A midwife is many women’s channel of care throughout the antenatal, intrapartum and postnatal period and is key in providing women with support and information to provide safe and compassionate care throughout their journey. This includes the promotion of normal birth while assessing the well-being of the woman and fetus and taking any preventative or emergency measures to ensure their well-being. A key role of a contemporary midwife is to be proactive in educating women to ensure women are empowered to make their own informed choices about their care. It is vital for a midwife to asses a woman’s needs and give her the necessary
- In contrast evidence
- Free to move and adopt other positions
- Woman centered
- How many women give birth and lay down
Why is the position in labor important/relevant?
The position of a woman is of significant importance and relevance in the role of a contemporary midwife. Having a choice of birth positions during labor can have a positive impact on the maternal birth experience, whereas restricting a woman from being able to mobilize and adapt to alternative positions during labor can have physical and psychological effects on the woman.
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Birthing in an upright position has benefits to both the woman and the fetus during labor. Gravity can help the fetus progress down the birth canal, in addition to this an upright position can also reduce the risk of the women’s aorta being compressed and reducing oxygen supply to the fetus. An upright position can also enable the fetus to adopt a good position when going through the pelvis and can help deliver stronger contractions. Studies using magnetic resonance imaging (MRI) have shown that the dimensions of the pelvic outlet become wider when a woman is in a squatting or kneeling position, rather than lying on their back (Gupta et al. 2017). Therefore, the labor is less likely to need intervention and can result in a more positive, normal birth experience for the woman.
Why I chose this topic
Role of the midwife in relation to position in the labor
It is key that the midwife is competent in her knowledge and can give the woman the correct information, backed up with the latest evidence. One of the key roles of a midwife is to be proactive in giving women accurate information and communicating it in a clear way when discussing alternative birthing positions. For example, during the early stages of labor, the midwife may encourage a woman to stand up and walk around if labor is slow. The midwife will explain to the woman that her labor may progress quicker if she is mobile or adopts more upright positions. It is important the midwife is competent in giving this information as this will give the woman the confidence to try alternative positions and make her own informed decision on the best position for her. As set out in the Better Births review (2016) midwives should provide unbiased opinions and information to help women develop their care plans and provide personalized, woman-centered care. A Cochrane systematic review (2013) investigated maternal positions and mobility in the first stage of labor. This found that the first stage of labor was up to one hour and twenty minutes shorter for women who adopted an upright position or walked around. This can reduce the need for medical intervention, as prolonged labour may result in the woman becoming exhausted or overwhelmed and needing medical intervention during the later stages of labor. There is also less chance of a woman using an epidural or having a cesarean section. The research also shows that there is less chance of the fetus being admitted to NICU, which shows benefits to both the woman and the fetus. These should all be communicated to the woman, so she is able to make an informed choice, by knowing the benefits and risks of each position. A survey conducted in Africa about women's knowledge and use of labour and birthing positions shown that 99.2% of women knew about birthing in the supine position, whereas only 66.4% and 60.6% knew about using walking and lateral positions during labour (Zileni et al., 2017, pp. 1-8).
On the other hand, although it is vital the midwife gives the woman information and encouragement to facilitate more upright, mobile positions during labor, it is important midwife should always respect a woman’s wishes and support her to utilize a position that she finds most comfortable and in control, rather than the position that is optimal in the midwife’s opinion. This position may not be an upright position, however, if the woman is comfortable in this position it is the midwife’s role to respect her decision and enable the woman to make her own informed choice. It is vital for the woman to remain in control during labor, this can prevent unnecessary intervention and help reduce pain and her reaction to it. The World Health Organisation (WHO) recommendations for intrapartum care for a positive childbirth experience (2018) recommends that women should be encouraged to adopt a birth position of their own choice, including an upright position, without forcing the position upon the woman. The Nursing and Midwifery Council (NMC) states that midwives should ‘encourage and empower people to share decisions about their treatment and care (Nursing and Midwifery Council NMC, 2018).
In addition to this the midwife should communicate effectively to see if the woman has a birth plan, which may outline what positions she would like to go in during different stages of labor. It is the midwife’s job to respect this plan and adjust where possible to facilitate this. For example, the midwife will ensure a birthing ball is available in the labor room if the woman has specifically requested to use the ball during labor, on her birth plan. This also keeps the woman upright and mobile and can help labor progress. This also shows the woman the midwife is committed to providing her with the best care and respecting her birth plan. communication is a key part of midwifery to ensure women are aware of different positions that can facilitate normal, safe birth. It is likely that a woman will want to adopt an upright position for the first stages of labor. However, as labor progresses many women may choose to lie down. This is where the midwife can be key in encouraging more upright positions as labor progresses and communicating the benefits of these positions to the woman regarding her progression in labor, while supporting her choice for the most comfortable position. NICE (2017) states that a it is important to ensure that the woman has control over what is happening to her and to be aware if the woman has a birth plan, if there is a birth plan ensure it is read and discussed with the woman.
However, regarding positions during labor it is the midwife’s role they act within the woman’s best interest, which may occasionally mean deferring from the birth plan. It is important the midwife recognizes the woman’s individual needs and how they might change. A key role of the midwife is to monitor the woman and fetus during labor and this should be considered by the midwife when discussing and encouraging different birthing positions. For example,
However, women with complex obstetric needs usually get left on CTG monitors. It is the midwife’s role to ensure that she delivers safe care to the woman but also encourages and facilitates different positions where available. For example, 7945745% of women were admitted to give birth on a labour ward. this could be due to continuous monitoring, however, devices such as ….. could be used to encourage mobility and different positions. Continuous CTG can restrict other beneficial interventions during labor, such as having a choice of labor and birth positions and being able to walk around freely. Upright positions with traditional epidural analgesia, which provides a dense neuraxial block, might not be feasible; however, most epidural analgesia currently provided are “low dose” and “mobile” epidural analgesia, which should enable a choice of birth positions.
The healthcare professional should ensure that the well-being of the baby can be adequately monitored in the woman’s chosen position. Should a change in a position be necessary to ensure adequate fetal monitoring, this should be effectively communicated to the woman.
A practical approach to positioning in the second stage for women desiring an upright birth position might be to adapt to a semi-recumbent or all-fours position just before expulsion of the fetus, to facilitate perineal techniques to reduce perineal tears and blood loss.
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