The Birth Process

1. The Birth Process
Mamie Guidera, CNM, MSN
Carol O’Donoghue, CNM, MSN, MPH

2. Normal Labor and birth:
Objectives
Introductions
Physiologic labor and birth: the basics
Phases of labor
Birth video
The P’s: Power, passageway, passenger, etc.
Briefs:
American birth (some of the) influences:
Where births take place
Cultural expectations of pain management
A word on Fetal Monitoring

3. What is “normal” labor?
An introduction

6. Length of first stage labor in healthy nulliparous
and multiparous childbearing women
adapted from Albers L. (2007) bold = nullips, italics = multips
Mean (hrs) 95th percentile (hrs)
Friedman (1978) 4.1 8.5
Kilpatrick Laros
(1989)
8.1 16.6
Albers, Schiff
Gorwoda (1996)
7.7 19.4
Albers (1999) 7.7 17.5
Friedman (1978) 2.4 7.0
Kilpatrick Laros
(1989)
5.7 12.5
Albers (1996) 5.7 13.7
Albers (1999) 5.6 13.8

7. Cervical Examination:
examining the passageway
Dilatation
Effacement
Station
Position
Consistency
Presenting part
Status of membranes

9. The Passage
Pelvic Bones and Pelvimetry

12. Passenger: Attitude

13. Passenger: Presentation

14. Passenger
Descent
Fetal head journey through the pelvis
until Crowning
Flexion
Fetal head tucks into chest
Important so that smallest diameter of head presents
May depend on pelvic type/shape

15. Passenger: Station
Engagement
AKA “dropping” or “lightening”
At the level of ischial spines = 0 station
Above ischial spines
-5 to -1
-5 = unengaged
Below ischial spines
+1 to +5
+5 = crowning

16. Passenger: Presentation

18. Second Stage of Labor
From 10 cm to birth of
baby
Pushing or expulsion
Contraction pattern
Duration

19. Birth
Perineal management
(keep your hands off
Mirror
Ask mother to feel the
baby’s head
Stay focused on
woman, not tasks

20. Third Stage of Labor
Birth of the placenta
5 to 30 minutes….or more
Signs of placental separation
Inspection
A word on Active Management of Third
Stage
Pitocin and prevention of postpartum
hemorrhage

21. Two Methods of Third Stage
Management
Physiologic (“expectant”) management
Oxytocics are not used
Placenta is delivered by gravity and maternal effort
Cord is clamped after delivery of the placenta
Active Management
Oxytocic is given
[Cord is clamped]
Placenta delivered by controlled cord traction (CCT) with
counter-traction on the fundus
Fundal massage after delivery of placenta

22. Part II:
Reality modern hospital birth: pain management,
monitoring, interference with physiologic birth

23. Physiology of labor pain: First stage
o Uterine contractions:
o Myometrial ischemia
Causes release of potassium, bradykinin, histamin,
serotonin
o Distention of lower uterine segments and cervix
o Stimulates mechanorecoptors
Impulses follow sensory-nerve fibers from paracervical and
hypogastric plexus to lumbar sympathetic chain
Enter dorsal horn of spinal cord at T10-12, L1

24. Pain pathways during labor: Late
first and Second stage
o Transition associated with greater nocioceptive
input related to increased somatic pain from
vaginal distention
o Distention of vagina, perineum, pelvic floor,
stretching of pelvic ligaments
o Pain signal transmitted to spinal cord via S2-S4
(includes pudendal nerve)

25. Pain Management in Active
Labor
Walking/Movement
Hydrotherapy
Back Rubs
Birth Ball, toilet
Maternal Preference
Analgesia/
Anesthesia
Others?

26. hydrotherapy

27. Continuous Labor Support
o Non-medical care by a trained
person
o Different definitions/criteria
depending on studies:
o “minimum of 80%” presence
o presence “without interruption, except
for toileting”
o Various terms: doula, labor
assistant, birth companion,
monitrice
o May refer to husband or untrained
female companion

28. Kennell J, Klaus M, McGrath S, Robertson S,
Hinkley C. Continuous Emotional Support During
Labor in a US Hospital: A Randomized Controlled
Trial. JAMA, May 1991; 265: 2197 - 2201.
•616 women
•Three arms: supported (doula), observed,
control groups
•Outcomes studied: epidural use, duration of
labor, oxytocin use, prolonged infant
hospitalization and maternal fever all
significantly less with supported group
•More spontaneous birth with supported
group

29. Hodnett, ED et al (2007). Continuous support for
women during childbirth (Review). Cochrane Database
of Systematic Reviews 2007, Issue 3. Art No.: CD 003766.
16 trials, all RCTS
o 13,391 women
o Women with CLS were:
o Less likely to have regional anesthesia
o Less likely to have any analgesia/anesthesia
o Less likely to have an operative delivery
o Less likely to report dissatisfaction and low leves
of control with the CB experience
o Less likely to use EFM
o …and were more likely to have a shorter
labor length and a spontaneous vaginal
birth.

30. Continuous Labor Support: Mechanism of Action from Hodnett (2007)
Positive impact
Mitigates
potentially
harsh
environment
Negative
experiences
may impede
labor
Negative
experiences may
impede adjustment
to motherhood
of
companionship
on mom
Mobility
encouraged by
support
person
fetopelvic
relationship
is enhanced
woman
uses
gravity
position changes
Support
person
decreases
anxiety of mom
stress hormones
(epinephrine)
fewer
abnormal
FHR
patterns
preserves
uterine
contractility
may be
reduced
Physiologic
impact of
continuous
labor support

31. Epidurals: how do they contribute to
prolonged labor or dx of labor dystocia, if at
all?
Length of labor
First stage labor not impacted
Studies do not uniformly look at or control for
confounding factors such as rate of dilation or rates of
spontaneous labor
Length of second stage longer
General agreement
Malpresentation
3 RCTs, 2 observational studies: significant
findings, significant crossover in RCTs
Lieberman O’Donoghue, Am J Obstet Gynecol 2002, 186(5):S31-S68.
Leighton Halpern Am J Obstet Gynecol 2002, 186(5):S69-77.

32. Monitoring for fetal well-being: the
evidence

33. Monitoring FHR: a short history
1600s:
Marsac of France describes the sound of FHTs
Marsac’s colleague Phillipe LeGaust mentions FHTS in a poem
Kilian proposes that FHTs be used to dx fetal distress and when a clinician
should intervene
1800s:
1818: auscultation via maternal abdomen helps dx fetal viability and fetal
lie
1893: VonWinckel defines criteria for fetal distress that remained
unchanged until the 1960s
Gabbe (2002), 4th Ed.

34. Monitoring FHR: a short history
1958
American Edward Hon (“father of EFM”) reports on instantaneous FHR recording
Hon collaborated with Calderyo-Barcia (Uruguay) and Hammacher (Germany) to
describe patterns that would diagnose fetal distress
1968:
Benson et al: review of 24,000 cases of auscultation and outcomes; determined
that “there was no reliable indicator of fetal distress in terms of FHR save in
extreme degree.”
Late 1960s: first commercially available electronic FHR monitor available
By late 1970s EFM used in most American labor and delivery units
By 1978, 66% of women EFM used during their labors
In 2002, 85% of labors included EFM
Gabbe (2002), 4th Edition; Williams (2005), 22nd Edition

35. Original Assumptions of EFM
Electronic fetal heart rate monitoring provided accurate
information
The information was of value in diagnosing fetal distress
It would be possible to intervene to prevent fetal death or
morbidity
Continuous electronic fetal heart rate monitoring was
superior to intermittent methods
Williams Obstetrics (2005), 22nd Edition

36. Monitoring FHR: the evidence
1968:
Benson et al: review of 24,000 cases of auscultation and outcomes;
determined that “there was no reliable indicator of fetal distress in terms of
FHR save in extreme degree.”
Thacker et al (2005) reported in the Cochrane Database (18,561
pregnancies):
Prevention of neonatal seizures
No prevention of cerebral palsy
Abnormal neurological outcomes not higher in infants managed by
intermittent auscultation vs. continuous EFM (CEFM)

37. Monitoring FHR: a short history
Thacker’s report now replaced by Alfirevic (2006; 37,000
women):
Seizures decreased; rare outcome 1/500 births
No increase in cerebral palsy, infant mortality “or other
standard measures of neonatal well-being”
Increase in cesarean section and instrumental deliveries
Limits movement of women during labor
CEFM may also mean that “some resources tend to be focused
on the needs of the CTG rather than the women in labour.”
Gabbe (2002), 4th Ed.; Williams (2005), 22nd Edition

38. Actual Outcomes of Widespread
EFM Use
By 1994, Symonds writes that 70% of obstetrical litigation
related to fetal brain damage is related to purported
abnormalities on the EFM tracing
Significant interobserver and intraobserver variability
Studies published prior to NICHD and after guidelines
(1982-2003)
Increase rate of Cesarean Section delivery
Increase use of Vacuum and Forceps
No reduction in perinatal mortality
Incidence of neonatal seizures significantly decreased
No reduction in cerebral palsy
ACOG Practice Bulletin 70 (2005); Williams (2005), 22nd Ed.

39. EFM vs Intermittent Auscultation (IA)
Research does not support one modality over the other
Most studies comparing the two were only conducted in low risk
patients; Alfirecvic (2006) did include patients receiving oxytocin
ACOG Practice Bulletin 70 (2005) states:
“Those with high-risk conditions (eg, suspected fetal growth restriction,
preeclampsia, and type 1 diabetes should be monitored continuously).”
Current USPSTF Guideline (1996 to present):
Routine intrapartum EFM not recommended
Insufficient evidence regarding its routine use in high risk pregnancies
http://www.ahrq.gov/clinic/uspstf/uspsiefm.htm Accessed 6/30/08

40. Oxytocin Augmentation

41. Clark SL, Simpson KR, Knox GE, Garite T.
Oxytocin: new perspectives on an old drug.
Am J Obstet Gynecol 2009;200:35.e1-35.e6.
We know of no other area of medicine in which
a potentially dangerous drug is administered to
hasten the completion of a physiologic process
that would, if left to its own devices, usually
complete itself without incurring the risk of drug
administration. Yet the administration of
oxytocin is often undertaken under precisely
these circumstances when labor is electively
induced or Braxton-Hicks contractions are
electively augmented.”

42. Medicalization of labor:
Parkland, Texas

43. The challenge is, can you provide
vigilance without intervention….
Don’t just stand there.
Do nothing!”

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