Positive Health Online

Introduction

For most women, pregnancy is a time of excitement, anticipation and planning, interspersed with periods of anxiety, fear and stress, all of which are quite normal. Generally, expectant mothers spend the early pregnancy coping with various physiological discomforts, e.g. sickness and backache, whilst trying to continue with their day-to-day lives. It is not until later that they begin to think about the impending birth, perhaps worrying about the pain and the actual delivery of the baby, but also planning for the way they would like it to be.

Normal labour occurs anytime between 37 and 42 weeks of pregnancy and involves a single foetus; labour should start spontaneously, progress normally without distress to mother or baby, and be completed within 24 hours. The baby should be born head-first and start to breathe spontaneously; there should be no trauma to either mother or baby. Thus, premature labour, multiple pregnancy, breech presentation, induction of labour, epidural pain relief, forceps delivery, Caesarean section and episiotomy (cut to enlarge the birth opening) are all considered deviations from normal, as is a labour which takes more than 24 hours or less than 3 hours (excessively rapid birth can cause neonatal brain haemorrhage).

Natural Childbirth

"Natural childbirth" is a concept which gained popularity as long ago as the 1950s, when Dr Grantly Dick-Read advocated a series of deep relaxation and breathing exercises, similar to contemporary hypnosis techniques. More recently, the term has evolved to mean a labour which starts, progresses and is completed without medical intervention, and one which empowers the mother to make choices about the way her labour is managed. It is, therefore, essentially a physiological labour, but contemporary moves to empower women have largely been a revolt against medical interference in childbirth, which started in the 1970s when women were increasingly encouraged to labour in hospital rather than at home, because the medical profession, unlike midwives, views birth as "only normal in retrospect". This led doctors to set parameters for what they considered to be 'normal' labour, a trend which has continued almost unabated ever since. Maternal dissatisfaction has resulted, over the years, in a series of maternity service reports including the Maternity Care in Action reports (1982,1984)[1] and the Changing Childbirth document (1993) [2] which advocated "choice, control and continuity" within antenatal and intrapartum care, yet in many respects little has changed.

Many women are committed to 'natural childbirth' which gives them an element of control over the process. A mother who is adequately supported during labour and who achieves a birth in which there has been little or no intervention, bonds with her baby more quickly and develops a positive approach to breastfeeding and parenthood. It is possible to attend antenatal 'preparation for birth' classes, although their availability on the NHS has diminished in recent years due to cost savings; most classes specifically on 'natural childbirth' are privately run and therefore not accessible to all women. It has been suggested, however, that 'natural childbirth' preparation has little effect on mothers' experiences or the rate of epidurals[3] and that the continued attendance of a known birth supporter, such as a midwife or doula, is more beneficial to the progress and outcome of birth.[4,5]

The Reality

Unfortunately, the reality of childbirth is often not in keeping with maternal expectations.[6] Some mothers have set ideas about labour, such as having the baby at home, being cared for by a midwife they know, avoiding induction, not being constrained by electronic monitors, coping without pain relief, being mobile, labouring in water, using complementary therapies, or delivering the placenta physiologically without the stimulus of drugs.

Of course, labour is a dynamic event where things can change quickly, so it is unwise for mothers to expect everything to go completely according to plan. However, for those who desire as natural a birth as possible, factors other than physiological progress may have a bearing on whether or not they achieve the birth they anticipate. NHS staff shortages may preclude mothers from having their 'own' midwife with them throughout the labour, and lead to increased use of electronic monitoring to replace human surveillance; cost savings may cause managers to discourage the availability of home birth; hospital bed shortages (full labour wards) may require women to transfer to another hospital where they know no-one, or to submit to the use of drugs to facilitate placental separation and delivery in the third stage of labour; and lack of medical confidence in performing vaginal breech births or in allowing women to labour for more than 24 hours, leads doctors to persuade women to have unnecessary Caesarean sections.

Women expect birth to be painful, but this can trigger a fear-tension-pain cycle which adversely affects progress. Western women have little experience of birth as a family event and view it as a 'medical' condition, where most have their babies in hospital. This often leads women to rush into the maternity unit at the first contraction but, once there, labour may slow down or stop all together. Doctors - and some midwives - become agitated if labour does not proceed according to their pre-prescribed parameters, and labour is therefore professionally 'managed' by various means intended to accelerate the process. This can lead to a 'cascade of intervention' whereby one intervention leads to another. For example, if a mother goes into hospital before labour is fully established, she is given a room with a bed on which she assumes she must lie, and then proceeds to suffer each contraction as a negative pain, rather than as a positive progression towards the birth, leading her to request analgesia earlier than she might otherwise have done. She may choose an epidural, which further confines her to the bed, increasing her stress levels and impeding progress, instead of allowing her to move around in an upright position (which aids progress). Lack of progress may indicate the use of synthetic hormone drugs to speed things up, with an attendant risk of foetal distress. The epidural drug essentially numbs the mother's lower half, so that, when the baby is ready to be born, already distressed, the mother can no longer feel where to direct her pushing, and a forceps delivery becomes necessary, automatically leading to an episiotomy. The stitches from the episiotomy make sitting to breastfeed uncomfortable, and eventually the mother changes to bottle feeding, depriving the baby of the natural immunity and other benefits of breast milk. So, from too-early an admission to hospital, this 'cascade' potentially leads to long term health sequelae for the child.

Reversing the Trend

More recently, professional concern has focused on the (still) escalating intervention rates, particularly Caesarean section, together with women's general dissatisfaction with the UK maternity services[7,8, 9] identified the changing demands of contemporary maternity care and highlighted rising rates of intervention as one of the contributing factors to the vast number of maternity "safety incidents." It also stressed the profound and long-lasting psychosocial and physio-pathological impact of birth experiences on women, a fact which is echoed by various authorities [10,11]. There is, then, a conscious move towards returning to 'natural childbirth' - or, at least, to physiological labour - which could, somewhat cynically, be attributed to a desire to reduce costs of both the interventionist clinical care and of litigation from dissatisfied mothers.

There have been several midwifery initiatives aimed at providing a more natural and home-like environment for birth, including the use of midwifery teams which enable mothers to become acquainted during pregnancy with the midwives who will care for them in labour, and the advent of low-risk birthing centres for women without medical or obstetric complications. The NHS Institute has specifically named "reduction in Caesarean section rates" as one of its ten most significant requirements to improve maternity care[12] and the Royal College of Obstetricians and Gynaecologists published a consensus statement on "making normal birth a reality[13] and began to focus on the process of labour rather than merely the outcome.

Many women turn to complementary therapies as a means of retaining control over their childbirth experiences and as additional choices for managing comfort and progress in labour.[14,15] Although the National Institute for Health and Clinical Excellence (NICE), highlights the lack of randomised controlled trials (RCTs) as a reason for discouraging women from using them in pregnancy and labour (National Collaborating Centre 2008), other policy documents recommend the provision of alternative choices for pain relief in labour.[16,17,18]

Complementary therapies may be used, either singly or in combination, to ease pain, anxiety and fear, to facilitate progress and to prevent or manage complications. Any therapy which assists in relaxing the mother, thereby reducing cortisol levels, will influence release of oxytocin, the hormone required to regulate conception, pregnancy, birth and lactation. Research has shown that using complementary therapies to aid wellbeing during pregnancy, and in labour, facilitates women to tackle the demands of childbirth, leads to greater maternal satisfaction, a reduction in the incidence of both short- and long term sequelae of childbearing and, consequently, safer and more cost effective maternity services.[19,20,21]

Conclusion

Childbirth in the UK is generally considered to be a safe - or at least a safe enough - event, but whilst women and their babies thankfully rarely die, the psychological morbidity for mothers whose labours have been less than satisfying can be long term. There have, over the last four decades, been constant demands to improve maternity services so that women gain a sense of satisfaction with their childbearing experiences, and although many aspects are changing positively, there is still some way to go. Complementary therapies and those who offer them, can go some way towards providing the support which women desire, both physical and psychological, and therapists are in an invaluable position to provide that support in conjunction with maternity professionals.

References

1. Maternity Services Advisory Committee. Maternity Care in Action Reports Parts I (Antenatal care) and II (Intrapartum care) HMSO London. 1982, 1984.
2. DoH Changing Childbirth Report of the expert maternity group, HMSO, London. 1993.
3. Bergström M, Kieler H, Waldenström U. Effects of natural childbirth preparation versus standard antenatal education on epidural rates, experience of childbirth and parental stress in mothers and fathers: a randomised controlled multicentre trial. BJOG. 116(9):1167-76. 2009.
4. Campbell DA, Lake MF, Falk M and Backstrand JR. A randomized control trial of continuous support in labor by a lay doula. J Obstet Gynecol Neonatal Nurs 35(4):456-64. 2006.
5. Manning-Orenstein G. A birth intervention: the therapeutic effects of Doula support versus Lamaze preparation on first-time mothers' working models of caregiving. Altern Ther Health Med. 4(4):73-81. 1998.
6. Young E. Maternal expectations: do they match experience? Community Pract. 81(10):27-30. 2008.
7. Hodnett ED et al Continuous support for women during childbirth Cochrane Database Syst Rev. (3):CD003766. 2007.
8. Matthews et al Rising caesarean section rates: a cause for concern? BJOG: An International Journal of Obstetrics & Gynaecology, 110(4) 346-349 (4). 2003.
9. King's Fund Safe Births Everybody's Business An independent enquiry into the safety of maternity services in England King's Fund London. 2008.
10. Lobert M DeLuca R Psychological sequelae of caesarean section review and analysis of their causes and implications Social Science and Medicine 64:2272-2284. 2007.
11. National Institute for Health and Clinical Excellence Final draft guidelines for consultation: Intrapartum care: care of healthy women and their babies during childbirth www.nice.org.uk/page.aspx?o=334322  2006.
12 NHS Institute for Innovation and Improvement High Impact actions for nursing and midwifery, London. 2009.
13. RCOG Making normal birth a reality Viewed online at www.rcog.org.uk/print/womens-health/clinical-guidance/making-normal-birth-reality  2007.
14. Williams J, Mitchell M Midwifery managers' views about the use of complementary therapies in the maternity services Complement Ther Clin Pract. 13(2):129-3. 2007.
15. Dooley M 2006 Complementary therapy and obstetrics and gynaecology: a time to integrate. Curr Opin Obstet Gynecol 18(6):648-52. 2007.
16. DoH Maternity Matters: Choice, access and continuity of care in a safe service DoH London 2007.
17. Lavand'homme P, Roelants F. Patient-controlled intravenous analgesia as an alternative to epidural analgesia during labor: questioning the use of the short-acting opioid remifentanil. Survey in the French part of Belgium (Wallonia and Brussels) Acta Anaesthesiol Belg. 60(2):75-82. 2009.
18..Green JM et al Greater expectations? Inter-relationships between women's expectations and experiences of decision making, continuity, choice and control in labour, and psychological outcomes: summary report Leeds: Mothers & Infant Research Unit. 2003.
19. Field T Pregnancy and labor massage. Expert Rev Obstet Gynecol. 5(2):177-181. 2010.
20. McNabb MT, Kimber L, Haines A and McCourt C . Does regular massage from late pregnancy to birth decrease maternal pain perception during labour and birth? A feasibility study to investigate a programme of massage, controlled breathing and visualization, from 36 weeks of pregnancy until birth. Complement Ther Clin Pract. 12(3):222-31. 2006.
21. Taghinejad H, Delpisheh A, Suhrabi Z. Comparison between massage and music therapies to relieve the severity of labor pain. Womens Health (Lond Engl). 6(3):377-81. 2010.

Further Information

info@expectancy.co.uk  www.expectancy.co.uk  Expectancy provides accredited courses for those who support women during pregnancy and birth, and offers a career pathway option for those wishing to specialise in this clinical field.