Science & Sensibility

By Christine H. Morton, PhD

 ”Experienced nurses practicing in a nurse-managed labor model have the potential to change patient outcomes.” 

Today, on Science & Sensibility, Christine Morton, PhD takes a look at a study examining the role of nurses in helping to achieve a vaginal birth for patients under their care.  No surprise from my point of view, my professional experience as a doula has demonstrated that L&D nurses play a critical role in the birth, and can really help a mother to achieve the outcome she desires.  Please enjoy Christine’s synopsis and interview with one of the study authors.- Sharon Muza, Community Manager

© 2013 Patti Ramos Photography

Readers of this blog are well aware of the 50% increase in cesarean delivery rates over the past decade, and are likely aware that the high US cesarean delivery rate is on the maternal quality and patient safety agendas for many organizations.  More attention will soon be focused on hospital rates (the Joint Commission recently expanded its performance measurement requirements such that as of January 1, 2014, all hospitals with more than 1100 annual births will be REQUIRED to report on the Perinatal Care Measure Set, which was the subject of a past blog post).  The Perinatal Care Measure Set includes a measure on the first birth cesarean among low risk women (nulliparous women who have cesareans at term, with singleton, vertex babies).  Furthermore, Centers for Medicare and Medicaid Services (CMS) is requiring that all states report rates of Elective Deliveries <39 Weeks as of 1/1/13 and it is likely that a similar requirement for the NTSV (Nulliparous Term Singleton Vertex) Cesarean measure is not far behind.

One indicator of this trend was the February 2012 symposium on preventing the first cesarean held jointly by National Institute of Child Health and Human Development (NICHD), the Society for Maternal Fetal Medicine (SMFM) and American Congress of Obstetricians and Gynecologists (ACOG.)  A comprehensive summary of the proceedings of that symposium was published in the November 2012 issue of Obstetrics and Gynecology, which is well worth reading but is available only with a subscription.  That same issue had a commentary on how to create a public agenda for reducing cesarean delivery, written by me and my California Maternal Quality Care Collaborative colleagues, which is free to all, thanks to our funder.

The attention to the detrimental health impact of our country’s cesarean rate for women and their babies is a good sign, coming as it does from powerful organizations with interests in providing care and paying for it.  Most of the focus on quality measurement reporting on cesarean delivery has been directed at hospital level (i.e., Leapfrog and The Joint Commission), though there is interest among payers and consumers for public reporting of provider-specific rates.  Virginia is one example where obstetric outcomes (cesarean, episiotomy) are publicly reported at the hospital and provider levels.  However, it is complicated to attribute outcome rates in obstetrics, which is increasingly a ‘team sport’ with multiple clinicians (physicians, midwives and nurses) involved in the care of a woman throughout her pregnancy and birth.

Yet, in all these domains (institutional, measurement, quality improvement), the role of nurses on cesarean delivery decisions and outcomes has been barely mentioned.  Neglecting the labor & delivery nurse’s role is unfortunately all too typical in public discourse around quality reporting, shared decision-making and improving outcomes in birth. I have become very interested in the nursing perspective as the more I learn about hospital birth, the more I realize that nurses are central to the management of labor & delivery units, and in measuring and reporting outcomes.  Thus, it was with great delight that I saw a new study, Intrapartum Nurses’ Perceived Influence on Delivery Mode Decisions and Outcomes in the January 2013 issue of JOGNN

Nurse-researchers Joyce K. Edmonds and Emily J. Jones conducted a semi-structured interview study with 13 nurses who were employed at a hospital with about 2000 births a year and overall cesarean rate of 36%.  These nurses work within a “nurse-managed labor model” which is characterized by a relatively autonomous nursing role, with intermittent communication with an off-site obstetrician.  Most nurses in the US practice within this type of model.  Nationally less than 10% of hospitals that do births are teaching hospitals, which have 24/7 access to physician consultation.  Other hospitals with 24/7 physicians on staff include HMOs like Kaiser Permanente, or those who have hospitalists.  In California, about half of all birthing facilities do not have an OB available onsite 24/7.

Shockingly few studies have looked at nurses’ role on the mode of delivery.   This is more striking when one considers the many specific nursing clinical practice responsibilities that may affect cesarean rates.  Nurses are largely responsible for assessing women during triage for admission, monitoring and assessing the health of mother/baby after hospital admission.  Nurses manage and administer oxytocin, assess and assist with labor pain, and are primary managers of second stage labor.  These practices occur within the administrative context of each hospital’s policies on admission in early labor, rates of interventions such as inductions (especially those for no medical indication), cesarean (especially those among the low risk population) and availability and rates of Vaginal Birth After Cesarean (VBAC).

Data for this study were drawn from semi-structured interviews with nurses who had a range of 10-40 years clinical experience in L&D.  Questions were specifically designed to elicit active practice and interaction with physicians (interactions with women were not addressed).  An example of a question asked of respondents, “Can you tell me about a time when you intervened to promote vaginal delivery or avoid a cesarean?”

The overarching theme in this study was how nurses described their efforts to ‘negotiate for more time’ during labor, to positively impact the likelihood of a vaginal delivery.   Negotiating for more time was defined in this study as “a form of nurse-physician interaction and an action taken to create the temporal space in which nursing interventions thought to affect delivery mode decisions operate”.    The authors found that nurses’ ability to negotiate for more time was based on their knowledge of labor and birth over their many years of experience, as well as their knowledge of individual physician practice patterns.  Furthermore, nurses’ awareness of physician and institutional-imposed time constraints was a key factor in negotiating for more time.

The important conclusion reached by the authors was that “experienced nurses practicing in a nurse-managed labor model have the potential to change patient outcomes.”  Despite the known limitations of this study – small sample of highly experienced nurses working at a single institution – I was intrigued and excited by the practice implications and the potential to develop quality improvement strategies for reducing cesarean deliveries that are specific to nurses.  So often, the labor & delivery nurses’ role is overlooked in this area and this study is an important contribution to our understanding of nurses’ influence in cesarean outcomes.   There is clearly more research and work to be done, and one of the authors, Joyce K. Edmonds, graciously responded to questions I had about the study and future directions for this research and quality improvement initiatives:

CHM: It was interesting that the range of experience represented in your study was 10-40 years – do you think your sample was more weighted toward the more experienced nurses?  Do you have any theories for why the lower end of the range was so high?  Were there nurses in that hospital with 2-3 years of experience?  Any thoughts about why they did or did not participate?

JKE:  Our sample was without doubt weighted to the experienced nurse, and we used the term experienced as a qualifier throughout the paper. This particular hospital staff was highly experienced, although, there were nurses with less than < 5 years experience. We think the sample was a self-selecting group of nurses who felt strongly about birth mode and the influence they had on birth mode decisions. Perhaps, less experienced nurses’ perspectives on birth mode were not as clearly developed as those who participated. It could also be that those who volunteered to participate were more supportive of promoting vaginal deliveries than those who did not participate. It could also be that scheduling conflicts with less experienced nurses prohibited them from participating.

Joyce Edmonds

CHM: I think the fluid nature of ‘time’ and the constraints on physician time bear further exploration.  In this regard, it would have been helpful have analyses of accounts where nurses felt they were ‘unsuccessful’ in buying more time for labor.  The counter-factual example can sometimes shed light on the dynamics – what didn’t work in this case? Do you have any unsuccessful stories in your data and/or did you analyze those?   It seemed as though all the nurses in your study DID negotiate for time, or at least provided you with accounts of when they did.  Were there any nurses who did NOT have a story to share about negotiating for more time?

JKE: All the nurses did talk about negotiating for time, which is the reason it emerged as the overarching theme.  Nurses did talk about not being able to negotiate for more time when cesareans were scheduled because the course of labor management was already established. They also seemed to have less influence when inductions were scheduled because again the labor management plan was established prior to their involvement in the care. I’d have to look back at the interviews with an eye toward specific counter-factual examples.

CHM: I also found it fascinating to read the quote that begins, “It almost feels like you’re working against the machine.” I was curious to know more about the justifications for that taboo of not being able to talk or confront the physician with the ‘agenda.’   In my interviews with OB nurses, I also came across this and think it is an important factor to explore further.  I imagine that nurses with less clinical experience are even less able to identify or recognize this ‘agenda’ and that comes with its own set of practice and policy issues for nursing training.  

JKE: I think the nurse physician relationship shapes the day-to-day work environment of the nurse. It is a long-term relationship relative to the nurse-patient relationship. It is likely that talking about or confronting a particular physician about the potential of an agenda could negatively disrupt the work environment, which is significantly related to nurses’ job satisfaction. Nurses want to be seen as team players and discussing the potential of physician ‘hidden agendas’ is like being a whistle blower. In addition to not wanting to disrupt the power balance, they may not want to invite scrutiny into their own practice patterns.

CHM: I was struck in particular by the account on page 5 of your paper that ends with the quote, “There are certainly situations where the baby needs to come out via C-section, but it is not as many as we do by any stretch.”  What situations?  What factors influence those decisions?  Where do nurses feel they lost power to bargain /buy more time?  

JKE: In this quote, the nurse is referring to medically indicated versus potentially unnecessary cesareans. I believe when nurses speak about cesareans they are not only focused on unplanned, intrapartum cesareans but also scheduled cesareans or scheduled inductions, which can result in a cesarean. It was clear from the interviews that nurses felt less invested in the decision-making process when women came in for scheduled cesareans or planned inductions. Nurses also spoke of how women are set up for failure during pregnancy—by way of unfavorable media messages, lack of unbiased childbirth education, and lack of risk reduction information from prenatal care providers.

CHM: I was intrigued that in this study you did not appear to ask about nurses’ views toward physiological birth (vaginal) and cesarean, or other indicators of their philosophy of birth.  The comment from the nurses who viewed themselves as a ‘dying breed’ begin to capture some sense of that – whether it is experience, knowledge, or philosophy of birth that unites them against this perceived different group of newer nurses.

JKE:  Great question, although it assumes that nurses’ personal philosophy of birth impacts their practice, which it likely does according to Reagan et al. In an attempt to keep the data focused on our main aim we did not ask nurses directly about their personal philosophy of birth. I believe the nurses in the study were united in their knowledge of childbirth–without the now pervasive assessment and intervention technology–knowledge borne out of experience.

CHM: How do you plan to follow up with this research and what are your future projects?    

JKE: Locally, we want to continue the discussion about the influence of nursing care and knowledge on cesarean rates that started with our interviews. Due to the sensitive nature of the topic and hospital policies, we have not had much success with direct follow-up where the study was conducted. However, we are very interested in presenting and discussing the results with other interested audiences. With regard to future projects, we are currently initiating a study to document the degree of nursing influence on cesarean rates at the level of the individual nurse, at an academic medical center and at a community hospital, building on the sentinel, yet dated, work of Radin et. al.  If the results are significant, we foresee the development of a quality improvement strategy directed at providing individual nurses routine (e.g., bi-monthly or quarterly) feedback on standard measures, such as risk adjusted primary cesarean section rates, cervical dilation at cesarean, and cesarean indication, based on the cohort of women in their care. Clearly, although not without great effort, such a strategy would need to be interdisciplinary and have adequate IT infrastructure and support. I also think nurses, as part of a team, should be involved in giving feedback about physician practice patterns in accordance with obstetric standards.

Are you an L&D nurse?  Can you comment on your experiences and how you feel your actions can influence the mode of birth.  If you are a doula, what has been your observation.  Doctor or midwife?  How do you view the role of the L&D nurse?  I look forward to a robust discussion. – SM

References

Edmonds, J. K. and Jones, E. J. (2013), Intrapartum Nurses’ Perceived Influence on Delivery Mode Decisions and Outcomes. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 42: 3–11. doi: 10.1111/j.1552-6909.2012.01422.x

Main, E.K., Morton, C.H, Hopkins, D., Giuliani, G.,  Melsop, K., and Gould, J.B (2012), Creating a Public Agenda for Maternity Safety and Quality in Cesarean Delivery, Obstetrics and Gynecology, November 2012; 120 (5):1194-1198.

Radin TG, Harmon JS, Hanson DA. Nurses’ Care During labor: Its Effect on the Cesarean Birth Rate of Healthy, Nulliparous Women. Birth. 1993;20(1):14-21.

Regan M, Liaschenko J. In the Mind of the Beholder Hypothesized Effect of Intrapartum Nurses’ Cognitive Frames of Childbirth Cesarean Section Rates. Qualitative Health Research. 2007;17(5):612-624.

Spong, C. Y. MD; Berghella, V. MD; Wenstrom, K. D. MD; Mercer, B. M. MD; Saade, G. R. MD (2012), Preventing the First Cesarean Delivery: Summary of a Joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists Workshop, Obstetrics & Gynecology, Volume 120(5), November 2012, p 1181–1193

Christine Morton ACOG, Cesarean Birth, Fetal Monitoring, Guest Posts, Maternal Quality Improvement, Maternity Care, Research, Transforming Maternity Care ACOG, Christine Morton PhD, CMQCC, CMS, Emily Jones, guest posts, Joint Commission, Joyce Edmonds, L&D nurse, labor and birth, NICHD, SMFM

I had waited excitedly for the release of Henci Goer and Amy Romano’s new book for a long time and was delighted to receive it after it was published in May 2012. Optimal Care in Childbirth: The Case for a Physiologic Approach was a robust, updated successor to Henci’s previous book; Obstetric Myths Versus Research Realities which was a well used source on my office bookshelf.

Both authors have a long history with Lamaze International. Prior to her current position with Childbirth Connection, directing the Transforming Maternity Care Partnership, Amy launched Science & Sensibility, and provided a keen and critical eye when analyzing, reviewing and sharing research items with readers. Henci Goer has been the long time resident expert on the “Ask Henci” forum hosted by Lamaze International, providing and sharing resources on a wide variety of pregnancy and childbirth topics with consumers and professionals alike, as well as a regular contributor to this blog. Please read the full bios of Amy and Henci on their website, where you can find complete information on their work, background and other works that they have authored.

As the title clearly states, this book is about childbirth, and as such, you will not find information on pregnancy, breastfeeding or newborn topics. Nor is this the type of text that childbirth educators would hand out in class for consumers to use. This book is heavy with sources, study outcomes and insights into current obstetric practices. But, as a guide to best practice, the book becomes a great repository of information that allows consumers and professionals alike to learn and make decisions about care that can help keep birth as physiological as possible. The book focuses on what factors affect, both positively and negatively, birth, so that an optimal outcome can occur.

The authors define optimal outcomes as “the highest probability of spontaneous birth of a healthy baby to a healthy mother, who feels pleased with herself and her caregivers, ready for the challenges of motherhood, attached to her baby, and goes on to breastfeed successfully.”

The chapters are well organized, with the topic of cesareans starting things off. Cesarean rates have never been higher, and many of the topics that Goer and Romano discuss later in the book often have the unintended consequence of contributing to the skyrocketing cesarean rates in this country. I think it is an important topic and one that receives a thorough evaluation by the authors.

Each chapter starts off with “contradicting” quotes from researchers working in the field of obstetrics, and I have to say, that reading these at the beginning of each chapter was something I looked forward to, a nice added bonus and really made me pause and consider the different viewpoints and how they influence practice today. The lead in for chapter 12 on epidurals and spinals contains one of my favorites:

“There is no other circumstance in which it is considered acceptable for a person to experience untreated severe pain, amenable to safe interventions, while under a physician’s care.” ACOG 2006

“Epidural anaesthesia remains one of childbirth’s best exemplars of iatrogenesis. It is a wonderful intervention for managing labour complications, especially as an alternative to general anaesthetic for caesarean sections, but has significant side effects that constantly need weighing alongside benefits. Though its rising popularity almost grants it the status of normative practice on some [U.K.] maternity unites, it remains incompatable with physiological labour.” Walsh 2007

Each chapter begins with a wonderful perspective on each topic, sharing history and cultural practices so the reader can understand how standard protocols found in most birthing facilities have come to be, even when not backed up by research. I think it is critical to include this information, for if there is to be a shift to more evidence based care in the field of obstetrics, we need to be aware and acknowledge that some practices may have evolved for legal, cultural, social or policy reasons having nothing to do with sound research.

The authors ask and answer the very questions that I find myself asking out loud, helping the reader to understand why we continually observe care that is known to not improve outcomes. For example, when discussing electronic fetal monitoring, the question “Why does use of continuous EFM persist?” in normal low risk labors is asked (and thoroughly answered) with supporting references for further information.

Each chapter contains a brief summary of action steps that women can take to receive optimal care, along with the supporting research that backs up these steps. These lists are great talking points both for educators to integrate in their classrooms, but also for consumers to discuss with their health care providers and understand why their care might deviate from that supported by research.

The conclusion of each chapter has what the authors call a “mini-review” and neatly summarizes the important topic statements and provides (and references) outcomes of studies so that the reader can evaluate for himself or herself the validity of the research. Though these sections are called reviews, I found them to be a very helpful component of the book, when looking for solid sources.

At the end of each chapter, all of the sources referenced in that chapter are listed.

Henci Goer

I was very appreciative throughout the book, for the definitions that the authors provided when discussing a topic. It is important (and helpful) to know how terms are defined, so that the reader can best understand the discussion. For example, in one of the cesarean chapters, one can find a list of “rate” terms, so when “primaparous cesarean rate” is discussed, this term has already been explained.

Several places throughout the book, in various callout boxes, Goer and Romano discussed the selective language that health care providers use when talking about childbirth and presenting information to families. I found these small detours fascinating, as I am very interested in the language that HCPs use to discuss risk, procedures and events with their patients.

The last chapters of the book take a look at choice of birth location, what the ideal maternity care system might include and includes information on maternal mental health. The appendices speak to common “less than optimal” situations, such as the OP fetus in labor, meconium staining and other circumstances that frequently cause concern and labor interventions. Again, the authors include information on optimal care in these cases that can help.

It is clear from some of the phrasing, chapter titles and choice of words in some of the discussions, that the authors have a bias towards a childbirth process that unfolds in a natural and physiological manner. This language, while potentially off-putting to those who firmly believe in the medical model, is effective in causing the reader to consider standard practices that make no logical “sense”, and certainly, references are provided for further research should the reader wish to investigate further.

I must say that I very much enjoyed this book, and I will find it very useful in my doula and Lamaze childbirth education practice. It is the type of book that one thumbs through frequently, when asked a question by a student or client, or when helping a client to prepare to speak to their health care provider about best practices and birth preferences. I think that any birth professional would do well to have this book on their shelf and be able to refer to it when necessary. This book represents a significant amount of research and I find great comfort in knowing that all the resources and references supporting the statements made in the book are available for me to source myself.

Amy Romano

I look forward to the release of the e-book version of this title, expected this fall, for the Kindle, iPad and other tablets, so that I could have easy access from wherever I am. I would be delighted if the references and sources could be routinely updated as new research is released and published, so that I can use this guide for many years to come, confident that it reflects the newest and most valid research. I know that is a formidable task, but I would gladly pay a small subscription fee to have an updated version as often as necessary.

This book is available for purchase from both Amazon.com and the Optimal Care in Childbirth website. The book is on the expensive side, costing approximately $50.00, but very well may become the go-to source for evidenced based research on your office shelf, so worth the investment. If you choose to purchase from the book’s site, there are bulk and wholesale discounts available.  For purchases made from the book’s website, the authors are providing a 15% discount for our Science & Sensibility blog readers and conference attendees. Enter code UXJXI52F at checkout to receive the discount.

I hope that you are planning to attend the upcoming Lamaze International Innovative Learning Forum next week, where both Amy Romano and Henci Goer have been invited to speak. You will have an opportunity to meet these authors, ask them questions, purchase this book and hear their powerful presentations. As a General Session Speaker, Amy’s session will be available as part of the “Virtual Conference” option for those unable to attend the conference in person.

Have you read Optimal Care in Childbirth?  Are you using it already in your practice?  Please share your thoughts and comments in our comment section here on the blog.  I look forward to hearing your views. – SM

References

ACOG committee opinion. No. 339: Analgesia and cesarean delivery rates. Obstet Gynecol 206;107(6):1487-8.

Walsh D. Evidenced Based Care for Normal Labor and Birth. London: Routledge; 2007.

Sharon Muza Book Reviews, Cesarean Birth, Childbirth Education, Epidural Analgesia, Fetal Monitoring, Healthcare Reform, informed Consent, Lamaze 2012 Annual Conference, Maternal Mental Health, Medical Interventions, New Research, Pain Management, Practice Guidelines, Research, Systematic Review, Transforming Maternity Care Amy Romano, Ask Henci, book review, Henci Goer, Lamaze 2012 Annual Conference, Lamaze Innovative Learning Forum, Lamaze International, Optimal Care in Childbirth, Research about pregnancy and birth, Sharon Muza

The  Canadian Medical Association Journal, published in their September 12, 2012 issue a very interesting study examining how a team approach to maternity care might improve maternal and neonat aloutcomes.  The study, Effect of a collaborative interdisciplinary maternity care program on perinatal outcomes  is reviewed here.

The Challenge

Photo Source: http://www.flickr.com/photos/jstownsley/28337593/

The number of physicians in Canada who provide obstetric care has declined in past years for reasons that include increasing physician retirement, closure of rural hospitals, liability concerns, dissatisfaction with the lifestyle and a difficulty in accessing maternity care in a variety of settings.  While registered midwife attended births may be on the rise, midwives in Canada attend less than 10% of all births nationwide.   At the same time as the number of doctors willing or able to attend births decline, cesarean rates are on the rise,  causing pressure on the maternity care system, including longer hospital stays both intrapartum and postpartum, which brings with it the associated costs and resources needed to accommodate this increase.

The diversity of the population having babies in many provinces is increasing, presenting additional challenges in meeting the non-French/English speaking population, who are more at risk for increased obstetrical interventions and are less likely to breastfeed.

The Study

In response to these challenges, the South Community Birth Program was established to provide care from a consortium of providers, including family practice physicians, community health nurses, doulas, midwives and others, who would work together to serve the multiethnic, low income communities that may be most at risk for interventions and surgery.

The retrospective cohort study examined outcomes between two matched groups of healthy women receiving maternity care in an ethically diverse region of South Vancouver, BC, Canada that has upwards of 45% immigrant families, 18% of them arriving in Canada in the past 5 years.  One group participated in the South Community Birth Program and the other received standard care in community based practices.

The South Community Birth Program offers maternity care in a team-based shared-care model, with the family practice doctors, midwives, nurses and doulas working together .  Women could be referred to the program by the health care provider or self refer.  After a few initial standard obstetrical appointments with a family practice doctor or midwife occur to determine medical history, physical examination, genetic history, necessary labs and other prenatal testing, the women and their partners are invited to join group prenatal care, based on the Centering Pregnancy Model.  Approximately 20% of the first time mothers choose to remain in the traditional obstetric care model.  10-12  families are grouped by their expected due date, and meet for 10 scheduled sessions, facilitated by either a family physician or midwife and a community nurse.  Each session has a carefully designed curriculum that covers nutrition, exercise, labor, birth and newborn care, among other topics.  Monthly meetings to discuss individual situations and access to comprehensive electronic medical records enhanced the collaboration between the team. Trained doulas, who speak 25 different languages, also meet with the family once prenatally and provide one on one continuous labor support during labor and birth. The admitting midwife or physician remains in the hospital during the patient’s labor and attends the birth.

After a hospital stay of 24-48 hours, the family receives a home visit from a family practice physician or midwife the day after discharge. Clinic breastfeeding and postpartum support is provided by a Master’s level clinical nurse specialist who is also a board certified lactation consultant.  At six weeks, the mother is discharged back to her physician, and a weekly drop in clinic is offered through 6 months postpartum.

The outcomes of the women in the South Community Birth Program were compared to women who received standard care from their midwives or family practice physicians.  Similar cohorts were established of women carrying a single baby of like ages, parity, and geographic region, and all the mothers were considered low risk and of normal body mass index.

The primary outcome measured was the proportion of women who underwent cesarean delivery.  The secondary outcomes measured were obstetrical interventions and maternal outcomes (method of fetal assessment during labor, use of analgesia during labor, augmentation or induction of labor, length of labor, perineal tramau, blood transfusion and length of stay) and neonatal outcomes (stillbirth, death before discharge, Apgar score less than 7, preterm delivery, small or large for gestational age, length of hospital stay, readmission, admission to neonatal intensive care unit for more than 24 hours and method of feeding at discharge).

Results

There was more incidence of diabetes and previous cesareans in the comparison group but the level of alcohol and substance use was the same in both groups.  Midwives delivered 41.9% of the babies in the birth program and 7.4% of babies in the comparison group.

When the rate of cesarean delivery was examined for both nullips and multips, the birth group women were at significantly reduced risk of cesarean delivery and were not at increased risk of assisted vaginal delivery with forceps or vacuum.

Interestingly, the birth program women who received care from an obstetrician were significantly more likely to have a cesarean than those receiving in the standard program who also received care from an obstetrician.  More women in the birth program with a prior cesarean delivery planned a vaginal birth in this pregnancy, though the proportion of successful vaginal births after cesareans dd not differ between the two groups.

The women in the community birth program experienced more intermittent auscultation vs electronic fetal monitoring and were more likely to use nitrous oxide and oxygen alone for pain relief and less likely to use epidural analgesia (Table 3).  Though indications for inductions did not differ, the birth program women were less likely to be induced.  More third degree perineal tears were observed in the birth program group but less episiotomies were performed.  Hospital stays were shorter for both mothers and newborns in the community program.

When you look at the newborns in the birth program, they were at marginally increased risk of being large for gestational age and were readmitted to the hospital in the first 28 days after birth at a higher rate, the majority of readmissions in the community and standard care group were due to jaundice. Exclusive breastfeeding in the birth program group was higher than in the standard group.

Discussion

The mothers and the babies in the community birth program were offered collaborative, multidisciplinary, community based care and this resulted in a lower cesarean rate, shorter hospital stays, experienced less interventions and they left the hospital more likely to be exclusively breastfeeding. Many of the outcomes observed in this study, especially for the families participating in the South Birth Community Program are in line with Lamaze International’s Healthy Birth Practices.  There are many questions that can be raised, and some of them are are discussed by the authors.

Was it the collaborative care from an interdisciplinary team result in better outcomes?  Was there a self-selection by the women themselves for the low intervention route that resulted in the observed differences?  Are the care providers themselves who are more likely to support normal birth self-selecting to work in the community birth program? Did the fact that the geographic area of the study had been underserved by maternity providers before the study play a role in the outcomes? Did the emotional and social support provided by the prenatal and postpartum group meetings facilitate a more informed or engaged group of families?

I also wonder how childbirth educators, added to such a model program, might also offer opportunity to reduce interventions and improve outcomes  Could childbirth educators in your community partner with other maternity care providers to work collaboratively to meet the perinatal needs of expectant families?  Would bringing health care providers interested in supporting physiologic birth in to share their knowledge in YOUR classrooms help to create an environment where families felt supported by an entire skilled team of people helping them to achieve better outcomes.

Would this model be financially and logistically replicable in other underserved communities and help to alleviate some of the concerns of a reduction in obstetrical providers and increased cesareans and interventions without improved maternal and newborn outcomes? And how can you, the childbirth educator, play a role?

References

Azad MB, Korzyrkyj AL. Perinatal programming of asthma: the role of the gut microbiota. Clin Dev Immunol 2012 Nov. 3 [Epub ahead of print].

Canadian Association of Midwives. Annual report 2011. Montréal (QC): The Association; 2011. Available: www .canadianmidwives.org /data/document /agm %202011 %20inal .pdf

Farine D, Gagnon R; Maternal Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada. Are we facing a crisis in maternal fetal medicine in Canada? J Obstet Gynaecol Can 2008;30:598-9.

Getahun D, Oyelese Y, Hamisu M, et al. Previous cesarean delivery and risks of placenta previa and placental abruption.Obstet Gynecol 2006;107:771-8.

Giving birth in Canada: the costs. Ottawa (ON): Canadian Institute of Health Information; 2006.

Godwin M, Hodgetts G, Seguin R, et al. The Ontario Family Medicine Residents Cohort Study: factors affecting residents’ decisions to practise obstetrics. CMAJ 2002;166:179-84.

Hannah ME. Planned elective cesarean section: A reasonable choice for some women? CMAJ 2004;170:813-4.

Harris, S., Janssen, P., Saxell, L., Carty, E., MacRae, G., & Petersen, K. (2012). Effect of a collaborative interdisciplinary maternity care program on perinatal outcomes. Canadian Medical Association Journal, doi: DOI:10.1503 /cmaj.111753

Ontario Maternity Care Expert Panel. Maternity care in Ontario 2006: emerging crisis, emerging solutions: Ottawa (ON): Ontario Women’s Health Council, Ministry of Health and LongTerm Care; 2006.

Reid AJ, Carroll JC. Choosing to practise obstetrics. What factors influence family practice residents? Can Fam Physician 1991; 37:1859-67.

Sharon Muza Babies, Breastfeeding, Cesarean Birth, Childbirth Education, Evidence Based Medicine, Fetal Monitoring, Healthy Birth Practices, Healthy Care Practices, Maternity Care, Medical Interventions, Midwifery, New Research, Research, Uncategorized breastfeeding, Canada, cesarean, Childbirth Education, epidurals, Healthy Birth Practices, hospitals, induction, interventions, maternity care quality, maternity care systems, MD, midwives, newborns, Sharon Muza, South Community Birth Program

By Rebecca L. Dekker, PhD, RN, APRN

Today’s post on the Evidence for Induction for Low Amniotic Fluid in a Healthy Pregnancy is a guest post by blogger Rebecca Dekker, owner of  the fairly new blog in the birth world, Evidence Based Birth that has been  very well received and enjoyed by many.  Look for an interview with Rebecca in an upcoming post where we will learn how this Assistant Professor of Nursing who teaches pathopharmacology and studies depression in patients with heart failure ended up writing the Evidence Based Birth blog appreciated by birth professionals.  I look forward to future posts and collaboration with Rebecca and thank her for her contribution today.- SM

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This question came from one of my readers:

“Low fluid seems to be the new “big baby” for pushing for induction. What does the research say about low fluid at or near term? From what I’ve been able to see in research summaries at least, there appears to be no improved outcome for babies, but I’d love to see the research really hashed out. I’m also curious about causes of low fluid (theorized or known), risks of low fluid, and perhaps as important if not more so, measurements of low fluid.”

This is a great question and I felt like it was a perfect topic for my first article for Science and Sensibility. Standard of practice in the U.S. is to induce labor at term if a mother has low amniotic fluid in an otherwise healthy pregnancy. In fact, 95% of physicians who practice maternal-fetal medicine feel that isolated oligohydramnios—low amniotic fluid in an otherwise healthy pregnancy—is an indication for labor induction at 40 weeks (Schwartz, Sweeting et al. 2009).

But what is the evidence for this standard birth practice? Let’s take a look at the evidence together.

First of all, what is oligohydramnios?

Oligohydramnios means low fluid inside the amniotic sac.

(oligo = little, hydr = water, amnios = membrane around the fetus, or amniotic sac).

Not sure how to pronounce oligohydramnios? Click here.

It is standard of care in the U.S. to induce women with isolated oligohydramnios at term.
Image Source drewesque 

What is amniotic fluid, and what does it do?

During pregnancy, the baby is surrounded by a liquid called amniotic fluid. Amniotic fluid helps protect the baby from trauma to the mother’s abdomen. Amniotic fluid cushions the umbilical cord, protects the baby from infection, and provides fluid, space, nutrients, and hormones to help the baby grow (Brace 1997).

During the second half of pregnancy, amniotic fluid is made up of the baby’s urine and lung secretions. This liquid originally came from the mother, and then flowed through the placenta, to the baby, and out through the baby’s bladder and lungs (Brace 1997).

This same amniotic fluid is then swallowed by the baby and re-absorbed by the lining of the placenta. Because the mother’s fluid levels are the original source of amniotic fluid, changes in the mother’s fluid status can result in changes in the amount of amniotic fluid. Amniotic fluid levels increase until the mother reaches about 34-36 weeks, and then levels gradually decline until birth (Brace 1997).

What can cause low amniotic fluid at term?

Both mother and baby factors can contribute to low amniotic fluid at term.

Mother factors:

• If the mother is dehydrated, this may lower the amniotic fluid levels. (Patrelli, Gizzo et al. 2012)
• Women are more likely to be diagnosed with low amniotic fluid levels during the summer, possibly because of dehydration. (Feldman, Friger et al. 2009)
• If a woman with low amniotic fluid levels at term drinks at least 2.5 Liters of fluid per day, she increases the likelihood that her amniotic fluid levels will be back up to normal by the time of delivery. (Patrelli, Gizzo et al. 2012)
• If the mother rests on her left side before or during the fluid measurement, this can increase amniotic fluid levels. (Ulker, Temur et al. 2012)
• If the mother’s water has broken (membranes ruptured), this will lead to a decrease in amniotic fluid. (Brace 1997)
• If the mother’s placenta is not acting sufficiently anymore, this may lead to a decrease in amniotic fluid. When this happens, it may be because the mother has a serious condition such as pre-eclampsia or intrauterine growth restriction. (Beloosesky and Ross 2012)

Baby factors:

• If the baby has a problem with the urinary tract or kidneys, this may decrease the flow of urine. (Brace 1997)
• In the 14 days before the start of spontaneous labor, the baby’s urine output starts to decrease. (Stigter, Mulder et al. 2011)
• As the baby gets closer to term, the baby swallows more amniotic fluid, thus leading to a decline in fluid levels. (Brace 1997)
• If the baby is post-term (after 42 weeks), he or she begins to swallow significantly more fluid, contributing to a decline in amniotic fluid. (Brace 1997)
• If the baby has a birth defect, he or she may swallow significantly more fluid, leading to low amniotic fluid levels. (Beloosesky and Ross 2012)

What is the best way to measure amniotic fluid levels?

The gold-standard method is to inject the amniotic sac with dye and then take samples of the amniotic fluid to check the dilution. However, this method is very invasive. So the most commonly used methods instead are 2 ultrasound techniques:  the amniotic fluid index (AFI) and the single deepest pocket (Gilbert 2012).

To calculate the AFI, the technician divides the uterus into 4 areas. The largest fluid pocket in each area is measured, and then these 4 numbers are added make up the AFI. An AFI value of 5 cm or less is considered oligohydramnios. With the single deepest pocket method, the technician looks for the largest pocket of amniotic fluid in the uterus. If the largest pocket is less than 2 cm by 1 cm, then that is considered a diagnosis of oligohydramnios (Nabhan and Abdelmoula 2009).

It is important to understand that amniotic fluid levels exist on a continuum and that there is no agreement among researchers about the cut-off value that predicts poor outcomes—the AFI level of 5 was arbitrarily chosen to define oligohydramnios (Nabhan and Abdelmoula 2009). Furthermore, a large body of research has shown that both AFI and single deepest pocket are poor predictors of true amniotic fluid volume. For example, the AFI catches only 10% of all cases of true oligohydramnios (10% sensitivity)(Gilbert 2012).

There are several factors that make it difficult to get an accurate ultrasound measurement. As fluid levels decrease, ultrasound results become less accurate. Inexperience on the part of the technician can reduce the accuracy of the test results, as well as the amount of pressure that the technician puts on the ultrasound probe. The position of the baby can also affect the accuracy of the results. (Nabhan and Abdelmoula 2009; Gilbert 2012).

So which is the best way to measure amniotic fluid?

In a Cochrane review, researchers combined the results from 5 randomized controlled trials with more than 3,200 women. In these studies, women were randomized to either the AFI method or the single deepest pocket method. Researchers found that when the AFI is used to measure amniotic fluid, women were 2.4 times more likely to be diagnosed with oligohydramnios, 1.9 times more likely to be induced, and 1.5 times more likely to have a Cesarean for fetal distress without any corresponding improvement in infant outcomes. The researchers concluded that the single deepest pocket measurement has fewer risks and should be the preferred way to measure amniotic fluid (Nabhan and Abdelmoula 2009).

What is the clinical significance of low amniotic fluid when a mother reaches 37 or more weeks?

In 2009, 91% of physicians believed that isolated oligohydramnios, or low amniotic fluid in an otherwise healthy pregnancy at term, was a risk factor for poor outcomes (Schwartz, Sweeting et al. 2009).

In the U.S., 91% of maternal-fetal physicians believe that isolated oligohydramnios at term is a risk factor for poor outcomes, and 95% will recommend labor induction.
Image Source robenjoyce

However, this belief is not accurate. In early studies on amniotic fluid and outcomes, researchers included babies with congenital defects , women with pre-eclampsia or intrauterine growth restriction (IUGR), and women who were post-term (past 42 weeks) in their samples. These women and babies are more likely to have low amniotic fluid, and they are also much more likely to have poor outcomes. So although early researchers found that babies born to women with low amniotic fluid had higher perinatal mortality rates (Chamberlain, Manning et al. 1984), higher Cesarean rates for fetal distress, and lower Apgar scores (Chauhan, Sanderson et al. 1999), the poor outcomes were due to the complications—not the low amniotic fluid (Gilbert 2012).

So, if a woman has TRUE ISOLATED oligohydramnios at term, meaning low amniotic fluid in a healthy pregnancy with a healthy baby at term (between 37 and 42 weeks), what are the risks?

There is no evidence that isolated oligohydramnios at term is a risk factor for poor outcomes. However, induction for isolated oligohydramnios leads to higher Cesarean rates. In a systematic literature review, I found 5 studies from the last 10 years. I will discuss the 3 highest quality studies here. For results from all 5, you can see my findings summarized in this Google document table here.

1. Locatelli et al. (2003) studied 3,049 healthy pregnant women who were between 40 and 41.6 weeks pregnant. The purpose of this study was to find out if low amniotic fluid (defined as AFI ≤ 5) led to poor outcomes. Eleven percent of women had low amniotic fluid, and these women had higher induction rates (83% vs. 25%), higher Cesarean rates (15% vs. 11%), and higher Cesarean rates for non-reassuring fetal heart rates (8% vs. 4%). Babies born to women with low amniotic fluid were more likely to have birth weights beneath the 10^th percentile (13% vs. 6%). There were no differences between groups with meconium staining, meconium aspiration, umbilical artery pH <7, or Apgar scores. There was only one stillbirth (in the normal fluid group) for a true knot in the umbilical cord.

After controlling for the fact that some women were induced and some women were having their first baby, the researchers found no association between Cesarean for non-reassuring heart rate and amniotic fluid. This means that the inductions were probably responsible for the higher Cesarean rates in the low amniotic fluid group. However, when the researchers controlled for gestational age, they found that the association between low birth weight and low amniotic fluid remained significant. This means that women with low amniotic fluid were 2 times more likely to have a baby that is born beneath the 10^th percentile. These babies may have had undiagnosed fetal growth restriction (IUGR), which is a separate risk factor for poor outcomes.

1. Manzaneres et al. (2006) compared outcomes from 206 healthy pregnant women who were induced for isolated oligohydramnios at term and 206 healthy pregnant women with normal amniotic fluid levels who went into spontaneous labor.  The women in both groups delivered between 37 and 42 weeks. The researchers found that the low amniotic fluid group was more likely to require forceps or vacuum delivery (26% vs. 17%), Cesarean delivery (16% vs. 6%), and have non-reassuring fetal status during labor (8% vs. 2%). The non-reassuring fetal status may have been due to the induction medications, but this explanation was not proposed by the authors. There were no differences between groups with birth weight, Apgar scores, meconium staining, neonatal admissions, or umbilical cord pH. In summary, the authors found that inducing labor for isolated oligohydramnios at term increased Cesarean and operative vaginal delivery rates without any improvement in newborn outcomes.

1. There was one small pilot study done in which researchers randomized women with isolated oligohydramnios at term to induction or watchful waiting. The researchers randomly assigned 54 women who were 41 weeks pregnant to either induction or watchful waiting. There were no differences between groups in any outcomes, including birth weight, Cesarean delivery, Apgar scores, or neonatal admission. This study was limited by its small sample size and the fact that it only included women who were 41 weeks pregnant (Ek, Andersson et al. 2005).

So what is the evidence for induction because of low amniotic fluid (without any other complications) at term?

There is no evidence that inducing labor for isolated oligohydramnios at term has any beneficial impact on mother or infant outcomes. Based on the lack of evidence, any recommendation for induction for isolated oligohydramnios at term would be a weak recommendation based on clinical opinion alone.

In summary, this is what I found about low amniotic fluid in an uncomplicated pregnancy at term (37-42 weeks):

• Ultrasound measurement is a poor predictor of actual amniotic fluid volume
• The single deepest pocket method of measurement has fewer risks than the AFI
• Poor outcomes seen with low amniotic fluid are usually due to underlying complications such as pre-eclampsia, birth defects, or fetal growth restriction
• The main risk of low amniotic fluid at term in a healthy pregnancy is induction (and Cesarean delivery as a result of the induction) and potentially the risk of lower birth weight
• Current evidence does not support induction for isolated oligohydramnios at term

Are women in your local areas being induced for isolated oligohydramnios at term? Are consumers and clinicians aware of this evidence? What is the standard of practice for evaluating amniotic fluid in your local facilities, AFI or Single Deepest Pocket? How do you discuss this in your classes and with your patients, clients and students?

References

1. Beloosesky, R. and M. G. Ross. (2012). “Oligohydramnios.”   Retrieved 8/20/12, 2012, from www.UpToDate.com
2. Brace, R. A. (1997). “Physiology of amniotic fluid volume regulation.” Clin Obstet Gynecol 40(2): 280-289.
3. Chamberlain, P. F., F. A. Manning, et al. (1984). “Ultrasound evaluation of amniotic fluid volume. I. The relationship of marginal and decreased amniotic fluid volumes to perinatal outcome.” Am J Obstet Gynecol 150(3): 245-249.
4. Chauhan, S. P., M. Sanderson, et al. (1999). “Perinatal outcome and amniotic fluid index in the antepartum and intrapartum periods: A meta-analysis.” Am J Obstet Gynecol 181(6): 1473-1478.
5. Ek, S., A. Andersson, et al. (2005). “Oligohydramnios in uncomplicated pregnancies beyond 40 completed weeks. A prospective, randomised, pilot study on maternal and neonatal outcomes.” Fetal Diagn Ther 20(3): 182-185.
6. Feldman, I., M. Friger, et al. (2009). “Is oligohydramnios more common during the summer season?” Arch Gynecol Obstet 280(1): 3-6.
7. Gilbert, W. M. (2012). Amniotic Fluid Disorders. Obstetrics: Normal and Problem Pregnancies. S. G. Gabbe. Philadelphia, PA, Elsevier. 6.
8. Locatelli, A., P. Vergani, et al. (2004). “Perinatal outcome associated with oligohydramnios in uncomplicated term pregnancies.” Arch Gynecol Obstet 269(2): 130-133.
9. Nabhan, A. F. and Y. A. Abdelmoula (2009). “Amniotic fluid index versus single deepest vertical pocket: a meta-analysis of randomized controlled trials.” International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics 104(3): 184-188.
10. Patrelli, T. S., S. Gizzo, et al. (2012). “Maternal hydration therapy improves the quantity of amniotic fluid and the pregnancy outcome in third-trimester isolated oligohydramnios: a controlled randomized institutional trial.” J Ultrasound Med 31(2): 239-244.
11. Schwartz, N., R. Sweeting, et al. (2009). “Practice patterns in the management of isolated oligohydramnios: a survey of perinatologists.” J Matern Fetal Neonatal Med 22(4): 357-361.
12. Stigter, R. H., E. J. Mulder, et al. (2011). “Fetal urine production in late pregnancy.” ISRN Obstet Gynecol 2011: 345431.
13. Ulker, K., I. Temur, et al. (2012). “Effects of maternal left lateral position and rest on amniotic fluid index: a prospective clinical study.” J Reprod Med 57(5-6): 270-276.

Rebecca Dekker, PhD, RN, APRN, is an Assistant Professor of Nursing at a research-intensive university and author of www.evidencebasedbirth.com. Rebecca’s vision is to promote evidence-based birth practices among consumers and clinicians worldwide. She publishes summaries of birth evidence using a Question and Answer style. You can contact Rebecca via email here.

Sharon Muza Evidence Based Medicine, Fetal Monitoring, Guest Posts, Healthy Birth Practices, Healthy Care Practices, informed Consent, Maternity Care, Medical Interventions, Systematic Review, Uncategorized AFI, Evidence Based Birth, Evidence Based Medicine, Fetal Monitoring, guest post, Healthy Birth Practices, induction, Oligohydramnios, prenatal ultrasound, Rebecca Dekker

As a childbirth professional or an expectant parent, do you wonder about the multitude of pain management techniques offered for childbirth?

As part of the Cochrane Collaboration, Leanne Jones and eight of her colleagues (2012) has published new research synthesizing divergent data constructs and summarizing 355 trials on pain management during childbirth. There are many detailed data tables associated with this study.

To view the entire study, Lamaze members can access the full Cochrane Library, via the Members Only Section.

A summary of the study is below.

Background

In 2007, the Cochrane Pregnancy & Childbirth Group (PCG) consumer’s group identified pain relief in childbirth as the topic of most importance to them.

This study was funded to provide an evidence-based summary of the efficacy and safety of pain management methods in childbirth for consumers, policy-makers, and childbirth educators.

Women experience pain in childbirth in varying degrees of intensity, influenced by physiological and psychosocial factors. Most women require some type of pain relief. Both non-pharmacological and pharmacological methods are used for pain management.

312 Studies Reviewed

Collecting the totality of evidence from existing randomized controlled trials, the researchers identified 18 total systematic reviews for inclusion in their study. 15 reviews were Cochrane reviews (257 included trials) and 3 were non-Cochrane reviews (55 included trials). Data from a total of 312 studies were reviewed in this study.

There were more studies of pharmacological interventions than non-pharmacological interventions.

13 Outcomes Identified for Inclusion

The researchers, in partnership with the PCG consumer group, identified these outcomes for inclusion in the study.

Effects of interventions

• Pain intensity (as defined by trialists)
• Satisfaction with pain relief (as defined by trialists)
• Sense of control in labor (as defined by trialists)
• Satisfaction with childbirth experience (as defined by trialists)

Safety of interventions

• Effect (negative) on mother/baby interaction
• Breastfeeding (at specified time points)
• Assisted vaginal birth
• Cesarean section
• Adverse effects (for women & babies)
• Admission to special care baby unit / NICU
• Apgar score less than at five minutes
• Poor infant outcomes at long-term follow-up (as defined by trialists)

15 Childbirth Management Methods Identified

The researchers identified a list of 15 childbirth pain management methods:

• placebo/no treatment
• hypnosis
• biofeedback
• intracutaneous or subcutaneous sterile water injection
• immersion in water
• aromatherapy
• relaxation techniques (yoga, music, audio)
• acupuncture or acupressure
• massage, reflexology or manual methods
• TENS
• inhaled analgesia
• opioid
• non-opioid drugs
• local anesthetic nerve blocks
• epidural

 As a Lamaze childbirth educator, how will you incorporate respect for your client’s individual decisions while presenting the Six Lamaze Healthy Birth Practices?

Results: Non-pharmacological Studies

The authors found that non-pharmacological methods are mostly used in midwife-led continuity of care births and/or where women had continuous intrapartum support. Such non-pharmacological methods are meant to break the fear-pain-tension cycle and to work within the pain paradigm. The pain paradigm of birth is a philosophy based on the idea that pain is a normal part of the physiology of labor and that women can use coping methods to manage the pain (Leap, 2008; as cited in Jones et al, 2012).

The researchers found the evidence for many non-pharmacological methods to be mostly incomplete as there is an average of only two studies for each method.

However, the following non-pharmacological methods are shown to provide pain relief and positive maternal psychological outcomes without invasive side effects: immersion in water, relaxation, acupuncture/acupressure and massage.

In addition, women report greater emotional satisfaction with childbirth when using immersion and relaxation. With the use of relaxation and acupuncture/acupressure, there is a decrease in the use of forceps and ventouse. There is a decrease in the amount of cesarean section associated with the use of acupuncture/acupressure.

The researchers report there is insufficient evidence to report on pain relief using the following methods: hypnosis, biofeedback, sterile water injection, aromatherapy and TENS.

Results: Pharmacological Studies

There are more studies of pharmacological methods versus non-pharmacological methods. The authors found that pharmacological methods relieve pain and have side effects.

Pharmacological methods are most likely to be used in settings with a pain relief paradigm. In the pain relief paradigm of labor, pain is considered barbaric, the benefits of analgesia outweigh the risks, and women should be free to use whatever pain relief methods she wishes, without guilt (Leap, 2008; as cited in Jones et al, 2012).

Comparative Pain Relief & Side Effects

Epidural, combined spinal epidural (CSE) and inhaled nitrous oxide & oxygen relieve pain better when compared to opioids (Jones et al, 2012).

Epidurals are associated with an increase of the use of forceps or ventouse, an increase in the risk of low blood pressure, low motor blocks, fever and urine retention (Amin-Somanuh, 2005; as cited in Jones et al, 2012). In addition, other side effects such as shivering, tinnitus, and respiratory or cardiovascular depression may occur. The authors state it is uncertain whether the use of epidurals interfere with breastfeeding (Reynolds, 2011; as cited in Jones et al, 2012).

Combined spinal epidurals (CSE) provide faster pain relief than traditional epidurals, but are associated with more feelings of itchiness, giddiness, sweating, and tingling (Jones et al, 2012).

Inhaled nitrous oxide is associated with minimal toxicity and rapid maternal and neonate elimination, but can cause feelings of nausea, drowsiness and sickness (KNOV, 2009; Rosen, 2002; as cited in Jones et al, 2012).

Non-opioid drugs (acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDS)) relieve pain for shorter periods of time as compared to opioid drugs (Bayarski, Hebbes, 200; as cited in Jones et al, 2012).

Opioid drugs (morphine, nalbuphine, fentanyl, parenteral and pethidine) are used worldwide. Parenteral opioids are reported to provide less pain relief than epidurals. Side-effects include impaired maternal capacity for decision-making, sedation, hypoventilation, hypotension and urine retention. Opioids readily cross the placenta, thus neonatal respiratory depression and hypothermia are also concerns. Pethidine is shown to affect fetal heart rate variability during labor (Sekhavat, 2009; Solt, 2002; as cited in Jones et al, 2012), thus continuous fetal monitoring is recommended. Neonatal effects are inhibited and early cessation of breastfeeding and decreased alertness (Nissen, 1995; Ransjo-Arvidsen, 2001; Righard, 1990; Rajan, 1994; as cited in Jones et al, 2012).

Limitations Found in the Studies

The authors state the studies use differing methods to measure pain management outcomes. Many do not at all measure maternal psychological outcomes (feelings of intrinsic self-control), mom-baby interaction, or breastfeeding and infant outcomes.

Conclusions

This study shows consumers rate pain management as a high priority in childbirth, however, after 30 years of research, standardized pain management and outcome measurements have not been created.

The authors suggest their outcome guidelines, developed with consumer input, be adopted for use in future research.

Overall, women should feel free to choose whatever methods of pain relief they wish, both non-pharmacological and pharmacological, for their individual childbirth experience.

As part of a childbirth preparation program, women should be informed of the efficacy and potential side-effects on both themselves and their babies of non-pharmacological and pharmacological methods of pain relief for childbirth.

Hopefully this study will generate an effort to standardize the constructs associated with research of measurements of pain management in labor, maternal psychosocial satisfaction, and maternal-baby outcomes.

References

Jones L, Othman M, Dowswell T, Alfirevic Z, Gates S, Newburn M, Jordan S, Lavender T, Neilson JP. Pain management for women in labour: an overview of systematic reviews. Cochrane Database of Systematic Reviews 2012, Issue 3. Art. No.: CD009234. DOI: 10.1002/14651858.CD009234.pub2

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