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NORMAL BIRTH AGAIN - SUPPORTING NORMAL BIRTH SKILLS (See the report on the 2004 meeting "Normal Birth - Is it possible in the 21st century?" at www.motherhood.org.uk/normal220404.htm)
This is a report of a meeting of the Forum on Maternity and the Newborn of the Royal Society of Medicine in association with the Royal College of Midwives on Monday 3rd June 2013.
Professor Lesley Page, president of both the Forum on Maternity and the Newborn of the Royal Society of Medicine and the Royal College of Midwives, introduced this as a joint meeting of both bodies, and referred to the relevant importance of the Grange Over Sands Normal labour and birth conference which was to commence in two days time.
She was followed by Sheena Byrom OBE, chairing the morning session. She described herself as a working midwife with a passionate belief in normal birth, who also chairs the Campaign for Normal Birth of the RCM. She encouraged delegates to Tweet during the meeting; for those wishing to read these comments later the hashtag was normalbirthrsm. Sheena laid out the aim of the positive birth experience, best for mother and baby, partner and family, while recognising that interventions and litigation are increasing, and women and the professionals are becoming more fearful. She identified that this meeting was part of the continuing conversation leading toward this ideal, in which all the actors, professional and managers as well as the mothers and their families, are taking part. This conference, with others, would contribute to a message for change.
Normalizing Birth: Culture and Environment
The following account is a précis of the paper given by the first speaker: Nicky Leap, Adjunct Professor of Midwifery, University of Technology, Sydney, and Visiting Professor of Midwifery, Kings College London.
"The way a woman is treated by the professional on whom she depends may largely determine how she feels about the experience for the rest of her life" (Penny Simkin 19921 )
Nicky started her presentation by stating that her aim was to stimulate the sharing of ideas and experiences, to share some research and education initiatives addressing the culture and environment in Western maternity services, and to discuss different perspectives on pain in labour. Over recent decades more women are fearful of pain in labour and expect to have an epidural. Ours is a pain-averse society and we maternity service providers often find ourselves engaging with pregnant women in offering a 'menu' of methods for relieving pain in labour. She suggested that, in offering this menu we may be implying that something will definitely be needed. Furthermore, to offer the menu during labour can undermine the wishes of women who hoped to avoid pharmacological pain relief.
Nicky discussed how, instead of going straight to the menu, a useful approach is to engage in conversations with women who are having their first baby about the nature of contractions: what a contraction is; how it builds, then fades away, lasts about a minute, and is followed by a rest. This approach can help women to see contractions as manageable with a rest in between, rather than continuous pain.
Nicky described research she had undertaken where midwives identified two ways of approaching pain in labour: 'working with pain' and 'pain relief'. In a straightforward labour women and their birth attendants can work with the 'normal pain' of physiology. 'Abnormal pain' is associated with malposition and dystocia, for which an epidural can provide much appreciated relief. When labour is uncomplicated and the right support is given (and endorphins, oxytocin and other hormones go to work), a woman will often proceed in labour without an epidural and later express her satisfaction at doing so. She has worked with her pain. Understanding and witnessing normal pain gives birth attendants confidence to deal with our own discomfort and override our conditioning to step in and provide 'adequate pain relief'.2
These days midwives tend to define labour pain as physiological, having a purpose, conferring power and potentially contributing to a positive experience. This is at odds with the International Association for the Study of Pain's definition of pain as: “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”. The efficacy, safety and ethics associated with pharmacological pain relief have been debated ever since James Young Simpson first gave labouring women ether and chloroform in 1847.
The anthropologist David Morris3 suggested: "Pain is never the sole creation of our anatomy and physiology; it emerges only at the intersection of bodies, minds and culture." The attitudes of caregivers to women in labour are a product of our individual bodies, minds and cultures and Nicky stressed that we must always be aware of this in our work. The NICE Guidelines on Intrapartum Care (2007) support this approach and encourage maternity care providers to consider how their own values and attitudes may influence how they support labouring women since variations in the use of analgesia often appear to be related more to professional opinion rather than to women's choices4 .
As identified in a large systematic review of pain and women's satisfaction with the experience of childbirth4 , the influences of pain, pain relief, and intrapartum medical interventions on subsequent satisfaction are neither as obvious, as direct, nor as powerful as the quality of the relationship with caregivers. 'Adequate pain relief' does not necessarily leave mothers more satisfied and many studies have identified that for the majority of women, coping with pain is linked with self sufficiency and self esteem. Furthermore, we have hard evidence from Cochrane systematic reviews that normal birth, a reduction in epidural use and a positive experience for women are all associated with midwifery led care: continuous one to one support in labour; upright positions, mobility; immersion in water during labour; alternative birth settings and home birth; and acupuncture and hypnotherapy.
Some practitioners believe that the epidural changed everything in the way women are supported during labour. There are system wide concerns about the iatrogenic risks, interventions e.g. instrumental births and rising caesarean section rates, and the costs and morbidity associated with the increasing use of epidurals. Some women share these concerns, but evidence suggests that many more women have used epidurals than had wanted to, with high transfer rates from some alongside birth centres. This has prompted questions about how we support women who want to avoid an epidural.
We all recognize that there are some midwives who have particular skills in what we used to call 'getting women through labour', providing a steady presence and gentle encouragement. Nicky described the art of 'midwifery muttering', of reassuring the woman's partner: "If you're worried, look at me; if I'm not looking worried, all's well." She reiterated the importance of knowing when 'to step in and take charge' with positive suggestions to relieve moments of panic. Staff shortages can result in the converse: the absent midwife, or one who comes in and out of the room to carry out observations, spending time with her back to the woman who needs her, writing notes.
In response to concerns that students may not be exposed to sufficient learning opportunities to feel confident and competent about helping women to achieve a normal birth, various learning packages are available,
though releasing NHS staff to attend workshops was a challenge; there was a suggestion that such learning packages to promote normal birth should be mandatory. All participants were in agreement that 'normal birth matters' and that women with complicated pregnancies and labours should be given the best possible births, within a culture of collaboration, respect and support between all maternity service providers. Continuity of carer is important, but the research at King's also identified ways of supporting women who had not previously met their midwives. Encouragement and the gentle art of persuasion - positive messages - have their place throughout pregnancy and labour.
Nicky concluded her presentation with a brief summary of research on Birth Unit Design being carried out at the University of Technology, Sydney. Women, their birth supporters and the midwives who attended them reviewed video footage of their labours in order to consider optimal environments to promote safe, satisfying birth. This project is also developing an international resource to share examples of birth unit design. She also mentioned a proposal for running normal birth workshops for hairdressers (yes, hairdressers!) to take advantage of the intimate relationship they often have with their pregnant clients, so that conversations can help women develop confidence in their abilities and the potential benefits of normal birth for the majority of women.
Birth is not just about making babies, birth is also about making mothers, strong confident capable mothers, who trust themselves and know their inner strength.
References to the presentation.
4. Am J Obstet Gynecol. 2002 May;186(5 Suppl Nature):S160-72.
Leap N, Sandall J, Buckland S, Huber U (2010). Journey to confidence:women's experiences of pain in labour and continuity of carer. The Journal of Midwifery and Women's Health 55(3) 234-242
Leap N, Sandall J, Grant J, Bastos MH, Armstrong P. (2009). Using video in the development and field-testing of a learning package for maternity staff: Supporting women for normal birth.
lnternational Journal of Multiple Research Approaches. 3 (3) 302-320
Leap N, Dodwell M, Newburn M. (2010). Working with pain in labour: an overview of evidence. Evidence based briefing paper: NCT publications.
Foureur M, Davis DL, Fenwick J, Leap N, ledema RA, Forbes I & Homer CS.2010. 'The relationship between birth unit design and safe, satisfying birth: developing a hypothetical model'. Midwifery,26 (5) 520-525. Leap, N. (2012) 'The power of Words revisited'. Essentially MIDIRS, 3 (1) 17-21
Effective support in labour.
Dr. Mary Ross-Davie, Educational Project Manager for Midwifery and Reproductive Health, NHS Education for Scotland.
Mary described her years of experience as a midwife, some of it independent, but latterly and importantly for her as a Surestart and perinatal mental health midwife. She saw too many women whose experiences of labour led to post-traumatic stress disorder (PTSD). A recurring theme in the stories of these women was a sense of abandonment in labour. Her talk was based on a doctoral study of intrapartum care focussing on the outcomes of continuous one to one midwifery support in labour. For this it was necessary to define high quality support and to develop reliable measurement of the quantity and quality of support. A review of the literature highlighted the centrality of support for women, and identified the behaviours which they described as key.
What do women want? Continous care, with or without (preferably with) the presence of a partner. It requires skills if it is to be of the necessary high quality, and full staffing. Mary and colleagues observed a crucial difference: the midwife who left a mother in labour after half an hour, saying "She wants an epidural", and another who would leave exhausted after three hours saying "She's had a lovely baby". There is much reliable research confirming the advantages of continuous care, but the quality of that care was not studied.
Singled out from this list of publications were those of Bowers and Hodnett. One mother, quoted in Bowers' review, said 'It's not so much what you do as how you do it'. Whether or not a partner is present women generally identify the need for the continuous presence of a nurse or midwife, emotional support and a friendly open attitude. As Nicky emphasized these were the key factors defining the woman/carer relationship, outweighing all the other variables as predictors of a satisfactory experience. World-wide these needs of women in labour are consistent.
The literature has led to a definition of high quality support in labour: it includes all of these elements, is continuous, and is experienced as supportive by the woman:
But she wanted to go further than this, incorporating with women's priorities from the literature the Institute of Medicine definition, that support should be patient centred, safe, effective, timely, equitable and efficient, and measuring the relationship between the observed behaviours of midwives and women's feelings about the support received. Now she had the SMILI (Supportive Midwifery in Labour Instrument) as her data collection instrument. This was followed by asking the mothers to complete a SCIB, the Support and Control In Birth questionnaire (Ford and Ayers 2009).
Mary once heard a midwife say 'She's got a partner in there, doesn't need me'. So we sat in the corner recording the observed emotional support behaviours, tangible, partner, informational and advocacy support, and also non-support behaviours including assessment and record keeping of the midwives, using our check list. The reliability of the list was confirmed in the pre-clinical testing phase using videos of labour. The key behaviours are represented on this pie chart:
It was a relief to find that emotional support was the major behaviour; this was observed in three-minute snapshots and would often take several different forms e.g. praise and reassurance, and this accounts for the total being over 100%. Indirect behaviour included writing notes, and again it was pleasing to see the low figure for this. Tangible support included holding a hand, rubbing a woman's back, bringing water. The lack of partner support was disappointing; it is much valued by women in labour. When the obsrvation performance of individual midwives was analysed we got a range between very infrequent and very frequent. All the midwives were providing one to one support which was mostly continuous (at least 80% of the time – Hodnett). When this was studied for up to 3 hours we found that a quarter of the midwives were in the room for 98% of the time; a statistical analysis confirmed that being out of the room correlated with the quality of emotional support – the more absence the less and poorer the support. Again detailed analysis of the types and frequencies of support correlated closely with the quality of a midwife's behaviour; some midwives were able to maintain their notes and blood pressure checks etc. as well as providing a lot of emotional support.
What type of support is most effective? Our quantitative data helped here in determining which were the key outcomes of SMILI. The mothers were asked to complete a SCIB within 48 hours of the birth, this timing probably providing us with the positive women's views of the quality of support they had received if compared with results (say) 6 weeks later. Most women were very pleased with the care they had experienced in labour, 5 out of 5, top marks for their midwives, although there were some negative reports with lower SCIB scores. The level of satisfaction was higher when the support was more continuous, including more emotional, tangible, informational and partner support and fewer negative behaviours. Verbal support and attentiveness scored highest for the midwives rated most highly by women, but the greatest difference was in rapport building behaviours. Even with closed eyes the women knew whether their midwives were smiling and positive, while they were aware of neutral demeanour in the low scoring midwives' behaviours.
The slide shows in the green column the SMILI results for midwives who received high scores in terms of support from women. The amber column shows the results for the overall average for the study and the red column has the frequencies of these behaviours for midwives who received lower scores from women. It confirms the observations described above, but is particularly interesting in the similarity of the quantity of assessment activity, which some have believed to be significantly different in the two groups.
We found that women were more likely to achieve a normal birth the more the midwife was present in the room. Also – and this is statistically significant – instrumental deliveries were more correlated with midwife absence, the proportions of absence being 12/13 for forceps, ventouse and CS, and 7.4 for SVD. Our observations when the midwife left the room were of mounting tension; her reason for leaving would often add to the tension. Similarly the proportions of verbal support correlated significantly: 92.1 for SVD, 52.9 for forceps and ventouse, and 14.6 for CS. The significance was unaffected when we allowed for epidural and risk pathways. Risk factors might lead to increased emotional support without altered statistical significance; we couldn't explain this.
Mary has laid out the findings in her PhD study, and she adds that none of the midwives had met any of the women taking part prior to their labours, though the rapport achieved suggested in some cases that they could have known the women throughout pregnancy, a tribute to the standard of care given. The midwives set the tone, "superheroes" using their powers for good. Mary had become accustomed to the high level of banter used in Scotland, and the positive friendly attitude commonly seen. Given the right staff-mother ratio this standard of care can be achieved in a hospital setting. She thanked all concerned for their help in enabling the study.
The Royal College of Midwives Campaign for normal birth: Getting off the bed.
Mervi Jokinen, Practice and standards development adviser, RCM.
This campaign's purpose is to collect the ideas of midwives about achieving normal birth, to increase their confidence in the practice of it and ways of supporting women through labour to birth and beyond. This has involved us in carrying out surveys covering a variety of relevant aspects: midwifery practice, home birth, positions used in labour and birth. Furthermore we have modified existing evidence based guidelines for midwifery led care in labour. We wanted a snapshot of what is happening nationally in the practice of midwifery and to highlight areas for improvement and promoting best practice. It's a reminder that good birth experiences can happen despite the challenges. Intervention and caesarean shouldn't be the first choice - they should be the last.
The Ten Top Tips of the campaign were designed to be significant but short and snappy. Get off the bed is an example, and we have evidence that mobility and positions in labour are important, as we heard from the first two speakers. The Campaign steering committee suggested obtaining a 'snapshot' of contemporary practice, setting objectives such as: to gain a national picture of the positions being used in labour and birth, highlight areas for improvement and promote normal birth best practice, to gather data to provide individual services with specific feedback on their performance in encouraging women to labour and give birth 'off the bed'. Feedback from consultant midwives for individuals on current practice in local units has proved useful; a survey was carried out by my colleague Jane Munroe under the title of her audit of quality and development.
A survey form based on these objectives has been circulated to 24 units in England, the data to be collected for one week in a single month in 2010. Basic information required was the type of unit obstetric or midwife led, whether the information related to a qualified midwife or a student, and importantly the type of birth. Tick boxes on positions and whether in labour or at birth were included, but more were added when midwives themselves noted lithotomy, lateral or other. 929 forms (46% of those supplied) were returned, coded for anonymity, recording the data for between 13 and 86 mothers over various units. Obstetric units were the main area of birth, most of the rest in midwifery led units, and 1% at home; 60% were first babies. The intention is that the total collated data are available for practical use and discussion.
Upright positions (supported standing, all fours, and sitting on a ball), as we recommend, were adopted in labour, though there is of course wide variation around these, and still 26% lay recumbent on the bed. Only 8% were delivered in a pool (I also favour relaxation in a bath, especially at home); there was no mention of a birthing stool, and whether by the mothers' wish or the midwives' preference most births took place on the bed, where 51% of normal births took place, 3% being described as in lithotomy position. Surprisingly 16% of normal births were reported to have been in that position in the 2010 Care Quality Commission Survey, and this deserves discussion. Instrumental births: ventouse (31%), forceps (28%), and caesarean sections (38%) were more likely to be associated with semi-recumbent positions during labour. Normal births were associated with the use of upright labour positions, but despite this nearly half of the women (49%) appear to have got onto the bed for the birth. The more the experience and qualifications of midwives present at the births made some difference in the choices of positions in the pool births and births on the bed than when students were involved.
These observations led to unsurprising recommendations, particularly our Top Tip Get off the bed, but also to consider using other positions which appear on our diagrams (below). Gravity is our greatest aid in giving birth, but for historical and cultural reasons in this society (although now obsolete) we still make many women give birth on their backs. We need to help women understand and practise alternative positions antenatally, feel free to be mobile and try different positions during labour and birth. There are also positions suitable for women whose labours are being monitored; one of our aims is to normalize birth, when possible, in complicated situations.
This and other material can be downloaded from the Campaign website at www.rcmnormalbirth.org.uk/practice/positions-in-labour-and-birth/ , and a 'Getting off the bed' positions swatch has become popular and is now available to download. All of which can be used in local units, contributing to their audits and to discussion with students, midwives and supervisors. Discussion of comparisons between our findings and the NICE guidelines will also be worthwhile.
Short video clips of positions in use for labour and birth have been prepared and are available as follows (but also in YouTube):
Leaning against the bed when connected to a monitor
Chair when connected to a monitor
Birth ball when connected to a monitor
All fours when connected to a monitor
All fours on a birthing mat
Leaning against a wall
Leaning against a partner
Positions for Labour and Birth Full length video
[For these videos the Campaign for Normal Birth thanks Belinda Ackerman, Lisa Cameron, Kathryn Gutteridge, Mole Productions and all involved at Serenity Birth Centre, Birmingham.]
Our resources are now in use abroad, with some modifications to do with copyright.
My thanks also to the RCM Consultant Midwives Forum.