Normalizing BirthNormalizing BirthJudith A. Lothian, RN, PhD, Judith A. Lothian, RN, PhD,

LCCELCCEJanuary 22, 2008January 22, 2008

What is normal birth?What is normal birth?• Physiologic labor and birthPhysiologic labor and birth• The natural process of labor and The natural process of labor and

birth birth • The unfolding of labor and birth as The unfolding of labor and birth as

nature designed the processnature designed the process

What is evidence-based What is evidence-based care?care?““Evidence-based care means using the Evidence-based care means using the

best research about the effects of best research about the effects of specific procedures, drugs, tests and specific procedures, drugs, tests and treatments to help guide decision treatments to help guide decision making” making”

Maternity Center Association, Maternity Center Association, 20002000

MethodologyMethodology• Cochrane LibraryCochrane Library• A Guide to Effective Care in Pregnancy A Guide to Effective Care in Pregnancy

and Childbirth (2000) and Childbirth (2000) Enkin et al.Enkin et al. • Systematic reviews: Systematic reviews: Nature and Nature and

Management of Labor Pain; Evidence Management of Labor Pain; Evidence Basis for the Ten Steps of Mother-Basis for the Ten Steps of Mother-Friendly Care (CIMS)Friendly Care (CIMS)

• Peer-reviewed journalsPeer-reviewed journals

Cochrane Library CategoriesCochrane Library Categories• BeneficialBeneficial• Likely to be beneficialLikely to be beneficial• Trade-offTrade-off• UnknownUnknown• Unlikely to be beneficialUnlikely to be beneficial• Harmful/ineffectiveHarmful/ineffective

The Norm in US BirthsThe Norm in US Births• Intervention intensiveIntervention intensive• Expecting troubleExpecting trouble• Fear related to safety and litigationFear related to safety and litigation• Fear of painFear of pain• Rising maternal deathsRising maternal deaths• Rising cesarean ratesRising 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 Restrictions movement ((75%),75%), eating (85%) drinking (57%)eating (85%) drinking (57%)• Epidural (71% of vaginal births)Epidural (71% of vaginal births)• Urinary catheter (43%)Urinary catheter (43%)• Instrument delivery Instrument delivery (39%)/(39%)/episiotomy episiotomy (25%)(25%)• Cesarean (32%)Cesarean (32%)

Listening to Mothers (2006)Listening to Mothers (2006)

The Simple Story of BirthThe Simple Story of Birth• Hormonal orchestrationHormonal orchestration• Role of painRole of pain• Care practices that promote normal Care practices that promote normal

birthbirth• Care practices that sabotage normal Care practices that sabotage normal

birthbirth

The Role of Pain in Labor and The Role of Pain in Labor and BirthBirth• Provides the alarm that brings supportProvides the alarm that brings support• Provides a guide for finding comfortProvides a guide for finding comfort• Promotes the progress of laborPromotes the progress of labor• Protects mother and babyProtects mother and baby

Lothian (1999), Lowe (2002), Buckley (in press)Lothian (1999), Lowe (2002), Buckley (in press)

Hormonal OrchestrationHormonal OrchestrationLabor and Birth Labor and Birth

• Oxytocin Oxytocin • Beta-endorphinsBeta-endorphins• CatecholaminesCatecholamines

Buckley, S. (2002) Ecstatic birth. Buckley, S. (2002) Ecstatic birth. Mothering. Mothering. 111, 51-61.111, 51-61.Buckley, S. (in press). Normal Physiologic Birth. NY: Childbirth ConnectionBuckley, S. (in press). Normal Physiologic Birth. NY: Childbirth Connection

At BirthAt Birth• High levels of oxytocin, endorphins, High levels of oxytocin, endorphins,

catecholaminescatecholamines• Mother alert and interestedMother alert and interested• Baby alert, eager, able to find the breast Baby alert, eager, able to find the breast

and self attachand self attach

The Culmination of Normal BirthThe Culmination of Normal Birth

Promoting, Protecting, Promoting, Protecting, SupportingSupporting

Normal Birth Normal Birth • Labor starts and continues on its ownLabor starts and continues on its own• Freedom of movementFreedom of movement• Labor supportLabor support• Non-supine positions for birthNon-supine positions for birth• No separation of mother and babyNo separation of mother and baby

Labor Begins on its Own

Labor Starts on its ownLabor Starts on its own• Baby is readyBaby is ready• Cervix soft, ripeCervix soft, ripe• Uterus sensitive to oxytocinUterus sensitive to oxytocin• Hormonal orchestra has warmed up Hormonal orchestra has warmed up

and is ready to begin the and is ready to begin the performanceperformance

ACOG Medical Indications for ACOG Medical Indications for Induction Induction • SROM without laborSROM without labor• Post-dates (42 completed weeks; 294 Post-dates (42 completed weeks; 294

days)days)• HypertensionHypertension• Health problems (uncontrolled diabetes)Health problems (uncontrolled diabetes)• ChorioamnionitisChorioamnionitis• IUGRIUGR

Perinatal Mortality (per 1000) According to Weeks of Perinatal Mortality (per 1000) According to Weeks of GestationGestation

• 37 Weeks37 Weeks 1717• 38 Weeks38 Weeks 6 6• 39 Weeks39 Weeks 4 4• 40 Weeks 40 Weeks 3 3• 41 Weeks 41 Weeks 2.5 2.5• 42 Weeks 42 Weeks 3 3• 43 Weeks 43 Weeks 5 5• 44 Weeks 44 Weeks 4 4

Campbell (1997) Campbell (1997) Obstetrics and GynecologyObstetrics and Gynecology

Induction for PostdatesInduction for Postdates““The induction of labor prior to 41 weeks of gestation The induction of labor prior to 41 weeks of gestation

is associated with increased cesarean delivery is associated with increased cesarean delivery rates.” rates.” ACOG (2000) ACOG (2000) Evaluation of Cesarean DeliveryEvaluation of Cesarean Delivery

““A policy of routine induction at 40-41 weeks in A policy of routine induction at 40-41 weeks in normal pregnancy cannot be justified in the light of normal pregnancy cannot be justified in the light of the evidence from controlled trials.”the evidence from controlled trials.”

Enkin et al (2000) Enkin et al (2000) A Guide to Effective Care in A Guide to Effective Care in Pregnancy Pregnancy and Childbirthand Childbirth

Risks of Premature BirthRisks of Premature Birth• Babies born at 32-33 weeks 6x more Babies born at 32-33 weeks 6x more

likely to die in first yearlikely to die in first year• Babies born at 34-36 weeks 3x more Babies born at 34-36 weeks 3x more

likely to die in the first yearlikely to die in the first year

Kramer (2000) JAMAKramer (2000) JAMA

Induction for MacrosomiaInduction for Macrosomia““Induction of labor for suspected Induction of labor for suspected

macrosomia does not improve macrosomia does not improve outcome, expends considerable outcome, expends considerable resources, and may increase the resources, and may increase the cesarean rate.”cesarean rate.”

ACOG (2000)ACOG (2000)

Continuous Labor

Support

Labor SupportLabor Support• 9 prospective, controlled studies9 prospective, controlled studies• Cochrane Library systematic review (Hodnett, et Cochrane Library systematic review (Hodnett, et

al, 2007)al, 2007)• CIMS:Evidence-Basis for the Ten Steps of Mother-CIMS:Evidence-Basis for the Ten Steps of Mother-

Friendly Care (Leslie & Storton, 2007)Friendly Care (Leslie & Storton, 2007)

• Decreased requests for pain medicationDecreased requests for pain medication• More positive reports of birth experienceMore positive reports of birth experience• Breastfeed for longer durationBreastfeed for longer duration• More likely to give birth vaginallyMore likely to give birth vaginally

Freedom of Movement

Throughout Labor

Maternal movement and Maternal movement and positioningpositioning• 14 prospective, controlled studies14 prospective, controlled studies• CIMS systematic review (2007)CIMS systematic review (2007)• Women as own controls in 7 studiesWomen as own controls in 7 studies• NO trial compares freedom of NO trial compares freedom of

movement to restricted movementmovement to restricted movement• No harm from freedom of movementNo harm from freedom of movement

Benefits of freedom of Benefits of freedom of movementmovement

• Less use of pain medicationLess use of pain medication• Less need for oxytocinLess need for oxytocin• Some positions help rotate the baby Some positions help rotate the baby

(hands and knees/lunge)(hands and knees/lunge)• Contraction intensity and efficiency Contraction intensity and efficiency

greater in standing or side-lyinggreater in standing or side-lying

Non-Supine Positions

for Birth

Birth in non-supine positionsBirth in non-supine positions• Routine use of supine position in second Routine use of supine position in second

stage is stage is harmful harmful ((Enkin et al, 2000)Enkin et al, 2000)• Respecting women’s choice of position Respecting women’s choice of position

for second stage of labor for second stage of labor is likely to be is likely to be beneficial.beneficial.

• Cochrane Library (Gupta et al, 2004)Cochrane Library (Gupta et al, 2004)

• Listening to Mothers Listening to Mothers (2006) 92% supine(2006) 92% supine

Benefits of the non-supine Benefits of the non-supine positionposition• Enlarges pelvic diametersEnlarges pelvic diameters• Reduces length of second stageReduces length of second stage• Reduces need for episiotomyReduces need for episiotomy• Reduction in assisted deliveriesReduction in assisted deliveries• Less severe painLess severe pain• Fewer abnormal fetal heart rate Fewer abnormal fetal heart rate

patternspatterns

Cochrane LibraryCochrane Library• Second stage starts with Second stage starts with

spontaneous pushing spontaneous pushing • No arbitrary time limitsNo arbitrary time limits• No evidence to support the value of No evidence to support the value of

directed pushingdirected pushing

Guidelines for PushingGuidelines for Pushing• Encourage spontaneous bearing-Encourage spontaneous bearing-

downdown• Discourage prolonged breath holdingDiscourage prolonged breath holding• Support rather than direct maternal Support rather than direct maternal

effortsefforts• Encourage women to change Encourage women to change

positions frequentlypositions frequently

Laboring Down Laboring Down • Wait until mother feels urge to pushWait until mother feels urge to push• Delayed pushing is not associated Delayed pushing is not associated

with adverse outcomeswith adverse outcomes• Delayed pushing is an effective Delayed pushing is an effective

strategy to reduce difficult deliveries.strategy to reduce difficult deliveries.

(Hanson, 2002; Fraser, 2000; McCartney, 1998)(Hanson, 2002; Fraser, 2000; McCartney, 1998)

What Sabotages Normal What Sabotages Normal BirthBirth• Intervention Intensive labor and birthIntervention Intensive labor and birth

Restrictions on eating and drinkingRestrictions on eating and drinkingContinuous electronic fetal monitoringContinuous electronic fetal monitoring

Routine use of intravenousRoutine use of intravenousEpidurals and other medicationEpidurals and other medication

No Routine

Interventions

Why no intravenous?Why no intravenous?• Life threatening emergencies rareLife threatening emergencies rare• IVs do not provide nutrition or energyIVs do not provide nutrition or energy• IVs restrict movement IVs restrict movement • Fluid overload contributes to Fluid overload contributes to

engorgement, artificially high birth engorgement, artificially high birth weightsweights

Why eat and drink?Why eat and drink?• Maintain energy reservesMaintain energy reserves• ComfortComfort• Avoid fluid overload and Avoid fluid overload and

fluid/electrolyte imbalancesfluid/electrolyte imbalances• General anesthesia rarely used. If it General anesthesia rarely used. If it

is used the airway is protected.is used the airway is protected.

Cochrane GuidelinesCochrane Guidelines• Routine intravenous is Routine intravenous is unlikely to be unlikely to be

beneficialbeneficial

• Withholding food and drink from Withholding food and drink from women in labor is women in labor is unlikely to be unlikely to be beneficialbeneficial

Electronic Fetal MonitoringElectronic Fetal Monitoring• Routine use related to increase in Routine use related to increase in

cesarean with no difference in cesarean with no difference in outcome for babyoutcome for baby

ACOG Guidelines on EFMACOG Guidelines on EFM““Obstetric practitioners may use Obstetric practitioners may use

intermittent auscultation rather than intermittent auscultation rather than continuous EFM”continuous EFM”

ACOG (2005)ACOG (2005)

Speeding Labor UpSpeeding Labor Up• Stronger, longer, more painful Stronger, longer, more painful

contractionscontractions• No endorphin releaseNo endorphin release• Need for IV, and continuous EFMNeed for IV, and continuous EFM• Restrictions on movement/comfortRestrictions on movement/comfort• More likely to need an epiduralMore likely to need an epidural

EpiduralsEpidurals• Lower rate of spontaneous vaginal delivery (8 RCTs, 27 Lower rate of spontaneous vaginal delivery (8 RCTs, 27

observational studiesobservational studies• Higher rate of instrumental vaginal delivery (10 RCTs, 27 Higher rate of instrumental vaginal delivery (10 RCTs, 27

observational studies)observational studies)• Longer labors, particularly in nulliparous women (8 RCTs, 27 Longer labors, particularly in nulliparous women (8 RCTs, 27

observational studies)observational studies)• More likely to have intrapartum fever (2RCTs and 6 observational More likely to have intrapartum fever (2RCTs and 6 observational

studiesstudies• 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 Lieberman, E., and O’Donoghue, C. (2002) Unintended effects of epidural analgesia during labor: A systematic review. labor: A systematic review. American Journal of Obstetrics and GynecologyAmerican Journal of Obstetrics and Gynecology. Vol.86, . Vol.86, No. 5No. 5

Anim-Somuah, Smyth & Howell (2006) Epidural versus non-epidural or no analgesia in Anim-Somuah, Smyth & Howell (2006) Epidural versus non-epidural or no analgesia in labour. labour. Cochrane Reviews.Cochrane Reviews.

Goer, Leslie, & Romano (2007) Evidence basis for the ten steps of mother-friendly care. Goer, Leslie, & Romano (2007) Evidence basis for the ten steps of mother-friendly care. Journal of Perinatal Education, Journal of Perinatal Education, 16 (1S).16 (1S).

Epidurals and Infant Epidurals and Infant OutcomesOutcomes• Increased rate of sepsis work-ups – Increased rate of sepsis work-ups –

maternal fevermaternal fever• 1.5 to 2.0 fold increase in 1.5 to 2.0 fold increase in

hyperbilirubinemia– mechanism not hyperbilirubinemia– mechanism not clearclear

• NBAS – some evidence that state NBAS – some evidence that state control affected for first days, may be control affected for first days, may be less alert and less mature in motor less alert and less mature in motor function for first month (mixed results)function for first month (mixed results)

Epidurals and BreastfeedingEpidurals and Breastfeeding• Not widely studiedNot widely studied• Mixed resultsMixed results• Jordan et al (2005) yesJordan et al (2005) yes• Beilin et al (2005) yes Beilin et al (2005) yes • Chang & Heamon (2005) noChang & Heamon (2005) no

Labor Analgesia & IBFAT Labor Analgesia & IBFAT ScoresScores• No medication 11No medication 11• IV opioids 8IV opioids 8• Epidural 8.5Epidural 8.5• IV opioids & Epidural 7IV opioids & Epidural 7

Riordan et al (2000) Riordan et al (2000) Journal of Journal of Human Human LactationLactation

OpiatesOpiates• 2 systematic reviews, 48 trials2 systematic reviews, 48 trials• Problems with power and designsProblems with power and designs• Opiates may aggravate gastric acid secretion, Opiates may aggravate gastric acid secretion,

contribute to respiratory alkalosis in mothercontribute to respiratory alkalosis in mother• No effect on length of labor, interventionsNo effect on length of labor, interventions

Bricker, L and Lavender, T. (2002) Parenteral opioids for labor pain Bricker, L and Lavender, T. (2002) Parenteral opioids for labor pain relief: A systematic review. relief: A systematic review. American Journal of Obstetrics and American Journal of Obstetrics and Gynecology. 186, 5Gynecology. 186, 5

Opiates and the NeonateOpiates and the Neonate• No RCTsNo RCTs• Observational studies suggest:Observational studies suggest:

neonatal respiratory depression neonatal respiratory depression decreased neonatal alertnessdecreased neonatal alertness inhibition of sucklinginhibition of suckling lower neurobehavioral scoreslower neurobehavioral scores delay in effective feedingdelay in effective feeding• Demerol half life in neonate is 15-23 hoursDemerol half life in neonate is 15-23 hours• Opiates best given more than three hours, or less Opiates best given more than three hours, or less

than one hour before deliverythan one hour before delivery

No Separation of Mother and No Separation of Mother and BabyBaby

Cochrane LibraryCochrane Library• Routine restriction of mother-infant Routine restriction of mother-infant

contact is contact is harmfulharmful..

• Separate only for a compelling Separate only for a compelling medical indication (medical indication (Enkin et al, 2000)Enkin et al, 2000)

• Cochrane Library (2003) Cochrane Library (2003)

Listening to Mothers (2006)Listening to Mothers (2006)• More than half the babies were More than half the babies were

separated from their mothersseparated from their mothers• 39% separated for ‘routine’ care39% separated for ‘routine’ care

Maternal benefits of non-Maternal benefits of non-separationseparation• Enhances maternal confidenceEnhances maternal confidence• Improves breastfeeding outcomesImproves breastfeeding outcomes• Enhances attachmentEnhances attachment• Stimulates oxytocin and endorphin Stimulates oxytocin and endorphin

releaserelease that reinforce mothering feelings, keep that reinforce mothering feelings, keep

mother calm, and help keep her baby mother calm, and help keep her baby warm.warm.

Infant benefits Infant benefits • Physiologic stabilityPhysiologic stability• Reduced time to effective latchReduced time to effective latch• Increased breastfeeding durationIncreased breastfeeding duration• Less cryingLess crying• Decreased exposure to infectionDecreased exposure to infection

What we Can Learn from What we Can Learn from NatureNatureAs is normal with As is normal with

gorillas, almost seven gorillas, almost seven week old baby week old baby Mashudu has not been Mashudu has not been out of his mother’s out of his mother’s arms since his birth.arms since his birth.

What gets in the way of using What gets in the way of using best evidence in practice?best evidence in practice?• Personal beliefsPersonal beliefs• Lack of knowledgeLack of knowledge• Restrictive hospital policiesRestrictive hospital policies• PatiencePatience

Evidence-Based Evidence-Based ResourcesResources• Lamaze Institute for Normal Birth Lamaze Institute for Normal Birth

(www.lamaze.org/institute/)(www.lamaze.org/institute/)• Childbirth Connection (Childbirth Connection (www.childbirthconnection.orgwww.childbirthconnection.org))• Cochrane Library (Cochrane Library (www.cochrane.org)www.cochrane.org)• A Guide to Effective Care in Pregnancy and A Guide to Effective Care in Pregnancy and

Childbirth Childbirth (Enkin et al, 2000)(Enkin et al, 2000)• The Evidence Basis for the Ten Steps of Mother-The Evidence Basis for the Ten Steps of Mother-

Friendly Care (2006) Friendly Care (2006) Coalition for Improving Coalition for Improving Maternity Services. Maternity Services. Journal of Perinatal Journal of Perinatal Education, Education, 16, 1 (S)16, 1 (S) (www.motherfriendly.org) (www.motherfriendly.org)

• The Official Lamaze Guide: Giving Birth with The Official Lamaze Guide: Giving Birth with Confidence Confidence (Lothian and DeVries, 2005)(Lothian and DeVries, 2005)

Care Practice Position Care Practice Position PapersPapers• Written for parentsWritten for parents• Available at Available at www.lamaze.orgwww.lamaze.org

(download)(download)• Journal of Perinatal Education Journal of Perinatal Education 16 (3) 16 (3)

September 2007 (on-line at Ingenta September 2007 (on-line at Ingenta and free)and free)