Fundamentals of Midwifery: A Textbook for Students (68 page)

Activity 7.3 Think about how third stage of labour is managed in your unit. What differing practices haveyou seen, and how does this relate to current evidence?List the advantages and disadvantages of both physiological and active management of the third stage of labour for mother and baby.
Perineal care
Antenatal discussion with women around perineal trauma offers them the opportunity to beproactive in preparing themselves, both physically and emotionally, and the use of perineal massage has been found to be useful (Beckmann and Garrett 2006).Over the last 30 years the incidence of episiotomy, which in some cases was routine, has significantly reduced. Research has shown this is not protective of further perineal damage. Indeed, episiotomy has been strongly associated with a higher frequency of anal sphincter trauma (Dudding et al. 2008). Since this has become a much more restricted practice, now mainly associated with instrumental birth or birth with intervention (Birthplace in England Col- laborative Group 2011; Hatem et al. 2008) many student midwives will never have performed an episiotomy during their training. It is, however important for students to be familiar with how this procedure would be carried out, should the need arise. It is also important for midwives to have the skill to repair perineal trauma since perineal tearing and episiotomy is associated with 85% of births (Albers et al. 2005). A reduction in episiotomy does not mean that there is no indication for perineal repair.Recently there seems to have been a trend towards leaving perineal trauma unsutured. It is unclear in the practice setting, whether this is because fewer women require or want suturing, or because midwives do not have the skills or do not want to suture because this is their prefer- ence. Whilst the evidence is limited regarding suturing or not suturing perineal tears, midwives are advised to be cautious of leaving trauma unsutured, unless the woman has expressly declined suturing (RCM 2012). Midwives must be aware of the way in which they impart infor- mation and the influence they have in their position as a trusted knowledgeable professional and must not abuse this in order to avoid carrying out a procedure they know women dislike and find uncomfortable. If midwives are not able to suture, then in the best interests of the woman, the midwife must seek assistance from either another midwife or a doctor to perform perineal repair.Suturing is a skill all midwives need to develop and maintain through ongoing education and training. It is part of timely, holistic and continued care, which the midwife should provide, reducing unnecessary exposure to multiple professionals. The Royal College of Midwives hasproduced comprehensive, evidence-based guidelines for midwives to follow (RCM 2012), and readers are advised to access these.‌
Activity 7.4 Follow the link below to access this research article by Ismail et al. (2013).Think about what this article says about perineal repair.Perineal Assessment and Repair Longitudinal Study (PEARLS): a matched-pair cluster rand- omized trial [Available online] http://www.biomedcentral.com/1741-7015/11/209
Decision-making
Figure 7.9 depicts a nurturing and enclosing womb, demonstrating the best way to assist thedecision-making process for birth, that is, to formulate a rationale based on the best evidence and guidance available. This is done while working through the experiential knowledge and intuitive views of both the woman and the midwife; discussing the benefits risks and alterna- tives and making collective decisions based on the woman’s needs.Being aware of the instinctive, innate, deeply emotional information the woman shows in her behaviour, such as being talkative, dependant, tearful, excited or fearful, will help to inform a midwife’s decision-making. The midwife will consider how the environment is impacting on the hormonal balance and how these are linked with factors such as nourishment, fluids, position andmovementinlabour. Alsoassessinganyimpactofpharmacologicalandnon-pharmacological pain management support e.g. water immersion, coupled with how the cognitive, knowledge- able aspects are helping or hindering progress. Together, women and carers can formulate a rationale that includes the expertise of the professional. Only then can the woman’s decisions about her needs and birth experience be informed.
Key points

Set a woman up with confidence in her capability to birth through providing compassionate
woman-centred care.

Support her by managing the environment to prevent unnecessary stimulation and anxiety forher, and encourage the optimal hormonal balance.

Always palpate the abdomen to determine descent of the fetal head in determining progress oflabour; do not rely on what can be seen at the vulva during slow pushing.

Know what deviations may occur and be that watchful guardian, yet being adequately proactive
when necessary.