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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:

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The Birth Process

Mamie Guidera, CNM, MSN

Carol O’Donoghue, CNM, MSN, MPH


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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


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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:

  • Where/how did you first learn about how a baby is born? What do you know about your own birth?

  • 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?

  • Is there such a thing as “good” pain? If you are an athlete, have you ever sought out physical discomfort? Why?

  • Have you ever been in pain? How did you deal with it?

  • What do you think is the role of the healthcare provider in birth?


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Birth in the United States

  • Site of birth

    • Hospital

    • Birth Center

    • Home

  • Model of birth

    • Medical Model

    • Midwifery Model


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Stages of Labor

  • First stage: early, active, transition

    • Dilatation

  • Second stage

    • Pushing and birth

  • Third stage

    • Delivery of placenta

  • Fourth stage

    • Postpartum


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Birth Video

  • Observe stages and phases of labor

  • Observe Maternal Behaviors!



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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


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Length of first stage labor in healthy nulliparous and multiparous childbearing womenadapted from Albers L. (2007)bold = nullips, italics = multips


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What are the signs and symptoms of impending labor? multiparous childbearing women

Bishop’s Score

Position

Consistency

Effacement

Dilatation

Fetal station and part

Importance of cervical status

Physiological Preparation for Labor


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Theoretical multiparous childbearing women

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

Initiation of Labor


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You tube!- dilatation and the cardinal movements multiparous childbearing women

http://www.youtube.com/watch?v=Xath6kOf0NE&feature=PlayList&p=6603A45DF81B89A9&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


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Dilatation multiparous childbearing women

Effacement

Cervix

Station

Contraction pattern

Membranes

Duration

What are the characteristics of each?

What are frequent maternal behaviors?

Pain management?

Early or Latent Phase, Active phase, Transition…


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Woman/Fetus multiparous childbearing women

Power

Passageway

Passenger

Position

Psyche

Providers/Support Persons:

Patience

Persistence

Practice/ Pain Relief

Psyche

The Ps of Labor


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Power: Influences multiparous childbearing women

  • Uterine force

  • Nutrition and fluids

  • Rest/Fatigue


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Power: Contractions multiparous childbearing women


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Passageway multiparous childbearing women

  • Soft tissues

    • Cervix

    • Vagina

    • Perineum


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Cervical Examination: examining the passageway multiparous childbearing women

  • Dilatation

  • Effacement

  • Station

  • Position

  • Consistency

  • Presenting part

  • Status of membranes


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The Passage multiparous childbearing womenPelvic Bones and Pelvimetry


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The Passage multiparous childbearing womenPelvic Bones and Pelvimetry


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Passenger multiparous childbearing women

  • Size of passenger

  • Number of passengers

  • Position of passenger:

    • Presentation

    • Lie


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Passenger: Attitude multiparous childbearing women


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Passenger: Presentation multiparous childbearing women


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Passenger multiparous childbearing women

  • 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


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Passenger: Station multiparous childbearing women

  • 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


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Passenger: Cardinal Movements multiparous childbearing women

  • http://www.youtube.com/watch?v=Xath6kOf0NE&feature=PlayList&p=6603A45DF81B89A9&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


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Passenger: Presentation multiparous childbearing women


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The Passenger multiparous childbearing womenFontanelles and Sutures


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Passenger multiparous childbearing women


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Passenger: Lie multiparous childbearing women


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Passenger: Position multiparous childbearing women

  • 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


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Position: Fetal and Maternal multiparous childbearing women

  • Most common position for labor and birth?

  • Best position for labor and birth?

  • Worst position for labor and birth?

  • …..think mother and baby


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Health care provider multiparous childbearing women

Support person(s)

Family

Friend

Doula

…let’s talk about this…

Woman giving birth

Knowledge

Fear

Support

Trust

Self

Provider

Beliefs, values, culture

Psyche


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From 10 cm to birth of baby multiparous childbearing women

Pushing or expulsion

Contraction pattern

Duration

Second Stage of Labor


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Perineal management multiparous childbearing women

(keep your hands off

Mirror

Ask mother to feel the baby’s head

Stay focused on woman, not tasks

Birth


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Third Stage of Labor multiparous childbearing women

  • 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


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Two Methods of Third Stage Management multiparous childbearing women

  • 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


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Part II: multiparous childbearing womenReality & modern hospital birth: pain management, monitoring, interference with physiologic birth


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Physiology of labor pain: First stage multiparous childbearing women

  • Uterine contractions:

    • Myometrial ischemia

      Causes release of potassium, bradykinin, histamin, serotonin

  • Distention of lower uterine segments and cervix

    • 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


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Pain pathways during labor: Late first and Second stage multiparous childbearing women

  • Transition associated with greater nocioceptive input related to increased somatic pain from vaginal distention

  • Distention of vagina, perineum, pelvic floor, stretching of pelvic ligaments

    • Pain signal transmitted to spinal cord via S2-S4 (includes pudendal nerve)


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Walking/Movement multiparous childbearing women

Hydrotherapy

Back Rubs

Birth Ball, toilet

Maternal Preference

Analgesia/ Anesthesia

Others?

Pain Management in Active Labor


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hydrotherapy multiparous childbearing women


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One-on-One Labor Support: the evidence multiparous childbearing women

  • If a doula was a drug, it would be considered unethical not to give it.” John Kennell, MD


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Continuous Labor Support multiparous childbearing women

  • Non-medical care by a trained person

  • Different definitions/criteria depending on studies:

    • “minimum of 80%” presence

    • presence “without interruption, except for toileting”

  • Various terms: doula, labor assistant, birth companion, monitrice

  • May refer to husband or untrained female companion


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Kennell J, Klaus M, McGrath S, Robertson S, Hinkley C. multiparous childbearing womenContinuous 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


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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

  • 13,391 women

  • Women with CLS were:

    • 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

    • Less likely to use EFM

  • …and were more likely to have a shorter labor length and a spontaneous vaginal birth.


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    Pathways of during childbirth (Review). Placement of Anesthetics for Labor Pain

    Eltzschig H et al. N Engl J Med 2003;348:319-332


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    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.


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    Monitoring for fetal well-being: the evidence of labor dystocia, if at all?


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    Monitoring FHR: a short history of labor dystocia, if at all?

    • 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.


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    Monitoring FHR: a short history of labor dystocia, if at all?

    • 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


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    Original Assumptions of EFM of labor dystocia, if at all?

    • 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


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    Monitoring FHR: the evidence of labor dystocia, if at all?

    • 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)


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    Monitoring FHR: a short history of labor dystocia, if at all?

    • 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


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    Actual Outcomes of Widespread EFM Use of labor dystocia, if at all?

    • 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.


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    EFM vs Intermittent Auscultation (IA) of labor dystocia, if at all?

    • 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


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    Oxytocin Augmentation of labor dystocia, if at all?


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    Clark SL, Simpson KR, Knox GE, Garite T. of labor dystocia, if at all?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.”


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    Medicalization of labor: of labor dystocia, if at all?Parkland, Texas


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    The challenge is, can you provide vigilance without intervention….

    Don’t just stand there.

    Do nothing!”


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    Questions & Comments? intervention….


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