The birth process l.jpg
This presentation is the property of its rightful owner.
Sponsored Links
1 / 68

The Birth Process PowerPoint PPT Presentation

  • Uploaded on
  • Presentation posted in: General

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:

Download Presentation

The Birth Process

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.

- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript

The birth process l.jpg

The Birth Process

Mamie Guidera, CNM, MSN

Carol O’Donoghue, CNM, MSN, MPH

Normal labor and birth objectives l.jpg

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

Slide3 l.jpg

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?

Birth in the united states l.jpg

Birth in the United States

  • Site of birth

    • Hospital

    • Birth Center

    • Home

  • Model of birth

    • Medical Model

    • Midwifery Model

Stages of labor l.jpg

Stages of Labor

  • First stage: early, active, transition

    • Dilatation

  • Second stage

    • Pushing and birth

  • Third stage

    • Delivery of placenta

  • Fourth stage

    • Postpartum

Birth video l.jpg

Birth Video

  • Observe stages and phases of labor

  • Observe Maternal Behaviors!

What is normal labor an introduction l.jpg

What is “normal” labor?An introduction

True vs false labor williams obstetrics 22nd edition l.jpg

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

Slide11 l.jpg

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

Physiological preparation for labor l.jpg

What are the signs and symptoms of impending labor?

Bishop’s Score





Fetal station and part

Importance of cervical status

Physiological Preparation for Labor

Initiation of labor l.jpg


Maternal factors






Fetal factors

Fetal cortisol


Cervical exam

Stripping of membranes


Artificial rupture of membranes


Nipple Stimulation

Initiation of Labor

You tube dilatation and the cardinal movements l.jpg

You tube!- dilatation and the cardinal movements


Early or latent phase active phase transition l.jpg





Contraction pattern



What are the characteristics of each?

What are frequent maternal behaviors?

Pain management?

Early or Latent Phase, Active phase, Transition…

The ps of labor l.jpg







Providers/Support Persons:



Practice/ Pain Relief


The Ps of Labor

Power influences l.jpg

Power: Influences

  • Uterine force

  • Nutrition and fluids

  • Rest/Fatigue

Slide18 l.jpg

Power: Contractions

Passageway l.jpg


  • Soft tissues

    • Cervix

    • Vagina

    • Perineum

Cervical examination examining the passageway l.jpg

Cervical Examination: examining the passageway

  • Dilatation

  • Effacement

  • Station

  • Position

  • Consistency

  • Presenting part

  • Status of membranes

The passage pelvic bones and pelvimetry l.jpg

The PassagePelvic Bones and Pelvimetry

The passage pelvic bones and pelvimetry23 l.jpg

The PassagePelvic Bones and Pelvimetry

Passenger l.jpg


  • Size of passenger

  • Number of passengers

  • Position of passenger:

    • Presentation

    • Lie

Slide27 l.jpg

Passenger: Attitude

Slide28 l.jpg

Passenger: Presentation

Passenger29 l.jpg


  • 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 l.jpg

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 l.jpg

Passenger: Cardinal Movements


    • Engagement – ischial spines

    • Descent Flexion Internal rotation- OT to OA

    • Extension Restitution- baby head realigns with body

    • External rotation

    • Expulsion – the body

Slide32 l.jpg

Passenger: Presentation

The passenger fontanelles and sutures l.jpg

The PassengerFontanelles and Sutures

Slide35 l.jpg


Slide36 l.jpg

Passenger: Lie

Passenger position l.jpg

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 l.jpg

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 l.jpg

Health care provider

Support person(s)




…let’s talk about this…

Woman giving birth







Beliefs, values, culture


Second stage of labor l.jpg

From 10 cm to birth of baby

Pushing or expulsion

Contraction pattern


Second Stage of Labor

Birth l.jpg

Perineal management

(keep your hands off


Ask mother to feel the baby’s head

Stay focused on woman, not tasks


Third stage of labor l.jpg

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 l.jpg

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

Slide44 l.jpg

Part II: Reality & modern hospital birth: pain management, monitoring, interference with physiologic birth

Physiology of labor pain first stage l.jpg

Physiology of labor pain: First stage

  • 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

Pain pathways during labor late first and second stage l.jpg

Pain pathways during labor: Late first and Second stage

  • 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)

Pain management in active labor l.jpg



Back Rubs

Birth Ball, toilet

Maternal Preference

Analgesia/ Anesthesia


Pain Management in Active Labor

Hydrotherapy l.jpg


One on one labor support the evidence l.jpg

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 l.jpg

Continuous Labor Support

  • 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

Slide51 l.jpg

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

Slide52 l.jpg

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.

  • Slide54 l.jpg

    Pathways 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 l.jpg

    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 l.jpg

    Monitoring for fetal well-being: the evidence

    Monitoring fhr a short history l.jpg

    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 history58 l.jpg

    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 l.jpg

    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 l.jpg

    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 history61 l.jpg

    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 l.jpg

    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 l.jpg

    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 Accessed 6/30/08

    Oxytocin augmentation l.jpg

    Oxytocin Augmentation

    Slide65 l.jpg

    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 l.jpg

    Medicalization of labor: Parkland, Texas

    The challenge is can you provide vigilance without intervention l.jpg

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

    Don’t just stand there.

    Do nothing!”

    Questions comments l.jpg

    Questions & Comments?

  • Login