The Birth Process Mamie Guidera, CNM, MSN Carol O’Donoghue, CNM, MSN, MPH.
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Transcript The Birth Process Mamie Guidera, CNM, MSN Carol O’Donoghue, CNM, MSN, MPH.
The Birth Process
Mamie Guidera, CNM, MSN
Carol O’Donoghue, CNM, MSN, MPH
Normal Labor and birth:
Objectives
Introductions
Physiologic labor and birth: the basics
Phases of labor
Birth video
The P’s: Power, passageway, passenger, etc.
Briefs:
American birth & (some of the) influences:
Where births take place
Cultural expectations of pain management
A word on Fetal Monitoring
Here’s the truth:
Childbirth is not only a physiologic phenomenon, but a cultural/sociological
experience. So before you walk onto the Labor Floor, ask yourself:
o
Where/how did you first learn about how a baby is born? What do
you know about your own birth?
o
Who (family member, friends, healthcare provider) or what (your
medical training, book, television show, movie) has influenced your
perception of labor? What birth stories come to your mind first?
o
Is there such a thing as “good” pain? If you are an athlete, have
you ever sought out physical discomfort? Why?
o
Have you ever been in pain? How did you deal with it?
o
What do you think is the role of the healthcare provider in birth?
Birth in the United States
Site of birth
Hospital
Birth Center
Home
Model of birth
Medical Model
Midwifery Model
Stages of Labor
First stage: early, active, transition
Dilatation
Second stage
Pushing and birth
Third stage
Delivery of placenta
Fourth stage
Postpartum
Birth Video
Observe stages and phases of labor
Observe Maternal Behaviors!
What is “normal” labor?
An introduction
True vs False Labor:
Williams Obstetrics (22nd edition)
True Labor:
Contractions occur at
regular intervals
Intensity gradually
increases
Discomfort is in the
back and abdomen.
Cervix dilates.
Discomfort is not
stopped by sedation
Contractions are
irregular
Intensity remains the
same
No cervical dilatation
Discomfort relieved
by sedation
Length of first stage labor in healthy nulliparous
and multiparous childbearing women
adapted from Albers L. (2007)
bold = nullips, italics = multips
Mean (hrs)
95th percentile (hrs)
Friedman (1978)
4.1
8.5
Kilpatrick & Laros
(1989)
8.1
16.6
Albers, Schiff &
Gorwoda (1996)
7.7
19.4
Albers (1999)
7.7
17.5
Friedman (1978)
2.4
7.0
Kilpatrick & Laros
(1989)
5.7
12.5
Albers (1996)
5.7
13.7
Albers (1999)
5.6
13.8
Physiological Preparation for Labor
What are the signs
and symptoms of
impending labor?
Bishop’s Score
Position
Consistency
Effacement
Dilatation
Fetal station and part
Importance of
cervical status
Initiation of Labor
Theoretical
Maternal factors
Progesterone
Estrogen
Oxytocin
Prostaglandin
Psyche
Fetal factors
Fetal cortisol
Artificial
Cervical exam
Stripping of
membranes
Prostaglandins
Artificial rupture of
membranes
Sex
Nipple Stimulation
You tube!- dilatation and the
cardinal movements
http://www.youtube.com/watch?v=Xath6
kOf0NE&feature=PlayList&p=6603A45DF8
1B89A9&index=38&playnext=2&playnext
_from=PL
• http://www.youtube.com/watch?v
=Xath6kOf0NE&feature=PlayList&p
=6603A45DF81B89A9&index=38&
playnext=2&playnext_from=PL
Early or Latent Phase, Active
phase, Transition…
Dilatation
Effacement
Cervix
Station
Contraction pattern
Membranes
Duration
What are the
characteristics of
each?
What are frequent
maternal behaviors?
Pain management?
The Ps of Labor
Woman/Fetus
Power
Passageway
Passenger
Position
Psyche
Providers/Support Persons:
Patience
Persistence
Practice/ Pain Relief
Psyche
Power: Influences
Uterine force
Nutrition and fluids
Rest/Fatigue
Power: Contractions
Passageway
Soft tissues
Cervix
Vagina
Perineum
Cervical Examination:
examining the passageway
Dilatation
Effacement
Station
Position
Consistency
Presenting part
Status of membranes
The Passage
Pelvic Bones and Pelvimetry
The Passage
Pelvic Bones and Pelvimetry
Passenger
Size of passenger
Number of passengers
Position of passenger:
Presentation
Lie
Passenger: Attitude
Passenger: Presentation
Passenger
Descent
Fetal head journey through the pelvis
until Crowning
Flexion
Fetal head tucks into chest
Important so that smallest diameter of head presents
May depend on pelvic type/shape
Passenger: Station
Engagement
AKA “dropping” or “lightening”
At the level of ischial spines = 0 station
Above ischial spines
-5 to -1
-5 = unengaged
Below ischial spines
+1 to +5
+5 = crowning
Passenger: Cardinal
Movements
http://www.youtube.com/watch?v=Xath6
kOf0NE&feature=PlayList&p=6603A45DF8
1B89A9&index=38&playnext=2&playnext
_from=PL
Engagement – ischial spines
Descent Flexion Internal rotation- OT to OA
Extension Restitution- baby head realigns with body
External rotation
Expulsion – the body
Passenger: Presentation
The Passenger
Fontanelles and Sutures
Passenger
Passenger: Lie
Passenger: Position
The relationship of a site of the
presenting part to the location on
maternal pelvis
Examples: LOA, ROP, RMT, LSA, etc.
Asyncliticism: lateral deflection of the
head with regards to the sagittal suture
Anterior or posterior
Position: Fetal and
Maternal
Most common position for labor and birth?
Best position for labor and birth?
Worst position for labor and birth?
…..think mother and baby
Psyche
Woman giving birth
Knowledge
Fear
Support
Trust
Self
Provider
Beliefs, values, culture
Health care provider
Support person(s)
Family
Friend
Doula
…let’s talk about this…
Second Stage of Labor
From 10 cm to birth
of baby
Pushing or expulsion
Contraction pattern
Duration
Birth
Perineal management
(keep your hands off
Mirror
Ask mother to feel
the baby’s head
Stay focused on
woman, not tasks
Third Stage of Labor
Birth of the placenta
5 to 30 minutes….or more
Signs of placental separation
Inspection
A word on Active Management of Third
Stage
Pitocin and prevention of postpartum
hemorrhage
Two Methods of Third Stage
Management
Physiologic (“expectant”) management
Oxytocics are not used
Placenta is delivered by gravity and maternal effort
Cord is clamped after delivery of the placenta
Active Management
Oxytocic is given
[Cord is clamped]
Placenta delivered by controlled cord traction (CCT) with
counter-traction on the fundus
Fundal massage after delivery of placenta
Part II:
Reality & modern hospital birth: pain management,
monitoring, interference with physiologic birth
Physiology of labor pain: First stage
o Uterine contractions:
o Myometrial ischemia
Causes release of potassium, bradykinin, histamin, serotonin
o Distention of lower uterine segments and cervix
o Stimulates mechanorecoptors
Impulses follow sensory-nerve fibers from paracervical and
hypogastric plexus to lumbar sympathetic chain
Enter dorsal horn of spinal cord at T10-12, L1
Pain pathways during labor: Late
first and Second stage
o Transition associated with greater nocioceptive
input related to increased somatic pain from
vaginal distention
o Distention of vagina, perineum, pelvic floor,
stretching of pelvic ligaments
o Pain signal transmitted to spinal cord via S2-S4
(includes pudendal nerve)
Pain Management in Active
Labor
Walking/Movement
Hydrotherapy
Back Rubs
Birth Ball, toilet
Maternal Preference
Analgesia/ Anesthesia
Others?
hydrotherapy
One-on-One Labor Support:
the evidence
If a doula was a
drug, it would be
considered
unethical not to
give it.” John
Kennell, MD
Continuous Labor Support
o Non-medical care by a trained
person
o Different definitions/criteria
depending on studies:
o “minimum of 80%” presence
o presence “without interruption, except
for toileting”
o Various terms: doula, labor
assistant, birth companion,
monitrice
o May refer to husband or untrained
female companion
Kennell J, Klaus M, McGrath S, Robertson S,
Hinkley C. Continuous Emotional Support During
Labor in a US Hospital: A Randomized Controlled
Trial. JAMA, May 1991; 265: 2197 - 2201.
•616 women
•Three arms: supported (doula), observed,
control groups
•Outcomes studied: epidural use, duration of
labor, oxytocin use, prolonged infant
hospitalization and maternal fever all
significantly less with supported group
•More spontaneous birth with supported
group
Hodnett, ED et al (2007). Continuous support for
women during childbirth (Review). Cochrane Database
of Systematic Reviews 2007, Issue 3. Art No.: CD 003766.
16 trials, all RCTS
o 13,391 women
o Women with CLS were:
o
o
o
o
Less likely to have regional anesthesia
Less likely to have any analgesia/anesthesia
Less likely to have an operative delivery
Less likely to report dissatisfaction and low leves
of control with the CB experience
o Less likely to use EFM
o …and were more likely to have a shorter
labor length and a spontaneous vaginal
birth.
Continuous Labor Support: Mechanism of Action from Hodnett (2007)
Positive impact
of
companionship
on mom
Mitigates
potentially
harsh
environment
Negative
experiences
may impede
labor
Negative
experiences may
impede adjustment
to motherhood
Physiologic
impact of
continuous
labor support
Mobility
encouraged by
support
person
Support
person
decreases
anxiety of mom
fetopelvic
relationship
is enhanced
stress hormones
(epinephrine)
may be
reduced
woman
uses
gravity &
position changes
fewer
abnormal
FHR
patterns
preserves
uterine
contractility
ways of
Placement of Anesthetics for Labor Pain
Eltzschig H et al. N Engl J Med 2003;348:319-332
Epidurals: how do they contribute to
prolonged labor or dx of labor dystocia, if at
all?
Length of labor
First stage labor not impacted
Studies do not uniformly look at or control for
confounding factors such as rate of dilation or rates of
spontaneous labor
Length of second stage longer
General agreement
Malpresentation
3 RCTs, 2 observational studies: significant
findings, significant crossover in RCTs
Lieberman & O’Donoghue, Am J Obstet Gynecol 2002, 186(5):S31-S68.
Leighton& Halpern Am J Obstet Gynecol 2002, 186(5):S69-77.
Monitoring for fetal well-being: the
evidence
Monitoring FHR: a short history
1600s:
Marsac of France describes the sound of FHTs
Marsac’s colleague Phillipe LeGaust mentions FHTS in a poem
Kilian proposes that FHTs be used to dx fetal distress and when a clinician
should intervene
1800s:
1818: auscultation via maternal abdomen helps dx fetal viability and fetal
lie
1893: VonWinckel defines criteria for fetal distress that remained
unchanged until the 1960s
Gabbe (2002), 4th Ed.
Monitoring FHR: a short history
1958
American Edward Hon (“father of EFM”) reports on instantaneous FHR recording
Hon collaborated with Calderyo-Barcia (Uruguay) and Hammacher (Germany) to
describe patterns that would diagnose fetal distress
1968:
Benson et al: review of 24,000 cases of auscultation and outcomes; determined that
“there was no reliable indicator of fetal distress in terms of FHR save in extreme
degree.”
Late 1960s: first commercially available electronic FHR monitor available
By late 1970s EFM used in most American labor and delivery units
By 1978, 66% of women EFM used during their labors
In 2002, 85% of labors included EFM
Gabbe (2002), 4th Edition; Williams (2005), 22nd Edition
Original Assumptions of EFM
Electronic fetal heart rate monitoring provided accurate
information
The information was of value in diagnosing fetal distress
It would be possible to intervene to prevent fetal death or
morbidity
Continuous electronic fetal heart rate monitoring was
superior to intermittent methods
Williams Obstetrics (2005), 22nd Edition
Monitoring FHR: the evidence
1968:
Benson et al: review of 24,000 cases of auscultation and outcomes;
determined that “there was no reliable indicator of fetal distress in terms of
FHR save in extreme degree.”
Thacker et al (2005) reported in the Cochrane Database (18,561
pregnancies):
Prevention of neonatal seizures
No prevention of cerebral palsy
Abnormal neurological outcomes not higher in infants managed by
intermittent auscultation vs. continuous EFM (CEFM)
Monitoring FHR: a short history
Thacker’s report now replaced by Alfirevic (2006; >37,000
women):
Seizures decreased; rare outcome 1/500 births
No increase in cerebral palsy, infant mortality “or other
standard measures of neonatal well-being”
Increase in cesarean section and instrumental deliveries
Limits movement of women during labor
CEFM may also mean that “some resources tend to be focused
on the needs of the CTG rather than the women in labour.”
Gabbe (2002), 4th Ed.; Williams (2005), 22nd Edition
Actual Outcomes of Widespread
EFM Use
By 1994, Symonds writes that 70% of obstetrical litigation
related to fetal brain damage is related to purported
abnormalities on the EFM tracing
Significant interobserver and intraobserver variability
Studies published prior to NICHD and after guidelines
(1982-2003)
Increase rate of Cesarean Section delivery
Increase use of Vacuum and Forceps
No reduction in perinatal mortality
Incidence of neonatal seizures significantly decreased
No reduction in cerebral palsy
ACOG Practice Bulletin 70 (2005); Williams (2005), 22nd Ed.
EFM vs Intermittent Auscultation (IA)
Research does not support one modality over the other
Most studies comparing the two were only conducted in low risk
patients; Alfirecvic (2006) did include patients receiving oxytocin
ACOG Practice Bulletin 70 (2005) states:
“Those with high-risk conditions (eg, suspected fetal growth restriction,
preeclampsia, and type 1 diabetes should be monitored continuously).”
Current USPSTF Guideline (1996 to present):
Routine intrapartum EFM not recommended
Insufficient evidence regarding its routine use in high risk pregnancies
http://www.ahrq.gov/clinic/uspstf/uspsiefm.htm Accessed 6/30/08
Oxytocin Augmentation
Clark SL, Simpson KR, Knox GE, Garite T.
Oxytocin: new perspectives on an old drug. Am J
Obstet Gynecol 2009;200:35.e1-35.e6
.
We know of no other area of medicine in which
a potentially dangerous drug is administered to
hasten the completion of a physiologic process
that would, if left to its own devices, usually
complete itself without incurring the risk of drug
administration. Yet the administration of
oxytocin is often undertaken under precisely
these circumstances when labor is electively
induced or Braxton-Hicks contractions are
electively augmented.”
Medicalization of labor:
Parkland, Texas
The challenge is, can you provide
vigilance without intervention….
Don’t just stand there.
Do nothing!”
Questions & Comments?