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Assessment of labour – knitting and sitting
Mrs. Kathryn Gutteridge, Consultant Midwife and Clinical Lead for low risk care, Sandwell and Birmingham Hospitals NHS Trust

To any trainees in my audience: have in your minds the idea of the midwife you want to become.

When first training as a psychotherapist, then becoming a midwife and later planning research, I realised that the skills I needed were listening and watching (the sitting and knitting) rather than intervening in a labour (the doing), other than by advising.

My doctorate research is around the continuum of fear and anxiety. The effect of the technocratic developments in obstetrics and midwifery of the last three decades has been, for women, a loss of faith in their bodies, and the loss of the experiences of birth, ageing and death from our communities causes anxiety when they are faced with them. This has led to a culture of birth which is fetus- rather than woman-centred:


The column on the left is self explanatory. On the right we see how timing and electronic fetal monitoring can come to rule the conduct of the labour, and how the family can be sidelined. Likewise fixed definitions laying down the time of onset of labour – dilatation of the cervix 4cms., regular strong contractions – these determine starting the partogram action line.

So here are the women, afraid of getting into hospital on time, frightened of imagined and unknown life-endangering complications, unwanted interventions (though what are they?) and pain. “Am I capable of giving birth? Will I tear? Will the baby be healthy?”. And the media aggravate their fear and loss of control.

How can we generate the right conditions in which to give birth? Starting my second consultant midwife post 6 years ago I learned that the induction of labour rate was 43%, caesarian section rate 37%, and that on average one woman per week had been in intensive care. I asked the midwives whether we were going to celebrate birth as joyful, or commiserate with the women as they arrived? I wanted them to be both professional and human, and proposed the wedding day approach.

The women need to feel that there's no day more important, when guests (including staff) are welcome, the environment is right, and they are central. I can describe a perfect home birth early in my community career – in a garden, providing a sense of freedom, intimacy - and it set the tone for me forever. Now our Serenity Birth Centre
1 has rooms devised to be (in my mind) like that garden. A shower, a wet room, no bed; we have five such rooms. The right environment and equipment for the right woman.

Women want kindness and compassion; they respond to a midwife's touch (a partner's, a doctor's) with relaxation. By reducing their stress during pregnancy in these ways we minimise the risks due to high adrenaline and cortisol levels: babies of low birth weight, premature labour and placental abruption. Around labour
1 women manifest subtle changes; vasodilatation causes flushing of the skin and heat close to the birth, when feeling restricted they want to strip off clothing, a heat maintained for the third stage, but which may be followed by loss of heat and shivering due to vasoconstriction. A woman who has been and is well supported goes naturally through changes in her breathing as labour progresses; she needs no instruction. It is helpful to recognise an occipito-posterior fetal position by the shape of the abdomen and a raising of the woman's leg indicating where the baby's back is.

We have been taught the stages of labour:


But observation often tells us that women's bodies have different ideas; they are now older, heavier and more sedentary than when this (Friedman's) curve was developed in 1954. Dilatation of the cervix from 4 to 10 cms., then an average 3.9 hours, now takes 6.5 hours (Laughton 2012). At transition we see changes in behaviour, exhibiting a sense of helplessness, tremors, vomiting, hiccoughs and tearfulness. She is more active and vocal, and less inhibited, and all this may tell us that we can get on with delivery, but NO: we must be patient until the baby is in the right place. Interpreting this behaviour makes this the hardest part of labour for midwives. Respect the “rest and be thankful” phase if it happens; I have seen a woman go to sleep for two hours and then wake up to have the “fetal ejection reflex” (Newton et al. 1966
3), give birth, and all was well.

Be with the women. Wherever you are in the service apply the same philosophy of care. Ask yourself “Are you ready to reclaim your midwifery skills, to be an advocate for normal birth? Are you confident and competent to deliver the care and to challenge the fear around childbearing, and so to recover birth for the future of midwifery?” If you are inspired you can inspire others, despite as now being asked to do more for less. The spiritual teacher Marianne Williamson has said:


And Eleanor Roosevelt: “No one can make you feel inferior without your consent”.
Mahatma Gandhi: “First they ignore you, then they laugh at you, then they fight you. Then you win”.



Birthing pool use for labour and waterbirth.
Ethel Burns, Senior Midwifery Lecturer, Oxford Brookes University.

The estimated use of birthing pools during labour in the UK is 10%, and it is estimated that 2.9% of women have a waterbirth in the UK. These figures seem rather small, but as proportions of the total annual births they add up to about 72,000 using pools and almost 22,000 women having waterbirths (2011 data). Nearly all UK maternity units have birthing pools, most plumbed in. At home births the Pool in a Box has proved useful, and some hospitals can accommodate women wishing to take their portable pool if they cannot access a pool in the hospital.

Research from randomised controlled trials and observational studies on the use of water immersion during labour and waterbirth in the UK and across different cultures showed an associated reduction in the need for analgesia and augmentation of labour, and that women were more likely to have a spontaneous vaginal birth (SVD). There were no differences in maternal infections or adverse effects in the newborns - perinatal morbidity and mortality with admission to neonatal intensive care - between women who used water immersion compared with women who did not do so. The trials had small sample sizes, but nonetheless agreed that the duration of labour was unchanged, with some finding longer second stages for women who used water immersion. As midwives we know how subjective estimates of duration (excepting the third stage, of course) can be. Subjective though it may be, an increase in maternal satisfaction is an aspect we welcome.

Research also showed a higher rate of intact perineum, reduction in episiotomy, and no increase in OASIS (obstetric anal sphincter damage) associated with water immersion during labour and waterbirth. No increase has been shown in the incidence of primary post-partum haemorrhage; this is important given that waterbirth usually involves a physiological third stage. There is some anxiety that an undiagnosed short umbilical cord may result in a snapped cord during a waterbirth, so it is wise to avoid hurrying the baby's head out of the water. This complication tends to be recorded when it occurs at waterbirths, but is strangely ignored when births are 'on land'.

In the context of the UK, waterbirth has been portrayed as a symbol of normalising birth; for example, the cover of the publication, "Making normal birth a reality", shows a water birth. The consensus statement from the Maternity Care Working Party, set up jointly by the Royal College of Midwives, the Royal College of Obstetricians and Gynaecologists and the National Childbirth Trust, stated the need to recognise, facilitate and audit normal birth. Another important publication, "High Quality Women's Health Care: A proposal for change" (13/07/2011), recommended that healthy pregnant women should give birth in midwifery led units.

Prior to my prospective study, research was conducted in the obstetric unit setting, so there was no evidence for birthing pool use in midwifery led units or homebirth. Results for studies which involved women of mixed parity were not presented by parity, and comparative studies did not clearly present results for women who used a birthing pool but left the pool before delivery.

I set out to examine the characteristics of women who chose the use of birthing pools during labour and waterbirth, and the intrapartum interventions and outcomes that they and their newborns experienced in their planned place of birth. I was also interested in exploring whether birthing pool use during labour and waterbirth might have a role to play in normalising birth for healthy pregnant women.

Our objective was to study 1000 women for each care setting so as to enable data collection for rare adverse events for a population of healthy pregnant women. In this prospective study, data was collected during labour and up to and including the seventh postnatal day.

There was a representative geographical spread of care settings which comprised 15 obstetric units (OU, 4,130 women), five alongside midwifery units (AMU, 2,100), nine freestanding midwifery units (FMU), and 155 planned homebirths. Due to the small number of planned homebirths, following a sensitivity analysis, these were merged with data for women who planned to give birth in an FMU. This resulted in a community group of 2,694 births.



The mean age of the women was 29 years, which corresponded with the national average. Average gestation was close to calculated term; a small number of women had a previous CS, induction of labour, or a breech presentation. Of the 23 (undiagnosed) breech births, four took place in water. Additional results are presented in the tables below. There were few adverse events.



(MROP = manual removal of placenta)

Hitherto research involving participants who laboured in midwifery units has not differentiated between AMU and FMU settings. This birthing pool study showed marked differences between the AMU and FMU/community in the incidence of intrapartum interventions. In particular nulliparous women cared for in the community were significantly less likely to have an epidural or episiotomy, and more likely to have a spontaneous birth. This compared advantageously with nulliparous women who used a birthing pool and planned to give birth in either an obstetric unit (OU) or AMU, where interventions were more frequent and outcomes were remarkably similar. These findings indicated that there may be cultural differences between midwifery led settings which might influence practice. For multiparous women, intrapartum interventions and outcomes did not vary significantly between care settings.

The percentage rates for episiotomy are OU 16.6, AMU 17.5 and community 8.7. The perineum was most intact in the community, least in the OUs, explained there by instrumental deliveries. There was one maternal death two months after the birth; amniotic embolism was diagnosed. There were two unexplained stillbirths and two unexplained neonatal deaths. In no case was birthing pool use during labour or waterbirth implicated. 

Overall 7915 women had SVDs, of which 5192 (58.3%) took place in water. Of the 2193 nulliparae who had water births 2131 (97.2%) had normal births as defined by the consensus definition. This composite outcome was characterised by spontaneous onset of labour, no epidural, and SVD with no episiotomy. Of the 2999 multiparae who had waterbirths 2904 (96.8%) had normal births.

As seen in the table below, newborn outcomes did not vary between care settings and adverse events were rare.


This has been the largest prospective study for the use of birthing pools in labour and the first to report results by parity and planned place of birth.

Implications of this study for practice and future research:
•The study provides further evidence justifying the offer of birthing pool care to women, particularly healthy nulliparae who plan to give birth in the community setting
  •Birthing pool use during labour and birth facilitates normal birth
•Perhaps birthing pool eligibility criteria should be revisited
•Differences between midwifery led settings require further research 
•Further research is required to explain maternal and midwife barriers and facilitators 

Physiological third stage
Professor Cecily Begley, Chair of Nursing and Midwifery, Trinity College Dublin

The way the third stage of labour progresses is not a separate entity in the birth process. It depends not only on the first two stages but on the mother's previous births and on her earlier life. Our most important role in its management is to facilitate as good a meeting of the baby with its mother and family as possible.

So how are we to argue the case for a physiological third stage with the strong supporters of the active alternative? Their case is that physiological is unnecessary, active is quicker. Well, the International Confederation of Midwives (ICM) tells us that every midwife is required to attend the birth of the placenta without the use of uterotonics and that knowledge of both active and physiological managements is a basic midwifery competency. The NICE guidelines would have us support the choice of women requesting physiological management. Only frequent use of this way gives us the confidence needed when supporting women who want it.

The other opposing argument is "women can die of PPH". Indeed they do so die in underdeveloped countries where the necessary skills and uterotonics are lacking. On the other hand the Centre for Maternal and Child Enquiries (CMACE) has only five of 2.3 million women dying of PPH in 2006 to 2008; of these, three lacked observations using Modified Obstetric Early Warning Score (MEOWS) charts, leaving the midwives unaware of excessive bleeding. None of the women were at low risk of haemorrhage and in two cases there were early warning signs: low preceeding Hb, concealed pregnancy at home. Mostly they were not having normal births attended by a midwife.The Cochrane review of third stage management compared active (AMTSL) and expectant (EMTSL) management of the third stage of labour. It comprised five studies totalling 6486 women in high income countries
1 [Begley 2011]. In three studies of 3134 women, all at low risk of bleeding, there was no difference in severe PPH (more than 1000 mls.) and postnatal anaemia between active and expectant management. There were however interesting differences in benefits and harms in the two groups:


The slide shows the harms associated with the two groups. The higher rate of blood loss of 500 to 1000 mls in the EMTSL group is insignificant (consider the amount happily given by blood donors), and I regard more than 1000 mls to be a PPH. There were very few transfusions required, but more needed oral iron supplements. The lower birth weight in the AMTSL group can be ascribed to cord clamping, which denies the babies 70 to 80 mls of blood, leading to an increased incidence of anaemia at age 3 to 6 months. These mothers have a few more re-admissions for secondary PPH. It is apparent that both management methods confer harms and benefits, and we have to discuss their choices with the women. However some of the research was done at a time when induction and augmentation of labour with oxytocin was common, and since this desensitises the uterus to oxytocin, these women should not be categorized as low risk; more research is needed.

When we introduced physiological third stage management in Dublin an unacceptable incidence of PPH fell from 21% to 6% as the midwives acquired the necessary skill; at first there had been flaws in the RCTs. In other research the trend shown was an advantage – lower blood loss - in EMTSL, despite which there remains in the minds of some clinicians, uninformed and unpractised in it, the fear of a risk to be avoided.

We can learn much from the MEET study (Midwives' Expertise in Expectant Third stage management)
2 (Begley et al 2011). "Watch and wait": if the first and second stages have been uneventful why can't we leave the third stage alone? It's a hands off process. Don't clamp the cord; leave it to stop pulsating. Meanwhile we attend to the wellbeing of mother and baby: skin to skin contact, breast feeding when it's the right time, keeping them warm. Observing the placental separation bleed, it was more in EMTSL than AMTSL, but there would be much less bleeding thereafter. We need to keep our attention on mother and baby: these minutes are important for their early relationship, but for delivery of the placenta have her truly upright, standing, walking, sitting on the toilet or birthing stool. Seeing the placenta moving down and when there are signs that the placenta is in the vagina experienced midwives give the cord "just a little lift" to guide it out; this is not controlled cord traction, the uterus is left alone, but without that assistance the placenta can stay in the vagina for a long time.So for low risk women the norm will happen. Syntocinon can still be used to treat unexpected blood loss; it is less effective if it is given as a preventative. Midwives have noticed a negative fetal reaction to early cord clamping; leave it for three minutes after pulsation has stopped.

Above all, watch and wait.

Key references

1. Begley CM, Gyte GML, Murphy DJ, Devane D, McDonald SJ, McGuire W. Active versus expectant management for women in the third stage of labour. Cochrane Database Syst Rev 2A10, lssue 7. Art. No.: CD007412.DOI:10.1002/14651858.CD007412. pub2

2. Begley C, Guilliland K, Dixon L, Reilly M, Keegan C, lrish and New Zealand midwives expertise in expectant management of the third stage of labour: the 'MEET' study. Midwifery 2011; Oct 18. [Epub ahead of print]

International Confederation of Midwives. Role of the midwife in physiological third stage labour. The Netherlands, lCM, 2008. THIRD%20STAGE%20OF%LABOUR.doc

McDonald SJ, Middleton P. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database of Systematic Reviews 2008, lssue 2. Art. No.: CD004074. D0l:10.1002/14651858.CD004074.pub2

New Zealand College of Midwives. Third stage management practices of midwife led maternity carers: an analysis of the New Zealand College of Midwives Midwifery Database lnformation 2OO4 -2008. Christchurch: The New Zealand College of Midwives, 2009.