Supporting and caring for women in labour
The first sign of discomfort building into regular and increasingly painful contractions elicits a mixture of emotions, ranging from anxiety to excitement about the impending birth. Wherever a woman chooses to give birth, the aim is to ensure that she receives one-to-one care that is individually adapted to her needs, and provided by a confident and competent midwife. The midwife needs to show commitment to respecting and addressing the emotional, psychological and physical requirements of the woman, ensuring she is comfortable throughout while providing the encouragement and support that is necessary to safely birth her baby.
Care will vary at the different stages of labour but is usually based on evidence such as the National Institute for Health and Care Excellence guidelines. However, what is paramount is that an effective partnership with the woman is established, built on successful communication and mutual trust. From the initial meeting the woman must be consistently informed and involved in decision making about her care and progress (Figure 28.1).
The midwife is expected to utilise a variety of practical and interpersonal skills with effective verbal and non-verbal communication being paramount. Information should be presented in a manner that is easy for the woman to understand. Observation of how she responds to the discussion and further targeted questioning is important so that the midwife is aware of any additional actions that may be required, thereby enabling genuine involvement in all aspects of decision-making. The midwife needs to observe the woman’s body language and facial expressions as labour progresses, and incorporate experience, intuitive skills, up-to-date evidenced knowledge and understanding of normal physiology to provide care, particularly during the transition period between first and second stage of labour.
To enhance emotional support, additional help from a birthing partner is important. The woman should be the focus, surrounded by individuals who are compassionate and caring towards her needs. This can reduce the feeling of isolation as well as fear and anxiety that may accompany the experience of labouring in a new environment. These are all measures that increase the likelihood of a shorter labour, with less need for pain relief and an increased probability of spontaneous birth.
Not all women feel the need to eat or drink during labour but if the woman wants to, she can be encouraged to drink energy providing isotonic drinks instead of water or a light diet can be encouraged as the risk of gastric aspiration and Mendelson’s syndrome is reduced due to the availability of epidurals and spinal analgesia. Eating, however, should be avoided if an opioid has been administered or risks of interventions during labour develop. Though not given routinely, H2 receptor antagonists ought to also be accessible to reduce the acidity of the stomach content.
Feeling fresh and keeping clean may be difficult for the woman at this time, but if desired, a warm bath or shower could be offered and could have the added effect of reducing pain. Alternatively, assistance with tepid sponging may be welcomed and provide opportunity for family involvement with her care. Keeping within universal infection prevention and control precautions remain vital.
The woman must be encouraged to make an informed choice about her method of pain relief (Chapters 78 and 79).
Where possible, the woman should be encouraged to remain mobile and be supported to adopt comfortable optimal positions that promote progression in labour (Chapter 27). This should also reduce the chances of developing decubitus ulcers (pressure sores) from prolonged immobility.
Urine retention and bladder distention can cause long-term bladder damage, while a full bladder affects descent of the presenting part and delays labour. The woman should be encouraged to urinate frequently, but if she has difficulty passing urine, then an in-and-out catheter may be required with an indwelling catheter being introduced if the procedure is required more than once. Once the birth has occurred, she should be monitored and encouraged to void within 6 hours of delivery, informing the midwife when this has occurred so it can be documented.
Her vital signs, the wellbeing of the fetus and progress of labour must be monitored and documented regularly in the notes and on the partograph (Figure 28.2).
Using the same principles of care, the midwife now needs to observe for signs of transition between first to second stage and impending birth (Box 28.1). As this stage comes to an end, with the crowning of the presenting part of the baby, the midwife facilitates the birth of the baby into a safe and warm environment; in many cases culminating with skin-to-skin contact between the baby and new mother. The assistance of a second midwife to attend to the baby maybe required.
With the birth of the baby, the midwife continues to attend to the woman’s comfort. Depending on her risk of postpartum haemorrhage and the woman’s wishes, the midwife is required to await physiological delivery of the placenta or actively manage the third stage. With recommended delayed cord clamping, observations for signs of separation (contracted uterus, fresh bleed with lengthening of the cord), this stage is completed with delivery of the placenta and control of bleeding. The midwife needs to remain vigilant for evidence of excessive bleeding, which may need to be acted upon to prevent a postpartum haemorrhage.