Normalizing Birth

1. Normalizing Birth Judith A. Lothian, RN, PhD, LCCE January 22, 2008

3. What is normal birth? • Physiologic labor and birth • The natural process of labor and birth • The unfolding of labor and birth as nature designed the process

4. What is evidence-based care? “Evidence-based care means using the best research about the effects of specific procedures, drugs, tests and treatments to help guide decision making” Maternity Center Association, 2000

5. Methodology • Cochrane Library • A Guide to Effective Care in Pregnancy and Childbirth (2000) Enkin et al. • Systematic reviews: Nature and Management of Labor Pain; Evidence Basis for the Ten Steps of Mother-Friendly Care (CIMS) • Peer-reviewed journals

6. Cochrane Library Categories • Beneficial • Likely to be beneficial • Trade-off • Unknown • Unlikely to be beneficial • Harmful/ineffective

7. The Norm in US Births • Intervention intensive • Expecting trouble • Fear related to safety and litigation • Fear of pain • Rising maternal deaths • Rising cesarean rates

8. “Intervention Intensive” • Induction (41%)/Augmentation (55%) • Intravenous (80%) • EFM (94% continuously) • Restrictions movement (75%),eating (85%) drinking (57%) • Epidural (71% of vaginal births) • Urinary catheter (43%) • Instrument delivery (39%)/episiotomy (25%) • Cesarean (32%) Listening to Mothers (2006)

9. The Simple Story of Birth • Hormonal orchestration • Role of pain • Care practices that promote normal birth • Care practices that sabotage normal birth

10. The Role of Pain in Labor and Birth • Provides the alarm that brings support • Provides a guide for finding comfort • Promotes the progress of labor • Protects mother and baby Lothian (1999), Lowe (2002), Buckley (in press)

11. Hormonal Orchestration Labor and Birth • Oxytocin • Beta-endorphins • Catecholamines Buckley, S. (2002) Ecstatic birth. Mothering. 111, 51-61. Buckley, S. (in press). Normal Physiologic Birth. NY: Childbirth Connection

12. At Birth • High levels of oxytocin, endorphins, catecholamines • Mother alert and interested • Baby alert, eager, able to find the breast and self attach

13. The Culmination of Normal Birth

14. Promoting, Protecting, SupportingNormal Birth • Labor starts and continues on its own • Freedom of movement • Labor support • Non-supine positions for birth • No separation of mother and baby

15. Labor Begins on its Own

16. Labor Starts on its own • Baby is ready • Cervix soft, ripe • Uterus sensitive to oxytocin • Hormonal orchestra has warmed up and is ready to begin the performance

17. ACOG Medical Indications for Induction • SROM without labor • Post-dates (42 completed weeks; 294 days) • Hypertension • Health problems (uncontrolled diabetes) • Chorioamnionitis • IUGR

18. Perinatal Mortality (per 1000) According to Weeks of Gestation • 37 Weeks 17 • 38 Weeks 6 • 39 Weeks 4 • 40 Weeks 3 • 41 Weeks 2.5 • 42 Weeks 3 • 43 Weeks 5 • 44 Weeks 4 Campbell (1997) Obstetrics and Gynecology

19. Induction for Postdates “The induction of labor prior to 41 weeks of gestation is associated with increased cesarean delivery rates.” ACOG (2000) Evaluation of Cesarean Delivery “A policy of routine induction at 40-41 weeks in normal pregnancy cannot be justified in the light of the evidence from controlled trials.” Enkin et al (2000) A Guide to Effective Care in Pregnancy and Childbirth

20. Risks of Premature Birth • Babies born at 32-33 weeks 6x more likely to die in first year • Babies born at 34-36 weeks 3x more likely to die in the first year Kramer (2000) JAMA

21. Induction for Macrosomia “Induction of labor for suspected macrosomia does not improve outcome, expends considerable resources, and may increase the cesarean rate.” ACOG (2000)

22. Continuous Labor Support

23. Labor Support • 9 prospective, controlled studies • Cochrane Library systematic review (Hodnett, et al, 2007) • CIMS:Evidence-Basis for the Ten Steps of Mother-Friendly Care (Leslie & Storton, 2007) • Decreased requests for pain medication • More positive reports of birth experience • Breastfeed for longer duration • More likely to give birth vaginally

24. Freedom of Movement Throughout Labor

25. Maternal movement and positioning • 14 prospective, controlled studies • CIMS systematic review (2007) • Women as own controls in 7 studies • NO trial compares freedom of movement to restricted movement • No harm from freedom of movement

26. Benefits of freedom of movement • Less use of pain medication • Less need for oxytocin • Some positions help rotate the baby (hands and knees/lunge) • Contraction intensity and efficiency greater in standing or side-lying

27. Non-Supine Positions for Birth

28. Birth in non-supine positions • Routine use of supine position in second stage is harmful (Enkin et al, 2000) • Respecting women’s choice of position for second stage of labor is likely to be beneficial. • Cochrane Library (Gupta et al, 2004) • Listening to Mothers (2006) 92% supine

29. Benefits of the non-supine position • Enlarges pelvic diameters • Reduces length of second stage • Reduces need for episiotomy • Reduction in assisted deliveries • Less severe pain • Fewer abnormal fetal heart rate patterns

30. Cochrane Library • Second stage starts with spontaneous pushing • No arbitrary time limits • No evidence to support the value of directed pushing

31. Guidelines for Pushing • Encourage spontaneous bearing-down • Discourage prolonged breath holding • Support rather than direct maternal efforts • Encourage women to change positions frequently

32. Laboring Down • Wait until mother feels urge to push • Delayed pushing is not associated with adverse outcomes • Delayed pushing is an effective strategy to reduce difficult deliveries. (Hanson, 2002; Fraser, 2000; McCartney, 1998)

33. What Sabotages Normal Birth • Intervention Intensive labor and birth Restrictions on eating and drinking Continuous electronic fetal monitoring Routine use of intravenous Epidurals and other medication

34. No Routine Interventions

35. Why no intravenous? • Life threatening emergencies rare • IVs do not provide nutrition or energy • IVs restrict movement • Fluid overload contributes to engorgement, artificially high birth weights

36. Why eat and drink? • Maintain energy reserves • Comfort • Avoid fluid overload and fluid/electrolyte imbalances • General anesthesia rarely used. If it is used the airway is protected.

37. Cochrane Guidelines • Routine intravenous is unlikely to be beneficial • Withholding food and drink from women in labor is unlikely to be beneficial

38. Electronic Fetal Monitoring • Routine use related to increase in cesarean with no difference in outcome for baby

39. ACOG Guidelines on EFM “Obstetric practitioners may use intermittent auscultation rather than continuous EFM” ACOG (2005)

40. Speeding Labor Up • Stronger, longer, more painful contractions • No endorphin release • Need for IV, and continuous EFM • Restrictions on movement/comfort • More likely to need an epidural

41. Epidurals • Lower rate of spontaneous vaginal delivery (8 RCTs, 27 observational studies • Higher rate of instrumental vaginal delivery (10 RCTs, 27 observational studies) • Longer labors, particularly in nulliparous women (8 RCTs, 27 observational studies) • More likely to have intrapartum fever (2RCTs and 6 observational studies • Increases cesarean, particularly in nulliparous women Lieberman, E., and O’Donoghue, C. (2002) Unintended effects of epidural analgesia during labor: A systematic review. American Journal of Obstetrics and Gynecology. Vol.86, No. 5 Anim-Somuah, Smyth & Howell (2006) Epidural versus non-epidural or no analgesia in labour. Cochrane Reviews. Goer, Leslie, & Romano (2007) Evidence basis for the ten steps of mother-friendly care. Journal of Perinatal Education, 16 (1S).

42. Epidurals and Infant Outcomes • Increased rate of sepsis work-ups – maternal fever • 1.5 to 2.0 fold increase in hyperbilirubinemia– mechanism not clear • NBAS – some evidence that state control affected for first days, may be less alert and less mature in motor function for first month (mixed results)

43. Epidurals and Breastfeeding • Not widely studied • Mixed results • Jordan et al (2005) yes • Beilin et al (2005) yes • Chang & Heamon (2005) no

44. Labor Analgesia & IBFAT Scores • No medication 11 • IV opioids 8 • Epidural 8.5 • IV opioids & Epidural 7 Riordan et al (2000) Journal of Human Lactation

45. Opiates • 2 systematic reviews, 48 trials • Problems with power and designs • Opiates may aggravate gastric acid secretion, contribute to respiratory alkalosis in mother • No effect on length of labor, interventions Bricker, L and Lavender, T. (2002) Parenteral opioids for labor pain relief: A systematic review. American Journal of Obstetrics and Gynecology. 186, 5

46. Opiates and the Neonate • No RCTs • Observational studies suggest: neonatal respiratory depression decreased neonatal alertness inhibition of suckling lower neurobehavioral scores delay in effective feeding • Demerol half life in neonate is 15-23 hours • Opiates best given more than three hours, or less than one hour before delivery

47. No Separation of Mother and Baby

48. Cochrane Library • Routine restriction of mother-infant contact is harmful. • Separate only for a compelling medical indication (Enkin et al, 2000) • Cochrane Library (2003)

49. Listening to Mothers (2006) • More than half the babies were separated from their mothers • 39% separated for ‘routine’ care

50. Maternal benefits of non-separation • Enhances maternal confidence • Improves breastfeeding outcomes • Enhances attachment • Stimulates oxytocin and endorphin release that reinforce mothering feelings, keep mother calm, and help keep her baby warm.