Women friendly care

Women-friendly care is life-saving and as studies have shown that women may refuse to seek care from a provider who "abuses" them or does not treat them well, even if the provider is skilled in preventing and managing of complications. Therefore, you should be supportive and friendly while you care for a woman in labour.

Assess the Individual Needs of Woman in Labour and Providing Appropriate Care

Every woman is a unique individual who will experience labour and birth differently. The individual need of the mother and her perception of labour relate to her previous experience which could greatly vary from individual to individual. Hence, when you provide care for a woman in labour, you have to provide care which is tailored to the individual needs and preference of each mother. This requires your sensitivity and awareness of the woman perception. Therefore, the care you provide should be individualised and continuous throughout the labour so that the mother has a good birth outcome and be satisfied with her labour experience.

Although providing support during labour does not make labour painless, it can make labour easier, shorter, and safer and help the mother to relax. Therefore, this study session is dedicated to introducing you to the various kinds of physical, emotional and psychological support that you could give for a mother taking into account her religion, ethnic and cultural needs.

Cleanliness

You should apply infection prevention principles and practices that you will learn later in this module. Keeping the cleanliness of the woman and her environment is vital for protecting the mother from infection and making the area conducive for her. Therefore, you should maintain the cleanliness of labouring and birthing area and clean up any spills.

You should also not forget to wash your hand with soap and water before and after each examination.

Provide Privacy

The best labour support will protect a woman's privacy and ensure that she is not disturbed so that she can tap into her inner wisdom and dig deep to find the strength she needs to give birth.

Keep impolite and unkind people away. You should also keep strangers away (as much as possible). A labouring mother could also be disturbed if she feels pressured to progress quickly. Therefore, you should also keep away individuals who could put pressure on her. Ideally, a labouring mother should be surrounded by family and health attendant who will listen, watch, and quietly and patiently encourage her, making sure that she is not disturbed and has the privacy she needs to do the work of labour. Moreover, information should be filtered; questions, interruptions and intrusions should be kept to a minimum.

You need to know that privacy does not mean being alone. Privacy means not being disturbed, being protected, and feeling safe as labour progress. You should provide a labour support that respects the woman's privacy, protects her from unnecessary interventions, ensures her safety and allows her to trust her inherent ability to give birth normally is important.

As the mother's labour attendant, you should guard the natural progress of labour against unnecessary interventions that could put both the woman and the baby's health at risk. For instance, some people believe that more drugs, tools and examination of the mother will make the birth safer. But that is usually not true - they can make the birth harder or cause problems. Injections or pills that are supposed to hurry the birth can make labour more painful, and can kill both the mother and the baby.

Position and Mobility

Several considerations govern the choice of position during the first stage of labour. Of these, the most important one is that of mother's preference - how she prefers to give birth. But some women need your encouragement to try different positions. Changing positions help the cervix open more evenly.

You should support the woman's choice of position (she can squat, take left the lateral position, kneel, stand supported by the companion or take any other position). Figures 3.1 and 3.2 indicate these positions clearly. All of these positions are good. You should also encourage the woman to move about freely; during the first stage of labour because walking and changing position in the first stage of labour reduces the duration of labour and contribute to a good birth outcome.

Helping the mother to manage her contractions

During the early stage of labour, there is a relatively wider gap for the contraction to come and go and this help woman to get some time to have rest and relax. The mother could even be able to sleep between these contractions. However, when labour progress through time, the contractions become more frequent and get stronger. This gives the mother little time to relax. Considering the decreasing strength and the tiredness they feel, most mothers could be afraid that they will not get enough strength to push down the baby at the time of delivery.

However, you should reassure the mother that, she will have the strength to push down the baby at the time of delivery. You should also advise the mother to relax, breath deep, lie or sit during contraction free times so that she will keep her strength for the time of delivery.

Touching and massaging

Comfort measures which provide natural pain relief can be very effective during labour and childbirth. Touching, massaging, etc. are some of these comfort measures.

Touching the mother gives her comfort and helps to buffer anxiety and pain during each contraction. You could reassure the mother by holding her hand, patting her hand or shoulder, providing a firm, still hand pressing on the lower back during contractions. All of these touchings convey reassurance, caring and understanding for the mother in labour. However, you should find out if the mother finds these touching as helpful because some mothers could find them disturbing.

Massage of the back could also help the mother to reduce pain and relax. Purposeful massage of the hand or other parts of the body also communicates caring. Massage takes the form of light or firm stroking, vibration, rubbing, deep circular pressure, and continual steady pressure. Stroking or rubbing the neck, shoulders, back, thighs, feet or hands is an effective pain-reliever. You should keep on asking the mother if the massage help to sooth her pain or if you should stop.

Putting a hot or cold cloth on the lower back or belly is another helpful method as well. Putting a cool, wet cloth on the forehead between contractions usually feels good for the mother, if she is sweating (see Figure below).

Making sounds/ vocalisation

Making sounds/vocalisation is making noise as a way to manage the stress of labour. Vocalisation gives a mother the ability to respond to the pain, stress, fear, tension or pressure that she feels. In effect, it is a way to release the tension that she is trying to prevent from building up.

How does it work?

Not all noise is the same. In order for vocalisation to work as a way to promote relaxation, the noise must be conducive to relaxing. Screaming, screeching, or any high-pitched noise does not come from a relaxed body, nor does it create a relaxing environment for the mother.

The type of noise to use in labour is low-toned moans, groans, humming, deep breathing, chanting or sighing. Low-toned noises are made from a relaxed throat, neck and chest with the mouth and jaw relaxed. You cannot make low-toned noises without being relaxed.

Pay particular attention to the noise the mother makes. If her voice gets high-pitched or she begins to scream, tell her to open her mouth and take a deep breath. Just opening her mouth should get her to relax her jaw and will bring the tone lower.

If the mother is struggling through a contraction, you may find that you need to make noise for her. Start making a low-toned noise near her face while you try to get her attention (see Figure 3.4, below). Most mothers will begin to imitate the noise you are making.

Breathing

The way a woman breathes can have a strong effect on how her labour will feel. Encouraging the mother to try different ways of breathing throughout labour is helpful.

You should teach the labouring mother to notice her normal breathing and encourage her to breathe out more slowly, making a sighing noise, and to relax with each breath. If she feels dizzy, unwell, is feeling pins-and-needles (tingling) in her face, hands and feet, encourage her to breathe more slowly.

How to guide a woman to breathe to avoid pushing down at the wrong time?

There are times throughout both stages of labour when the mother wants to push or bear down, and it is not the right time. Most women want to hold their breath during these particularly difficult moments. You should tell the mother to avoid holding her breath. To prevent pushing especially at the end of the first stage of labour, teach the mother to pant, to breathe with an open mouth, to take in 2 short breaths followed by a long breath out. During the delivery of the head also you should advise the mother not to push, but to breathe steadily (Figure 3.5).

Drinking energy fluids during labour

Since a woman in labour uses much of her energy and fluid in her body, you should encourage her to take enough fluid but not hard foods. During the first stage of labour, she should drink a high-calorie fluid such as tea, soft drinks, soup or fruit juice at least 1cup every hour so that the mother could get both the water and energy she needs.

If the woman does not get enough fluid during her labour, she will be dehydrated, and she could not be energetic and get quickly tired. This makes her labour much longer and harder. If you see any signs of dehydration, you should advise her to take enough fluids.

Passing urine regularly

It is important that you encourage the woman to try and pass urine regularly. If her bladder is full, it will cause pain and also make her contractions weaker which could result in a longer labour. A full bladder could also affect the pushing out of the placenta.

You could check a full bladder, on the mother's lower belly just above the pubic hair line. It feels on your hand like a plastic bag full of water, and the shape is also visible. However, you should not let the bladder get that full. So the mother should pass urine regularly. However, since the mother is in labour pain, she might not remember this, so you should encourage her to pass urine every 2 hours.

Emotional and psychological support for the woman in labour

You have understood that every woman needs a different kind of support because their individual needs are different. However, all mothers want to be treated with kindness, respect and dignity. They also need your attention and understanding. This is why emotional and psychological support during labour is considered to be very important.

Providing emotional and psychological support during labour make the woman to feel accepted, reduces her fear and anxiety related to the whole labour experience and helps her to find needed resilience during labour. Many pieces of evidence also show that emotional and psychological support make the woman to feel more satisfied and also result in a good delivery outcome.

Having a personal support (birth companion)

Having a support person (husband, close relatives or friends, etc.advices) of the woman choice around who is helpful and patient makes the mother to feel relaxed and supported. Therefore, you should encourage the woman to have a person of her preference to support her throughout labour and birth.

While the companion supports the mother, there is some advice you should give to him/her. For instance, you should encourage the companion to give adequate support to the woman during labour and childbirth. The companions of the mother should also be advised to encourage the mother, help her to breathe and relax, encourage her to drink fluids, assist her to urinate and do other supportive actions as per the local practices which do not disturb labour or delivery.

You should also tell the birth companion not to encourage the woman to push when it is not time, not to restrict the woman from freely moving when she wants to and not to give advice other than given by you.

Good communication

You should have a warm and friendly care for a mother in labour. It is mandatory that you should consider the emotional, psychological and social wellbeing of the woman while you communicate with her. When you provide care, you should show respect for her beliefs, tradition and culture because doing so makes the woman feel accepted.

You should obtain permission/ consent before you examine the mother. Explain what you are going to do and discuss the findings with her and her companion. It is the woman's right to have privacy during examination and discussion, get information about the progress of the labour, the condition of her and the baby as well. If the mother is known HIV positive, find out what she has told the companion and respect her wishes

As the labour progress, explain for her and the companion what to expect, and reassure her that you will be with her throughout the process of giving birth. Sometimes the labour pain could make the woman to be anxious and fearful. You should investigate the cause, give praise, encouragement and reassurance, listen to the woman and be sensitive to her feelings. Giving her information on the process and progress of her labour is also helpful

Examples of care that is women-friendly

Examples of care that is not women-friendly

Individualizes care to woman's needs Recognizes the richness and spiritual significance of community and culture Is aware of traditional beliefs regarding pregnancy and childbirth Cooperates and liaises with traditional healthcare system when possible Provides culturally sensitive care Respects and supports the mother-baby: Encourages bonding Keeps baby with mother Places baby on mother's abdomen (at breast) immediately after birth Speaks to the woman in her own language Observes rules and norms of her culture as appropriate Is aware of who makes decisions in her life and with respect to her choice involves that person in discussions Works with traditional birth attendants when possible Learns about traditional practices: Promotes/builds on positive traditional practices Offers alternatives to those that are harmful

Does not respect woman or her culture or background Rude, offensive, demeaning language by health personnel Physically restrains, pushes or hits the woman Insists on routine procedures that are convenient for the healthcare provider but may be shameful or disgusting to the woman, eg lithotomy position only, routine episiotomy, frequent vaginal exams, assembly-line fashion of care Excludes partner or companion from care Separates mother and baby