MOTHER FRIENDLY CARE DURING LABOUR
42-5 SHOULD ALL WOMEN BE GIVEN AN ENEMA DURING 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.
42-6 SHOULD A WOMAN BE SHAVED BEFORE DELIVERY?
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.
42-7 SHOULD A WOMAN BATH OR SHOWER DURING LABOUR?
Warm water can be very soothing during labour and help 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.
42-8 SHOULD WOMEN BE ALLOWED TO DRINK WATER DURING LABOUR?
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. Women should take nothing by mouth if they are being prepared for caesarean section under general anaesthetic.
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 |
42-9 SHOULD WOMEN BE STARVED DURING LABOUR?
Women are often forbidden to eat in labour as it is feared they may vomit and inhale the stomach contents into their lungs if they are given a general anaesthetic. However, recent studies show that starvation during labour does not reduce the risk of inhalation during general anaesthetic. Therefore, women should not be deprived of food during labour unless they are being prepared for a caesarean section under general anaesthesia. Small, frequent snacks are preferred by most women. 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 |
42-10 SHOULD WOMEN BE ALLOWED TO EAT AND DRINK BEFORE A GENERAL ANAESTHETIC?
Women who are having a trial of labour or are at high risk of needing a caesarean section under anaesthetic 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 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.
42-11 IS IT SAFE TO WALK AROUND DURING LABOUR?
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 the woman is able to move about freely.
| WOMEN SHOULD BE ENCOURAGED TO MOVE ABOUT AND WALK AROUND DURING LABOUR |
42-12 SHOULD A WOMAN REMAIN IN HER OWN CLOTHES 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.
42-13 IS IT HELPFUL TO HAVE A COMPANION DURING LABOUR?
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:
- Labour progresses better (shorter labours).
- Less pain with less need for analgesics (e.g. pethidine).
- Fewer caesarean sections.
- More self esteem.
- Greater success with breast feeding.
- Better relationship with the infant.
- Less postnatal depression.
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 |
42-14 WHO SHOULD BE THE LABOUR COMPANION?
The 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.
*** Doula is a Greek word meaning “a woman who helps other women”.
42-15 WHAT IS THE ROLL OF A LABOUR COMPANION?
The labour companion should support, encourage and praise the mother. Labour can be very lonely, frightening and bewildering if it is experienced 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 THE LABOUR COMPANION IS TO ENCOURAGE AND SUPPORT THE WOMAN DURING LABOUR AND DELIVERY |
42-16 IS FETAL HEART MONITORING ESSENTIAL IN A NORMAL LABOUR?
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 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. 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.
42-17 SHOULD ALL WOMEN BE OFFERED PAIN RELIEF IN LABOUR?
Labour is almost always painful. If the mother is not stressed 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.
42-18 SHOULD EARLY ARTIFICIAL RUPTURE OF THE MEMBRANES BE ENCOURAGED?
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 |
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