objectives how do we support spontaneous labor and … spontaneouslabor .pdfpuerperium can have life...

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Holly Powell Kennedy, PhD, FACNM, FAAN Helen Varney Professor of Midwifery

Care for women in spontaneous labor:

Evidence-based management

Disclosures: I have no conflicts of interest

Acknowledgements: � The UK/US Fulbright Commission

� The Burdett Trust for Nursing

� ACNM Foundation� Childbirth Connection

� UCSF Academic Senate

� The New Hampshire Charitable Trust

� TriService Nursing Research Program

� The Renfield Trust

� The women, clinicians, & leaders who have participated in my research

Objectives

� Examine the evidence to support spontaneous labor and birth

� Review specific care practices supportive of spontaneous labor and birth

� Identify critical resources to help units adapt practices supportive of spontaneous labor and birth

How do we support spontaneous labor and birth?

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How do we support spontaneous labor and birth?

WHO states that childbirth interventions should be based on best evidence for the mother and optimal level of intervention should be to achieve best outcomes

World Health Organization (2015)

Are we really using evidence to the mother’s and infant’s advantage?

… what evidence and outcomes matter?

Photo courtesy B. Reid

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Salutogenic Birth . . .that which creates health


The examination of how we care for women during labor and birth

Belief in the normalcy of pregnancy and birth

The art of doing “nothing” well (where less is more)

Optimal health of the mother and baby in the given situation

Kennedy HP. (2000). A model of exemplary midwifery care. Results of a Delphi study. Journal of Midwifery and Women’s Health, 45(1), 4-19

Belief in the normalcy of pregnancy and birth

The art of doing “nothing” well (where less is more)

Optimal health of the mother and baby in the given situation

Kennedy HP. (2000). A model of exemplary midwifery care. Results of a Delphi study. Journal of Midwifery and Women’s Health, 45(1), 4-19

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Onset of labor

• Upregulation of OTRs• Electrical connection of muscle

cells for coordinated CTX• Cervical ripening• Shift from PG receptors to

increasing uterine stimulants• Inflammation• Activation of spinal-cord pain

relief pathways

David N. Figlio DN; Guryan J; Karbownik K; Roth, J. (2016). JAMA Pediatrics (online).

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We are also learning that the window of the puerperium can have life long effects for the

mother and the child

Normal physiology of labor & birth

� Oxytocin – endogenous v. exogenous� Beta-endorphins� Catecholamines� Cortisol (Eustress)� Prolactin� Prostaglandins

Buckley, S. J. (2015). Hormonal physiology of childbearing: evidence and implications for women, babies, and maternity care. Washington, D.C.: Childbirth Connection Programs, National Partnership for Women & Families.

What factors support the release of maternal endogenous oxytocin in labor?

A. Continuous fetal monitoring

B. Eye-to-eye contact

C. Diet restrictionD. Diminished sensory

stimulation

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Oxytocin release �� sensory stimulation� eye-to-eye contact� acupressure� eating� suckling� warmth� water immersion� companions

� pleasing sounds� pleasing views� Ferguson reflex� sexual activity� smiling (muscle)� relaxation� nor-adrenaline� love

. . . we are the instruments

Photo by Michelle Wellborne; courtesy Y. Neumann

Oxytocin release �� sensory stimulation� eye-to-eye contact� acupressure� eating� suckling� warmth� water immersion� companions

� pleasing sounds� pleasing views� Ferguson reflex� sexual activity� smiling (muscle)� relaxation� nor-adrenaline� love

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CMQCC Recommendations

� Readiness (improving the culture of care, awareness, and education)� Recognition & prevention (supporting

intended vaginal birth)� Response (managing labor

abnormalities)� Reporting (using data to drive

improvement)

Smith, H., Peterson, N., Lagrew, D., Main, E. (Eds). (2016). Toolkit to Support Vaginal Birth and Reduce Primary Cesareans.: A Quality Improvement Toolkit. Stanford, CA: California Maternal Quality Care Collaborative.

CMQCC Recommendations

� Readiness (improving the culture of care, awareness, and education)� Recognition & prevention (supporting

intended vaginal birth)� Response (managing labor

abnormalities)� Reporting (using data to drive

improvement)


Improving the culture of care, awareness, and education1. Improve quality of & access to childbirth

education2. Improve communication through shared

decision-making at critical points in care3. Bridge the provider knowledge gap4. Improve support from senior hospital

leadership and harness the power of clinical champions

5. Transition from paying for volume to paying for value


Do you know what the women in your care are reading?

Where are they getting their information?

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Kennedy, Nardini, Mcleod-Waldo, Ennis. (2009). A discourse analysis of top selling childbirth advice books. BIRTH, 36(4), 318.

Pain has a purpose;different from suffering

Pain has no purpose and is unacceptablePain

Keep this in mind: Those of us who took a little nip from the epidural tap are usually the life of the champagne celebration in our rooms after the baby is born, while our American Gothic counterparts are sound asleep with every capillary in their cheeks broken.

If you are birthing in a hospital you automatically become part that system. A woman's intolerance of labor pain may not be to pain, but to other people's response to it.

Becoming a mother – minimal messages about women’s strength or values of childbearing processes

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Evidence-based practice includes which of the following:

A. The best available scientific evidenceB. The clinician’s skill and judgmentC. The desires of the patient

A. a

B. a & b

C. a & cD. a, b, & c

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Institutional ethnography

Understand how women are supported in the achievement of physiologic normal birth or ‘optimal’ birth in the presence of social/medical/obstetric complexity in 2 NHS Trusts (London 2008)

Antenatal Guidelines 2nd Edition Oct 2007 (Notes)

� Following the initial booking appointment the women will be given their notes to carry throughout their pregnancy.

Kennedy, H.P., Grant, J., Walton, C., Shaw-Battista, J., Sandall, J. (2010). Normalizing birth in England: a qualitative study. Journal of Midwifery and Women’s Health, 55(3), 262-269.

When is a prenatal record more likely to be lost?

A. When the hospital retains it?

B. When the woman retains it?

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American College of Nurse-Midwives http://www.birthtools.org

Resources

National Institutes of Clinical Excellence (NICE) Intrapartum Guidelineshttp://www.nice.org.uk/guidance/cg190

Resources

Optimal Care in Childbirth: The Case for a Physiologic Approach (Romano & Goer, 2013) http://www.optimalcareinchildbirth.com

Resources

Normal Childbirth: Evidence and Debate (Downe, 2008) (Available at Amazon.com)

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Resources

Dixon, L., Fullerton, J.T., Begley, C. Kennedy, H.P., & Guilliland. (2011) International Journal of Childbirth, 1(3), 179.







Our leaders are visible and vocal: the workforce

There is an open culture in which staff are supported and challenged in their decision making – “Lets talk …”








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The New Normal: Redesigning Maternity Care for Low-Risk Women


Key strategies for supporting “intended” vaginal birth

1. Implement institutional policies that uphold best practices – safely reduce routine intervention in low risk women

2. Implement early labor supportive care policies and establish criteria for active labor admission

3. Improve the support infrastructure and supportive care during labor


Nourishing women (body)In cases of normal, low risk labours,

women should be encouraged to eat and drink as their appetite dictates. With progression of labour the amount that women will take decreases and therefore should not be forced upon them. It is important to let women choose and decide.


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1. Implement institutional policies that uphold best practices – safely reduce reduce routine intervention in low risk women




Helping women stay home in early labor

I think sometimes they admit them too early. Like women come in at you know, 1 to 2 cm and they admit them very early and give them epidurals right off the bat. I feel like they’re not really in good labor on their own, and that kind of impedes the process (nurse).


1. Implement institutional policies that uphold best practices – safely reduce reduce routine intervention in low risk women




Unit design

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. . . and it was like a haven . . .



4. Encourage the use of doulas and work collaboratively to provide labor support

5. Utilize best practice recommendations for laboring women with regional anesthesia

6. Implement intermittent monitoring policies for low risk women

7. Implement current treatment and prevention guidelines for potentially modifiable conditions


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Photo courtesy E. Knobf







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. . . we ask the question, “why was she put on the monitor?”








�Trust in women�Trust in birth�Use of evidence�Teamwork & respect�Integrated systems of care

Successful models


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Critical steps�Personal & institutional commitment

to keeping low risk women, low risk�Use the evidence and the physiology

– always question if intervening is the best option�Bring in experts to help – change

takes careful thought & strategy�All stakeholders must engage

(including women) – it has to be a team approach

Critical steps�Small steps with team development,

training, & evaluation�Childbirth education – think about

completely different approaches and make it available to all women�Branding & marketing – how to

present it to women�Track, evaluate, & disseminate

Keep that oxytocin flowing…


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Thank you for the invitation to join you in this dialogue


objectives how do we support spontaneous labor and … spontaneouslabor .pdfpuerperium can have life...

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