Keeping the

1
Keeping the Normal in Normal Birth

• Interdisciplinary Panel Discussion
• November 30th, 2006

2
Normal Birth A Problematic Notion

• Wide range of normal amongst labouring women
• Notion of normal has different meanings in
  different contexts
• WHO Definition
• Obstetric Normality in Active Management of
  Labour
• Intervention has become the norm in contemporary
  culture

3
WHO Definition of Normal Birth

• Spontaneous in its onset
• low-risk at the start and throughout labour and
  delivery.
• Baby is born spontaneously in the vertex position
  between 37 and 42 gestation
• Following birth both mother and infant are in
  good condition.

4
Normal Progression in Active Management of Labour

• Strict diagnostic criteria for labour onset
• Artificial Rupture of the Membranes (ARM) if
  dilatation not maintained at rate of l cm/ hr
• Augmentation with synthetic oxytocin if
  dilatation not increasing at this same rate
• Charting of labour progress the partogram.
• The provision of customized childbirth education
  continuous 1 on 1 support

5
Intervention As Normal

• Physiologic Birth The spontaneous head-first
  delivery of a single baby without employment of
  narcotics, entinox or epidurals, synthetic
  hormones-induction or augmentation of labor,
  artificial rupture of the membranes or
  episiotomy. (Midwifery)

• Physiologic birthrate in Nova Scotia4
• 1.75 for first time mothers

• 5 for women having their second or subsequent
  baby

6
Birth Intervention Menu

• Continuous Electronic Fetal Monitoring
• IV Drip
• Catheterization
• Epidurals, Narcotics, Entinox
• Labour Induction
• Artificial Rupture of Membranes
• Labour Augmentation
• Operative Assisted Delivery
• Caesarean Sections

7
Intervention Menu The Gaps

• 1 to 1 Continuous caregiver support (Midwife/
  Douala/ Other trained birth attendant)
• Consistent Information, Education and Support re
  Non-pharmacological Pain Relief Methods
• Nourishment

8
Interventions The Cascade Effect

• Cascade
• A succession of thingseach of which activates,
  effects, or determines the next

• Understanding the Cascade of Interventions

9

• The Cascade of Intervention6
• Directional Relationships highlighted in this
  diagram have all been established in scientific
  literature.
• To interpret the diagram begin with an
  intervention of interest and follow arrows from
  that point.

10
Select Birth Indicators (2001)7
Indicator Canadian Nfld Provincial Range National Range
C/Section 22.5 26.6 24.8 - 31.5 9.2-31.5
VBAC 26.7 12.5 7.0 - 14.4 7.0-60.7
Vaginal Assisted 16.2 18.6 17.1 - 28.2 2.5-28.2
Vaginal Unassisted 61.3 54.8
Inductions 20 13
Epidurals 45.4 34.4 8.3-50.5 3.9-74.6
11
NL Intervention Rates By Region(2005)8
Indicator Eastern Central Western Labrador Grenfell Province Change (01-05)
C/Section 31.1 29.4 26.5 26.5 29.8 3.3
C/S 1st time moms 31.6 30.6 25.0 30.7 30.5 N/A
Vaginal Assisted 12.4 12.4 11.6 5.6 11.7 - 6.9
Vaginal Unassisted 56.5 58.3 61.9 67.8 58.5 3.7
Induced 26.3 28.8 17.8 19.7 25.0 12
Epidurals 39.7 7.9 43.7 5.9 32.9 -1.5
12
Why Should We Be Concerned?
13

• Caesarean
• Sections

• Infant Risks
• Breathing Problems
• Low Apgar Scores
• Fetal Injury
• Increased Neonatal Deaths NICU Admissions
• Premature Birth
• Lower Breastfeeding Initiation
• Increased Asthma Incidence
• Higher Stillbirth Rate amongst women with
  previous C/S

• Maternal Risks
• Operative Post-Op complications e.g. bleeding,
  clots, infections, transfusions
• Increased pain, length of recovery, hospital stay
  and re-admission
• Respiratory complications
• Secondary infertility
• Ectopic pregnancy
• Placental abruption/ adherence problems
• uterine rupture before and during labor
• Need for further surgeries (e.g. Hysterectomy,
  bladder repairs)

14

• Caesarean Sections
• The Financial Costs 9

• Average Cost of Caesarean Delivery Without
  Complications in 2002/2003
• 4600

• Average Cost of Vaginal Delivery Without
  Complications in 2002/2003
• 2700

15
Best Practice Guidelines

• The World Health Organization (WHO) states that
  no region in the world is justified in having a
  cesarean rate greater than 10 to 15 percent.10

16
Explaining The Trend
17
References

• 1. Kaufman KJ, Effective control or effective
  care, (roundtable debate active management part
  2) Birth, 1993 20(3) 150-61
• 2. World Health Organisation (1996). Care in
  Normal Birth A practical guide.
  www.who.int/reproductive-health/publications/MSM_9
  6_24/MSM_96_24_Chapter1.en.html
• 3. Thornton, J.G (1996). Active management of
  labour. BMJ, 313 378. http//www.bmj.com/cgi/cont
  ent/full /313/7054/378
• 4. Source The Reproductive Care Program of NS
• 5. The second national U.S. Listening to Mothers
  survey (2006). http//www.marketwire.com/mw/releas
  e_html_b1?release_id175714
• 6. Cascade of Intervention http//www.acegraphic
  s.com.au/parents/obstetric/diagram.html
• 7. Canadian Institute for Health Information
  (2004) Giving Birth In Canada A Regional
  Profile. http//secure.cihi.ca/cihiweb/products/GB
  C2004_regional_e.pdf
• 8. Prepared By the NL Centre for health
  Information, November 8th, 2006
• 9. Canadian Institute For Health Information
  (2006) Giving Birth in Canada The Costs.
  http//secure.cihi.ca/cihiweb/products/Costs_Repor
  t_06_Eng.pdf
• 10. WHO Guidelines for Caesarean Sections -
  http//www.childbirth.org/section/CSFact.html