1
Labour and normal birth

Cathy Charles

1. The birth environment
2. Signs that precede labour
3. First stage of labour
4. Analgesia
5. Regional anaesthesia
6. Mobility and positions
7. Transition
8. Second stage of labour
9. Pushing
10. The birth
11. Third stage of labour
12. After the birth
13. Mental health/safeguarding
14. Early discharge home
15. Appendix 1.1: Group B Streptococcus

Introduction

Undisturbed birth . is the balance and involvement of an exquisitely complex and finely tuned orchestra of hormones.

(Buckley, 2004a)

The most exciting activity of a midwife is assisting a woman in labour. The care and support of a midwife may well have a direct result on a woman's ability to labour and birth her baby. Every woman and each birthing experience is unique.

Many midwives manage excessive workloads and, particularly in hospitals, may be pressured by colleagues and policies into offering medicalised care. Yet the midwifery philosophy of helping women to work with their amazing bodies enables many women to have a safe pleasurable birth. Most good midwives find ways to provide good care, whatever the environment, and their example will be passed on to the colleagues and students with whom they work.

Some labours are inherently harder than others, despite all the best efforts of woman and midwife. A midwife should be flexible and adaptable, accepting that it may be neither the midwife's nor the mother's fault if things do not go to plan. The aim is a healthy happy outcome, whatever the means.

This chapter aims to give an overview of the process of labour, but it is recognised that labour does not simplistically divide into distinct stages. It is a complex phenomenon of interdependent physical, hormonal and emotional changes, which can vary enormously between individual women. The limitation of the medical model undermines the importance of the midwife's observation and interpretation of a woman's behaviour.

Facts and recommendations for care

• Women should have as normal a labour and birth as possible, and medical intervention should be used only when beneficial to mother and/or baby (DoH, 2007; NICE, 2016).
• Midwife-led care gives the best outcomes worldwide: more spontaneous births, fewer episiotomies and epidurals, better breastfeeding rates. Women report that they feel more in control of their labour (Sandall et al., 2016).
• Although 88% of women give birth in an obstetric unit many would not choose to: low-risk women (i.e. around 60%) should also be offered the choice of birth either at home or in a midwife-led unit; a woman has a right to choose her place of birth (DoH, 2007; NICE, 2014; NHS England, 2016).
• Women should be offered one-to-one care in labour (NICE, 2014). The presence of a caring and supportive caregiver has been proved to shorten labour, reduce intervention and improve maternal and neonatal outcomes (Green et al., 2000; Hodnett et al., 2013).
• The UK birth rate continues to rise, while England alone is short of 3500 midwives (RCM, 2016).
• 1-2% of mothers develop birth-related post-traumatic stress disorder (Andersen et al. 2012) and midwives can too (Sheen et al., 2015).
• The attitude of the caregiver seems to be the most powerful influence on women's satisfaction in labour (NICE, 2014).
• 89% of fathers attend the birth (Redshaw and Heikkila, 2010); other relationships, e.g. same-sex couples, have been less closely studied.
• The birth rate for women aged >40 rose above that for women <20 for the first time since 1947 (ONS, 2016).
• 27.5% of births in England and Wales are to women born overseas (ONS, 2016).
• 20% of pregnant women in England are clinically obese (Health and Social Care Information Centre, 2016), increasing the risk of complications.

Mode of delivery

• The UK normal birth rate is around 60% (ONS, 2016; NHSD, 2017).
• The instrumental delivery rate is around 10-15% (ONS, 2016; NHSD, 2017).
• The episiotomy rate for England is around 20% (see Chapter 4).
• The caesarean section (CS) rate is around 26% (NHSD, 2017).

The birth environment

In what kind of surroundings do people like to make love? A brightly lit bare room with a high metal bed in the centre? Lots of background noise, with a series of strangers popping in and out to see how things are going? The answers to these questions may seem obvious. If we accept that oxytocin levels for sexual intercourse are directly affected by mood and environment, why is it that women in labour receive less consideration? The intensely complex relationship between birth and sexuality is an increasing source of study and reflection by birth writers.

Once women gave birth where and when they chose, adopting the position they wanted, using their instinctive knowledge to help themselves and each other. Recently birth has become more medicalised, and the place of birth often restricted. No one would deny that appropriate intervention saves lives. For some women an obstetric unit is the safest choice, and for others it feels like the safest, so that makes them feel happier. But does it have to be the choice for everyone?

The clinical environment and increased medicalisation of many birth settings directly affect a woman's privacy and sense of control (Walsh, 2010a). Home-like birthing rooms ('alternative settings'), even within an obstetric unit, increase the likelihood of spontaneous vaginal birth, labour/birth without analgesia/anaesthesia, breastfeeding at 6-8 weeks postpartum and satisfaction with care; these rooms also result in a reduction in oxytocin augmentation, assisted vaginal/CS birth and episiotomy (Hodnett et al., 2012). This may be due partly to the fact that women simply feel more relaxed at home, or in a home-like setting. However, simply changing the curtains and hiding the suction machine does not always mean a change of philosophy of care. A more telling factor may be that the type of midwives who choose to work in the community or birth centre, or who gravitate towards more home-like rooms, are those with a less interventionist approach.

Women should be able to choose where to give birth; it would be still more wonderful if women could simply decide in labour whether they wish to stay at home or go to a birth centre or an obstetric unit, and indeed if they could change their mind during labour. Such choices do exist, but UK service provision is patchy. The Better Births report (NHS England, 2016) and the Best Start report (Scottish Government, 2017) may influence change in this respect. It is also heartening to see midwife-led units opening in Northern Ireland: there are now eight, whereas in 2000 there were none at all (Healy and Gillen, 2016). In many other countries women have little or no choice.

Although it has been estimated that at least two-thirds of women are suitable for labour at home or in a midwife-led birthing centre (DoH, 2007), and 87% of women believe that birth in a stand-alone birth centre is a safe option (Rogers et al., 2011), for many reasons most mothers and midwives in the UK will still meet in labour in an acute unit. It is incumbent on all midwives to make the environment, irrespective of its location, warm, welcoming and safe. Always remember that the quality of the caregiver is the thing that most strongly influences a woman's satisfaction with her labour.

Midwives who are asked by family or friends, or perhaps a previous client, to deliver them outside normal working conditions may refer to the guidance produced by the Royal College of Midwives (RCM, 2017a). Most things are possible with good communication and flexibility.

The RCM Campaign for Normal Birth http://www.midwives.org.hk/doc/resources/RCMTopTipsenglish.pdf) suggests 'ten top tips' to promote normal birth (Box 1.1). The Association for Improvements in the Maternity Services (AIMS, 2012) has also produced 'ten top tips for what women want from their midwives', which include compassion, courage, respect and positivity: 'Women appreciate midwives who are genuinely confident and upbeat when . women are flagging . and who are able to . encourage: "you're doing so, so well", "you're amazing", "you're so strong", "well done, that's another one gone".'

Box 1.1 Ten top tips for normal birth (RCM, 2017b).

(1) Wait and see

The single practice most likely to help a woman have a normal birth is patience. In order to be able to let natural physiology take its own time, we have to be very confident of our own knowledge and experience . of normal birth - and know when the time is right to take action.

(2) Build her a nest

Mammals try to find warm, secure, dark places to give birth - and human beings are no...