Midwives are the experts in normality.^1,2 The publication of the National Maternity Strategy³ promotes the role of the midwife by supporting the normalisation of pregnancy and birth. It also recognises the importance of the birth environment and the benefits of a positive birthing experience for women. Midwives have an important role in promoting and facilitating physiological birth. 

The National Maternity Strategy³ does much to strengthen the role of the midwife. It maps out how improvements can be made, ensuring that maternity care is safe and of a high quality. The overarching theme is based on the principle that childbirth is a natural, physiological process. It acknowledges that because women are unique, their needs will vary, some requiring more specialised care, but ultimately “insofar as possible all pathways should support the normalisation of pregnancy and birth”.⁴

The strategy strongly recognises the importance of the birth environment. Evidence shows that the birth environment affects birth outcomes and the woman’s experience.^5,6,7,8,9 Environment is an encompassing term, which not only includes the physical nature of the birthing space, but also the emotional and psychological space –the ‘inner emotions’ of labouring women, which are created between the midwife and the woman.

In the birth environment, layout of the physical space can increase movement and maximise positioning during labour and birth, ultimately improving the potential for normal birth.^7,10 Simple reorganisation of the labour room can help, such as dimming the lights, moving the bed, or raising the level of the bed to allow a woman to stand or use it as a head support should she wish to sit on a birthing ball. Having a policy of closing labour room doors, avoiding unnecessary interruptions and minimising the number of people present creates a sense of privacy and security. 

According to Odent^5,6 this is essential for women to labour effectively. Women who feel afraid or anxious produce stress hormones such as adrenaline and cortisol that inhibit the release of oxytocin and prolactin, adversely affecting labour.^5,6 Anderson⁸ supports this stating that the midwife must create an atmosphere of safety allowing a birthing woman to “disconnect mind from body”. In essence, safety extends far beyond the physical reality of drugs, machines and technology; it is about privacy, security, a sense of belonging and being cared for by compassionate people who believe in physiological birth.⁷ 

At the Coombe Women and Infants University Hospital (CWIUH), physiological birth is supported by encouraging mobility and advising women to adopt upright positions during labour and birth. Aides such as birthing balls and stools, bean bags, floor mats and ceiling slings are available. Women with risk factors who require continuous foetal monitoring (CTG) are offered telemetry CTG, and similarly women requiring intravenous fluids/medication are facilitated to use a birthing ball/bean bag. 

CWIUH midwives aim to introduce a sense of normality for all women, even those with risk factors and/or specialised needs. The use of hydrotherapy is facilitated in the form of showers and a birthing pool. The CWIUH is one of four units in the Republic of Ireland with a birthing pool, and also facilitates water birth. Since 2013, more than 270 women have used the pool for pain relief, and 80 women have opted to have a water birth. Since January 2016, the service is being provided under the remit of a Water Immersion Study, which aims to compare water to land for labour and birth for healthy women with uncomplicated pregnancy. Although similar studies have been conducted internationally^11,12,13 and much has been written about the potential benefits and risks of water birth,^{14,15,16,17,18,19} it is the first of its type in Ireland.

Those who choose to use hypnobirthing are supported and women are encouraged to bring their choice of music or they can listen to music available in the room. In order to support natural oxytocin^5,6 production, doors are closed and lights are dimmed. Noise and unnecessary interruptions are kept to a minimum. Women’s choices are respected, and some write a birth preference list. This is drawn up in the antenatal period between the woman and her midwife/doctor. Some women opt to have two support people present during labour. The first is usually their partner and the second a doula (or birth companion), who can be either a professional employed by the woman, or someone who the woman feels will be a support through the labour and birth such as her mother/sister/friend. 

It is evident from the publication of the National Maternity Strategy, that the Department of Health acknowledges that improvements need to be made on the provision of maternity care in Ireland. The strategy recognises the valuable role the midwife has in bringing about these changes. Challenges exist in the service, but midwives need to be passionate in their pursuit of high quality services that meet the needs of the women, babies and families in their care.

References

1. Nursing & Midwifery Board of Ireland (NMBI). Code of Professional and Ethics for Registered Nurses and Registered Midwives. NMBI: Dublin, 2014.
2. Nursing & Midwifery Board of Ireland. Scope of Nursing and Midwifery Practice Framework. NMBI. Dublin, 2015.
3. Department of Health (DoH). Creating a Better Future Together: National Maternity Strategy 2016-2026. DoH: Dublin, 2016. 
4. Langford S.  ‘Chairs Foreword’ in Department of Health. Creating a Better Future Together: National Maternity Strategy 2016-2026. Pg.: 3. DoH: Dublin, 2016.
5. Odent M. Childbirth in the Age of Plastics. Pinter & Martin: London, 2003.
6. Odent M. Childbirth and the Evolution of Homo-sapiens. Pinter & Martin: London, 2014.
7. Walsh D. Evidence and Skills for Normal Labour and Birth: A Guide for Midwives. Second Edition. Routledge: London, 2012.
8. Anderson T.  Feeling safe enough to let go; the relationship between a woman and her midwife during the second stage of labour: In: Kirkham M Ed. The Midwife-Mother Relationship. Second Edition.  Palgrave Mac Millan: London, 2010.
9. Foureur M. Creating birth space to enable undisturbed birth. In: Fahy K, Foureur M and Hastie C. Birth Territory and Midwifery Guardianship: Theory for Practice, Education and Research. Books for Midwives: Edinburgh, 2008; 55-77.
10. Kemp E, Kingswood CJ, Kibuka M, Thornton JG. Positions in second stage of labour for women without epidural anaesthesia. Cochrane Database of Systematic Reviews 1:Cd008070, 2013.
11. Burns E, Boulton MG, Cluett E, Cornelius V R, and Smith LA.  Characteristics, intervention and outcomes of women who used a birthing pool: a prospective observational study. Birth 2012; 39(3): 192-202.
12. Geissbuehler V, stein S, Eberhand J. Water births compared with land births: an observational study of nine years‘, Journal of Perinatal Medicine, 2004; 32 (4): 308-314.
13. Chineze et al.  A retrospective comparison of water birth and conventional vaginal deliveries. European Journal of Obstetrics and Gynaecology and Reproductive Biology, 2000; 91: 15-20.
14. Nutter E, Meyer S, Shaw-Battista J, and Marowitz A.  Water birth: an integrated analysis of peer-reviewed literature.  Journal of Midwifery and Women’s Health. 2014; 59: 286-319.
15. Cluett ER and Burns E. Immersion in water in labour and birth. Cochrane Database of Systematic Reviews 2009, Issue 2.
16. Bovbjerg ML, Cheyney M, Everson C. Maternal and new-born outcomes following water birth: the Midwives Alliance of North America statistics project, 2004-2009 cohort. Journal of Midwifery and Women’s Health, 2016 (access www.jmwh.org).
17. Taylor H, Kleine I, Bewley S, Loucaides E and Sutcliffe A. Neonatal outcomes of water birth: a systemic review and met-analysis.  Arch Dis Child Fetal Neonatal Ed, 2016; 0:F9. Doi: 10.1136/archdischild-2015-309600.
18. Royal College of Obstetricians and Gynaecologists/Royal College of Midwives Joint Statement No. 1.  Immersion in Water During Labour and Birth.  RCOG & RCM: London, 2009.
19. National Collaborating Centre for Women’s and Children’s Health. Intrapartum Care: Care of Healthy Women and their Babies During Childbirth. Royal College of Obstetricians and Gynaecologists: London, 2014.