who provides physical and emotional support). Another woman is anxious about the midwifery support she will receive in labour.
Most women will instinctively seek support and help in labour. In times past, this support was traditionally the role of female atten- dants such as lay midwives and family members. Since the 1970s, male partners have become commonplace in the birthing room. It is widely recognised that labouring women perceive a need for empathic companionship and support (DH 1993) and that their reac- tions to labour may be infl uenced by the support they receive (Enkin et al. 1996). Midwives are ideally placed to offer support in terms of physical care and information-giving and should also be able to offer emotional support and advocacy (MIDIRS and the NHS Centre for Reviews and Dissemination 2003). However, not all midwives are able to fulfi l the support needs of women. There are many reasons for this, not least of which is the increasing pressure that midwives are under to care for several labouring women at once. Therefore most maternity units welcome one or more close companions to offer emotional support to the labouring woman.
There is evidence that women who receive continuous support in labour require less pharmacological analgesia, have fewer operative births and are more satisfi ed with the outcome of their labour (Hodnett et al. 2004), while women who perceive little professional or lay support in labour appear more likely to suffer post-traumatic stress six weeks postnatally (Czarnocka and Slade 2000). Spiby et al.
(2003) note that women expect midwives to offer coping strategies for pain and that these help to enhance the experience of labour and reduce distress.
Continuity of care and continuous care
In reviewing current evidence, Sandall (2004) concludes that there is convincing, research-based evidence that women receiving continu- ity of care from a team of midwives are less likely to need pharmaco- logical pain relief in labour or to have technical intervention. Maternal satisfaction is also increased. However, there is good evidence that continuous support during labour has more of a positive impact on childbirth outcome and on women’s perception of labour than conti- nuity of support alone (Sandall 2004). This may include advice, infor- mation, physical assistance or emotional support and may be from either a midwife or a layperson, such as a friend of family member.
The Cochrane review of support for women during childbirth (Hodnett et al. 2002; cited in Sandall 2004) demonstrated that women who have continuous support during labour are less likely to have an opera- tive birth, analgesia or report dissatisfaction with their experience.
However, the benefi ts of continuous support were shown to be greater when the supporter was not a member of the hospital staff.
There is ample evidence that physical, emotional and psycho- logical support in labour enhances the experience for the woman and reduces the likelihood of intervention (Enkin et al. 1996). Mid- wives should therefore allow the labouring woman her choice of birth partner throughout labour.
Activity
• Find out what the policy on your maternity unit says about birth partners.
• Not all women are accompanied by a birth partner. Consider how a midwife can give additional support to an unaccompanied woman.
• Some birth companions are not there through the woman’s own free choice. Consider situations when this might arise and how, as the midwife, you would handle it.
Pushing in second stage
Case Notes
The midwife has just examined Julie and found her cervix to be fully dilated. Julie is experiencing frequent, strong contractions and is starting to get an urge to bear down. Julie’s partner wants to know what he should do – should he encourage her to push?
A typical childbirth scene as portrayed by the media includes a doctor or midwife urging a labouring woman to take a deep breath, hold it as long as possible and push with all her might. This was once common practice in the UK, but there is no current evidence to support it. Indeed, this Valsalva manoeuvre, as it is known is now associated with fetal compromise due to the reduction in oxygen- ated maternal blood crossing the placenta during the manoeuvre (Thompson 1993; Roberts 2002). Current evidence suggests that instinctive, physiological pushing behaviour is less harmful to the fetus and the woman (Sleep 1990).