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? 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 .

Stages of Labor First stage: early. transition Dilatation Second stage Pushing and birth Third stage Delivery of placenta Fourth stage Postpartum . active.

Birth Video Observe stages and phases of labor Observe Maternal Behaviors! .

What is “normal” labor? An introduction .

 Cervix dilates.  Discomfort is not stopped by sedation  Contractions are irregular  Intensity remains the same  No cervical dilatation  Discomfort relieved by sedation .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.

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italics = multips Mean (hrs) Friedman (1978) Kilpatrick & Laros (1989) Albers.7 5.7 7.5 16.1 8.7 5.7 13.7 95th percentile (hrs) 8.6 19.4 17. Schiff & Gorwoda (1996) Albers (1999) 4.6 7.0 12.5 13. (2007) bold = nullips.8 .Length of first stage labor in healthy nulliparous and multiparous childbearing women adapted from Albers L.4 5.5 Friedman (1978) Kilpatrick & Laros (1989) Albers (1996) Albers (1999) 2.1 7.

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  Artificial Cervical exam Stripping of membranes Prostaglandins Artificial rupture of membranes Sex Nipple Stimulation Fetal factors Fetal cortisol .

com/watch?v =Xath6kOf0NE&feature=PlayList&p =6603A45DF81B89A9&index=38& playnext=2&playnext_from=PL .youtube.youtube.com/watch?v=Xath6 kOf0NE&feature=PlayList&p=6603A45DF8 1B89A9&index=38&playnext=2&playnext _from=PL • http://www.dilatation and the cardinal movements http://www.You tube!.

Active phase. Transition…  Dilatation  Effacement  Cervix  Station  Contraction pattern  Membranes  Duration  What are the characteristics of each?  What are frequent maternal behaviors?  Pain management? .Early or Latent Phase.

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 .

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The Passage Pelvic Bones and Pelvimetry .

The Passage Pelvic Bones and Pelvimetry .

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Passenger Size of passenger Number of passengers Position of passenger: Presentation Lie .

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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 .

baby head realigns with body External rotation Expulsion – the body .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.Passenger: Cardinal Movements http://www.

Passenger: Presentation .

The Passenger Fontanelles and Sutures .

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Passenger .

Passenger: Lie .

RMT.Passenger: Position The relationship of a site of the presenting part to the location on maternal pelvis Examples: LOA. LSA. ROP. Asyncliticism: lateral deflection of the head with regards to the sagittal suture Anterior or posterior . etc.

.think mother and baby .Position: Fetal and Maternal Most common position for labor and birth? Best position for labor and birth? Worst position for labor and birth? ….

culture …let’s talk about this… .Psyche  Woman giving birth Knowledge Fear Support Trust Self Provider  Health care provider  Support person(s) Family Friend Doula Beliefs. values.

Second Stage of Labor  From 10 cm to birth of baby  Pushing or expulsion  Contraction pattern  Duration .

not tasks .Birth  Perineal management (keep your hands off Mirror  Ask mother to feel the baby’s head  Stay focused on woman.

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 .

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

bradykinin. histamin. L1 .Physiology of labor pain: First stage o Uterine contractions: o Myometrial ischemia Causes release of potassium. 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.

pelvic floor.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. stretching of pelvic ligaments o Pain signal transmitted to spinal cord via S2-S4 (includes pudendal nerve) . perineum.

toilet  Maternal Preference  Analgesia/ Anesthesia  Others? .Pain Management in Active Labor  Walking/Movement  Hydrotherapy  Back Rubs  Birth Ball.

hydrotherapy .

” John Kennell.One-on-One Labor Support: the evidence  If a doula was a drug. MD . it would be considered unethical not to give it.

monitrice o May refer to husband or untrained female companion . except for toileting” o Various terms: doula. labor assistant.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. birth companion.

Hinkley C. 265: 2197 . Continuous Emotional Support During Labor in a US Hospital: A Randomized Controlled Trial. JAMA. Klaus M. Robertson S. observed. oxytocin use. prolonged infant hospitalization and maternal fever all significantly less with supported group •More spontaneous birth with supported group . McGrath S. duration of labor.Kennell J. •616 women •Three arms: supported (doula). control groups •Outcomes studied: epidural use. May 1991.2201.

Issue 3. Art No. all RCTS o 13. 16 trials. Cochrane Database of Systematic Reviews 2007.391 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 support for women during childbirth (Review).Hodnett. ED et al (2007). .: CD 003766.

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 & 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.

000 cases of auscultation and outcomes. 22nd Edition . 66% of women EFM used during their labors  In 2002.”  Late 1960s: first commercially available electronic FHR monitor available  By late 1970s EFM used in most American labor and delivery units  By 1978.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. determined that “there was no reliable indicator of fetal distress in terms of FHR save in extreme degree. Williams (2005). 85% of labors included EFM Gabbe (2002). 4th Edition.

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).

561 pregnancies):  Prevention of neonatal seizures  No prevention of cerebral palsy  Abnormal neurological outcomes not higher in infants managed by intermittent auscultation vs.000 cases of auscultation and outcomes.Monitoring FHR: the evidence  1968:  Benson et al: review of 24. continuous EFM (CEFM) . 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.

” Gabbe (2002).. 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. Williams (2005). rare outcome 1/500 births No increase in cerebral palsy. 22nd Edition .000 women): Seizures decreased. >37.Monitoring FHR: a short history  Thacker’s report now replaced by Alfirevic (2006. 4th Ed.

22nd Ed. 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). .Actual Outcomes of Widespread EFM Use  By 1994. Williams (2005).

ahrq. preeclampsia. suspected fetal growth restriction.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.gov/clinic/uspstf/uspsiefm. and type 1 diabetes should be monitored continuously). Alfirecvic (2006) did include patients receiving oxytocin  ACOG Practice Bulletin 70 (2005) states:  “Those with high-risk conditions (eg.”  Current USPSTF Guideline (1996 to present):  Routine intrapartum EFM not recommended  Insufficient evidence regarding its routine use in high risk pregnancies http://www.htm Accessed 6/30/08 .

Oxytocin Augmentation .

if left to its own devices. Knox GE. Yet the administration of oxytocin is often undertaken under precisely these circumstances when labor is electively induced or Braxton-Hicks contractions are electively augmented.200:35.  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. Garite T. Simpson KR. Am J Obstet Gynecol 2009.e6 .” . Oxytocin: new perspectives on an old drug.e1-35. usually complete itself without incurring the risk of drug administration.Clark SL.

Texas .Medicalization of labor: Parkland.

The challenge is. Don’t just stand there. Do nothing!” . can you provide vigilance without intervention….

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