Being with a woman while she does the work
The companion manual in this library on maternal and obstetric nursing covers what goes wrong in pregnancy and how it is managed. This one covers the practice itself: what a midwife actually does across a labour that is going normally, which is the great majority of them, and how doing it well changes the outcome. That is not a soft claim. Continuous support in labour, freedom to move, unhurried attention and a known attendant are associated with shorter labours, fewer interventions and better experiences, and they are among the few things in maternity care that improve outcomes while costing almost nothing. This subject also carries a responsibility unlike any other in nursing: for most of the hours of a birth, the person holding the situation is the midwife, alone.
The name describes the role: being present with somebody through something they are doing themselves. This is not a sentimental framing but a clinical one, because the evidence that continuous presence changes outcomes is substantial and the practice of leaving a labouring woman alone between observations is a relatively recent institutional habit rather than a standard of care.
The great majority of pregnancies and births proceed without complication, and a system organised entirely around the minority that do not will intervene in the many to catch the few. The skill of midwifery is holding both at once: supporting a normal process without interfering, while watching closely enough to recognise the moment it stops being normal.
Doing nothing visible is frequently the correct action and is mistaken for doing nothing. A midwife sitting quietly with a labouring woman is assessing progress, contractions, colour, behaviour, coping, the partner, the room temperature and the time since she last passed urine, continuously. The absence of intervention is not the absence of care.
For most of the hours of a labour, the person holding the situation is the midwife, frequently alone and frequently at night. Recognising deterioration, deciding when to call, and being believed when you do are therefore central skills of this subject rather than peripheral ones, and they are exercised under fatigue.
Beyond measurement and screening, antenatal contacts build the relationship that determines whether a woman tells you something worrying, attends when she should, and trusts an instruction in labour. A great deal of what makes a birth go well was established in a clinic room months earlier by somebody unhurried.
Women prepare better for labour when they know what to expect, including that it will be painful, how long it may take, what the options are and what happens if something changes. Reassurance that removes the truth leaves somebody unprepared and frequently frightened at the moment it matters, and honest preparation is protective rather than alarming.
A birth plan records what somebody wants and is not a contract with physiology. Its value is that it makes preferences known in advance so they can be honoured where possible and departed from with explanation where not. A woman whose plan was abandoned without anybody explaining why frequently describes the birth as traumatic even when the outcome was good.
A companion of the woman's own choosing, present continuously, is associated with better outcomes and is recommended internationally. Arranging this, and protecting it against institutional habits that exclude companions, is a specific and evidence-based intervention rather than a courtesy.
Labour usually begins with irregular tightenings that become longer, stronger and more frequent over hours, and distinguishing this from the practice contractions of late pregnancy is a common first assessment. Timing, regularity, whether they continue with movement, and what the woman's own sense is together answer it better than any single feature.
Women admitted before labour is established have longer labours and more intervention, which is why assessment and a return home where appropriate is a genuine clinical decision and not a rejection. It has to be handled carefully, because being sent home feels like being disbelieved and the woman must leave knowing exactly what would bring her back.
History, the pattern of contractions, abdominal examination for the baby's position and descent, listening to the fetal heart, observations, and the woman's own account. Examination internally is done when it will change something rather than routinely on arrival, and it always requires explanation and consent.
When the waters break, the colour, the smell, the time and the fetal heart all matter, and clear fluid, the absence of fever and a normal heart rate are what make continued observation reasonable. This is one of the few situations in normal labour where a specific finding — discoloured fluid — changes the plan immediately.
The cervix softens, shortens and opens while contractions become progressively stronger, and the baby descends and rotates. Progress is not linear and periods of apparent stall are common and frequently resolve, which is why patience is a clinical skill here and why the impulse to act on a single slow hour causes a great deal of unnecessary intervention.
Contractions, descent, the woman's behaviour and, when indicated, cervical assessment together describe progress. Assessments are spaced because each is uncomfortable and carries a small infection risk, and the decision to examine should always have an answer to the question of what will change depending on the result.
Intermittent listening at defined intervals is appropriate in a labour progressing normally, and continuous monitoring is reserved for situations where there is a reason. Continuous monitoring in low-risk labour increases intervention without improving outcomes for the baby, which is one of the better-established findings in maternity care and one of the most frequently ignored.
Drinking, eating lightly if she wants to, passing urine regularly, changing position, moving about, warmth, dim light, quiet and privacy all influence how labour proceeds. A full bladder slows progress; lying still on a bed slows progress; fear slows progress. These are physiological effects rather than comforts.
A record of labour built contemporaneously — contractions, heart rate, observations, examinations, what was discussed and agreed — is both the clinical picture and, if something goes wrong, the only account of what was happening. Reconstructing it afterwards produces something less accurate and, in any review, something that looks worse than it was.
Pain in labour accompanies a normal process, which makes it different from almost all other pain a nurse meets, and it does not mean damage is occurring. Explaining that distinction genuinely changes how it is experienced, because pain interpreted as dangerous is experienced as more severe than the same pain understood as expected.
Continuous presence, freedom to move and choose position, warmth and water, massage and counterpressure, breathing that the woman controls, a quiet dim room, and somebody who does not appear alarmed. These are effective, they are available everywhere, and they are the first line rather than what is offered while waiting for something better.
A woman's choices about pain relief are hers, and both pressing an epidural on somebody who did not ask and withholding one from somebody who did are failures. The professional position is to make sure she knows what is available, what each involves and what it means for mobility and monitoring, and then to support what she chooses.
Towards the end of the first stage many women become distressed, say they cannot continue, become irritable or want to leave, and this is a recognisable phase rather than a sign that something has gone wrong. Recognising it allows a midwife to reassure accurately — that this usually means it is nearly time — which is one of the more useful things she will say all night.
Many women feel an involuntary urge to push as the baby descends, and following that urge is generally better than being directed to push against the clock. Prolonged directed pushing with a held breath is associated with more perineal damage and more fetal distress, and the older practice of coaching it from the moment of full dilatation has largely been abandoned for those reasons.
Upright, kneeling, side-lying and squatting positions all have advantages over lying flat on the back, which narrows the pelvic outlet and compresses the large vein returning blood to the heart. The single most consequential thing a midwife does here may be to make the room a place where moving is expected rather than exceptional.
Slow controlled birth of the head, warmth applied to the perineum, and communication that allows the woman to stop pushing at the right moment all reduce serious tearing. Routine cutting of the perineum is not recommended and has been abandoned as a routine in most places, though it persists widely.
Time limits for the second stage exist and are guides rather than deadlines, and the question is always whether mother and baby are well and progress is occurring rather than what the clock says. Intervening because an hour has passed while both are entirely well is a common way that a normal birth becomes an assisted one.
The head is born, restitutes, and the shoulders follow with the next contraction. Most of this requires the midwife's hands to do very little and her attention to do a great deal — watching the colour, the tone, the cord, the perineum and the woman all at once, and being ready without appearing to be.
Placing the baby directly onto the mother's chest, dried and covered, keeps the baby warm, stabilises breathing and heart rate, colonises them with the mother's own organisms, and supports the first feed. It is one of the highest-value and lowest-cost interventions in the whole of newborn care, and it is displaced constantly by routines that could wait.
Delaying clamping for a period after birth allows blood to continue passing to the baby and improves their iron stores for months, and it is recommended where the baby is well. The cord is cut with a clean instrument, and clean cord care afterwards prevents a substantial amount of newborn infection in settings where that is a major cause of death.
The placenta separates and is delivered, and this is the period in which the most common cause of maternal death begins. Watching blood loss, the tone of the uterus, and the woman's condition during and after this stage is where the attention belongs, and it is exactly when everybody is looking at the baby.
A newborn loses heat extremely fast, especially when wet, and cold babies deteriorate. Drying immediately, removing the wet cloth, covering the head, and keeping them against the mother addresses this without equipment, and thermal care is one of the few newborn interventions that works equally well in a hospital and in a house with no electricity.
Breathing, colour, tone, heart rate and response can all be assessed with the baby on the mother's chest. Separating a well baby for routine measurement and washing is an institutional habit that costs warmth, contact and the first feed, and almost everything in it can wait an hour.
Babies held skin to skin frequently find the breast themselves within the first hour, and early initiation is associated with better feeding outcomes afterwards. The midwife's role is mostly to protect the hour from interruption and to help with positioning and attachment if needed rather than to take over.
Most babies who do not breathe at birth respond to being dried, stimulated, kept warm and given effective ventilation, and the single most important determinant of outcome is that somebody begins within the first minute. Every birth attendant needs this skill, practised regularly, because it is required rarely and always without warning.
The management of obstetric emergencies is learned in practical drills with a teacher and equipment, repeated regularly, because under stress people perform what they have rehearsed rather than what they have read. This chapter is written to aid recognition and to convey urgency, and deliberately does not describe manoeuvres or treatments.
The leading direct cause of maternal death worldwide, and frequently underestimated because blood is absorbed by bedding and because a young healthy woman compensates until she suddenly does not. Estimating loss by weighing rather than by eye, watching the pulse rather than the blood pressure, and calling early are what change outcomes.
Seizures in pregnancy or shortly after birth are an emergency, and they are preceded in most cases by a rising blood pressure, headache, visual disturbance, upper abdominal pain or swelling that somebody recorded. Acting on the warning signs rather than on the seizure is the whole of prevention, and the warning signs appear in antenatal records repeatedly.
When the head is born and the shoulders do not follow, the situation is urgent and time-limited, and it is managed by a rehearsed sequence performed calmly. It is the clearest example in this manual of a skill that must be drilled, because it happens without warning and there is no opportunity to look anything up.
Maternal sepsis develops quickly and is missed because fever, tachycardia and discomfort are attributed to ordinary postnatal recovery. A woman who feels unwell, has a rising pulse, offensive discharge or abdominal tenderness in the days after birth needs assessment rather than reassurance, and deterioration can be rapid.
Bleeding, uterine tone, blood pressure, temperature, pain, the perineum or wound, passing urine, legs, mood and feeding. Most postnatal deterioration announces itself in one of these, and most postnatal care consists of asking about them properly rather than of any procedure.
Most difficulties are practical — positioning, attachment, pain, exhaustion, conflicting advice — and most are solved by somebody skilled sitting down with the mother rather than by information. Time spent here is clinical work, and framing it that way is part of it being given.
Brief tearfulness in the first days is common and settles. Persistent low mood, inability to enjoy the baby, hopelessness or thoughts of harm are not, and need assessment. Mental illness is among the leading causes of maternal death in the year after birth in several countries, which is why asking about mood is a clinical observation and not conversation.
A woman leaving hospital needs to know what is normal, what is not, what would mean coming back immediately, who to contact and when she will be seen. Given at the door to somebody anxious to leave, none of it is retained, which is why it is said earlier, written down, and said to whoever is going home with her.
Postnatal care is conventionally described as ending at around six weeks, which bears little relation to how long recovery actually takes. Pain, exhaustion, incontinence, difficulty with sex, and low mood commonly persist well beyond it and are then presented to somebody who has no record of the birth. Saying plainly that these can last longer, and that they are worth raising rather than enduring, is what gives a woman permission to come back.
Women across many countries report being shouted at, hit, examined without consent, left alone, denied companions, refused pain relief and having procedures performed without explanation during childbirth. This is documented rather than anecdotal, it is a recognised category of harm, and pretending it is rare would make this manual dishonest.
Every examination, every procedure and every touch requires explanation and agreement, and being in labour does not supply it. A woman in pain who does not object has not consented, and the fact that a procedure is routine, urgent or in her interest does not remove the requirement to say what you are doing and ask.
Women recall the details of how they were treated during birth for decades, and the memory shapes whether they seek care again, how they feel about the child, and what they tell other women in their community. A technically excellent birth conducted without kindness is remembered as a bad birth, and that has consequences for everybody.
Witnessing a colleague treating a woman badly is common and speaking up is hard, particularly for a student or a junior midwife. What remains available is remaining with the woman, explaining afterwards, documenting factually, and raising it through the defined route. Doing nothing is a choice with consequences for the next woman.
Maternal deaths are overwhelmingly concentrated in low-income countries and in the poorest parts of wealthier ones, and most are preventable with care that already exists. The single strongest determinant is whether a skilled attendant is present and whether emergency care can be reached in time, which makes this a question of workforce and transport as much as of clinical knowledge.
Where birth at home is planned, attended by a skilled midwife, with a working plan for transfer, outcomes for low-risk women are good. Where it happens because there is no alternative, no attendant and no transport, it is a different situation entirely, and conflating the two in either direction misleads.
Deciding to transfer, arranging it, and travelling with the woman is a defining midwifery skill in much of the world. The decision is made on the basis that things may deteriorate rather than that they have, because the journey takes time that a haemorrhaging woman does not have, and delay in deciding is one of the classic contributors to maternal death.
Deaths follow delay in deciding to seek care, delay in reaching a facility, and delay in receiving adequate care once there. Each has different causes — cost, permission, distance, transport, staffing, supplies — and locating which delay killed a particular woman is how services actually improve. All three are outside the birth room.
In much of the world the woman who is haemorrhaging cannot be transfused, which changes every priority: preventing loss matters more, recognising it earlier matters more, and the decision to transfer is made sooner because the journey is the treatment. Knowing in advance what your facility actually has — how much fluid, whether there is oxygen, whether the vehicle exists and who drives it at night — is preparation rather than pessimism, and it is done before the emergency rather than during it.
In some countries a midwife practises independently, prescribes, and refers directly; in others every decision is taken by a doctor. The clinical practice is similar; the authority is not. Knowing precisely where your own boundary sits, and where the regulation says it sits rather than where custom puts it, is a professional requirement.
Calling early and being wrong is a minor cost; calling late is not. The situations where midwives report having hesitated are consistent: at night, when the senior person has been unhelpful before, when the finding is subtle, and when they doubt themselves. Knowing that this is the pattern is the best available defence against it.
Every midwife eventually raises a concern and is not taken seriously. What matters is that a route to go further exists and that using it is treated as correct rather than as going over somebody's head. Knowing that route in advance, before a night when it is needed, is part of preparing for practice.
Midwifery records are examined more frequently than almost any others, because outcomes are occasionally catastrophic and reviews are thorough. Contemporaneous, factual, timed entries describing what was observed, what was done and what was discussed protect the woman first and the midwife second, and they cannot be constructed afterwards.
Obstetric emergencies are rare for any individual midwife and catastrophic when they occur, which is exactly the combination that rehearsal exists for. Units that run regular drills — with the actual equipment, in the actual room, including calling for help and including the people who will really be there — perform measurably better when it happens, because under stress people do what they have practised rather than what they have read. Skipping drills because the ward is busy is the most common false economy in this subject.
Abdominal palpation establishes how the baby is lying, which way it is facing, which part is presenting, and how far it has descended into the pelvis, and it can be done anywhere with no equipment. In settings without routine imaging it is the principal means of knowing what is inside, and in settings with imaging it remains the assessment that happens at every contact rather than occasionally.
A baby facing the mother's back generally negotiates the pelvis more easily than one facing forwards, which tends to produce longer labours, severe back pain and a slower second stage. Knowing the position explains what the woman is experiencing, allows it to be named rather than treated as poor progress, and informs which positions and movements may help.
How far the presenting part has descended frequently tells you more about progress than cervical dilatation alone, particularly late in labour, and it can be assessed abdominally without an internal examination. A cervix that appears static while the head is descending is a labour progressing, and reading only one of the two measures produces unnecessary intervention.
The fetal heart is heard best over the baby's back, which means palpation determines where to listen, and a midwife who listens in a fixed place regardless of position will sometimes hear nothing and cause alarm. It also means an unexpected difficulty in finding the heart is information about the baby's position before it is anything else.
Labours vary enormously in length and many that appear to have stalled resume without any intervention. The clinically important distinction is between a labour that is simply slow with a well mother and baby, and one where the baby cannot pass — which shows itself in a pattern of findings rather than in the clock alone, and which is genuinely urgent.
A full bladder, dehydration, exhaustion, fear, being immobilised on a bed, a room full of people, and a woman who does not feel safe all slow labour measurably. Addressing those before considering anything else is both cheaper and more likely to work, and it is repeatedly skipped in favour of intervention because it is less visible as action.
A woman who has been labouring for many hours without sleep, food or fluid will stop progressing, and this is a solvable problem rather than a failure of her body. Rest, warmth, something to drink, a change of scene, and a period without anybody examining her are legitimate clinical interventions with a defensible rationale.
Escalation is based on the whole picture — the mother's condition, the baby's heart, the pattern of contractions, descent, and the findings over time — rather than on a single number crossing a line. Presenting that picture to whoever decides, rather than presenting one measurement, is what produces a good decision.
A slow controlled birth of the head, warmth applied to the perineum, positions other than flat on the back, and clear communication that allows the woman to stop pushing at the right moment. These are what the evidence supports, and routine cutting of the perineum is not among them and has been abandoned as a routine in most places while persisting widely in practice.
The extent of a tear is established by careful examination after birth, with consent, in good light, and with adequate pain relief. Under-assessment is common, it is how serious injuries involving the anal sphincter are missed, and a missed injury of that kind produces incontinence that changes a woman's life and is far harder to repair later.
It requires consent, adequate analgesia, good light, correct positioning and an unhurried approach, and being performed immediately after a birth in a busy room is not a reason to do any of it badly. Women describe a poorly conducted repair as among the worst parts of their birth, sometimes worse than the labour.
Pain on sitting, difficulty passing urine or opening the bowels, and pain during sex months later are common, under-reported and frequently dismissed. Asking about them specifically at postnatal contacts, rather than waiting for the woman to raise something embarrassing, is what allows them to be treated.
Stillbirth, neonatal death, miscarriage and the birth of a baby with an unexpected condition all occur in maternity settings, frequently without warning, and the midwife present is the person who holds it. Nothing in training prepares anybody adequately for the first time, and knowing in advance what is usually helpful is a small amount of preparation that is better than none.
Not being left alone, the baby being treated with visible care and called by name, being offered time with the baby without pressure in either direction, photographs and mementoes where wanted, honest information, and staff who did not appear frightened of them. What harmed was being avoided, being rushed, and euphemism instead of plain words.
Euphemisms leave parents uncertain about what has actually happened and are remembered as evasion. Saying that the baby has died, simply and without a preamble that delays it, is kinder than any attempt to soften it, and then stopping and staying rather than filling the silence with arrangements.
Attending a death in this setting affects staff profoundly and is frequently followed by an immediate return to another labour. Organisations that acknowledge this, allow a pause, and check on people days later retain their midwives; those that do not lose them, and the loss is rarely attributed to the cause.
A pregnant woman with capacity may accept or refuse any intervention, including one recommended for the baby, and her right to refuse is not reduced by pregnancy in most legal systems. This is uncomfortable for staff, it arises genuinely, and a midwife's role is to make sure the decision is informed and then to support her and continue caring for her.
A choice requires knowing what is proposed, what the alternatives are including doing nothing, what each involves, and what is known and unknown about the consequences. Presenting only the recommended option with the risks of declining it is not information, and women recognise the difference immediately.
Much of midwifery advocacy is small and immediate: saying aloud that the woman has asked for a moment, repeating her question to a doctor who did not hear it, pointing out that consent has not been sought, reminding a room that she can hear everything being said. These are unglamorous and they are the job.
A woman may make a choice you believe is wrong, and supporting her afterwards without punishing her for it is the professional position. Documented, informed refusal is a legitimate clinical outcome rather than a failure, and the relationship being intact afterwards is what makes her willing to come back if things change.
Millions of women alive today have been cut, and a midwife working in the regions where it is practised, or anywhere those communities have migrated to, will care for them. Encountering it for the first time during a labour, with no preparation and no idea what it means for the birth, serves nobody, which is why it belongs in a manual on practice rather than being left to a specialist elsewhere.
Depending on the extent, it can cause difficulty passing urine, recurrent infection, painful sex, obstructed labour, severe tearing, and psychological consequences that surface during examination and birth. Assessment antenatally rather than at the moment of birth allows the type to be identified, a plan to be made, and any necessary procedure to be discussed and consented to calmly.
Ask routinely rather than selectively, in private, using neutral language, and without any expression of shock. A woman who sees revulsion on a midwife's face will not disclose anything else for the rest of the pregnancy. The examination is her body being discussed, not a custom being judged, and she may have strong and complicated feelings about it that are hers.
In many countries the practice is illegal, reporting duties exist, and the safety of any daughters may need to be considered. These obligations differ completely between jurisdictions, they can sit in tension with the woman's trust, and knowing exactly what your own law requires before the conversation happens is the only way to handle it honestly.
Pregnancy in adolescence carries higher risks of hypertensive disease, obstructed labour and preterm birth, and complications of pregnancy and childbirth are among the leading causes of death in girls of this age worldwide. Alongside the clinical risk sits interrupted education, economic dependence, and frequently a pregnancy that was not chosen, all of which shape what care is actually useful.
Adolescent mothers are commonly either infantilised or expected to manage as adults, and both fail. What works is speaking to her directly rather than to her mother, seeing her alone for part of every contact, being explicit about confidentiality and its limits, and not assuming who the decision maker is in her household.
Pregnancy later in life carries higher rates of hypertensive disease, gestational diabetes, chromosomal conditions and intervention at birth, and the additional monitoring this brings can turn a wanted pregnancy into a sequence of appointments about risk. Naming the risk accurately, without implying that a normal outcome is unlikely, is a real skill.
A pregnancy in a very young girl raises questions about the circumstances of conception, and a midwife may be the first professional in a position to ask. These are handled through the defined route rather than personally, with the woman told what will happen, and the obligation to act does not wait for certainty.
The period after a birth is when a woman is in contact with services, thinking about her body, and at her most receptive to a conversation about whether and when she wants another child. It is also when the subject is most often skipped, because everybody is focused on the baby and because raising it feels intrusive so soon after a birth.
Pregnancies close together carry higher risks of preterm birth, low birth weight, anaemia and maternal depletion, and the effect is largest where nutrition is already marginal. This makes birth spacing a health intervention rather than only a personal preference, and it is one of the more effective ones available in settings with high maternal mortality.
Breastfeeding suppresses fertility only under specific conditions that are frequently not met, and a great many women conceive while believing they are protected. Explaining precisely when it does and does not apply, rather than repeating a general reassurance, prevents a common and consequential misunderstanding.
In many households the decision about contraception is not the woman's alone, and a method requiring cooperation or that is visible may not be usable for her. Asking what would actually be possible in her situation, discreetly, produces a workable plan where a standard explanation of options produces agreement and no use.
A woman's nutrition, anaemia, blood pressure, glucose control, weight and any condition identified during this pregnancy all affect the next one, and the postnatal period is when something can be done about them. Treating postnatal care as the end of an episode rather than the beginning of the next is a structural reason why the same problems recur.
Stages of labour and their management, monitoring choices in low-risk labour, immediate newborn care, recognition of haemorrhage and of hypertensive emergency, and consent during labour. Practical examinations test recognition and initial response rather than definitive management.
Support the normal process, monitor appropriately for the risk level, explain and obtain consent for everything, recognise deviation early, call for help without delay, and document. Answers that intervene routinely in a normal labour, or that omit consent, lose marks consistently.
Recommending continuous monitoring in a low-risk labour; directing pushing from full dilatation; separating a well baby for routine care in the first hour; treating a normal blood pressure as reassurance in a woman who is bleeding; assuming labour pain means something is wrong.
Stay in the room. Say what you are about to do and ask. Let her move. Put the baby on her chest and leave them there. Weigh the blood rather than guessing. Call early. These six are most of what this manual contains and none of them require equipment.