The word midwife originated from “mit wif” an Anglo-Saxon phrase meaning “with woman” and this definition is still used today (Kate Sheppard Midwifery, 2010). In learning about what a midwife is or does, it is mentioned frequently that they are the guardians of normal childbirth. Normal birth has been defined in numerous ways by numerous people and organisations. There is debate about whose definition should be used - the woman birthing the baby, the midwife who might be catching the baby or the hospital or birthing unit where she might be delivering. We will explore different definitions, it will be discussed what the significance of normal physiological birth is - to mother, baby, family and wider society and how it relates to the role of the midwife in protecting and promoting physiological birth.
What is normal birth?
Normal physiological labour is a beautifully choreographed dance of nature between the woman and her baby (or babies). The feature role in this dance, with many of the instigating hormonal changes coming from it, belongs to the baby. Supporting but still vital roles are played by the fetal membranes, the placenta and the endocrine system of the woman. In New Zealand, the Ministry of Health (MoH) uses the definition of normal birth published by the World Health Organisation (WHO) which is “spontaneous in onset, low-risk at the start of labour and remaining so throughout labour and delivery. The infant is born spontaneously in the vertex (head down) position between 37 and 42 completed weeks of pregnancy. After birth mother and infant are in good condition.” This definition does not however mention interventions, pharmacological or otherwise. The use of the words spontaneous and low-risk does not exclude the use of, say, an epidural or episiotomy which many would consider to not be within the limits of normal birth.
The Information Centre of the NHS in England go further with their definition of normal birth which is “without induction, without the use of instruments, not by caesarean section and without general, spinal or epidural anaesthetic before or during delivery”. Gould (2000) illustrates the many definitions given for the word 'normal' and for the word 'labour' in her article, Normal Labour: a concept analysis. In her research with the Association of Radical Midwives (ARM) she found that they described normal birth as a 'purely normal physiological event with no interventions'.
ARM identified artificial induction of labour, syntometrine, syntocinon, artificial rupture of membranes, directed pushing and episiotomy as interventions as part of an 'abnormal' birth. Gould went further to denote four distinct characteristics of physiological labour – it occurs in a naturally defined progression; continuous cervical effacement/dilation and appropriate fetal descent, both caused by consistent and painful contracting of the uterus climaxing in the natural birth of a well fetus followed by expectoration of the complete placenta and all membranes and without obvious issues in woman or baby; it is hard work; and mobility is essential.
Many midwives believe it is the definition of normal birth or labour by the woman in labour that is most relevant. (Gould, 2000; Gilkison et al., 2005) Downe (2004) proposed that each woman had their own 'unique normality' of birth. Walsh (2001) found that many midwives experienced a polarity between textbook definitions of birth and what actually happens in practice. Hence, the definition of normal birth ebbs and flows with the fluidity of individual experience. For example, one woman may see acupuncture as an intervention in birth where the next may not and another woman could class the midwife performing a vaginal examination as an intervention while her friend does not and so forth. (Walsh, 2001) Birth is an interpretive realm, an incredibly individual journey and, even where two women have had similar experiences and outcomes, their personal interpretation of it can be vastly different.
As already alluded to 'normal birth' means different things to different people. Earl (2004) in her Masters thesis entitled 'Keeping Birth Normal: Midwives’ experiences in a secondary care setting' found that midwive's definitions of normal birth widely varied. Here are three midwive's perspectives:
'Normal means with a reasonable amount of time, with the woman remaining in control, with a baby that's happy throughout the labour and delivery' (p.65)
'Normal birth to me would be, most deliveries other than forceps ventouse caesarean, and I probably now would exclude an epidural. But I would accept syntocinon and an episiotomy...' (p. 66)
'A normal birth is when a woman delivers a baby vaginally by herself with some encouragement from a midwife or doctor or support people and the baby and mother are healthy afterwards...(y)es I think epidurals are part of a normal delivery.' (p. 67)
I posed the question of what normal birth is was posed to three women who all experienced very different births - two were having a subsequent baby and one was having her first baby.
'Given my two very different experiences I don't think one can define what a "normal" birth is. I think due to circumstance and situation it is whatever is right for the mother and the circumstances at the time...I think without intervention on both my babies (Baby 2 almost arrived at 32 weeks) by the medical fraternity they may not have made it. And given Baby 1 was an IVF baby, there was no "natural" in his entire process.'
'For me personally I think a normal birth is ideally a natural birth (although I know from friends and people at Playcentre that the norm is to take some level of pain relief. Most people have gas and heaps succumb to epidural when it gets too much)...I know it hurts for everyone and some people have a really hard labour but I definitely think pain threshold, length of labour and state of mind play a huge part in your labour experience.'
'For me normal birth meant home birth, no pain, except when baby head came out and 5 hours labour. Most people I know are more obsessed about "having pain", that they actually don't enjoy it and get tense and of course when you get tense you feel pain and labor gets longer.'
The physiological, psychological and social importance of physiological birth
The significance of normal physiological birth is far-reaching and not necessarily quantifiable, especially long-term. The physiological, psychological and social benefits to the women, babies, their families and wider society are intricately linked. If we analyse the perspectives of women and midwives above, a central theme in most of them is pain – or relief of it. Pain is a physiologically necessary part of labour as without it there is something wrong although how it is experienced by individual women is as varied as birth itself. Pain means that the uterus is contracting well and consistently so the cervix is effacing and dilating and the baby descends through the birth canal ready to be born. The feeling of pain during labour can be looked upon as a brief moment in time where something that may not be enjoyable has to be experienced to achieve something amazing in the end. It has been reported by women that experience normal physiological birth that the pain is extraordinarily temporary and once the baby is placed upon your chest, the pain melts away.
Humenick (2006) analysed a few studies from the 1970s that examined the correlation between pain and birth experience. They found women that were awake and feeling the pain during their birth gave their experience a much higher rating than those women that were not conscious. It was found that significant psychological benefits when normal birth is the outcome include a 'sense of accomplishment' and that women's self-esteem and improved familial connections can be eternally influenced by their childbirth experience. It is important to note these studies as numerous health professionals take it upon themselves as their sole purpose to decrease the level of pain experienced by women in labour. In protecting the birth environment, our job as midwives is to protect the woman through her pain journey, offering natural alternatives, making sure she is as prepared as she can be and managing her fear around it. Although pain is a physiological experience it is closely linked to psychological and believe it or not social issues.
Society through the media and medical mindsets has created a situation where women have an irrational fear of the pain of childbirth and have lost belief in their natural instincts and processes. Pregnancy and birth is portrayed as an illness for which medical intervention is necessary and that hospital is the safest to birth. This societal thinking and lack of confidence in women to birth normally has undermined both midwives and women themselves. (Parker, 2009) There seems to be a common view that birth is something negative and it is better to not actually experience it, ie. have an epidural and or caesarean section. The media communicating predominantly negative stories (fictional and non-fictional) about birth and midwives exacerbates the fear based moral panics that only seem to serve the medical maternity industry.
In 2008, the MoH released a Maternity Action Plan 2008 - 2012 in which it stated the vision for maternity services being '(w)omen will experience pregnancy and motherhood as normal life events with confidence in their ability to give birth.' The most common alternative outcome to or disturbance of normal birth is caesarean section followed by instrumental delivery. According to the provisional 2008 MoH statistics, the caesarean section rate was 24% and instrumental delivery (forceps and vacuum extraction - ventouse) was a total of 8%. Within a 20 year period the caesarean section rate has increased by over 50% - the rate being 11.7% in 1988. This is alarming not only because 11% of the 2008 total caesarean section rate were for electives but also that the WHO recommended caesarean section rate is 15%.
There is also the cost to society and family when a woman has a caesarean section – apart from the initial cost to the taxpayer of the invasive surgery which is $3,000 to $4,000 (“C-section risk to babies: study”, 2008), there is the amount of time for healing which can be up to six weeks excluding any subsequent complications. This puts pressure on the family unit with more extensive care required for the woman and baby and in turn society if the partner, grandparent or other family member is unable to work due to providing this care. There is also the physiological effects of the fetus when not born vaginally – the fetus is prepared for life 'on the outside' by the natural birthing process. This process is bypassed when a baby is delivered by caesarean hence recovery time for the baby is also increased.
Another aspect of having a caesarean section is the psychological effects it can have. As in the previously mentioned studies regarding pain in childbirth, Clement (2001) also found that women than did not have a normal birth but had a caesarean section gave their birth experience a lower rating. It was also discovered that there seems to be some indication that women that have caesarean sections have a higher likelihood to have issues in bonding with their infant, their self-esteem and to suffer from postnatal depression and puerperal psychosis.
Breastfeeding can also be affected by the mode of birth. Cunningham, Jelliffe and Jelliffe (1991) found some of the physiological benefits of breastfeeding are to boost an infant's immune system and help to prevent some illnesses (especially respiratory and gastric) and infections. It can also assist the mother's body to return to normal (contract the uterus and lose pregnancy weight) and delay the resumption of menstruation. In their study regarding the link between caesarean sections and the early initiation of breastfeeding, Rowe-Murray and Fisher concluded that having a caesarean section was a significant barrier to the early commencement of breastfeeding.
Protecting and disturbing physiological birth
The primal cycle of birth can be easily disturbed hence a midwife's role in protecting and promoting normal labour is essential to the achievement of a successful outcome. The WHO has named four practices supported by the guardian of birth – whoever that may be – that encourage a normal birth and two additional practices were put forward by Lamaze International. The six research-based practices are 'labour begins on its own; freedom of movement throughout labour; continuous labour support; no routine interventions; spontaneous pushing in non-supine positions; and, no separation of mother and baby.' (Romano & Lothian, 2008) Skin to skin contact is a well researched practice where both mother and baby benefit. It helps solidify the bonding process, increases the release of oxytocin for quicker expulsion of the placenta and also to encourage the let-down reflex for colostrum and in turn milk (New Zealand Breastfeeding Authority [NZBA], 2003).
The protection of the birth environment as part of the midwife's role can mean the difference between a straightforward physiological birth and an 'abnormal' or traumatic one. (Odent, 1996; Odent, 2000; Parker, 2009, Eddy, 2006) 'Cascade of intervention' is a term used in childbirth circles to explain where one intervention can lead to another and another instigating a cycle of intervention. For example, having a epidural can mean that a woman may have difficulty urinating and pushing, labour can slow down and mobility is minimised. These side effects can mean that further interventions such as the use of syntocinon to strengthen contractions, a catheter to assist with urinating, fetal monitoring, fluids intravenously and an instrumental delivery (forceps or ventouse) are necessary for labour to proceed (Childbirth Connection, 2009). Hence, it is part of a midwife's role in upholding the principle of informed consent, that a woman wanting an epidural has the 'cascade of intervention' explained to her so that she is making a fully informed decision.
Odent (2000) states that any disruption of the birth environment can stop a naturally occuring reflex called the “fetus ejection reflex”. This reflex was first pioneered by Niles Newton in 1966, revisited in 1987 and Odent expanded on it further in 2000. During well established labour, the fetus ejection reflex is said to be characterised by a brief and sudden period of irrational extreme fear. The woman may say things like 'just give me a c-section' or 'I can't do this anymore'. This period is accompanied by a marked increase of oxytocin (a hormone in labour that enables contractions and milk excretion) and adrenaline levels. A collection of strong contractions follow where the woman has renewed energy and can not help but push. An erect leaning forward position is usually preferred during the fetus ejection reflex as this position opens the pelvis and allows an easier journey through the birth canal for the baby (and woman). Odent suggests that 'the true role of the midwife is to protect an environment that makes the ejection reflex possible’ and supporting this that a woman must feel ‘private, safe and relaxed’ in order to facilitate the normal birth process.
Promoting physiological birth
Eddy (2006) proposes five interventions that should be part of a midwife's arsenal in order to encourage birth's natural processes. Maximising the environment and position have already been mentioned but eating and drinking in labour as desired, reviewing the woman at home early in labour and using evidence based fetal monitoring have not. The necessity for a woman to be able to eat and especially drink in labour is very high. Dehydration can slow contractions as muscles need water to be able to function properly. Ketosis (a condition where an excessive amount of ketones (metabolised fat by-product) are in the body because it has no carbohydrates to metabolise and hence is metabolising fats as an alternative) (Gray, Smith & Homer, 2009) which can also slow contractions can be averted by an appropriate nutritional intake during labour.
Walsh (as cited in Eddy, 2006) found that assessing women early on in their labour can lessen avoidable interventions. If they are intending to birth at a hospital, ensuring they do not transfer before labour is convincing and effective. Fetal monitoring is another area of debate in Midwifery and the New Zealand College of Midwives (NZCOM) released a statement in 2005 regarding this issue purporting that 'intermittent auscultation of the foetal heart is the most appropriate method of assessing foetal wellbeing in an uncomplicated labour'. In other words, a midwife should only need to use electronic contiuous fetal monitoring if there is concern for the woman or baby.
The role of the midwife in protecting and promoting normal birth is a delicate balance between not implying time limits based around stages of labour in textbooks, acting as a strong, supportive, non-judgemental partner and guardian in the birth space and, keeping the woman and baby safe. It is a constant internal assessment whereby the midwife supports the normal physiological birth process while ensuring the principles of midwifery practice in New Zealand - partnership, continuity of care, women-centred care and informed consent are upheld. (NZCOM, 2008)
Roles between different kinds of midwives may vary – the role of a homebirth midwife in promoting normal birth may be to guard the environment and 'do nothing', just be there. However, the role of an independent midwife attending a woman birthing in hospital or a hospital midwife may have a harder job in protecting the birth environment and promoting normal birth. However, the four aforementioned principles can still be upheld regardless of what kind of midwife is supporting or the location of the birth.
So let’s wrap it up…
There are numerous significant benefits in having a normal birth – physiological, psychological and social. In today’s day and age, even with the huge amount of research in favour of normal birth and a less medicalised experience of labour, there is still somewhat of a negative public view of childbirth. Maternity services throughout the world do appear to be aware of this and are working towards achieving a more positive attitude to the awesome, natural and instinctual process that is pregnancy and labour. There is also the positive birth movement of which there are many initiatives and organisations facilitating the reclamation of the pregnancy and birth process as a normal life event where the way women are treated and the language used throughout the process is vital to the success of it.
Empowering women throughout their birthing journey and as a midwife to protect and promote physiological birth, we should let women use their own definition of normal birth. We must protect and promote their individual definition whilst ensuring we are able to uphold this in our own minds. As a midwife promoting normal physiological birth we must use all the tools available to us, be fierce, non-judgemental guardians of the birth space, foster the partnership between midwife and woman through continuity of care, woman-centred care and, informed consent supported by appropriate communication and currency of evidence-based information.
- Michelle Pearson, Registered Midwife NZ
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