Rhythms in Labour 1st Stage

1
Rhythms in Labour (1st Stage)

• Origins of progress mindset
• Variations as physiology, not pathology
• Skills for sussing out labour rhythms
• Subverting assembly line birth
• Practice recommendations

2
Origins of Progress Mindset

• Two trends
• Movement of birth from home/village into
  institutions
• USA 1920s onwards, UK 1970s onwards
• Centralisation of birth in larger larger
  institutions
• Prompted two responses
• Adoption of industrial/business model (Perkins,
  2004)
• Pathologisation of labour length

3
Adoption of Industrial/Business Model (Perkins,
2004)

• Fordism assembly-line model
• Process driven (making a car birthing a baby)
• Movement along a series of compartmentalised
  stages
• Throughput output of numbers
• Time determined
• Taylorism management model to make assembly-line
  efficient economical
• Demarcated roles
• Tightly regulated controlled
• Low level of autonomy
• Management/worker split

4
Pathologisation of Labour Length

• Friedman Curve (1954)
• Introduction of Partogram (Phillpott Castle,
  1972)
• Nomograms in the UK (Studd, 1973)
• Active management of labour (O'Driscoll, 1986)
• Driven by poor outcomes assoc. with prolonged
  labour up to 1960s

5
Friedman Curve (1954)
C D e i r l v a i t c a a t l
i o n
Active Phase
Latent Phase
Hours
6
Philpott Castle (1972) Partogram
Alert Line
Transfer Line
Action Line
Cerv Dilat
Hours
7
Studds (1973) Nomogram
Cerv Dilat
Hours
8
Contextual Issues around Labour Progress Mindset

• Research into labour progress done in medicalised
  settings using intrusive interventions
• Therefore was research measuring physiology or
  how womens bodies behave in medicalised setting?
• Albers (1999) midwifery research of nullips
  indicates stages of labour maybe longer than
  first thought
• Zhang et al (2002) Friedman curve not
  appropriate for nullips as labours slower
• Gurewitsch et als (2002) research grand multips
  may labour more slowly than multips
• Organisational imperative re getting women
  through the system (industrial model)
• New understanding of birth hormones

9
Birth Hormones and Undisturbed Labour (Buckley
2004,)

• Oxytocin hormone of social interaction and
  altruism, involved in sexual activity, orgasm,
  labour, birth, breastfeeding
• Catecholamines adrenaline noradrenaline,
  produced in response to pain, trigger optimum
  levels of oxytocin
• Beta-endorphins (natural opiate) produced in
  response to pain, inhibit oxytocin
• Balance of oxytocin, catecholamines, endorphins
  required to maximise progress of labour. Hormones
  originate in primitive brain and inhibited by
  neocortical stimulation
• language, bright lights, being observed
• Sensitive cocktail of hormonal, interpersonal,
  environmental effects

10
Rhythms in Early labour (Latent Phase)

• Defining start of labour (Burvill, 2002)
• Whose judgement
• Dynamic event
• Listening and affirming womens version of events
  (Gross et al, 2003)
• Wide variation in womens experience
• Delivery Suites are entirely unsuitable for
  latent phase (Bailit et al, 2005)
• More C/S, augmentation, EFM

11
Rhythms in Early labour (Latent Phase)

• Reduction in labour interventions if
• Stay at home (Hemminki Simukka, 1986)
• Attend a Triage Facility (Lauzon Hodnett, 2004)
• Attend a free-standing Birth Centre (Jackson et
  al, 2003)
• See a midwife, rather than obstetrician (Turnbull
  et al, 1996)
• Individualise care (Simkin Ancheta, 2000)

12
Rhythms in Early Labour Womens Responses in a
Birth Centre (Walsh, 2004)

• A woman came in at midday. It was her first baby.
  Her husband was with her but she was really in
  early labour so they went back home. They
  returned in the early evening but again her
  cervix was just two to three centimetres dilated.
  She was contracting but comfortable. Her husband
  had a commitment as a DJ for a local rugby club
  that evening and they decided he should go and do
  it. The woman stayed behind until about nine pm
  but was bored as much as anything. The field note
  entry continues
•  She says I think I would just rather go and be
  with him so she went and sat with him at the
  rugby club do. Hes doing the DJing and she is at
  the back, sitting down and while all thats going
  on she is obviously quietly labouring because
  when she comes back at 12.30 am, she delivers, so
  shes fully dilated when she gets back into the
  unit after being out there with her hubby.

13
Rhythms in Mid Labour (Active Phase)

• Environmental ambience (place of birth), social
  ambience (birth companions and continuity) play
  major role in promoting optimum physiological
  response.
• Downe McCourt (2004) call Unique normality,
  different for each women
• Variations in physiology Individual template
  for labour
• Albers (1999) work showing longer nullip labours,
  Gurewitsch et als (2002) slow grand multip
  labours
• MANA Curve with plateaus (Davis et al, 2002)
• Pasmo phenomenon of labour stopping and
  restarting hours/days later (Gaskin, 2003

14
Rhythms in Mid Labour Womens Responses in a
Birth Centre (Walsh, 2004)

•  It was the week before Christmas and I had one
  lady who was five centimetres when she came in.
  Actually she was really more six but she was
  desperate to get her Christmas shopping done
  you know she had this little window of time to do
  it and now this! So because the labour wasn't
  that strong we decided she could go shopping and
  come back afterwards. She came back and
  delivered a couple of hours later. I was still
  here when she came back and she got her shopping
  done and then she went home that night after the
  baby was born. You have got to be flexible here.
  That's one of the nice things here, you can use
  common sense.

15
Rhythms in Mid Labour Latest Research Findings

• No difference in C/S between action line of 2 hrs
  or 4 hrs (Lavender et al, 1998)
• Women preferred earlier intervention (Lavender et
  al, 1999)
• 4 hr action line assoc. with less C/S, less
  syntocinon (WHO, 1994)
• Nulips labour up to 26 hours, multips 24 hours
  normally (Cesario, 2004)
• Baseline dilatation rate of 0.5 cms/hour
  recommended by Cochrane (Enkin et al, 2000)

16
Rhythms in Mid Labour What to do if prolonged

• If mother and baby are fine, options
• continue physical, psychological, social support
• try interventions to enhance birth physiology
  e.g. posture/mobility change
• (Simkin Ancheta, 2000)
• HydrotherapyRCT of syntocinon augmentation or
  hydrotherapy for slow labour in primips (Cluett
  et al, 2004)
• Less epidural (47 v 66)
• Less syntocinon (71 v 96)

17
Rhythms in Mid Labour What to do if prolonged

• Medical interventions if required
• try amniotomy shortens labour by 1-2 hrs in
  nullips (Fraser et al, 2005)
• try syntocinon if membranes ruptured
• evidence of morbidity if prolonged active phase
  unresponsive to syntocinon (Cardozo, 1982)

18
V/Es and the Progress Mindset

• Painful, traumatic, associated with Post
  Traumatic Stress Disorder (Menage 1996)
• Past history of sexual abuse? (Robohm
  Buttengheim, 1996)
• Ritual that disempowers women (Bergstrom et al
  1992)
• Repeated VEs of unproven value (Devane 1996,
  Enkin 1992)
• Poor inter-observer reliability (Clement, 1994)
• Infection (Imseis et al, 1999)
• Up to 12 hour duration between VEs for nullips
  Thornton quoted in Lee (2004)

19
Skills for Recognising Labour Rhythms

• Pattern of contractions
• Maternal behaviour
• Purple line (Hobbs, 1998)
• Frontal suture ridge
• Abdominal palpation 5ths palpable (Stuart,
  2000)
• Vocalisations mark transition (Baker Kenner,
  1993)
• Intuitive (Davis-Floyd Davis, 1997)
• Emotional nuance reading (Kennedy et al, 2004)
• Being comfortable with uncertainty (Sookhoo
  Biott, 2002)

20
Subverting Assembly-Line Birth

• Disconnecting labour and birth from the time line
• Labour out of hospitals (home, birth centres, or
  where woman is comfortable)
• Ready availability, but not necessarily presence
  of a midwife
• Work as being with, not doing to (Fahy, 1998)

21
Subverting Assembly-Line Birth

• Leap (2000 ) the less we do, the more we give
• Kennedy (2000) doing nothing
• Being comfortable when there is nothing to do
• Drinking tea intelligently
• You have to be able to knit if you work here.

22
Practice Recommendations

• Maternity services need to prioritise the
  creation of a suitable environmental and social
  ambience for individual women
• Services should facilitate women in early labour
  either staying at home, going to a birth centre,
  or attending a triage facility (avoid delivery
  suites if at all possible)
• Time variations in labour could be understood as
  differing rhythms for different women, not as
  potential pathology
• Midwives should facilitate womens choices and
  respect their preferences
•  

23
Practice Recommendations

• Services should facilitate midwives acquiring
  skills in recognising labour rhythms, including
  developing their intuition
• If partograms are used
• then a four hour action line is a useful marker
  for recognising prolonged labour
• with a minimal cervical dilatation rate of 0.5
  cm/hour
• Care for prolonged labour should prioritise
  physiological/psychological/social support before
  medical interventions
• Services should review their use of V/Es in
  labour in the light of these recommendations

24
Questions

• How might you go about addressing the shift from
  labour progress mindset to a labour rhythms
  approach?
• How could the use of intuition in sussing out
  labour rhythms be encouraged?
• What options have you got where you work around
  care of women in early labour and can they be
  improved?
• What steps can you take to optimise birth
  environment and social ambience for labouring
  women you care for?