2                                             Mother friendly                                             care during     ...
MOTHER FRIENDLY CARE DURING LABOUR, DELIVER Y AND THE PUERPERIUM             27with kindness, compassion, patience, gentle...
28    MOTHER AND BABY FRIENDLY CAREvery comforting. Unless there is a medical          to bring some fruit with them. Allo...
MOTHER FRIENDLY CARE DURING LABOUR, DELIVER Y AND THE PUERPERIUM              29feel more comfortable and confident in the...
30    MOTHER AND BABY FRIENDLY CAREanalgesia (pethidine or morphine), inhaled            may arise. A natural childbirth i...
MOTHER FRIENDLY CARE DURING LABOUR, DELIVER Y AND THE PUERPERIUM             31In a large regionalised maternity service, ...
32   MOTHER AND BABY FRIENDLY CAREOften a compromise position can be found.         or perineal tear, and reduce the risk ...
MOTHER FRIENDLY CARE DURING LABOUR, DELIVER Y AND THE PUERPERIUM            332-32 What may be the emotional effects of   ...
34     MOTHER AND BABY FRIENDLY CARE     fluids during labour, episiotomy and          can be done once the mother has had...
MOTHER FRIENDLY CARE DURING LABOUR, DELIVER Y AND THE PUERPERIUM         352-43 What are ‘baby blues’ or ‘postnatal       ...
36    MOTHER AND BABY FRIENDLY CAREstimulation or even neglect. They are at an           followed by an enema. Later a nur...
MOTHER FRIENDLY CARE DURING LABOUR, DELIVER Y AND THE PUERPERIUM            375. What is evidence based medicine?         ...
38   MOTHER AND BABY FRIENDLY CARE7. Does it help women in labour if they           3. What are some of the benefits of ha...
MOTHER FRIENDLY CARE DURING LABOUR, DELIVER Y AND THE PUERPERIUM         397. Why do you think this woman felt so         ...
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Mother and Baby Friendly Care: Mother friendly care during labour, delivery and the puerperium

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Newborn Care was written for healthcare workers providing special care for newborn infants in level 2 hospitals. It covers: An essential tool in the initial and ongoing training and teaching of any healthcare worker – Miriam Adhikari, South African Journal of Child Health, Primary Newborn Care was written specifically for nurses, midwives and doctors who provide primary care for newborn infants in level 1 clinics and hospitals. It covers: Mother and Baby Friendly Care describes gentler, kinder, evidence-based ways of caring for women during pregnancy, labour and delivery. It also presents improved methods of providing infant care with an emphasis on kangaroo mother care and exclusive breastfeeding. It covers: mother-friendly care in pregnancy, a modern approach to normal labour, skin-to-skin care of infants, encouraging breastfeeding, a baby-friendly nursery.

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Mother and Baby Friendly Care: Mother friendly care during labour, delivery and the puerperium

  1. 1. 2 Mother friendly care during labour, delivery and the puerperium INTRODUCTION TOObjectives MOTHER FRIENDLY CAREWhen you have completed this unit youshould be able to: 2-1 What is mother friendly care during• Define and give mother friendly labour, delivery and the puerperium? care during labour, delivery and the As with mother friendly care during puerperium. pregnancy, this is a method of caring for• Explain why routine shaving and enemas women where the interests of the woman and her fetus or newborn infant are considered are no longer needed. above those of the hospital or clinic staff.• Understand why most women can walk Mother friendly care is good care. Wherever around, take a shower or eat and drink possible, it is based on good scientific during labour. evidence. Many women find present labour• Give the reasons for a labour companion. practices unpleasant and, therefore, avoid• List the advantages of a ‘natural delivering in a clinic or hospital. Instead, they prefer to deliver at home. childbirth’.• Explain why an episiotomy is usually not 2-2 What are the principles of mother necessary. friendly care during labour, delivery and• Define the Better Births Initiative. the puerperium?• Prevent separating mother and infant They are the same as the principles of mother after delivery. friendly care during pregnancy, i.e. managing each woman as an individual and caring for her
  2. 2. MOTHER FRIENDLY CARE DURING LABOUR, DELIVER Y AND THE PUERPERIUM 27with kindness, compassion, patience, gentleness or requests an enema. Modern enemas can beand respect. Both the woman’s physical and given quickly and painlessly. However, soilingemotional needs must be considered. during delivery is not always prevented by the use of enemas. Women in labour should be2-3 How can a woman be helped to play an allowed a choice. Remind them that passing aimportant part in her own care? small amount of stool at delivery is common and is easily managed by the midwife.Labour, delivery and the puerperium are anideal opportunity to allow and encouragewomen to play an active role in their own care. There are no good reasons for the routine use ofThey should understand what will happen and enemas during labour.what is expected of them. It is very importantto explain to a woman what is occurring. It is Similarly, there are no good reasons for givingvery frightening for a woman if she does not caster oil or any other medicine to promoteunderstand what is happening to her and her stooling before labour.baby. Fear may slow her progress of labour. 2-6 Should a woman be shaved before2-4 What staff behaviour is not considered delivery?as mother friendly? For many years, all women expecting a vaginal1. Being rude, aggressive, indifferent, cheeky delivery had their perineum shaved during and insensitive to the woman’s needs, labour. It was believed that this would reduce feelings and wishes. the risk of infection following an episiotomy2. Emotionally or verbally abusing women. or tear and make the repair easier. In contrast,3. Ignoring what the woman’s says or requests. it has been shown that shaving often causes4. Slapping, pushing or in any way physically minor cuts which increase the risk of skin abusing women. infection after delivery. Many women find5. Giving woman the ‘silent treatment’ and perineal shaving painful and feel embarrassed not communicating with them. at being shaved. The shaved area also feels6. Accusing women of presenting in labour uncomfortable and itches when the new too early or too late, or for forgetting their hair starts to grow. There is a risk of HIV antenatal card at home. transmission if an unsterile blade is used.MOTHER FRIENDLY CARE There are no medical reasons for shaving the perineum before delivery.DURING LABOUR Similarly, there are no medical reasons for shaving a woman prior to caesarean section.2-5 Should all women be given an enema Pubic hair can simply be cut short. However,during labour? some women would prefer the upper boarderIn the past many women were routinely given of their pubic hair shaved to avoid the painan enema at the start of labour to empty the later of removing the surgical strapping.bowel. It was believed that this would speedlabour and delivery. Passing stool during 2-7 Should a woman bath or shower duringdelivery can be an embarrassing and unpleasant labour?experience. Although enemas are no longergiven routinely, some women would prefer to Warm water can be very soothing duringhave an empty bowel before delivery. An enema labour and helps to reduce pain andshould be given if the woman feels constipated discomfort. Relaxing in a warm bath can be
  3. 3. 28 MOTHER AND BABY FRIENDLY CAREvery comforting. Unless there is a medical to bring some fruit with them. Allowing foodindication, there is no harm in either showering and fluids during labour prevents ketosis andor bathing during labour. Rupture of the hypoglycaemia. Ketones in the urine indicatesmembranes is not a contraindication to bathing. that the mother is not getting enough energy.It is important that the bath is very well washedout before it is used. Underwater deliveries havenot shown an increased risk of infections due to Food should not be routinely withheld in labour.water entering the vagina before delivery. 2-10 Should women be allowed to eat and Women should be allowed to shower or bath drink before a general anaesthetic? during labour. Recent studies show that starvation during labour does not always prevent inhalation ofTherefore, the old fashioned routine of ‘oil, stomach contents during general anaesthetic.bath and enema’ is no longer practised. However it seems wise that women should take nothing by mouth if they are being2-8 Should women be allowed to drink prepared for caesarean section under generalwater during labour? anaesthetic. Women who are having a trial of labour or are at high risk of needing aMost women in labour want to drink. Not caesarean section can take clear fluids butdrinking in labour is like running a marathon not solids during the active phase of the firstwithout taking any fluids. No fluid intake stage of labour. Women who are waiting for anduring labour may result in dehydration and elective caesarean section should be starvedacidosis which can cause fetal distress. Even of food but can continue to have small sips ofwomen having a trial of labour should be clear fluids until two hours before the generalallowed to have sips of clear fluids anaesthetic. Most women having an electiveIt is better if repeated, small amounts of water caesarean section in the morning are starvedor sweet tea are drunk than a large amount at a of solids from the previous evening.time. Some women prefer drinks that are cold.If a woman cannot take fluids by mouth during 2-11 Is it safe to walk around during labour?labour, she should receive an intravenousinfusion (‘drip’) of maintenance fluid (e.g. Most women should be encouraged to walkRinger’s lactate) to prevent dehydration. around and keep mobile rather than remaining in bed during labour. They can relax in a chair or find a comfortable position. There are Women should take small sips of water during many disadvantages to a woman lying on her labour. back, such as postural hypotension. Labour progresses faster, with less pain, if a woman is able to move about freely.2-9 Should women be starved duringlabour? Women should be encouraged to move about andWomen should not be routinely starved during walk around during labour.labour. Small, frequent snacks are preferredby most women. They should not have a largemeal. Some women do not want to eat during 2-12 Should a woman remain in her ownlabour but most will need to drink. Taking clothes during labour?food during a long labour helps to preventexhaustion. Snacks such as glucose sweets, There is no need for a woman to wear hospitaljelly or fruit are preferred. Encourage women clothes during a normal labour. Many women
  4. 4. MOTHER FRIENDLY CARE DURING LABOUR, DELIVER Y AND THE PUERPERIUM 29feel more comfortable and confident in their NOTEDoula is a Greek word meaning ‘a womanown clothes. To avoid blood stains, most who helps other women’.women prefer to change out of their ownclothes for the delivery. 2-15 What is the roll of a labour companion? A labour companion should support,2-13 Is it helpful to have a companion encourage and praise the mother. Labour canduring labour? be very lonely, frightening and bewilderingTraditionally women delivered at home where if one is a alone. The labour companion canthey were surrounded and supported by rub the mother’s back, help her with hertheir family and friends. Now most women breathing, help her to turn while lying, getlabour alone in hospital as family have been her something to eat or drink and support herdiscouraged because of the fear of infection, while walking. The birth companion shouldlack of privacy for other patients, and the stay with the woman throughout her labour,disruption of the labour ward routine. providing physical and emotional support.Unfortunately a lack of staff usually prevents a Trained doulas can also help after deliverymidwife staying with a woman throughout her with breastfeeding. The role of the labourlabour and delivery. companion is different from that of the person who conducts the labour and delivery.Many trials have shown the benefits of alabour companion, which include: The role of a labour companion is to encourage1. Labour progresses better (shorter labours).2. Less pain with less need for analgesics (e.g. and support the woman during labour and pethidine). delivery.3. Fewer caesarean sections.4. More self esteem. 2-16 Is fetal heart monitoring essential in a5. Greater success with breast feeding. normal labour?6. Better relationship with the infant.7. Less postnatal depression. It is very important that the condition of the fetus is monitored during every labour. ThisWomen do not want to labour alone. Therefore, can usually be done with a fetal stethoscope orit is important that every woman in labour hand held Doppler ultrasound fetal heart rateshould receive the companionship she needs. monitor. Once the base line fetal heart rate between contractions has been determined, Every woman should be encouraged to have a the fetal heart should be listened to during and companion in labour. after a contraction to detect any decelerations. It is important to be gentle as the procedure can be uncomfortable, especially during2-14 Who should be the labour companion? a contraction. Electronic fetal heart rate monitoring (‘CTG’) usually is only needed ifEach woman should choose her own labour the infant is at high risk of fetal distress.companion if possible, such as her husband,partner, friend or relative. A professionalor lay birth companion (doula), previously 2-17 Should all women be offered painunknown to the mother, can also be of great relief in labour?help and support. Many women prefer another Labour is almost always painful. If the motherwoman to support them in labour. Doulas is not distressed by the pain, analgesia is notare particularly important when there are not indicated. However analgesia must be madeenough midwives to support women in labour. available to all women who ask for it. Women should have a choice of no analgesia, opiate
  5. 5. 30 MOTHER AND BABY FRIENDLY CAREanalgesia (pethidine or morphine), inhaled may arise. A natural childbirth is not anEntonox (50% nitrous oxide with 50% oxygen) unsupervised delivery.and epidural analgesia if the service is available.Encouragement, a warm bath or shower, or 2-20 What are the advantages of naturalgently rubbing the lower back, relaxation, childbirth?breathing techniques and a ‘birth ball’ arevery helpful. Infants are often sleepy for the It gives the mother the pride, joy andfirst few hours after opiate analgesia. A caring, satisfaction of having been in control of hercompetent midwife and labour companion are own labour and delivery. It enables the motheroften the best form of pain relief. to have a choice in what she wants.2-18 Should early artificial rupture of the 2-21 Is it better if a doctor delivers allmembranes be encouraged? infants?Previously, early artificial rupture of the Most healthy women who are expecting amembranes (active management of labour) normal delivery and a healthy infant at termwas encouraged to speed up the first stage of can be safely delivered by a trained midwife.labour, allow the early detection of meconium Delivery by a doctor is only needed if a seriousstained amniotic fluid and reduce the risk of complication is expected in the mother orundiagnosed prolapse of the cord. Recently, infant. There is no medical reason why normalspontaneous rupture of the membranes is deliveries should be conducted by a doctor. Inpreferred as studies have questioned the many countries most deliveries are very ablybenefits of early, artificial rupture unless there conducted by midwives.are clear medical indications. This is especiallyimportant in communities with a high rate Most women can be safely delivered by a trainedof HIV positive women as the risk of HIV midwife.transmission to the infant increases as theduration of membrane rupture becomes longer. 2-22 Should all women be delivered in Routine early rupture of the membranes is no hospital? longer practiced. Many women can be safely delivered at a primary care maternity clinic (midwife obstetric unit). Only where complications are present or are expected, need a womanMOTHER FRIENDLY CARE deliver in hospital.DURING DELIVERY There are many advantages if a healthy woman with a normal pregnancy can be delivered at a maternity clinic:2-19 What is ‘natural childbirth’. 1. Closer to her home and family.A natural childbirth is a delivery where 2. More likely to have a normal vaginalthere is minimal medical interference and delivery without medical intervention.the women has as much control as possible. 3. Discharged home sooner.Women should be encouraged and allowed to 4. Cheaper both to mother and healthhave a natural childbirth whenever possible. service.However, the labour and delivery should be 5. Often preferred by mother.supervised and monitored by a skilled person 6. More ‘homely’ and less impersonal.to detect and manage any complication which
  6. 6. MOTHER FRIENDLY CARE DURING LABOUR, DELIVER Y AND THE PUERPERIUM 31In a large regionalised maternity service, There are times where it may be best if theabout half of all pregnant women can be father leaves the delivery room for a while.safely delivered at a clinic. The other half Either if the mother wishes it or during aare referred to hospital during the antenatal medical procedure. The father should notperiod or during labour because of one or interfere with the management of the woman.more risk factors. The father should be encouraged to attend the With cafeful selection, many women can be labour and delivery. safely delivered at a maternity clinic. 2-26 Should children be allowed to watch a2-23 Can women be safely delivered at delivery?home? Although this is usually not allowed duringWith careful selection, some women can be clinic or hospital deliveries, children are oftendelivered safely at home. However, excellent present during home deliveries. Childrentransport and communication are needed in know that their mother is pregnant and askcase of an emergency. A warm, well lit home questions about the delivery. Being present at awith clean water and other basic facilities are delivery can be either a frightening or excitingalso needed. In poor communities, many of experience for a child. It is important to explainthese requirements are missing. Instead of to children what to expect, that their motherhome deliveries, it is preferable that women will have some pain, and that this is normal.deliver in a clinic close to their home. 2-27 Must a woman lie on her back during2-24 Should every delivery be conducted delivery?by a trained birth assistant? Many women are still expected to lie on theirEvery effort must be made to ensure that backs during delivery (supine position). Thisa trained birth assistant is present at every has been shown to be the worst position fordelivery, i.e. a doctor, professional midwife or the fetus as the uterus presses down on thewell trained traditional birth attendant (TBA). mother’s main blood vessels which can causeHaving a trained birth attendant at every maternal hypotension and a reduced blooddelivery is one of the most important factors in flow to the placenta, resulting in fetal distress.reducing both maternal and perinatal mortality. It is also very difficult to bear down effectivelyIt is very dangerous for family members or in this position. Labour ward staff, however,untrained birth assistants to conduct deliveries, have tended to prefer the supine position as itespecially if they are not experienced. provides the best access to the delivering head. Many women prefer to find their own most2-25 Should the father be present at the comfortable position during delivery. Somedelivery? want to squat, crouch, kneel or lie on theirIf possible, and if the woman wants him there, side. Some women may wish to change theirthe father should be present during labour position during delivery. It is important toand delivery. It is important that he support allow a woman to choose the position thathis wife or partner and share in the experience feels best for her. The upright (squatting,of childbirth. Being present is important crouching or kneeling) and side-lying (lateral)in strengthening bonds between mother positions results in less pain, better progress ofand father and developing bonds between the second stage and less perineal tears.father and infant. Often fathers can attend acaesarean section.
  7. 7. 32 MOTHER AND BABY FRIENDLY CAREOften a compromise position can be found. or perineal tear, and reduce the risk ofFor example, the mother can squat or kneel vaginal damage and stress incontinenceon the bed, holding onto the top of the bed for after the delivery. However, both a caesareansupport, and then lie down once the head has section and an anaesthetic also have dangers,crowned. Labour ward staff should get used to especially infection and thrombo-embolism.delivering women in different positions. The risk of complications, both to mother and infant, is higher with a caesarean section. In poor countries, the lack of staff and facilities Women should be guided and encouraged to find make a personal choice impossible. Many of the most comfortable position during delivery. the fears of a normal delivery can be avoided with good care and a full explanation.2-28 Is a routine episiotomy needed by all NOTE The financial benefit and convenienceprimiparous women? of an elective caesarean section, rather than a spontaneous labour, are also very attractive toNo. There are no good reasons for performing doctors and private health facility managers ina routine episiotomy on all primiparous wealthy communities. In many countries, andwomen during labour. the private sector in South Africa, the rate of caesarean section is far above the expected rate of 15%, approaching 50% in some circumstances.2-29 Is it better to do an episiotomy than A high rate of ‘social caesars’ is not in the bestallow the perineum to tear? interests of mothers and infants.For many years it was believed and taught thatis was better to perform an episiotomy than 2-31 What should be done if a womanallow the perinuem to tear. This is now known requests a caesarean section where thereto be incorrect as there are more complications are no good clinical indications?with an episiotomy than with a first or second Explore with her the reasons why she wantsdegree tear. A first or second degree tear is a caesarean section. Often these fears areeasier to repair and results in less trauma, based on incorrect knowledge. Explain theless suturing, better healing, less dyspareunia correct facts to her. It is important to stress(painful sex) and less urinary and bowel the feeling of achievement and the bondingincontinence later. An episiotomy does not experience with her infant after a normalalways prevent a third degree tear. delivery. The hospital stay is also shorter afterAn episiotomy should only be performed a normal delivery while the risk of problemswhen there is a good medical indication, such with future deliveries is less. Infants born byas prolonged second stage of labour or fetal elective caesarean section are at an inceaseddistress during the second stage. risk of needing admission to an intensive or high care unit. However, if she persists with her request for a caesarean section, her wishes Episiotomies should be avoided where possible. must be considered. Some women have an extreme and irrational fear of giving birth. This may result from a previous traumatic2-30 Should women be allowed to choose a birthing experience, rape or sexual abuse.caesarean section? Birth choices should be discussed towards theIn many industrialised countries, it is common end of pregnancy or at the onset of labour.for women to ask for an elective caesarean Lack of hospital facilities and staff often limitsection to avoid the expected pain, discomfort, the option of a ‘social caesar’.embarrassment and inconvenience of aspontaneous vaginal delivery. A caesareansection will also avoid a possible episiotomy
  8. 8. MOTHER FRIENDLY CARE DURING LABOUR, DELIVER Y AND THE PUERPERIUM 332-32 What may be the emotional effects of 2-36 How can changes in labour andan unplanned caesarean section? delivery practice be made?Many women, who have had a normal It is not easy to change labour and deliverypregnancy and expect a vaginal delivery, practices which have been used for many years,are very disappointed if they have to have especially if these practices are convenient toan unplanned caesarean section for medical the staff and hospital management. However,reasons. They feel that they have failed after all every effort must be made to change practicesthe preparation at antenatal classes. This may and attitudes to those that are based on goodbe bad for their self esteem and even interfere scientific evidence and provide better carewith the normal bonding process with their to the mother. Changes often have to beinfant. These women need emotional support introduced slowly, one at a time. A lot of time,and reassurance. energy and commitment are needed to make changes. Both the staff and mothers should2-33 What are the advantages and be told, and should understand, the reasondisadvantages of an induction of labour if for the change. The staff need to be educated,there are no medical indications? encouraged and supported.Sometimes women ask, or their doctors NOTE Midwives and doctors are ethically and professionally obliged to make changes to theirsuggest, that labour should be induced at a behaviour and practice as better ways of caringconvenient time. These social advantages for patients are found.must be balanced against possible medicaldisadvantages. If the induction fails, acaesarean section may be needed. Induced 2-37 What is the better births initiative?labours also have a greater risk of a longer and The Better Births Initiative (BBI) is anmore painful first stage or an instrumental international project to improve the quality ofdelivery. Infants born after an induced labour care during labour and childbirth by listeningare at an increased risk of respiratory distress, to women’s views and using the best evidenceeven in a term pregnancy. Therefore, very available. BBI promotes efficient, effectiveserious thought must be given before a ‘social’ and beneficial practices and stresses thatinduction of labour is done. women should be treated with humanity and respect. It is important that care provided2-34 How can a woman’s dignity be during labour and delivery is based on the bestprotected during delivery? evidence rather than on traditional practices. Staff should be committed to improving care.By being able to express her own opinionand make her wishes known, and by having The four main messages of BBI are:these seriously considered by caring staff. The 1. Encourage women to drink enough fluidsbirth attendants must always be aware of the and eat if hungry during labour.mother’s right to dignity and privacy. 2. Encourage women to have a partner, friend or lay carer (doula) for support during2-35 How should women be encouraged labour.during delivery? 3. Stop routine procedures during labourMany women are afraid and feel out of control that are of little or no proven benefit, e.g.during delivery. They may not understand shaving, enemas, delivering in a supinewhat is happening and they may be in pain. position (on her back) and separatingSupport and encouragement are, therefore, mothers and their infants.an essential part of managing a delivery. It 4. Avoid routine treatments that are of littleis totally unacceptable to ever shout or hit a or no benefit, e.g. artificial rupture ofwoman during delivery. membranes, stay in bed with intravenous
  9. 9. 34 MOTHER AND BABY FRIENDLY CARE fluids during labour, episiotomy and can be done once the mother has had a chance routine suctioning all infants after birth. to meet her infant. Usually they can be done while the mother holds her newborn infant.Evidence based medicine is health carebased on information obtained by carefullyconducted, randomised controlled trials and 2-41 Should the infant stay with theextensive systematic reviews of the current mother?literature. This is preferable to personal If possible, the infant should stay with theopinions and expert views which are often mother. This is possible after most deliveries.proved to be incorrect. Bonding during the first hour after delivery (the ‘golden hour’) is particularly important.MOTHER FRIENDLY CARE The mother and infant should not be separatedAFTER DELIVERY after delivery.2-38 When should the infant be given to 2-42 How can the mother play an active rolethe mother? in preventing a postpartum haemorrhage?With a normal delivery and a healthy mother The mother can play an important role inand infant, the infant should be given to the the prevention of postpartum bleeding,mother as soon as possible after delivery. especially during the first hour afterUsually this is done after the infant has been delivery. Breastfeeding directly after deliverydried, briefly examined, the cord cut and the encourages the uterus to contract. She should1 minute Apgar score has been assessed. be asked to be aware of vaginal bleeding and immediately call for help should she start2-39 What should the mother be to bleed excessively. Usually only one orencouraged to do once she is given her two sanitary pads are soaked after a normalinfant? delivery. She can also be shown how to assess the height of her fundus and feel whether herShe should be encouraged to give kangaroo uterus is well contracted. Again she shouldmother care with the infant placed on her immediately inform the nurse or doctor ifnaked chest. The infant can be covered with her uterus relaxes or increases in size. Shea dry, warm towel. Kangaroo mother care must also have been shown how to rub hersoon after delivery promotes bonding and uterus and be instructed to do this at regularsuccessful breastfeeding. Most mothers want intervals. She should keep her bladder empty.to hold and examine their infants immediately In this way the mother is able to monitor herafter birth. The mother should also be uterus. This is particularly important if thereencouraged to breastfeed. This may speed up are inadequate staff to closely monitor eachthe third stage of labour by stimulating uterine mother after delivery.contractions. There is no need for a routinefive minute Apgar assessment if the infant isnormal and did not need any resuscitation. Women should be encouraged to play an active role in the management of their labour and2-40 When should the routine procedures delivery.be done on the newborn infant?These routine procedures, such as givingvitamin K, placing prophylactic ointment ordrops into the eyes and identifying the infant,
  10. 10. MOTHER FRIENDLY CARE DURING LABOUR, DELIVER Y AND THE PUERPERIUM 352-43 What are ‘baby blues’ or ‘postnatal to depression at other times of life. Womenblues’? with postnatal depression feel tearful and sad, they may worry excessively, may be irritableMost women normally feel anxious and and feel angry, are afraid of being alone,tearful for a few days after delivery when they feel they cannot cope, and can have suicidalare faced with the overwhelming tasks and thoughts. Often there are changes in appetiteresponsibilities of caring for a newborn infant. and sleep pattern with tiredness and loss ofGiving birth is also often the start of major energy. They often have a loss of self esteem,changes in their lives. A woman may feel that cannot concentrate and lose their sex drive.she is no longer attractive to her husband. They feel hopeless, inadequate and guilty andThese very strong emotions, ‘the blues’, usually have no enjoyment. They often feel a lack ofstart three or four days after delivery and joy in their infant and may even fear that theyonly last a few days. Uncommonly they may could harm the infant. Anxiety may presentlast a few weeks. Staff need to explain that with fearfulness, panic attacks or a wide rangeirrational tearfulness is very common and will of physical complaints such as weakness,disappear without treatment. Emotional and restlessness, shortness of breath and dizziness.practical support by staff, family and friends isimportant. If the woman does not feel better Postnatal (puerperal) psychosis occurs inby two weeks after delivery, a diagnosis of about 1/1000 deliveries. These women havepostnatal depression must be considered. lost touch with reality and hear voices or have hallucinations. There behaviour is very abnormal. They are often paranoid (believe Postnatal ‘blues’ are normal in the first week unreasonably that people or even their infant after delivery. are plotting against them) and need urgent psychiatric care to avoid hurting themselves and their infant.2-44 What is postnatal depression?Postnatal depression may occur at any time 2-46 Which women are at an increased riskduring the year after delivery. Surprisingly, the of postnatal depression?symptoms of depression usually are alreadypresent during pregnancy, but worsen after 1. Women with a past history of depressiondelivery. In industrialised countries, about or other mental problems.15% of women have postnatal depression. 2. Women from poor socioeconomicThe incidence appears to be much higher in circumstances.poor communities with greater social and 3. Women with little physical and emotionaleconomic problems. support at home. 4. Women with emotional problems NOTE Recent research suggests that the incidence (unwanted pregnancy, previous history of of postnatal depression may be as high as 30% in abuse or pregnancy loss). some poor communities on South Africa. Anxiety may be equally common. 2-47 How may maternal postnatal depression affect the infant? Postnatal depression is not uncommon. Postnatal depression affects a mother’s ability to interact with her infant. These women2-45 What are the features of postnatal often feel alone, despairing and isolated, anddepression? find their infants difficult or demanding. The physical and emotional development of thesePostnatal depression usually presents with children may be slow as the poor mother-features of both depression and anxiety, similar infant interaction may result in a lack of
  11. 11. 36 MOTHER AND BABY FRIENDLY CAREstimulation or even neglect. They are at an followed by an enema. Later a nurse shaves herincreased risk of child abuse. pubic hair and she is asked to bath. When she NOTE Suicide is a major cause of maternal questioned whether the shave was necessary, mortality in industrialised countries. Following she was told that it is routine management motor vehicle accidents, suicide is the of all women in labour. Her boyfriend is commonest cause of coincidental maternal death informed that he cannot attend the delivery. in South Africa. When the woman complains about the attitude of the staff she is shouted at and told2-48 How can women be screened for that she can deliver at home if she chooses.postnatal depression? 1. Is it essential that the bowel should beIf possible, women who are depressed or at emptied before delivery?high risk of depression should be identifiedduring pregnancy as an early diagnosis results No. ‘Oil and enema’ are no longer routinein a better outcome. A caring health worker practice. Some women however request thatcan usually recognise pregnant women who they have an enema to empty the bowel as theyare depressed. However, a formal screening are afraid they may soil during delivery. Theretool is available. All women who are thought to is no scientific evidence that an enema speedshave symptoms and signs of depression should up labour and delivery.be referred to a counsellor, social worker or thecommunity mental health team for evaluation 2. Why should all women in labour beand management. Often depressed women are shaved?afraid of being referred for assessment. There is no need to shave women in labour.Women with antenatal depression also Often long pubic hair is trimmed. Contrary toneed understanding, support, psychological earlier belief, shaving does not reduce the risktherapy and often medication. Support groups of infection in a perineal tear or episiotomy.are helpful and simply listening can be of Small cuts made during shaving may increasegreat value. Antidepressants are safe during the risk of skin infection.pregnancy and breastfeeding. Kangaroomother care, touch therapy and breastfeeding 3. Is it not dangerous to bath during labour?are all useful in helping depressed mothersbond with their infants. No. Bathing and showering during labour are safe. They do not increase the risk of infection or fetal distress. Many women like to lie in a Postnatal depression can be screened for during warm bath during labour as it reduces pain. pregnancy. Some women even ask to deliver in a bath of warm water. NOTE The Edinburgh postnatal depression scale is a questionnaire that can be used both antenatally 4. Are routine protocols of management and postnatally to assess for depression and anxiety. Cognitive therapy and antidepressants still needed in a labour ward? are usually used in management. Yes. It is important to have a plan of management that all the staff can understand and use as a guide to care. However, routineCASE STUDY 1 management should be determined by evidence based medicine whenever possible.A young primigravid woman with mild Mothers should know what is going to happenhypertension presents in labour at the local and be given choices where possible.hospital. She is given a tablespoon of caster oil
  12. 12. MOTHER FRIENDLY CARE DURING LABOUR, DELIVER Y AND THE PUERPERIUM 375. What is evidence based medicine? labour pains and speeds up labour. Women can relax in a chair or adopt any positionThis is health care which is based on which gives them the most comfort. Lying forinformation obtained by carefully conducted, hours on her back during labour is not goodrandomised controlled trials and extensive for her or her fetus.systematic reviews of the current literature. Thisis preferable to personal opinions and expertviews which are often proved to be incorrect. 2. Do women need to wear a clinic gown during labour?6. Why should fathers be allowed to attend No, although some women prefer to changethe delivery of their infant? out of their own clothes before delivery to avoid blood staining.If possible, and if the woman wants himthere, the father should be present duringlabour and delivery. It is important that he 3. What are the advantages of allowingsupports his wife or partner and shares in women to wear their own clothes inthe experience of childbirth. Being present is labour?important in strengthening bonds between It is one of the many small parts of ‘mothermother and father and developing bonds friendly care’ which makes labour an enjoyablebetween father and infant. and meaningful experience rather than a very stressful time. Paying attention to providing7. What do you think of the manner in which good, kind and gentle care improves thethis woman’s complaint was handled? quality of service that is offered to women. Mother friendly care is good for the mother,There is no excuse to shout and be aggressive infant and staff.with patients, especially when they arefrightened and confused. Suggesting that shedelivers at home is dangerous and unethical 4. Is it safe for women in labour to eat andpractice. drink? During a normal labour there is no danger if the woman eats and drinks. Frequent drinksCASE STUDY 2 prevent dehydration. Small snacks prevent hypoglycaemia and ketosis. Food such asDuring a normal labour at a district hospital, glucose sweets, jelly or fruit is preferred. Onlya woman is told she must stay on her bed and if a woman is being prepared for a generalnot walk around. Her clothes are taken away anaesthetic should she not eat.and she is given a clinic gown. She is allowedto have sips of water during early labour but 5. When should a woman be given painasked not to eat anything. She is not given relief in labour?any pain relief. She is afraid to ask and does When she feels she needs it. Women mustnot know whether analgesia is available at the be asked and given a choice as they often areclinic. She is worried that the fetal heart is embarrassed, shy or afraid to ask.not being monitored as she was taught duringantenatal classes. 6. Is it necessary to monitor the fetal heart in a normal, low risk labour?1. Should a woman in normal labour haveto remain on her bed? The fetal heat must always be monitored in labour. At a maternity clinic this can usuallyNo. Women should be encouraged to walk be done with a fetal stethoscope or hand heldaround during labour. This helps to relieve fetal heart rate monitor.
  13. 13. 38 MOTHER AND BABY FRIENDLY CARE7. Does it help women in labour if they 3. What are some of the benefits of havingattended antenatal classes? a labour companion?Yes. It helps enormously if women know what Women labour faster and need less analgesia.to expect and understand what occurs during They feel more satisfied with their labour andlabour and delivery. This reduces their anxiety delivery and bond better with their infants.and pain and enables mothers to participate in Having a labour companion is a typicalthe decisions made during labour. example of mother friendly care. 4. Why is a woman’s choice of the bestCASE STUDY 3 position to deliver important? Many women prefer not to deliver while lyingA woman is admitted in labour to a primary on their backs. This is also not the best positioncare maternity clinic. Every effort has been for the infant. Some want to squat, crouch,made to provide a mother friendly service kneel or lie on their side. It is importantduring labour. As she does not have her that women are given a choice. Midwivespartner with her she is offered a labour soon learn how to deliver infants in differentcompanion. She is also asked by the midwife positions. The second stage of labour is fasterwhat position she would prefer during with less risk of a peritoneal tear if the motherdelivery. The woman is thrilled with her good is in an upright or lateral (side lying) position.delivery experience which contrasts to theefficient but very unfriendly care she received 5. What are the advantages of low riskwith the birth of her previous child when the women delivering at a maternity clinic?staff insisted that all primigravid mothersmust have an episiotomy. On the third day A maternity clinic (midwife obstetric unit)after delivery she seems well but complains of near their homes is more convenient for mostfeeling upset, without any obvious reason, and women than a hospital. The labour ward in acannot stop crying. maternity clinic is more relaxed with midwives managing normal deliveries. It is safer than1. What is a labour companion? home deliveries in most poor communities and avoids some of the unnecessaryA labour companion is someone who stays investigations and interventions that arewith a woman throughout her labour and common in hospitals. While high risk womendelivery to encourage and support her. should be managed in hospital, where all theTraditionally, women never laboured alone but additional facilities are available, almost all lowalways had a companion. risk women can be safely and well cared for in a maternity clinic.2. Who can be a labour companion?Usually her partner, a friend or someone in 6. What is the Better Births Initiative?her family. If no one suitable is available she BBI is an international project which aims atcan be offered a professional or lay labour improving care during labour and delivery bycompanion (a doula) whom she has not met introducing mother friendly care, based on thebefore. The role of the labour companion is best evidence available. BBI is good care. Alldifferent from that of the person who conducts labour wards should be encouraged to adoptthe labour and delivery. the principles of BBI.
  14. 14. MOTHER FRIENDLY CARE DURING LABOUR, DELIVER Y AND THE PUERPERIUM 397. Why do you think this woman felt so 8. How can postpartum depression beupset? detected early?She almost certainly has the ‘blues’. With Postpartum depression often presents duringunderstanding, explanation and support she pregnancy and then becomes worse aftershould recover in a few days. If she is no better delivery. An awareness by health workers ofafter two weeks, suspect postnatal depression, the features of depression and anxiety can leadand refer her for counselling or assessment. to an early diagnosis. A screening tool can alsoShe has no features of puerperal psychosis. be used to identify women who are depressed or at high risk of depression.

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