Having a Baby in Scotland 2015: Maternity Care Survey

Chapter 3: Care During Labour and Birth: Intrapartum Care

Summary of key results

• 74% of women rated the care they received in labour as excellent.
• 66% of women said that during their pregnancy they were given enough information about pain relief for labour and birth.
• 59% said they always had enough help to enable them to cope with their pain during labour.
• 73% of women were able to move around and choose a position that made them most comfortable during labour, only 32% give birth in an upright position.
• 84% of women said that if they raised concerns during labour these were always taken seriously and 77% of women who called for assistance during labour said that they always received it within a reasonable time.
• 83% of women said that all staff introduced themselves.
• 77% of women said that they were always involved enough in decisions about their care and 95% that their birth partner was always involved in their care as much as they wanted.
• 92% of women said that they had a period of skin to skin contact with their baby following birth.
• Women's comments indicated that they valued the support of skilled, supportive and confident staff who listened to their concerns, took time to give them explanations and involved them and their birth companions in decisions. Women were disappointed by staff who were dismissive of their concerns, in particular relating to uncertainty about whether labour had started.

Place of birth

3.1 As in the previous survey almost all women (98%) said that their baby was born in a hospital (Table 12) with only 1.3% of women having given birth at home. There was a slight decrease in the percentage of women who experienced a normal vaginal birth (Table 13) and a corresponding rise in the percentage of planned caesarean births compared to findings in 2013, mirroring the trend of increased planned caesarean births noted across Scotland (and in many other countries) over the last 15 years.

Table 12. Place of birth

Where was your baby born?
	2015
	% (n=1,821)	Confidence Interval
In hospital	98	(98.1 , 98.7)
At home	1	(1.2 , 1.5)
Other	0	(0.0 , 0.5)

Table 13. Type of birth

Thinking about the birth of your baby, what type of delivery did you have?
	2013		2015
	% (n=2,349)	Confidence Interval	% (n=2,023)	Confidence Interval
A normal vaginal delivery	56	(54.1 , 57.6)	53	(51.1 , 55.1)
An assisted vaginal delivery	14	(12.9 , 15.4)	14	(12.5 , 15.4)
A planned caesarean delivery	13	(12.1 , 14.6)	16	(14.3 , 17.3)
An emergency caesarean delivery	17	(15.3 , 18.0)	17	(15.7 , 18.8)

Care and support during labour and birth - support for normal birth

3.2 The provision of skilled supportive care is essential for all women throughout labour and birth regardless of setting. Safe and effective care during labour comprises not only the essential aspects of clinical monitoring of the health of mother and baby and of the progress of labour, but also involves providing the supportive and encouraging care necessary to help mothers to cope with childbirth. Women were asked about their experiences of care during labour and birth relating to supportive care, being treated with respect and dignity, communication with staff and involvement in decision making.

3.3 A fundamental aspect of high quality care during labour and birth is assisting women to cope with the pain that they experience, whether they choose a pharmacological method of pain relief such as pethidine, or epidural anaesthesia, or natural comfort methods such as massage or water. Two new questions in this year's survey asked women whether they felt that they were given enough help to cope with their pain during labour. Only 59% of women said that they always were, 29% said that they were most of the time and 12% said that they were not always given the help they needed. Experiences in this area varied by Health Board, with 69% of women in NHS Dumfries & Galloway saying that they always had enough help compared with 46% and 49% in NHS Ayrshire & Arran and NHS Forth Valley respectively (Table 14).

Table 14. Pain management for labour and birth

During your pregnancy, were you given enough information about the pain relief you could use when giving birth?
	2015
	% (n=1,646)	Confidence Interval
Yes, definitely	66	(64.1 , 68.5)
Yes, to some extent	27	(24.9 , 29.1)
No, but I would have found it useful	7	(5.5 , 7.8)
Did you feel that you had enough help to enable you to cope with your pain during labour?
	2015
	% (n=1,709)	Confidence Interval
Yes, always	59	(56.8 , 61.2)
Yes, most of the time	29	(27.1 , 31.2)
No	12	(10.4 , 13.4)

3.4 There is some research evidence that women should be encouraged and enabled to remain active during labour and to adopt more upright positions for birth^[7],[8], for example through the use of floor mats, birth balls and birthing pools. Women were asked if they were able to move around and choose the position in which they were most comfortable. The majority of women (73%) said that they were (Table 15) however a significant minority (27%) said they were only sometimes or not at all. As with the last survey, excluding women who gave birth by caesarean section, the majority of women said that they gave birth on a bed (87%) with only 10% choosing to give birth either on a floor mat or birth pool. As in the 2013 survey it appears that few women give birth in more upright positions and a majority appear to give birth while lying on their backs. Overall 27% said they gave birth lying flat or lying supported with pillows (as distinct from sitting supported by pillows) and a further 34% of women said that they gave birth lying with their legs in stirrups. While this group includes women who had an assisted vaginal birth (forceps or ventouse assisted birth), additional analysis of the unweighted survey data suggests that 32% of women who had a normal vaginal birth gave birth lying flat and a further 16% said they gave birth with their legs in stirrups.

Table 15. Mothers activity and position during labour and birth

During your labour, were you able to move around and choose the position that made you most comfortable?
	2013		2015
	% (n=1,738)	Confidence Interval	% (n=1,431)	Confidence Interval
Yes, most of the time	74	(72.2 , 76.0)	73	(70.4 , 75.0)
Yes, sometimes	20	(17.8 , 21.3)	21	(18.9 , 23.1)
No, not at all	6	(5.3 , 7.4)	6	(5.0 , 7.5)
Where did you give birth?
	2013		2015
	% (n=1,668)	Confidence Interval	% (n=1,401)	Confidence Interval
On a bed	88	(86.7 , 89.5)	87	(84.9 , 88.2)
On a mat on the floor	2	(1.6 , 2.9)	3	(2.2 , 3.8)
In a water or birthing pool	6	(5.1 , 7.1)	7	(5.6 , 8.1)
Other	4	(2.7 , 4.4)	4	(2.6 , 4.5)
What position were you in when your baby was born?
	2013		2015
	% (n=1,662)	Confidence Interval	% (n=1,389)	Confidence Interval
Sitting / sitting supported by pillows	19	(17.5 , 21.1)	17	(15.3 , 19.3)
On my side	7	(5.6 , 7.9)	5	(3.7 , 5.8)
Standing, squatting or kneeling	14	(12.7 , 15.8)	15	(13.1 , 16.5)
Lying flat / lying supported by pillows	26	(23.8 , 27.8)	27	(24.9 , 29.7)
Lying with legs in stirrups	31	(29.0 , 33.2)	34	(31.3 , 36.3)
Other	3	(2.0 , 3.4)	2	(1.4 , 2.8)

Trust and confidence in staff

3.5 For all women labour and birth is a time of increased vulnerability and all should receive care in an environment in which they feel safe and secure and in which their dignity is respected. There is good research evidence that continuous skilled support through labour and birth improves both health outcomes and women's experiences of birth^[9] . A positive finding was that the majority of women (81%) said that they were not left alone at any time when it concerned them during labour (Table 16). However, 19% said that they were left alone at some time when it concerned them and a few women reported being left alone at more than one time point. Of this 19%, most women said that they were left alone during early labour. However, 6% said that they were left alone in the later stages of labour and 2% said that they were left alone during the birth when this made them feel concerned.

Table 16. Being left alone during labour or birth

Were you (and/or your partner or a companion) left alone by midwives or doctors at a time when it worried you?
	2013		2015
	% (n=2,337)	Confidence Interval	% (n=2,036)	Confidence Interval
Yes, during early labour	10	(8.9 , 11.1)	9	(8.3 , 10.7)
Yes, during the later stages of labour	7	(5.7 , 7.6)	6	(5.1 , 7.0)
Yes, during the birth	1	(0.8 , 1.6)	2	(1.2 , 2.2)
Yes, shortly after the birth	6	(5.1 , 6.8)	5	(4.0 , 5.7)
No, not at all	80	(78.9 , 81.8)	81	(79.2 , 82.4)

3.6 Around half of women said that they raised a concern during labour and of those who did a large majority (84%) said that they felt their concerns were taken seriously (Table 17). However, of the women who said that they called for assistance while they were in labour almost one in four said that they only sometimes or did not receive assistance within what they considered to be a reasonable time. Women from the NHS Borders and NHS Dumfries & Galloway reported particularly positive experiences in this area.

Table 17. Raising concerns during labour and birth

If you raised a concern during labour and birth, did you feel that it was taken seriously?
	2013		2015
	% (n=1,331)	Confidence Interval	% (n=1,146)	Confidence Interval
Yes	84	(82.5 , 86.2)	84	(82.0 , 86.2)
No	16	(13.8 , 17.6)	16	(13.8 , 18.0)
When you called did you receive assistance within a reasonable time?
	2013		2015
	% (n=2,162)	Confidence Interval	% (n=1,670)	Confidence Interval
Yes, always	79	(77.0 , 80.1)	77	(74.8 , 78.8)
Yes, sometimes	17	(15.3 , 18.2)	17	(15.2 , 18.7)
No	5	(3.9 , 5.5)	6	(5.2 , 7.4)

3.7 In results very similar to those reported in 2013 the majority of women said that they definitely had trust and confidence in staff who cared for them during labour (Table 18) and birth, and 89% reported that they were always treated with respect and dignity (Table 19).

Table 18. Trust and confidence in staff during labour and birth

Did you have confidence and trust in the staff caring for you during your labour and birth?
	2013		2015
	% (n=2,338)	Confidence Interval	% (n=2,017)	Confidence Interval
Yes, definitely	83	(82.1 , 84.8)	83	(81.6 , 84.7)
Yes, to some extent	15	(13.2 , 15.8)	14	(12.6 , 15.4)
No	2	(1.5 , 2.5)	3	(2.2 , 3.5)

Table 19. Being treated with respect and dignity during labour and birth

Thinking about your care during labour and birth, were you treated with respect and dignity?
	2013		2015
	% (n=2,332)	Confidence Interval	% (n=2,014)	Confidence Interval
Yes, always	88	(86.7 , 89.1)	89	(87.6 , 90.2)
Yes, sometimes	10	(9.0 , 11.2)	9	(7.9 , 10.3)
No	2	(1.5 , 2.5)	2	(1.4 , 2.6)

Communication, information and involvement

3.8 Women are in general advised to contact a midwife or the maternity hospital when they think labour has begun and to remain at home until labour has become established; however there is considerable research highlighting the uncertainty that many women and their families feel about whether labour has started and when they should seek admission to hospital^[10] . The questionnaire contained one question about women's experience of contacting maternity services at the start of labour. The large majority of women (87%) reported that they were given appropriate advice and support at this time (Table 20) an increase from 85% in 2013.

Table 20. Contacting the hospital for advice at the start of labour

At the very start of your labour, did you feel that you were given appropriate advice and support when you contacted a midwife or the hospital?
	2013		2015
	% (n=1,835)	Confidence Interval	% (n=1,579)	Confidence Interval
Yes	85	(83.3 , 86.4)	87	(85.6 , 88.9)
No	15	(13.6 , 16.7)	13	(11.1 , 14.4)

3.9 NHS Scotland supports the campaign ' Hello my name is' (http://hellomynameis.org.uk/). The campaign aims to remind staff that it is a fundamental aspect of person centred and compassionate care that all staff introduce themselves properly to the women that they are caring for. The survey asked women whether all the staff caring for them during their labour and birth had introduced themselves and found that the majority of women said that they did. There does appear to be some scope for improvement in this simple aspect of care quality as 16% of women reported that not all staff introduced themselves (Table 21). This proportion was broadly similar across all Health Boards. However, almost all women (90%) said that they were always spoken to in a way that they could understand.

Table 21. Communication with staff during labour and birth

Did the staff caring for you introduce themselves?
	2013		2015
	% (n=2,310)	Confidence Interval	% (n=1,988)	Confidence Interval
Yes, all of the staff introduced themselves	81	(80.0 , 82.9)	83	(81.8 , 84.9)
Some of the staff introduced themselves	17	(15.4 , 18.2)	15	(13.9 , 16.9)
Very few or none of the staff introduced themselves	2	(1.2 , 2.2)	1	(0.8 , 1.7)
Thinking about your care during labour and birth, were you spoken to in a way you could understand?
	2013		2015
	% (n=2,337)	Confidence Interval	% (n=2,017)	Confidence Interval
Yes, always	89	(88.2 , 90.4)	90	(88.8 , 91.2)
Yes, sometimes	9	(8.1 , 10.3)	9	(7.9 , 10.3)
No	1	(1.1 , 1.9)	1	(0.5 , 1.3)

3.10 As in the 2013 survey almost all women (95%) said that their partner or someone else close to them was as involved in their care during labour and birth as they wanted (Table 22). However, almost one in four women were not always involved enough in decisions about their care. More women in NHS Borders and NHS Dumfries & Galloway said that they were involved enough, compared with those in other areas.

Table 22. Involvement and decision making during labour and birth

If your partner or someone else close to you was involved in your care during labour and birth, were they able to be involved as much as they wanted?
	2013		2015
	% (n=2,300)	Confidence Interval	% (n=1,982)	Confidence Interval
Yes	95	(94.0 , 95.6)	95	(94.3 , 96.1)
No	5	(4.4 , 6.0)	5	(3.9 , 5.7)
Thinking about your care during labour and birth, were you involved enough in decisions about your care?
	2013		2015
	% (n=2,287)	Confidence Interval	% (n=1,967)	Confidence Interval
Yes, always	78	(76.7 , 79.7)	77	(75.0 , 78.5)
Yes, sometimes	17	(15.9 , 18.7)	18	(16.7 , 19.9)
No	5	(3.7 , 5.3)	5	(4.1 , 5.9)

Skin to skin contact

3.11 A period of uninterrupted skin to skin contact between mother and baby immediately following birth is recommended to support bonding and attachment and as a precursor of breast feeding. Almost all women (92%) said that they had a period of skin to skin contact following birth (Table 23).

Table 23. Skin to skin contact following birth

Did you have skin to skin contact with your baby shortly after birth?
	2013		2015
	% (n=2,052)	Confidence Interval	% (n=1,781)	Confidence Interval
Yes	91	(89.3 , 91.7)	92	(90.5 , 92.9)
Yes, but I did not want this	1	(0.3 , 0.9)	0	(0.1 , 0.8)
No	9	(7.7 , 10.0)	8	(6.7 , 9.0)

Overall rating of care during labour and birth

3.12 Overall 74% of women rated their care in labour as excellent a further 19% saying that it was good. Notably, all of the women who responded from Dumfries & Galloway said that their care was good or excellent.

Chart 2 - Overall rating of care during labour and birth

What women said about their care during labour and birth

3.13 Overall 755 women commented on their experiences of labour and birth representing 37% of the total questionnaire sample. In line with the survey finding that 92% of women rated their overall care during labour and birth positively, a large number of women chose to make comments that were positive or had a significant positive element. Comments clearly highlighted the paramount importance of health care staff to women's experiences of labour and birth. Supportive and confident midwives and medical staff could make even the most difficult birth a positive experience, while staff who were perceived as less than compassionate or uncaring had a very negative impact upon women.

Care and support

3.14 Many women praised the competence and skill of the health professionals who had supported them during labour and birth; commenting in order to commend the midwives who supported them during the birth. Student midwives were also specifically mentioned by women as being a significant support. Qualities that were appreciated in midwifery staff included calmness, understanding, a sense of humour, and being able to create a sense for women of being 'in safe hands'.

'Our journey from husband and wife to mum and dad was made all the more special because of the midwives we met, they were outstanding. Some people choose the right vocation in life, the staff we met during my labour are definitely some of them'.

'The midwife I had during labour was excellent, I couldn't have asked for a better person to be with me. She was caring and really supportive and I felt safe and not afraid'.

3.15 Women appreciated continuity of care, and although they did not appear to expect this, where they knew the midwife or doctor who cared for them, or were supported by the same staff throughout the labour and birth this was described very positively.

'I had the same midwife that delivered my first baby and she was excellent, as were the staff working that night'.

'Had a student midwife with me during all stages of labour and she was fantastic'.

3.16 Some women had particularly appreciated the professionalism of the doctors who cared for them in hospital. Anaesthetists who were able to bring an air of calm to a surgical delivery were mentioned by a number or women, as were consultants who worked with the midwives to ensure a safe outcome for mother and baby.

'When being rushed along for an emergency section everything was explained to me by the anaesthetist and he explained everything to me every step by step during my section. I think this is what kept me calm all the way through'.

'I didn't want to follow the consultant proposed plan of inducing me via a drip after having had my waters broken. The midwife was brilliant in listening to me and helping me 'negotiate' with the consultant to safely agree a plan forward which resulted in me having an easy, natural water birth. The consultant was also helpful in listening and being flexible within what she felt were safe boundaries'.

3.17 Not all women had positive experiences and a number made specific comment on the way that they were treated by the staff caring for them during labour and birth. For some women the impact of the poor care they felt they had received from staff had a significant impact upon them and on their memories of giving birth.

'At one point there were too many people talking at me. A stressed midwife took over my care and I went from being in control to trying to escape from her! She was very aggressive and negative'.

3.18 A number of women commented that although their care overall was good or excellent, there were one or two staff who treated them less well or whose approach lacked professionalism.

'Most of the midwives did an excellent job. However, I feel one midwife was patronising and did not fully listen to when I requested specific pain relief'.

'Difficult to answer previous questions, as the first midwife I had was very set in their ways, patriarchal, showed their personal dislikes about some of my questions/preferences. Second midwife, however, was fantastic and listened to my wishes'.

Confidence and trust in staff

3.19 A number of women referred in their comments to the importance of having sufficient skilled health professionals available to assist them during labour and delivery.

'The staff were helpful and caring and knowledgeable. However they were clearly over worked and rushed, this led to many different staff coming in just briefly and no real continuity and little time. This was unfair as the staff who were trying their hardest to offer very good service'.

3.20 Women commented on the clinical skill and expertise of the health professionals caring for them in both negative and positive terms. Women were disappointed by their birth experience when staff had not inspired confidence in their ability to make good, timely decisions to ensure the well-being of mother and baby. Conversely a number of women commented that had it not been for the decisive actions of medical staff their babies' lives or their own lives may have been at risk.

'The nurses and doctors who helped with my labour and birth did more than an excellent job, they helped save my baby'.

Being left alone

3.21 A number of women made comment on the experience of being left alone in labour. The survey responses overall suggest that whilst most women were not left alone in labour at a time that worried them, around 20% of women were and the comments give some insight into the ways this affected women's experience of their care.

'We were left in the midwife unit for 6 hours alone. We were not even offered a glass of water. The midwife was all on her own, spread thinly'.

'My only issue was during early labour. There was only one midwife on duty at one point with three patients. We didn't see much of her and I felt I was left alone in the pool for too long'.

3.22 Some of the comments indicate that women felt that understaffing had a negative impact upon their labour or birth.

'The named midwife during my labour was fantastic but due to shortage of staff she was continually called out during birth, this happened on more than 20 occasions which heightened my stress levels

3.23 Striking the delicate balance between providing women with sufficient support to enable them to make their own choices when possible, and being a reassuring and constant presence when necessary was clearly appreciated. Some women had been grateful to have a midwife with them throughout their labour; other women had enjoyed being given space and time alone during labour, knowing that midwives were available when needed.

'Midwives during my labour were very helpful, caring and friendly. Me and my partner were left alone, because I asked for it and when I needed them back, we called them and they helped me to finish the birth. It was a beautiful experience'.

Communication and involvement in decision making

3.24 In many of the comments women refer to whether they were listened to by the medical professionals who cared for them during labour and birth. Some women felt that although they knew something was not right their intuitions or requests for assistance were disregarded by staff, to detrimental effect.

'I suffered a medical problem during labour and I expressed my pain and concerns that something was not quite right and nobody took me seriously. I was left alone twice during these times for over 1 hour while in pain with no pain relief offered at that point'.

'It was a few members of staff that made my experience traumatic. Had they not ignored me, I may not have had such a traumatic labour and my baby may have not got so distressed if they helped me when I was repeatedly asking for help'.

3.25 Other women indicated that their wishes or birth plan were not respected or followed by the medical staff caring for them or that as events unfolded they were not given sufficient time to make their views known, and be involved in decisions.

'Midwife carried out episiotomy, which I questioned at the time. Felt I was forced to say yes to it, as was quite a quick labour and couldn't really concentrate on what was going on. Felt midwife should have asked me a bit more about why I wasn't keen for it'.

Admission in to the labour ward

3.26 The less positive experiences and issues that women commented on were quite diverse. However there were some aspects of the intrapartum care experience that women had particularly strong views upon and these concerned the process of admission to the labour ward, and the experience of induction.

Care in Early Labour

3.27 A particular dichotomy in care experience highlighted by many women, was between the quality of care they received in early labour or pre-labour, and the care they received once they were admitted to the labour suite to have their babies. It is notable that women commented upon this issue across the whole range of experiences of early labour and pre-labour; whether they were induced in hospital, awaiting a planned surgical birth, at home wondering if they should be in hospital yet, or in the reception or triage area of the hospital awaiting admission to the labour ward.

Maternity Triage

3.28 In their comments about the process of gaining access to the hospital to have their babies, women often emphasised that once admitted to hospital the care they received was good or excellent. However the process of contacting the hospital, having their labour assessed, and waiting for space to labour and birth their babies was found to be very stressful for a large proportion of the women who chose to comment about this stage of their care. Staff working in triage areas were described less positively in the comments than staff on labour wards, and were viewed by a number of women as being disinterested, apathetic or even rude.

'Excellent care in labour suite, where I had baby. Early stages - telephoned unit who were very dismissive and patronising. Seen by them and again, dismissive until examined me. Made me feel like I was bothering them unnecessarily'.

'Labour ward was brilliant. It was stressful trying to get through triage to the labour ward and I was already very advanced in labour when we arrived there'.

3.29 Some women were disappointed that they were not listened to when they were confident in their knowledge of their own bodies, particularly if this was not their first pregnancy.

'When I called the hospital I was told to try a hot bath and paracetamol at home, but as it was my 3rd baby I did not feel this was appropriate so I decided to go to hospital. I'm glad I did because if I had listened to the advice I would have given birth in the bath!!'

3.30 One issue raised by a number of women was that they had to spend part of their labour in surroundings which were not helpful to the process of labour or that they felt were inappropriate for the stage of labour they were at.

'I was encouraged to sit in a waiting room and my baby was born 40 minutes later'.

'There was a bed shortage in the ward, so I spent my labour in a ward where mothers are induced. Had no gas and air until I was moved hours before baby was born. Was very stressful'.

Induction

3.31 A number of women commented about the process of having their labour induced in hospital. The majority of these comments were negative in nature although a few women commented that they felt well cared for and supported by staff.

'As I was induced my birth plan could not be followed to the letter for obvious reasons. My midwife made every effort to discuss the birth plan with me and explained reasons for doing things differently. She made it very personal and I am forever grateful for her contribution to a safe and happy delivery and labour'.

3.32 Women were particularly unhappy about having to go into labour without their partners present since hospital policy would not allow them to stay for an induction. Some women said that they felt that they had to deal with the early stages of a fast progressing labour alone, without the support of a partner or sufficient pain relief.

'My husband was not allowed in when I needed him the most which made me stressed and very upset'.

'I was induced.. My partner had to leave the hospital, it was a long and lonely night (and painful). I was only allowed to call him in when I was moved to the delivery room. Surely women should be allowed to have their partners there'.

Pain Relief

3.33 Timely access to adequate pain relief was an expectation that was not met for a considerable number of the women who provided comments, reflecting the findings of the questionnaire on this point. Some women felt that they had to wait too long for pain relief, others did not receive their chosen form of pain relief, either because of lack of appropriately trained staff, timing, or the unavailability of drugs or natural methods such as water birth.

'My previous labours had been really quick so I was desperate very early on for strong pain relief. Nobody seemed to be doing anything about that or believed that my contractions could be so strong so quickly. Eventually I received gas and air but I didn't get anything stronger quickly enough!'

'The only issue I met was that I was not able to get the epidural shortly after I arrived at the hospital, as the only anaesthetist, was not available, and I had to wait 3 hours 30 before getting it'.

3.34 Other women felt that their deliveries could have been more straightforward if they had been able given sufficient pain relief to cope with each stage.

'The midwife should have listened to my concerns and need for pain relief. I strongly believe an emergency C-section would have been avoided but their way was the only way! The medical team were great however'.

Being able to move around during labour

3.35 Relatively few women made comment upon their freedom to move and remain active in labour or to choose the position in which they gave birth. However there were some women who commented that they would have liked to have a more active labour and birth than was supported by hospital staff or that they were asked to lie down when this was not something they wanted to do.

'I arrived at hospital in what I knew were the late stages of labour but didn't feel as though I was taken seriously. The midwife insisted on me lying on my back to examine me when this was an incredibly uncomfortable position for me'.

'Was able to stand up/sit on ball in labour suite with first midwife but after shift change second midwife insisted on back with feet in stirrups, ….. Found pushing in this position very difficult and no explanation given as to why it was needed'.

3.36 There were however some women who felt they had been well supported to have the active birth they wanted.

'As I was induced early I was concerned about the process, however everyone was so supportive and informative. I was able to have a nice active birth and move as much as I could while being attached to the infusion and monitors. The labour midwife moved with me to make sure my monitors were in the right place'.

'I had the most positive birthing experience possible… My baby was born in the pool and I used Entonox for pain relief. My husband came in the pool and caught our baby. We were allowed home the same day. Staff were amazing I would do it all over again in a heartbeat!'