Transcript Perinatal Pain Management: An Update

Normalizing Birth
Judith A. Lothian, RN, PhD, LCCE
January 22, 2008
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
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
• 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
Cochrane Library Categories
• Beneficial
• Likely to be beneficial
• Trade-off
• Unknown
• Unlikely to be beneficial
• Harmful/ineffective
The Norm in US Births
• Intervention intensive
• Expecting trouble
• Fear related to safety and litigation
• Fear of pain
• Rising maternal deaths
• Rising cesarean rates
“Intervention Intensive”
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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)
The Simple Story of Birth
• Hormonal orchestration
• Role of pain
• Care practices that promote normal birth
• Care practices that sabotage normal birth
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)
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
At Birth
• High levels of oxytocin, endorphins,
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•
catecholamines
Mother alert and interested
Baby alert, eager, able to find the breast and self
attach
The Culmination of Normal Birth
Promoting, Protecting, Supporting
Normal Birth
• Labor starts and continues on its own
• Freedom of movement
• Labor support
• Non-supine positions for birth
• No separation of mother and baby
Labor
Begins
on its
Own
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
ACOG Medical Indications for Induction
• SROM without labor
• Post-dates (42 completed weeks; 294
days)
• Hypertension
• Health problems (uncontrolled diabetes)
• Chorioamnionitis
• IUGR
Perinatal Mortality (per 1000) According to Weeks of Gestation
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37
38
39
40
41
42
43
44
Weeks
Weeks
Weeks
Weeks
Weeks
Weeks
Weeks
Weeks
17
6
4
3
2.5
3
5
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 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
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
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
• Cochrane Library systematic review (Hodnett, et al,
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2007)
CIMS:Evidence-Basis for the Ten Steps of MotherFriendly Care (Leslie & Storton, 2007)
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Decreased requests for pain medication
More positive reports of birth experience
Breastfeed for longer duration
More likely to give birth vaginally
Freedom of
Movement
Throughout
Labor
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
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
Non-Supine
Positions
for Birth
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
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
Cochrane Library
• Second stage starts with spontaneous
pushing
• No arbitrary time limits
• No evidence to support the value of
directed pushing
Guidelines for Pushing
• Encourage spontaneous bearing-down
• Discourage prolonged breath holding
• Support rather than direct maternal efforts
• Encourage women to change positions
frequently
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)
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
No
Routine
Interventions
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
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.
Cochrane Guidelines
• Routine intravenous 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
ACOG Guidelines on EFM
“Obstetric practitioners may use intermittent
auscultation rather than continuous EFM”
ACOG (2005)
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
Epidurals
• Lower rate of spontaneous vaginal delivery (8 RCTs, 27 observational
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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).
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)
Epidurals and Breastfeeding
• Not widely studied
• Mixed results
• Jordan et al (2005) yes
• Beilin et al (2005) yes
• Chang & Heamon (2005) no
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
Opiates
• 2 systematic reviews, 48 trials
• Problems with power and designs
• Opiates may aggravate gastric acid secretion,
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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
Opiates and the Neonate
• No RCTs
• Observational studies suggest:
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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
No Separation of Mother and Baby
Cochrane Library
• Routine restriction of mother-infant
contact is harmful.
• Separate only for a compelling medical
indication (Enkin et al, 2000)
• Cochrane Library (2003)
Listening to Mothers (2006)
• More than half the babies were separated
from their mothers
• 39% separated for ‘routine’ care
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.
Infant benefits
• Physiologic stability
• Reduced time to effective latch
• Increased breastfeeding duration
• Less crying
• 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
• Lack of knowledge
• Restrictive hospital policies
• Patience
Evidence-Based Resources
• Lamaze Institute for Normal Birth
(www.lamaze.org/institute/)
Childbirth Connection (www.childbirthconnection.org)
Cochrane Library (www.cochrane.org)
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• 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)
(www.motherfriendly.org)
• The Official Lamaze Guide: Giving Birth with Confidence
(Lothian and DeVries, 2005)
Care Practice Position Papers
• Written for parents
• Available at www.lamaze.org (download)
• Journal of Perinatal Education 16 (3)
September 2007 (on-line at Ingenta and
free)