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Can We Prevent Persistent Occiput Posterior Babies?

January 29th, 2013 by avatar

Today, regular contributor Henci Goer, co-author of the recent book, Optimal Care in Childbirth; The Case for a Physiologic Approach, discusses a just published study on resolving the OP baby during labor through maternal positioning.  Does it matter what position the mother is in?  Can we do anything to help get that baby to turn?  Henci lets us know what the research says in today’s post. – Sharon Muza, Community Manager

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In OP position, the back (occiput) of the fetal head is towards the woman’s back (posterior). Sometimes called “sunny side up,” there is nothing sunny about it. Because the deflexed head presents a wider diameter to the cervix and pelvic opening, progress in dilation and descent tends to be slow with an OP baby, and if OP persists, it greatly increases the likelihood of cesarean or vaginal instrumental delivery and therefore all the ills that follow in their wake.

Does maternal positioning in labor prevent persistent OP?

This month, a study titled “Is maternal posturing during labor efficient in preventing persistent occiput posterior position? A randomized control trial” reported on the use of maternal positioning in labor to rotate OP babies to occiput anterior (OA). Investigators randomly allocated 220 laboring women with OP babies either to assume positions designed to facilitate rotation or to recline on their backs. The positions were devised based on computer modeling of the mechanics of the woman’s pelvis and fetal head according to degree of fetal descent. The position prescribed for station -5 to -3, i.e., 3-5 cm above the ischial spines, a pelvic landmark, had the woman on her knees supporting her head and chest on a yoga ball. At station -2 to 0, i.e., 2 cm above to the level of the ischial spines, she lay on her side on the same side as the fetal spine with the underneath leg bent, and at station > 0, i.e., below the ischial spines, she lay on her side on the same side as the fetal spine with the upper leg bent at a 90 degree angle and supported in an elevated position.

http://flic.kr/p/9Rs7mL

 

The good news is that regardless of group assignment, and despite virtually all women having an epidural (94-96%), 76-78% of the babies eventually rotated to OA. The bad news is that regardless of group assignment, 22-24% of the babies didn’t. As one would predict, 94-97% of women whose babies rotated to OA had spontaneous vaginal births compared with 3-6% of women with persistent OP babies. Because positioning failed to help, investigators concluded: “We believe that no posture should be imposed on women with OP position during labor” (p. e8). 

Leaving aside the connotations of “imposed,” does this disappointing result mean that maternal positioning in labor to correct OP should be abandoned? Maybe not.

Of the 15 women with the fetal head high enough to begin with position 1, no woman used all 3 positions because 100% of them rotated to OA before fetal descent dictated use of position 3. I calculated what percentage of women who began with position 2 or 3, in other words fetal head at -2 station or lower, achieved an OA baby and found it to be 75%—the same percentage as when nothing was done. What could explain this? One explanation is that a position with belly suspended is more efficacious regardless of fetal station, another is that positioning is more likely to succeed before the head engages in the pelvis, and, of course, it may be a combination of both.

Common sense suggests that the baby is better able to maneuver before the head engages in the pelvis. If so, it seem likely that rupturing membranes would contribute to persistent OP by depriving the fetus of the cushion of forewaters and dropping the head into the pelvis prematurely. Research backs this up. A literature search revealed a study, “Associated factors and outcomes of persistent occiput posterior position: A retrospective cohort study from 1976 to 2001“ finding that artificially ruptured membranes was an independent risk factor for persistent OP. Returning to the trial, all women had ruptured membranes because it was an inclusion factor. One wonders how much better maternal positioning might have worked had this not been the case, and an earlier trial offers a possible answer.

In the earlier trial, “Randomized control trial of hands-and-knees position for occipitoposterior position in labor,” half the women had intact membranes. Women in the intervention group assumed hands-and-knees for at least 30 minutes during an hour-long period while the control group could labor in any position other than one with a dependent belly. Twelve more women per 100 had an OA baby at delivery, a much bigger difference than the later trial. Before we get too excited, though, the difference did not achieve statistical significance, meaning results could have been due to chance. Still, this may have been because the population was too small (70 intervention-group women vs. 77 control-group women) to reliably detect a difference, but the trial has a bigger problem: fetal head position at delivery wasn’t recorded in 14% of the intervention group and 19% of the control group, which means we don’t know the real proportions of OA to OP between groups.

Take home: It looks like rupturing membranes may predispose to persistent OP and should be avoided for that reason. The jury is still out on whether a posture that suspends the belly is effective, but it is worth trying in any labor that is progressing slowly because it may help and doesn’t hurt.

Does maternal positioning in pregnancy prevent OP labors?

Some have proposed that by avoiding certain postures in late pregnancy, doing certain exercises, or both, women can shift the baby into an OA position and thereby avoid the difficulties of labor with an OP baby. A “randomized controlled trial of effect of hands and knees posturing on incidence of occiput posterior position at birth (2547 women) has tested that theory. Beginning in week 37, women in the intervention group were asked to assume hands-and-knees and do slow pelvic rocking for 10 minutes twice daily while women in the control group were asked to walk daily. Compliance was assessed through keeping a log. Identical percentages (8%) of the groups had an OP baby at delivery.

Why didn’t this work? The efficacy of positioning and exercise in pregnancy is predicated on the assumption that if the baby is OA at labor onset, it will stay that way. Unfortunately, that isn’t the case. A  study, “Changes in fetal position during labor and their association with epidural anesthesia,” examined the effect of epidural analgesia on persistent OP by performing sonograms on 1562 women at hospital admission, within an hour after epidural administration (or four hours after admission if no epidural had been administered), and after 8 cm dilation. A byproduct was the discovery that babies who were OA at admission rotated to OP as well as vice versa.

Take home: Prenatal positioning and exercises aimed at preventing OP in labor don’t work. Women should not be advised to do them because they may wrongly blame themselves for not practicing or not practicing enough should they end up with a difficult labor or an operative delivery due to persistent OP.

Do we have anything else?

Larry P Howell aafp.org/afp/2007/0601/p1671.html

We do have one ray of sunshine in the midst of this gloom. Three studies of manual rotation (near or after full dilation, the midwife or doctor uses fingers or a hand to turn the fetus to anterior) report high success rates and concomitant major reductions in cesarean rates, if not much effect on instrumental vaginal delivery rates. One study, “Manual rotation in occiput posterior or transverse positions: risk factors and consequences on the cesarean delivery rate,” comparing successful conversion to OA with failures reported an overall institutional success rate of 90% among 796 women. A “before and after” study, “Digital rotation from occipito-posterior to occipito-anterior decreases the need for cesarean section,” reported that before introducing the technique, among 30 women with an OP baby in second stage, 85% of the babies were still OP at delivery compared with 6% of 31 women treated with manual rotation. The cesarean rate was 23% in the “before” group versus 0% in the “after” group. The third study, “Manual rotation to reduce caesarean delivery in persistent occiput posterior or transverse position,” compared 731 women having manual rotation of an OP baby in second stage with 2527 women having expectant management. The success rate of manual rotation was 74% and the overall cesarean rate in treated women was 9% versus 42% in the expectantly managed group.

Manual rotation is confirmed as effective, but is it safe? This last study reported similar rates of acidemia and delivery injury in newborns. As for their mothers, investigators calculated that four manual rotations would prevent one cesarean. The study also found fewer anal sphincter injuries and cases of chorioamnionitis. The only disadvantage was that one more woman per hundred having manual rotation would have a cervical laceration.Take home: Birth attendants should be trained in performing manual rotation, and it should be routine practice in women reaching full dilation with an OP baby.

What has been your experience with the OP baby?  Is what you are teaching and telling mothers in line with the current research?  Will you change what you say now that you have this update?  Share your thoughts in the comment section. – SM

References and resources

Cheng, Y. W., Cheng, Y. W., Shaffer, B. L., & Caughey, A. B. (2006). Associated factors and outcomes of persistent occiput posterior position: a retrospective cohort study from 1976 to 2001. Journal of Maternal-Fetal and Neonatal Medicine19(9), 563-568.

Desbriere R, Blanc J, Le Dû R, et al. Is maternal posturing during labor efficient in preventing persistent occiput posterior position? A randomized controlled trial. Am J Obstet Gynecol 2013;208:60.e1-8. PII: S0002-9378(12)02029-7 doi:10.1016/j.ajog.2012.10.882

Kariminia, A., Chamberlain, M. E., Keogh, J., & Shea, A. (2004). Randomised controlled trial of effect of hands and knees posturing on incidence of occiput posterior position at birth. bmj328(7438), 490.

Le Ray, C., Serres, P., Schmitz, T., Cabrol, D., & Goffinet, F. (2007). Manual rotation in occiput posterior or transverse positions: risk factors and consequences on the cesarean delivery rate. Obstetrics & Gynecology110(4), 873-879.

Lieberman, E., Davidson, K., Lee-Parritz, A., & Shearer, E. (2005). Changes in fetal position during labor and their association with epidural analgesia.Obstetrics & Gynecology105(5, Part 1), 974-982.

Reichman, O., Gdansky, E., Latinsky, B., Labi, S., & Samueloff, A. (2008). Digital rotation from occipito-posterior to occipito-anterior decreases the need for cesarean section. European Journal of Obstetrics & Gynecology and Reproductive Biology136(1), 25-28.

Shaffer, B. L., Cheng, Y. W., Vargas, J. E., & Caughey, A. B. (2011). Manual rotation to reduce caesarean delivery in persistent occiput posterior or transverse position. Journal of Maternal-Fetal and Neonatal Medicine24(1), 65-72.

Simkin, P. (2010). The fetal occiput posterior position: state of the science and a new perspective. Birth37(1), 61-71.

Stremler, R., Hodnett, E., Petryshen, P., Stevens, B., Weston, J., & Willan, A. R. (2005). Randomized Controlled Trial of Hands‐and‐Knees Positioning for Occipitoposterior Position in Labor. Birth32(4), 243-251.

Recommended resource: The fetal occiput posterior position: state of the science and a new perspective http://www.ncbi.nlm.nih.gov/pubmed?term=simkin%202010%20posterior by Penny Simkin.


 

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Iatrogenic Norms: How Fast Do First-Time Mothers Beginning Labor Spontaneously Actually Dilate?

August 25th, 2010 by avatar

Iatrogenic (adjective): induced in a patient by a health care provider’s activity, manner, or therapy. An iatrogenic disorder is caused by medical personnel or procedures or develops through exposure to a health care facility.

Iatrogenic norm: a defined range of normal values for a biological process that, rather than describing actual normal physiology, instead measures the consequences of a health care provider’s beliefs, actions, or therapies or the effects of exposure to a health care facility.

Clinicians today base labor management on norms for cervical dilation rate in active phase labor (assumed to begin somewhere between 3 and 5 cm dilation in women contracting regularly) derived from research conducted decades ago by Friedman and colleagues (the famous “Friedman curve”). According to this research, in first-time mothers, the slowest 10%, an arbitrary cutoff for abnormally slow progress, dilate at a rate of 1.2 cm per hour or less. This norm has been enshrined in the “action lines” of the graphs of “dilation versus time” routinely used to manage labor. The “action” taken when women fail to progress at this minimal rate is administration of intravenous oxytocin to strengthen contractions, and such women are at high risk for cesarean surgery for labor dystocia. If this criterion is overly stringent, women with normally progressing labors will be subject to potentially harmful treatment and surgical delivery unnecessarily.

Concern over this possibility led a group of investigators to conduct a systematic review of studies analyzing active labor duration, progress rate, or both in active first-stage labor in first-time mothers, and the lead author, Jeremy Neal, presented the results at the recent Normal Labour & Birth International Research Conference. Neal began his talk with a look at the body of evidence that gave rise to this concern. I won’t bore you with the details, but suffice it to say that studies using Friedman’s norms for progress diagnose anywhere from one-quarter to one-half or more of first-time moms as requiring treatment for abnormally slow progress. If progress is abnormal in that many women, then something is wrong with the definition of normal, or, as Neal put it:

Either many nulliparous women are admitted prior to progressive (active) labor yet held to dilation expectations of “active‟ labor and/or common expectations of active labor dilation rates (e.g. 1 cm/hr) are unrealistically fast.

The group’s review pooled data from 25 studies encompassing thousands of low-risk first-time mothers with spontaneous labor onset at 36 weeks of pregnancy or more. It found that contrary to Friedman, 1.2 cm was actually the mean rate of dilation, not the rate in the slowest 10%, and the limit for the threshold of slowest acceptable progress rate fell at 0.6 cm, half that rate. (This, by the way, is not a physiologic norm because studies included women with epidurals and labor augmentation, and since all data came from hospital studies, laboring women would have been subject to policies that could affect progress rate such as confinement to bed. That being said, the review found that epidural use did not change results.)

Neal then added that active labor is assumed to progress at a constant rate, but some data suggest that rate of progress may be slower at the beginning of active phase and accelerate as it continues. In other words, the action “line” is another iatrogenic norm because it should be an action “curve.” If this is true, using an action line would put even more women progressing normally in early active phase in jeopardy of the “dystocia” diagnosis and all that follows.

Neal concluded with: “Revision of existing ‘active’ labor expectations and/or revision of criteria used to prospectively identify active labor onset is warranted and such efforts should supersede efforts to ‘change’ labor to fit existing expectations.” “From his mouth to God’s ears,” as they say—or at least to the ears of obstetricians.

Nevertheless, while revising norms to match reality would take a big step in the right direction, I would argue it doesn’t go nearly far enough because it still sticks us with the assumption that active first-stage dilation progresses smoothly. Anyone who has spent time with laboring women knows that this is often not the case. Neat graphical lines (or curves) come from averaging many highly variable individual labors, so the very expectation of how labors progress, at whatever pace, is itself an iatrogenic norm.

Moreover, the published review points out that both the old and the proposed new threshold for “abnormal” are statistically derived (e.g. two standard deviations beyond the mean). No study links a cut point for “abnormally slow” with an increase in perinatal morbidity, but averting adverse outcomes should form the basis for intervening medically because of the risks of intervention. In fact, even if a study tried to establish an outcome-based threshold, it would be hard to determine whether the increase was due to labor duration per se or to the interventions used to treat slow labor. So we have yet another iatrogenic norm, this one having to do with a definition of “abnormal” with no clinical significance.

In short, forcing labor to conform to artificial, arbitrary guidelines does more harm than good. A simplistic cookbook approach to the knotty problem of labor dystocia has obvious appeal, but what is truly needed to achieve the best outcomes with the least use of medical intervention is thoughtful evaluation, individualized care, and above all, patience so long as mother and fetus are tolerating labor. Labor graphs and action lines do no more than exemplify H. L. Mencken’s truism, “For every complex problem there is a solution that is simple, neat—and wrong.”

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Disputed Territory: A doctor reviews “Birth Territory and Midwifery Guardianship: Theory for practice, education, and research”

November 16th, 2009 by avatar

This is a guest contribution from Katharine Hikel, MD. Dr. Hikel is a writer on women’s health for Medscape/WebMD. Peer-trained in feminist women’s health clinics, she is also a graduate of Harvard and the University of Vermont College of Medicine. She lives in northern Vermont with her family.

Birth TerritoryReview:
Birth Territory and Midwifery Guardianship: Theory for practice, education, and research
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Edited by Kathleen Fahy, Maralyn Foureur, Carolyn Hastie.
Butterworth Heinemann (Elsivier): Books for Midwives. 2008

The next vital revolution in maternity care may well be the overhaul and redesign of the birthplace. In “Birth Territory and Midwifery Guardianship,” writers describe the relationship of the birth setting to the emotional-physiological state of laboring women.  In this regard, ‘Birth Territory’ encompasses not only physical space, but also personal relationships, power structures, and access to knowledge.

Maternity care as we know it has evolved along divergent roads: the midwifery, expectant-management ‘natural’ approach; and the obstetric, interventive, ‘actively-managed’  model.  Midwifery care is a woman-centered approach; it relies on relationships which support women’s natural abilities to give birth. The obstetric model, designed by and for doctors, operates on  principles of academic exclusiveness, described by Louis Menand:

It is a self-governing and largely closed community of practitioners who have an almost absolute power to determine the standards for entry, promotion, and dismissal in their fields. The discipline relies on the principle of disinterestedness, according to which the production of new knowledge is regulated by measuring it against existing scholarship through a process of peer review, rather than by the extent to which it meets the needs of interests external to the field…

[T]he most important function of the system is not the production of knowledge. It is the reproduction of the system. To put it another way, the most important function of the system, both for purposes of its continued survival and for purposes of controlling the market for its products, is the production of the producers

Academic obstetrics is impervious to knowledge and input from other disciplines; it exists in a closed, parallel world; it exists not for the purpose of taking care of women, but for the purpose of taking care of itself. The chief concern of any obstetrical unit is the viability of the department, of the program; if outcomes figure into that, well and good; but women’s actual experiences and opinions, because they are not part of the published literature, are of no concern.  Small wonder, then, that so little thought has been given to the environment of hospital birth, other than for the convenience of hospital practitioners.

Meanwhile, midwives have continually concerned themselves with what the authors of Birth Territory and Midwifery Guardianship call ‘the elements in the geography, architecture, and metaphysics of birth spaces to which women will consciously and unconsciously respond.’

In their book, the writers – midwives, and an architect of birth spaces – asked women what they wanted in their birthing places. Responses included:

  • A pleasant place to walk
  • Sufficient pillows, floor mats, bean bags
  • Availability of snacks and drinks
  • En suite toilet, shower, bath; a birth pool
  • Comfortable accommodations for companions and families
  • A homey, non-clinical environment
  • Control over temperature
  • Control over brightness of light
  • Privacy; not being overheard by others
  • Not being watched
  • Control over who comes into the room

The majority of birthing women surveyed did not have these options. The authors argue that lack of a woman-centered birthing environment, and little control over that environment, are reasons for high rates of obstetric intervention. Labor and birth are whole-being experiences; the autonomic nervous system will shut the whole process down if the woman perceives stress, threat, or danger.  In typical hospital settings, with shift changes, strangers walking in and out, bright lights, confinement to bed and monitor, and restricted oral intake, it is no wonder that the process doesn’t go as smoothly as it could. “Failure to progress” – the diagnostic reason given for 50% or more cesareans – is largely an environmental issue.

Katharine Hikel, MD

Katharine Hikel, MD

Birth territory is also defined by relationships; yet medical obstetrics has constantly worked to sequester birthing women away from all sources of comfort, including non-medical practitioners; only in the 1960s were fathers and partners invited into hospital delivery rooms; and only lately, with the advent of doula practices, has one-to-one attendance – the cornerstone of midwifery – become recognized as a significant predictor of good outcome.  But few hospital practices are relationship-centered. Prenatal visits are fifteen or twenty minutes long, mainly focused on weight gain and lab work. There’s usually a team of doctors and midwives; the person who’s available at the time of one’s birth is not a matter of preference, but of the practice’s call schedule.

Obstetrics is statistics-based, not relationship-based; obstetricians know that the average due date is 40 weeks from the last menstrual period; they know that if a woman is laboring (in a hospital) with waters broken for over 12 hours, her chance of infection skyrockets; they know that the Friedman labor curve shows that the average progression of dilation is one centimeter per hour; they know that the average pushing phase is under two hours. They are under pressure to make everyone fit those statistical norms, and they have the tools to make it so; and that’s what they do.

The best birth territory requires the best attendants. Fahy and her coauthors argue that birth is a reflection of relationships – with oneself, and with others; that relationships depend on love, and spiritual development (words you will never see in any obstetrical textbook).  In developing the best birth attendants, they see open-heartedness as a requirement for good practice; they describe the characteristics of a good practitioner in Buddhist terms of ‘right relationship’: empathy; ethical behavior; self-awareness; capacity for love. In a chapter called “Reclaiming the sacred in birth,” they describe the conditions for nurturing ideal midwives: ‘to know and nurture themselves within their own families and communities,’ and emphasizes working on personal development, as well as clinical skills, with a supervisor or professional partner. The training environment of midwives should encourage the development of nurturing and intimate, though professional, relationships with her clients; it is that relationship that forms a necessary part of optimal birth territory.

The territory of obstetrics residents is largely devoid of patient-relationship considerations; it is rather consumed with concerns about on-call hours, clinical rotations, numbers of procedures, and one’s place in the departmental hierarchy. The knowledge itself is based in pathology – ‘problem-oriented’ – a diagnostic/treatment approach that assumes there’s trouble, and goes about finding it. This works well in the rest of medicine, which is really about disease; but colors the teaching approach to the normal, healthy event of childbirth.  The knowledge that’s important – taught and practiced – is all within the limits of academic obstetrics, which ignores, if not devalues, ‘nonscientific’ knowledge. The ‘permitted’ knowledge supports what the authors call the ‘metanarrative’ of academic medicine: the postmodern myth that the safest and best place to give birth is under obstetric management. Any knowledge that counters that myth is disputed or ignored.

The history of obstetrics is also viewed differently from within the specialty than without. The obstetricians’ view, reproduced in most obstetrical textbooks, is the development of one intervention after another, all by men – from forceps to vacuum extractions. The authors present a larger-scale view:

Medicine in the late 19th and early 20th centuries was composed almost entirely of men who shared the same power base as other dominant males: they were white, well-educated and from economically richer families. It was these males who owned or managed every institution of society: the army, the church, the law, the newspapers, the government, etc. These privileges, combined with an informal brotherhood of dominant men, created a powerful base for the success of the medical campaign to subordinate midwifery.

The authors describe the territory of hospital birth as disputed ground, where the biological requirements of birthing women are at odds with the design of institutions.  They provide ample evidence about how the dominance of obstetricians’ needs over women’s welfare has contaminated the culture of birth. In a wonderful section on oxytocin – the hormone of love, bonding, social interaction, birth, and lactation – they describe the effects of this natural hormone:

[T]he higher the level of Oxytocin, the more calm and social the mother; thereby stress is reduced; levels of the stress hormone cortisol drop; pain threshold is increased…  body temperature is regulated… and heart rate and blood pressure are lowered… Women’s response to stess may not be the automatic ‘fight or flight’ response seen in men, but is more likely to be the ‘calm and connection’ system integrated by Oxytocin.

These oxytocin-mediated events are most necessary during labor and birth; they are best enabled if the birth territory includes oxytocin-positive relationships.  Oxytocin is thought to be the source of women’s power to endure labor and birth; and its pathways are the most likely to be deranged by the institutional birth environment – the lack of oxytocin-facilitating relationships of trust and love, as well as the routine administration of oxytocin-blocking drugs such as epidurals and Pitocin – a form of artificial oxytocin that has never been proven safe in long-term outcome studies. Blocking oxytocin, whether through fear, disturbance, or Pitocin, leads to disrupted or painfully difficult labors.  These authors suggest that disruption of normal oxytocin pathways, and supplanting them with intrapartum Pitocin exposure, may also result in serious mental health problems on the love-and-relationship axis: schizophrenia, autism, drug dependency, suicidal tendencies, and antisocial criminal disorders. It’s not just the mother who’s affected by the birth territory.

But what is the best birth environment?  In a chapter called “Mindbodyspririt architecture: Creating birth space,” architect Bianca Lepori describes her designs for hospital-based birth rooms that are meant to enhance, not counteract, women’s abilities to give birth. She created suites of rooms with “Space and freedom to move; to be able to move to the dance of labor; to respond to the inner movements of the baby; to walk, kneel, stretch, lie down, lean, squat, stand, and be still.” The rooms have “Soft and yielding surfaces; or firm and supportive surfaces; different textures; the right temperature; soft curves; darkness or dim light.” A birthing woman can be ‘immersed in water, flowing or still; respected, safe, protected, and loved.”  Access to the suite is through an antechamber; the bed is farthest away from the lockable door, and not visible from it, so that privacy is respected.

Lepori’s birth architecture reproduces the comforts of home. There is access to the outdoors, and private walking places. There are birth stools, exercise balls, bean bags, hooks for hammocks or ropes for stretching. Tubs and beds are large and accessible from both sides. There are accommodations for families. There are comfortable chairs for nursing. Medical equipment – supplies, oxygen – is tucked behind a screen or put in a closet. A refrigerator and light cooking equipment is available. This ‘birth territory’ certainly outshines the typical hospital OB floor; though it begs the question: Why not just stay home?

The answer, of course, is that, for those four to ten percent of births that truly need intervention, the OR is right there. It’s better not to have to transport a woman whose labor has turned complicated; it makes sense – for many – to have all the birth territory under one roof.

This birthing-suite design indeed takes into account the all-encompassing, body-mind-spirit event of childbirth. It honors laboring, birthing women and families; it respects the process. It worked well for a designated maternity hospital in New Zealand – a facility already designed for childbearing. But most US hospitals are multi-use facilities; and though obstetrics is among the best money-makers for hospitals, childbirth is the only event that occurs there that is not related to illness or trauma.

The real question is, why not remove birth completely from the pathology-centered hospital model? Why not redesign birth territory to maximize best outcomes, minimize intervention, and replace the present medicalized view of birth as a disaster waiting to happen with the more normative, expectant-management, midwifery view? Move the whole shebang, from the waiting room to the surgical suite, out of the hospital and back into the community where it belongs.

Why not indeed. The major obstacle to any redesign of the territory of birth is resistance from the field of obstetrics. The American Congress of Obstetricians and Gynecologists (which recently changed its name from the American College of Obstetricians and Gynecologists, reflecting a major shift in interest from academics to politics) has a 23-member lobbying arm, “OB-GYNS for Women’s Health PAC”, which describes itself on its web site:

Ob-Gyns for Women’s Health and Ob-Gyn PAC help elect individuals to the U.S. House of Representatives and Senate who support us on our most important issues. Individuals who understand the importance of our work, who care about the future of our specialty, who listen to our concerns, and who vote our way. In only a few short years, Ob-Gyn PAC has helped elect ob-gyns and other physicians to the U.S. Congress, and has become one of the largest and most influential physician PACs in America.

Only five of the 23 members are women; all ten of its board of directors are men. Current issues occupying the group are “Stopping Medicare payment cuts, ensuring performance measures work for our specialty, preserving in-office ultrasounds” (though there are still no long-term studies on the effects of ultrasound on the developing fetus, or on women, for that matter); and “winning medical liability reform,” which means limiting liability for malpractice.
Meanwhile,  the Medicaid Birth Center Reimbursement Act – Senate Bill #S.1423 (House Bill HR 2358) – is not on the list of bills that ACOG supports, even though this expansion of birth territory would probably better outcomes, and certainly cost less than the hospital OB model.

The only bad thing about “Birth Territory and Midwifery Guardianship” is that obstetricians will not read it.

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Do We Need a Cochrane Review to Tell Us That Women Should Move in Labor?

October 25th, 2009 by avatar

I am reposting this post from the archives in anticipation of this week’s Healthy Birth Blog Carnival about movement in labor. It was one of the first posts I ever wrote, back before anyone was reading this blog. It’s also one of my personal favorites.

Earlier this year, media outlets shared the news of a new Cochrane review that concludes upright positions are beneficial because they shorten labor by about one hour. The birth blogs were buzzing about this, and the consensus is that we should feel delighted and vindicated to have the scientific evidence to prove what women and midwives have always known.

ResearchBlogging.orgCochrane reviews synthesize all of the research on a particular topic, and because the reviewers bring together and analyze all of the data from many studies, the study population gets very big. Big populations yield greater statistical power and often (but not always) more reliable findings.

Prior to this Cochrane review there was a large body of literature on movement in labor, including a good sized U.S. randomized controlled trial. There was even another systematic review! But this body of research never consistently supported the hypothesis that movement improved labor and birth outcomes. Now we have a Cochrane review, which is the gold standard for evidence-based practice.  So we can put the evidence-based “stamp of approval” on freedom of movement.

But, were we any less justified in endorsing freedom of movement before the Cochrane? Although studies have given us inconsistent results as to whether movement shortens labor or decreases the need for c-section, a few conclusions have been loud and clear from the literature since researchers began looking at maternal position and movement:

  1. Women prefer to move around, primarily because they experience less pain when they can move.
  2. Women who stay in bed usually do so because they are connected to machines or IV lines, and/or because a health care provider tells them to.
  3. Movement and walking are not harmful to the woman or the baby.

Freedom of movement is the thing that would happen if women did not have any interaction with a health care system or provider in labor. In other words, it’s the default state of affairs. Anything that we do in the name of “health care” to improve upon this normal unfolding of things is referred to as an “intervention”. In scientific research, researchers compare a control group, which should represent the default/normal, with an experimental group, which represents the intervention. The burden of proof should be on the intervention.

Somehow, things have gotten turned around, and the normal condition is now the “experiment” and the intervention is the “control”. In addition to being irrational, this is a set-up to perpetuate conventional obstetric care, which imposes unhealthy and unfounded restrictions on women in labor. This is because in “intervention versus control” research, you have to show that the intervention performs significantly better, otherwise the control condition remains standard practice. While many of us believe that encouraging a laboring woman to move when and how she wants to is healthier and safer than making her stay in bed, waiting for evidence that it produces better health outcomes is putting a burden of proof on normal birth that has never been applied to routine intervention. Besides, lack of evidence of harm, less pain, and maternal satisfaction are valid and important outcomes in and of themselves, and provide the justification we need to reject routine policies and practices that restrict maternal movement.

Lawrence A, Lewis L, Hofmeyr GJ, Dowswell T, & Styles C (2009). Maternal positions and mobility during first stage labour. Cochrane database of systematic reviews (Online) (2) PMID: 19370591

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When is an induced labor “prolonged”? (Your guess is as good as mine.)

October 1st, 2009 by avatar

I seriously have no time to blog right now. I’m flying to Orlando for the Lamaze Conference this afternoon, and there’s plenty on the to do list still! But I was putting the finishing touches on my powerpoint talk this morning and I had to get a little something off my chest. My talk is called Optimizing Labor Progress: What the Research Does and Does Not Tell Us. I of course include a section about how we define labor progress (debunking the Friedman Curve, etc.)  At the last moment, I added this slide:

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That’s right, we have essentially no data on how “normal” labor should progress when labor is induced. And in fact, the recent Practice Bulletin describing the clinical management of induction of labor put out by American College of Obstetricians and Gynecologists provides no guidance on how to assess or promote healthy progress in induced labors. The Practice Bulletin also provides no information to help providers or women themselves determine when the harms of cesarean surgery are outweighed by the benefits of getting a baby out sooner.  The only thing ACOG has to say on the matter is this:

Labor progression differs significantly for women with an elective induction of labor compared with women who have spontaneous onset of labor. Allowing at least 12–18 hours of latent labor before diagnosing a failed induction may reduce the risk of cesarean delivery. (p. 698)

ACOG cites only one study to support the fact that induced labors don’t progress the same way that spontaneous labors do. That study was undertaken in first time mothers undergoing elective induction, hardly a group whose outcomes can be generalized to all induced labors.

I’m just wondering, how are clinicians supposed to make rational decisions about when to recommend a cesarean in an induced labor? And how are women to know whether to go along with those recommendations? I have a feeling I’ll be blogging about this again soon.

Off to Orlando!

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