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

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

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

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

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

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

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

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

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

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

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

The Culmination of Normal Birth The Culmination of Normal Birth

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

Labor Begins on its Own

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

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

Perinatal Mortality (per 1000) According to Weeks of Gestation 37 Weeks17 37 Weeks17 38 Weeks 6 38 Weeks 6 39 Weeks 4 39 Weeks 4 40 Weeks 3 40 Weeks 3 41 Weeks Weeks Weeks 3 42 Weeks 3 43 Weeks 5 43 Weeks 5 44 Weeks 4 44 Weeks 4 Campbell (1997) Obstetrics and Gynecology

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 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

Risks of Premature Birth Risks of Premature Birth Babies born at weeks 6x more likely to die in first year Babies born at weeks 6x more likely to die in first year Babies born at weeks 3x more likely to die in the first year Babies born at weeks 3x more likely to die in the first year Kramer (2000) JAMA

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

Continuous Labor Support

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

Freedom of Movement Throughout Labor

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

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

Non-Supine Positions for Birth

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

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

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

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

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

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

No Routine Interventions

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

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

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

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

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

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

Epidurals Lower rate of spontaneous vaginal delivery (8 RCTs, 27 observational studies Lower rate of spontaneous vaginal delivery (8 RCTs, 27 observational studies Higher rate of instrumental vaginal delivery (10 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) Longer labors, particularly in nulliparous women (8 RCTs, 27 observational studies) More likely to have intrapartum fever (2RCTs and 6 observational studies More likely to have intrapartum fever (2RCTs and 6 observational studies Increases cesarean, particularly in nulliparous women 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).

Epidurals and Infant Outcomes Increased rate of sepsis work-ups – maternal fever Increased rate of sepsis work-ups – maternal fever 1.5 to 2.0 fold increase in hyperbilirubinemia– mechanism not clear 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) 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)

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

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

Opiates 2 systematic reviews, 48 trials 2 systematic reviews, 48 trials Problems with power and designs Problems with power and designs Opiates may aggravate gastric acid secretion, contribute to respiratory alkalosis in mother Opiates may aggravate gastric acid secretion, contribute to respiratory alkalosis in mother No effect on length of labor, interventions 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

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

No Separation of Mother and Baby

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

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

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

Infant benefits Physiologic stability Physiologic stability Reduced time to effective latch Reduced time to effective latch Increased breastfeeding duration Increased breastfeeding duration Less crying Less crying Decreased exposure to infection Decreased exposure to infection

What we Can Learn from Nature As is normal with gorillas, almost seven week old baby Mashudu has not been out of his mother’s arms since his birth.

What gets in the way of using best evidence in practice? Personal beliefs Personal beliefs Lack of knowledge Lack of knowledge Restrictive hospital policies Restrictive hospital policies Patience Patience

Evidence-Based Resources Lamaze Institute for Normal Birth ( Lamaze Institute for Normal Birth ( Childbirth Connection ( Childbirth Connection ( Cochrane Library ( Cochrane Library ( A Guide to Effective Care in Pregnancy and Childbirth (Enkin et al, 2000) A Guide to Effective Care in Pregnancy and Childbirth (Enkin et al, 2000) The Evidence Basis for the Ten Steps of Mother-Friendly Care (2006) Coalition for Improving Maternity Services. Journal of Perinatal Education, 16, 1 (S) ( The Evidence Basis for the Ten Steps of Mother-Friendly Care (2006) Coalition for Improving Maternity Services. Journal of Perinatal Education, 16, 1 (S) ( The Official Lamaze Guide: Giving Birth with Confidence (Lothian and DeVries, 2005) The Official Lamaze Guide: Giving Birth with Confidence (Lothian and DeVries, 2005)

Care Practice Position Papers Written for parents Written for parents Available at (download) Available at (download) Journal of Perinatal Education 16 (3) September 2007 (on-line at Ingenta and free) Journal of Perinatal Education 16 (3) September 2007 (on-line at Ingenta and free)