Every stage of child bearing from conception to delivery is as important as the other and various women go through the various stages differently. Some find it straight forward and without any complications while others have issues from the day they conceive. In this assessment, i will be looking at Linda’s episode of care during labour. My rationale for choosing this episode of care is because i feel it is extremely important to be aware of everything that happens in her body during this period so as to be able to identify if something was to go wrong with either Linda or her baby. I have found that some women do not know what to expect when they are in labour and are very terrified of the experience. It is therefore the duty of us student midwives and the qualified midwives to reassure them and to show them that we know what we are doing so that they can feel secure. An appendix has been attached to the end of this essay with details of Linda’s history, her labour and delivery.
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Demonstrate an understanding of underlying anatomy and physiology related to the woman during the period of care
When Linda got pregnant, her body began to go through changes at different stages of her pregnancy. These changes carried on until after she delivered her baby. These changes affected different aspects of her body such as her hormones and her body systems. Her normal uterus is capable of contracting spontaneously, and it is mostly the progesterone secreted from the placenta that suppresses the activity of the uterus during pregnancy, maintaining the fetus within the uterus and the cervix remains firm. At term, changes take place in the cervix that make it softer, and uterine contractions become more frequent and regular. The specific mechanisms of these changes remain unclear. Linda’s labour can be divided into three stages, which as other women, are not equal in length. The first stage is from the onset of labour to full dilatation which usually lasts 8-12 hours in a first labour and 3-8 hours in subsequent labours. The second stage is from full dilatation of the cervix to delivery of the baby which usually lasts 1-2 hours in a first labour and 0.5-1 hours in subsequent labours. The third stage of labour is from delivery of the baby to the delivery of the placenta which could last up to an hour if physiological and 5-15 minutes if actively managed. In Linda’s labour, her first stage lasted for 5 hours, her second stage lasted for 17 minutes and the third stage lasted for 23 minutes.
In Linda’s body, the primary change underlying the process of the first stage is progressive dilatation of the cervix. This brings about the recognizable symptoms and signs of labour. The cervix is supplied with nerve endings and as it starts to dilate, the nerve endings cause the pain of labour. In addition, the plug of viscous mucus that protects against the entry of bacteria during pregnancy often appears as a show. The support of the fetal amniotic fluid is reduced due to the dilatation of the cervix. This causes the membranes to rupture which could be a sign of active labour. According to the British Midwifery Journal 1999, under normal circumstances regular uterine contractions are prompted by the development of contacts between cells considered to be sites of low resistance. These gap junctions are sites of low electrical resistance which allow the passage of depolarization waves from one muscle cell to another across the uterus. Where possible the process corresponds with the ripening of the cervix. If the contractions start or the membranes rupture before the cervix is ready, the process is stimulated by the release of prostaglandins from the membranes and the uterine decidua. Then labour has to pass through a latent phase during which the cervix dilates very slowly.
Hormones play a large part in the body during the natural process of labour and it is important to know what they do so as to be able to explain to women like Linda. Oxytocin is the love hormone and is the hormone that gets contractions of labour started. Oxytocin in the blood responds with receptors in the uterus, and the number of receptors in the uterus grows during pregnancy and also during labour. Endorphins are the body’s natural pain killers, and they too increase in the body as labour progresses. Adrenaline also has a role in labour, which include giving Linda bursts of energy when she needs it to push the baby out, when the time comes. Having a more comfortable labour involves a balance of these hormones.
Another area that changes occurred during Linda’s labour is the supply of oxygen. The oxygen supply is lesser during labour because contractions get in the way of oxygenated maternal blood to the placenta. However, the fetus more often than not adapts well to this. The fetal circulation is unaffected by contractions (as the fetus is enclosed within the uterus), except there is cord entanglement with compression. The normal oxygen pressure in the fetal blood prior to labour is about 4 kPa. During labour it falls to about 3 kPa. Nevertheless, redistribution of the flow within the fetus to protect the vital organs such as the heart and brain means that a healthy fetus copes well with this stress.
Once Linda’s baby is born, the uterus continues to contract strongly and can now retract, decreasing noticeably in size. This causes the placenta to detach from the uterine wall. If the placenta is allowed to be delivered with normal contractions which is the physiological management, this can take up to an hour. Active management where a drug called syntocinon, depending on the hospital, is used speeds this process and reduces average blood loss by about 50 %( Rogers J et al, 1998).
Reflect on their own role within the care team involved in the woman’s care, demonstrating understanding of multi professional working
Working as a student midwife comes with a lot of benefits. These benefits are what help us become professional midwives according to the NMC codes and policies. We have various roles to play in the multi professional teams we work with and our efforts are appreciated by both the team and the clients we are caring for. According to the NMC code of professional conduct, we are supposed to act like professional midwives who have their own principles to follow. This is because we start practicing from the time we are students and not when we qualify as midwives. These principles, under the NMC code 2010, include making the care of your clients your first priority and respecting their dignity at all times, working with others to promote and protect those in your care including their families and the general community, provide a high standard of care and practice at all times, be honest and open and act with integrity and finally we are supposed to uphold the reputation of our profession always.
The care women receive during labour and birth is very crucial because it could affect them both physically and emotionally in the long and short term (NICE 2012). This care can be affected by the team of professionals caring for the women and the way they work together. Multi professional working is part of everyday practice in healthcare. McCray 2009 defines multi professional working as practice among different professional groups but not necessarily in collaboration. This means decisions can be made with women and their families but each professional group will work separately in delivering the agreed care plan. One major part of multi professional working is teamwork. Team work brings about positive results in the care given to women and their families. Furthermore, when health care professionals are working together to reach a common goal, team work makes it easier to achieve this. Multi professional working has its own benefits which bring about positive results to the team, the women and the organisation as a whole. First of all there is a sense of team identity. People feel like they are a part of the company and that they are being recognised and appreciated. Secondly, communication is straightforward, as long as the members of the team are aware of the methods of communication used. Thirdly, there is less duplication and omission. When everyone in the team is assigned a particular role, there is less chance of people doing the same thing. Finally, for the benefit of the organisation, organising training for the team is straightforward and easy to facilitate because everyone knows what they are doing and when they are able to attend. In general, every organisation needs to follow multi professional practice in order to achieve a common goal and get positive results.
Consider the health and social needs of the woman and her family and the impact this had on the care given
The importance of health and social support changes as women’s needs change as they move form pregnancy to labour to delivery. Women in labour such as Linda and her family should always be treated with kindness, respect and dignity. The views, beliefs and values of the woman, her partner and family in relation to her and her baby’s care should always be respected(NICE 2012). We gave Linda the opportunity to make her own decisions when the need arose such as the type of birth she wanted to have, the location (depending on her past medical history), the type of third stage delivery she wanted and if she wanted her baby to have the vitamin K injection. This made her more confident and in control of what was happening around her.
Linda did not have any medical history is the past so she did not need any extra care from the doctor or other health care professionals. Having said this, we were still obliged to follow the hospital’s policies in making sure that both Linda and her baby were healthy and happy at all times. We did this by monitoring Linda’s blood pressure, temperature, pulse and respiratory rates. We also made use of foetal monitoring with a sonic aid to access the heart rate to make sure the baby was not going into distress. All these findings were documented in according to the NMC code (2010) on record keeping.
Throughout Linda’s pregnancy until she delivered her baby, she was given quite a lot of informative support through the classes she attended, the books and leaflets that she was given, the conversations she had with her midwives and other mothers. This was very important for her because she felt in control and aware of the changes in her body and what to expect every week.
During Linda’s antenatal classes, she was advised to consider birth partners in her birth plan and to inform them before hand so that they are aware and ready. The need for birth partners is very essential because it makes the women more relaxed because they have familiar faces around them. Linda had two birth partners with her and this was in accordance with the hospital policies. The role of her birth partners was to show emotional support, physical support, mental support and social support. According to Leach J, 2012, in addition to these functions stated above, the birth partners also act as informants and advocates to the women. From Linda’s experience, we could see that she listened to her birth partners more than she did to the midwives. We also observed that she told them to answer some questions on her behalf. Even though this was happening, we still made sure we confirmed with her that she was aware of the situation and the decisions being made.
As health care professionals, it is our responsibility to make sure that women like Linda are comfortable in their living environment. We need to be aware of any situations that could cause problems during her labour or birth. Such problems could arise from financial stress, extended family or problems in relationships. During Linda’s admission, we were able to gather that she was financially stable and secure. We also gathered that she had no problems whatsoever at home. This made her labour more straight forward.
Another area that we made available for Linda during her labour was one to one care. She liked the idea of coming into hospital and we looking after her without other people going in and out of the room. Hatem, 2009 et al said that one to one midwifery care has four main benefits- provides less intervention during labour and birth, there is less need for pain relief during labour and birth, there is a higher likelihood of normal delivery and there is a higher likelihood of successful breastfeeding. From these four points, we found that Linda benefited from the fact that there was less intervention because nobody needed to come into the room except when required and this made her very comfortable, she had a normal delivery, she used only entonox as pain relief and she breastfed very well and being given the right support.
Discuss the system of maternity care within which care was given and explore the possible implications for midwifery care, the woman and her family and the impact this may have had on her normal physiological processes during the period of care
There are various systems of care used in midwifery practice today. Some of these include midwife led care, independent midwives, specialist midwifery care, caseload midwifery and home birth midwifery. The care that Linda received during her time in the hospital was midwifery led care.
Midwifery led units or birth centres are maternity units managed by midwives in a hospital setting or a community setting (NCT 2011). According to the Royal College of Midwives 2002, birth centres came into existence in a place called La Casita in Santa Fe, New Mexico in the mid-1940s and the Su Clinica Familiar in Raymondville, Texas. In New York, the Maternity Center Association established the first birthing centre in 1975 and its aims were to provide low cost, family-centred care. They were developed widely to meet the needs of rural communities and provided care to women who were categorised as low-risk, based on medical assessment. In the 1990s, Zander and Chamberlain (1999) acknowledged that 75% of care given to pregnant women came from midwives and that the midwifery model of care could become the dominant model in later times.
The establishment of birthing centres in the 1980s in the US and in the 1990s in the UK has led to more women getting satisfaction from their care, expansion of some midwifery roles and in many cases changes in the delivery of medical care for some doctors (Walker, 2001).
In 2010, a Cochrane review found out that women who had received care from a birthing centre compared to women who received care in a hospital have fewer interventions medically, are more likely to have spontaneous vaginal deliveries, experience more satisfaction generally and are more successful with breastfeeding (NCT 2011).
As any other system of care, the midwifery led care also has its implications. If women like Linda decide to have their baby on a midwife led unit, they are advised that they cannot receive an epidural if they require it. Furthermore, if any complications occur during labour or delivery, they would have to either be transferred to the hospital ward or may have to wait for the health care professionals needed. There are more benefits that implications of the midwifery led unit.
Linda and her family were very comfortable on the unit and this led to her being relaxed and in control. The unit is supposed to create a ‘home from home’ feeling so that women don’t feel like they are actually in a hospital.
The physiology of labour can be affected by the system of care being delivered. This is because the body needs to be relaxed and ready for the delivery of the baby. When a woman is tense and panicking, the baby senses it and becomes distressed. There are five main practices that promote the normal physiological process of labour- allowing labour to start on its own, freedom of movement during labour, continuous labour support, spontaneous pushing in non supine positions and no separation of mother and baby after delivery. It is impossible to carry out these practices on other hospital wards because majority of the women are strapped to the cardio topographic monitors or they are being induced or their babies need to be assessed and therefore separated from the mothers. The midwifery led unit is the only place that these practices can all be carried out, therefore giving the women more chances of them to labour naturally.
Midwife led care is an area that is fast growing because women get the satisfaction they require from their experiences and Linda is one of those women. Midwives are aware of the importance of multi professional working and that is why they deliver exceptional care to women during these most important times of their lives.
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