In a phenomenological study exploring the woman’s encounter with the midwife during childbirth, Berg et al (1996) concluded that the presence of the midwife was the central theme. This ‘presence’ encompassed the need to be seen as an individual, to have a trusting relationship and to be supported and guided. Although the word midwife means ‘with woman’, women are able to perceive the difference between a midwife who is in the room but focusing on other tasks rather than on her, and the midwife who is there for her. Osterman & Schwartz-Barcott (1996) described ‘presence’ as a measure of the focus of the carer’s energy and the quality and nature of the interaction. Not perceiving the midwife as supportive is a significant factor in women forming a negative perception of their birth in the long term (Waldenstrom et al 2004, Baston et al 2008, Rijnders et al 2008).

The woman’s partner (if she has one) should be encouraged to be actively involved in supporting the woman, if this is what she wants. In a study designed to measure fathers’ attitudes and needs in relation to being with their partner during labour and birth (Hollins Martin 2008) it was identified that the majority of fathers wanted to be actively involved and considered themselves to be the most appropriate person to support their partner. However, some people feel anxious when confronted with a hospital environment and the unpredictability of labour. The midwife can help create a relaxed and friendly atmosphere by remaining calm and approachable and engaging with the father throughout labour (Fathers Direct 2007).

The partner may need some direction and praise themselves, in order to continue to provide support to the labouring woman. Practical support is valued by women (Ip 2000) and he or she may feel most useful if given an active role to play, such as massage and passing drinks, etc. The partner also needs to be valued as the person who knows the woman better than anyone else in the room.

Successive Confidential Enquiries into Maternal Deaths (Lewis (2004) and Lewis (2007)) highlight lack of communication and teamwork as significant contributory factors. Mutual respect between all professions is vital, not only to enable midwives to undertake their roles without unnecessary interference but also to know that when assistance is requested it is available and justified. While acknowledging that midwives are the key providers during labour, Porter (2003) underlines the principle that midwives must remain alert to deviation from a normal course and be prepared to take appropriate action. The midwife must refer to an appropriate health professional if she detects a deviation from normal that is outside her current sphere of practice (NMC 2004).

The practice of restricting women’s oral intake during labour has been widespread although variable throughout the UK (Singata & Tranmer 2003). This tradition was based on the risk of aspiration of gastric contents during general anaesthesia, a potentially fatal complication. However, this risk has been significantly reduced due to more advanced anaesthetic techniques and preference for regional anaesthesia. Withholding fluids and food does not ensure an empty stomach (O’Sullivan 1994) but does increase the risk of ketosis during labour, especially in primiparous women (Broach & Newton 1988). Anderson (1998) challenges the concept that ketosis in labour is pathological, suggesting that it is a physiological response that does not require treatment. A small randomized controlled trial (Scrutton et al 1999) found that eating a light diet during labour prevented the development of ketosis but that residual gastric volume increased. Enkin et al (2000) suggests that a small, low-residue diet is a sensible alternative to fasting. As labour progresses, women are less inclined to eat, but will need to have regular fluid, determined by their thirst. NICE intrapartum guidelines (2007) support the intake of a light diet and oral fluid intake throughout labour. Care must also be taken to ensure that the woman does not force herself to consume excessive amounts of water over and above her thirst. Although few in number, there are cases reported in the literature where women and their babies have suffered serious complications caused by water intoxication during labour (Johansson et al 2002). NICE guidelines (2007) suggest that isotonic drinks may be more beneficial than water during established labour.

There is no evidence to support the use of antacids or H2-receptor antagonists routinely for low risk women in labour (NICE 2007). However, the use of opioids during labour is associated with delayed gastric motility (Jordan 2002), and the woman should not be encouraged to eat if she has received such pharmacological analgesia, either by the intramuscular or epidural route (NICE 2007): the use of antacids or H2-receptor antagonists should be considered in this situation.

As labour advances, uterine contractions become more frequent, more painful and last longer. The woman will require more support and encouragement as the length of time between contractions reduces and they are more challenging to endure. Staying with the woman will enable the student to develop the essential midwifery skills of assessing the length, strength and frequency of contractions (with a gentle hand on the uterine fundus) and how they impact on the woman’s behaviour. The frequency of contractions should be documented half-hourly (NICE 2007). Translating what she sees and feels to the partogram, as with all skills, gets easier with practice.

Vaginal examination is also employed to assess progress of labour, but should be limited in its use. NICE intrapartum care guidelines recommend vaginal examination every 4 hours, or more frequently in response to clinical circumstances or the woman’s request. It should always be preceded by abdominal palpation to identify fetal lie, presentation and engagement, position and fetal heart rhythm. For procedure for vaginal examination, see Chapter 2.

The most important reason for vaginal examination should be to provide feedback to the woman about how her labour is progressing. She should always be the first to know what the findings are – it is her information. Other indications sometimes used include: to confirm presentation; to exclude cord prolapse following rupture of the membranes; to rupture the forewaters; to prepare for administration of pharmacological pain relief; to confirm full dilation; and/or to apply fetal scalp electrode. Many of these indications are of doubtful necessity (Hanson 2003), and should not be used as an opportunity ‘just to see what is happening’. Midwives should also tune in to the other signs that labour is progressing well and not rely too heavily on this invasive examination for her information (Hoadley 2007). As vaginal examination is an imprecise tool when conducted by different practitioners, where possible the same midwife should undertake subsequent examinations.

A midwife should supervise students undertaking vaginal examination so that she can describe her findings and receive guidance and instruction. This procedure can be uncomfortable and embarrassing for women, and it is all too easy for the student who is endeavouring to interpret what she is feeling to neglect the fact that there is a thinking, feeling women attached to the cervix she is trying to find.

The findings from abdominal palpation and vaginal examination should be written on the partogram. This tool alerts the practitioner if progress in active labour falls outside cervical dilatation of 1cm an hour. Following a large randomized controlled trial (WHO 1994) it is recommended that action for delay in labour should only be taken if progress falls 4cm to the right of the alert line, as this results in fewer caesarean births, less augmentation of labour and a reduced incidence of prolonged labour. A subsequent trial (Lavender et al 2006) confirmed that taking action after 2 hours increased intervention rates without improving maternal or neonatal outcomes, when compared to a 3- or 4-hour action line. NICE (2007) recommend the use of a 4-hour action line. See Box 3.1 for a summary of observations.