Download Birth Never Changes

Overview of today’s presentation
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Two main approaches to maternity care
How these affect outcomes for mother and baby
Conclusions regarding normalcy of birth today
The doula’s role in normalizing birth
Birth Never Changes
• Throughout time, in all
countries & cultures, the
physiologic process of birth
is the same as it has always
been.
Canadian Task Force:
“What is Normal Birth?”
• Natural means “existing or derived
from nature; not made, caused by, or
processed by humankind.*
Childbirth is ‘natural’ if there is little
or no human intervention.”
Birth Today– Two Approaches
• Birth as Nature Intended
▫ Psychophysiologic (“mind-body”)
Management
• Industrialized (Medicalized) Birth
▫ “obstetric package”
Psychophysiologic Management
• Designed to maintain and enhance the woman’s
resources for giving birth
▫ Psychological
▫ Physiological
• Based on these premises
▫ Woman’s state of mind influences labor process
▫ Her participation increases good outcomes
▫ Low intervention and cesarean rates are
desirable
Industrialized
(Medicalized)
Management
• Designed to replace or alter the body’s own
resources with med/tech interventions
• Gives more control over the birth process
• Based on these premises
▫ The normal process is unreliable or unsafe
▫ Overall, outcomes are improved with a package of
routine interventions
▫ Requires less skill for difficult births, easier to teach
▫ Inductions, cesareans are no worse and may be
better for mother or baby than normal birth
What Price are We Paying?
• As cesarean and induction (without
medical indication) rates rise, key
indicators of quality care worsen--
Original intention – to improve outcomes
Now that it has become “usual care,” are
outcomes improving?
What is “Normal Birth?”
• Defined by physiology?
▫ The “physiological norm” does not change.
• Defined by typical care practices – the
“statistical norm?”
▫ Changes constantly, with geography, culture,
and institution
• Is this association causal or
coincidental?
▫ Influenced by new knowledge, technology,
societal trends
• If epidural rate is 85%, it is the norm, but
is it normal?
Why is the distinction
important?
• The physiological norm -- standard against
which all care practices must be measured.
▫ How and how much is the normal process altered?
▫ How are outcomes affected?
▫ What are the tradeoffs?
• Maternity services can be rated by how
closely they adhere to principles of
physiological birth.
A 2011 report of insurance billing records for 2008
Childbirth Connection’s Analysis
Childbirth Connection’s conclusions
• “Complicating conditions” high rates of minor or
modifiable risk factors and preventable
coomplications
• High prevalence of diagnoses based on
unreliable screening tests or subjective clinical
judgment
• Caused by overuse of questionable medical
procedures (induction, C/S, episiotomy
• Payment tied to number or procedures –
incentive to dx high risk & disincentive to
promote health and prevention
• Our current Maternity Care payment and
reporting system causes misleading and inflated
views of risks of childbearing
• See Childbirth Connection’s “Blueprint for
Action: Steps toward a High-Quality High-Value
Maternity Care System
http://transform.childbirthconnection.org/blue
print.
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How does place of birth affect labor?
• A “safe” undisturbed environment supports
spontaneous behavior and facilitates
secretion of oxytocin (“love hormone”)
• A strange environment with invasive noisy
equipment is disturbing and may increase
anxiety and catecholamine production
Compare usual “medicalized practices
with “physiologically normal” practices
▫ Interferes with effects of oxytocin
▫ Slowed labor, adverse fetal response
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How does the caregiver affect labor?
• Midwifery:
▫ Fewer costly, risky interventions
▫ Attention to women’s psychosocial needs
▫ Better outcomes for selected populations
• Obstetrics:
▫ A surgical specialty
▫ Appropriate for high risk situations
▫ Less personal care, more reliance on tests and
technology
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How does the way labor begins affect
labor?
• Spontaneous – ensures fetus’s readiness for
life outside mother’s uterus
• Elective induction increases
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Late term prematurity
NICU admissions, mother-baby separation
Labor time in hospital
Cesareans for fetal distress, failed induction in
nullips
▫ Postpartum hemorrhage
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How does continuous support affect
labor?
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How does hydration affect labor?
• Continuous doula support increases
• Intravenous hydration may lead to—
▫ Spontaneous vaginal birth
▫ Maternal satisfaction with birth
▫ Psychological well-being
▫ Inconvenience and discomfort for mother
▫ Fluid overload, hyponatremia, foot and hand
swelling that lasts for days
▫ Mother feeling deprived of basic comfort
• Continuous doula support decreases
• Drinking her choice of liquids
▫ Pain medications use
▫ Surgical delivery (cesareans, instruments)
▫ NICU admissions
▫ Enhances sense of normalcy for mother
▫ Usually adequate in normal labor
• Caution: Too much oral fluid can lead to fluid
overload and prolonged labor….
• “Usual care” – just the opposite
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How does care of the amnionic sac affect
labor?
How does type of monitoring affect labor?
• Electronic fetal monitoring associated with
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• Artificial rupture of membranes (ROM)-
More C/S for non-reassuring FH Tracings
No improvements in newborn outcomes**
Restrictions of mother’s activity
Inability of cg to auscultate FHT
▫ May speed labor (by average 40 min.)
▫ May cause a pre-existing fetal malposition to
become persistent
▫ Increases chance of infection
• Spontaneous ROM
• Auscultation is less disturbing to the mother,
and
• Auscultation has as good outcomes as EFM
▫ Usually occurs late in 1st stage or in 2nd
▫ May enhance chance of rotation to OA
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How do pain & medications affect
labor?
• Suffering may increase likelihood of trauma
and PTSD
• Narcotics ineffective and unpleasant
• Epidural reduces pain, but not suffering;
• Is invasive and unsafe without precautions
and interventions
• Side effects –
▫ low blood pressure, fever, fetal malposition and
distress, urine retention, slow progress
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How do positions and movement affect
labor?
• Supine position or restriction of movement
▫ Increases dystocia, malposition, pain, fetal
distress, maternal stress
• Freedom of movement and choice of position
▫ Increases comfort, decreases above effects
▫ Enhances maternal satisfaction
▫ Some studies find shorter labors
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How do pushing positions affect labor?
• Supine position (most common in NA)
▫ Narrows birth canal, increases effort needed to
birth baby
▫ Increases vacuum, forceps deliveries
▫ Increases pelvic floor damage, episiotomy
▫ Prolongs 2nd stage
• Non-supine positions & mother’s choice
▫ Increase chance for spontaneous birth
▫ Reduce pelvic floor damage
▫ Increase mother’s satisfaction
How does perineal care affect birth?
• Routine episiotomy
▫ More 3rd and 4th degree lacerations
▫ Prolonged postpartum pain & healing
▫ No benefit to mother or baby, except rarely
• Avoidance of episiotomy
▫ 30 – 50% intact perinea
▫ If combined with non-supine positions and
spontaneous bearing down, few long-term pelvic
floor problems
▫ Less pain, faster healing
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How do pushing techniques affect
labor?
• Prolonged breath holding & straining
▫ Increases fetal distress
▫ Increases pelvic floor damage
▫ Increases long-term problems of pelvic floor
relaxation
• Delayed or spontaneous bearing down
▫ More intact perinea & spontaneous births
▫ Fewer 3rd & 4th degree tears
▫ Improved fetal well-being
How does surgical birth affect
outcomes?
• May prevent serious problems for mother or baby
• Sometimes necessitated by earlier interventions
• V-E/ forceps
▫ Damage to mother’s perineum
▫ Swelling, bruising of baby
• Cesarean
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All the risks of major abdominal surgery
Increased maternal problems in future childbearing
Prolonged time required for neonatal adaptation
Prolonged maternal recovery
Delayed or compromised mother-infant interaction
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How does natural birth affect
outcomes?
• To mother
▫ Hormonal enhancement of positive maternal feelings &
behaviors
▫ Usually quicker recovery time
• To baby
▫ Optimal condition at birth (no need to recover from
medications, procedures)
• To both
▫ Mutual regulation between mother and baby
 Temperature
 Breastfeeding
• To family
▫ Ready and able to adjust to their new roles together
▫ JOY!!!
How does timing of cord clamping
affect baby?
• Immediate clamping & cutting
▫ Enables removal of baby to warmer,
▫ Doesn’t prevent jaundice, as believed
• Delaying clamping for 2 min. or more
▫ Allows physiologic transfusion of blood between
baby and placenta
▫ Improves infant hematologic status at 2 and 6
months (i.e., less anemia)
▫ Encourages close mother-infant contact
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How do the first days after birth affect
mother and baby?
• Mother and baby together promotes
▫ Establishment of “on cue” breastfeeding
▫ Mutual regulation of temperature
▫ Maternal behavior
• Father-baby skin-to-skin contact in first day
and after promotes protectiveness and
closeness toward baby
• Separation increases newborn distress and
maternal depression or detachment
World Health Organization criteria for
normal birth
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Spontaneous onset, 37-42 wks
Low risk at start & remaining so
Spontaneous birth of vertex
Mother & baby in good condition
• “Normal birth” – a diagnosis made in
retrospect
Numerous definitions. . .
(We’ll focus on two definitions)
What is Normal Labor?
(cont.)
•Gould (midwife) adds to WHO:
▫ Labor and birth involves strenuous
physical work by mother,
▫ Includes movement by mother (seeking
comfort & progress), and
▫ Movement by fetus through the birth
canal
•“Movement and the notion of hard
work are crucial to a midwifery
understanding of normal labor.”
--D. Gould, J Adv Nurs, 2000
Psychosocial Outcomes of Normal
Labor (Gould)
• A healthy mother and baby who are ready to
adjust together to their new roles;
• Empowerment of the woman
• Sense of achievement from her own productive
efforts and her ACTIVE control (rather than
passive role) in the birth.
Supporting & Preserving Normal Birth
• Besides playing the role proven to be effective
in improving outcomes…
• Model confidence in the physiological process,
not a sense of urgency or need to control it.
Watch before acting.
▫ Patience and confidence: “Babies come out:”
Help her accept her labor pattern. “Labor
unfolds at its own pace.”
• Easier said than done. . .
Supporting & Preserving Normal Birth
Supporting & Preserving Normal Birth
 Think of your own practice. Do you
 Feed or lead her desire to start labor?
 Urge her to keep moving, changing positions, to
hasten labor, even if progress is occurring?
 Suggest bath to stop labor that begins at night?
 Do you suggest that labor may not be
proceeding normally with words or actions?
 Are you uncomfortable not “doing something?”
• We mustn’t rush the woman or the process, as
long as mother and baby are doing well.
• This does not mean that we never intervene
with suggestions, encourage activity
• Guidance, not commands or management
• It means we are relaxed and patient, because
this reinforces her confidence
▫ We are not controlling or authoritative,
unless we really need to be
▫ When there’s a deadline or a problem, then
we act!
“How Normal is Birth Today?”
The Normal Birth Supporter’s
Motto
If it ain’t broke,
don’t fix it!
Conclusions
• What will be the impact on the human species if
giving birth and being born are removed from
the life cycle?
• Does it matter?
• Rarely do women have normal births in
the countries of North America or in
most other countries.