Humans have a gestational age of about 40 weeks, though a normal gestational period is from 37 to 42 weeks. It is the greatest desire of both the mother and midwives that the baby comes in to the world safely and with very little traumata. .This essay seeks to examine how the midwife is the ‘expert of the normal’ and their role in the promotion of normality in childbirth . We also look at the midwife’s role in promoting normality in childbirth, This is relation to waterbirth care will be explored through knowledge and evidence based midwifery practice.
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Promoting normality in childbirth can be defined as encouraging woman and professionals to consider vaginal birth without any intervention. It includes acting as an advocate for prospective mothers and ensuring that in all or most birth experiences normality is addressed in such away that will reduce the fear in woman. Focus must be paid mostly to high risk women. These include young mothers, first time mother and those who have had terrible experiences in the past.
One of the best ways to encourage normality in childbirth is to make potential mothers to believe that it can be done with less pain and trauma, especially using the tool of advocacy.Attaining 100% normality is not about forcing women to have normal births and predispose them to believe there will be neither pain nor trauma. Neither can we encourage a laissez faire posturing where a woman’s choice is the mantra, and midwifery and obstetric expertise counts for nothing in the equation (Elaine, 2005)
For the purpose of this study, the writer will focus on the midwife’s role in promoting the benefits of waterbirth and giving women the choice. The opportunity to have water birth should be offered to all healthy women who have straightforward deliveries.
In 1803, a medical journal featured the first recorded water birth in modern times. After 48 hours of labour, a woman used a hot bath out of desperation. She had no choice but to give birth in the water, as the baby arrived as she was relaxing, before she even had time to complete her bath. Influenced by her personal experience, in 1998, Harper (2005) decided to create Waterbirth International. The aim of this organisation is to provide up to date and accurate information about the part water could play in labour and birth. Harper continues “to make waterbirth an available option for all women”. (Harper, 2005) states that “option is the key word in knowing that this method of birth is not for every woman, but every woman should be given an informed choice of whether it makes sense for her”.
The Royal College of Midwives describes waterbirth as a process which results in reduced trauma and stress to both mother and baby. During the birth process there is an interactive symbiotic relationship between the mother and the baby. However, there is always the risk of trauma to the mother and the fetus at the point of interaction. An increasing number of women are opting for waterbirth. This concept has existed since early civilization when women used water to relieve the discomfort of childbirth. Now, waterbirth is offered to women who have a low risk pregnancy and involves the use of a tub specially designed for childbirth, which is supported by both The Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives. It appears that waterbirth presents very few complications, but the guidelines produced will go even further to ensure that complications are minimised. These include firm adherence to the eligibility criteria, management of chord rupture and infection control. (Harper, 2005)
Approximately 80% of human beings are delivered by midwives. A word which literally means ‘with women’; they are trained to assist women during pregnancy, labour and the first year of the baby’s life. Midwives have been long established throughout the world as the most appropriate persons to provide care to women during their reproductive years. Because of her professional training, a midwife has the knowledge and skills necessary to support the mother, as well as the rest of the family, with care, education and counselling. Apart from having an outstanding safety record, various studies have proved that midwives produce exceptional results.
According to Elaine (2005), the five lowest rates of infant mortality as well as use of technology have been recorded in countries where midwives are present in the birthroom, without a physician. As skilled specialists, midwives play a vital role in supporting and maintaining the high standard of normal childbirth. Maternity services can play their part in developing the midwife’s expertise and autonomy by ensuring that there are suitable opportunities for meaningful practice. Midwives should also be valued for their skill and dedication. It is very important therefore, for a midwife to be confident and competent enough to give legitimate and safe informed advice to the mother;this will help in achieving the desired optimum results in promoting normality. Since they have to be proficient in supporting normal childbirth in a variety of settings without supervision, including the home, midwives are required to work to the NMC standards. This will ensure legitimate, safe and successful practices during the entire childbirth process (DoH, (2007), NMC, (2008) The midwife’s roles include encouraging normal birth, using preventive measures, recognising complications in mother and baby, facilitating the access of relevant services and implementing emergency procedures. To achieve this, the midwife must work in partnership with the woman both before and after childbirth (International Confederation of Midwives, 2005). Good communication is an essential skill for a midwife. Clients feel confident to make their own decisions without anxiety when they believe that they are valued enough to be listened to and efforts are made to facilitate their understanding (RCM, 2006).
Miller (2006), recommends that every woman who has a normal pregnancy should be offered the opportunity of water birth. He maintains that this will result in a more fulfilling experience for both mother and child while increasing the midwife’s job satisfaction. Most women prefer waterbirth, but there must be meaningful discussions with the midwife before making this decision.
However, a woman must have all the information, including the pros and cons, as well as support in order to make an informed decision about the use of waterbirth.Waterbirth should also be discussed as an option for pain relief during childbirth and leaflets and other information should be provided (MIDIRS, 2008). There are no major differences to the results produces by analgesia, except for the fact less epidural, spinal or par cervical pain relief is required during water birth. As we move away from the high induction rates of the 1970’s more women are choosing to give birth at home and in local birth centres (Wickham, 2005) Women want continuity of care, choice in the care they are provided with and control over the process of childbirth.
Waterbirth should be viewed as an alternative method of care and management in labour and as one which must, therefore, fall within the duty of care and normal sphere of the practice of a midwife. Waterbirth is not considered to be a ‘treatment’ (Wickham, 2005) It is important that midwives have up-to-date knowledge and information on the latest research and evidence relating to the advantages and disadvantages of labour or birth in water (RCOG/RCM 2006)
Benefits of waterbirth
Waterbirth has several , including the following: It facilitates mobility and enables the mother to assume any position which is comfortable for labour and birth; speeds up labour; reduces blood pressure; gives mother more feeling of control; provides significant pain relief; promotes relaxation; conserves her energy; reduces the need for drugs and intervention; gives mother a private protected space; reduces perineal trauma and eliminates episiotomies; reduces caesarean rates; it is highly rated by mothers – typically stating, they would consider giving birth in water again; it highly rated by experienced providers; and it encourages an easier birth for mother and a gentler welcome for baby (Harper, 2005)
Burns et al., (2006) believes that waterbirth is associated with higher maternal satisfaction than birth on dry land. In a questionnaire assessing women’s views on waterbirth, Richmond (2003) found that when women got into the pool in labour many of them described feelings of complete relaxation. Lying in warm water gives a sense of relaxation, but whether it actually reduces pain is unproven. A perception of relaxation, pain relief, ease of movements and more holistic experience made labour in water a popular choice during the 1980s. Women felt they were given immediate pain relief and the warmth was soothing. Many mothers enjoyed the buoyancy and mobility the water gave them. (Richmond, 2003) Also, Miller (2006) believes that women using a water pool feel more empowered and less exposed. Immersion in water increases self control in a secure, warm, private and quiet environment, thus encouraging the promotion of normality. There are considerable perceived benefits of using immersion in water during labour, including less painful contractions and less need for pharmacological analgesia, shorter labour, less need for augmentation, with no known adverse effects for the woman herself (Thoeni et. al, 2005)
However, there may be rare but clinically significant risks for the baby born under water. Possible complications that may be associated with water birth include fresh water drowning, neonatal hyponatremia, neonatal waterborne infectious disease, cord rupture with neonatal hemorrhage, hypoxic ischemic encephalopathy, and death. The rates of these complications are likely to be low but are not well defined (Wax and Wilson, 2004) In his/her study of this phenomena, (Cluett, 2004) concluded that there was no significant difference in other important clinical outcomes, including duration of labour, operative delivery and perineal trauma. There were no increased adverse outcomes for the baby (Cluett, 2004)
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Otigbah et al., (2000) found in a study comparing waterbirths and conventional vaginal deliveries, concluded that labouring and delivering in water is associated with a shorter labour and reduced perineal trauma for primigravidae women. (Gilbert and Tookery, 2004) concluded that perinatal mortality is not substantially higher among babies delivered in water than among those born to low risk women who delivered conventionally (Gilbert and Tookery, 2004). Although there is no evidence of higher perinatal mortality or admission to special care baby units (SCBUs) for birth in water; caution is advised because of small numbers, possible under-reporting of SCBU admission and exclusion of women who were in labour in water but gave birth conventionally after complications. (Cluett et. al, 2004)
All women require less analgesia. Odent (2000) suggests that if a small number of recommendations are taken into account, using water during labour will seriously compete with epidural anaesthesia. Most of the available evidence is restricted to healthy women with uncomplicated pregnancy at term although there is some evidence that labouring in water under midwifery care may be an option for slow progress in labour, reducing the need for obstetric intervention, and offering an alternative pain management strategy (Cluett et. al, 2004)
Gessbuhler et al., (2004) found that perineal trauma is minimised during a waterbirth: episiotomy is hardly ever needed; there are fewer first and second degree perineal lacerations, and fewer vaginal and labial tears. Hale (2008) believes this is owed to the softening effect of the warm water and the woman’s ability to relax her perineum more readily. Support from the water slows the crowning of the baby’s head and offers perineal support which decreases the risk of tearing (Garland, 2004) Women with prolonged labour found a reduction in obstetric intervention following immersion in water and instrumental delivery is also rarely necessary Cluett et. al, (2004) and Beech (2008) points out that labouring in a birth pool encourages an upright position and increases the pelvic diameter which often increases the rate of cervical dilatation. Waterbirth reduces the need for pain relieving drugs; however, if it does not work the woman has the option of choosing other forms of pain relief.
Maternal and fetal infection rate is however, comparable to traditional deliveries (Zanetti-Daellenbach et. al, 2006) and (Thoeni et. al, 2005) The selection of a low-risk collective is essential to minimize the risks with the addition of strictly maintained guidelines and continuous intrapartum observation and fetal monitoring. Waterbirths are justifiable when certain criteria are met and risk factors are excluded (Zanetti-Daellenbach et. al, 2006). Monitoring of the fetal heart using underwater Doppler should be standard practice. If the woman raises herself out of the water and exposes the fetal head to air, once the presenting part is visible, she should be advised to remain out of the water to avoid the risk of premature gasping under water. All birthing pools and other equipment (such as mirrors and thermometers) should be disposed of or thoroughly cleaned and dried after every use, in accordance with local infection control policies. Disposable sieves should be made available to ensure that the pool remains free from maternal faeces and other debris. Local information and guidelines regarding prevention of legionella build up in water supply from seldomly used pools should be obtained from local NHS trust estates and should be adhered to. Midwives should use universal precautions and follow local trust infection control guidelines. (Wickham, 2005) All midwives should ensure that they are competent to care for a woman who wishes to have a waterbirth and have a good understanding of the basic principles of caring for a woman in labour, and should make themselves aware of local policies and guidelines.
Midwives, managers and supervisors of midwives should ensure that training in caring for a woman who wishes to have a waterbirth is undertaken by midwives who undertake intrapartum care, in order to increase choice for women and promote normality and ensure quality care. Midwives’ roles after all are that of “with woman” serving the needs of healthy, childbearing women, not the sick and dying (Zanetti-Dallenbach et. al, 2006)
In the same way as the woman who wants a natural birth with little or no intervention, where will she be if as midwives, we do not speak for her? The aim of promoting normality is that every women’s birth experience is a positive one, and finally it is important to achieve the women choice .
CONCLUSION AND RECOMMENDATIONS
The joy of motherhood stems not only from reduced trauma and stress for both mother and child, it also comes from the power of choice exercised by the mother. So far, we have established that normality in childbirth should be the rule and that although several psychological, sociological and medical factors may weigh against it, scientific research still offers it as perhaps the most desirable. However, the midwife’s role begins with the use of communication and advocacy to encourage women and professionals to consider normal birth as a viable and safe option, just as the concept of waterbirth as a way of reducing discomfort of childbirth should be embraced by those who have normal birth.
In the light of these findings I wish to make the following specific recommendations:
1 Women should be helped through advocacy and communication to make a deliberate choice of normal birth.
2 They should also be helped to make an informed decision about the use of waterbirth.
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