The Rhythms of Labour – Denis Walsh

For those who don’t know Denis, and I hadn’t heard him speak before the MAMA conference, he is a midwife.  A rare thing to find a male midwife, but I have to say that those I have met along the way have been fantastic, and I have come to believe that if a man decides to pursue midwifery he really must have a calling and a passion to do it, given that it is such a woman-dominated profession.  Denis is now Associate Professor of Midwifery at Nottingham University, having done his PhD in the Birth Centre model, and his research awareness is second to none.  I have to admit that I (and a few others whose names I shan’t mention) now have a bit of a crush on him – I found him truly captivating to listen to and would love to hear more.

The focus of his presentation was looking at how a woman progresses in labour and how the institutionalisation of birth (from the 1920s in the States) meant that there has been an adoption of a business/industrial model – a pathologisation of labour length for women.  If you think of it in its simplest terms it is daft – how on earth can you quantify how a woman should give birth?  As Denis says, “the stages are an artificial imposition on labour”.  A study done in 1954 looking at cervical dilatation (as a complete aside I haven’t heard that expression before – dilatation instead of dilation – is there a difference?) came up with a partogram called the Friedman Curve.  However, as is so often the case, the study was flawed – certainly from a doula’s perspective – women were strapped to a bed, sedated, with IVs in, given 2 hourly internals etc.  It gave rise to the Icm per hour statistic that we all hear so often.  Apparently the current Cochrane recommendation is that there should be a baseline dilatation rate of 0.5cm an hour (Enkin, 2000).

In Dublin hospitals in the 1970s the spiralling birth rate meant that they introduced an active management of labour.  Women’s labours were limited to 10 hours.  There was aggressive management of slow progress – ARM and use of synto.  There was one-to-one midwifery care, but it did not lower the c-section rate.  This led to the perception that a primip’s body does not know how to labour and that women need augmentation.

Thankfully, in the past ten years there has been a backlash against the “progress” model.  In 2009, evidence gathered in studies of 6000 women showed that “we cannot recommend routine use of the partogram as part of standard labour management and care” (Lavender).  And Zhang, in 2010, concluded that cervical dilatation (that word again!) is not linear but parabolic, and that the active phase of labour commences between 5 and 6 cm.  MANA, the Midwives of North Amercia have challenged the orthodoxy of linear progress and have introduced the concept of a physiological plateau – the woman’s labour starts, and then there is a plateau phase before the parabolic curve that Zhang talks about kicks in.  So what happens if a woman is in the plateau phase and that is misdiagnosed as “failure to progress”?  By interfering with the woman’s body do we cause more problems?  Does putting up synto to boost a woman’s uterus that may be having a necessary pause, just exhaust the body more, as well as distressing the baby?  Denis was telling us that there are other ways of finding out if a woman’s uterus is “exhausted”, such as measuring lactic acid levels if the membranes have broken.

In relation to our work Denis was able to talk about how best to support women so that their labour rhythms are not disturbed too much.  He referenced Sarah Buckley’s work, but seemed a bit reticent going in to detail about birth hormones in view of the fact that we had already heard from Kerstin Ovnas-Moberg, Queen of Oxytocin, herself!  He referenced Downe & McCourt’s concept of “unique normality” – labour will be different for every woman, but it will be normal for her.  He talked about the ideal ways of assessing a woman in labour and how Delivery Suites are entirely unsuitable for the latent phase of labour (Bailit et al 2005), and that “staying at home is the best model” (Janssen, 2006).  He wished that every woman could be assessed by a midwife at home, rather than having to endure transfers in, busy triage offices and the possibility of having to return home.  What was really reassuring for me though, was his discussion of what to do if a woman has a prolonged mid-labour.  His instinct, as long as mother and baby are fine, is to watch and listen.  Rather than rushing to put up the syntocinon, rupture membranes etc he talks about continuing to offer physical, psychological and social support, making recommendations of ideas to  enhance birth physiology, such as posture or mobility changes.  In a tone of incredulity he describes how midwives have become “gatekeepers to the bath”, preventing women from accessing a birth pool because she isn’t far along enough.  He says that water is a free choice for women in labour, and something she can get in and out of whenever she wants.  Apparently Smythe concluded in 2007 that ARM is “no longer recommended as may increase c/s rate”, and oxytocin augmentation is associated with low APGARs, neonatal intensive care and operative delivery (Oscarsson, 2006).

Denis then talked about midwifery skills for recognising labour, rather than resorting to vaginal examinations, which are so often painful, have been linked with PTSD (Menage, 1996) and described as a ritual that “disempowers women” (Bergstrom, 1992).  He said that VEs are on offer, not a requirement, and that women have the right to refuse them, but that using the word “decline” rather than “refuse” might come across as less hostile.  Watching the pattern of contractions, observing maternal behaviour, looking for the purple line which shows up in 76% of women (Shepherd, 2010), warming up of the mother’s anterior fontanelle, temperature change in the lower leg, sacral bulge and goosebumps over the buttocks, abdominal palpation, vocalisations by the mother, and midwife instincts (sense of smell, feelings in the body, the need to open their bowels etc) are all really useful skills.  As Denis remarked, “exactly what is it that is going on being with a woman in labour … it is very powerful … some things that really count can not be counted.”  I loved the fact that he emphasised that labour works best when the woman is enveloped in care and compassion from her companions and is in an environment of tranquility and calm where trust, not fear, is the dominant force.  He talked about being rather than doing and quoted Leap (2000), “the less we do, the more we give”.  I am more comfortable with the expression Kennedy (2000) uses, which is “doing nothing well” and the idea of being comfortable when there is nothing to do, of drinking tea “intelligently” and knitting!  How lucky we are that we can do those things with women in labour – we are not bound by the bureaucracy, protocols and rigid guidelines of NHS trusts.  How frustrating though that a lot of this more recent research has been written up in obstetric journals but hasn’t yet filtered down into the practice of labour wards.  Lets hope that we begin to see more positive change in the near future and that the work of doulas is recognised for being so beneficial to women in labour.