Association of Radical Midwives

From MIDWIFERY MATTERS, Issue No.95, Winter 2002

Definitions of Normality

Sue Hanson

What do we mean by 'normal´ labour? Do we mean 'natural´? Or does anything not involving instruments or theatres count? What is an SVD? A spontaneous vaginal delivery, or a spontaneous vertex delivery, and is it different from a ND? I think we need to work out what we mean, before we can consider how to achieve it, or indeed, if, we want to achieve it.

The caesarean section rate is rising. Can it be right that up to a third of women are unable to have a baby vaginally these days? The desire for normality may be in response to this. Midwives are the experts in normal labour - if the section rate gets too high - are we out of a job? On the other hand, is 'normal´ whatever the majority has? Do we look for some sort of average, mean or mode, to determine the most usual - in which case, in some places could this actually be caesarean delivery?

What could we mean by normal labour?

Perhaps we mean 'natural´, but this may not be a good choice of word, since 'natural´ has been used to describe anything from muesli bars to shampoo, and has become virtually meaningless. And it could also be said that it is 'natural´ for some women and babies to die in childbirth.

Do we mean 'drug free´? If so, do we include Entonox? Or diamorphine? Or an epidural, as long as the baby comes out without instruments? And how do we record a birth after shoulder dystocia? Often the design of notes means that this recorded as a 'normal delivery´, but how normal did it feel to the staff involved?

Perhaps there is an element of how it felt to the woman and her partner. If she feels that it went well, was it a normal labour? But again, this is not necessarily what the staff involved would have felt. If you are the midwife who has spent hours watching a suspicious CTG, and assisting with several FBSs, then even if the woman is happy with her labour, you probably don´t feel it´s been normal. On the other hand, a planned caesarean can be a very satisfying and joyful experience, but would we want this classed as normal?

Physiological

'Physiological' might be a better word to choose. A labour that goes as it should with no interference in any way. But what counts as intereference? But - could we truly do this? Over the millennia, we have learned a lot and cannot get back to a state where actions are purely instinctive. Even if you choose to labour without drugs, has the simple act of going into hospital affected your labour right from the start? Odent has talked about events which inhibit the flow of oxytocin - bright lights, being asked questions, being watched. Perhaps home birth is the nearest we can get, so does that mean that those of us who work in hospital will never experience 'physiological´ birth? We often use the word 'physiological´ to describe a passively managed third stage, but even for this, a 'physiological third stage´ has different meanings to different people - when, where and how and, indeed, if you should clamp the cord, for example. Do we actually know what a 'physiological´ labour is?

Judgmental

The word 'normal´ also has a bit of a judgmental feel to it. Anything other than 'normal´ is, by definition, 'abnormal´. Do we want to label any woman as abnormal? When does 'normal´ become 'abnormal´? If you have been labelled 'abnormal´ can you ever get back to being treated as 'normal´?
Changing Childbirth emphasised the need for women´s choice, and it seems unfair to throw it back in women´s faces by implying that some choices make them abnormal.

Midwives’ Choices

What about the midwife´s choice? Have we got our own hidden agenda? In our aim for 'normality´ might we go too far? Might a woman have preferred to have had a Syntocinon drip to speed things up, rather than waiting out a 'rest and be thankful´ latent second stage? Maybe we should ask her - but have we got the unbiased evidence-based information to help her make her choice? We may want to achieve 'normality´, but the woman may want to achieve:
* A quick labour
* A pain free labour
* An elective caesarean
How far are we prepared to go? What is the deciding factor - a woman´s choice or our wish for normality?

Defining Normal Labour

We need to have some new definitions. These can be used to describe parts of labour, and could be used in discussion with women to compose a relevant birth plan. This is necessarily more long winded, but may be more helpful. How about these?

Physiological
   This is when there are no interventions of any kind, no drugs, no TENS, and the woman may follow her instincts and behave as she wants. She may choose to labour and give birth in water.
Drug free:
   The woman has no drugs, but she may use TENS, homeopathic remedies, aromatherapy, reflexology and so on.
Straightforward:
   There are no interventions, but drugs may be used to help cope with pain. This includes opiates and epidurals. No oxytocic drugs are used.
Intervention:
   Interventions could include the use of instruments, oxytocin, surgery and manoeuvres such as those used to manage a shoulder dystocia.
Augmented:
   Augmentation should refer to a labour augmented with syntocinon or augmented by an ARM.
Spontaneous:
   Birth without the use of oxytocics, prostaglandins or ARM.
Induced:
   Labour started off using drugs or ARM, for a particular reason that should be stated.
Complicated:
   When there is a significant deviation from the norm.
Managed:
   A managed labour would involve some sort of medical intervention or drug use for some specific and named purpose.

   These terms could be used throughout a labour, and at different times a woman´s labour could be classified in different ways. Most women will start off with physiological labour, then may move into another category.
   For example, Jane Bloggs went into spontaneous physiological labour. She had a straightforward first stage, managed by diamorphine for pain relief. Her second stage was complicated by shoulder dystocia but her third stage was straightforward and managed with Syntocinon.
   These definitions may need further refining. For example, actions such as continuous fetal monitoring could be viewed as an intervention.

Delivery or Birth?

   There is also the issue of whether we talk about deliveries or births. Perhaps it is now time to define the difference. However much we prefer to talk of women giving birth, in hospital I feel that many women are delivered of their baby. We could distinguish between birth and delivery thus:
Gave birth:
   This could mean when a woman´s baby emerges from her vagina under her own efforts without the aid of instruments or surgery.
Delivered:
   This could refer to instrumental deliveries, caesareans, and probably shoulder dystocia. Does an episiotomy change a birth into a delivery?

Using my definitions, my feeling is that we are all striving towards increasing the rate of straightforward labours and births. Some midwives may feel that the way ahead is by increasing the number of drug free and physiological labours. However, others may feel that this is unrealistic, and see the way ahead to be altering parameters such as rigid time-scales to give more chance of a straightforward vaginal delivery.

   If we decide to use some variation of the definitions of labour outlined above, then it will mean using more words to describe a labour. It won´t be enough to just be say,
   “She had an SVD”.
   After all, is it just the birth itself we are interested in, or are we concerned with the whole package? I feel that there would be advantages to being more specific. We would be much more aware of what is normal, or physiological - or whatever we decide to call it - and we can think about what we are aiming for at different times in a labour. It will also help us to find out what women want from their labours. I have never before thought to ask a woman, “What do you want to achieve in your labour?” because I have always narrowed it down to questions about pain relief. This tool could help us to find out more about what women actually want.
   What do you think?

LW updated February 4, 2005

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