Reflection is learning from experiences, that takes into account previous knowledge and incorporating new knowledge to improve practice (Jasper and Rosser, 2013). Further, reflection is also a tool for expressing emotions and students’ feelings (Alphonso, 2007 and O’Donovan, 2006). In this essay, I will be using the Marks – Maran and Rose reflective cycle (1997) to reflect on my experience of caring for a woman in labour. I will explore how birthing positions and effective communication can affect labour.
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For confidentiality reasons, I will be using the pseudonyms Sophie for the mother and Harry for the father to respect their identity. (The Nursing and Midwifery Council, 2018) I shall also be referring to the midwife I worked with as ‘the midwife’.
The midwife and I started our shift and took handover to care for a labouring woman in the birth centre named Sophie. The only other person in the room was Sophie’s husband, Harry. The room was dimly lit, with mood lighting, gentle music playing and had special shaped couches, allowing it to be homelike and a calm and relaxed environment for Sophie to give birth. Sophie was in second stage labour but was progressing slowly, which slightly concerned the midwife as she was multiparous. The midwife performed a vaginal examination on Sophie and felt baby’s head was in an asynclitic presentation, which affected Sophie from progressing as quickly. To allow the baby’s head to turn and fully engage, myself and the midwife encouraged Sophie to move or change to a position where she was not semi-recumbent as this was preventing her pelvis from widening.
Sophie however, was reluctant to move as she was in pain and had been in labour thirteen hours so felt exhausted and lacked energy. We explained the risks that if she did not move or change position her labour may not progress as well, leading to interventions such as an instrumental delivery or a caesarean section. Although Sophie still did not want to, hearing the risks prompted her to listen to our advice and so we supported her to use the birth ball and birth stool. After a few minutes, Sophie decided she did not like them, so the midwife and I decided she may feel better kneeling and supported her to get in this position on the couch. Sophie preferred this position compared to the birthing ball and stool but was still trying to lie down. In the best interests of Sophie, I and the midwife folded the couch in half so that she was not tempted to lie down again and was able to remain in a kneeling position as the couch accommodated for this. We put the bean bag on top of the couch so that Sophie could lean and rest her upper body to make her feel more comfortable. I reassured Sophie this would help baby’s head turn and descend as she is keeping her pelvis wide and more open. I passed Sophie the Entonox each time she felt a contraction coming and held her hand as a form of comfort, whilst reassuring her how well she was doing. Meanwhile, Harry rubbed her back as a method of pain relief and reassurance. Sophie’s behaviour changed dramatically and started saying she cannot do it and felt she needed to open her bowels, I and the midwife took this as a good sign that baby’s head was descending and was making good progress. We carried on reassuring her and encouraging her to go with what her body was telling her. She opened her bowels and then said she could feel baby’s head. Sophie kneeled back on the couch and began pushing and gave birth to a baby girl.
Right from the beginning of walking into the room to take over care myself, the midwife, Sophie and Harry all wanted the same goal, which was for Sophie to birth a healthy baby. This allowed us all to build up a trusting relationship from the beginning. Sophie’s aim was to birth her baby vaginally without any interventions, so I and the midwife wanted to support and encourage her to do so. Sophie had been given pethidine not long before we took over care, this made Sophie very restless and tired and made it a bit more difficult to have an open conversation with her as she just wanted to sleep. (REFERENCE EFFECTS OF PETHIDINE) After Sophie consenting to a vaginal examination and not being able to feel the posterior fontanelle but instead the side of the baby’s head, Sophie started to worry and panic that this would cause a problem. We reassured Sophie that this does not necessarily mean she cannot have a vaginal birth, she will just have to move around and change position to try and allow the baby’s head to descend. We let her know we would do everything within our realms to keep her in the birth centre, so she could have her vaginal birth. (REFERENCE WORKING IN YOUR ABILITIES) With Sophie still being lethargic she was still reluctant to move, this caused the midwife to become more assertive but compassionate at the same time to get Sophie to listen and change positions. In the back of my mind, I started to worry that Sophie may end up having interventions during her labour and not have a vaginal birth. This made me more determined to support Sophie to change position, so myself and the midwife worked as a team to get Sophie into a position which was not a supine position. After trying different positions, Sophie was the most comfortable kneeling on the couch.
Changing Sophie’s position had a positive impact for Sophie, as not long after being in the kneeling position it allowed her pelvis to widen and allow the baby’s head to rotate to come down the birth canal and be born. The midwife and I were so pleased for Sophie who not only birthed a healthy baby girl but birthed her vaginally as she wished. Sophie and Harry were so thankful for us helping her to birth her baby but also that the midwife became assertive with her but also encouraged her and reminded her that she could do this. I was conscious that as a student midwife I had gained minimal practical experience and was therefore very conscious and nervous that I could make a situation worse rather than better for the midwife and Sophie if I were to do or say anything wrong. I am also aware that I am younger than many women in my care which may also suggest inexperience and make women nervous. I was therefore very keen to appear calm, confident and competent and ensure that my presence was beneficial to Sophie whilst carrying out the instructions of the midwife to the best of my ability.
In a recent 2017 Cochrane review and meta-analysis, Gupta et al combined the results of thirty-two randomized, controlled trials that included more than nine thousand birthing women in hospital settings. In these studies, people were randomly assigned to either upright or non-upright positions during the second stage of labour. The researchers defined upright positions as sitting on a birthing stool or cushion, kneeling, squatting and hand and knees. They defined non-upright positions as lying on side, semi-sitting and lithotomy. In comparison with non-upright positions, people who were randomly assigned the upright positions in the second stage of labour were; twenty-five per cent less likely to have a forceps or vacuum-assisted birth, twenty-five per cent less likely to have an episiotomy and fifty-four per cent less likely to have an abnormal fetal heart rate pattern. (Gupta et al, 2017)
It is suggested that women in upright positions give birth more easily because the pelvis can expand as the baby descends; gravity may also aid this, and the baby may benefit because the weight of the uterus will not be putting pressure on the mother’s major blood vessels which supply oxygen and nutrition to the baby. Upright positioning also helps the uterus contract more strongly and efficiently and helps the baby get in a better position to pass through the pelvis. (Gupta, 2017)
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“Another possible way to classify birthing positions is whether the body weight is on or off the sacrum, or the large tailbone at the base of the spine. Positions that take the weight off the sacrum and allow the pelvis to expand might make spontaneous birth more likely.” (Edqvist et al, 2016) These positions include; kneeling, standing, hands-and-knees, squatting and using a U-shaped birth seat.
The Royal College of Midwives (RCM) in the U.K. recommends the use of active and upright positions to assist with labour and delivery. In their guidelines, they urge midwives to be proactive in demonstrating and encouraging different positions in labour, since women often “choose” to do what is expected of them, and the most common image of the labouring woman is “on the bed.” Since the environment is key to freedom of movement, RCM suggests that there should be a variety of furniture and props available in the room to encourage people to try different positions: bean bags, mattresses, chairs, and birth balls. They recommend that midwives support mothers with suggestions on how to remain upright even if they’re in a situation that might limit mobility.
In a publication by the World Health Organization (WHO) called “Care in Normal Birth,” the WHO concludes that women in labour should adopt any position they like, while preferably avoiding long periods lying supine (WHO, 1996). They recommend that birth attendants need training in supporting births in other positions than supine, since much of the positive effect of upright birthing positions depends on the birth attendant’s experience with the position and willingness to support the mother’s choice of position.
- What internal factors influenced my decision making? (e.g., local policy and procedures; custom and practice)
- What external factors influenced my decision making?
- What sources of knowledge did/should have influenced my decision-making?
- What other choices did I have?
- What might have been the consequences of these other choices?
- How do I now feel about the experience in light of reflecting on it?
What does this experience mean to me now (in terms of my future practice)?
How has this experience changed my knowing and understanding?
What have I learned and how am I different as a result of reflecting on this
- Alphonso, C.D., 2007. Reflection on a critical incident. Contemporary nurse, 24(1), pg.89-92.
- Dekker, R. (2018). Evidence on: Birthing Positions – Evidence Based Birth. [online] Evidence Based Birth. Available at: https://evidencebasedbirth.com/evidence-birthing-positions/ [Accessed 14 May 2019].
- Edqvist, M., Blix, E., Hegaard, H. K., et al. (2016). “Perineal injuries and birth positions among 2992 women with a low risk pregnancy who opted for a homebirth.” BMC Pregnancy Childbirth 16(1), pg.196.
- Jasper, M. and Rosser, M., 2013. Reflection and reflective practice. Professional development, reflection and decision-making in nursing and healthcare. Chichester: Wiley-Blackwell, pp.41-82.
- O’Donovan, M., 2006. Reflecting during clinical placement–Discovering factors that influence pre-registration psychiatric nursing students. Nurse Education in Practice, 6(3), pp.134-140.
- Royal College of Midwives (2012). Evidence Based Guidelines for Midwifery-Led Care in Labour. [Accessed online 14 May. 2019].
- The Nursing and Midwifery Council. (2018). Read The Code online. [online] Available at: https://www.nmc.org.uk/standards/code/read-the-code-online/ [Accessed 15 Feb. 2019].
- World Health Organization (1996). Care in Normal Birth: A Practical Guide. [Accessed online 14 May. 2019].
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