Care in Normal Birth: A Practical Guide (1996)

Category A: Birth Practices Which Are Demonstrably Useful and Should Be Encouraged

In 1996, the World Health Organization (WHO) assembled birth experts from around the world to identify common practices in normal birth that were justified, that improved birth outcomes, and that ought to be encouraged for sound care in normal birth.1 At the same time, WHO identified common birth practices that are known to be harmful, unnecessary, underused as well as those interventions that required further study to determine their merit in the care of child bearing families. In a way, as presented, the listing of intervention by category serves as a “sort of” report card for birthing facilities in that either the intervention is or is not currently practiced. This article “speaks to” the first of the four categories of common birth practices and the rationale of those interventions WHO identified seventeen years ago. The practices to be encouraged are in bold type and listed below.

Category A: Practices which are demonstrably useful and should be encouraged

1. The acceptance of a woman’s personal plan (her wishes) for her birth is important.1  Some would say that birth defies planning, as indeed it does. No one can predict the course a labor will take; that can be known only retrospectively. However, what is known is that the childbirth experience impacts “long term physical and psychological health, breastfeeding, mother-infant attachment and parenting” (Goer, p. 3).2  Birth becomes part and parcel of a woman’s sense of self and her life history. Consequently, it is imperative that a mother be allowed to make her own birth choices, the consequences of which later define who she is as a woman and mother. Birth wishes are the expressed desires of childbearing parents that outline their birth preferences for the healthcare provider. The essence of birth wishes ask that the mother be treated with respect, that she is has the right to make choices as an autonomous individual, and that no interventions in the birth occur without her consent. Birth wishes should be developed during the prenatal period and shared with the healthcare provider before labor begins.

2. Risk assessment (80-85% of pregnancies and labors are normal)1, 2 at each prenatal visit, during labor and birth by caregivers (nurses, midwives and physicians) is essential. Risk factors are identified and provisions made for complications that may arise from the acknowledged risk factors. “When complications arise, the mother actively participates in resolving them” (Goer, p. 5)2. If, between 37 and 42 completed weeks of gestation, no risk factors have been identified, the labor ought to be viewed as a low-risk event, which is what most labors and birth are. 1,2

3. When labor begins, the monitoring of the woman’s physical and emotional well-being throughout the birth process and after birth is of great importance. It is only recently that researchers have begun to appreciate that a pregnant woman’s psychosocial health extends as a continuum from pre-conception through her postpartum experience. 3,4  This well-being requires an address of a woman’s privacy rights, her choice of labor companions, and the avoidance of extraneous persons in the labor room. The medical model of care is based upon the belief that pregnancy and birth are risky and potentially dangerous circumstances from which mothers ordinarily must be rescued. In contrast, the physiologic model of care (more the midwifery philosophy) affirms the health and normalacy of pregnancy and birth and trusts in the innate ability of a mother to birth her child and to participate actively in her care.5,6,7,8   The medical model of care is physician and staff oriented while the physiologic approach puts the woman at the center of things. The medical approach is authoritative. In contrast, the physiologic strategy promotes collaborative decision-making2.

4. Oral fluids and food during labor and delivery are of vital importance.9 Fear of aspiration of stomach contents in the event of emergency surgery and the use of general anesthesia drives the restriction of food and drink for mothers during labor and birth. However, research has demonstrated that “the restriction of food and liquid intake during labor does not guarantee reduced stomach content (WHO, p. 9).1 The American Society of Anesthesiologists acknowledges that “oral intake of clear liquids during labor improves maternal comfort and satisfaction” (Goer, p. 251).2  When self-regulated by thirst, the intake of fluids causes no harm.10  The energy requirements of labor are much like that of a marathon. If a mother is to birth, she must be hydrated and fed to meet the demanding work of labor and birth. Both maternal and fetal well-being require an address of a mother’s nutritional needs during birth.11 In 2007, researchers Parsons, Bidewell, & Griffiths concluded that “With the lack of reliable evidence to support any type of diet for women in labour… the best practice may be to leave the decision about oral intake to the instincts of the women who are in labour” (p.137).12

5. A woman’s informed choice for the place of birth should be respected. Until the last century, most childbearing women birthed their children among friends and family members in a familiar, comfortable and secure place sustained by customs and traditional knowledge. Birth was a family event. It was totally other than the medically manipulated and orchestrated incident that birth has become today in a technology-centered and driven culture.  Indeed, never before in human history have birthing practices been so reliant on medical interventions.2 And yet, the more sophisticated the care, the more common interventions, complications, and poor birth outcomes have become and yet the maternal mortality rate continues to rise. 2 Stress in labor can prolong the progress of labor because the stress hormones (cortisol and adrenaline) are not labor conducive but rather are the opposite. High levels of cortisol and adrenaline are labor retardant. Consequently, childbearing women labor better in a familiar place in the presence of companions they know well. “It is safe to say that a woman should give birth in a place she feels safe” (WHO, p. 12)1 “in a woman-centered, low technology environment that maximizes family safety” (Goer, p. 485).2 A freestanding birth center provides for this sort of environment. Women who begin the care in freestanding birth centers have fewer interventions and restrictions, experience fewer forceps, vacuum, and cesarean births 13 and less often have episiotomies (surgical incision) or tears of the pelvic floor and skin (perineum).2   The birth outcomes of birth centers improves the experience of care, improves the health of populations and reduces childbearing expenditures.14 Home birth is another option for low-risk mothers. Concerns with hospital safety issues, laboring in the presence of strangers, previous negative hospital birth experiences, the high-tech interventionist culture of hospitals, and the lack of autonomy propel women to opt for home birth attended my midwives.2 Findings of studies of planned home births in the United States document that “women who have home births attended by certified nurse-midwives have a safety profile equal to or better than the profiles of  women who had hospital births in similar populations” (Cox, p. 145).15

6. Providing labor care with the fewest interventions, in concert with where the mother feels confident and safe to give birth16 ought to be a priority of healthcare providers. Normal birth of low-risk women requires little other than “encouragement, support and a little tender loving care” (WHO, p. 13). 1 Procedure-intensive hospital stays, pregnancy and birth care, followed by newborn care are the most expensive “condition” for private insurers.17  In the United States (reflective of current Bahamian birthing practices), six of the fifteen most commonly performed hospital procedures in the entire population were birth related; medical induction and methods to hasten birth (2), suturing of episiotomies/lacerations (6), cesarean birth (7), circumcision (8), fetal monitoring (13) and artificial rupture of the amnionic sac(14).18 Labor is literally pushed by routine or common measures applied to a primarily healthy population—interventions including labor induction, labor augmentation, staff-directed maternal pushing, and forceful pressure applied by staff on women’s abdomens at the time of birth. Birth is also frequently pulled by interventions such as vacuum extraction/forceps, cesarean section, pulling on the cord to hasten birth of the placenta, and the separation of babies from mothers after birth.17 One intervention increases the use of secondary and even tertiary interventions to treat the side effects of the preceding intercessions. The sum total of these intervention-begotten-interventions is to create a false sense of the riskiness of birth and the “perinatal paradox: doing more and accomplishing less”.19

7. Respect for a mother’s privacy during birth (clothing she wishes to wear, birthing companions, position preferences, single-client labor rooms, and breast-feeding privacy) is most important. Oxytocin, the love hormone, drives the contractions of labor. As such, oxytocin is a shy hormone.20  This is to say this “mother-maker” works best in a calm, dimly lit, quiet sanctuary in the presence of unobtrusive trusted companions. Under these conditions, a laboring woman will intuitively move, breathe, make sounds, and do what it takes to birth her baby most easily. “This is her genetic and hormonal blueprint” (Buckley, p. 3).21 Movement of a mother from a labor room to another room for birth and lying her on her back not only disrupts the work of oxytocin and the progress of labor, but also imposes an insensitive onlooker duress upon a mother and her labor in its final minutes.

8. Caring support of the mother by her healthcare givers (physicians, nurses, midwives, doulas) promotes birth. “The ethos of caring comprises a healthcare provider’s respect for the dignity of the patient and a striving for a genuine communion and understanding of the unique human being” (Wickberg et al.,p.639).22  Because most births are normal and healthy, the trained midwife (proponents of the wellness of pregnancy and birth) “appears to be the most appropriate and cost effective type of health care provider” for normal pregnancies and births (WHO, p.6).1 This orientation of pregnancy care reserves the skill and expertise of the obstetrician (gynecologist and surgeon) to high risk pregnancies. Among developed nations, only the United States and Canada (I would add the Commonwealth of the Bahamas to the list) depend upon specialists (overseers), rather than midwives, to care for low-risk pregnant women.23 Research studies conducted in Sweden, Australia and Britain affirm that mothers are more satisfied with midwife-managed pregnancy care than they are with the consultant (physician) led care.24 Today, the increasing rates of childbirth-related posttraumatic stress disorder and maternal suicide suggest that labor and birth environments fail to meet the supportive care mothers desire and or need.17

9. Respecting a mother’s choice of labor companions and the presence of those support persons throughout her labor and birth is birth-friendly.16,25,26,27  Research has affirmed the positive impact “one single person” who provides “continuous empathetic and physical support during labor” has upon birth outcomes (WHO, p. 12).1,  Documented benefits include, shorter labors, less use of systemic analgesia and epidural anesthesia, fewer Apgar scores < 7 and fewer forceps and vacuum extractions and even enhances breastfeeding rates even six weeks later.2,26, 27, 28  Obstetric outcomes are most improved and intervention rates most dramatically lowered by birth doulas, trained labor support professionals.26 In addition to the aforementioned outcomes, doula care reduces the incidence of immediate post-partum hemorrhage, maternal fever infection, post-partum depression, as well as health complications of the neonate.28  The supportive role of the birth doula empowers parturient mothers because these clients are able to make birthing choices with a sense of control in their labor. Of all birthing attendants, the birth doula is most favorably ranked in the United States.17 Research affirms that doula attended mothers have positive birth experiences and memories that contribute to enhanced maternal-infant interaction.28 Furthermore, doulas, because of their complimentary role, enhance paternal labor support and are viewed as positive members of the birthing team by fathers.26, 28

10. Information about birth from healthcare providers as desired or requested by the mother and/or family and is necessary for informed consent and is an ethical and human right mandate.  Human dignity is the conceptual/ theoretical basis for human rights.1   An anchoring principle of bioethics and healthcare practice is that of autonomy, the capacity of the individual to self-determine. This is the right to make choices regarding one’s own welfare free of coercion from others. Informed choice means that clients have the information necessary to make educated and informed decisions about their healthcare. The requirements to execute an informed decision include: adequate disclosure of information by healthcare providers, that the decision is voluntary and deliberate, that the client understands the information and that the client is capable to make decisions.29 Commonly, when an intervention is suggested, the reasons for and benefits of the practice are stressed while the risks of the intervention are minimized or not even mentioned at all. Alternative actions are rarely presented. Evidence-based practice “gives priority to care paths and practices that are effective and the least invasive, with limited or no known harms whenever possible” (Sakala, p. 21).17  Frequently, obstetrical practice preferences are based more upon consensus and belief than they are supported by good and scientific evidence. A 2011 scrutiny of the American College of Obstetricians and Gynecologists’ practice bulletins revealed that only 25.5% of recommended practices were based on solid and consistent research findings (Wright et al. p.1).30 Over time interventions, once employed for specific problems, become the norm and subsequently routine. Consequently, one can only wonder the accuracy of the information given to laboring women by their physicians when it is not evidence-based (research affirmed). Research affirmed care practices question interventions and the use of that intervention when the benefits are marginal when compared to the established harm of the suggested practice.17

11. The use of non-pharmacological (non-medicinal) methods of pain relief (labor support, positioning, movement, hydration, immersion in water, herbs, music, hot and cold compresses) favor labor’s progess. Labor is painful. However, well-supported laboring women do find ways to cope with the physiologic genesis of that discomfort (uterine muscle contracting long and hard, fetal descent and the accompanying stretching of maternal soft tissue).16  Continuous labor support, freedom of movement, position choice, immersion in water, nourishment, hypnosis, touch, massage, application of hot and cold “compresses” to body parts, music, acupressure, and privacy are viable alternatives to self-administered nitrous oxide (inhalation anesthesia), narcotics in combination with synergistic medications (pethidine and Benedryl/Phenergan), and the epidural.2,16, 28  Attention-focused techniques (breathing patterns, verbal support and relaxation) draw a mother’s focus away from labor discomfort (WHO).1  Women, educated for childbirth and trusting in their body’s ability to birth as it is designed to do, are more likely to labor drug free.31 However, many obstetricians believe that “there is no circumstance in which it is considered acceptable for a person to experience untreated severe pain, amenable to safe intervention, while under a physician’s care” (Goer, p. 267).2  This bias suggests to clients that they are incapable of birthing without pharmaceutical intervention.

12. Intermittent fetal monitoring (listening to the baby’s heartbeat each hour for 10 minutes) is the preferred method of fetal surveillance. The most common obstetrical intervention during labor and birth is fetal heart rate monitoring even though fetal heart rate patterns are poor predictors of the unborn’s well-being.32 When first begun, electrical heart rate monitoring (EFM) of the fetus during labor and birth was expected to alert physicians of pending fetal distress thereby enabling obstetricians to rescue the baby before lasting harm occurred. The “inventor” of EFM predicted that EFM could save as many as 20,000 babies a year and cut the number of brain injured babies by 50%.33  The obstetrical community was quick to buy into the theory of EFM and by 1976, most hospitals had fetal monitors and most used them continuously during labor even though EFM was not improving birth and neonatal outcomes as predicted.2  What continuous EFM did do was to increase the likelihood of unnecessary cesarean birth or the use of forceps or vacuum assisted births. Continuous EFM confined mothers to bed, often restricting the mother’s position so the fetal heart rate could be more easily monitored. The focus of labor became the machine and the printed strip of the baby’s heart rate pattern relative to maternal uterine activity. Indeed, “since the advent of EFM, EFM tracings and the debate surrounding their interpretation have proved more valuable to plaintiff’s lawyers than to physicians seeking potential patterns of fetal distress” (Lent, p. 834).34  It was only after obstetricians began promulgating the extravagant claims about the compelling evidence of the fetal rescue made possible by the use of EFM that litigation became the obstetrical nightmare it has become.2 Indeed today, no professional maternity care organization recommends routine use of EFM.35 Viable alternatives to continuous EFM are the old-fashioned, low tech auscultation using a fetoscope (pregnancy-specific stethoscope) or the hand-held doppler to periodically monitor fetal well-being and intermittent EFM (monitoring the fetal at specified intervals for a specified length of time).1  Intermittent auscultation promotes the progression of labor by facilitating upright positions and movement in labor and enhancing maternal comfort and satisfaction. Birth outcomes are no different with this less restrictive intermittent monitoring and are a more labor and maternal friendly means of assessing fetal status.2

13. Use of disposable materials and appropriate cleaning of reusable materials is an obvious requirement of any birth. The less often an item is used, the less likely contamination from one patient to the next is going to occur. Ignaz Semmelweis, “the father of infection control”, 36 introduced the importance of hand washing and the necessity of cleansing reusable birthing instruments and equipment with appropriate disinfectant agents. But, it was not until decades later, after the affirming research of Pasteur, Koch, and Jenner, that Semmelweis’ germ theory and the correctness of his antiseptic techniques were accepted.36  Today, antiseptic prophylaxis is well understood, accepted, and practiced world-wide. Birth does not require a sterile environment but it does demand cleanliness in three areas, hands, perineal area and of the umbilical cord. 1

14. The use of universal precautions (protection from body fluids) during labor, delivery and the handling of the newborn is of paramount importance. These precautions are protective strategies that have been formulated to protect individuals from possible infection from body fluids, potential sources of infection.37  The intent of universal precautions is to specifically prevent the transmission of HIV, Hepatitis B and other bloodborne infections in health-care settings.38  Amnionic fluid and maternal blood are potential sources of infection for healthcare providers and clients alike. Consequently, adherence to the guidelines of universal precautions is essential in the business of birthing babies. Gloves should be worn during vaginal examinations, during birth, when handling the newborn and the placenta.1

15. Freedom of position and movement during labor and (16) the use of upright positions in labor (gravity positive) are two labor helpful practices that complement each another.16  Mobility and upright postures enhance the progress of labor if only perhaps because the activity itself prohibits interventions commonly imposed on normal labors (continuous EFM, intravenous therapy, induction or augmentation of labor, artificial rupture of membranes, epidural use). Strategies known to facilitate mobility are labor space that is ample for walking and the changing positions, the use of birth balls, labor pools or tubs, hypnosis, acupuncture, the freedom of the mother to manipulate her environment (moving furniture, control of lighting , noise, and traffic flow in and out of the mother’s private space) the presence non-medical labor companions, and supportive staff.2  Most mothers, after admission to do not ambulate but rather labor in bed.39  Supine positions are more painful for mothers and compromise uterine (hence placental) blood flow because of the compression of aorta and vena cava blood vessels by the heavy uterus,1  which can interfere with adequate oxygenation of the fetus. The hands and knees position in the first stage of labor can help rotate a baby into a more favorable birth position and alleviate persistent back pain.35  In the second stage of labor, squatting or kneeling increases pelvic diameters and employs the benefit of gravity to enhance fetal descent.16,28  In contrast, the supine position in labor and birth “flattens” the pelvis and requires that the mother push her baby out “uphill” and against gravity.

17. Careful monitoring of the progress of labor as it presents is a must and is consistent with the WHO mandate for continuous risk assessment through the course of pregnancy and birth. The assessment of progress of labor is best accomplished by observing the mother, her response to the labor at the time, the frequency, duration, and intensity of uterine contractions, increasing vaginal discharge, spontaneous rupture of membranes and changes in maternal contour caused by descent of the fetus.2  In 1996, WHO recommended, and continues to recommend, the use of a partograph or partogram,1  a chart in which dilation of the cervix and descent of the fetal head are graphed over time to document the progress of labor. Prolonged progress of labor (dystocia) suggests who may not have a normal delivery.40  The partogram used by WHO in 1996 has been modified twice since to reflect a changing understanding of the impact of prelabor on the timing of the onset of active labor. While the partogram serves some in labor well (the slow to progress in active labor) for most labors it is unnecessary. The degree of cervical dilation, descent of the fetal head, and uterine contractions as well as the maternal response (physically, mentally, and spiritually) to each of these assessments is the best indicator of labor’s progress.1

18. The protective use of oxytocin (syntocinon) in the third stage of labor (birth of the placenta and the amnionic sac) is an active management strategy (AMTSL) and is implemented to prevent early postpartum hemorrhage (excessive blood loss within 24 hours after birth).  AMTSL (immediate clamping of the umbilical cord, administration of oxytocin to stimulate a steady state of uterine contraction, and immediate delivery of the placenta encouraged by traction on the umbilical cord) is the current practice world-wide.1  In many underdeveloped, resource poor countries, where mothers are at risk for complicated pregnancies because of diet (anemia), poverty, and lack of access to pregnancy care, post-partum hemorrhage is one of the leading causes of maternal death.41  In these circumstances, AMTSL saves lives. However, these interventions are being called into question because existing research “does not provide relevant and valid evidence about the effectiveness” 41  of a non-intervention approach in the third stage of labor in the care of women without risk for postpartum hemorrhage

19. Maintaining sterility in the clamping and cutting of the cord is essential. Tetanus of the umbilical cord, caused by unclean severing and/or handling of the newborn cord, continues to be a significant cause of neonatal death, especially in poverty stricken communities where there is limited access to health care, hygienic birthing conditions, and immunization. In 1980, an estimated 800,000 newborns died world-wide because of tetanus of the umbilical cord.42  A high risk approach of at least two doses of tetanus toxoid vaccine administered to all women of childbearing age has been widely adopted and dramatically reduced the incidence of neonatal death due to tetanus of the umbilical stump. Improved sanitation and a hygienic cutting of the umbilical cord and care of the neonate’s umbilical stump have further decreased the incidence of neonatal death by tetanus infection.

20. Chilling of the newborn (hypothermia), if uncorrected, can handicap severely the transitioning of the neonate from intra-uterine to extra-uterine life and independent existence. Consequently, prevention of hypothermia is essential for the newborn’s well-being. Most places of birth have radiant warmers in which babies are placed to keep them warm. While these warmers do keep babies warm, current research outcomes clearly document that the baby warmer is not the best way to warm the neonate.2,16,43, 44  Today, it is known that the mother is the best heat source for her newborn and is the most effective means of thermoregulation,45  even for fragile, preterm and/or low birthweight babies.46

21. Skin-to-skin contact (SSC) of the newborn with a parent at birth (a breast feeding friendly practice) and breastfeeding of the newborn in the first hour after birth has life-long benefits for mothers, babies, and society44  simply because of the many known life-long health benefits breastfeeding affords mothers and their babies. Immediately after birth, the infant should be positioned naked and prone on the mother’s abdomen with his back covered by a warmed towel/blanket. Skin-to-skin contact enhances newborn transition to extrauterine life by helping to stabilize respirations, heart rate surges, blood sugar, and body temperature.43  SSC promotes maternal and newborn attachment and appears to promote neurobehavioral development and organization44  that improves sucking reflexes thereby facilitating breastfeeding in the first hour or two after birth.43  “…This time is exceptional, from a hormonal perspective, and will never again occur for this mother and her baby. Mother Nature’s superb design, includes peak levels of the hormones of love, pleasure, excitement and tender mothering, which optimize attachment as well as the initiation of breastfeeding. Interference with this opportunity by separation of mother and baby may have significant implications in the short, medium, and long terms” (Buckley, p 13).21

22. Routine examination of the placenta and placental membranes (amnionic sac) after their delivery is mandatory. Leading causes of postpartum hemorrhage and infection are retained placental fragments and/or placental membranes after the birth of the placenta. Consequently, after the delivery of the placenta and accompanying membranes, the placental surface and edges must be examined to assure the delivery of the entire organ and the attached membranes. If any segment (cotolydon) of the organ or its edges appear to be missing, exploration of the uterine cavity must be pursued. 1

To view references (PDF) go to: http://bahamaislandsinfo.com/images/stories/2013/wk-05-17-13/DoulaReferencesCatA.pdf