A Focus on Physiologic Birth

Introduction DUMMY TEXT

 

U.S. maternity care is characterized by overuse and misuse of obstetric interventions, and underuse of beneficial practices that promote optimal maternal and newborn health. The use of interventions in labor and birth has become the norm in the United States. National statistics from the Listening to Mothers III survey (1) tell us:

 

  • More than half of all pregnant women receive synthetic oxytocin to induce or augment labor, which requires additional interventions to monitor, prevent, or treat side effects.(2)
  • Fewer than half of women walk around in labor, despite evidence that movement and ambulation promote labor progress.(3)
  • More than two-thirds of women give birth flat on their backs, despite evidence that this increases the likelihood of instrumental vaginal delivery and episiotomy.(4)
  • One third of women deliver their babies via cesarean, a major abdominal surgery with potential for serious short- and long-term health consequences for the woman, her baby, and future pregnancies.(5)

 

Hospital accreditation will be tied to reporting of maternity care performance, and physiologic birth practices can effectively improve performance.Beginning in January 2014, accredited hospitals with at least 1,100 births per year are required to report to the Joint Commission on perinatal core measures.(6) Measures that are amenable to improvement by implementing physiologic care in labor and birth include:

 

  • nulliparous, term, singleton, vertex cesarean rate
  • elective delivery before 39 weeks
  • episiotomy
  • exclusive breast milk feeding during the hospital stay

 


Increasing access to care that promotes and supports physiologic birth is a major national strategy for achieving high-quality, high-value care. In 2012, the National Priorities Partnership Maternity Action Team, a multi-stakeholder group of leading national organizations and agencies, set aspirational goals and worked on the development and implementation of a plan to reduce elective deliveries prior to 39 weeks to 5% or less and reduce cesarean section in low-risk women to 15% or less.(7) A major focus of this national effort is engaging consumers and providers in efforts to promote full-term physiologic childbirth.

What is physiologic birth?
A normal physiologic labor and birth is one that is powered by the innate human capacity of the woman and fetus. This birth is more likely to be safe and healthy because no unnecessary interventions disrupt normal physiologic processes.(8) Some women and/or fetuses will develop complications that warrant medical attention to assure safe and healthy outcomes. However, supporting the normal physiologic processes of labor and birth, even in the presence of such complications, has the potential to enhance best outcomes for the mother and infant.(9-12)

In 2012, the three major U.S. midwifery organizations issued a consensus statement titled, “Supporting Healthy and Normal Physiologic Childbirth.” According to this statement, normal physiologic childbirth: (13)

  • is characterized by spontaneous onset and progression of labor;

  • includes biological and psychological conditions that promote effective labor;

  • results in the vaginal birth of the infant and placenta;

  • results in physiological blood loss;

  • facilitates optimal newborn transition through skin-to-skin contact and keeping the mother and infant together during the postpartum period; and

  • supports early initiation of breastfeeding.


The following factors disrupt normal physiologic childbirth:

  • induction or augmentation of labor;

  • an unsupportive environment, i.e., bright lights, cold room, lack of privacy, multiple providers, lack of supportive companions, etc.;

  • time constraints, including those driven by institutional policy and/or staffing;

  • nutritional deprivation, e.g., food and drink;

  • opiates, regional analgesia, or general anesthesia;

  • episiotomy;

  • operative vaginal (vacuum, forceps) or abdominal (cesarean) birth;

  • immediate cord clamping;

  • separation of mother and infant;

and/or

  • any situation in which the mother feels threatened or unsupported.


Supporting and Fostering Physiologic Birth: Expected benefits for women

  • reduced peripartum morbidity, primarily through avoidance of surgery and its complications(5)

  • reduced chronic disease, through improved likelihood of breastfeeding (14)

  • improved experience of care, through access to supportive care and involvement in decision making (15)

  • reduced out-of-pocket costs of maternity care, primarily through reduced cesarean delivery (16)


Supporting and Fostering Physiologic Birth: Expected benefits for babies

  • reduced chance of iatrogenic harms related to augmentation, induction of labor, and instrumental vaginal birth (11, 17-18)

  • reduced chance of chronic disease related to cesarean delivery(19) and disrupted or delayed breastfeeding (20)

  • Improved maternal-infant attachment (21)

  • Expected benefits for nurses

  • increased professional satisfaction

  • improved performance on measures likely to be linked to payment, including patient experience measures (e.g. HCAHPS survey)

  • plausible reduction in adverse events and related liability claims or payouts due to reduced use of oxytocin, a high-alert medication implicated in half of obstetric claims(2)


Expected benefits for obstetricians/midwives

  • increased professional satisfaction

  • improved performance on measures likely to be linked to payment as payment reforms roll out

  • plausible reduction in adverse events and related liability claims or payouts due to reduced use of oxytocin, a high-alert medication implicated in half of obstetric claims(2)


Expected benefits for administrators

  • improved performance on measures likely to be linked to payment and accreditation as reforms roll out, including

  • nulliparous, term, singleton, vertex cesarean rate

  • elective delivery before 39 weeks

  • episiotomy

  • exclusive breast milk feeding during the hospital stay

  • experience of care measures (e.g. HCAHPS survey).

  • plausible reduction in adverse events and related liability claims or payouts due to reduced use of oxytocin, a high-alert medication implicated in half of obstetric claims(2)

  • plausible reduction in staff turnover as physiologic care may be more rewarding for clinicians and nurses.


References:

  1. Declercq ER, Sakala C, Corry MP, Applebaum S, Herrlich A. Listening to Mothers III: Pregnancy and Birth. New York: Childbirth Connection, 2013.

  2. Clark SL, Simpson KR, Knox GE, Garite TJ. Oxytocin: new perspectives on an old drug. Am J Obstet Gynecol 2009;200:35.e1,35.e6.

  3. Lawrence A, Lewis L, Hofmeyr GJ, Dowswell T, Styles C. Maternal positions and mobility during first stage labour. Cochrane Database Syst Rev 2009;(2):CD003934.

  4. Gupta JK, Hofmeyr GJ, Shehmar M. Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database Syst Rev 2012;5:CD002006.

  5. Goer H, Romano A, Sakala C. Vaginal or cesarean birth: What is at stake for women and babies? A best evidence review. New York: Childbirth Connection, 2012.

  6. The Joint Commission Expands Performance Measurement Requirements 2012. Joint Commission. (Accessed 5/19, 2013, athttp://www.jointcommission.org/the_joint_commission_expands_performance_measurement_requirements/).

  7. NPP Action Teams 2012. National Quality Forum. (Accessed 5/19, 2013, at http://www.qualityforum.org/Setting_Priorities/NPP/NPP_Action_Teams.aspx).

  8. Romano AM, Lothian JA. Promoting, protecting, and supporting normal birth: a look at the evidence. J Obstet Gynecol Neonatal Nurs 2008;37:94-105.

  9. Hatem M, Sandall J, Devane D, Soltani H, Gates S. Midwife-led versus other models of care for childbearing women. Cochrane Database Syst Rev 2008;(4):CD004667.

  10. Low LK, Seng JS, Miller JM. Use of the Optimality Index-United States in perinatal clinical research: a validation study. J Midwifery Womens Health 2008;53:302-9.

  11. Cragin L, Kennedy HP. Linking obstetric and midwifery practice with optimal outcomes. J Obstet Gynecol Neonatal Nurs 2006;35:779-85.

  12. Murphy PA, Fullerton JT. Development of the Optimality Index as a new approach to evaluating outcomes of maternity care. J Obstet Gynecol Neonatal Nurs 2006;35:770-8.

  13. 13. American College of Nurse-Midwives, Midwives Alliance of North America, National Association of Certified Professional Midwives. Supporting Healthy and Normal Physiologic Childbirth: A Consensus Statement by ACNM, MANA, and NACPM. Silver Spring, MD: ACNM, MANA, NACPM, 2012.

  14. Schwartz E. Infant Feeding: Seeing the Whole Picture (presentation). Atlanta: First Food Forum, 2013.

  15. Hodnett ED. Pain and women’s satisfaction with the experience of childbirth: a systematic review. Am J Obstet Gynecol 2002;186:S160-72.

  16. Truven Health Analytics. The Cost of Having a Baby in the United States. Ann Arbor, MI: Truven Health Analytics, 2013.

  17. Johantgen M, Fountain L, Zangaro G, Newhouse R, Stanik-Hutt J, White K. Comparison of labor and delivery care provided by certified nurse-midwives and physicians: a systematic review, 1990 to 2008. Womens Health Issues 2012;22:e73-81.

  18. Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database Syst Rev 2012;10:CD003766.

  19. Hyde MJ, Mostyn A, Modi N, Kemp PR. The health implications of birth by Caesarean section. Biol Rev Camb Philos Soc 2012;87:229-43.

  20. Newburg DS, Walker WA. Protection of the neonate by the innate immune system of developing gut and of human milk. Pediatr Res 2007;61:2-8.

  21. Moore ER, Anderson GC, Bergman N, Dowswell T. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev 2012;5:CD003519.


 

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