Chapter 1 Attitudes and conduct
Childbirth is a physiological function. It is natural that women should want to perform this function in the way that they consider most appropriate. Individual preconceived ideas, the media, and social and cultural background all contribute in varying degrees to the expectations of the woman in labour. Safety of the woman and fetus or newborn must be the prime objective. However, the birth of a baby should also be remembered as a happy and enriching experience. Labour can only be deemed to have been successfully conducted when these ideals are satisfied.
Attendant medical personnel may have views of their own about the conduct of labour. However, the outcome is unlikely to be considered a success unless medical staff feel they have achieved good rapport with the parturient woman and conducted the labour to enhance the ideals discussed above. The following guidelines may benefit those who have not appreciated the importance of correct attitudes and conduct as salient measures of proper labour ward management.
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A congenial atmosphere should be maintained to emphasise the concept that labour and delivery are not illnesses. This should not lead us to believe that a degree of professionalism is not respected by women or their attendant partners. Anxiety is associated with childbirth. Modesty is not automatically relinquished merely because a woman is in labour. Decorum and suitable attire enhance this rapport.
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The shift system for staffing means it is seldom possible for the same medical team to attend for the whole course of labour, although supervision remains the prerogative of the obstetrician in charge. All attendants should have a thorough knowledge of the woman’s history and preferences.
This will avoid inadvertent comments which prejudice rapport and undermine confidence.
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Modern technology is used in the labour ward to enhance the safety of the woman and fetus. When the reasons for its use and the value of its application are explained, these instruments and special equipment will be viewed by parents as ancillary aids rather than an intrusion. For example, showing the woman and her partner the pattern of some basic fetal heart rate recordings can invite a sense of additional involvement and commitment.
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For women with their own preferences for the conduct of labour, ascertain the type of antenatal preparation she has had. Within reason, support the concepts and practices she expects. Introduction of alternative practices or procedures at this late stage can confuse, with the resultant loss of confidence. Special preferences which may endanger the woman and fetus should be fully discussed, preferably during the antenatal period, so that risk can be explained and minimised. Flexibility in the attitude of the attendant staff is all important, but it is an indictment against our training and values if we jeopardise the welfare of our charges by subscribing without comment to fashionable idiosyncrasies that we believe may put them at risk of possible medical hazards.
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Husbands or partners are encouraged to stay with the women throughout labour. Demanding or aggressive behaviour on their part may reflect feelings of helplessness in the perceived situation or guilt because they have subjected their partner to the traumas of childbirth. Ensure a woman is comfortable, and if needed there is ready access to analgesia. Ask after the woman’s comfort when her partner is present so that he can be verbally reassured by her. If a woman is obviously overreacting, explain in the presence of the partner that such behaviour is not conducive to an atmosphere of calm for the birth of their baby. This direct approach reinforces communication between the partners to benefit all concerned.
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Husbands or partners are there to provide support and encourage the ethos of participation by both in the birth of their offspring. This role must be emphasised during operative procedures when a reassuring voice or quiet hand clasp can assist maternal relaxation and control.
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Caesarean section performed under regional anaesthesia may be better accepted if the partner attends to support the woman. There is no justification for the partner’s presence if general anaesthesia is used. Minors should not attend labours. Their mother’s natural reactions may be misconstrued and frighten or create anxiety.
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Tact is all important when dealing with women whose expectations are not realised. Women who approach labour convinced that all things natural are beneficial may be disappointed. Nature is often cruel and capricious and has not endowed all women with the means to easy childbirth. Realisation that they are not one of Nature’s fortunates can come as an unpleasant surprise. Full explanation helps to dispel some of the feelings of guilt and failure when an assisted delivery is anticipated.
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Women who are used to positions of responsibility in society may have difficulty in accepting advice or the ‘dictates’ of labour ward staff whom they may consider more junior. Rapport and confidence is enhanced if these women can observe the efficiency and obstetric training exhibited by their attendants.
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A normal obstetric situation can develop rapidly into an emergency. Anticipation by thorough knowledge of the woman’s history and an appreciation of the significance of that history by the woman and her partner is important. Equally important is knowledge of the correct procedures to be followed when an emergency arises. Regular drills for emergencies to familiarise all staff with emergency procedures are essential. A professional and calm approach reduces anxiety and psychological stress.
All of us who attend labouring women must learn to appreciate the limitations of our individual expertise and that of the ‘system’ in which we work. If we maintain the welfare of the woman and fetus as our prime objective, there should be no reluctance to seek help from more experienced colleagues when required.
Labour is a reminder of Nature’s insistence on survival of the fittest. The role of the obstetric team should be to allow what is physiological to continue, but to intervene where appropriate to counter Nature’s indiscretions.
Expectations are, however, exceptionally high and when these are not realised the trend is ready resort to legal redress. The challenge is to provide the highest quality of service within the constraints of both fiscal and human resource. Safe delivery for woman and baby becomes a fundamental expected right while quality is measured in terms of satisfaction and the softer paraphernalia around the delivery process. This is best achieved by what I describe as negotiated care when the informed recipient (woman) and providers (medical carers) enter into a dialogue to determine within the boundaries of risk the acceptable option for all. Expectations are underlined at the outset leaving medical carers to focus effort on the process and incorporate issues for quality.
Some women will have special requirements and these are set out in Box 1.1.
Box 1.1 Guideline for women with special requirements
High expectations and intolerance of any complication mean that a woman may seek legal redress whenever the outcome is unexpected or untoward. Special requirements or wishes to dictate management must be fully discussed, and risk and likely outcome explained. These exchanges should then be carefully documented. Verbal consent for special procedures such as induction of labour should be notated. The woman’s signature is required for surgical procedures such as caesarean section or sterilisation. Additional considerations are:
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Women are encouraged to indicate their requirements by ‘birth plans’. Discuss their contents and ability to comply before onset of labour.
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Find out reasons behind their requests, for example social and cultural needs or anxiety after previous obstetric experience. Detailed explanation and reassurance may suffice to correct misconceptions.
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Communication is all important. Inadequate communication is the basis of many legal proceedings. Avoid unprofessional loose remarks.
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If a woman’s request is difficult to accept discuss care with a colleague or legal representative if negotiation cannot achieve a compromise.
Informed consent
Women’s rights and wishes must be a priority. Current guidelines are given in detail in Chapter 2. Specifically note:
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Obtaining and providing consent is a process in which a woman’s mental competence and understanding must be ensured and her right to change is recognised.
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Refusal of treatment must be explored fully to exclude inadequate information or misconception. Document discussions. Obtain the woman’s signature or disclaimer form to release medical attenders and hospital from responsibility. Notify relevant authorities.
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Parents cannot override consent provided by a child (under 16 years of age) who is assessed as competent (Gillick competent). However, parents can obtain legal sanction to provide consent if a competent child refuses treatment which can benefit.
Satisfaction with care
This is best achieved when medical carers are welcoming and helpful, when women participate in decision making and pain relief is well managed.
Specific risk factors requiring attention
The latest Confidential Enquiry into Maternal and Child Health (Why Mothers Die, 2000–2002) drew attention to need for special requirements for minority ethnic groups, e.g. black African women and asylum seekers, the socially disadvantaged, among whom domestic violence and substance misuse may be more likely, and those with medical histories, e.g. severe psychiatric history, cardiac diseases and body mass index of 35 or more.