Contraction Patterns of LabourHow do they influence our management of care to support the normal process of labour?

Know the normalWork with the abnormal to make it normal

In the past quarter century, advances in medical

technologyhave been accompanied by an

increase inintervention-intensive labour

and birth ( Hamilton, Martin, & Ventura, 2006 ).

Nature ’ s simpleplan for birth has been replaced by

a maternity caresystem that routinely interferes

with the normal physiologicalprocess and in doing so introduces

unnecessaryrisks for mother and baby.

Women no longer have confi -dence in their ability to give birth without technologic intervention.

The physiological mechanisms of labour and

childbirthare NOT completely

understood.

Intrinsic factors within the uterine muscle affect contractions and

progressive cervical dilation. Thus,spontaneous onset of term labour

signifies the baby’sreadiness to be born as well as the

mother ’s physiologicalreceptiveness to the process.

Don’t pick a plum before it is ripe

The Cervix needs to be soft

With good observation applied anatomy and physiology, and

critical thinking during the birthing process it is possible

to achieve normal vaginal birth.

One of my failings as a midwife is my inability to assess the strength and effectiveness of uterine contractions. I am often asked

How strong are her contractions?

How effective are her contractions

Can we measure the effectiveness of contractions?

Failure to understand labour

Early interventions Pain relief Epidurals Artificial rupture of membranes Oxytocinon/Syntocinon/Pitocin C section

There are Many theories

Friedmann defined the three stages of labour

Latent and active Second stage Third stage

These theories do not have any application to anatomy

and physiology or to the contraction patterns of

labourthey merely measure time

frames.

Failure to diagnose labour

In 2013, researchers published a report of 38,484 first-time C-sections that occurred among a national sample of women. The overall C-section rate among first-time mothers was 30.8%. More than 1 in 3 (35%) of these C-Sections were due to a diagnosis of “failure to progress,” or slow progress in labour. This means that 10%, or 1 in 10, of all first-time mothers in the U.S. had a C- Section for failure to progress during the years 2002-2008 (Boyle, Reddy et al. 2013).

More than 4 in 10 of these women who had C-sections for failure to progress had not even reached 5 cm dilation before they were taken to surgery. This means that many of these women were still in very early labour when they were told that they weren’t dilating fast enough (Boyle, Reddy et al. 2013).

Progress and Time A substantial number of women have unplanned

C- Sections for failure to progress during a medical induction. In a 2010 study that included 233,844 new-borns born between 2002 and 2008, researchers found that about half of all induced women who had C-sections for failure to progress had not reached 6 cm yet (53%)– indicating that they were still in very early labour when their inductions were labelled as “failed”

(Zhang et al., 2010b).

The baby is the passenger presentation is important

Power of uterine contractions are they doing the Job

The Pelvis

Outdated 3 P’s

Passenger

Power

PassageFriedmann 1955

Midwives perspective to look at the bigger picture and plan care to support the normal physiological process of child birth

The 5 P’s• Passenger• Power• Passage• Psyche• Preparation

The Art of Midwifery Consider the Five P’s Observe contraction

patterns Apply anatomy and

physiology to the six stages of labour

Know the birthing hormones and applied anatomy and physiology

Look at the bigger picture then plan yourcare/advice

And education to get the best outcomes for the individual woman

Labour contractions can increase and decrease in

frequency following admission to hospital. This

may be associated with dilatation and posture

rather than anxietyMidwifery 2009 June 25: (3)242-52 Epub2007 july 12

Missing from the statementNo reference to applied anatomy and physiology

What is really Happening?

Clock watching and timing

X

Lack of understanding leads to

Contractions are slow

Augmentation that is in apropriatley managed

Need to know latent and active phase

Lets augment the process

Foetal distress Caesarean Neonatal units

Are there 6 stages of Labour? Descent

Effacement

Active Transition Second Stage Third stage

Descent• The transverse

muscles of the uterus contract to facilitate the descent of the head into the pelvis

Oestrogen levels begin to fall and go over a few weeks

Descent

The transverse muscles continue to assist the head to descend into the pelvis. At some stage prostaglandin is released. The cervix softens. The longitudinal muscle begins to contract from the fundus to pull back the cervix over the head. This gives a picture of variable contractions. The rounded contractions giving height as the longitudinal muscles do their job. Short and sharp contractions as the head continues to descend into the pelvisEffacement

and early dilation

Effacement

Regular coordinated contractions as oxytocin is released

The longitudinal muscles pull s the cervix back over the baby’s head

Usually greater than 5cm on admission

Can stop for 1-2 hours prior to transition

Endorphins are released to assist with maternal pain management.

Active Phase

Dilation

Contraction patterns may change

The body knows what to do. If the baby is in posterior position there will be more

descent patterns of contractions with back pain. Babies sometimes rotate in and out of posterior

position as the baby corkscrews down into the pelvis If baby is moving from ROA to LOA. The mother needs to move position to help her baby

turn. Augmentation may drive down the Op baby and

cause obstruction if forced. In my experience forcing a baby down in the OP

position may weaken the uterus.

Can’t do it Won’t do it Cut it out Give me an

epidural Get me out of

here It’s all your fault I hate you

TransitionUsually occurs around 7-8cm

Adrenaline is released the flight and fight hormone

Can last around 20 minutes

Amy and Jo Worlds Apart

Jo in a large tertiary Hospital

Opinions for child birth

No choices Not ambulant Augmentation Fetal Distress LSCS

Amy in a midwifery led unit

Ambulant Choices Positioning Squatting Well informed Normal delivery Elated about her

experience

Case scenarios Mary home birth

Rajeshri- induction Jo- Posterior birth Kshama -

Unprepared Noha- Waterbirth

Picture perfect

Tough love and bargaining

Positioning

Tough love/positioning Tough love

Early admission leads to intervention

Burnt out midwives More midwifery staff for one to one care. High intervention rates Increases the risk of LSCS Increased risk babies requiring intensive care Affects on breastfeeding Postnatal depression Increased staffing levels Exhausted obstetricians

The Birthing Environmentwarmsafeprivatequietdark

Active Birth

Hospital Walking Garden

Understand the contraction patterns of labour

Understand and apply anatomy and physiology of the uterus

Take into account the Five P’s when making decisions

Understand the roles of birthing hormones

Midwife’s Role

To support the normal physiological process of childbirth

My intervention rate was much higher.

I did not understand the normal physiological process of labourI did not know how to manage the contraction patterns of labouror manage care applied to the 5P’s with a midwifery perspective

I did not know how to educate and empower my womenI was not strong enough to provide tough love

In the beginning I spent many of 16 hours with women on delivery unit.

Now I can drink tea. Usually only two to fours hours on Delivery unit.

Thanks to the continuity of care, reflection of practice, use of

complementary therapies, my vaginal birth rate is around 95%.

My epidural rate is around 4%

“Very few women spend a long time in hospital and have faith in childbirth. When midwives learn

from reflection, share knowledge and work as a team the future for our families will be sound”

Irene Chain Midwife

Your Decisions Affect the woman for life Take into consideration the professional team If not sure Ask If you don’t apply the anatomy physiology,

mental state you will have longer times on delivery maternal exhaustion and burnt out colleagues

We are a team with a wealth of knowledge and experience

Recommendations Support the natural process Tough love where necessary Better antenatal education Ambient Rooms and acceptance for women who

have little support Support your colleagues/and better communications On call sleep room for health professionals with

facilities. Empower women to take charge No CTG monitoring for low risk women