Natural Delivery, Family Practice Style

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Natural Delivery,Family Practice Style

• Samantha Maplethorpe, M.D., M.P.H.

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Goals

• Improve knowledge and confidence in management of
  childbirth among Family Practice residents
• Enhance advancement through different
  developmental stages during maternity care
  training in residency

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Training Level Specific Stages

• As of June
• R1s Begin continuity patient deliveries,
  function more autonomously, gain comfort in
  prenatal care and counseling
• R2s Develop own style, increase decision making
  capacity, increase independence, build confidence
  in decisions
• R3s Prepare to fly solo, work in different
  hospitals, and with different populations

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Questions for the Audience

• What is Natural Delivery?
• What defines transition?
• Does water immersion increase chance for
  infection?
• Does labor induction increase C-sections?
• What would you say if your patient asked you to
  attend her for home birth?
• Childbirth Classes Advise attendance?

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Objectives

• By the end of this talk, you will be able to
• Define Natural Delivery
• Describe the unique approach of Family Centered
  Maternity Care
• Identify resources on evidence-based maternity
  care
• Discuss the evidence supporting various
  interventions and non-interventions in labor and
  delivery

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Family Centered Maternity Care

• Seeking care that is the best of all worlds
• Why do we do what we do so well?
• Patient-Centered
• Evidence Based
• Community-Oriented

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Definitions

• Natural Delivery
• Patient-Centered Care
• Evidence-Based Practice
• Community-Oriented

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Definitions Natural Delivery

• What does Natural Delivery mean?
• No epidural?
• No pain meds?
• Place of birth? At home?
• No interventions such as IVs, amniotomy, IUPC,
  FSE, EFM?
• Hands on vs. hands poised?

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Definitions Natural Delivery (cont.)

• Primum non nocere
• Informed by knowledge of and respect for normal
  labor physiology
• Emphasizes working in tune with natural
  processes
• Respects the mother-baby dyad

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Definitions Natural Delivery (cont.)

• Approaches labor management as a continuum with
  pregnancy and new parenthood
• Builds on prenatal rapport with parents and
  subsequent care for newborn
• Treats labor delivery as a family experience
• Interventions performed only when evidence
  supports their use for specific maternal or fetal
  indications.

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Definitions Patient-Centered

• Build doctor-patient relationship over the course
  of prenatal care, which allows for longitudinal
  discussion patient education
• Listen to patients familys wishes, ideas
• Negotiate goals with patient family
• Communicate openly to facilitate flexibility when
  changes changes in labor care necessary

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Definitions Patient-Centered (cont.)

• Respect that this is the patients delivery
• Recognize patients likely to have the most severe
  pain of their life (80 rated pain of labor very
  severe or intolerable)
• Understand that pain varies among women, each
  labor of an individual woman may be quite
  different
• Take time to understand their perspective, past
  labor experiences, expectations.

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Definitions Evidence-based

• Conscientious, judicious, and explicit use of
  current best evidence in making decisions about
  the care of individual patients
• Counter to the tradition-based obstetric legacy

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Definitions Evidence-based (cont.)

• Evidence in obstetrics?
• Archie Cochrane, 1972
• RCTs needed to better inform practices regarding
  pregnancy and childbirth
• Obstetrics had been least successful in using
  research evidence to guide practice
• This approach concern expanded to all other
  areas of medicine
• Systematic reviews of RCTs followed, and EBM was
  born

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Reviewing the EvidenceAvailable Resources

• American Journal of Obstetrics and Gynecology
• Evidence-based Obstetrics Gynecology
• Maternity Center Association website
• Clinical Evidence by BMJ
• Cochrane Library
• National Guideline Clearinghouse
• Up To Date

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Reviewing the EvidenceAssessing the Quality

• Who does the studies, how does this affect the
  questions that get asked?
• Specialty-specific goals of care
• -Priority given to each womans personal
  experience of childbirth -- sacrifice safety?
• -Minimize perinatal morbidity
  mortality--increase mothers risk or discomfort?
• -Rising cost of care limited resources
  --decreases individual choice and sense of
  excellence?

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Reviewing the EvidenceAssessing the Quality
(cont.)

• Differences in objectives result in different
  outcomes being measured, such as womens
  satisfaction with childbirth or direct measures
  of death, disease, disability, vs indirect
  measures of fetal well-being
• Family Practitioners strive to balance these
  priorities, must be familiar with the evidence
  supporting decisions

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Definitions Community-Oriented

• Tailor care to available treatments
• Know available services H20 immersion, walking
  epidurals, continuous care
• Know standards of care in community
• Know about community served urban vs. rural,
  high risk vs. low risk, etc.
• Consider societal imperatives limited resources,
  patient safety, access, quality

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Antepartum Anticipation of Childbirth

• Childbirth classes -- advise attendance?
• Continuity of caregiver
• GBS culture
• Birth plans expectations
• - Preparing a hospital bag
• - Discussing labor events
• - Alleviating fears

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Antepartum Continuity of Care

• Care during pregnancy, childbirth, and postnatal
  period often provided by multiple caregivers
• Controlled trials comparing continuity of care
  with usual care during pregnancy, childbirth and
  the postnatal period
• Studies show beneficial effects, but not clear
  whether these are due to greater continuity of
  care or to midwifery care.

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Peripartum Diagnosis of Labor

• When should women call or come in?
• Best times to come to hospital, avoid early
  admissions, improve outcomes
• Avoiding early admissions leads to less
  anesthesia, fewer dystocias, fewer c-sections
  better patient satisfaction

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Peripartum Induction of Labor

• Prevention of post-dates
• Stripping membranes
• Breast stimulation
• Okay to induce at 41 weeks with favorable cervix
  in a multip -- no increased risk of C-section

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Peripartum Other Interventions

• Pubic or perineal shaving no decrease in rates
  of infection, possible increase in rates of
  gram-negative infections
• Enemas no decrease in rates of infection or
  perineal complications, cause discomfort for
  women and increase costs of delivery

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Peripartum Other Interventions (cont.)

• Continuous caregiver support appears to have a
  number of benefits for mothers and their babies
  with no apparent harmful effects.
• Hands-knees position for fetal malpresentation
  appears to result in short term effects on fetal
  position no other outcomes reported.

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Intrapartum Pain Management

• Pharmacologic
• Epidurals superior pain relief combination of
  anesthetics and opioids work best to block
  somatic component
• Spinals intrathecal analgesia w/opioids only
  allows for ambulation (doesnt affect muscle
  strength)

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Intrapartum Pain Management (cont.)

• Pharmacologic (cont.)
• Paracervical pudendal blocks
• Systemics opioids, phenothiazines,
  antihistamines, barbiturates, benzodiazepenes,
  nitrous oxide, PCAs

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Intrapartum Pain Management (cont.)

• Non-pharmacologic
• Transcutaneous electrical nerve stimulation
  (TENS) involves delivery of current through a
  series of electrodes applied to the skin surface
  review of studies found it to be ineffective.
• Hypnosis acupuncture not shown to be effective
  in studies, may work for individual women

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Intrapartum Pain Management (cont.)

• Non-pharmacologic (cont.)
• Water immersion No significant differences for
  pain relief, augmentation and duration of first
  stage of labour, meconium stained fluid and
  perineal trauma neonatal outcomes such as Apgar
  scores, umbilical arterial pH values and neonatal
  infection rates also showed no differences.

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Intrapartum Pain Management (cont.)

• Non-pharmacologic (cont.)
• Psychoprophylaxis Emphasize patients role in
  controlling her own experience while receiving
  support from family and friends.
• Little evidence that psychoprophylaxis,
  relaxation techniques, or even childbirth classes
  reduce psychological stress or increase
  satisfaction during labor.

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Intrapartum Pushing

• Anatomical onset of 2nd stage may not coincide
  with expulsion phase womans urge to bear down
• If wants to push before 8 cm, needs methods to
  resist (panting, breathing techniques, pain
  relief
• If a rim of cervix and urge to push, probably
  okay to do, but not to exhaustion
• Epidurals may decrease, delay or increase urge to
  push

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Intrapartum Pushing (cont.)

• Laboring down
• Sustained breathholding and directed pushing may
  shorten 2nd stage of labor, but can decrease
  umbilical artery pH

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Intrapartum Positions

• Upright posture vs. recumbent
• Birth chair or stool reduces episiotomies but
  increasd second degree tears and EBL perhaps due
  to trauma
• Birth cushion/wedge led to reduced 2nd degree
  tears, assisted deliveries while episiotomies and
  PPH were similar
• Squatting position fine if woman is comfortable
• Toilet for laboring down
• Ultimately women should be encouraged to deliver
  in most comforatble position

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Intrapartum Duration of 2nd Stage

• Widespread policy to impose arbitrary limits on
  2nd stage based on nullip/multip status.
• Associations but not causations have been made
  between longer second stage and perinatal
  mortality, PPH, puerperal fever, neonatal
  seizures, and acid-base status of baby.

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Intrapartum Duration of 2nd Stage (cont.)

• Length of second stage is often curtailed by
  active pushing or operative delivery but maternal
  and fetal trauma may not be justified.
• If mother and baby are stable, and there is
  evidence of descent there are no grounds for
  intervention.

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Intrapartum Perineal Care

• Two-thirds of all nulliparous women sustain
  trauma requiring suture.
• Vacuum should be used for maternal or fetal
  indications rather than forceps to reduce
  perineal trauma
• Routine episiotomy not supported by the evidence
• Type of suture material for repairs, continuous
  vs. interrupted stitches

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Third Stage Active versus expectant management

• Evidence supports active management (pitocin,
  early cord clamping/cutting, controlled cord
  traction)

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Early Skin to Skin Contact

• Positive effects on breastfeeding, infant
  temperature, infant blood glucose, infant crying,
  maternal affectionate love/touch.
• Breastfeeding within 30 minutes increases
  oxytocin to improve uterine contraction, placenta
  and blood expulsion.

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Ongoing Evidence Based Reviews

• Repair vs nonrepair of perineal trauma
• Postnatal parental education for improving family
  health
• Maternal positions and mobility during first
  stage labour
• Restricting oral fluid and food intake during
  labour
• Pushing/bearing down methods used during the
  second stage of labor

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Case Anxious Annie

• 24 yo G1 at 20 weeks is looking forward to the
  birth of her first child and wants to know if she
  should prepare in any way. What do you tell her?

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Case

• Now at 37 weeks, uncomplicated pregnancy, has
  heard that pregnancy sometimes goes beyond her
  due date. She has carefully planned her
  relatives arriving and her maternity leave and
  wants to know what she can do to prevent being
  pregnant much past her due date.
• What do you tell her?
• What can you do?
• Should she try primrose oil?

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Case

• She follows your advice and presents to L D at
  38 5/7 wks with her birth plan in hand and is
  ready for an epidural. Her cervix is 2 cm
  dilated, she has been contracting every 5 minutes
  for 3 hours.
• What do you tell her?
• What are the risks and benefits of an epidural,
  when can she get one, when is too late to get one?

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Case

• She returns from walking 3 hours with her husband
  on LD and is now at 4 cm dilation and has
  thought about that epidural and wants to wait for
  now. She is excited but a little scared and
  wants to hear more about pain management options
  at this point and techniques to help her baby
  come faster.
• What would you like to tell her?
• What would you like the L D nurse to have
  available
• The nurse would like to place an IV now, what do
  you say?
• Annie wants to know if she can try the jacuzzi
  and can she have a little something to eat or
  drink?is that okay?

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Case

• She has done well with positioning techniques,
  the labor ball and counterpressure but she is
  having a lot of back pain. You check her cervix
  and decide she is OP, what would you like to do?
• Does she have to have these uncomfortable bands
  around her stomach all the time?

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Case

• After 2 more hours she is completely dilated and
  is in a lot of pain now, what do you say?
• Should she start pushing?
• Her husband isnt sure what to do to help, any
  tips for him?

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Case

• She has been laboring down for two hours making
  slow but steady progress with adequate
  contractions and reassuring FHR tracing
  intermittently, she feels the urge to push, how
  long will you let her push before you intervene?
• How will you guide her pushing?
• What position should she be in?
• Will you use techniques to massage the perineum
  while she pushes?

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Case

• She has pushed the baby downed and is crowning
  but the babys head doesnt stay down between
  contractions, she is getting tired, any
  suggestions?
• How will you manage her perineum during delivery
  of the head?

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Case

• With the use of the mirror she has successfully
  delivered the babys head, anterior and posterior
  shoulders follow easily, you clamp the cord and
  dad cuts the cord. No meconium, baby is pink and
  vigorous, what do you do with baby?
• She has only a small midline posterior lac that
  looks like it could use a repair, what kind of
  suture would like to use, what will be your
  technique?

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Case

• Nice Job! You take numerous pictures with the
  family, help mom to get baby latched, finish
  paperwork in the room while answering questions
  and after about a half an hour you do the newborn
  exam with mom and dad and they thank you
  profusely.