Fundamentals of Midwifery: A Textbook for Students (63 page)

Pathways of care during the intrapartum period.

require the knowledge and skills provided by a medical practitioner and a transfer to consultant- led care, but the majority of care will still be monitored and provided by the midwife. It is the clinical decision making skills of the midwife to support appropriate referral to medical staff when there is recognition of normal processes being compromised (NMC 2009) that is crucial to the safety of woman and baby.‌

The evidence from the Birthplace in England study (Birthplace in England Collaborative Group

2011), highlights the effect of ownership of the environment and the authority stance that can result. A community midwife is the guest in the woman’s home, whilst medical ownership exists in the hospital. A birth centre setting seems to be a woman-centred balanced ownership with a nurturing orientation (Walsh 2004). The environment debate to date has been focused on how the surroundings should be homely, improving the surroundings with wallpaper and pictures aimed at reducing anxiety, allowing the physiology of labour to unfold. However Lothian (2006) argues that women say they would just like it to be less medicalised and that they feel safe knowing things are at hand ‘just in case’. Hospital birth centres have been associated with lower rates of intervention and higher rates of satisfaction (Hodnett et al. 2012). For those women choosing home birth, is it about feeling ‘in control’ in her own environment, or ‘safe’ cocooned by the familiar in the heart of her family?

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Activity 7.1

Think about a woman who decided on a home birth; why did she want this? How confident was

she about birthing? Did the staff support her decision? Were there any issues? What skills must the midwife employ to ensure that this is the best environment for the woman? What special skills will be needed if the woman’s decision to have a home birth goes against medical advice?

Some women may choose to prepare for giving birth by attending formal or informal group

sessions. As discussed in Chapter 6, maternity services and other organisations provide antena- tal classes in some form in most areas. Equally some women look to complementary and alter- native therapies such as hypnotherapy and acupuncture, not provided for in mainstream health services (see Chapter 14: ‘Complementary and alternative medicines’ where these are explored in greater depth). The aim is to prepare women and partners for the birth experience and the early weeks of parenting; to discuss what to expect and develop coping strategies. This may follow the traditional maternity service provision or classes that women pay for individually. Some women choose not to undertake any preparation or antenatal education and recognise they have prepared themselves by their virtual presence at the labours of others by watching reality television programmes. Some women enter the intrapartum experience without prepa- ration and appear to do very well, while others appear to have prepared well and have a desire to do birth without intervention, yet start to fear the pain of contractions and doubt their ability in being able to birth normally once in labour.

The bio-physical mechanism by which the fetus undertakes the journey through the birth canal

Longitudinal lie of the fetus, an anterior fetal denominator (occiput for cephalic presentation) and an attitude of flexion.

The onset of strong regular contractions to enable the fetus to descend through the pelvis.

Following further descent through transition: the head rotates on the pelvic floor;

the face sweeps the perineum and the head is born;

internal rotation of the shoulders occurs and is demonstrated as restitution.

At the next contraction the shoulders are born and the body follows by lateral flexion.

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Clinical consideration

Look out for women who seem to just believe they can do it and those who seem very scared. What are the interventions and outcomes of each of their birth experiences?

It is useful to consider three elements when assessing labour and the potential success of a

vaginal birth – the power, passage and passenger. The power relates to the effectiveness of the uterine activity attempting to expel the fetus from the woman’s body. The passage is through the pelvis and soft tissues, often called the birth canal. The passenger is the fetus undertaking the journey, playing an active part, in relation to its position and lie in the birth canal. The bio- physical mechanism by which this all happens is depicted in Table 7.1.

Labour has traditionally been identified and documented in a prescriptive way as ‘stages’ of labour. This suggests that a woman ends one stage, suddenly entering the next stage, highlight- ing different care approaches and requirements for each of the stages and any potential assist- ance that may be required. More recently, from a woman-centred approach for normal labour, phases or rhythms of labour have been described, highlighting the experience of each phase (Walsh 2011). Midwives are perfectly placed to watch and monitor women to know when the stability of maternal and fetal wellbeing is evident and when support, recommendations and actions are required to assist them. A deep understanding of labour progress and the signs of developing problems is therefore essential.

For some time now the latent phase has been considered from a clinician’s perspective rather than the lived experience of the woman, which Walsh (2011) highlights may be very different. This phase is determined as the time when the cervix is effacing (softening, shortening and becoming thin) in the presence of the hormone prostaglandin. A woman may or may not experi- ence painful uterine activity during this time; at some point however uterine activity becomes evident. Deciding whether this is the process of effacement and labour preparation or an active labour that will progress is sometimes difficult for both the woman and the midwife. Diagnosing onset of labour is generally undertaken by performing a vaginal examination, assessing the findings and utilising the information gained to advise the woman and plan care. Effacement of the cervix and its application to the cephalic presenting part, along with good descent of the