By Alison Perry
"OK dear, with this next contraction I want you to get really angry at the pain. Let's get this baby delivered. You're going to have to work a lot harder since you're not progressing. If we don't see this baby in the next twenty minutes we're going to have to get the doctors in here again. Big breath in ... now push!"
The night midwife had recently started her shift. However, she had already decided that this primip had been pushing for long enough.
The epidural that had worked well for the labouring woman was now dragging her mind from her body. The recent flurry of doctors into the room hadn't helped. Their conversations on policies, time, and the fate of her baby had distracted her. Finally, between contractions she blurted out, "I have never in my life been accused of being an underachiever. I'm doing my best. The threatening tone you're using with me isn't helping. Please stop."
I smothered a smile of satisfaction. For hours I had been desperate to facilitate better communication between the woman and the midwife, to somehow secure some solitude. Mentally, I had repeatedly removed the giant wall clock which had become the focus of this birth. However, as a first year student working under a midwife mentor I was painfully aware that the delivery room was an inappropriate forum in which to incite change and that it would only aggravate the tense dynamics. I knew that my advocacy for this woman at this time would have to affirmed in my own quiet way.
Without words, the woman turned her attention to me, we locked eyes and, contraction by contraction, she birthed her baby. I welcomed her daughter into my shaking hands. The extra midwives, doctors and forceps trolley filed out of the room. After that night, however, I continued to be struck by the midwife's abusive verbal communication. I decided to see how my reactions fitted in with current research on verbal communication during labour.
One midwife researcher reminds us that it is "women" who give birth, not "girls", "mums" (or "dears"). Their status therefore should be recognised in our choice of words (1997). At the birth I have described, I had stayed late beyond my shift. I couldn't help noticing that the night midwife knew nothing of the intelligent, articulate and funny woman that hours of conversation had allowed me to know. Had she been interested in her as an individual woman, rather than a task, she would have thought twice before using such language; "dear" was condescending, an inappropriate term of endearment.
Mainstream midwifery literature claims that women who are made to feel they are coping well will usually continue to cope and progress well (Bennett and Brown, 1996). Indeed, it is not a new understanding of the birth process to link the physiology of birth with the psychology of birth. Positive verbal support is a core precept of midwifery teaching.
'Mayes' style midwifery also underlines the idea that the midwife can instill confidence and therefore progress, in labouring women through praise, the tone of her voice, and the quietness of her manner (Sweet and Tiran, 1997). However, from my own experience, it can be seen that often this theory is not put into practice.
Physiologically, a threatening place of birth will slow the birth process. Robertson reminds us that in negative circumstances women seek safety. Oxytocin levels then fall, and the progress of labour is slowed. Alternatively, adrenaline stimulates the uterus, stalling further cervical dilatation (1997). The ensuing diagnosis of "failure to progress" in turn exacerbates this normal hormonal response (Robertson, 1997).
Changing Childbirth instructed that the woman should be the focus of care in order to maximise her own control (DoH, 1993). During this birth, however, time was the main focal point. The woman was ceaselessly directed towards the clock.
Much current research refutes second stage limitations. When a woman and her fetus are coping with labour, and progress is continuing, arbitrary time limits on the second stage are unjustified (Enkin, Kierse and Chalmers, 1989). I have since read the local hospital policy on second stage and found that time limits are, in fact, absent from labour ward protocols. However, current practice suggests that this recent change has yet to influence practice (local hospital policy 1998). Personally, I look forward to attending births wearing a discrete watch (for the sake of documentation).
Language of Birth
Whatever the implications of verbal communication, the words themselves deserve closer appraisal. Leap and others have analysed the language of birth. They have criticised phrases and words such as "failure to progress', "delivery' (versus birth) and "incompetent' (used to describe the cervix) as degrading women's experiences and accomplishments in childbirth (Leap, 1992; Oakley, 1993). Others have declared that it is difficult to give support and praise when the value system pervades the language we use. By our language we unwittingly reveal our perceptions and politics. The birth I attended featured much language of doubt and negativity. As midwives we need to be acutely aware of these nuances and actively seek out postive language and imagery for birth.
Do we need the verb "to push'?
The subject of "pushing' during second stage continues to be controversial. Most midwifery teaching recognises a need for adaptation and variety (Davis, 1987). Within that body of research there is much that advocates undirected pushing. Enkin, Kierse and Chalmers have gone so far as to state that there is no data to support directed pushing during second stage and in fact it may be harmful (1989). Robertson claims that verbal communication is best avoided altogether and that safety is increased if a woman is left to tune into her body (1997). The sense of achievement felt by women following undisturbed births, and certainly shared by the woman about whom I have written, underlines the potential confidence gained from childbirth.
The role of the student at births is unique. In the absence of autonomy, skill, and experience, it is an ideal opportunity for reflection. At the birth, which I have recalled here, I was first and foremost a woman helping another woman. I followed instinct and took my cues from her. As I journey into midwifery I hope that my exposure to academic research and clinical experience bolsters rather than erodes the simplicity of that relationship. As a woman I have a fundamental respect for women and their ability to give birth. As midwives it is our duty to protect access to this life enhancing achievement.
Turning the "woman-centred' rhetoric of contemporary midwifery into reality depends on effective communication (Tennant and Butler, 1999; Flint, 1992; Robertson, 1997; Leap, 1992). Caroline Flint reminds us not to forget the influence midwives can have over women's experience of birth and that the right words at the right time can make a long labour bearable. Richens (1999) urges us to expand our concepts of evidence-based practice by factoring in what women are actually saying to us. After we experience, after we research, and after we reflect upon communication with women in labour, this student midwife proposes that if we still have nothing nice to say, let us say nothing at all.
Alison Perry
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Cunningham A (1998). 'Normal Labour', Countess of Chester Hospital NHS Trust Policies No 1.
Davis E (1987). Hearts and Hands: A midwife's guide to pregnancy and birth, Celestial Arts, Berkeley.
Department of Health (1993). Changing Childbirth, HMSO, London.
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Leap N (1992). 'The power of words', Nursing Times, 88, 21, May 1992, 60-61.
Oakley A (1993). Essays on Women, Medicine and Health, Edinburgh University Press, Edinburgh.
Richens Y (1999). 'Listening to Mothers: Improving evidence-based practice', British Journal of Midwifery, 7, 11, November 1999, 670.
Robertson, A (1997). The Midwife Companion: The art of support during labour, ACE Graphics, Camperdown, Australia.
Tennant J and Butler M (1999). 'Communication: Issues for change', British Journal of Midwifery, 7, 6, June 1999, 359-362.
This article was originally published in Midwifery Matters ISSUE 86 Autumn 2000, p9-10
LW updated February 4, 2005