Care Practices that Promote Normal Birth II

Care Practices that Promote Normal Birth II

  Autor Lamaze Institute for Normal Birth Data: 10.11.2006


Care Practices that Promote Normal Birth II

A pregnant woman from Lamaze course in asks the prenatal educator: "On television it shows that most women in labor are in bed. They are connected to machines, such as the one which monitors the baby's heart. Isn't childbirth healthier with today's technology?

The development of medical care has made birth safer, especially for women with high risk pregnancies or premature babies. Obstetric interventions such as intravenous lines (IV), electronic fetal monitoring (EFM), augmentation (speeding up the birth) and epidural anesthesia are considered routine in many hospitals. However, research has not shown that these interventions improve birth outcomes for all women. In fact, research suggests that if there is not a clear medical indication (reason) for an intervention, interference with the natural process of labor and birth is unlikely to be beneficial and can even be harmful. Interventions can be simple, such as separating mothers and new - born after birth, or complex, such as the use of continuous electronic fetal monitoring for a normal labor.

Food and Beverage Restrictions

Restricting liquids and foods during labor is a widespread tradition of midwifery. It began some 50 years ago, when women gave birth under general anesthesia, without respiratory protection. The tradition is based on the belief that rapid reduction of stomach contents will give the chance of aspiration of gastric (stomach contents entering the lungs), if a woman vomits during general anesthesia to be greatly reduced. However, anesthesia techniques have improved considerably over the past 50 years. General anesthesia is rare in modern obstetrics; aspiration is rare in modern anesthesia; no period of fasting guarantees an empty stomach; and clear liquids leave the stomach almost immediately. For these reasons, many health care providers no longer restrict eating and drinking during normal labor.
American Society of Anesthetists (AAS) and American College of Obstetricians and Gynecologists (CAOG) recommend that women with low-risk labor drink clear liquids during labor. Midwives often recommend snacks and fluids to provide energy for a long labor. Obstetricians and Gynecologists Society of Canada states that a woman in active labor should be given a light liquid diet. Cochrane Pregnancy and Childbirth Group, an obvious respected worldwide source of information based on evidence, recommends the use of a diet low in fat and low-residue for labor. Anesthetists conduct studies on the safety of eating during labor. The tradition of restricting eating and drinking during labor has changed as new research and discoveries have appeared.

Use of Intravenous Fluids

Intravenous therapy has been used routinely to prevent dehydration of women prohibited to eat and drink and to provide quick access to the vein in case of emergency. However, the need of IV to all women during labor was put into question. Life threatening emergencies are very rare in women with low- risk labor; IV does not offer nutrition or energy like that offered by food and fluids; some women find that IV is painful and stressful; and IV makes that women find it difficult to change positions and freely move around. According to the Cochrane Pregnancy and Childbirth Group, routine use of IV does not appear to be beneficial. If labor is induced or speeded up, if you have an epidural, or if you cannot drink and eat, then you will need an IV.

Continuous Electronic Fetal Monitoring

Baby's heartbeat can be monitored either by auscultation (listening with a stethoscope or a Doppler device) or by electronic fetal monitoring. EFM can be done continuously (constantly) or intermittently (occasionally). An intermittent electronic monitoring example is when the monitor is left on the woman in labor for 20 minutes every hour and removed during the remaining 40 minutes. While the monitor is off, the woman in labor is free to move around and use comfort measures such as bath tub or shower. EFM continues to restrict a woman's ability to move and change positions, usually this meaning that the woman stays in bed. Her access to a wide variety of comfort measures such as the use of a shower, bath tub, labor ball, may be restricted. Recommendations for monitoring by auscultation depends if a woman is considered to have labor with or without risk. For low-risk labors, experts recommend that nurses listen to the baby's heartbeat every 30 minutes during active labor (phase in which the cervix opens to 10 cm) and at every 15 minutes during the second stage (when she pushes).
For high-risk labor, the nurse should listen to the baby's heartbeat every 15 minutes during active labor and every 5 minutes during the second stage. According to the American College of Obstetricians and Gynecologists (CAOG) and the Association for Women's Health, Obstetric and Neonatology nurses
(as FOaN), healthy women with no complications can be monitored either by intermittent auscultation or by EFM. Studies comparing auscultation with EFM revealed that there is no difference regarding the results for the baby. However, mothers with EFM have more cesarean births. CaOG suggests instead using auscultation instead of EFM as a means of reducing the cesarean rate.
Discuss with your doctor about the use of intermittent auscultation and intermittent EFM instead of continuous EFM. However, if you have medical complications, if labor is induced or speeded up artificially, if you have an epidural, or if there is a problem during labor, you will need continuous EFM.

Speeding up labor: artificial rupture of membranes and augmentation of labor

Limiting time labor may sound appealing, but supervening in pace and length of labor without a medical indication is unlikely to be benefic. Each labor is unique and is influenced by a number of factors, including the size and position of the baby, woman's ability to move freely, the trust that she feels and the support she receives during labor. Breaking the bag of water (rupture of membranes) may shorten the labor, but there are some repercussions. The water bag surrounding it protects the baby from infections and pressure, as it moves toward the birth canal. Research suggests that when the membranes are ruptured early in labor, cesarean birth rate increases. Because of the fact that prolonged rupture of membranes is associated with an increased risk of infection for both mother and baby, time begins to flow into a realistic manner as possible, once the membranes have ruptured. If labor is not progressing, a physician may suggest the use of artificial oxytocin (Pitocin) to speed labor. In normal labor, oxytocin is released by the brain. When oxytocin is released at a high level, endorphins are also released. Endorphins, natural pain- suppression hormones, help women cope with labor, reducing pain perception. Pitocin, artificial oxytocin, given through an IV perfusion, does not reach the brain; therefore, it does not cause the release of endorphins. Pitocin changes the labor in other ways. The contractions of women who received Pitocin are stronger, longer, and often more painful. If Pitocin was given, women need other interventions such as IV infusion and continuous EFM. When they received Pitocin, women are usually restricted to stay in bed, without the comfort of moving around freely or using hot bath or shower. More powerful contractions, the loss of endorphins and the inability to use comfort measures increase the likelihood that women will need epidural analgesia.
According to the Cochrane Pregnancy and Childbirth Group, allowing women to move around and eat and drink as they please may be at least as effective and certainly more pleasant for a considerable number of women who are supposed to need augmentation. Research suggests that amniotomy (rupture of membranes) and augmentation with Pitocin should be reserved for women with truly abnormal labor progression. None of them should be used on principles of routine.

Epidural Analgesia

Most women fear the pain of labor and birth and are eager to use drugs against pain, especially when the medication is as effective as epidural in terms of pain relief. In some hospitals more than 90% of women have epidural analgesia during labor. 60% of women in a U.S. survey reported that they had an epidural. However, 26% to 41% of these women were unaware of the side effects of epidurals. In case of an epidural, because the pelvic muscles relax, it may take longer until the baby rotates and descends through the birth canal. The absence of pain can interfere with the natural release of oxytocin and may lead to the need to stimulate labor with Pitocin. Since epidural medication can cause a drop in blood pressure, the use of IV fluids before and after the epidural is recommended. For drugs used in epidurals can lower mother's blood pressure, the fetal heartbeat rhythm must be monitored continuously with EFM. Some women with epidurals do not feel the need to urinate, and it may be necessary to install a catheter to empty their bladders. Changes in the physiology of labor and delivery, and interventions required to ensure the safety of the mother and child during an epidural, prepare the ground for a number of possible side effects. Studies have indicated that epidurals are associated with a low rate of spontaneous vaginal births, an increased rate of instrumental deliveries (forceps or vacuum), and longer labors, particularly for women having their first baby. Studies have also shown that women with epidurals have higher rates of fever during labor. As a result, their babies may need to be tested and treated for possible infections, which leads to their separation from their mothers. Evidence shows that epidural use, especially among mothers having their first baby, can increase the rate of cesarean birth. It is normal to carefully weigh risks and benefits of epidurals before taking a personal decision. Each labor is unique. If your labor is very long and you're very tired, epidural use may provide a beneficial break. There could be medical indications for epidural, for example, if you need a cesarean. If you are very active during labor and you are free to move and find comfort in a variety of ways, it is unlikely that you need an epidural, to be installed early in labor, or to need so many drugs. Using a small dose of medicine for an epidural, which is later used during labor, and allowing exhausting before pushing forward, you can reduce the rate of unwanted effects.

Lamaze International Recommendations

Lamaze International recommends that you avoid restrictions on food and fluids, and discuss with your doctor about using IV infusions, continuous EFM, artificial rupture of membranes, labor augmentation and epidural, so that they will be administered only if there is a medical indication. Lamaze International encourages you to trust in your ability to give birth without routine interventions, and to choose a doctor and a hospital that use medical interventions only if necessary.



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