A midwife’s role in supporting women in labour begins in the antenatal period with the establishment of the relationship between each midwife and each woman (Guilliland & Pairman 1995). For a midwife to be able to provide effective and individualised care, she must spend time with each woman, getting to know her and her desires and dreams for the birth of this baby. Spending time getting to know each other also enables trust to develop, and anxieties, fears and misconceptions to be acknowledged before labour starts (Homer et al 2008; Pairman 1998). Unexplored fears and issues can exacerbate the challenges that occur in labour, and without this understanding a midwife will find it more difficult to provide woman-centred care (Edwards 2005).

The midwifery definition of labour relies on each woman’s perceptions, and will always be unique to the individual woman and therefore difficult to define in an exact way. Within the midwifery model of care, the woman is the focus and therefore her perceptions are the governing factors when providing care in labour (Gould 2000).

The knowledge that a midwife gains through the partnership relationship established with each woman guides her ability to support the woman to use her own strength to labour and birth her baby. As the woman moves through the various stages of her labour, the midwife’s role in facilitating and promoting normal physiological labour and birth relies on her ability to be ‘with the woman’ (Daellenbach 1999; Pairman 1998). The ability to provide supportive midwifery care in labour is a multifaceted skill. The parameters of normal labour and birth are individual to each woman. To be able to recognise what is ‘normal’ for each woman, a midwife needs to be available to her and alert to the ebbs and flows of that woman’s experience. By truly being ‘with’ the woman, the midwife is able to recognise and acknowledge the complexity of a process that is at once emotional, spiritual and physical (Chapman 2003). With this acknowledgement comes understanding of the factors that may affect labour and birth both positively and negatively. The combination of the birth environment, relationships with partners and carers, the physiological processes of labour and birth, and psychological influences can have a profound effect on the progress of a woman’s labour (Walsh 2001).

Box 24.1 Benefits of continuity of midwifery care for women in labour

• More women feeling in control during labour and childbirth

• More likely to have a spontaneous vaginal birth

• Reduced use of regional anaesthesia/analgesia

• Less episiotomy

• Less instrumental birth

• More likely to initiate breastfeeding

(Source: Hatem et al 2008)

Decision points for midwifery care in labour and birth

Throughout this chapter, decision points are identified to provide a framework for provision of midwifery care. Developed by the New Zealand College of Midwives (NZCOM) in 1993 and revised in 2008, the decision points identify those times when a midwife ought to make a midwifery assessment, although it is recognised that assessments are based on individual need (NZCOM 2008a). The decision points outline what information needs to be shared between each woman and midwife at each assessment point as well as the health information and midwifery care that should be provided.

THE CONTINUUM OF LABOUR AND BIRTH

Labour has traditionally been separated and compartmentalised into arbitrary stages, unimaginatively labelled first, second, third and, more recently, fourth stages. For midwives and women, the reality is that labour and birth are a continuous process (McCormick 2003; Wickham 2003). Even so, as a woman moves into and through her labour process, there are recognisable emotional and physical changes. As a part of midwifery assessment it is important to understand and recognise these changes, to identify normal progress. Reorienting thinking about labour to acknowledge the physiological process as experienced by women has led some researchers to define labour as consisting of:

• latent phase to the onset of active phase

• active phase to onset of transition

• transition to birth

• birth to skin-to-skin (Downe 2000).

This chapter reflects this understanding of labour and birth as a continuum, and discusses midwifery care from the perspective of a midwife providing continuity of care.

RECOGNISING LABOUR

Normal labour occurs between 37 and 42 weeks gestation (McCormick 2003; NICE 2007). As a woman approaches the end of the pregnancy she will often experience an increase in intensity of Braxton Hicks contractions and commonly an increase in vaginal discharge/mucus. Other signals indicating that labour may be imminent include further descent of the baby into the pelvis and bouts of strengthening uterine activity. The advent of approaching labour can elicit intense emotional responses in some women, ranging from acute apprehension to excited anticipation. Midwives must be sensitive to these feelings and changes, and be able to reinforce the normality of these responses.

During the antenatal period, a midwife will have discussed with the woman the signs and symptoms to aid recognition of the beginnings of labour (see Clinical point ‘Signs of labour’). She will identify with the woman when to make contact and what information will be sought at this initial contact. It is helpful to summarise this discussion in the woman’s notes so that she can remind herself of these points later and as reassurance for her and her family.

Clinical point

Signs of labour

• Increasingly intense contractions that become painful

• Increasingly regular and more-frequent contractions

• Vaginal discharge of bloodstained mucus (called a ‘show’); may occur before contractions commence

• Vaginal discharge of clear fluid if membranes rupture spontaneously; can occur before contractions and is considered a sign of labour if accompanied by contractions and cervical dilation.

Labour: latent phase to onset of active phase

The latent phase is recognised as a valid phase of labour but is difficult to define and poorly understood (Enkin et al 2000; Walmsley 2003). It has been described as the start of uterine contractions until progressive dilation of the cervix commences (Enkin et al 2000). Confusing the latent phase with a poorly progressing active phase can lead to inappropriate and unnecessary interventions that may affect the outcomes for mother and baby. This can occur because duration of the latent phase varies from woman to woman. There is no consensus in the literature on what constitutes the length of a normal latent phase. Definitions vary from 6 to 8 hours up to 24 to 36 hours (Enkin et al 2000; NICE 2007; Stables 1999; Walmsley 2003).

Some women may not experience the latent phase of labour, but for those who do, it can be a confusing time. It is common for women to need time, support and reassurance for labour to establish and become progressive. Viewing labour and birth as a normal process enables a woman to find her own way through her own unique experience. Encouraging her to listen and trust her body, and to rest and fuel her body, enables the process of birth to happen at its own pace. Rest, food and fluids, supportive, professional midwifery care, and the avoidance of unnecessary interventions will assist most women through this time (Simkin & Ancheta 2000). It is important to remember that slow progress in the first stage of labour does not necessarily mean the presence of a problem or abnormality (Enkin et al 2000; Simkin & Ancheta 2000).

Critical thinking exercise

Michelle is expecting her third baby. She is not planning to have any more babies after this one and has really enjoyed being pregnant. Michelle is at 41 weeks and five days gestation and has had a full night of irregular painful contractions. Although she has not slept, Michelle is not in established labour. Her two children, aged two years and five years, are due to wake soon, and her mother, sister and best friend have arrived to be with her in the expectation that she will have her baby today. Michelle’s two previous children were born in hospital and she is planning to have this baby at home. Her mother thinks she should be in hospital with a doctor.

1. What issues may influence what happens next?

2. What is the midwife’s role in facilitating a supportive environment for Michelle?

FIRST DECISION POINT IN LABOUR WHEN THE WOMAN OR HER SUPPORT PERSON FIRST INFORMS THE MIDWIFE THAT SHE IS IN LABOUR

At this stage a woman begins to notice signs that she may be in labour, and makes contact with her midwife to inform her that she may be in labour. A midwife will need to ask questions in order to assess whether the woman is in labour and whether she needs a physical assessment and attendance by the midwife. A midwife will need to gather information about the woman’s general state and how she is coping, and review the woman’s history to this stage. The following questions should be asked of the woman:

• Is she having discomfort/pain? When did this start? The midwife needs to ascertain whether the pain is caused by uterine activity/contractions.

• What are her contractions like? Where does she feel them? How often do they come? How long do they last?

• Can she talk through them? Does resting or being active change their pattern?

• How is she feeling? Who is there to support her?

Clinical point

Characteristics of the latent phase

• The contractions are short, irregularly spaced and easily interrupted by inactivity and distractions (e.g. the woman’s other children, unexpected visitors, loud noises, taking a bath).

• The woman may be able to sleep for short periods.

• The woman will often still feel hungry.

• The woman will still be connected to what is going on around her (e.g. she will join in on conversations and may be able to talk during a contraction).

Table 24.1 Factors that can affect the progress of labour

Supportive influences	Unsupportive influences
• Trust in the woman’s body and the birthing process • Sensitive, nurturing, appropriate supporters • Comfortable environment—a feeling of safety, privacy, familiarity • Knowing that other children are well cared for • A known, trusted midwife who supports the birth plan • Opportunities for rest periods, able to eat and drink as she desires	• Unexplored fears and distrust of labour and birth • Inappropriate, insensitive supporters • Environment uncomfortable, noisy, distracting, lack of space and privacy • Woman’s concern about her children or other family members • A midwife who is unfamiliar with and/or unsupportive of the birth plan • Tiredness and hunger

• Has she had any vaginal discharge? If so, what does it look like (e.g. bloodstained mucus or watery discharge)?

• Does she think her membranes have ruptured? If so, what colour is the liquor (clear, pink, green or brown/black)?

• Has her baby been moving in the last few hours?

• Does she want the midwife to attend?

On the basis of this assessment, a midwife will decide whether to visit the woman at home. Sometimes a woman can be reassured by phone that she is in the latent phase of labour and asked to contact the midwife again when the contractions become more regular, frequent and painful, or if there are any other signs that labour is progressing. If a midwife is not certain of the progress of labour, then a home visit should be made before a woman is advised to come into the maternity unit. Research shows that women who are reviewed in early labour have shorter labours, fewer epidurals, less synthetic oxytocin augmentation and more positive birthing experiences (Walsh 2000a). The key assessment is whether the woman is in latent or active labour; if she is in latent labour she should be encouraged to stay at home.

If a visit is made, the midwife should make a full assessment of the woman and her baby and document this (see details of assessment later in the chapter). An abdominal examination to define the position of the baby and listen to the baby’s heart rate gives the midwife and the woman information to reassure and guide further advice. If the baby isn’t in an optimal position, recommendations can be made regarding strategies for the woman to work with (Sutton 2003). Vaginal examinations, while not generally warranted at this stage, may assist in the diagnosis of the latent phase, as minimal dilation will have occurred (Chapman 2003). Observing the woman’s behaviour will help the midwife differentiate between latent and active labour.

If the woman is in latent labour and is well supported at home by friends and family, it may then be appropriate to leave her and return when she requires additional midwifery support and/or labour becomes active. The woman needs to know that the latent phase is normal and may be lengthy, and that it is not the time for clock-watching (Baston 2004). The woman should continue with her usual activities but ensure that she continues to eat, rest and sleep so that she can find the focus and energy required when labour does establish.

At home, women can work with the latent phase by being able to rest in their own bed, walk in their garden, lean against their kitchen bench, kneel into a beanbag or take a warm bath. Women planning to birth in hospital should try to use all the resources available to them at home before going into the hospital environment, which does not favour the latent phase (Walsh 2000a). Being confined to one room and exposed to the sounds of other women in active labour does nothing to support the woman or give her confidence when she still has many hours of labour ahead of her.

Before leaving, the midwife needs to ensure that the woman knows how and when to make contact with her.

SECOND DECISION POINT IN LABOUR WHEN THE WOMAN WANTS INTERMITTENT SUPPORT FROM THE MIDWIFE

At this stage a woman contacts her midwife because she feels labour is progressing or changing and she wants more support, or the midwife may have contacted the woman to ask about how she is feeling and how labour is progressing. As with the first decision point, a key assessment is to ascertain whether the woman is still in latent labour or if she is in established labour, and if so, what progress she is making. The woman should be visited at home and the assessments and discussions should be considered.

Box 24.2 What to consider for an early labour assessment

• Assess the woman’s wellbeing, including her emotional and behavioural responses.

• Assess the adequacy of her food and fluid intake, and her ability to rest.

• Consider physical assessments including abdominal palpation, strength, length and frequency of contractions, blood pressure, and the baby’s wellbeing, including heart rate.

• If her membranes have ruptured, assess the colour of the liquor.

• Discuss the relevance of a vaginal examination at this point.

• Documentation of findings, advice given and plan for ongoing care.

If the woman is still in the latent phase, then midwifery care and advice will continue as before. If the woman has progressed into early labour, she may feel the need for intermittent support from the midwife. If the woman is well supported at home by friends and family, then the midwife may be able to leave for periods of time, always ensuring that she can be contacted if required and clearly stating when she will return for a further assessment. The woman is advised to eat and drink and move about as she wishes. Once labour establishes, the woman is likely to want continuous support from her midwife.

Labour: active phase to onset of transition

Active labour is characterised by contractions that increase in intensity, length and frequency. The pattern of contractions tends to be more regular and is less affected by external influences than those that characterise the latent phase. The active pattern of contractions causes effacement and dilation of the cervix and promotes the descent and rotation of the baby through the pelvis. The individuality of each woman’s experience means that the frequency of contractions in active labour may vary, for example, from every three minutes for some women to every 10 minutes for others.

Traditionally, normal progress has been identified by a cervical dilation rate of 1 cm/hour in active labour. This definition was based on the work of Friedman in the 1950s and has been universally adopted to assess the parameters of ‘normal’ progress (Friedman 1954). (For more detailed information on this aspect of labour progress, see Chapter 37.) However, in reality, many midwives and women know that what is slow progress for one woman may be acceptable for another. There is continued debate about what actually constitutes a normal cervical dilation rate. Much of the research undertaken to identify ‘normal’ progress in labour has been undertaken in medicalised settings and has focused mainly on the rate of cervical dilation while ignoring other physiological changes and influences (Philpott & Castle 1972; Seitchik 1987; Studd 1973). More recent work challenges these findings and encompasses a holistic approach to labour assessment that centres on the woman and baby’s wellbeing rather than on the length of labour (Albers 1999; Crowther 2000). Albers (1999), in her study of the duration of labour in low-risk women, found that normal labour for these women lasted longer than many clinicians expect. This research suggests that a cervical dilation rate of 0.3–0.5 cm/hour may be more appropriate and recommends the revision of criteria determining normal labour progress.

Clinical point

Characteristics of the active phase

• Contractions are of increasing regularity, strength, length and frequency.

• The woman needs to move about and cannot rest in one position for long.

• The woman will be less connected to what is going on around her and increasingly will not be able to talk through contractions; increasingly she will go ‘into herself’ as the labour ‘takes her over’.

• The woman may not feel like eating.

• On abdominal palpation, the baby is felt to have moved down further into the pelvis.

• On vaginal assessment of the cervix, increasing effacement, softening and dilation is felt, and the baby’s head descends lower into the pelvis.

Research activity

Familiarise yourself with the research on the duration of normal labour, e.g. Albers (1999) and Crowther (2000). How will the conclusions of this research assist you in supporting women experiencing a labour that does not conform to the ‘1 cm cervical dilation/hour’ paradigm?

Clinical point

When doing home visits to women in labour, bring a full birth kit in case of unexpected or unplanned homebirth—see Table 24.2.

Note that it is sensible to keep a birth kit in your car when visiting women at home at any time, so that you are prepared for unexpected situations.

Table 24.2 What to bring to a home birth

Preparation for home birth	Equipment for assessment and care of the woman and her baby
Preparation for home birth	Woman	Baby
• A strong and well-founded belief in birth as a normal physiological process • An in-depth understanding of the physiology of normal birth • A continuous and unobtrusive presence that is eternally vigilant • A means of monitoring the wellbeing of the woman and her baby during labour, birth and the post-birth period • A copy of the woman’s birth plan • A set of well-developed midwifery skills, including emergency skills • A list of telephone numbers for emergency assistance • A second midwife (present during late second stage and birth) • A set of clearly identified notes in which to record the details of events as they unfold • Birth notification documents • Prescription pad, referral pad	• Watch with a second hand • Stethoscope and sphygmomanometer • Thermometer, bath thermometer • Vaginal assessment swabs and solution (used if membranes have ruptured) • Sterile gloves for vaginal assessment/s and conduct of birth • Amnihook • Birth pack, large plastic sheet/incontinence sheets • Woman’s own container for placenta or plastic bag • Container bags for soiled equipment/swabs • Torch with adequate light for suturing (a headlamp works well) • Suturing material: 20 cc syringe, 22-gauge needle, 1% plain lignocaine (20 mL ampoule) • Sterile vaginal swabs • Drugs: synthetic oxytocin (Syntocin) 5 and 10 unit ampoules (keep refrigerated and use a cold storage container for transport) and synthetic oxytocin/ergometrine (Syntometrine) 1 mL syringes and needles • Oxygen available with Hudson mask • Cannulation equipment (16- and 14-gauge cannulae) and tourniquet • Normal saline and/or Ringers Lactate/Hartmans and IV giving set • Sharps disposal unit	• Pinard stethoscope and/or Doppler Sonicaid (one that is safe to use in water) • Suction equipment for the baby • Cord clamp (or traditional cord ties according to cultural practice) • Infant Laerdahl bag and mask, and infant airways • Oxygen cylinder and gauge, tubing • Baby scales (weight conversion chart) • Tape measure • Vitamin K

For further information contact:

• Homebirth Aotearoa (New Zealand); New Zealand College of Midwives (www.midwife.org.nz)

• Australian College of Midwives Inc for a copy of the Application for Accreditation as an Independently Practising Midwife. This contains prompts for the midwife to consider skills in perineal repair, neonatal resuscitation and maternal resuscitation. In addition this asks the midwife to determine what she or he has available in terms of equipment for fetal monitoring and resuscitation, maternal assessment and care including resuscitation, drugs and communication equipment.

(Source: This table was prepared by Maralyn Foureur, 2005.)

THIRD DECISION POINT IN LABOUR WHEN THE WOMAN WANTS CONTINUOUS SUPPORT FROM A MIDWIFE

As a woman becomes established in labour she will usually want continuous support from her midwife. The active phase of labour demands complex midwifery care as the midwife works in partnership with the woman. The midwife’s role is to help the woman and her family and supporters to follow their birth plan, while at the same time making regular assessments of progress and determinations as to whether the progress is ‘normal’ for this woman and her baby. As labour advances, the woman will often require more support and encouragement to help her work through the challenges ahead.

Staying with the woman is an essential midwifery role. Being ‘with the woman’ requires not only the physical presence of the midwife but also her focus and attention. Women identify that the quality of the ‘presence’ of the midwife is directly related to the midwife’s energy and commitment to her (Baston 2004; Lavender & Kingdon 2006). The midwife can also encourage the woman’s support people to be as involved as the woman needs. The midwife needs to recognise that support people may have their own anxieties during the labour, which may impinge on their ability to support the woman. The midwife can guide support people to participate in nurturing the woman to maintain a positive environment.

If the woman is planning to have her baby in a maternity facility, she will need to be transferred to the facility once she is in the active phase of labour. The midwife needs to be alert to the possible impact of this new environment on the woman and her support people (Cluett 2000) (see Clinical point ‘What to consider when moving from home to hospital’).

Clinical point

What to consider when moving from home to hospital

• Visit at home to assess progress and discuss transfer to hospital with woman.

• Check the birth plan. Did the woman think she would feel more comfortable transferring in early or more established labour? How does she feel now?

• If unable to assess progress from observations and discussions with the woman, consider vaginal examination.

• Distance from the woman’s home to the hospital—that is consider transfer time.

• Mode and availability of transport, comfort during transfer.

• Collect ‘tools’ to take into hospital—for example supporters, own pillow, wheat bag, food, drink, music, massage oils, car seat and clothes for baby, fresh clothes for the woman.

• Ensure equipment is available in case of unexpected, unplanned home birth.

Research findings

Women’s recognition of the spontaneous onset of labour

Reported signs and symptoms	Number (%)
Reported signs and symptoms	Nulliparae	Multiparae
Recurrent pain	62 (32.8)	80 (44.4)
Non-recurrent pain	51 (27.0)	41 (22.8)
Watery loss	30 (15.9)	17 (9.4)
Bloodstained loss	17 (9.0)	16 (8.9)
Gastrointestinal symptoms	8 (4.2)	2 (1.1)
Emotional upheaval	8 (4.2)	14 (7.8)
Sleep disturbance	6 (3.2)	5 (2.8)
Other	7 (3.7)	5 (2.8)
Total	189 (100)	180 (100)

A study was undertaken to assess how women experience spontaneous onset of labour at term. The authors found that:

No single test, clinical or otherwise, can determine the onset of labor, both objectively and with a reasonable degree of precision. Caregivers should listen to women and listen carefully instead of applying arbitrary measures as to how and when labor started … The right questions, as indicated by our data, are not ‘When did the contractions start?’ or ‘When did contractions become regular?’ but ‘When did your labor start?’ and ‘How did you know?’ … This is especially important, since spontaneous onset of labor rarely occurs in controlled environments, such as maternity units, hospitals, or research settings (p 270).

(Source: Gross et al 2003)

Facilitating a supportive labour environment

Wherever a woman is birthing, it is important to assess the labouring and birthing environment to take into account the wishes of the woman and the factors that will enhance and support her normal physiological labour. These include ensuring adequate open spaces to move around, a nearby toilet, comfortable furniture, low or adjustable lighting, support people, and, for many women, privacy and quiet (Newburn 2003). Assisting the woman to make use of these ‘tools’ will help her to use her intuition and instinct to find the right place and positions for effective, active labour.

The birth space needs to feel safe for that woman. This concept of a ‘safe place’ incorporates both physical and psychosocial/spiritual safety that cannot be imposed on the woman (Parratt & Fahy 2004). Most women appear to labour most effectively when there is an atmosphere of calm and the focus is on her and her experience. Some women, however, feel self-conscious and prefer to be left alone or to have the distraction of their supporters’ conversations, the television, their favourite music or even their children being busy around them. It is therefore important to talk to the woman to find out what she wants. Taking into account cultural preferences is also imperative in facilitating an appropriate environment for effective labour. For example, it may be inappropriate for there to be men (including the father of the baby) present or it may be that the woman’s entire family, including aunts, uncles and grandparents, are to be actively involved.

Most women who begin their labour spontaneously will do so at home. It is well documented that women

A MIDWIFE’S STORY

Rachel is expecting her first baby. She has a very loving and supportive family but has been very clear during the pregnancy that she does not want her parents present at the labour and birth. In her birth plan Rachel’s birth team includes her husband Warwick, her student midwife Julie and her midwife Stella. Rachel’s parents have read the birth plan, but when Rachel arrives at the hospital her parents are with her as well as Warwick and Julie. Rachel is in active labour and not able to talk during or in between contractions. She has buried her head in a beanbag and is not communicating with anyone. Her labour appears to be progressing very quickly as she starts to make expulsive sounds with each contraction. Her midwife Stella has the birthing room ready when they arrive and sits close to Rachel, reassuring her as the contractions build in length and intensity.

Questions

1. What are the most appropriate assessments Stella needs to make to identify that Rachel and her baby are well and that her labour is progressing normally?

2. How may the midwife honour Rachel’s birth plan?

should be encouraged to stay at home when in early labour, and that women are more relaxed and have more options in their own environments (Baston 2004). For those women who choose not to birth at home, the timing for transfer to hospital is crucial. If too soon, it may disrupt the flow of labour and slow progress, thus risking unnecessary intervention. If too late, there is the risk of birthing somewhere unplanned, such as at home or— worse—in a car, where the environment may carry risks for the mother or baby.

Once the woman is in hospital, creating a calm, positive, welcoming atmosphere will assist in reducing tension and anxiety (Lavender & Kingdon 2006). This can be a challenge when confined to one room. If the midwife arrives at the hospital before the woman, she should ensure that there is something available for the woman to drink, the lighting is dimmed and the room is warm. To make adequate space for the woman to be active in labour, consider placing the bed against the wall (or removing it from the room) and using beanbags, pillows and soft mats if available. This will signal to the woman when she arrives that there is not an expectation that she lie on the bed.

Research has shown that lying supine is not only uncomfortable for women but also does not aid the descent and rotation of the baby through the pelvis, and can contribute to fetal distress. Supine positions can compromise the uterine blood flow during labour and have been shown to decrease the intensity and frequency of contractions (Enkin et al 2000; NICE 2007). The physical layout of the labour environment will have a significant influence on what positions a labouring woman adopts, and if a woman is given many options this will have a positive impact on the birth outcome (Hodnett et al 2005). The culture of the birthing facility will influence a woman’s behaviour in labour, and if there is an expectation that the bed is to be used then she may feel pressured to do so.

Women who labour at home are rarely at a loss as to where to go or what to do next. Given the freedom of their own space, most women will adopt a variety of positions and use a number of rooms throughout their labour. If a woman is able to move freely at will and rest when her body tires, she will find the right places to labour in. The midwifery role is to be willing to support her wherever it is that she chooses to be, and to offer advice and suggestions when required.

Very few women at home will lie on their bed except when trying to rest or sleep, so when women move to the hospital environment from home the midwife needs to positively encourage and support women to continue moving freely and adopting different positions. By trying to make the labour room more home-like, midwives will assist in minimising disturbance to the flow of a woman’s labour and this will be of significant benefit to a woman and her baby (Hodnett et al 2005). This requires skill, effort and thought. As a woman’s contractions increase in strength and intensity, the midwife needs to be constantly thinking ahead about what position changes, ideas and strategies she may need to suggest, to support and encourage the woman through the challenges ahead.

Clinical point

Advantages of being upright in labour

• Increases uterine blood flow which increases efficiency of uterine contractions and improves oxygen availability to the baby.

• Assists rotation and descent of the baby through the pelvis.

• Reduces the need for pharmacological analgesia.

• Enables the woman to find the positions most comfortable for her and to be able to respond to her body’s needs.

A MIDWIFE’S STORY

Sarah has arrived at a rural primary birthing unit with her client Rebecca, who is in active labour with her first baby. She does not have a partner and her support person has not yet arrived at the unit. Rebecca’s plan is to birth naturally and drug-free. Sarah finds that the one birthing room with a pool is not available and they have to use another room. The room they are now in has no shower or bath, just a hand basin, a bed and a couple of chairs. There is one midwife on duty who has offered to help if required. Rebecca is finding the contractions really challenging and is asking for some pain relief. There is a bath/shower available in another part of the unit and there are a variety of mats and cushions in the storage cupboard.

Question

What resources does Sarah have available to support Rebecca to find her own strength to labour and birth her baby without pharmaceutical analgesia?

Eating and drinking in labour

Women experiencing normal labour should be free to eat and drink as their body demands (Enkin et al 2000; NICE 2007). However, the NICE guidelines (2007) advise caution with food intake when women have been administered opioids, as these increase the potential for nausea and vomiting and cause slowing of digestive action.

Labour is a physically challenging process and requires as much fuel as any other strenuous activity. Most women will still feel able to snack on light foods in early labour, but as the contractions intensify may feel less inclined to eat. A recent Australian study (Parsons et al 2007) found no adverse outcomes associated with eating during labour. It is useful to talk with the woman prior to labour about what she thinks she may like to eat, and ensure that those foods are available to her. Most hospitals do not provide a particularly wide range of foods, so if the woman is planning to birth in hospital she may need to bring her own food with her. Some institutions have protocols that require labouring women to fast. For many women this may not present a problem, as they are already unwilling to eat when in active labour. But for others, enforced hunger becomes an extremely unpleasant experience. It may also lead to ketosis and poor progress in labour (Micklewright & Champion 2002). Having the freedom to eat whenever and whatever she chooses allows a woman to be in control, and reinforces the concept that labouring women know what their bodies need (Pengelley 2002; NICE 2007).

Women should be encouraged to drink according to their thirst, but may sometimes need prompting to drink when the labour becomes all-consuming. If a woman’s fluid intake is inadequate or she is experiencing episodes of vomiting, she will soon become dehydrated, especially if the physical demands of her labour cause her to sweat excessively (Micklewright & Champion 2002). This is particularly the case if the woman is labouring in a bath or birthing pool. One of the first symptoms of dehydration is fatigue, and this can disrupt the progress of labour and make it difficult for the woman to feel motivated and active. Decreased urine output may also be an indication for the need to increase fluid intake. If women are enabled to follow their inclinations about drinking, they are unlikely to become dehydrated (McCormick 2003).

Working with contractions

When each woman experiences contractions, a midwife needs to observe their length, strength and frequency, the body language of the woman and the impact on the contractions of the positions she adopts. Many women who experience lower back and sacral pain will adopt a leaning-forward position or be on their hands and knees. Squatting or soaking in a warm bath may help those with intense suprapubic pain. Sitting on the toilet is an ideal place to be when the contractions’ intensity builds, and this position also assists in widening the pelvic outlet. A woman’s instinct is to find a position that assists her in dealing with the contraction, and often this action also allows the baby to rotate into a more favourable position (Sutton 2003).

Much has been written about the ‘labour dance’ (Kitzinger 1997; Vincent 2002). As a midwife it is a privilege to watch a woman unrestricted by technology, rules and expectations of others, listening and responding as her body tells her. The dance may be evident by rhythmic rocking, hip circling and adjustments of position as the contractions exert their energy and power. As the labour moves forward, each woman’s dance will adapt to the physiological changes that are occurring in her body. For example, a woman who has previously been pacing and swaying with contractions may suddenly need to be rocking backwards and forwards on her hands and knees. For others who have found the birthing pool or bath soothing, it may now be more comfortable to be leaning against a wall with pressure applied to the sacrum. The use of moist heat can be particularly effective. This can be provided by soaking hand towels in very hot water, then wringing them out and applying them at the start of a contraction. Where they are placed depends on where the woman is feeling her contractions most. An attentive support team will soon recognise the signs that a contraction may be beginning, and have the heat available before the contraction has reached its full intensity. The use of heat provides comfort and a positive sensation, which may assist a woman as she works with her contractions.

Midwifery support in labour is about reading the cues and suggesting positions and actions that will assist the constant shifts in each woman’s experience. This may require the active involvement of supporters and the midwife by the provision of touch, massage, acupressure and physical support. It is also about trusting that the woman will find her own way and supporting, with patience, the time that the woman needs to do this.