The Birth Process

Mamie Guidera, CNM, MSN Carol ODonoghue, CNM, MSN, MPH

Normal Labor and birth: Objectives

Introductions Physiologic labor and birth: the basics
Phases of labor Birth video The Ps: 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

Heres 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? 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?

o o

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) Friedman (1978) Kilpatrick & Laros (1989) Albers, Schiff & Gorwoda (1996) Albers (1999) 4.1 8.1 7.7 7.7

95th percentile (hrs) 8.5 16.6 19.4 17.5

Friedman (1978)
Kilpatrick & Laros (1989) Albers (1996) Albers (1999)

2.4
5.7 5.7 5.6

7.0
12.5 13.7 13.8

Physiological Preparation for Labor What are the signs and symptoms of impending labor? Bishops Score
Position Consistency Effacement Dilatation Fetal station and part

Importance of cervical status

Initiation of Labor
Theoretical
Maternal factors
Progesterone Estrogen Oxytocin Prostaglandin Psyche

Artificial
Cervical exam Stripping of membranes Prostaglandins Artificial rupture of membranes Sex Nipple Stimulation

Fetal factors
Fetal cortisol

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

Health care provider Support person(s)

Family Friend Doula

Beliefs, values, culture

lets 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 babys 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 Physiologic impact of continuous labor support

Mitigates potentially harsh environment

Mobility encouraged by support person

Support person decreases anxiety of mom

Negative experiences may impede labor

Negative experiences may impede adjustment to motherhood

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 & ODonoghue, 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 Marsacs 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

Thackers 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.

Dont just stand there. Do nothing!

Questions & Comments?