Considering promoting normality in the high risk environment
(April 2015)
Contrary to the information the media would have us believe, a majority of women still will go into labour without the need for induction and will give birth vaginally (NICE 2014). Currently however most of those women will also birth in an obstetric unit, though hopefully the dissemination of the new NICE guidance will start to have an impact of chosen place of birth given that around 45% of women are at low risk of complications in labour.
So it would seem that most midwifery care in labour is given to women on a high risk unit at present. As a student midwives we are taught about the normal physiology of birth, that the mechanism of labour is facilitated by a delicate balance of hormones and that oxytocin is an element to be treasured and worked with. Of course we are also taught about when labour and birth takes a more complicated route and what action to take in those situations, and the inclination sometimes is to imagine that all normality is left behind in these situations.
The challenge then, in order to promote a positive birth experience for women and a satisfying role for midwives is to find a way, in the midst of the high risk environment, to promote normality whilst obviously providing safe and competent evidence based care. The Trust I train in is a high risk unit and so I have developed an interest in promoting normality in that environment. This post is an accumulation so far, of what I have gleaned from speak to midwives, reading, and tuning into my own experience as a three times labouring woman. My hope is that this will continue to develop through my own experience as a qualified midwife.
It is a well-known and expected phenomenon that women’s contractions often ease off when she arrives at the hospital. The triage midwife, while speaking to her on the ‘phone may well have heard her experiencing 3 ‘good, strong’ contractions in a 10 minute period, however the ride in the car, the ride in the lift and the knock at the door of labour ward were frankly a bit too much for oxytocin to cope with and it has gone into hiding as adrenaline has soared. Entering labour ward where she might hear the sounds of other women labouring, the sounds of staff at home in their environment may be a daunting experience and so the very first thing that can be done is to meet her at the door rather than ‘buzzing’ her through, causing her to have to walk the lonely and bewildering walk to the desk. Meeting her at the entrance of our ‘home’ and welcoming her and her attendants as anticipated guests may go some distance to inviting oxytocin back into the room. Immediately offer your own name… “Hello my name is…”
The labour room itself plays a huge part in this invite to oxytocin. Pushing the bed to the side of the room can help to remove the focus from the bed and reduce the inevitability of ending up on it. If your unit has a separate triage for labour assessments then this is probably easier to handle. If assessment is necessary in the room however then using positive language about the temporary nature of using the bed may help, or using the other birth furniture such as couches and crash mats instead. Completely removing the bed may seem almost outrageous but can you see a way this could be done on your unit?
Practicalities such as having the clock in an unobtrusive part of the room as possible to keep the focus away from the passage of time and having music playing softly already in the room even if it’s just the hospital radio. Drape sheets and blankets over the crash mats and bean bags to create a softer looking environment. Have the lights already on low before she comes to the room and use lamps where possible as it creates a nicer light. Fake candles, fairy lights and mood lamps can make a real difference to the mood of the room. Ensure the water jug and cup are already there as well as anything you need for the initial assessment so that following your lovely warm welcome you are not immediately abandoning her to gather the things you need. Always draw the curtain and ensure the ‘Privacy’ note on the door is turned, then always knock and ask permission to enter ‘her’ room. Wall art, murals and positive affirmation posters take a bit more money but make clinical hospital walls appear softer. Some active birth rooms have hoops in the ceiling so women can lean on and hang from ropes or sheets. When money is being raised for the unit, ensure some is put aside for the replacement of batteries which many of these things go through like water when used regularly.
Promoting water for pain relief is recommended by NICE guidance and this is far more common in birth centres than it is in obstetric units. Depending on other risk factors it may be that a woman can still use the pool even if she is having IV antibiotics and midwives have found ways around this such as cutting parts off gloves and covering the venflon or simply helping the woman to keep that hand out of the water. It may be an irritation she is prepared to cope with for the pay-off of labouring in water. Water is excellent for back pain and so informing the woman about the benefits of water for a long OP labour may be helpful. If the woman requires a CTG according to your Trust protocol and there is a wireless one available, then use it. Anecdotally many of these sit idle as they are seen as unreliable, often just because they take longer to set up and the woman has to leave the water to be monitored on dry land.
Many Trusts now have aromatherapy protocols and so if your Trust offers this, aim to get trained and start using it. Uses in normal labour include relaxation as well as clary sage to promote strong contractions.
Promote normal physiology so talk to the woman about staying upright, moving and resting regularly throughout labour in order to allow gravity to play its part. Use the toilet in a physiological third stage to ensure emptying of the bladder as well as helping her remain upright. Putting the baby to the breast early for essential skin to skin contact, and not rushing to weigh the baby also helps with a physiological third stage though this may be more of a challenge on a busy labour ward. Discuss third stage early on so that the woman is able to make an informed decision rather than an emotive decision made in a rush when it’s all over.
And finally (though this post is by no means an exhaustive list)… stay with your woman. Make the most of this as a student midwife! Continuous one to one care reduces the need for interventions and increases the satisfaction of the woman in her labour and birth as she feels supported, listened to, cared for and safe with birth attendants she trusts. Be watchful and maintain your belief in the power of the normal physiology of labour and the impact that belief can have on labours which stray from the path.
Bibliography
NICE 2014. Intrapartum Care: Care of healthy women and babies during childbirth. NICE Guidance
Mavis Kirkham & Margaret Jowitt 2012. Optimising Endorphins. The Practising Midwife. December 2012:33-35
RCM 2015. Better Births. Online http://www.rcmnormalbirth.org.uk/ten-top-tips/
Judith Lothian 2002. Promoting, Protecting and Supporting Normal Birth. Online http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1595117/
Lee Seekings Norman 2008. Believing in Normal. AIMS. Online http://www.aims.org.uk/Journal/Vol20No4/believingInNormal.htm
Sara Wickham 2011. Stretching the Fabric: From technocratic normal limits to holistic midwives negotiations of normalcy. Online http://sarawickham.com/wp-content/uploads/2013/04/em-stretching-the-fabric.pdf
So it would seem that most midwifery care in labour is given to women on a high risk unit at present. As a student midwives we are taught about the normal physiology of birth, that the mechanism of labour is facilitated by a delicate balance of hormones and that oxytocin is an element to be treasured and worked with. Of course we are also taught about when labour and birth takes a more complicated route and what action to take in those situations, and the inclination sometimes is to imagine that all normality is left behind in these situations.
The challenge then, in order to promote a positive birth experience for women and a satisfying role for midwives is to find a way, in the midst of the high risk environment, to promote normality whilst obviously providing safe and competent evidence based care. The Trust I train in is a high risk unit and so I have developed an interest in promoting normality in that environment. This post is an accumulation so far, of what I have gleaned from speak to midwives, reading, and tuning into my own experience as a three times labouring woman. My hope is that this will continue to develop through my own experience as a qualified midwife.
It is a well-known and expected phenomenon that women’s contractions often ease off when she arrives at the hospital. The triage midwife, while speaking to her on the ‘phone may well have heard her experiencing 3 ‘good, strong’ contractions in a 10 minute period, however the ride in the car, the ride in the lift and the knock at the door of labour ward were frankly a bit too much for oxytocin to cope with and it has gone into hiding as adrenaline has soared. Entering labour ward where she might hear the sounds of other women labouring, the sounds of staff at home in their environment may be a daunting experience and so the very first thing that can be done is to meet her at the door rather than ‘buzzing’ her through, causing her to have to walk the lonely and bewildering walk to the desk. Meeting her at the entrance of our ‘home’ and welcoming her and her attendants as anticipated guests may go some distance to inviting oxytocin back into the room. Immediately offer your own name… “Hello my name is…”
The labour room itself plays a huge part in this invite to oxytocin. Pushing the bed to the side of the room can help to remove the focus from the bed and reduce the inevitability of ending up on it. If your unit has a separate triage for labour assessments then this is probably easier to handle. If assessment is necessary in the room however then using positive language about the temporary nature of using the bed may help, or using the other birth furniture such as couches and crash mats instead. Completely removing the bed may seem almost outrageous but can you see a way this could be done on your unit?
Practicalities such as having the clock in an unobtrusive part of the room as possible to keep the focus away from the passage of time and having music playing softly already in the room even if it’s just the hospital radio. Drape sheets and blankets over the crash mats and bean bags to create a softer looking environment. Have the lights already on low before she comes to the room and use lamps where possible as it creates a nicer light. Fake candles, fairy lights and mood lamps can make a real difference to the mood of the room. Ensure the water jug and cup are already there as well as anything you need for the initial assessment so that following your lovely warm welcome you are not immediately abandoning her to gather the things you need. Always draw the curtain and ensure the ‘Privacy’ note on the door is turned, then always knock and ask permission to enter ‘her’ room. Wall art, murals and positive affirmation posters take a bit more money but make clinical hospital walls appear softer. Some active birth rooms have hoops in the ceiling so women can lean on and hang from ropes or sheets. When money is being raised for the unit, ensure some is put aside for the replacement of batteries which many of these things go through like water when used regularly.
Promoting water for pain relief is recommended by NICE guidance and this is far more common in birth centres than it is in obstetric units. Depending on other risk factors it may be that a woman can still use the pool even if she is having IV antibiotics and midwives have found ways around this such as cutting parts off gloves and covering the venflon or simply helping the woman to keep that hand out of the water. It may be an irritation she is prepared to cope with for the pay-off of labouring in water. Water is excellent for back pain and so informing the woman about the benefits of water for a long OP labour may be helpful. If the woman requires a CTG according to your Trust protocol and there is a wireless one available, then use it. Anecdotally many of these sit idle as they are seen as unreliable, often just because they take longer to set up and the woman has to leave the water to be monitored on dry land.
Many Trusts now have aromatherapy protocols and so if your Trust offers this, aim to get trained and start using it. Uses in normal labour include relaxation as well as clary sage to promote strong contractions.
Promote normal physiology so talk to the woman about staying upright, moving and resting regularly throughout labour in order to allow gravity to play its part. Use the toilet in a physiological third stage to ensure emptying of the bladder as well as helping her remain upright. Putting the baby to the breast early for essential skin to skin contact, and not rushing to weigh the baby also helps with a physiological third stage though this may be more of a challenge on a busy labour ward. Discuss third stage early on so that the woman is able to make an informed decision rather than an emotive decision made in a rush when it’s all over.
And finally (though this post is by no means an exhaustive list)… stay with your woman. Make the most of this as a student midwife! Continuous one to one care reduces the need for interventions and increases the satisfaction of the woman in her labour and birth as she feels supported, listened to, cared for and safe with birth attendants she trusts. Be watchful and maintain your belief in the power of the normal physiology of labour and the impact that belief can have on labours which stray from the path.
Bibliography
NICE 2014. Intrapartum Care: Care of healthy women and babies during childbirth. NICE Guidance
Mavis Kirkham & Margaret Jowitt 2012. Optimising Endorphins. The Practising Midwife. December 2012:33-35
RCM 2015. Better Births. Online http://www.rcmnormalbirth.org.uk/ten-top-tips/
Judith Lothian 2002. Promoting, Protecting and Supporting Normal Birth. Online http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1595117/
Lee Seekings Norman 2008. Believing in Normal. AIMS. Online http://www.aims.org.uk/Journal/Vol20No4/believingInNormal.htm
Sara Wickham 2011. Stretching the Fabric: From technocratic normal limits to holistic midwives negotiations of normalcy. Online http://sarawickham.com/wp-content/uploads/2013/04/em-stretching-the-fabric.pdf
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