Assessing progress in the first stage of labour

*Written before an exam as revision where I believed this type of question would come up and completed after the exam for here. The question that I answered was “How does the midwife assess progress in the first and second stages of labour?” I’ve only answered the first part of the question here.*

I will discuss the role of the midwife, and what the student midwife must learn, in assessing progress in the first stage of labour.

The first stage of labour can be defined as ‘from the onset of regular contractions to the full dilation of the cervix’. It can further be divided into latent phase-up to 4cm dilation, active phase-from 4cm to 10cm dilatation and the transitional phase-from about 8cm to fully dilated. [On a side note, I read an interesting article about the misleading guide of stages in labour-Winter and Cameron, 2006. ‘The 'stages' model of labour: Deconstructing the myth’. British Journal of Midwifery, 14, 8. If anyone would like to read it, message me through Facebook].

The midwife records labour progress on a partogram, including the cm’s dilated, engagement, foetal heart rate and amniotic fluid draining. The partogram contains a graph with an action line by which the midwife assesses and compares the woman’s labour to the recommended guidelines. It is considered ‘normal’ for the active phase to last 12 hours; NICE guidelines recommend that progress should be 2cm per 4 hours.

Of course, not all women and their bodies are the same, these are just common signs. We must always make our observations and conclusions specific to each woman we care for in labour. 

There are a number of external signs of progress the midwife can observe, these include the strength, length and frequency of contractions, the mother’s behaviour, her breathing, her ability to cope, her voice, the presence of a bloody show,  the ‘purple line’ and the Rhombus of Michaelis.

During the latent phase of labour when contractions start they are usually short, far apart and not very strong. The woman can cope with them well and is able more or less to continue with her day. The latent stage in the primiparous woman usually lasts 3-4 hours, shorter in the multiparous, however this is can vary greatly.

 As labour continues into the active phase once the contractions increase in length, get closer together and stronger. She will now require more support and coping mechanisms to manage with the contractions. Contractions should build up to three every ten minutes and be approximately 45 seconds or longer in length, they should continue this way throughout the active stage of labour. The mother will not be able to talk through these contractions and her breathing may be deeper and heavier through them to cope. Bloody show is mucous from the vagina and blood from the cervix combined and indicates cervical dilation, as the cervix dilates there is usually more bloody show present. The purple line may become noticeable now, this is a purple line that appears from the anus up the buttock cleft. As the second stage progresses it will become longer towards the top of the buttock cleft and many midwives have noticed that once it reaches the top the woman in fully dilated. Another sign that midwives have found over the years that indicates nearing full dilation is the presence of the rhombus of Michaelis. The rhombus of Michaelis is a diamond shape protrusion (for want of a better word!) on the woman’s lower back that becomes visible as the bones adjust to allow the baby’s further descent into the pelvis. It is most visible when the mother leans forward and reaches her arms out, apparently also a sign of transition.

It has often been noted that once the woman meets the transitional stage her contractions may ease off a little but her urge to push will begin taking place. It is well known to hear a woman claim she cannot do this anymore, demanding pain relief and asking for the care providers to ‘end it all’ once she reaches transition stage (Fraser and Cooper, 2009). During transition if the membranes have not ruptured yet this is often when it occurs. This allows for the presenting part to descent further into the pelvis and apply itself well to the cervix. A sign from the baby that full dilation is nearing are decelerations during the peak of a contraction, this can indicate ‘foetal head or cord compression’ meaning the head is descending well. 

The first stage ends and the second stage of labour begins once pushing commences.

As mentioned before, every woman and her body is different and it is only by observing and working with each individual that we can care for her and assess her progress accurately. All of the above signs can be observed by interacting with the woman, asking her questions and simply becoming aware of her behaviour.

Feel free to ask me any questions about anything I’ve said here. Sorry if I’ve got something wrong, do correct me! Also, I happy to try find articles for people on any of the above :-)

Fantastic related listen: The second recording on the list, ‘Ungloved and Observing’ by Gloria Lemay http://internationaldayofthemidwife.wikispaces.com/International+Day+of+the+Midwife+2011

Inspired!

Inspired. This is the feeling I have come away with after each presentation made as part of the Virtual International Day of the Midwife (May 5^th) online conference. I listened in to some of the discussions on the day and am catching up with the other now at http://www.internationaldayofthemidwife.wikispaces.com. Midwifes who I look up to and admire were talking there, it was wonderful to hear them speak so passionately about their lives work.

I was inspired to write this post today (and hopefully will be much more actively writing from now on!) after listening to Joy Johnston (http://www.aitex.com.au/joy.htm) talk about how important it is for midwives to blog. By blogging we are reaching our thoughts and words out into the world, we will never make a difference staying silent! So I hope to keep up to date on this blog now, even if some of the posts are short.

I was inspired by Lisa Barrett (http://www.homebirth.net.au/) and Mary Sidebotham and all the other participants at both presentations to speak out about midwifery, get the word out about how birth is normal and should be trusted and treated as such! One quote that someone brought up that really hit home with me was “Speak your truth-even if your voice shakes”. I personally find it difficult to voice my opinion and speak up when I have something important to say. Now I will be speaking my truth even though I know my voice will, at the least, shake!

I was inspired and reminded by Gloria Lemay (http://www.glorialemay.com/blog/index.php) to trust women’s bodies.  She spoke about recognising the signs of progression in the woman’s body in labour and the importance of observation, not interference, in labour and birth. Gloria discussed how the assumptions of midwives are always being challenged and being fooled by women’s bodies, I took from this that a midwife must always be learning from every experience and never take anything for granted.

I feel so proud to be a part of this group of wonderful women, birth activists, midwives, student midwives and you. You should feel proud too, we are a very special collection of people!

Now, I really encourage you to go listen to some (or all perhaps) of the recordings and feel inspired too. I believe that they will soon be turned into MP3 files so we can download them to our iPods, I know I will be grabbing them as soon as they are there so I will have the inspiration of many at my fingertips!

My first time assisting a birth!

So I’d been on the labour ward for two very long and tiring 12 hour shifts, on my the third and final day of the week the ward manager proclaims it’s my time to deliver a baby! I felt very nervous then, especially as the midwife I’d been told to work with wasn’t very sure about it having just been qualified herself. Instead of freaking out, I accepted. I knew it was going to have to happen soon, I just didn’t think it would be coming now.

The mother’s epidural had already started working by the time I arrived and she seemed happy and relaxed. Being her second baby she wasn’t the anxious first time mum. We knew she was 4-5cm and of course didn’t know how much longer her labour could be, as with all, and so the waiting game was in session.  Mum was sleepy so I let her sleep, only disturbing her for the routine temperature and blood pressure takings (something I’m growing so accustomed to now).  I read her notes a few times over, each time understanding a little more of midwifery shorthand and doctors scrawls. A lot of fiddling with the CTG machine to stop it making the alarming noises that were worrying dad! Having a machine interpret the natural human body patterns will always seem to me to be strange... Why interfere with nature in the first place?

When the time came for mama to start pushing, she couldn’t feel much... but with some good (directed) pushes baby came down very quickly. Even if I don’t like ‘purple pushing’ (take a deep breath, close your mouth and push, no, don’t make a sound) unfortunately most women with an epidural are unable to feel their bodies telling them to push and need this coaching... When baby was nearly here another more senior midwife came in to help, she was great! As the midwife I was working with felt unsure about teaching a student, this midwife knew just what to do! She grabbed my arm and hand from where it was hovering apprehensively over the midwife’s hand and placed it in the correct position on the other side of the baby’s head. At this point I wasn’t really sure what my hand was meant to be doing... I let it support babies head and apply a little pressure, it felt about right. I followed the action of the other midwife as best I could, concentrating as if my life depended on it! ‘Pant, pant, pant’ was being instructed alongside ‘now a little push’ as the baby’s head slowly emerged into the world, squashed and looking rather displeased with its fortune! I noted its slow rotation as the midwife hooked her finger round the cord and pulled it over the baby’s head. The next push was the final as me and the midwife wriggled the babies shoulders free and the rest of her body flew out with a big gush of amniotic fluid-which I noticed with surprise was warm, of course, but this was something I’d never thought of before! Baby was out! Everyone was smiling with joy as me and the midwife fumbled with cord clamps and I handed dad the scissors to perform his ritualistic task. A beautiful and big healthy girl, with generous Apgars of 9 and 10, was new in the world and I’d been a part of her entrance. I was and will remain forever delighted with my first participation in a birth!

However, a midwives work does not finish there. As the primary midwife went off to get a number for this baby who hadn’t a name yet, the task of delivering the afterbirth lay to me. With direction from the senior midwife I managed ok, well I think anyway! When told to apply traction I was scared of pulling to hard, I got the hang of it though once the placenta began to separate. I felt silly when being told off for wrapping the cord around the clamp as I’d seen before, no need for this, I was told; just move the clamp further up. I then felt like a real grown up midwife when I caught the placenta and knew to allow the membranes to follow. I felt so happy to be trusted with inspecting for tears. The praise from the midwife felt amazing and I have not stopped smiling since!

Well I'd better say hello...

Hello whoever is out there...be you wannabes, trained or other student midwifes or perhaps just random passers by!

Many people ask how I first came to decide on midwifery, such a selective and particular niche?
I always start by explaining how my mother has been such a wonderful inspiration in me making this desision, she is and will always be the gate to my path of midwifery. She had two wonderful homebirths with my younger sisters after having a a 'failed' homebirth and horrible hospital experience with me. Mum has always talked to us about her pregnancies and births and answered our inquisative questioning. I remember waking up as my youngest sister was born and seeing her as a new newborn baby and I really value that special moment of seeing my naked red haired baby sister in my dads arms as mum birthed the placenta. My interest and fascination in pregnancy and birth has been growing since I could talk and would point at other babies and tell my mum, "Look mummy, it's a beebee" in my Jordie accent to watching births on Youtube as a young teen.
Once I began voicing my wishes to become a midwife I knew nothing could stop me.
However I did have a wobble in my aspirations once... When it came time to begin choosing careers to study in my fifth year of secondary school I was surprised to realise I was scared of the thought of midwifery. I think the idea of the responsibility it would mean I'd have to hold had shaken me and I was worried that the dream I'd had would be crumbled by fear. I let these thoughts sit and it dawned on me that if I pursued anything other than midwifery I would always regret it and there my joy of life bubbled and exploded again and I was back on the road to becoming a midwife!

Why not study nursing first and then specialise as a midwife?
Because I never want to wash old men! There are more complex reasons than that also of course... I worked so hard through my two leaving cert years and at my exams that I had no intention of then studying something for four years that I didn't even want to do in the long run, no, to me it is a waste of time! And I'm very happy I made that decision now I've started the course.

Why homebirth?
So many reasons!! But rather than being just very supportive of homebirth I'd like to see myself as being a midwife who is supportive of what each individual mother feels is best for herself once she is informed and comfortable with her decision. Because the people who matters most are the mother, baby and their family, not the midwife or doctor. I understand there is much to dicuss regarding homebirth and will no way attempt to start it now! It will come in bits and pieces as I learn more =)

Well, I think that's it for today and soon I will tell you of my first few weeks I have been experiencing as a student midwife!

And no matter who you are, I do hope you enjoyed learning a bit about me, my mind and my life.

Slan!