Elloise Richards, S00117666.

MIDW 216
There are many suggestions through evidence and observation that the birthing environment can influence the progress of a normal labour. The sights, smells, sounds, layout and womans perception of her security all play a role in promoting a state of relaxation needed for a normal labour. This essay will explore the benefits of a relaxed emotional state on labour and how to protect it with a positive birth environment, as well as explore the physiological advantages of an environment that facilitates mobility during labour. It is important midwives consider these factors to encourage women in actively taking part in their births and, therefore, be empowered. The Australian Nursing and Midwifery Council Competency standards (ANMC, 2008) state the responsibility of midwives to provide an optimal birth experience for women through understanding of the normality and physiological process of childbirth. Through the use of evidence-based practice, midwives can facilitate this experience and provide the best possible outcome to each individual through current research on the optimal birth environment. Further, there is much evidence to support the influence of the birth environment on labour and how to maximise the hospital setting to the womans needs. Additionally, there are observations coming out of both clinical and home birth settings surrounding the profound effects of the environment on labour. This essay will focus on creating positive birth environments in standard, hospital settings.

A womans emotional response to the birth environment is shown to impact the normal progression and physiology of labour. There are a number of reasons as to why a woman might feel fear, anxiety or stress in a standard, hospital setting. For example, regardless of the setting, parity can influence the emotional response to labour as some women enter their births with fear of the unknown (Dahlen et al., 2008), so sensitivity to this current evidence is important. Specific to this topic, women being cared for in an environment with unfamiliar people can create

Elloise Richards, S00117666. MIDW 216

vulnerability and anxiety for her (Walsh, 2004). A study of womens desires from their carers in maternity settings discovered that women would like to enter one that brings calm and is without stress (Huber and Sandall, 2007). It is therefore important to try and create peace and relaxation as soon as she enters the hospital to empower the woman with control over her birth and continue with normal labour. Grantly Dick-Read (2004) and Ina May Gaskin (2003) have both explored theories surrounding the physiological impacts of fear and anxiety on labour. Dick-Read (2004), who worked in obstetrics, noted the neuromuscular tension created by fear which, in turn, delays labour through decreased uterine contractions. Gaskin (2003), an independent midwife, explored the effects of emotions on labour, particularly stress. She notes that stress increases adrenalin, which counteracts oxytocin levels needed for rhythmic uterine contractions. Whilst the normal physiology of labour and birth rely on hormones, studies have investigated the effects of hormones from stress or fear on labour. Anxiety, tension or fear are shown to increase the level of stress hormones (catecholamines) above what is normal for labour, which decrease the frequency or intensity of uterine contractions (Alehagen et al., 2005). Buckley (2004) also states that the rise in catecholamines (adrenaline, noradrenaline and cortisol) can stimulate the fight or flight response, which if it occurs in the in the early stages of labour, leaves the body reducing uterine blood flow as a form of protection. This can mean that the muscle contractility needed for labour is slowed or stopped. These physiological reactions are crucial to understand when caring for women, as environmental changes can be undertaken to try and prevent the stress or fear and help women avoid intervention, maintain maternal and fetal wellbeing, and protect a normal labour.

Stress or fear can occur for a woman as soon as she enters the hospital, so it is important to create an environment that is relaxed and comfortable. Walsh (2007),

Elloise Richards, S00117666. MIDW 216

explains the slowing of contractions upon entering the hospital as a normal response to the change of environment. Therefore, removing or minimizing these emotions as soon as a woman enters the hospital is vital. Interestingly, Dick-Read (2004) was fascinated by the positive effect the soothing presence of a midwife had on a woman upon admission, this is just one of the many things that can be provided for a woman upon admission to create a positive birth environment. Eddy (2006) suggests maximising the labour environment by lowering the lighting, protecting privacy at all times, facilitating the womans ability to feel safe to communicate her needs and vocalize as needed. These all make an attempt at creating a peaceful environment that is safe, calm and the womans own. Carlsson (2010) noted that this state of calm will help the woman to focus on her bodys natural rhythm and maintain power over her choices and therefore empower her. Leap (2006) explored the notion of creating a homely environment for birth, which is quiet and comfortable and filled with support and encouragement. Surrounding the woman with a birth support, partner or doula, to provide continuous support has been found to have positive effects on a womans labour. Hodnett et al. (2011) describes emotional support as most effective if provided early in labour and is reassuring and full of praise. Continuous support was also stated to reduce the need for intervention and increases the chances of a normal labour and birth. Ina May Gaskin (2004) makes further sense of this research through her own observations of companionship during labour. The warmth and encouragement that comes from birth supports is described as more effective than drugs. She explores endorphins,natures opiates, and how with physical activity, feeling support, love and most importantly, no fear, endorphins are released. These endorphins block the reception of pain, therefore allowing relaxation (Gaskin, 2004). This specific physiological response protects a normal labour as it can reduce pain experienced by the woman. Additionally, the continuous support can remind the woman of the normality of what is happening to build the womans confidence and self-belief. Midwives should allow room for these childbirth supports and involve them

Elloise Richards, S00117666. MIDW 216

when appropriate, as well as attempt to create an environment that is calm, homely, and comfortable and with familiar, supportive faces. Remaining though, is the need for maternal mobility during labour, as the physiological benefits are fundamental in protecting a normal, physiological labour.

It is important for midwives to create an environment that promotes and facilitates mobility during labour. The Coalition for Improving Maternity services (CIMS) have formed 10 evidence-based steps of mother-friendly care which state the freedom of movement during labour as number four on the list as there is much evidence surrounding this step of mother-friendly care (Hotelling, 2007). Studies have explored the relationship between movement and labour and birth outcomes. Lawrence et al., (2009) reviewed the literature on the effects of upright positions and mobility during the first stage of labour to see if there was any impact on the woman. There was much evidence that upright positions and movement reduce the use of epidural analgesia, suggesting less intensity in pain. This is because being able to change positions or sit upright creates higher comfort for women and helps them manage contractions more easily. Further, there was a decrease in the total length of labour for women who were upright instead of flat or in the semi-recumbent position. Walsh (2007) states this being due to gravity aiding the descent of the fetal head. Zwelling (2010) states that mobility facilitates maternal-fetal circulation for both fetal and maternal wellbeing. If there is decreased utero-placental blood flow from a woman lying on her back, there is less blood to the fetus meaning oxygenation is reduced and late decelerations can occur. This response interrupts a normal labour. Maternal hypotension can also occur from the heavy uterus compressing the inferior vena cava from lying flat (Zwelling, 2010). These are fundamental processes that need to be protected for a normal labour, as well as fetal and maternal wellbeing, so an environment that facilitates upright positioning and movement in labour is a

Elloise Richards, S00117666. MIDW 216

necessity. A quantitative studied investigated womens experiences of mobility in labour and what best facilitated it. It was found that the advice and support given by midwives was the most powerful tool in helping women find the best position or movement, women valued this guidance and support (De Jonge & Lagro-Janssen, 2004). Midwives should allow a woman to autonomously choose what position is most comfortable for her and empower her with that choice, however, if the position is supine or semi-recumbent it is important that this choice is also respected. If the environment promotes freedom of movement by offering suggestions and removing physical obstructions, this can work towards empowering the woman with her choices and providing guidance in achieving a normal labour.

Midwives that work to protect a normal, physiological birth will consider the factors explored in this essay. Fear is an emotional response that can heavily interfere with a normal labour at a hormonal level, so midwives should be actively reassuring women, protecting their environments from stress or fear, and promoting relaxation through comfort and calm. Accommodating birth supports present at the birth, and promoting the womans autonomy in choosing labour positions, will also maintain the womans control over her labour and reach a positive birth outcome and, most importantly, empowerment.

Elloise Richards, S00117666. MIDW 216

References

Alehagen, S., Wijma, B., Lundberg, U. & Wijma, K. (2005). Fear, pain and stress hormones during childbirth. Journal of Psychosomatic Obstetrics & Gynecology 26(3), 153-165 DOI: 10.1080/01443610400023072

Australian Nursing and Midwifery Council. (ANMC). (2006). National competency standards for the midwife. Canberra: ANMC. Retrieved from: http://www.anmc.org.au/

Buckley, S.J. (2009). Gentle birth, gentle mothering. New York: Random House, Inc

Carlsson, I-M., Ziegert, K., Sahlberg-Blom, E., Nissen, E. (2012) Maintaining power: Womens experiences from labour onset before admittance to maternity ward. Midwifery, 28, 86-92

Dahlen, H.G., Barclary, L.M., Homer, C.S.E. (2008) The novice birthing: theorizing first-time mothers experiences of birth at home and in hospital in Australia. Midwifery, 26, 5363. DOI:10.1016/j.midw.2008.01.012

De Jonge, A. & Lagro-Janssen, A.L.M (2004) Birthing positions: A qualitative study into the views of women about various birthing positions. Journal of Psychosomatic Obstetrics & Gynecology, 25(1), 47-55. DOI: 10.1080/01674820410001737432

Dick-Read, G. (2004). Childbirth without fear. (6th ed.). London: Pinter & Martin Ltd.

Eddy, A. (2006). Midwifery interventions for the promotion of physiological birth. Obstetricians and Gynaecologists 8(4), 14-15. DOI: 10.1080/01674820410001737432

Elloise Richards, S00117666. MIDW 216

Gaskin, I.M. (2003). Ina Mays guide to childbirth. New York: Bantam Dell

Hodnett, E.D., Gates, S., Hofmeyr, G.J., Sakala, C., Weston, J. (2011). Continuous support for women during childbirth (review). Cochrane Database of Systematic Reviews, 2. DOI: 10.1002/14651858.CD003766.pub3.

Hotelling, B.A. (2007). The coalItion for improving maternity services: Evidence basis for the ten steps of mother-friendly care. The Journal of Perinatal Education,16(2), 38-43. DOI: 10.1624/105812407X197744

Huber, U.S. & Sandall, J. (2007). A qualitative exploration of the creation of calm in a continuity of carer model of maternity care in London. Midwifery 25, 613-621 DOI:10.1016/j.midw.2007.10.011

Lawrence, A., Lewis, L., Hofmeyr, G.J., Dowswell, T., Styles, C. (2009) Maternal positions and mobility during first stage labour. Cochrane Database of Systematic Reviews, 2. DOI: 10.1002/14651858.CD003934.pub2.

Leap, N. (2006). An ideal birth environment? The right facilities and support for women. British Journal of Midwifery, 14(1), 46. Retrieved from CINAHL Plus with Full Text

Walsh, D. (2004). Care in the first stage of labour. In Macdonald, S., & Henderson, C. (Eds.), Mayes midwifery (pp 428-457). (13th ed.). Edinburgh: Bailliere Tindall.

Walsh, D. (2007). Evidence-based care for normal labour and birth: A guide for midwives. New York: Routledge

Elloise Richards, S00117666. MIDW 216

Zwelling E. Overcoming the challenges: Maternal movement and positioning to facilitate labor progress. Am J Maternal Child Nurs. 2010;35(2):72-8