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Chapter 7‌
Intrapartum midwifery careJulie Flint
University of Hull, Hull, UK
Sue Townend
Calderdale and Huddersfield NHS Foundation Trust, West Yorkshire, UK
Learning outcomesBy the end of this chapter the reader will be able to:

explain parameters of normality in labour

discuss some of the challenges that midwives and women face in reducing the medicalisationof labour and birth

monitor the wellbeing of mothers and their unborn children in normal labour

determine when deviations from the norm may occur in the intrapartum period

provide evidence based care in the intrapartum setting.
Introduction
The emphasis of the midwife’s role in the provision of maternity care continues to lie within theboundaries of normal childbirth. The increasing rates of intervention in childbirth cause a great deal of debate, and the current medical model for childbirth is much criticised. It is paramount that student midwives base their knowledge and skills within the context of women centred care when pregnancy and birth are physiologically normal. Equally, as all women deserve the best care, all aspects of compassionate and competent care need to be applied to complex situ- ations to give all women and their babies the best start to family life.This chapter will focus on normal labour and birth and the role and responsibilities of the midwife, highlighting how an understanding of anatomy and physiology informs care provision and ensures a woman-centred approach. Place of birth and the influence of birth preparation education as a way to empower women are also included.
Fundamentals of Midwifery: A Textbook for Students
, First Edition. Edited by Louise Lewis.© 2015 John Wiley & Sons, Ltd. Published 2015 by John Wiley & Sons, Ltd. Companion website: www.wileyfundamentalseries.com/midwifery
Facilitating and maintaining normality in childbirth
Thebirthofababyisatimewhenawomanhasanopportunitytodevelopasanindividualandreach her full potential; the support and care she receives can influence her outlook and progress throughout that journey and for the rest of her life. It is evident that if she feels some sense of per- sonal control of the situation, she may have a more positive experience and higher levels of satisfac- tion (Goodman et al. 2004). This can be achieved by having the ability to make choices about the place of birth that best suits her wherever possible; having some understanding of what is happen- ing to her through the process of labour and planning some coping strategies both prior to and during labour, making decisions along with the professionals giving care at the time (see Chapter 6:‘Antenatal midwifery care’where decision making is explored in greater depth).Those persons present at the time of labour and birth can influence the outcome both posi- tively and negatively, through their actions and words, with the potential to increase or decrease intervention. Often, this person is someone unknown to the woman. It is therefore essential for midwives to develop and feel confident in practising midwifery that is reflexive and adaptable within that midwife–woman relationship as explained by Kirkham (2010), in a gentle supportive manner. The midwifery role is one of expert practitioner. Practising as a skilled birth attendant (World Health Organization (WHO) 2004) requires an absolute grounding in the fundamental skills of midwifery which encompass the softer, caring and nurturing nature, sound knowledge base and clinical skills. This is what makes a midwife different and unique. A woman needs assurance that the person – the midwife she is putting her trust in – has the knowledge, skills and expertise including intuition, to care for her appropriately.It is during the intrapartum period that woman-centred care reaches the peak of importance for influencing the birthing experience. Women seek to have a carer who is ‘on their side’ one who discusses the benefits, risks and potential alternatives to any suggested interventions; allowing the women to make her own informed choice. This can help to support women to have personal control, rather than the carer assuming responsibility for knowing best and choosing options from a menu of actions to assist the woman (Kirkham 2004).The more straightforward and uncomplicated the birth, the greater the likelihood for the mother of achieving skin-to-skin contact with her baby, enjoying that first meeting and encour- aging the baby’s pre-feeding behaviours (Porter and Winberg 1999). The woman is less likely to have untoward outcomes such as genital tract trauma, suffer exhaustion or have undergone surgery. If the woman feels she has had a satisfactory experience she may feel increased self- worth, self-esteem and self-confidence in the transition into parenthood, with perhaps less potential for postnatal depression (Thompson et al. 2002).Armed with knowledge and compassion, the skill for the midwife is to provide safe, effective care for all women regardless of the level of complexity in the pregnancy or throughout the intrapartum period. Some women face challenges when they have hopes and choices that lie outside clinical guidance, or are hoping to prevent interventions they may feel are unnecessary when known medical conditions and situations become evident.Figure 7.1 Demonstrates how different pathways of care and intervention can lead to different outcomes in birth experience. The flow chart represents how the lead carer for the woman may fluctuate between the midwife and the obstetrician. Confusion may occur when the woman remains within the parameters of normality, monitored by midwives, but with varying degrees of intervention to achieve a vaginal birth, for example; pharmacological methods of pain relief, amniotomy, intravenous infusion and cardiotocograph (CTG) monitoring. The woman may
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Direct access to Midwife or General Practitioner (GP) referral Midwife undertakes booking for care and screening Assesses any risks of ill health to mother and baby
Pregnancy
Medical review of case by consultant obstetrician
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Midwifery monitored care throughout pregnancy
Referred or regular consultant review if high or developing risk of ill health
Onset of Labour at home or birth centre
^{Onset of labour in obstetric unit}
Labour
Midwifery monitored care
Possible transfer to obstetric unit
Midwifery monitored care with medical availability/ input
Physiological normal birth
No intervention
Normal vaginal birth with varying degrees of intervention which may include;