Imagine a darkened room with lanterns illuminating the corners and casting a soft glow over the peaceful atmosphere. Soothing music is playing and the peaceful splashing of water can be heard. The atmosphere is relaxed, there are only a handful of people in the room talking calmly with each other.
Now, imagine a different room: The light is bright from the neon lights on the ceiling, the walls are white and there is a bed standing in the middle of the room with metallic edges around it, exposing the person lying on it. There is a constant coming and going, the voices are loud and professionally busy. The atmosphere is charged with impatience for "it" to happen.
Which room would you prefer to give birth in?
Birth used to be a private affair taking place at home or in a birth center. The woman was accompanied throughout labour by a midwife and members of her family. She was in her own environment and others did not intrude. Today, for many women birth is a very public experience. It takes place in a hospital where the woman's view of privacy may not be shared by all the health care workers she encounters. Many interventions that were intended for use in the minority of women who experience pregnancy complications are now routinely used for all women.
The International Confederation of Midwives (ICM) is constantly advocating for the health of women before, during and after pregnancy. ICM has developed a Position Statement, "Keeping Birth Normal," that defines normal birth as:
a unique dynamic process in which fetal and maternal physiologies and psychosocial contexts interact (with the goal of mother and baby being well).
Normal birth is where the woman commences, continues and completes labour with the infant being born spontaneously at term, with cephalic birth presentation (head first), without any surgical, medical, or pharmaceutical intervention, but with the possibility of referral when needed.
But what exactly is meant by this rather complex definition?
It recognizes that birth has physical and psychological aspects and that it is a life cycle event.
We must not ignore the crucial responsibility we each have as individual midwives in keeping childbirth normal, thereby doing our best to prevent those complications that contribute to mortality and morbidity even occurring. In the absence of definite indications for intervention, we must do what we can to support clinical situations remaining normal.
This requires knowledge and respect of the physiological processes of pregnancy, birth and postpartum and a personal commitment by each of us in clinical practice to support physiology in our every day work as midwives. This is achieved by both our attitudes and our actions.
Physiological processes in childbirth can be described as natural processes and are apparent when the course of normal pregnancy, labour and birth are left undisturbed. This does NOT mean women should be unattended by a midwife.
Antenatal education for women, whether in a group setting or one to one, should include information on the natural process of labour, birth and the postpartum period including the physiology of establishing breastfeeding. This information is best given by a person who truly believes childbirth to be a normal life event and not a medical condition. Usual fears and anxieties on the part of the woman can begin to be addressed prior to the onset of labour as we all know that fear and helpful hormones are physiologically not good company in a normally progressing labour.
The environment where women give birth plays a significant part in enabling labour to progress normally. For example, we all know that low risk women are less likely to have a normal birth, without unnecessary intervention, if they are required to give birth in a large hospital which could also be a long way from their home. Not only in these settings, but in all situations before any intervention is considered (e.g. ARM, induction of labour, episiotomy) we must be able to honestly answer to ourselves and to women, that the procedure being considered is not denying physiology the opportunity to triumph.
Physiological labour and birth are supported when women are supported emotionally and physically, when they are provided with complete privacy, when they have the support of a person or people dear to them, when they are encouraged to use water and/or move around and adopt different positions to ease the pain of contractions and to aid giving birth. Women and families are reassured by feeling the midwife attending them is confident and competent -- that they are in "good hands." Most of all though, women need to be shown kindness by the midwife and to be treated with dignity and respect at what is a vulnerable and hugely significant time of their lives. We cannot underestimate the lasting impact the experience of giving birth has on women. The way they were made to feel at this time stays with mothers forever.
Supporting physiology following the birth begins with immediate skin to skin time for mother and baby. This time should only be interrupted if a change in the condition of either mother or her baby occurs. In order to facilitate successful breastfeeding and emotional attachment, both of which are life saving for a baby, mothers and babies need to remain close and not be separated.
The promotion of normal birth, the safest way to give birth, is part of the Scope of Practice of a midwife, and it is our view that trusting and actively supporting physiology is the main way in achieving this.