Midwifery Delivery Secrets REVEALED

1. Midwifery Delivery Secrets REVEALED Lindsay Griffith, CNM Tania Lopez, CNM

2. Midwifery “Tricks” • Not tricks – • Education and Clinical Background of Nurse- Midwives • Nurses first: Approach Person / Family focused and solution oriented • Not Problem or Disease Focus • Natural Pairing: Nurse (family focus) + Midwifery (With Woman)

3. NOT a Bashing Session • Most of these “quotes” are from our own midwife-delivered patients! • Opportunity to hear the patient’s side of the story – and to listen to what patients are wanting for their labor experience • Consumer requests are driving change in health care routines.

4. What’s the Deal With … • Delayed cord clamping • Skin to Skin • Prolonged pregnancy • Herbs used in pregnancy • Childbirth classes • Eating and drinking in labor • Keep your hands out of the vagina • No IV • Unconventional Delivery positions • No Erythromycin Ointment • No vitamin K • Intermittent Monitoring • Hydrotherapy • Water Birth • Laboring Down • Episiotomy • The birth plan

5. Why Do Things Differently? • Patients are requesting • Evidence of benefits • Evidence of no harm

6. Culture of Birth is Changing “I think that natural is a stupid word. What does it mean in this society? I just wanted to have my birth. You know what I mean? I wanted to be the one who was making the decisions, or we were making the decisions. I didn’t want to have a ‘natural’ birth … I just wanted to be able to trust myself in the experience of being pregnant and the experience of giving birth and I want to now be able to do that with raising my children.” The art of medicine: the cultural evolution of natural birth

7. Technocratic birth • Being managed by technicians, governed by law of science

8. “I just didn’t feel like I got to participate in the birth.” “At the moment the bottom of the bed disappeared and she was placed in stirrups, it became a procedure that was happening to her - it was no longer our birth.” (Quote from patient’s husband)

9. “Prepared Childbirth” • Provider : “I’ll tell you what I do when I get a patient who wants to do the Bradley Method… I just fire them.” • Patient : “Why does it matter to them what I do? What do they mean when they say ‘I don’t DO natural Childbirth’? I’m not asking them to have the baby for me.”

10. Lamaze • Introduced in France in 1951 by Dr. Fernand Lamaze • incorporating techniques he observed in Russia. • childbirth classes, relaxation, breathing techniques and continuous emotional support from the father and a specially trained nurse, • Spread in the United States late 1950s • Today’s Lamaze affirms the normalcy of birth, acknowledges women’s inherent ability to birth their babies. Supporting and protecting every woman’s right to give birth, free to find comfort in a wide variety of ways, and supported by her family and all members of the health care team.

11. Bradley • Developed in 1947 by Robert A. Bradley, M.D. • Husband-Coached Childbirth, first published in 1965. • The Bradley Method emphasizes that birth is a natural process: mothers are encouraged to trust their body and focus on diet and exercise throughout pregnancy; and it teaches couples to manage labor through deep breathing and the support of a partner or labor coach. • Teaching couples to cope with birth in a more socially acceptable way --- Relax!! Don’t scream!! • Has turned into a point of contention between provider and patient

12. Culture of Alternative Birth Patients’ request … • Low intervention • Non-medicalized • Natural • Unmedicated • Gentle • Informed Decisions What they are really asking for is ……… • Autonomy for family • Choices • Less Chaos

13. “Even though it was the same nurses and the same room that I would have had if a midwife was there, it seemed like the nurses were so confused that we wanted all the things we were told were ‘normal’ midwife procedures”

14. “Should I Make a Birth Plan?” • Birth planning • Discussion “birth plan” • The WRITTEN birth plan • Improved outcomes? Improved satisfaction? • Nurse Perceptions

15. “I kept telling them what we wanted and they kept saying ‘there is no time for that’”

16. “Can I Wear my Own Gown in Labor?” • The gown begins a powerful process of the symbolic inversion of the most private region of the woman's body to the most public. Its openness intensifies the message of the woman's loss of autonomy: not only does it expose intimate body parts to institutional handling and control, it also prevents her from simply walking out the door anytime she chooses. Like a prison inmate, she is now marked in society's eyes as belonging to a total institution

17. “Do I have to have an IV?” CON • Awkward • Painful • Confining • No nutritional value • “sick person” • Inhibition of lactation • Hypervolemia • Hypoglycemia PRO • Anesthesia desires • Medication delivery • Rehydration • Access for bleeding

18. Eating and Drinking in Labor • NPO • Ice chips • Clear liquids • Soft diet • Regular diet • What nutritive value is there in 125 cc of LR an hour?

19. “I felt like I was strapped down during the entire labor. I think if I would have been allowed to walk around and change positions during labor, I wouldn’t have had such a long labor and had to push for 3 hours. Plus I was exhausted from being unable to eat or drink anything for over 12 hours.”

20. Intermittent Monitoring • Nurses and Providers blame each other for not being “comfortable” • Lack of understanding of the research and evidence • What is the AWHONN and ACOG definition of intermittent monitoring? • Consider nurse/patient ratio at respective facility • Consider Unit Needs

21. “What About an Enema? Do you recommend those?” • Is there a place for the antiquated enema? • RN conversation with midwife: “I think you need to talk to more of your patients about getting an enema. If it were me, I would be mortified at the thought of having a bowel movement with everyone in the room watching.” • Thank goodness we can prep the perineum, gotta keep that vagina sterile!!

22. Laboring Down Provider Quote: “The concept of ‘Laboring Down’ came from lazy nurses not wanting to have a delivery at shift change.” • AWHONN research

23. “Why wouldn’t they let me push when I wanted to, I could feel everything, I WANTED to push - so why were they yelling at me telling me to push?”

24. Hands in Vagina for Pushing • Perineal “massage”: • Good or Bad?

25. “I’d Like to Deliver in Whatever Position I’m Most Comfortable” • Positioning options • Lithotomy position • Hands & Knees • Broken Bed • Best position to get the baby out

26. “It always amazed me how we were told not to lay on our back during the entire pregnancy, yet for three hours of pushing, I was laying flat on my back.”

27. Laying down • In both sitting and reclining positions in bed, the mother's cardiac output is reduced, the inferior vena cava and the lower aorta are compressed, resulting in reduced blood circulation in the mother and reduced blood supply to the baby

28. Standing • Established in 1976: an increase of 30 to 40 mmHg pressure is exerted by the fetal head on the cervix as a result of the effects of gravity. • frequency of the contractions is the same, effectiveness is greater, and hence the efficiency and rate of the dilatation of the cervix is improved • tend to require less pain medication • No adverse effects from standing or walking

29. Side lying • Most of those mothers who preferred standing or walking in early labor reported that after they had entered the most active phase of labor (defined as beginning at 5-6 centimeters dilation), they preferred side-lying in bed

30. “Different” positions • Women's preferences for supine vs. upright positions for delivery - without exception, more positive responses from women using the upright position. • Easier pushing, less pain during pushing, fewer backaches, shorter second stages, fewer forceps deliveries, and fewer perineal tears • Advantages for the baby - better Apgar scores and better cord gases • CONS? Inconvenient for provider.

31. Why NOT lithotomy? • Focuses most of the woman's body weight squarely on her tailbone, forcing it forward and thereby narrowing the pelvic outlet, which both increases the length of labor and makes delivery more difficult • Compresses major blood vessels • Contractions are weaker, less frequent, and more irregular. Pushing is harder to do because increased force is needed to work against gravity • Legs wide apart in stirrups can result in • venous thrombosis, nerve compression, increasing the likelihood of tears because of excessive stretching of the perineal tissue and tension on the pelvic floor

32. Epis leading to tears • 1989 Study of over 240 first-time hospital-birthers showed that proportion of deep perineal lacerations was • lowest (0.9%) in women without episiotomy who were not confined to the lithotomy position; • greatest (27.9%) in women delivered in stirrups with an episiotomy • there was more than a twenty-fold increase in the rate of deep laceration when episiotomy was used • a fourteen-fold increase in the rate of deep perineal lacerations when stirrups were used

33. “She just let the baby fly out without any control, that’s why I think I tore”

34. Skin-to-Skin Delayed Cord Clamping • Improved breastfeeding rates • Improved transition of the newborn • Improved thermoregulation • What does evidence say?

35. “After waiting so many weeks and working so hard to get her out, all I could think of was holding her in my arms. I wanted to grab her the second I saw her.”

36. “It wasn’t a BAD experience, it just wasn’t really a BIRTH. I think it must be what people mean when they say who DELIVERED their baby.”

37. Fear of Hospital Birth • Driving people to out-of-hospital birth • Fear of what will happen is greater than fear of complications

38. Not for Fun • Knowing when and when to NOT utilize these alternative techniques • Thick mec / chorio – not safe for intermittent monitoring and water birth • Consider broken bed for hx of macrosomia or prolonged, dysfunctional labor • Each patient presents unique challenges • Be sure to include the patient in your plans and explain rationale

39. Patient Perceptions • Whether reality or not, a perception is the patient’s reality. • Listening to patients and making small adaptations in practice. • Patients will catch on if you are very agreeable during the first and second trimester but then start back-peddling during the 3rd trimester during the tough questions: • Episiotomy rate • c/s rate • What if you are not on call when I come into the hospital and the other physician will not honor my birth plan?

40. Lancet Article, 2011 • Birthing women and scholars alike are more apt to see medical technology in terms of what women think and do about it, rather than what is simply done to them