Tag Archives: labor and delivery

Home births rose almost 30% in US from 2004-2009

USA Today reports, “Births taking place outside of the traditional hospital setting increased 29 percent between 2004 and 2009, from 0.56 percent of all births to 0.72 percent – almost 30,000 births – according to a new report from the US Centers for Disease Control and Prevention.” Continue reading

The Essential Role of the Father (and a Doula) in Childbirth — “Let my people go!”

In the 1990s, I published a number of papers in the medical and birthing literature to help birthing families design and experience safer and more satisfying birthing experiences.

On of the articles I published was for a midwifery journal on the issue of whether the father of the baby should be in the delivery room or not  (Larimore WL. The Role of the Father in Childbirth. Midwifery Today. Issue No. 51, Autumn, 1999, 15-7).

Here’s the text of that original article:

During the late 1960s and the early 1970s, the earliest days of fathers’ involvement in childbirth in America, men were expected to be intimately involved as advisors, coaches and decision-makers for the woman (Simpkin, P., 1992).

However, experienced birth observers commented that few men seemed to be comfortably, confidently, and competently able to meet either the physical or the emotional needs of the woman in labor (Kierse, MJNC, et al., 1989).

Thus, the concept of the father as “birth coach” was increasingly reported to be impractical or unworkable and was therefore either abandoned or just tolerated by many prenatal instructors and L&D nurses (Simpkin, ibid).

The hope that the father would be an effective labor support companion failed to meet its hoped for potential for a number of complex but related reasons.

  1. Most men had virtually no knowledge of and certainly no experience with the birth process or obstetrical procedures;
  2. Many men did not want to be a labor coach (and there were women who resented being “coached”);
  3. Most men were unwilling or unable to ask doctors or nurses questions and seemed unwilling to serve as their partner’s birth advocate or ombudsman;
  4. Most men found it difficult to maintain confidence and perspective in a strange environment filled with busy, authoritative professionals;
  5. During the birth process, most men felt helpless, as they were unable to control the process or the outcome;
  6. Furthermore, as the birth process intensified, most men seemed to become more uncomfortable and to pull away from, not toward their partner;
  7. Men, in general, seemed to become distressed over witnessing the woman’s pain or discomfort; and
  8. Because of these and other reasons, most men were not able to provide the constant reassurance and nurturing that women need during the labor process.

Research has substantiated some of these anecdotal observations and may explain why most men appear to be ineffective birth companions—at least in the sense of positively effecting birth outcomes.

In general, the research done to date reveals that male partners play an important but minor role during labor and birth of most women.

In other words, when it comes to evidence-based medicine, having a man involved in the birth process is “better than nothing,” but not much! At least not nearly as helpful and effective as a female support companion.

The effect of male partners on the labor and birth process has been compared to the effect of trained and experienced female labor support persons (doulas) Clear differences in favor of the doula have been noted.

For example, first-time fathers touch their female partner in labor only 20 percent of the time compared to 95 percent for experienced doulas.

The study also found that male partners spent significantly less time with their laboring partners and were physically close to them for much less time than doulas (Bertsch TD, Nagashima-Whalen L, Dykeman S, Kennell JH, McGrath S. Labor support by first-time fathers: Direct observations with a comparison to experienced doulas. J Psychosom Obstet Gynecol 1990;11:251-60).

In addition, the behavior of first-time fathers has also been compared to female relations or friends of the laboring mother (untrained or “lay” doulas).

These studies also demonstrate that men do not appear to provide the same support as women.

Most male labor partners remain significantly farther from the laboring woman than females. When the laboring woman’s discomfort increases, the supporting women move closer to the laboring woman and the man moves back or away or even leaves the labor area.

It appears to me, as a male who has had the privilege to attend over 2,500 births, that it is time for male birth attendants to say to the birthing community, “Let my people go!”

For the most part my people (men) appear to not want to be there (at least all the time), are uncomfortable there (especially in the early active stage of labor), and want to be given the freedom and the permission to come and go.

It appears that there are reasons for birth attendants to learn how and when to use men in the birth process and when to “let them go”!

In addition to a woman’s almost intuitive desire and ability to effectively touch and nurture a laboring woman, the medical literature indicates that women supporting women during labor (at least when compared to male companions) seem to use more phrases of a specific, active, supportive nature.

Men tend to do more “general” talking. It appears that the birthing literature documents that women are able to more effectively communicate to women during labor and birth.

These data and observations, although true for most men, do not, of course, apply to all men.

Most male labor and birth partners (preferably the baby’s father) can play an essential role in providing support for most birthing women. Furthermore, a female partner or support person (doula) cannot make some of the unique contributions that the male partner can make, as the male partner may have a more intimate knowledge of the woman and love for her and her child (Kennell, J.H., 1991).

It is almost as if some men are able or gifted to be able to “turn on” or “activate” a more nurturing role during labor and delivery.

Nevertheless, the active and effective male support person during labor appears to constitute a small minority of male birth partners. This was demonstrated in one study, which described the man’s role in labor in one of three ways:

  1. The “Coach” – who actively assisted and led the woman in breathing and relaxation techniques and took responsibility for her management of labor.
  2. The “Teammate” – who followed suggestions from the woman or nurse as to what to do. The “teammate” took his lead from others and was “there to help.”
  3. The “Witness” – who viewed himself as a companion to “hold the woman’s hand,” to observe labor and to witness the birth.

In this report, 20 percent of the fathers were “coaches,” 20 percent were “teammates,” and 60 percent were “witnesses.”

The witness is the role that is least likely to make any difference in the birth – as far as outcomes.

Furthermore, and of much credit to their gender and much benefit to their laboring partners, the “witnesses” were most likely to recruit a woman to assist in labor support (Kierse et al., ibid).

Therefore, any expected positive effects upon birth outcomes by male support during labor may be overemphasized.

However, according to several studies, the male’s presence during labor and birth is still important to many women.

Furthermore, fathers appear to be able to provide more continuous support to a woman in labor than do most labor and delivery nurses: “In general, fathers were significantly more likely than nurses to be present in the labor room, to offer a comforting item, and to touch their partner” (Nicholson J, Gist NF, Klein RP, Standley K. Outcomes of father involvement in pregnancy and birth. Birth 1983;10:5-9).

In addition, mothers rate the father’s presence as significantly more helpful than that of the nurses and the father’s presence at the birth strongly increased the mother’s satisfaction with the birthing experience.

It is important to recognize the possibility that sometimes the presence of a man during the labor process can be disruptive or harmful to some women.

Some midwives have reported to me experiences in which the father actually disrupts the birth process.

For example, the cervix has been seen to “reform” or “constrict” in laboring women when a man enters the labor room.

Other midwives report to me that they have observed ‘arrest of labor’ or ‘labor dysfunction’ when a man enters the labor room.

These experienced and sensitive female birth attendants say that if the man’s relationship with the laboring woman has been marked by violence or abuse (or even if the laboring woman has been abused by other men), then these phenomena are even more likely.

These anecdotal observations need to be studied. Further research in this area would be very important for birth attendants.

Based upon the current birthing literature, it appears that there is no evidence of harm from allowing the father to be as actively involved during pregnancy and the birth process as he wishes to be and as his laboring partner wants him to be, despite the possible negative consequences to the labor process of having at least some men involved in the process. (Doulas of North America, 1998).

A midwife that I greatly admire spoke about the role of the father this way: “On the nascent fashion for fathers to attend the delivery of their offspring, Sheila Judge wrote: ‘Roll up for the greatest show on earth, come and view your baby’s birth! Blood, urine, sweat, and faecal matter, a great treat for a prospective pater’” (Midmer et al., 1995).

Over the last twenty years, the value of a woman supporting a woman before, during and after birth (the doula) has been firmly established in the medical literature.

Women supporting women in birth is, in my opinion, the most important and underutilized tool that maternity care providers can employ, and which fathers can insist upon, to keep labor normal.

The Cochrane Collaboration stated, “Thirteen trials, involving more than 4,900 women, were included in the Review. The continuous presence of a trained support person reduced the likelihood of medication for pain relief, operative vaginal delivery, Cesarean delivery, and a 5-minute Apgar score less than 7. Continuous support was also associated with a slight reduction in the length of labour. Five trials evaluated the effects of support on mothers’ views of their childbirth experiences; while the trials used different measures (overall satisfaction, feeling very tense during labour, failure to cope well during labour, finding labour to be worse than expected, and level of personal control during childbirth), in each trial the results favoured the group who had received continuous support.”

Another review stated, “. . . delivery units should routinely endeavor to provide continuous professional support in labour” (Seitchik, J. et al., 1987).

Yet, another review concludes, “There is no more cost-effective or simple strategy to improve the health of laboring women than using the doula” (Sosa, R. et al., 1980).

I would agree completely with John Kennell, MD, who said, “If a doula were a drug, it would be unethical not to use it.” (Kennell JH. Doulas: Into the mainstream of maternity care. Birth 1998;25:213-4)

The father who wants to attend his laboring partner’s birth without the assistance of one or more supportive women (doulas and a midwife) may be placing his desires above the best care available for his partner.

It is becoming increasingly apparent to me that the role of the doula and the father are in no way competitive and in many ways complementary.

With a doula present during and after the birth process, many inappropriate societal expectations and significant pressures are taken off of the father.

Female support persons allow the male to participate at his own comfort level and free him to enter and leave the labor and birth room(s) as desired.

In my experience, fathers usually feel relieved and de-stressed when they can rely on one or more doulas for help and guidance.

A partnership with doulas and midwives can allow a man to feel more significant, reduce his stress and discomfort, and allow him to enjoy the experience more fully.

For those fathers who want to and who can play a more active support role, the doula is still able to assist and guide him in effective ways to help his partner during and after labor and birth.

Can maternity care nurses provide continuous support? Usually they cannot.

One study of over 3,000 quarter-hour observation periods at a university hospital in Montreal found that 6.1 percent of nursing time was spent in activities including “physical comfort emotional support, instruction, and advocacy” (Gagnon AJ, Waghorn K.  Supportive care by maternity nurses: A work sampling study in an intrapartum unit. Birth 1996;23:1-6).

Nearly 75 percent of the nurses’ time, across all shifts and days of the week, was spent outside the room of the parturient, suggesting “the need for perinatal caregivers and hospital administrators to reexamine how nurses spend their time, given the evidence from randomized trials showing the beneficial effects of continuous support on birth outcomes” (Gagnon AJ, Waghorn K.  Supportive care by maternity nurses: A work sampling study in an intrapartum unit. Birth 1996;23:1-6).

A retrospective study at a large public hospital in the United States found that nulliparous patients cared for by nurses for the shortest amount of time prior to the birth (presumably resulting in less time to have “the doula effect”) had a 19% cesarean birth rate compared to only a 4.9%  for those nurses who spent the most time with the patient – no matter which physician was attending the case.

The likelihood of a normal labor and delivery was also increased in patients whose labor nurses were more likely to use a form to record psychosocial data than the nurses who were less likely to fill this out. The authors assumed that filling out this form was an indicator of nurses who spent more time with the patient (Radin, 1993).

Therefore, it appears that the maternity nurse can, if she chooses, be an effective part of the laboring woman’s effective support team.

Unfortunately, since most maternity care nurses appear to either be unable or unwilling to provide the continuous support that a birth mom needs, the responsibility to choose, empower and equip a continuous support team for pregnancy, labor, birth and the postpartum period appears to rest upon the birth mom and her male partner.

Caring and evidence-based birth attendants would appear to be well-served to assist a birth family in choosing such a support team.

One meta-analysis reported this: “Depending on the circumstances, ensuring the provision of continuous support may necessitate alterations in the current work activities of midwives and nurses, such that they are able to spend less time on ineffective activities and more time providing support” (Seitchik, J., ibid).

For many women, then, the ideal birthing support team may include the father of the baby, one or more close female friends or family members and the doula.

The doula should normally be present as an addition to, and not necessarily instead of, the male partner and female friends or family who the birth mom desires to have attend the birth.

Potentially, the doula, male partner, and supportive female friends or relatives may make the perfect team for the woman and her birth attendants (labor nurses, midwives, and/or physician). Each should complement the other’s strengths.

One meta-analysis recommended this: “Given the clear benefits and no known risks associated with intrapartum support, every effort should be made to ensure that all laboring women receive support, not only from those close to them but also from specially trained care givers (nurses, midwives, or lay women). This support should include continuous presence, the provision of hands on comfort, and encouragement” (Seitchik, ibid).

Based upon this review of the birthing literature, it appears reasonable for birth attendants, birth moms, and the male partner to all vigorously seek to recruit an active labor support team that could include female friends or family, a doula, and the father.

Also, based upon this literature, it would appear that birth attendants (midwives, family physicians and obstetricians) who fail to facilitate and encourage the formation of such a support team do so at their and their patients’ peril.

Recognizing the potential strengths and weakness of the father’s role along with the role the father desires during the birth process (coach, teammate or witness) will facilitate the effectiveness of the entire support team and the outcomes the birth family will experience.

Giving the father the freedom to be comfortable and the permission to participate (or NOT participate) in the birth process, as he desires, appears to be appropriate.

One of the most important roles that we prenatal and birth caretakers will ever have may be to encourage, empower and equip the father:

  1. to help organize and facilitate his partner’s female support team,
  2. to learn how to communicate more effectively with his partner, and
  3. to prepare for his critically essential purpose as father to the new child.

Here’s another blog series of mine you might enjoy, “How to Keep Normal Labor Normal”:

  1. Philosophy,
  2. Partners,
  3. Professionals,
  4. Pain control,
  5. Procedures,
  6. Patience,
  7. Preparation,
  8. Positions,
  9. Payment, and
  10. Prayer.

Should dads be in labor and delivery?

Ten years ago I published an article for a midwifery journal on the issue of whether the father of the baby should be in the delivery room or not  (Larimore WL. The Role of the Father in Childbirth. Midwifery Today. Issue No. 51, Autumn, 1999, 15-7). I’ve reprinted the original article here in the post, “The Essential Role of the Father (and a Doula) in Childbirth — ‘Let my people go!'”

In that article, I concluded:

Recognizing the potential strengths and weakness of the father’s role along with the role the father desires during the birth process (coach, teammate or witness) will facilitate the effectiveness of the entire support team and the outcomes the birth family will experience.

Giving the father the freedom to be comfortable and the permission to participate (or NOT participate) in the birth process, as he desires, appears to be appropriate.

One of the most important roles that we prenatal and birth caretakers will ever have may be to encourage, empower and equip the father:

  1. to help organize and facilitate his partner’s female support team,
  2. to learn how to communicate more effectively with his partner, and
  3. to prepare for his critically essential purpose as father to the new child.

Many decades ago, the father of the baby was relegated to the waiting room. The birth of the baby and the announcement of the baby’s sex was once imparted to the father over the phone.

Yet now it’s often the father himself who often tell their exhausted partner the sex of the child she has just delivered.

Now, an article by the BBC is rehashing a debate that is often hidden from birthing families — a debate that asks: Could men be more of a hindrance than a help in the delivery room?

French obstetrician Michel Odent says yes, and even blames fathers for an increasing rate of births by Caesarean section.

At a debate hosted this week by the Royal College of Midwives, Dr. Odent argued against what he dubs “the masculinisation of the birth environment”.

The presence of an anxious male partner in the labour room makes the woman tense and slows her production of the hormone oxytocin, which aids the process of labour, so the French doctor contends.

This, he said, makes her much more likely to end up on the operating table having an emergency Caesarean section.

“Having been involved for more than 50 years in childbirths in homes and hospitals in France, England and Africa, the best environment I know for an easy birth is when there is nobody around the woman in labour apart from a silent, low-profile and experienced midwife,” he says.

“Oxytocin is the love drug which helps the woman give birth and bond with her baby. But it is also a shy hormone and it does not come out when she is surrounded by people and technology. This is what we need to start understanding.”

He will be debated by Duncan Fisher, a leading advocate for fathers, who, while pressing for more preparation for fathers, argues they are there because women want them to be – “and we should trust mothers’ instincts”.

Here we come

Certainly men’s appearance on the labour ward does co-incide with a rising number of caesarean births – although ironically their arrival was in part a backlash against doctor-led, highly-medicalised care in favour of a more woman-centred approach.

In the 1960s only about a quarter of men in the UK attended the birth of an infant, today it is well over 90%.

It is seen as an important rite of passage for any involved father, as well as a marker of social progress – the less developed a country, the more likely childbirth is to be seen as a woman’s business best conducted behind closed doors.

“But I think the other issue is the lack of one-to-one care of women by midwives,” says Winnie Rushby of Doula UK, an organisation which provides birthing support from experienced, but non-medically trained women. “Fathers have been called on to provide that help.

“Some of them are very attuned to the emotional and psychological needs of their partner. But if they are shocked by bodily fluids and very agitated by the pain they see her in, this could play on her mind and stop her psychologically entering the place she needs to be to deliver the baby – the birthing ‘zone’, if you like.

“We’ve gone from men not being there to virtually all men being there. We need to find a new medium, where there is no shame in discussing whether the father should be there or not. Women need to start asking if they really do want him there – and if so, is he prepared for what will go on.”

Staying home

In fact, the greatest advocate of putting men in the mix was US doctor Robert Bradley, who in 1962 published Father’s Presence in Delivery Rooms. This was a review of 4,000 cases when husbands were present.

He concluded, quite contrary to Dr. Odent, that the husband’s presence as a so-called “birth coach” actually helped the woman to relax. “With husbands coaching, we have more than 90% totally unmedicated births. No other approach comes near to that figure,” he wrote.

Iran only recently allowed fathers into the delivery room after the health ministry in Tehran asked doctors to reduce the number of Caesarean births.

At 70% it has been among the highest in the world, and has been explained largely by women’s fear of childbirth. Bringing in the men, it was hoped, would provide women with the reassurance they needed to deliver their baby without surgery.

Whether some men do in fact aid or irk in the delivery room is likely to remain a staple – and unresolved – debate, as any clinical trial would be almost impossible to conduct.

“But what we do know is that there are many reasons why the number of emergency caesarean sections has risen – including obesity, older mothers, and fear of litigation – none of which have anything to do with the presence of dads,” says Patrick O’Brien, a consultant from the Royal College of Obstetricians and Gynaecologists.

“Having a baby together is an intense, life-changing experience that most couples want to experience together. The father can be an immensely reassuring presence for the mother.

“And as for the suggestion that men won’t cope with the so-called gore – well, most of his role can be carried out at the head-end, talking, mopping her brow, offering sips of water. Of course a man shouldn’t feel forced to be there, but I have yet to meet one who said after the birth of his baby – ‘I wish I’d stayed at home’.”

How to Keep Normal Labor Normal – Part 13 – Summary

This blog series is designed to help women who are developing a birth plan join together with like-minded birthing professionals so as to have a shorter and safer labor and birth. In past blogs we’ve looked at my 10 “P’s” of keeping labor shorter and birth safer.

In this blog I’ll present some summary comments. Although written primarily for professional birth attendants, I hope information will be helpful to lay women planning their birth.

Summary

One critical review summed it up by stating, “Doing everything for everyone is neither tenable nor desirable. What is done should be inspired by compassion and guided by science … As(care givers), we are ethically bound to be sure that the tests, procedures, and treatments we provide are worth the money, pain, and inconvenience that they cost. The methods to assess technologies are well accepted and widely available; what remains to be seen is whether we as a profession and a nation have the moral courage to use them.”(67)

Said another way, “If you mess around with a process that works well 98% of the time, there is potential for much harm.” (29)

Symposia or round-table discussions of maternity caregivers are usually “notable, particularly for the extent of disagreement among … authorities concerning how labor should be managed”(17) however, maternity caregivers should all be willing to “… critically assess the effects of each medical practice or procedure on the childbearing family’s comfort and sense of mastery, as well as on their safety.

Aspects of care for which safety benefits are small or unproved should remain subject to the choices and preferences of the woman giving birth.” (5)

In conclusion, there appears to be a growing literature in avoiding unnecessary intervention and in studying mechanisms for increasing the occurrence of normal labor by reducing dystocia and misdiagnosed “fetal distress” so as to reduce unnecessary operative deliveries, thus increasing the occurrence of normal deliveries.

In many ways this literature discussed the delusion (fixed false belief) that technology can or will control the labor and delivery process and strives to balance non-intervention and intervention in such a way as to maximize outcome at the lowest possible cost while increasing our patients’ satisfaction with the birth process.

In some ways, this means that forward thinking maternity care providers will have to advance their patient care armentarium by abandoning some routines and procedures and, in a sense, going back or stepping back in time to combine the best of the “old style” with the best of “science.”

Since it appears that midwives are more likely as a group to practice the “10 P’s,” it seems reasonable that their considerable skills should be utilized more often in teaching family physicians and obstetrician-gynecologists.

One experienced practitioner described the “old ways” this way: “The editorial, ‘Family-centered birthing’(26) proves that medicine, like life, runs in cycles. The editorial brought back many memories of my early days in practice the 1950s in a southern Texas community of 2000 – 30 miles from two small country hospitals and 50 miles from more sophisticated care in San Antonio.” (88)

“My obstetrics professor at the University Medical Branch at Galveston offered the following five precepts for (keeping labor normal and) delivering babies at home:

  1. tell the men to boil water and collect newspapers — it gives them something (useful) to do;
  2. spread a thick layer of newspapers over the bed (they are sterile, comfortable, and) to protect the mattress (which reduces the mother’s anxiety about a dirty mattress – for lessening any worries increases the speed of the labor);
  3. after assuring yourself that the labor is progressing normally, take the leftover newspapers into another room and begin to read them (while smoking a slow smoking cigar in a slow rocking rocker);
  4. utilize the assistance of (as many) female family and friends (as you can find); and
  5. do not practice meddlesome obstetrics.”(88)

“After delivering several hundred babies at home (at $40 each, with payment not always guaranteed) by daylight, firelight, and flashlight, I found family-centered birthing was intellectually rewarding, emotionally satisfying and remarkably safe. (I lost no mothers and only one infant and that was because of a knotted cord).”(88)

How many of us would like at the end of a career to be able to report similar professional outcomes and similar patient satisfaction outcomes associated with similar perinatal morbidity and mortality?

Based upon this review, it does appear that there are a substantial number of potential interventions and non-interventions that maternity care providers and/or systems could and should consider to assist their laboring patients in increasing their (and our) chances in keeping normal labor normal.

It seems to be reasonable for maternity caregivers to replace the “3 P’s” of obstetrics with the “10 P’s” of family-centered birthing.

In this author’s opinion, maternity caregivers in America, particularly physicians, are “poised on the edge of an unequaled opportunity … to bring family-centered maternity care into the mainstream … It is an opportunity to ripe to resist, too grand not to grasp.”(26)

Midwives and doulas, for the most part, and to the shame of their physician colleagues or adversaries, are already there.

Here’s the entire series:
Introduction
The Costs of Abnormal Labor
The “10 Ps”:
Philosophy,
Partners,
Professionals,
Pain control,
Procedures,
Patience,
Preparation,
Positions,
Payment, and
Prayer
Summary
Citations:
    Citations:
    (5) Smith MA, Acheson LS, Byrd JA, et. al. A critical review of labor and birth care. J Fam Pract 1991;33:281-292.
    (26) Larimore WL. Family-centered birthing: history, philosophy, and need. Fam Med 1995;27:132-138.
    (29) Hon, E. In: Young D. Crisis in obstetrics-the management of labor. Int J Childbirth Education 1987, August: 13-5.
    (67) Grimes DA. Technology follies: the uncritical acceptance of medical innovation. J Am Med Assoc 1993;269:3030-3033.
    (88) Nixon SA. Am Fam Physician 1994;47:1353-1354.

    How to Keep Normal Labor Normal – Part 12 – Prayer

    This blog series is designed to help women who are developing a birth plan join together with like-minded birthing professionals so as to have a shorter and safer labor and birth. Although written primarily for professional birth attendants, I hope information will be helpful to lay women planning their birth. Today we’ll look at the tenth “P” of my 10 “P’s” of keeping labor shorter and birth safer — prayer.

    Although labor and delivery has been considered a “spiritual event” by midwives at least since the publication of Spiritual Midwifery(82) in the 1960’s, there is some recent literature that looks at the influence of spiritual beliefs on labor and delivery outcomes.

    One study which examined whether family physicians were aware or not of their patient’s spiritual belief systems stated, “these results suggest that family physicians are infrequently aware of faith beliefs and experiences among their patients.” (83)

    Others have commented on how important a component spirituality is to medical care in general: “We emphasize the importance of understanding the relationship between patients’ religious beliefs and their ability to deal with stress,” (84) and that, “Spirituality is an important aspect of health care that is not often addressed in modern day primary medical practice.

    The authors conclude that, when appropriate, spiritual issues should be addressed in patient care since they may have a positive impact on patient health and behavior.” (85)

    One excellent review shared with practitioners a method for reviewing a patient’s spiritual belief systems using the acrostic SPIRIT where:

    • S = Spiritual belief system;
    • P = Personal spirituality;
    • I = Integration and involvement;
    • R = Ritual practices and/or restrictions;
    • I = Implications for medical care;
    • T = Terminal event (delivery) planning. (86)

    Although prayer and strongly internalized religious belief systems have been shown to have a positive association with positive health outcomes, very little data is available for maternity care outcomes.

    For an event that midwives consider “intuitively spiritual” (82) the paucity of research is surprising.

    However, one study did examine the influence of religious belief on maternity care outcomes and concluded, “Maternal and neonatal complications occurred significantly more often in women who identified themselves as having no religious preference than in women who had a religious affiliation … We conclude that a small positive influence of religion … appears to be a directly beneficial effect.” (87)

    Here’s the entire series:

    1. Philosophy,
    2. Partners,
    3. Professionals,
    4. Pain control,
    5. Procedures,
    6. Patience,
    7. Preparation,
    8. Positions,
    9. Payment, and
    10. Prayer.

      Citations:

      (82) Gaskin IM. Spiritual Midwifery. 3rd edition. Summertown, TN : The Book Publishing Co., 1990.
      (83) King DE, Sobal J, Haggarty J 3d, Dent M, Patton D. Experiences and attitudes about faith healing among family physicians. J Fam Pract 1992;35:158-62.
      (84) Sherill KA, Larson DB. Adult burn patients: the role of religion in recovery. S Med J 1988;7:819-24.
      (85) McKee DD, Chappel JN. Spirituality and medical practice. J Fam Pract 1992;35:201-8.
      (86) Maugans T. The SPIRITual history. Arch Fam Med 1996;5:11-6.
      (87) King DE, Hueston W, Rudy M. Religious affiliation and obstetric outcome. South Med J 1994;87:1125-8.
      (82) Gaskin IM. Spiritual Midwifery. 3rd edition. Summertown, TN : The Book Publishing Co., 1990.
      (83) King DE, Sobal J, Haggarty J 3d, Dent M, Patton D. Experiences and attitudes about faith healing among family physicians. J Fam Pract 1992;35:158-62.
      (84) Sherill KA, Larson DB. Adult burn patients: the role of religion in recovery. S Med J 1988;7:819-24.
      (85) McKee DD, Chappel JN. Spirituality and medical practice. J Fam Pract 1992;35:201-8.
      (86) Maugans T. The SPIRITual history. Arch Fam Med 1996;5:11-6.
      (87) King DE, Hueston W, Rudy M. Religious affiliation and obstetric outcome. South Med J 1994;87:1125-8.

      How to Keep Normal Labor Normal – Part 11 – Payment

      This blog series is designed to help women who are developing a birth plan join together with like-minded birthing professionals so as to have a shorter and safer labor and birth. Although written primarily for professional birth attendants, I hope information will be helpful to lay women planning their birth. In this blog, we’ll look at the ninth “P” of my 10 “P’s” of keeping labor shorter and birth safer — payment.

      Interestingly, if operative deliveries and cesareans can identify labor or delivery processes that are not normal, then the medical literature lists several payment mechanisms that may be associated with keeping normal labor normal.

      First, is the capitation of maternity care services, as “…the probability for cesarean section is lower for an HMO delivery than for a fee-for-service delivery …”(79)

      Not only does capitation, when it reaches a health care service area reduce the incidence of operative deliveries in the capitated systems, but “…  HMO and IPA penetration … have important effects on c-section rates, not only in HMO/IPA settings, but throughout an area.”(79)

      In one California study, “…  successive lower rates (of c-sections) were observed for women covered by private insurance (29%), non-Kaiser HMOs (27%), Medi-Cal (23%), Kaiser (20%), self-pay (19%), indigent services (16%).”(80)

      In addition, “VBACs occurred twice as frequently in women covered by Kaiser (20%) and indigent services (25%), compared to private insurance (8%).”(80)

      Not only this, but the reasons for operative deliveries significantly chanted as “the associations between payment source and cesarean section use were also noted for the indications of breech presentation, dystocia, and fetal distress.”(80)

      In addition, in this study, “Accounting for maternal age and race/ethnicity did not alter these findings.” (80)

      A second payment mechanism that seems to reduce the prevalence of operative delivery is the provision of salaries for maternity care providers, as “… mothers with private, fee-for-service insurance have higher c-section rates than mothers who are covered by staff-model HMOs (where all the doctors are paid a salary), who are uninsured, or who are publicly insured.” (81)

      A third payment option that seems to be associated with reduced operative deliveries is the same payment regardless of the type of delivery (vaginal, operative vaginal, or cesarean) or the type of care giver (midwife or physician): “… typically insurers pay at least 50% more for cesarean section than for vaginal deliveries … (and) … c-section rates were unrelated … to perinatal outcomes … (Therefore, and) … given these results, insurers should consider paying a flat fee for obstetric services unless differing risk levels or risk-adjusted outcomes justify different amounts.” (42)

      One interesting commentary recently stated that “… the bottom line for managed care organizations tends to be cost of care. In other words, bad outcomes are no longer profitable … Because normal births without technical interventions tend to be relatively inexpensive, practices such as intermittent auscultation, avoidance of anesthesia, and a strong emphasis on labor support have a greater chance of acceptance. … Therefore, changes in health care financing, particularly managed care with capitation, may further support these changes.” (42)

      Here’s the entire series:

      1. Philosophy,
      2. Partners,
      3. Professionals,
      4. Pain control,
      5. Procedures,
      6. Patience,
      7. Preparation,
      8. Positions,
      9. Payment, and
      10. Prayer.

        Citations:

        (42) Nesbitt TS. Rural maternity care: new models of access. Birth 1996;23:161-5.

        (79) Stafford RS. Cesarean section use and source of payment: an analysis of California hospital discharge abstracts. Am J Public Health 1990;80:313-5.

        (80) Keeler EB, Brodie M. Economic incentives in the choice between vaginal delivery and cesarean section. Milbank Q 1993;71:365-404.

        (81) Finkler MD, Wirtshcafer DD. Why pay extra for cesarean-section deliveries? Inquiry 1993;30:208-15.

        (79) Stafford RS. Cesarean section use and source of payment: an analysis of California hospital discharge abstracts. Am J Public Health 1990;80:313-5.

        (80) Keeler EB, Brodie M. Economic incentives in the choice between vaginal delivery and cesarean section. Milbank Q 1993;71:365-404.

        (81) Finkler MD, Wirtshcafer DD. Why pay extra for cesarean-section deliveries? Inquiry 1993;30:208-15.

        How to Keep Normal Labor Normal – Part 10 – Positions

        This blog series is designed to help women who are developing a birth plan join together with like-minded birthing professionals so as to have a shorter and safer labor and birth. Although written primarily for professional birth attendants, I hope information will be helpful to lay women planning their birth. Today we’ll look at the eighth “P” of my 10 “P’s” of keeping labor shorter and birth safer — positions (or position change).

        Many maternity caregivers forget that “ambulation is also a treatment,”(17) however, “most laboring women expect to and are expected to labor mostly in bed,”(61) despite the fact that “women seem to prefer freedom of movement”(27,61, 74) in labor.

        Avoiding the dorsal recumbent position in the labor bed, changing of positions in labor and delivery, and ambulation of the laboring patient may be helpful in preserving normal labor.

        “Restriction of mobility, which occurs as a result of using fetal monitors and/or intravenous lines, results in increased epidural analgesia, increased diagnosis of ‘fetal distress,’ and increased cesarean section rates. Upright posture or ambulation was associated with decreased narcotic analgesia and epidural anaesthesia.”(75)

        Position change in labor seems to be not only a critical element, but “unassisted laboring women will assume, over 50% of the time, standing, crouching, squatting, sitting, or kneeling positions.”(74)

        “When given the freedom to assume any position desired without interference or instruction, (is associated with) a high degree of position change, with an average of 7.5 positions per woman.”(76)

        “Physiologic positioning is a major component of pain management, and women throughout the world use body positioning to make labor more comfortable and efficient. Two factors distinguish a woman’s natural choice of position”(27) as opposed to the provider’s choice.

        “First, there is no single ideal labor position — women will constantly change position to be comfortable”(27) and there appears to be no reason to stop them.

        “Second, except in many Western industrialized countries, almost all women give birth in some form of upright position, be it standing, sitting, or squatting.”(27) “Position changes may also be useful in encouraging rotation of the head to an anterior position or in the alleviation of dystocia.”(77)

        “There is good evidence that postion change is useful in achieving good progress in labor, is well tolerated, and can be safely accomplished. Position change may be more important than a single ‘best’ position.”(5)

        “(Why do nurse midwives have lower cesarean section rates for dystocia (and presumably less dystocia) than family physicians?) It is possible that … subtle clinical differences … such … as the use of position change in labor or patient massage — clinical skills practiced by midwives but infrequently used by family physicians (may explain the difference).”(46)

        “It appears clear that laboring women should move, change positions, move again, and avoid supine recumbency. Also, comfort, safety, and optimal physiologic functioning, not blind routine and physicians’ convenience, should be the criteria used in determining labor and delivery positions for each individual.”(75)

        “Women and their birth attendants should be educated in and encouraged to practice different labor and birth positions to allow for greater opportunities to achieve comfort, alleviate dystocia or malposition, and better adapt to individual needs.”(5)

        In summary, a recent meta-analysis reported that there are “… clear advantages for women in adopting an upright posture … when compared to being recumbent … less discomfort, intolerable pain, difficulty in bearing down, abnormal delivery, perineal/vaginal trauma, vulva edema, and wound infections”(78) as “positions and movement contribute to both comfort and labor progress … (and) if progress slows, a change of position or movement will often end it.”(61)

        Here’s the entire series:

        1. Philosophy,
        2. Partners,
        3. Professionals,
        4. Pain control,
        5. Procedures,
        6. Patience,
        7. Preparation,
        8. Positions,
        9. Payment, and
        10. Prayer.

          Citations:

          (5) Smith MA, Acheson LS, Byrd JA, et. al. A critical review of labor and birth care.   J Fam Pract 1991;33:281-292.

          (17) Young D. Crisis in obstetrics – the management of labor. Int J Childbirth Education 1987, August: 13-5.

          (27) Fenwick L.  Birthing:  techniques for managing the physiologic and psychosocial aspects of childbirth.  Perinatal Nurs 1984, May/June:51-62.

          (46) Hueston WJ, Rudy MA.  A comparison of labor and delivery management between nurse midwives and family physicians.  J Fam Pract 1993;37:449-454.

          (61) Simpkin P.  Reducing pain and enhancing progress in labor: a guide to nonpharmcologic methods for maternity caregivers.  Birth 1995;22:161-71.

          (74) Hundley VA, Cruickshank FM, Lang GD, et. al.  Midwife managed delivery unit: a randomized controlled comparison with consultant led care.  Br Med J 1994;309:1400-1404.

          (75) McKay S, Mahan CS.  Laboring patients need more freedom to move.  Contemporary Ob/Gyn 1984;24:90-119.

          (76) Carlson M, Diehl JA, Sachtleben-Murray M, McRae M, et.al.  Maternal position during parturition in normal labor.  Obstet Gynecol 1986;68:443-447.

          (77) Andrews CM.  Changing fetal position.  J Nurs Midwife 1980;25:7-12.

          (78) Nikodem VC.  Upright vs recumbent position during second stage.  In:  Pregnancy and childbirth module (eds. Enkin MW, Keirse MJNC, Renfrew MJ, Neilson JP), ‘Cochrane Database of Systematic Reviews’: Review No. 03335, 6 May 1994.  Oxford: Update Software, 1994, Disk Issue 1.

          This blog series is designed to help women who are developing a birth plan join together with like-minded birthing professionals so as to have a shorter and safer labor and birth. Although written primarily for professional birth attendants, I hope information will be helpful to lay women planning their birth.
          Today we’ll look at the eighth “P” of my 10 “P’s” of keeping labor shorter and birth safer — positions (or position change).
          Many maternity caregivers forget that “ambulation is also a treatment,”(17) however, “most laboring women expect to and are expected to labor mostly in bed.”(61) despite the fact that “women seem to prefer freedom of movement”(27,61, 74) in labor.  Avoiding the dorsal recumbent position in the labor bed, changing of positions in labor and delivery, and ambulation of the laboring patient may be helpful in preserving normal labor.  “Restriction of mobility, which occurs as a result of using fetal monitors and/or intravenous lines, results in increased epidural analgesia, increased diagnosis of ‘fetal distress,’ and increased cesarean section rates.  Upright posture or ambulation was associated with decreased narcotic analgesia and epidural anaesthesia.”(75)
          Position change in labor seems to be not only a critical element, but “unassisted laboring women will assume, over 50% of the time, standing, crouching, squatting, sitting, or kneeling positions.”(74)  “When given the freedom to assume any position desired without interference or instruction, (is associated with) a high degree of position change, with an average of 7.5 positions per woman.”(76)
          “Physiologic positioning is a major component of pain management, and women throughout the world use body positioning to make labor more comfortable and efficient.  Two factors distinguish a woman’s natural choice of position”(27) as opposed to the provider’s choice.  “First, there is no single ideal labor position — women will constantly change position to be comfortable”(27) and there appears to be no reason to stop them.  “Second, except in many Western industrialized countries, almost all women give birth in some form of upright position, be it standing, sitting, or squatting.”(27)  “Position changes may also be useful in encouraging rotation of the head to an anterior position or in the alleviation of dystocia.”(77)
          “There is good evidence that postion change is useful in achieving good progress in labor, is well tolerated, and can be safely accomplished.  Position change may be more important than a single ‘best’ position.”(5)  “(Why do nurse midwives have lower cesarean section rates for dystocia (and presumably less dystocia) than family physicians?)  It is possible that…subtle clinical differences…such…as the use of position change in labor or patient massage — clinical skills practiced by midwives but infrequently used by family physicians (may explain the difference).”(46)
          “It appears clear that laboring women should move, change positions, move again, and avoid supine recumbency.  Also, comfort, safety, and optimal physiologic functioning, not blind routine and physicians’ convenience, should be the criteria used in determining labor and delivery positions for each individual.”(75) “Women and their birth attendants should be educated in and encouraged to practice different labor and birth positions to allow for greater opportunities to achieve comfort, alleviate dystocia or malposition, and better adapt to individual needs.”(5)
          In summary, a recent meta-analysis reported that there are “…clear advantages for women in adopting an upright posture… when compared to being recumbent…less discomfort, intolerable pain, difficulty in bearing down, abnormal delivery, perineal/vaginal trauma, vulva edema, and wound infections”(78) as “positions and movement contribute to both comfort and labor progress…(and) if progress slows, a change of position or movement will often end it.”(61)

          How to Keep Normal Labor Normal – Part 9 – Preparation

          This blog series is designed to help women who are developing a birth plan join together with like-minded birthing professionals so as to have a shorter and safer labor and birth. Although written primarily for professional birth attendants, I hope information will be helpful to lay women planning their birth.
          Today we’ll look at the seventh “P” of my 10 “P’s” of keeping labor shorter and birth safer — patient preparation (or psyche prep).
          Most maternity care givers seem to accept the proposition that a prepared patient is infinitely preferable to an unprepared one.  The literature in this area is best summed up by saying that “all patients should receive basic (prenatal) education…”(5)  If a care giver helps or encourages a woman to prepare an individualized birth plan, the literature would seem to indicate, then labor is more likely to remain normal, primarily because a woman becomes aware of their options.  “95% of women said that they would encourage other women to use the (birth) plan.  It increased their understanding about the labor and birth, and the hospital options open to them…Women said (the birth plan) was helpful, helped them express their needs and preferences, enhanced their confidence, and improved communication between them and staff…Birth plans show the commitment of health caregivers to recognizing and supporting diversity, allow for critical reappraisal of existing hospital policies and practices, and provide an opportunity for quality improvement in the context of client rights and preferences.”(30)
          What is even more interesting is the research that seems to indicate that prenatal preparation may effect postpartum psychosocial outcomes.  For example, “prenatal parenting communication classes had a significant impact on postpartum anxiety, postpartum marital satisfaction, and postpartum adjustment.”(73)  “An increasing body of evidence in the scientific literature indicates that the well-prepared woman, with good labor support…is unlikely to need analgesia or anesthesia and is unlikely to require cesarean section.”(42)
          However, not only patients benefit from education about non-interventional options and interventions that can increase the chance of keeping normal labor normal, because “…we know that the rate of cesarean section can be reduced by half by education programs based in community hospitals.  Such programs teach physicians techniques of labor, active management of labor, and the appropriate use of electronic monitoring.”(15)
          Here’s the entire series:
          Introduction
          The Costs of Abnormal Labor
          Philosophy,
          Partners,
          Professionals,
          Pain control,
          Procedures,
          Patience,
          Preparation,
          Positions,
          Payment, and
          Prayer
          Summary

          This blog series is designed to help women who are developing a birth plan join together with like-minded birthing professionals so as to have a shorter and safer labor and birth. Although written primarily for professional birth attendants, I hope information will be helpful to lay women planning their birth. Today we’ll look at the seventh “P” of my 10 “P’s” of keeping labor shorter and birth safer — patient preparation (or psychological prep).

          Most maternity care givers seem to accept the proposition that a prepared patient is infinitely preferable to an unprepared one. The medical literature in this area is best summed up by saying that “all patients should receive basic (prenatal) education …”(5)

          If a care giver helps or encourages a woman to prepare an individualized birth plan, the literature would seem to indicate, then labor is more likely to remain normal, primarily because a woman becomes aware of their options.

          “95% of women said that they would encourage other women to use the (birth) plan. It increased their understanding about the labor and birth, and the hospital options open to them … Women said (the birth plan) was helpful, helped them express their needs and preferences, enhanced their confidence, and improved communication between them and staff … Birth plans show the commitment of health caregivers to recognizing and supporting diversity, allow for critical reappraisal of existing hospital policies and practices, and provide an opportunity for quality improvement in the context of client rights and preferences.”(30)

          What is even more interesting is the research that seems to indicate that prenatal preparation may effect even postpartum psychosocial outcomes.

          For example, “prenatal parenting communication classes had a significant impact on postpartum anxiety, postpartum marital satisfaction, and postpartum adjustment.”(73)

          Also this: “An increasing body of evidence in the scientific literature indicates that the well-prepared woman, with good labor support … is unlikely to need analgesia or anesthesia and is unlikely to require cesarean section.”(42)

          However, not only patients benefit from education about non-interventional options and interventions that can increase the chance of keeping normal labor normal, because “… we know that the rate of cesarean section can be reduced by half by education programs based in community hospitals. Such programs teach physicians techniques of labor, active management of labor, and the appropriate use of electronic monitoring.”(15)

          Here’s the entire series:

          1. Philosophy,
          2. Partners,
          3. Professionals,
          4. Pain control,
          5. Procedures,
          6. Patience,
          7. Preparation,
          8. Positions,
          9. Payment, and
          10. Prayer.

            Citations:

            (5)Smith MA, Acheson LS, Byrd JA, et. al. A critical review of labor and birth care.   J Fam Pract 1991;33:281-292.
            (15) Paul RH.  Toward fewer cesarean sections: the role of the trial of labor (editorial).  NEJM 1996;335:735-6.
            (30) Moore M, Hopper U.  Do birth plans empower women?  Evaluation of a hospital birth plan.  Birth 1995;22:29-36.

            How to Keep Normal Labor Normal – Part 8 – Patience

            This blog series is designed to help women who are developing a birth plan join together with like-minded birthing professionals so as to have a shorter and safer labor and birth. Although written primarily for professional birth attendants, I hope information will be helpful to lay women planning their birth. Today we’ll look at the sixth “P” of my 10 “P’s” of keeping labor shorter and birth safer — patience.

            “We’ve forgotten that most women deliver in time.  If you allow 24 hours to elapse before intervening, you wouldn’t have the high cesarean rate … we’re  not doing the combination of the right things in managing labor.”(29)  Not only are the “24-hour” or the “12-hour” rules open to debate, but the “2-hour” rule is also being questioned:  “The two-hour rule for second stage is passé.  We studied 4000 women in which we found no direct effect of the duration of second stage of labor on immediate measures of perinatal outcome of maternal morbidity.”(70)

            Of interest, the literature suggests that in some cases intervention delay can be helpful.  For example, “…patients cared for by nurse midwives, who have to see a family physician before referral to an obstetrician for cesarean section, require additional time…which may have afforded the patient enough time to progress in labor and obviated the need for a cesarean section.  The implication is that a large number of cesarean sections for dystocia could be avoided if patients were allowed to labor longer.”(72)

            “We’ve forgotten that most women deliver in time. If you allow 24 hours to elapse before intervening, you wouldn’t have the high cesarean rate … we’re  not doing the combination of the right things in managing labor.”(29)

            Not only are the “24-hour” or the “12-hour” rules open to debate, but the “2-hour” rule is also being questioned:  “The two-hour rule for second stage is passé. We studied 4000 women in which we found no direct effect of the duration of second stage of labor on immediate measures of perinatal outcome of maternal morbidity.”(70)

            Of interest, the literature suggests that in some cases intervention delay can be helpful.

            For example, “… patients cared for by nurse midwives, who have to see a family physician before referral to an obstetrician for cesarean section, require additional time … which may have afforded the patient enough time to progress in labor and obviated the need for a cesarean section. The implication is that a large number of cesarean sections for dystocia could be avoided if patients were allowed to labor longer.”(72)

            Citations:
            (29) Hon, E. In: Young D. Crisis in obstetrics-the management of labor. Int J Childbirth Education 1987, August: 13-5.
            (70) Cohen, W.  In: Young D. Crisis in obstetrics – the management of labor. Int J Childbirth Education 1987, August: 13-5.
            (71) Sandmire HF, DeMott RK.  Auscultation of the fetal heart presents advantages over electronic monitoring.  Wis Med J 1995;94:661-3.
            (72) Hueston WJ, Rudy MA.  A comparison of labor and delivery management between nurse midwives and family physicians.  J Fam Pract 1993;37:449-454.

            How to Keep Normal Labor Normal – Part 7 – Procedures

            This blog series is designed to help women who are developing a birth plan join together with like-minded birthing professionals so as to have a shorter and safer labor and birth. Although written primarily for professional birth attendants, I hope information will be helpful to lay women planning their birth. Today we’ll look at the fifth “P” of my 10 “P’s” of keeping labor shorter and birth safer — procedures.

            A primary dictum of ethical medical care is to not cause harm. Therefore, increased evidence of outcome or evidence based decision making is clear in the literature. “While enthusiasm for … evidence-based medicine is growing, several barriers … persist.”(67)

            One of the best discourses on this topic merits repeating:

            “First, ‘seduction by authority’ has reigned for centuries. Decisions about a new technology must be based on the weight of the scientific evidence, not on the perceived prestige of its proponent, as occurred … with electronic fetal monitoring.”

            “A second impediment is the ‘false idol of technology.’ Many American physicians not only accept new technology without critical appraisal, but they also seem to worship it. Some of this penchant for mew gadgets and procedures relates to the fundamental problem of physicians’ being paid for doing things to patients, rather than for keeping them well … Awareness is now growing, that doing things to patients … may actually make them sick — as well as poor.”

            “A third hurdle is the inevitable tendency to let sleeping dogmas lie.  That routine episiotomy for delivery has prevailed for over a half century without critical assessment and that widespread electronic fetal monitoring continues, despite recent studies, reflect the inertia that drives medical practice.”

            “A fourth problem is the pursuit of pedantry in medical education.  As noted by Pickering, medical education in the United States is, to a large extent, worship at the improbable shrine of useless information.  We produce ‘scientific illiterates’ who are filled like an overstuffed sofa with the products of science, but who are not scientific in their approach to clinical questions or new technologies.”

            “A fifth stubborn problem is the paradigm of clinical practice: numerators in search of a denominator.  Many of us practice medicine by the last disaster we encountered — or heard about.”

            “Doing everything for everyone is neither tenable nor desirable.  What is done should be inspired by compassion and guided by science … As physicians, we are ethically bound to be sure that the tests, procedures, and treatments we provide are worth the money, pain, and inconvenience that they cost. The methods to assess technologies are well accepted and widely available; what remains to be seen is whether we as a profession and a nation have the moral courage to use them”(67)

            It would appear that physicians involved in maternity care for the last 60 years have been guilty, in large part of many if not all of the above charges. The current debates about continuous EFM and routine episiotomy occupy a fair amount of literature debate.

            Routine episiotomy

            Routine episiotomies are still performed by the majority of obstetrician-gynecologists, but the practice has been increasingly criticized.

            One critical review says that, “routine episiotomy for uncomplicated spontaneous vertex vaginal deliveries is not indicated.”(5)

            The first North American randomized controlled trial on episiotomy reported that “there is no evidence that liberal or routine episiotomy prevents perineal trauma or pelvic floor relaxation. Virtually all severe perineal trauma was associated with median episiotomy. It is our recommendation that liberal or routine use of episiotomy be abandoned.”(68)

            Of interest is the suggestion that “(there is) an intriguing association between episiotomy utilization and other procedures and management style.”(40)

            “The question, ‘Do you routinely perform episiotomies?’, if answered in the affirmative, is highly predictive of providers who routinely perform a variety of interventions (whether indicated or not), who have ‘high-control,’ ‘medical model,’ or ‘maximin approach’ labor philosophies, and who have higher rates of cesarean birth secondary to ‘dystocia’ ”(69) and “… we have determined that physicians who use episiotomy frequently and routinely often do so as part of an interventionalistic pattern or style of practice.”(40)

            Interestingly, this interventionalistic style resulted in patients who “… experienced less satisfaction with the birth experience (p<0.01) than the patients of physicians who viewed the procedure very unfavorably.”(40)  This observation, if valid, would also support the “first P” of the provider’s philosophy.

            Routine continuous electronic fetal monitoring

            The critical reviews, editorials, and comments on continuous EFM exist in the writings both of those who support and oppose routine obstetrical intervention.

            The latter group appreciates comments such as those attributed to one of the first developers of fetal monitoring, Edward Hon, M.D., “Not all women should be electronically monitored … most women in labor are better off at home than in the hospital with a fetal monitor … Most obstetricians don’t understand the monitor. They’re dropping the knife with each drop in the fetal heart rate. The cesarean section is considered as a rescue mission of the baby by the white knight, but actually you’ve assaulted the mother.”(29)

            Less polemic comments, however, equally encourage physicians interested in keeping normal labor normal to consider avoiding the monitor:

            “Routine EFM has not been shown to improve perinatal outcomes. There is an association between routine EFM and an increased frequency of cesarean sections.  Periodic auscultation is at least as effective as EFM in detecting fetal distress in otherwise low-risk women and promotes greater patient-provider contact.”(5)

            Another review suggests that “if an unnecessary cesarean section is considered a morbidity outcome of labor, then continuous electronic monitoring is contraindicated in normal patients.”(13)

            Recently a protocol to help maternity caregivers increase their rate on intermittent auscultation (thus attempting to increase the rate of “normal labor”).(71)

            A reasonable summary of the issue of avoiding routine or potentially unnecessary procedures or interventions was found in one critical review which encouraged providers of maternity care to “… critically assess the effects of each medical practice or procedure on the childbearing family’s comfort and sense of mastery, as well as on their safety. Aspects of care for which safety benefits are small or unproved should remain subject to the choices and preferences of the woman giving birth.”(5)

            Here’s the entire series:

            1. Philosophy,
            2. Partners,
            3. Professionals,
            4. Pain control,
            5. Procedures,
            6. Patience,
            7. Preparation,
            8. Positions,
            9. Payment, and
            10. Prayer.

            Citations:

            (5) Smith MA, Acheson LS, Byrd JA, et. al. A critical review of labor and birth care.   J Fam Pract 1991;33:281-292.
            (13) Scherger JE.  Management of normal labor and birth.  Primary Care 1993;20:713-719.
            (29) Hon, E. In: Young D. Crisis in obstetrics-the management of labor. Int J Childbirth Education 1987, August: 13-5.
            (40) Klein MC, Kaczorowski J, Robbins JM, Gauthier RJ, et.al.  Physicians’ beliefs and behavior during a randomized controlled trial of episiotomy. Can Med Assoc J 1995;153:769-79.
            (67) Grimes DA.  Technology follies: the uncritical acceptance of medical innovation.  J Am Med Assoc 1993;269:3030-3033.
            (68) Klein MC, Gauthier RJ, Jorgensen SH.  Does episiotomy prevent perineal trauma and pelvic floor relaxation?  [article].  Online J Curr Clin Trials [serial online] 1992 Jul 1;1992(Doc No 10).
            (69) Klein MC.  Personal communication.
            (70) Cohen, W.  In: Young D. Crisis in obstetrics – the management of labor. Int J Childbirth Education 1987, August: 13-5.
            (71) Sandmire HF, DeMott RK.  Auscultation of the fetal heart presents advantages over electronic monitoring.  Wis Med J 1995;94:661-3.

            How to Keep Normal Labor Normal – Part 6 – Pain Control

            This blog series is designed to help women who are developing a birth plan join together with like-minded birthing professionals so as to have a shorter and safer labor and birth. Although written primarily for professional birth attendants, I hope information will be helpful to lay women planning their birth. Today we’ll look at the fourth “P” of my 10 “P’s” of keeping labor shorter and birth safer — pain control.

            “Controlling the pain of labor without harm to (the) … labor process remains a major focus for maternity care.”(61) This focus has resulted in the escalation of epidural use, despite the fact that epidurals continue to be controversial.

            Even so, meta-analysis and critical reviews are available.

            “Epidural, when properly administered, provides excellent analgesia, although it is associated with prolonged labor, results in higher rates of instrument-assisted delivery, increased use of oxytocin, and possibly increased cesarean -section rate…as up to 47% of fetal heart rate tracings may be abnormal after epidural blockade.”(5)

            One meta-analysis says that “recent study contains well documented data showing an approximate increase of two hours in the length of the 1st stage of labour.”(62)  A population based study says that “epidural use increases the average length of second stage of labor by 38 minutes in primiparas and 23 minutes for multiparas.”(63)

            Another tact of the attack on epidurals says that “women who receive an epidural were 4.3 times more likely to have a cesarean than those who did not (17% vs 4%) … when all factors were controlled for, epidural anesthesia was associated with a 3.7 fold increase for cesarean section, and a 6.5 fold increase for failure to progress. They also had slower rates of dilation (0.5 vs 1.2 cm/hr).”(64)

            However, meta-analysis data seem to confirm this criticism:  “There is a significant increase in the cesarean section rate in the three largest studies which were of sufficient size to report an incidence of cesarean section. The major reason for this seems to be an increase in the cesarean section rate for fetal distress.” (62)

            “The only two trials in which relevant data were reported confirm that epidurals predispose to a two fold increase in the incidence of malrotation of the presenting part, and a four fold increase in the use of instrumental delivery.”(62)

            One meta-analysis summed it up this way, “…Given such strong evidence of the effects of epidural analgesia on the dynamics of labour, a mother receiving epidural analgesia can no longer be considered to be having a ‘normal’ labour.”(62)

            If this is true, then it follows that avoiding epidural, by definition, will help keep normal labor normal, at least until further study shows that different techniques dispel these criticisms.

            Although whirlpool baths in labor (called by some “the midwives’ epidural”(65)) seem to have “…positive effects on analgesia requirements, instrumentation rates, condition of the perineum and personal satisfaction…”(65), all of which help keep normal labor normal; however, they may significantly lengthen labor.(65,66)

            Overlooked by many maternity caregivers is the literature that says, “…Many simple, effective, low-cost methods to relieve labor pain can be initiated by nurses, midwives, or physicians with the potential benefits of improved labor progress, reduction in the use of riskier medications, (improved) patient satisfaction, and lower costs … Unfortunately, training and practice in the use of these measures are not included in the education of most maternity caregivers … This lack of knowledge is at least partially responsible for today’s reliance on drug management of labor pain.  Employing a broad range of effective and simple techniques can promote the laboring woman’s physical comfort … and labor progress.”(61)

            Here’s the entire series:

            1. Philosophy,
            2. Partners,
            3. Professionals,
            4. Pain control,
            5. Procedures,
            6. Patience,
            7. Preparation,
            8. Positions,
            9. Payment, and
            10. Prayer.

            Citations:

            (5) Smith MA, Acheson LS, Byrd JA, et. al. A critical review of labor and birth care.   J Fam Pract 1991;33:281-292.
            (61) Simpkin P.  Reducing pain and enhancing progress in labor: a guide to nonpharmcologic methods for maternity caregivers.  Birth 1995;22:161-71.
            (62) Howell CJ.  Epidural vs non-epidural analgesia in labour.  In:  Pregnancy and childbirth module (eds. Enkin MW, Keirse MJNC, Renfrew MJ, Neilson JP), ‘Cochrane Database of Systematic Reviews’: Review No. 03399, 6 May 1994.  Oxford: Update Software, 1994, Disk Issue 1.
            (63) Johnson S, Rosenfeld JA.  The effect of epidural anesthesia on the length of labor.  J Fam Pract 1995;40:244-247.
            (64) Stephenson J.  Epidural during first stage of labor quadruples risk of C-section.  Fam Pract News 1995, March 15:29.
            (65) Rush J, Burlock S, Lambert K, Loosley M, Hutchison B, et. al.  The effect of whirlpool baths in labor: a randomized, controlled trial.  Birth 1996;23:136-43.
            (66) Bastide A.  A randomized, controlled trial of a whirlpool bath on labour, birth and postpartum.  In: Chalmers I, ed.  Oxford Database of Perinatal Trials, version 1.2, disk issue 8, record 5789.  Oxford: Oxford University Press. 1992.

            How to Keep Normal Labor Normal – Part 5 – Professional Birth Attendants

            This blog series is designed to help women who are developing a birth plan join together with like-minded birthing professionals so as to have a shorter and safer labor and birth. Although written primarily for professional birth attendants, I hope information will be helpful to lay women planning their birth. Today we’ll look at the third “P” of my 10 “P’s” of keeping labor shorter and birth safer — professionals.

            When the literature discusses the effect of the care giver on birth, it generally discusses the midwife or the physician.  However, there is at least one study that suggests that the choice of the nurse we use in labor can effect outcome.

            “Nursing care has been shown to influence length of labor, use of pain medications, and women’s physiological outcomes … this retrospective study … in a large not for profit hospital … with nulliparous women … (showed) large differences in cesarean birth rates between nurses in the lowest quintile (4.9%) and the highest quintile (19%) … the lowest quintile (also showed) the shortest times form assumption of care to delivery … (and were) less likely to have forceps … (and) more likely to use a form to record psychosocial data than the nurses in the highest quintile.”(49)

            There is some risk-controlled data that compares the outcomes of midwives and family physicians.

            “Family physicians and nurse midwives managed patients in labor similarly, but nurse midwives were more likely to achieve vaginal delivery and do so without an episiotomy (40% vs 30% primip, p=.02; 20% vs 10% multip, p=.007).

            Primiparous women managed by family physicians were more likely to under go cesarean section resulting from the diagnosis of dystocia (14% vs 8%, P=.05) … with a relative risk of 2.79 for cesarean if patients had their labor managed by a family physician (p<.001).”(46)

            In addition, “family physicians fall between the higher episiotomy (and intervention) rates of obstetricians and the lower rates of midwives.”(46)

            However, “similarities in the obstetrical philosophies of family physicians and nurse midwives have led some to suggest that a natural alliance should exist between these health professionals. However, there are only a few descriptions of successful alliances of midwives and family physicians.”(46)

            “Most family physicians have philosophical and practice styles that are similar and maternity care outcomes that are remarkably similar (to midwives)…and (family physicians and midwives) should work closer together.  The potential advantages are numerous and the disadvantages more imagined that real.”(39)

            At least 15 studies compare midwives to physicians (obstetricians or obstetricians and family physicians).(50)

            One randomized, controlled trial in Canada typifies the results of most:  “… midwives are less likely to use a variety of interventions such as cesarean delivery (4.0% vs. 15.1%), episiotomy (15.5% vs. 32.9%), epidural (12.9% vs. 23.7%), along with a reduction in the use of routine ultrasound, intravenous drug use, hospital length of stay, and neonatal ICU admission.”(51)

            It appears that midwives keep normal labor normal more often than their physician colleagues and that their utilization in a “… health care system is an appropriate use of health care dollars,”(51) especially since the trend in this study is confirmed by meta-analysis.(50)

            There is some data, controlled for patient risk status, that compares the outcomes of family physicians and obstetrician-gynecologists.  One report states that “…the observed socioeconomic biases in the use of cesarean sections (by obstetricians) have not been reported for maternity care rendered by family physicians.”(52)

            Another says that “Obstetricians performed episiotomies more frequently, used oxytocin augmentation more often, and supervised labors during which an increased frequency of major lacerations in patients occurred.”(53)

            “Family physicians and obstetricians differ in their management of labor and delivery.  In general, … family physicians tend to use less oxytocin both for induction and augmentation and were less likely to perform invasive interventions such as amniotomy, episiotomy, and instrument delivery. Family physicians have been reported to have cesarean section rates that were approximately 33% less than the rates of obstetricians in the same institution.”(46)

            “(Low-risk) patients of obstetricians were almost three times as likely to have a cesarean delivery than were family physicians; cesarean section rate was 11.3% for obstetricians compared to 3.8% for family physicians (p=.0052).”(54)

            “Even after adjustment for … risk, obstetrician-supervised teaching services had … more frequent use of epidural anesthesia, and higher episiotomy and cesarean section rates than family practice teaching services.”(55)

            Although all these data contain significant selection bias,(53) at the very least there appears to be no harm to the midwife’s or family physician’s noninterventional approach to labor: “The style of obstetrical management by (midwives and) family physicians is characterized by significantly less intervention during labor. Yet this style of management does not adversely affect maternal and newborn outcomes.”(56)

            “Taken overall, it appears that the literature paints a picture that could be interpreted to say that if one wants to keep normal labor normal, one should utilize more midwives and family physicians and reserve most obstetrician services for the specialized cases they are best trained to manage.”(42)

            Certainly, it seems appropriate to ask physicians or policy makers who oppose maternity care provision by midwives or family physicians to replicate better (or, at least equivalent) outcomes.

            As a result of outcomes such as those discussed above “… a recently described maternity model … had nurse-midwives for care of routine obstetric and newborn patients; family physicians in an intermediate role, particularly with assisted deliveries, complicated pregnancies, and sicker newborns; and obstetricians providing cesarean sections and high-risk consultations.”(42)

            In Great Britain, the differences in providers, their philosophies, their practice styles and their outcomes is leading to an environment where “both general practitioners and midwives are to be involved in the training of future obstetricians and both will take part in their assessment.  Already obstetricians no longer teach or examine midwives.”(57)

            However, all maternity caretakers should be “… knowledgeable in obstetric crisis management …”(39,42) (such as is taught in the Advance Life Support in Obstetrics [ALSO] Course(58-60)), and they should be ,”… trained…in a philosophy of noninterventional, patient-centered, not facility-centered, maternity care and birthing based on the view that birth, a life event, more often than not needs practitioners who are adept at the ancient art of ‘doing nothing.’  They will know when it is suitable ‘to do nothing,’ when they are appropriately ‘doing nothing,’ and will do it well.  In fact, they should know how to and when to ‘do nothing’ extremely well.”(39)

            Here’s the entire series:

            1. Philosophy,
            2. Partners,
            3. Professionals,
            4. Pain control,
            5. Procedures,
            6. Patience,
            7. Preparation,
            8. Positions,
            9. Payment, and
            10. Prayer.

            Citations:

            (39) Larimore WL, Reynolds JL.  Family practice maternity care in America: ruminations on reproducing an endangered species – family physicians who deliver babies.  J Am Bd Fam Pract 1994;7:1-11

            (42) Nesbitt TS.  Rural maternity care: new models of access.  Birth 1996;23:161-5.

            (46) Hueston WJ, Rudy MA.  A comparison of labor and delivery management between nurse midwives and family physicians.  J Fam Pract 1993;37:449-454.

            (47) Thornton JG, Lilford RJ.  Active management of labour: current knowledge and research issues.  BMJ 1994;309:366-369.

            (48) Hodnett ED.  Support from caregivers during childbirth.  In:  Pregnancy and childbirth module (eds. Enkin MW, Keirse MJNC, Renfrew MJ, Neilson JP), ‘Cochrane Database of Systematic Reviews’: Review No. 03871, 3 October 1994.  Oxford: Update Software, 1994, Disk Issue 1.

            (49) Radin TG, Harmon JS, Hanson DA.  Nurses’ care during labor:  its effects on the cesarean birth rate of healthy, nulliparous women.  Birth 1993;20:14-20.

            (50) Brown SA, Grimes DE.  Nurse practitioners and certified nurse midwives: a meta-analysis of nurses in primary care.  Washington, DC:  American Nurses’ Association 1993.

            (51) Harvey S, Jarrell J, Brant R, Stainton C, Rach D.  A randomized, controlled trial of nurse midwifery care.  Birth 1996;23:128-33.

            (52) Hueston WJ.  Obstetric referral in family practice.  J Fam Pract 1994;38:368-372.

            (53) Chambliss LR, Daly C, McDearis AL, et. al.  The role of selection bias in comparing cesarean birth rates between physician and midwife management.  Obstet Gynecol 1992;80:161-165.

            (54) Applegate JA, Walhout MF.  Cesarean section rate: a comparison between family physicians and obstetricians.  Fam Pract Res J 1992;12:255-262.

            (55) Hueston WJ, Rudy M.  Differences in labor and delivery experience in family physician- and obstetrician-supervised teaching services.  Fam Med 1995;27:182-187.

            (56) MacDonald SE, Voaklander K, Birtwhistle RV.  A comparison of family physicians’ and obstetricians’ intrapartum management of low-risk pregnancies.  J Fam Pract 1993;37:457-462

            (57) Mathews D.  Birth of the midwife/obstetrician.  Lancet 1995;345:532.

            (58) Beasley JW, Damos JR, Roberts RG, Nesbitt TS.  The advanced life support in obstetrics course. A national program to enhance obstetric emergency skills and to support maternity care practice.  Arch Fam Med 1995;4:206

            (59) Beasley JW, Damos JR, Roberts RG, Nesbitt TS.  The advanced life support in obstetrics course. A national program to enhance obstetric emergency skills and to support maternity care practice.  Arch Fam Med 1994;3:1037-41.

            (60) Beasley JW, Byrd JE, Damos JR, Roberts RG, Koller WS.  Advanced life support in obstetrics course [editorial].  Am Fam Physician 1993;47:579-80.

            (61) Simpkin P.  Reducing pain and enhancing progress in labor: a guide to nonpharmcologic methods for maternity caregivers.  Birth 1995;22:161-71.

            How to Keep Normal Labor Normal – Part 4 – Partners

            This blog series is designed to help women who are developing a birth plan join together with like-minded birthing professionals so as to have a shorter and safer labor and birth. Today we’ll look at the second “P” of my 10 “P’s” of keeping labor shorter and birth safer – partners.

            Although written primarily for professional birth attendants, I hope information will be helpful to lay women planning their birth.

            Any emotional, physical, and/or spiritual support during labor appears to be more advantageous than no support.

            “Human, physiological support is given to the laboring woman in most cultures surveyed … massage, light touching, abdominal lifting, accupressure, hand-holding, stroking, relaxation, and warm water or lotions all seem to help … but in all cases the woman is rarely left to labor alone.”(35)

            “Evidence is accumulating to indicate that environments that provide attentive bedside and nurse services to patients with functional dystocia have a higher incidence of patients who deliver vaginally.”(44)

            an>There is no data that a child’s support of his or her mother during labor is helpful to keeping the labor normal; however, “The scant existing evidence indicates that there is no short-term harm to the sibling child who observes the birth, and suggests the possibility of an increase in nurturing behaviors.”(5)

            Males (the father of the baby) supporting women during labor may be overemphasized, but still is important, at least to the laboring woman: “In general, fathers were significantly more likely than nurses to be present in the labor room, to offer a comforting item, and to touch their partner … Mothers rated the father’s presence as significantly more helpful than that of the nurses.”(45)

            “The father’s presence at the birth strongly increases the mother’s satisfaction with the birthing experience. No evidence of harm exists from allowing the fathers to be actively involved in labor and delivery.”(5)

            One nurse midwife in Great Britain encouraged men with this poem, “Roll up for the greatest show on earth, come and view your baby’s birth!  Blood, urine, sweat, and faecal matter, a great treat for a prospective pater.”(38)

            Women supporting women in birth, however, may be the most important and underutilized tool that maternity care providers can employ to keep labor normal.

            “Continual emotional support has been shown to have a saluatory effect on labor … it is possible that midwives and family physicians differ in the amount of time spent with patients and the amount of emotional support offered in the labor … thus explaining the higher cesarean section rate among family physicians when compared with nurse midwives.”(46)

            Doula-supported births were significantly less likely to result in cesarean section (8.2% vs 18%, p=.004), forcep delivery (8.2% vs 26%, p<.001), or use of epidural anesthetic (7.8% vs 55.3%, p<.001).”(5)

            “No fewer than 10 randomized trials, including 3336 women, have examined the issue (of active management of labor). Meta-analysis of these trials supports the idea that psychological support (by a female companion) is effective in:

            • reducing analgesia requirements (and their potentially deleterious effects),
            • shortens first and second stage labour,
            • lowers the incidence of cesarean section and operative vaginal delivery, and
            • improves fetal outcome.”(48)

            “There have been no randomized trials of the total package of active management (which includes continuous one-on-one midwife and nursing care involving “eyeball-to-eyeball care  with continuous physical touch”)(17) or of the use of strict diagnostic criteria alone, but trials of early amniotomy, early oxytocin, and these interventions combined do not suggest that these interventions are effective in reducing rates of cesarean sections or operative vaginal deliveries.”(47)

            “In contrast, the provision of continuous professional support in labour seems to reduce both types of operative delivery. (In other words,) “… the effective ingredient seems to be the presence of a (female) companion in labour … (Therefore,) delivery units should routinely endeavor to provide continuous professional support in labour, but routine use of amniotomy and early oxytocin is not recommended.”(48)

            One meta-analysis said, in summary, “Given the clear benefits and no known risks associated with intrapartum support, every effort should be made to ensure that all laboring women receive support, not only from those close to them but also from specially trained care givers (nurses, midwives, or lay women).

            This support should include continuous presence, the provision of hands on comfort, and encouragement.

            Depending on the circumstances, ensuring the provision of continuous support may necessitate alterations in the current work activities of midwives and nurses, such that they are able to spend less time on ineffective activities and more time providing support.”(48)

            “There is no more cost-effective or simple strategy to improve the health of laboring women than using the doula.”(39)

            Here’s the entire series:

            1. Philosophy,
            2. Partners,
            3. Professionals,
            4. Pain control,
            5. Procedures,
            6. Patience,
            7. Preparation,
            8. Positions,
            9. Payment, and
            10. Prayer.

            Citations:

            [5] Hoffman, Martin, “Parental Discipline and Child’s Moral Development” Journal of Personal Social Psychology 5 (1967): 45-57.
            (35) Joint statement endorses family centered birthing.  Am Nurse 1978;10:1, 11.
            (36) Rollins AJ, Kaplan JA, Ratkay ME, Goodlin RC, et. al. A homestyle delivery program in a university hospital.  J Fam Pract 1979;9:407-14.
            (37) Larimore WL.  Family-centered birthing: a niche for family physicians.  Am Fam Physician 1993;47:1365-6.
            (38) Mathews D.  Birth of the midwife/obstetrician.  Lancet 1995;345:532.
            (39) Larimore WL, Reynolds JL.  Family practice maternity care in America: ruminations on reproducing an endangered species – family physicians who deliver babies.  J Am Bd Fam Pract 1994;7:1-11.
            (40) Klein MC, Kaczorowski J, Robbins JM, Gauthier RJ, et.al.  Physicians’ beliefs and behavior during a randomized controlled trial of episiotomy. Can Med Assoc J 1995;153:769-79.
            (41) Silverman, S.  Episiotomy – to cut or not to cut?  Is there really a question?  Cybele Report 1985:2-4.
            (42) Nesbitt TS.  Rural maternity care: new models of access.  Birth 1996;23:161-5.
            (43) Hedstrom LW, Newton N.  Touch in labor: a comparison of cultures and eras.  Birth 1986;13:181-186.
            (44) Seitchik, J. In: Young D. Crisis in obstetrics – the management of labor.  Int J Childbirth Education 1987, August: 13-5.
            (45) Nicholson J, Gist NF, Klein RP, Standley K. Outcomes of father involvement in pregnancy and birth.  Birth 1983;10:5-9.
            (46) Hueston WJ, Rudy MA.  A comparison of labor and delivery management between nurse midwives and family physicians.  J Fam Pract 1993;37:449-454.
            (47) Thornton JG, Lilford RJ.  Active management of labour: current knowledge and research issues.  BMJ 1994;309:366-369.
            (48) Hodnett ED.  Support from caregivers during childbirth.  In:  Pregnancy and childbirth module (eds. Enkin MW, Keirse MJNC, Renfrew MJ, Neilson JP), ‘Cochrane Database of Systematic Reviews’: Review No. 03871, 3 October 1994.  Oxford: Update Software, 1994, Disk Issue 1.

            How to Keep Normal Labor Normal – Part 3 – Philosophy

            This blog series is designed to help women who are developing a birth plan join together with like-minded birthing professionals so as to have a shorter and safer labor and birth. Today we’ll look at the costs of “birth philosophy.” Although written primarily for professional birth attendants, I hope information will be helpful to lay women planning their birth. Today we’ll look at the first “P” of my 10 “P’s” of keeping labor shorter and birth safer — philosophy.

            In the past, labor has been viewed by many (perhaps most) physicians as a process that can and must be managed by physicians for their pregnant patients.

            Standard obstetrical text books discuss the three “P’s” of labor management:

            • Power,
            • Passage, and
            • Passenger.

            Some have expand these basic 3 to include a fourth “P”: either “Positions” (meaning position changes during labor and delivery) or “Psyche” (meaning psychosocial preparation and support).

            However, there is appearing in the literature increasing comment that most labor does not need to be interventionally managed and that knowing when and how not to intervene may be an higher order skill than routinely intervening.(26-28)

            Said another way, “if you mess around with a process that works well 98% of the time, there is potential for much harm.”(29)

            “In populations where medical intervention is used only when clearly necessary, more than 90% of women will have a healthy birth outcome without any intervention.”(13)

            Asking the birthing literature the question, “What then can maternity care providers do to keep normal labor normal?” has lead this me to develop what I call the “Ten ‘P’s’ of keeping normal labor normal.” In this blog we’ll look at the first “P.”

            1) Philosophy

            There appears to exist among maternity care professionals a philosophical spectrum that extends from that which views labor as a “natural process” to that which views labor as a “disease process.”

            Maternity care givers always lean towards one end or the other of this philosophical spectrum as “… underlying these contrasting views are incompatible assumptions about the nature of women.”(16)

            “One model assumes that women are capable, reasoning beings who can actively manage their birth experience, whereas the other sees them as possessing a reproductive system that is unreliable, inefficient, and tricky, thus requiring expert monitoring and management.”(30)

            The “disease process” approach to maternity care has been expounded since the onset of the specialty of obstetrics, at least in America, where founders of the specialty reported, “Childbirth is a decidedly pathologic process … analogous to being impaled on a pitch fork”(31) and “… the fundamental reason why obstetrics is on such a low plane in the opinion of the profession … (and) in the mind of the public, is just because pregnancy and labor are considered normal, and therefore anybody, a midwife, a medical student, or even a neighbor knows enough to take care of such a function.(32) “By declaring labor and delivery a ‘disease,’ it was possible for an obstetrician to attain the same professional status as his (sic) medical and surgical colleagues.”(33)

            Recent reviews are sharply critical of this philosophy: “(I use) the metaphor of production in the workplace for the act of reproduction in the medical model, in which women are seen as powerless and separate in some sense from their bodies.  The uterus is viewed as a machine, the woman as a laborer, and the physician as the supervisor-mechanic-fixer.”(34)

            Partially as a result of this philosophy “… the current US pregnancy care system commonly applies technological interventions to most mothers.”(26)

            Others have clearly elucidated the opposite end of this philosophical spectrum: “Whether childbirth is experienced as a natural physiologic, family-oriented event or a ‘high-tech’ medical procedure has far more to do with the attitude and approach of a parturient’s medical and nursing attendants than with her clinical condition.”(27)

            “Whereas common obstetric practice manages the parturient’s physician functions to conform to a medically determined ideal (the medical pathway), the more conservative ‘physiologic pathway’ gains maximum benefit from her inherent physical and psychological resources to make childbirth more natural, more satisfying, and safer.”(27)  “This approach to pregnancy care recognizes that most women do not need to be technologically delivered of their babies but, rather, need to be allowed to have their babies simply and physiologically born.”(26)

            “The term “family-centered maternity care” (FCMC) developed (in the 1970s) as a consumer reaction to the depersonalization of birth that had been the management standard for childbirth during the first half of the century.

            The philosophy and focus shifted from technologization to personalization, from birth as a biomedical event to birth as a normal developmental task.”(28)

            The existing technological system used in most hospitals is “… an expensive system and tended to overlook and sometimes ignore the individual woman and her childbirth process … and (is) called … high-tech, low touch obstetrics.”(26)

            Therefore, “it is not surprising that … women have been the prime instigators in a movement toward … efforts to naturalize and humanize childbirth.”(26)

            After consumers came nurses who stated in 1978 that, “… family-centered birthing should be the norm in American obstetrics …”(35)

            At about the same time the term “family-centered birthing” appeared in a physician’s article, but only as an alternative: “The Homestyle Delivery Program, an alternative birth service at UC Davis … was developed … in response to the needs and desires of patients and physicians to participate in a more natural family centered birthing process.”(36)

            It wasn’t until 1993 that this term entered the mainstream physician literature: “We need to recognize that the attempt to model obstetrics in family practice after highly a technical obstetrician-gynecologist model has failed. A different paradigm — family-centered birthing — is more appropriate …”(37) and could be “… called the low-tech, high-touch obstetrical approach … as family-centered birthing is both a philosophy and a learned group of skills and practices that emphasize a natural process, and not a disease. Women must be encouraged, equipped, and enabled, without unnecessary and nonindicated intervention, to complete one of the most essential roles given to them, to birth their children.”(26)

            One obstetrician’s interventionalistic policies were lampooned by Sheila Judge, the night midwifery sister at Sheppey General Hospital, in 1968:  “Blood pressure erratic, they lose an ounce — That’s enough! The boss will pounce!”(38)

            For midwives or general practitioners who sought to emulate their interventionalistic obstetrical colleagues, she wrote:  “Aseptic, scientific, and quite spell free, is how modern midwifery aims to be — The newest procedures are always the greatest, it’s bound to be good if it’s the latest!”(38)

            One amusing analogy of the technologically obsessive states that, “The bomb squad approach to maternity care, which asserts that every pregnant woman is a time bomb ready to ‘go off’ and needs a bomb disposal squad, is to most family physicians and midwives dissatisfying, unsafe, and unsatisfactory, particularly for the provision of routine family-centered maternity care.”(39)

            One author showed that “physician beliefs … (link) directly to clinical actions and their consequences …”(40) ; however, there is little in the literature describing how or if maternity caregivers can or will change from one end of the philosophical spectrum to the other, but that which exists indicates that this process is both difficult and prolonged and usually progresses along a somewhat predictable continuum.(26,41)

            What does the research say about one philosophical approach or the other?

            “To date, all studies of … expectant, non-interventional style of pregnancy care have shown, that when applied to low-risk women, the approach has excellent outcomes, compared to similar women managed in more interventionalistic methods.  This appears to be true whether the maternity care providers are family physicians, midwives, or obstetricians.”(26)

            There should be no question that “… it is critical that the style of practice be geared toward keeping healthy patients healthy.”(42)

            It does appear that a care giver’s belief and philosophy effects the maternity care that they practice.

            Here’s the entire series:

            1. Philosophy,
            2. Partners,
            3. Professionals,
            4. Pain control,
            5. Procedures,
            6. Patience,
            7. Preparation,
            8. Positions,
            9. Payment, and
            10. Prayer.

            Citations:

            • (13) Scherger JE.  Management of normal labor and birth.  Primary Care 1993;20:713-719.
            • (26) Larimore WL. Family-centered birthing: history, philosophy, and need. Fam Med 1995;27:132-138.
            • (27) Fenwick L. Birthing: techniques for managing the physiologic and psychosocial aspects of childbirth. Perinatal Nurs 1984, May/June:51-62.
            • (28) Midmer DK. Does family-centered maternity care empower women? The development of the woman-centered childbirth model. Fam Med 1992;24:216-21.
            • (29) Hon, E. In: Young D. Crisis in obstetrics-the management of labor. Int J Childbirth Education 1987, August: 13-5.
            • (30) Moore M, Hopper U. Do birth plans empower women? Evaluation of a hospital birth plan. Birth 1995;22:29-36.
            • (31) Pomeroy, DeLee JB, In: Thacker SB, Banta HD. Benefits and risks of episiotomy: an interpretative review of the English language literature, 1860-1980. Obstet Gynecol Surv 1983;38:322-338.
            • (32) DeLee JB, In: Fishbein M. Joseph Bolivar DeLee: crusading obstetrician. New York: EP Dutton, 1949.
            • (33) King CR. Where is the woman in obstetrics and gynecology? Pharos 1989;52:8-11.
            • (34) Martin E. The woman in the body. A cultural analysis of reproduction. Open University Press, 1987.
            • (35) Joint statement endorses family centered birthing. Am Nurse 1978;10:1, 11.
            • (36) Rollins AJ, Kaplan JA, Ratkay ME, Goodlin RC, et. al. A homestyle delivery program in a university hospital. J Fam Pract 1979;9:407-14.
            • (37) Larimore WL. Family-centered birthing: a niche for family physicians. Am Fam Physician 1993;47:1365-6.
            • (38) Mathews D. Birth of the midwife/obstetrician. Lancet 1995;345:532.
            • (39) Larimore WL, Reynolds JL. Family practice maternity care in America: ruminations on reproducing an endangered species – family physicians who deliver babies. J Am Bd Fam Pract 1994;7:1-11.
            • (40) Klein MC, Kaczorowski J, Robbins JM, Gauthier RJ, et.al. Physicians’ beliefs and behavior during a randomized controlled trial of episiotomy. Can Med Assoc J 1995;153:769-79.

            How to Keep Normal Labor Normal – Part 2 – The Costs of Abnormal Labor

            This blog series is designed to help women who are developing a birth plan join together with like-minded birthing professionals so as to have a shorter and safer labor and birth. Today we’ll look at the costs of “abnormal labor.” Although written primarily for professional birth attendants, I hope information will be helpful to lay women planning their birth.

            The medical literature has many, many articles that discuss the potential risks and costs for not keeping normal labor normal; including:

            • increased dystocia (dysfunctional, abnormal labor),
            • increased fetal distress, and
            • the increase in unnecessary operative deliveries.

            (1)  Increased dystocia

            Although, “… dystocia has remained a poorly defined term,”(1) for the purposes of this paper “… dystocia is divided into two major categories.

            The first category of dystocia, true cephalopelvic disproportion, is characterized by failure of descent of the head after complete dilation and includes the diagnosis of persistent occiput posterior.

            The second category, inefficient uterine action, is defined as failure of the cervix to dilate (<1cm/h with no more than 7 contractions per 15 min) and the head to descend … (and) is divided into four subcategories:

            1. unsuccessful attempt at induction,
            2. error in the diagnosis of labor (defined as regular painful uterine contractions that are accompanied by one or more of four additional criteria:
              • dilation,
              • effacement in primiparas,
              • rupture of the membranes, and
              • loss of the mucous plug or bloody show(3)),
            3. inadequate response to treatment, and
            4. oxytocin not given.”(2)

            Undoubtedly “ …the most significant step toward a solution to the problem of dystocia … has been the recognition of certain fundamental differences between nulliparous and parous women…”(3) and recognizing that dystocia can be caused by certain management practices.  However, “… lack of objectivity (in defining dystocia) may result in variations in practice patterns seen for dystocia.”(1)

            Preventing dystocia will, by definition, help keep normal labor normal.

            (2)  Increased fetal distress and “fetal distress”

            To diagnosis fetal distress when it does not exist is not in the best interest of the laboring woman.

            “Like dystocia, fetal distress has remained a poorly defined term.”(1) Surgical or operative intervention “for the diagnosis of ‘fetal distress’ appears to vary depending on institutional and other nonclinical factors,”(1) and “…the observation that cesarean deliveries for ‘fetal distress’ peak during nighttime hours raises the possibility that the interpretation of fetal monitoring tracing is influenced by physician and patient fatigue or other clinical factors.”(1)

            Much reliance for the diagnosis of fetal distress has “been placed on the interpretation of fetal monitor tracings, which has been shown to have great interrater variability.”(4) This has caused some to critically question the routine use of continuous electronic fetal monitoring (EFM).(5-13)

            “Of concern is not only the lack of benefit (of EFM) to women in labor, but also the high false-positive rate of electronic recording resulting in more diagnosis of ‘fetal distress’ and increased intervention in labor, including cesarean section.”(13)

            Clearly, preventing true or false fetal distress will, by definition, help keep normal labor normal.

            3)  Increased cesarean delivery rate

            There have been strong calls in the literature for physicians to improve their cesarean rates.(5,6,1326)

            For example, “In the US in 1992, 22.6% of deliveries were C/S (of 3.97 million births). The projected optimum would be 5-12%, and in 1992 only 90 hospitals in the US were <15%: 35% (were for) previous CS (50-55% should be VBAC, instead of 25.4%), 34% (for) dystocia (abnormal progress in labor), 12% breech (version should work about 66%), 9% “Fetal distress” (50-90% reduced with intermittent auscultation).”(14)

            If these projections are correct, keeping normal labor normal by avoiding, as much as possible, dystocia and false diagnosis of fetal distress could reduce cesarean rates by 20 – 40%.

            In the US, the cesarean section rate is “iatroepidemic”(17) according to Emanuel Friedman, MD, who says, “physicians should be forbidden to do a cesarean in the latent phase of second stage labor … 70% of cesareans are unnecessary for women with protraction disorders and 50% are unnecessary for arrest disorders.”(17)

            Others would say, “The most common indication for a first cesarean section is dystocia (difficult or prolonged labor), which accounts for about one third of all cesarean sections in the United States, approximately twice as high a rate as in other countries with similar medical care systems.”(15)

            With labor dystocia, “…provider, payer, and institutional biases have been implicated in causing variations in cesarean delivery rates.”(1,22,23)

            “There is general agreement that a solution to the problem of dystocia would go a long way toward resolving the contentious issue of high cesarean birth rates.”(2)

            In addition to dystocia, “…cesarean delivery for fetal dystocia is responsible for some of the increase in cesarean section rates.”(1,24,25)

            Mortimer Rosen, MD points out, “Managing labor is still an art…the rising cesarean rate suggests that the art of patient care may be in jeopardy.”(17)

            Here’s the entire series:

            1. Philosophy,
            2. Partners,
            3. Professionals,
            4. Pain control,
            5. Procedures,
            6. Patience,
            7. Preparation,
            8. Positions,
            9. Payment, and
            10. Prayer.
              REFERENCES:
              (1) Hueston WJ, McClaflin RR.  Variations in cesarean delivery for fetal distress. J Fam Pract 1996;43:461-7.
              (2) Byrd JA, Lytton DE, Vogt SC, et. al.  Diagnostic criteria and the management of labor. J Fam Pract 1988;27:595-599.
              (3) O’Driscoll K, Foley M, MacDonald D.  Active management of labor as an alternative to cesarean section for dystocia. Obstet Gynecol 1984;63:485-490.
              (4) Tussing AD, Wojtowycz MA.  Health maintenance organizations, independent practice associations, and cesarean section rates. Health Serv Res 1994;29:75-93.
              (5) Smith MA, Acheson LS, Byrd JA, et. al. A critical review of labor and birth care. J Fam Pract 1991;33:281-292.
              (6) Cibils LA.  On intrapartum fetal monitoring. Am J Obstet Gynecol 1996;174:1382-9.
              (7) Paneth N, Bommarito M, Stricker J.  Electronic fetal monitoring and later outcome. Clin Invest Med 1993, Apr 16:159-65
              (8) Rosen MG, Dickinson JC.  The paradox of electronic fetal monitoring: more data may not enable us to predict or prevent infant neurologic morbidity. Am J Obstet Gynecol 1993;168:745-51.
              (9) Sandmire HF.  Whither electronic fetal monitoring? Obstet Gynecol 1990;76:1130-4.
              (10) Snydal SH.  Responses of laboring women to fetal heart rate monitoring. A critical review of the literature. J Nurse Midwifery 1988;33:208-16
              (11) Prentice A, Lind T.  Fetal heart rate monitoring during labour–too frequent intervention, too little benefit? Lancet 1987;2(8572):1375-7.
              (12) Neilson JP. EFM vs intermittent auscultation in labour. [revised 04 May 1994] In: Keirse MJNC, Renfrew MJ, Neilson JP, Crowther C (eds.) Pregnancy and Childbirth Module. In: The Cochrane Pregnancy and Childbirth Database [database on disk and CDROM]. The Cochrane Collaboration; Issue 2, Oxford: Update Software; 1995. Available from BMJ Publishing Group, London.
              (13) Scherger JE.  Management of normal labor and birth. Primary Care 1993;20:713-719.
              (14) Horton R.  Unnecessary caesarean sections in USA. Lancet 1994;343:1351-2.
              (15) Paul RH.  Toward fewer cesarean sections: the role of the trial of labor (editorial). NEJM 1996;335:735-6.
              (16) Lumley J, Astbury J.  Birth rites, birth rights.  Sphere Books, 1980.
              (17) Young D. Crisis in obstetrics – the management of labor. Int J Childbirth Education 1987, August: 13-5.
              (18) Sakala C.  Medically unnecessary cesarean section births: introduction to a symposium. Soc Sci Med 1993;37:1177-98.
              (19) Sakala C.  Midwifery care and out-of-hospital birth settings: how do they reduce unnecessary cesarean section births? Soc Sci Med 1993;37:1233-50.
              (20) LoCicero AK.  Explaining excessive rates of cesareans and other childbirth interventions: contributions from contemporary theories of gender and psychosocial development. Soc Sci Med 1993;37:1261-9.
              (21) Burns LR, Geller SE, Wholey DR.  The effect of physician factors on the cesarean section decision. Med Care 1995;33:365-82.
              (22) Goyert BL, Bottoms SF, Treadwell MC.  The physician factor in cesarean birth rates. N Eng J Med 1989;320:706-9.
              (23) McCloskey L, Pettitti DB, Hobel CJ.  Variations in the use of cesarean delivery for dystocia: lessons about the source of care. Med Care 1992;30:126-35.
              (24) Placek PJ, Taffel SM. Recent patterns in cesarean delivery in the United States. Obstet Gynecol Clin North Am 1988;15:607-27.
              (25) Farrell SJ, Anderson HP, Work BA. Cesarean section: indications and postoperative mortality. Obstet Gynecol 1980;56:696-700.

              How to Keep Normal Labor Normal – Part 1 – Introduction

              This blog series is based upon an article I wrote, along with my friend, Matt Cline, MD, that appeared in the Primary Care Clinics of North America. In today’s blog I’ll present some introductory comments. I hope you’ll share this series with anyone you know planning or preparing to have a baby. Continue reading

              A blast from the past – YouTube video shows Dr. Walt’s ‘groundbreaking’ web events of 1999

              Speaking of memories (here on Memorial Day), I have fond memories of hosting a live, 5-night-a-week, cable TV show, “Ask the Family Doctor” on America’s Health Network and then Fox’s Health Network from 1995 – 2000. All-in-all, about 854 shows. Perhaps none was more watched than the first live birth on the Internet.

              More Information: Continue reading