For this assignment, I have created visual aids to be used to inform Crystal on the importance of monitoring maternal vital signs and abdominal examination in labour. Crystal is hoping for a spontaneous labour and birth with no pharmaceutical pain relief so it is key she sees these comprehensive assessments as guarding, promoting and facilitating her normal physiological process while ensuring safety by identifying complications for her and her baby 1,2.
For the visual aids, I have created some affirmation displays with associated information about routine maternal checks that may be offered to Crystal during labour.
 
These designs can be used in several ways:

• a three-fold, double sided flyer with the other side being upside down so image/affirmation section can be cut out separately.
• 6 separate cards on thicker board to be cut or folded for display in the birth setting.
• Poster size prints of the affirmation sections that can be framed in the birth space to remind Crystal of the importance of the checks by association.

 
I have used some of my own feminine and nature-based images that will aim to increase her sense of comfort, relaxation, and well-being. Feminine and nature images have also been shown to lower maternal heart rates, shorten labours, reduce epidural use and increase Apgar scores 3,4 that will support Crystal’s aspirations. I have used a consumer-friendly font and use non-medical language. I have used affirmations taken from the website ‘Healthline’ 5.
 
I see the aid being used as a handout in an antenatal session with some more detailed discussion had with each page/card. The discussion can then be sustained with Crystal using the affirmations within her own home and labour setting. The maternity setting can enhance this association and the environment by using the framed versions in the labour room.

It is important when talking to a woman about these clinical checks that often care settings impose time constraints which do not allow for their individual variation of spontaneous labour, but that informed consent will be acknowledged and her autonomy supported 20.
 
To support her autonomy, midwives are required to be with the woman rather than only doing things to her to then become better attuned to her evolving situation and safety. Midwives can integrate these clinical checks into the whole dynamic of care, rather than having them be the central concern 21.

This essay will evaluate the influence of environmental and philosophical factors on the normal progress of labour and the midwife’s role in relation to these. In this context the normal progress of labour is defined as the spontaneous onset and advancement of labour and includes the physiological and psychological environments that support effective labour resulting in the vaginal birth of the baby and afterbirth 1.

When addressing the influence of environmental and philosophical factors on this normal development it is important to first address the natural interplay of hormones in this process. Labour and birth include neurobiological processes that facilitate the neuroendocrine, psychological, and physiological aspects of parturition 2,3. These systems include oxytocin mediated endogenous pain, fear, and stress relief, which influences the mothers ́ experiences, behaviour and physiology to birth and facilitates their transition to motherhood 2,3.

When this process is affected by the adrenalin mediated fight-or-flight reflex, thus increasing stress and anxiety, there is an increase in maternal beta-endorphins to high levels that extend the labour process by influencing this easily modifiable oxytocin system, thereby decreasing the chances of normal birth 3. 

The presence of undesired persons, brisk procedures, separation from planned known support, bright environment, bothersome noises, time pressure, lack of privacy, practices that impinge upon the labouring woman’s body, and an emphasis on policy rather than individualised response to women’s needs and preferences all increase maternal adrenalin levels 3. Oxytocin is not released in the presence of high levels of adrenaline and it is how this stress, anxiety and fear can change a labouring woman's neurohormonal constitution 3,4. Understanding the profound importance of respecting and promoting this hormonal development is not enough to promote normal birth if the birthing environment does not support normal birth physiology 5,3.

The birth environment is a multifaceted concept that includes the physical structures, sensory influences, birth companions, and care provider’s presence and philosophies, as well as psychological spaces of territory, safety, spirituality, and culture 5,6.

Much research has been done around the physical birthplace design and its importance in safer maternity care and improved staff experiences 7,8. Aspects of design that have been found to support the natural hormonal cascade of birth include: having access to a bath and shower, private ensuite toilet facilities, adjustable ambient and natural light, and space to move freely with flexible room configurations to enable privacy and avoid feeling exposed 7,4. 

Setola et al. 7 and Aburas et al. 9 also discuss the use of feminine and nature based artwork and images to increase a sense of comfort, relaxation, and well-being, lower maternal heart rates, shorten labours, reduce epidural use, increase Apgar scores, and screen medical equipment.

Jenkinson et al.’s 4 report also includes the positive impact of design features including soft floor furnishings, windows with views of natural landscapes, and access to nature and spaces for relevant traditional ceremonies.

Maintaining oxytocin requires a woman to be in a calm, non-threatening and supportive environment that feels private, safe, familiar and undisturbed 3. This sense of security and intimacy is enhanced by being in a space that feels welcoming, comfortable and cosy and offers the choice to personalise 7. It also requires an atmosphere to foster distraction from pain to support this hormone orchestration 7. This form of ambient environment consistently demonstrates lower rates of neonatal admissions, labour augmentation, analgesia use, instrumental and caesarean section births, episiotomies, and active management of the placenta 10,7.

Normal labour progress is also enhanced by physical support from labour companions and the birth environment should be accommodating them 7,11. It should be set up to support the midwives with features of friendliness, functionality, and freedom to do their job as guardians for a healthy, normal birth 12. Research shows that labour wards are mainly organised to reduce risks and treat complications and are thus dominated by care focussed on pathology which is important but also hinders and limits the midwife in their role to protect the women’s hormonal safety bubble 10. 

In this support role, midwives have a presupposition to protect this bubble from disruptions and establish a private, undisturbed atmosphere of familiarity, safety and autonomy 6,10. This can be initiated by establishing the family’s needs and preferences and encouraging them to personalise the space to be more homelike 6,10,13. This could include covering or moving the equipment that emphasises risk, and being recumbent, like the centrality of the bed, and encouraging active, upright positions 8,10. Upright and changing positions are better for the baby; they enhance normal labour and reduce the rate of instrumental birth, episiotomy, and shorten second stage of labour 14.

The midwife can facilitate this calm space by adjusting the lighting, reducing unnecessary noise, offering music and aroma-therapy, and providing equipment like birth balls, stools, and other apparatus to promote a physiological labour 5,4. They may offer the stress relief of physical touch or massage, and reassurance that in turn mediates oxytocin release to reduce pain and fear 2,3.

It is important to ensure that the birthing woman does not feel observed as it can impact on her sense of privacy 15,16. If the midwife looks relaxed and has a place to sit, the mother feels reassured of their presence and that there are no time constraints to the process 10. The neocortex can also be disrupted by language, therefore, remaining silent and unobtrusive and asking only necessary questions will help maintain a state of hormonal balance 16. Any necessary communication should be sensitive and effective during this intrapartum care 17.

Other midwifery roles to maintain this conducive environment include ensuring the room, water, and towels for the baby are an appropriate temperature, providing food and water, partner support and preparation and checking of safety and medical equipment in the space 18. Complementing this care would be the inclusion of continuity of carer 6.

The birth environment is also affected by the woman’s relationship with her midwife and the philosophy the midwife has 4. Often this philosophy is hard to differentiate from place of birth 19 but will be independently evaluated as an influence on the normal birth process.

Birth philosophy can usually be broken into two main categories: the ‘medical/technocratic model’ and the ‘midwifery/holistic/social model’ 20. Grigg’s 20 medical model is doctor and pathology centred and includes ideas of the body and mind being separate, birth being a hospitalised medical condition, and technology, supervision and intervention being needed to ensure an outcome of a live mother and baby. This model views pain as a problem needing relief, therefore influencing the normal progress of labour, leading the birthing environment to become a ‘surveillance room’ 7.

The midwifery model focusses on care being woman centred where midwives are the experts of the normal birth process and includes features of holistic, psychosocial, experiential, and emotional care guarded by observation and focusing not only on a healthy mother and baby but also on birth satisfaction 20. This philosophy of supporting and promoting the physiological process is grounded in the midwifery codes and competencies 11,21,22. It involves ‘working with pain’ as normal and positive 23 and focuses on creating a birthing room that is a ‘sanctum’ 7.

The choices and philosophies of women and their partners are influenced by their maternity experiences and knowledge, personal, sociocultural, and political norms, but the major influence is their sense of safety and their belief regarding risk 19,24. There is often a struggle between a desire for a physiological birth, the increasing perceived risk technology can avoid, and the perceived positive experience that technology can offer 5. 

Women and midwives often choose a birthplace as a protection from or stimulus for their philosophy of childbirth 25. Most women choose to give birth in a hospital setting because it is a good match for what they believe 26, whereas woman with philosophies that seek physiological comfort measures and options such as waterbirth may choose to birth at home 27.

Midwife partnerships that involve an individual shared birth philosophy exhibit more sustainability and individual satisfaction, and create fewer communication breakdowns due to tensions and subcultures within the workforce 15,28. This also benefits women who have chosen their midwife or place of birth according to their birth beliefs by ensuring they receive the same philosophical continuity of “care” no matter who attends them 29. 
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Although philosophy of birth may guide principles for behaviour and choices around intrapartum care, it is important to remember that each woman’s birth is individual and care should remain woman-centred 19. This is especially relevant when working with cultural groups who are often stereotyped as having uniform beliefs 30. Women are all cultural beings with varying values and beliefs and yet they are all individuals with their own experiences influenced by class, gender, age, religion and sexual orientation 30.

Ultimately women want to give birth to healthy babies in an environment that is clinically and psychologically safe and with care providers who support their philosophical beliefs 11.

This essay has evaluated how these aspects of philosophy and environment have the potential to influence the normal progress of labour through the hormonal system. It has addressed how a midwife can respond to these factors in a culturally competent, collaborative and evidence-based way to assess, plan and provide safe psychological and clinical care.