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As with mother friendly care during pregnancy, this is a method of caring for women where the interests of the woman and her fetus or newborn infant are considered above those of the hospital or clinic staff. Mother friendly care is good care. Wherever possible, it is based on good scientific evidence. Many women find present labour practices unpleasant and, therefore, avoid delivering in a clinic or hospital. Instead, they prefer to deliver at home.
They are the same as the principles of mother friendly care during pregnancy, i.e. managing each woman as an individual and caring for her with kindness, compassion, patience, gentleness and respect. Both the woman’s physical and emotional needs must be considered.
Labour, delivery and the puerperium are an ideal opportunity to allow and encourage women to play an active role in their own care. They should understand what will happen and what is expected of them. It is very important to explain to a woman what is occurring. It is very frightening for a woman if she does not understand what is happening to her and her baby. Fear may slow her progress of labour.
In the past many women were routinely given an enema at the start of labour to empty the bowel. It was believed that this would speed labour and delivery. Passing stool during delivery can be an embarrassing and unpleasant experience. Although enemas are no longer given routinely, some women would prefer to have an empty bowel before delivery. An enema should be given if the woman feels constipated or requests an enema. Modern enemas can be given quickly and painlessly. However, soiling during delivery is not always prevented by the use of enemas. Women in labour should be allowed a choice. Remind them that passing a small amount of stool at delivery is common and is easily managed by the midwife.
There are no good reasons for the routine use of enemas during labour.
Similarly, there are no good reasons for giving caster oil or any other medicine to promote stooling before labour.
For many years, all women expecting a vaginal delivery had their perineum shaved during labour. It was believed that this would reduce the risk of infection following an episiotomy or tear and make the repair easier. In contrast, it has been shown that shaving often causes minor cuts which increase the risk of skin infection after delivery. Many women find perineal shaving painful and feel embarrassed at being shaved. The shaved area also feels uncomfortable and itches when the new hair starts to grow. There is a risk of HIV transmission if an unsterile blade is used.
There are no medical reasons for shaving the perineum before delivery.
Similarly, there are no medical reasons for shaving a woman prior to Caesarean section. Pubic hair can simply be cut short. However, some women would prefer the upper boarder of their pubic hair shaved to avoid the pain later of removing the surgical strapping.
Warm water can be very soothing during labour and helps to reduce pain and discomfort. Relaxing in a warm bath can be very comforting. Unless there is a medical indication, there is no harm in either showering or bathing during labour. Rupture of the membranes is not a contraindication to bathing. It is important that the bath is very well washed out before it is used. Underwater deliveries have not shown an increased risk of infections due to water entering the vagina before delivery.
Women should be allowed to shower or bath during labour.
Therefore, the old fashioned routine of ‘oil, bath and enema’ is no longer practised.
Most women in labour want to drink. Not drinking in labour is like running a marathon without taking any fluids. No fluid intake during labour may result in dehydration and acidosis which can cause fetal distress. Even women having a trial of labour should be allowed to have sips of clear fluids
It is better if repeated, small amounts of water or sweet tea are drunk than a large amount at a time. Some women prefer drinks that are cold. If a woman cannot take fluids by mouth during labour, she should receive an intravenous infusion (‘drip’) of maintenance fluid (e.g. Ringer’s lactate) to prevent dehydration.
Women should take small sips of water during labour.
Women should not be routinely starved during labour. Small, frequent snacks are preferred by most women. They should not have a large meal. Some women do not want to eat during labour but most will need to drink. Taking food during a long labour helps to prevent exhaustion. Snacks such as glucose sweets, jelly or fruit are preferred. Encourage women to bring some fruit with them. Allowing food and fluids during labour prevents ketosis and hypoglycaemia. Ketones in the urine indicates that the mother is not getting enough energy.
Food should not be routinely withheld in labour.
Recent studies show that starvation during labour does not always prevent inhalation of stomach contents during general anaesthetic. However it seems wise that women should take nothing by mouth if they are being prepared for Caesarean section under general anaesthetic. Women who are having a trial of labour or are at high risk of needing a Caesarean section can take clear fluids but not solids during the active phase of the first stage of labour. Women who are waiting for an elective Caesarean section should be starved of food but can continue to have small sips of clear fluids until two hours before the general anaesthetic. Most women having an elective Caesarean section in the morning are starved of solids from the previous evening.
Most women should be encouraged to walk around and keep mobile rather than remaining in bed during labour. They can relax in a chair or find a comfortable position. There are many disadvantages to a woman lying on her back, such as postural hypotension. Labour progresses faster, with less pain, if a woman is able to move about freely.
Women should be encouraged to move about and walk around during labour.
There is no need for a woman to wear hospital clothes during a normal labour. Many women feel more comfortable and confident in their own clothes. To avoid blood stains, most women prefer to change out of their own clothes for the delivery.
Traditionally women delivered at home where they were surrounded and supported by their family and friends. Now most women labour alone in hospital as family have been discouraged because of the fear of infection, lack of privacy for other patients, and the disruption of the labour ward routine. Unfortunately a lack of staff usually prevents a midwife staying with a woman throughout her labour and delivery.
Many trials have shown the benefits of a labour companion, which include:
Women do not want to labour alone. Therefore, it is important that every woman in labour should receive the companionship she needs.
Every woman should be encouraged to have a companion in labour.
Each woman should choose her own labour companion if possible, such as her husband, partner, friend or relative. A professional or lay birth companion (doula), previously unknown to the mother, can also be of great help and support. Many women prefer another woman to support them in labour. Doulas are particularly important when there are not enough midwives to support women in labour.
A labour companion should support, encourage and praise the mother. Labour can be very lonely, frightening and bewildering if one is a alone. The labour companion can rub the mother’s back, help her with her breathing, help her to turn while lying, get her something to eat or drink and support her while walking. The birth companion should stay with the woman throughout her labour, providing physical and emotional support. Trained doulas can also help after delivery with breastfeeding. The role of the labour companion is different from that of the person who conducts the labour and delivery.
The role of a labour companion is to encourage and support the woman during labour and delivery.
It is very important that the condition of the fetus is monitored during every labour. This can usually be done with a fetal stethoscope or hand held Doppler ultrasound fetal heart rate monitor. Once the base line fetal heart rate between contractions has been determined, the fetal heart should be listened to during and after a contraction to detect any decelerations. It is important to be gentle as the procedure can be uncomfortable, especially during a contraction. Electronic fetal heart rate monitoring (‘CTG’) usually is only needed if the infant is at high risk of fetal distress.
Labour is almost always painful. If the mother is not distressed by the pain, analgesia is not indicated. However analgesia must be made available to all women who ask for it. Women should have a choice of no analgesia, opiate analgesia (pethidine or morphine), inhaled Entonox (50% nitrous oxide with 50% oxygen) and epidural analgesia if the service is available. Encouragement, a warm bath or shower, or gently rubbing the lower back, relaxation, breathing techniques and a ‘birth ball’ are very helpful. Infants are often sleepy for the first few hours after opiate analgesia. A caring, competent midwife and labour companion are often the best form of pain relief.
Previously, early artificial rupture of the membranes (active management of labour) was encouraged to speed up the first stage of labour, allow the early detection of meconium stained amniotic fluid and reduce the risk of undiagnosed prolapse of the cord. Recently, spontaneous rupture of the membranes is preferred as studies have questioned the benefits of early, artificial rupture unless there are clear medical indications. This is especially important in communities with a high rate of HIV positive women as the risk of HIV transmission to the infant increases as the duration of membrane rupture becomes longer.
Routine early rupture of the membranes is no longer practiced.
A natural childbirth is a delivery where there is minimal medical interference and the women has as much control as possible. Women should be encouraged and allowed to have a natural childbirth whenever possible. However, the labour and delivery should be supervised and monitored by a skilled person to detect and manage any complication which may arise. A natural childbirth is not an unsupervised delivery.
It gives the mother the pride, joy and satisfaction of having been in control of her own labour and delivery. It enables the mother to have a choice in what she wants.
Most healthy women who are expecting a normal delivery and a healthy infant at term can be safely delivered by a trained midwife. Delivery by a doctor is only needed if a serious complication is expected in the mother or infant. There is no medical reason why normal deliveries should be conducted by a doctor. In many countries most deliveries are very ably conducted by midwives.
Most women can be safely delivered by a trained midwife.
Many women can be safely delivered at a primary care maternity clinic (midwife obstetric unit). Only where complications are present or are expected, need a woman deliver in hospital.
There are many advantages if a healthy woman with a normal pregnancy can be delivered at a maternity clinic:
In a large regionalised maternity service, about half of all pregnant women can be safely delivered at a clinic. The other half are referred to hospital during the antenatal period or during labour because of one or more risk factors.
With careful selection, many women can be safely delivered at a maternity clinic.
With careful selection, some women can be delivered safely at home. However, excellent transport and communication are needed in case of an emergency. A warm, well lit home with clean water and other basic facilities are also needed. In poor communities, many of these requirements are missing. Instead of home deliveries, it is preferable that women deliver in a clinic close to their home.
Every effort must be made to ensure that a trained birth assistant is present at every delivery, i.e. a doctor, professional midwife or well trained traditional birth attendant (TBA). Having a trained birth attendant at every delivery is one of the most important factors in reducing both maternal and perinatal mortality. It is very dangerous for family members or untrained birth assistants to conduct deliveries, especially if they are not experienced.
If possible, and if the woman wants him there, the father should be present during labour and delivery. It is important that he support his wife or partner and share in the experience of childbirth. Being present is important in strengthening bonds between mother and father and developing bonds between father and infant. Often fathers can attend a Caesarean section.
There are times where it may be best if the father leaves the delivery room for a while. Either if the mother wishes it or during a medical procedure. The father should not interfere with the management of the woman.
The father should be encouraged to attend the labour and delivery.
Although this is usually not allowed during clinic or hospital deliveries, children are often present during home deliveries. Children know that their mother is pregnant and ask questions about the delivery. Being present at a delivery can be either a frightening or exciting experience for a child. It is important to explain to children what to expect, that their mother will have some pain, and that this is normal.
Many women are still expected to lie on their backs during delivery (supine position). This has been shown to be the worst position for the fetus as the uterus presses down on the mother’s main blood vessels which can cause maternal hypotension and a reduced blood flow to the placenta, resulting in fetal distress. It is also very difficult to bear down effectively in this position. Labour ward staff, however, have tended to prefer the supine position as it provides the best access to the delivering head.
Many women prefer to find their own most comfortable position during delivery. Some want to squat, crouch, kneel or lie on their side. Some women may wish to change their position during delivery. It is important to allow a woman to choose the position that feels best for her. The upright (squatting, crouching or kneeling) and side-lying (lateral) positions results in less pain, better progress of the second stage and less perineal tears.
Often a compromise position can be found. For example, the mother can squat or kneel on the bed, holding onto the top of the bed for support, and then lie down once the head has crowned. Labour ward staff should get used to delivering women in different positions.
Women should be guided and encouraged to find the most comfortable position during delivery.
No. There are no good reasons for performing a routine episiotomy on all primiparous women during labour.
For many years it was believed and taught that is was better to perform an episiotomy than allow the perineum to tear. This is now known to be incorrect as there are more complications with an episiotomy than with a first or second degree tear. A first or second degree tear is easier to repair and results in less trauma, less suturing, better healing, less dyspareunia (painful sex) and less urinary and bowel incontinence later. An episiotomy does not always prevent a third degree tear.
An episiotomy should only be performed when there is a good medical indication, such as prolonged second stage of labour or fetal distress during the second stage.
Episiotomies should be avoided where possible.
In many industrialised countries, it is common for women to ask for an elective Caesarean section to avoid the expected pain, discomfort, embarrassment and inconvenience of a spontaneous vaginal delivery. A Caesarean section will also avoid a possible episiotomy or perineal tear, and reduce the risk of vaginal damage and stress incontinence after the delivery. However, both a Caesarean section and an anaesthetic also have dangers, especially infection and thrombo-embolism. The risk of complications, both to mother and infant, is higher with a Caesarean section. In poor countries, the lack of staff and facilities make a personal choice impossible. Many of the fears of a normal delivery can be avoided with good care and a full explanation.
Explore with her the reasons why she wants a Caesarean section. Often these fears are based on incorrect knowledge. Explain the correct facts to her. It is important to stress the feeling of achievement and the bonding experience with her infant after a normal delivery. The hospital stay is also shorter after a normal delivery while the risk of problems with future deliveries is less. Infants born by elective Caesarean section are at an increased risk of needing admission to an intensive or high care unit. However, if she persists with her request for a Caesarean section, her wishes must be considered. Some women have an extreme and irrational fear of giving birth. This may result from a previous traumatic birthing experience, rape or sexual abuse. Birth choices should be discussed towards the end of pregnancy or at the onset of labour. Lack of hospital facilities and staff often limit the option of a ‘social caesar’.
Many women, who have had a normal pregnancy and expect a vaginal delivery, are very disappointed if they have to have an unplanned Caesarean section for medical reasons. They feel that they have failed after all the preparation at antenatal classes. This may be bad for their self esteem and even interfere with the normal bonding process with their infant. These women need emotional support and reassurance.
Sometimes women ask, or their doctors suggest, that labour should be induced at a convenient time. These social advantages must be balanced against possible medical disadvantages. If the induction fails, a Caesarean section may be needed. Induced labours also have a greater risk of a longer and more painful first stage or an instrumental delivery. Infants born after an induced labour are at an increased risk of respiratory distress, even in a term pregnancy. Therefore, very serious thought must be given before a ‘social’ induction of labour is done.
By being able to express her own opinion and make her wishes known, and by having these seriously considered by caring staff. The birth attendants must always be aware of the mother’s right to dignity and privacy.
Many women are afraid and feel out of control during delivery. They may not understand what is happening and they may be in pain. Support and encouragement are, therefore, an essential part of managing a delivery. It is totally unacceptable to ever shout or hit a woman during delivery.
It is not easy to change labour and delivery practices which have been used for many years, especially if these practices are convenient to the staff and hospital management. However, every effort must be made to change practices and attitudes to those that are based on good scientific evidence and provide better care to the mother. Changes often have to be introduced slowly, one at a time. A lot of time, energy and commitment are needed to make changes. Both the staff and mothers should be told, and should understand, the reason for the change. The staff need to be educated, encouraged and supported.
The Better Births Initiative (BBI) is an international project to improve the quality of care during labour and childbirth by listening to women’s views and using the best evidence available. BBI promotes efficient, effective and beneficial practices and stresses that women should be treated with humanity and respect. It is important that care provided during labour and delivery is based on the best evidence rather than on traditional practices. Staff should be committed to improving care.
The four main messages of BBI are:
Evidence based medicine is health care based on information obtained by carefully conducted, randomised controlled trials and extensive systematic reviews of the current literature. This is preferable to personal opinions and expert views which are often proved to be incorrect.
With a normal delivery and a healthy mother and infant, the infant should be given to the mother as soon as possible after delivery. Usually this is done after the infant has been dried, briefly examined, the cord cut and the 1 minute Apgar score has been assessed.
She should be encouraged to give kangaroo mother care with the infant placed on her naked chest. The infant can be covered with a dry, warm towel. Kangaroo mother care soon after delivery promotes bonding and successful breastfeeding. Most mothers want to hold and examine their infants immediately after birth. The mother should also be encouraged to breastfeed. This may speed up the third stage of labour by stimulating uterine contractions. There is no need for a routine five minute Apgar assessment if the infant is normal and did not need any resuscitation.
These routine procedures, such as giving vitamin K, placing prophylactic ointment or drops into the eyes and identifying the infant, can be done once the mother has had a chance to meet her infant. Usually they can be done while the mother holds her newborn infant.
If possible, the infant should stay with the mother. This is possible after most deliveries. Bonding during the first hour after delivery (the ‘golden hour’) is particularly important.
The mother and infant should not be separated after delivery.
The mother can play an important role in the prevention of postpartum bleeding, especially during the first hour after delivery. Breastfeeding directly after delivery encourages the uterus to contract. She should be asked to be aware of vaginal bleeding and immediately call for help should she start to bleed excessively. Usually only one or two sanitary pads are soaked after a normal delivery. She can also be shown how to assess the height of her fundus and feel whether her uterus is well contracted. Again she should immediately inform the nurse or doctor if her uterus relaxes or increases in size. She must also have been shown how to rub her uterus and be instructed to do this at regular intervals. She should keep her bladder empty. In this way the mother is able to monitor her uterus. This is particularly important if there are inadequate staff to closely monitor each mother after delivery.
Women should be encouraged to play an active role in the management of their labour and delivery.
Most women normally feel anxious and tearful for a few days after delivery when they are faced with the overwhelming tasks and responsibilities of caring for a newborn infant. Giving birth is also often the start of major changes in their lives. A woman may feel that she is no longer attractive to her husband. These very strong emotions, ‘the blues’, usually start three or four days after delivery and only last a few days. Uncommonly they may last a few weeks. Staff need to explain that irrational tearfulness is very common and will disappear without treatment. Emotional and practical support by staff, family and friends is important. If the woman does not feel better by two weeks after delivery, a diagnosis of postnatal depression must be considered.
Postnatal ‘blues’ are normal in the first week after delivery.
Postnatal depression may occur at any time during the year after delivery. Surprisingly, the symptoms of depression usually are already present during pregnancy, but worsen after delivery. In industrialised countries, about 15% of women have postnatal depression. The incidence appears to be much higher in poor communities with greater social and economic problems.
Postnatal depression is not uncommon.
Postnatal depression usually presents with features of both depression and anxiety, similar to depression at other times of life. Women with postnatal depression feel tearful and sad, they may worry excessively, may be irritable and feel angry, are afraid of being alone, feel they cannot cope, and can have suicidal thoughts. Often there are changes in appetite and sleep pattern with tiredness and loss of energy. They often have a loss of self esteem, cannot concentrate and lose their sex drive. They feel hopeless, inadequate and guilty and have no enjoyment. They often feel a lack of joy in their infant and may even fear that they could harm the infant. Anxiety may present with fearfulness, panic attacks or a wide range of physical complaints such as weakness, restlessness, shortness of breath and dizziness.
Postnatal (puerperal) psychosis occurs in about 1/1000 deliveries. These women have lost touch with reality and hear voices or have hallucinations. There behaviour is very abnormal. They are often paranoid (believe unreasonably that people or even their infant are plotting against them) and need urgent psychiatric care to avoid hurting themselves and their infant.
Postnatal depression affects a mother’s ability to interact with her infant. These women often feel alone, despairing and isolated, and find their infants difficult or demanding. The physical and emotional development of these children may be slow as the poor mother-infant interaction may result in a lack of stimulation or even neglect. They are at an increased risk of child abuse.
If possible, women who are depressed or at high risk of depression should be identified during pregnancy as an early diagnosis results in a better outcome. A caring health worker can usually recognise pregnant women who are depressed. However, a formal screening tool is available. All women who are thought to have symptoms and signs of depression should be referred to a counsellor, social worker or the community mental health team for evaluation and management. Often depressed women are afraid of being referred for assessment.
Women with antenatal depression also need understanding, support, psychological therapy and often medication. Support groups are helpful and simply listening can be of great value. Antidepressants are safe during pregnancy and breastfeeding. Kangaroo mother care, touch therapy and breastfeeding are all useful in helping depressed mothers bond with their infants.
Postnatal depression can be screened for during pregnancy.
A young primigravid woman with mild hypertension presents in labour at the local hospital. She is given a tablespoon of caster oil followed by an enema. Later a nurse shaves her pubic hair and she is asked to bath. When she questioned whether the shave was necessary, she was told that it is routine management of all women in labour. Her boyfriend is informed that he cannot attend the delivery. When the woman complains about the attitude of the staff she is shouted at and told that she can deliver at home if she chooses.
No. ‘Oil and enema’ are no longer routine practice. Some women however request that they have an enema to empty the bowel as they are afraid they may soil during delivery. There is no scientific evidence that an enema speeds up labour and delivery.
There is no need to shave women in labour. Often long pubic hair is trimmed. Contrary to earlier belief, shaving does not reduce the risk of infection in a perineal tear or episiotomy. Small cuts made during shaving may increase the risk of skin infection.
No. Bathing and showering during labour are safe. They do not increase the risk of infection or fetal distress. Many women like to lie in a warm bath during labour as it reduces pain. Some women even ask to deliver in a bath of warm water.
Yes. It is important to have a plan of management that all the staff can understand and use as a guide to care. However, routine management should be determined by evidence based medicine whenever possible. Mothers should know what is going to happen and be given choices where possible.
This is health care which is based on information obtained by carefully conducted, randomised controlled trials and extensive systematic reviews of the current literature. This is preferable to personal opinions and expert views which are often proved to be incorrect.
If possible, and if the woman wants him there, the father should be present during labour and delivery. It is important that he supports his wife or partner and shares in the experience of childbirth. Being present is important in strengthening bonds between mother and father and developing bonds between father and infant.
There is no excuse to shout and be aggressive with patients, especially when they are frightened and confused. Suggesting that she delivers at home is dangerous and unethical practice.
During a normal labour at a district hospital, a woman is told she must stay on her bed and not walk around. Her clothes are taken away and she is given a clinic gown. She is allowed to have sips of water during early labour but asked not to eat anything. She is not given any pain relief. She is afraid to ask and does not know whether analgesia is available at the clinic. She is worried that the fetal heart is not being monitored as she was taught during antenatal classes.
No. Women should be encouraged to walk around during labour. This helps to relieve labour pains and speeds up labour. Women can relax in a chair or adopt any position which gives them the most comfort. Lying for hours on her back during labour is not good for her or her fetus.
No, although some women prefer to change out of their own clothes before delivery to avoid blood staining.
It is one of the many small parts of ‘mother friendly care’ which makes labour an enjoyable and meaningful experience rather than a very stressful time. Paying attention to providing good, kind and gentle care improves the quality of service that is offered to women. Mother friendly care is good for the mother, infant and staff.
During a normal labour there is no danger if the woman eats and drinks. Frequent drinks prevent dehydration. Small snacks prevent hypoglycaemia and ketosis. Food such as glucose sweets, jelly or fruit is preferred. Only if a woman is being prepared for a general anaesthetic should she not eat.
When she feels she needs it. Women must be asked and given a choice as they often are embarrassed, shy or afraid to ask.
The fetal heat must always be monitored in labour. At a maternity clinic this can usually be done with a fetal stethoscope or hand held fetal heart rate monitor.
Yes. It helps enormously if women know what to expect and understand what occurs during labour and delivery. This reduces their anxiety and pain and enables mothers to participate in the decisions made during labour.
A woman is admitted in labour to a primary care maternity clinic. Every effort has been made to provide a mother friendly service during labour. As she does not have her partner with her she is offered a labour companion. She is also asked by the midwife what position she would prefer during delivery. The woman is thrilled with her good delivery experience which contrasts to the efficient but very unfriendly care she received with the birth of her previous child when the staff insisted that all primigravid mothers must have an episiotomy. On the third day after delivery she seems well but complains of feeling upset, without any obvious reason, and cannot stop crying.
A labour companion is someone who stays with a woman throughout her labour and delivery to encourage and support her. Traditionally, women never laboured alone but always had a companion.
Usually her partner, a friend or someone in her family. If no one suitable is available she can be offered a professional or lay labour companion (a doula) whom she has not met before. The role of the labour companion is different from that of the person who conducts the labour and delivery.
Women labour faster and need less analgesia. They feel more satisfied with their labour and delivery and bond better with their infants. Having a labour companion is a typical example of mother friendly care.
Many women prefer not to deliver while lying on their backs. This is also not the best position for the infant. Some want to squat, crouch, kneel or lie on their side. It is important that women are given a choice. Midwives soon learn how to deliver infants in different positions. The second stage of labour is faster with less risk of a peritoneal tear if the mother is in an upright or lateral (side lying) position.
A maternity clinic (midwife obstetric unit) near their homes is more convenient for most women than a hospital. The labour ward in a maternity clinic is more relaxed with midwives managing normal deliveries. It is safer than home deliveries in most poor communities and avoids some of the unnecessary investigations and interventions that are common in hospitals. While high risk women should be managed in hospital, where all the additional facilities are available, almost all low risk women can be safely and well cared for in a maternity clinic.
BBI is an international project which aims at improving care during labour and delivery by introducing mother friendly care, based on the best evidence available. BBI is good care. All labour wards should be encouraged to adopt the principles of BBI.
She almost certainly has the ‘blues’. With understanding, explanation and support she should recover in a few days. If she is no better after two weeks, suspect postnatal depression, and refer her for counselling or assessment. She has no features of puerperal psychosis.
Postpartum depression often presents during pregnancy and then becomes worse after delivery. An awareness by health workers of the features of depression and anxiety can lead to an early diagnosis. A screening tool can also be used to identify women who are depressed or at high risk of depression.