Supporting a Physiologic Approach to Pregnancy and Birth E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 726

Veröffentlichungsjahr: 2013

Beschreibung

Supporting a Physiologic Approach to Pregnancy and Birth: A Practical Guide provides an overview of current evidence and a range of practical suggestions to promote physiologic birth within the United States healthcare system. Presenting the latest evidence available on practical approaches and minimal interventions, this book looks into clinic exam rooms and hospital labor units to investigate the possibilities for improving the pregnancy and labor experience. Contributors discuss recent research and other published information and present a range of ideas, tools, and solutions for maternity care clinicians, including midwives, nurses, physicians, and other members of the perinatal team. An invaluable resource, Supporting a Physiologic Approach to Pregnancy and Birth is a must-have practical guide for those involved in all aspects of pregnancy and birth.

Leseprobe

Contents

Contributors

Foreword

Acknowledgments

Section 1 Understanding a physiologic approach

Chapter 1 The case for a physiologic approach to birth: An overview

Spending and doing too much

Looking for something different

A look inside

Chapter 2 The physiology of pregnancy, labor, and birth

Introduction

Physiologic adaptive changes in pregnancy

Physiology of labor

Psychobiological responses to labor

Summary

Chapter 3 A supportive approach to prenatal care

Introduction

Typical approach to prenatal care

Preconception and interconceptional care: Begin a supportive approach early

Supportive physiologic prenatal care: What is it?

Components of supportive prenatal care

Comprehensive care/psychosocial care

Optimizing the prenatal care setting

Group prenatal care as an alternative to individual care

Common discomforts of pregnancy

Preparation during pregnancy for a physiologic approach to labor and birth

Inclusivity of partners, families, and support persons

Strategies to help women achieve their preferred birth experience

Conclusion

Chapter 4 Supporting a physiologic approach to labor and birth

Introduction: What is “normal” childbirth?

What is a physiologic approach to childbirth?

Promoting the natural physiologic rhythm of labor

Progressing in first stage labor

Entering and progressing through second stage labor

Care of the woman giving birth

Specific practices that can disrupt normal physiological labor and birth

Summary

Section 2 Interventions and approaches

Chapter 5 Promoting comfort: A conceptual approach

Introduction

Historical context of comfort

Kolcaba’s theory of comfort

Pain and comfort during childbirth

What women bring to birth

The midwifery model of care

Chapter 6 Continuous labor support

Introduction

Continuous labor support: An evidence-based practice that supports normal physiologic birth

Review: The labor process and the fear-tension-pain cycle

How well is she coping? Pain versus suffering

Elements of labor support

What is presence?

Summary

Chapter 7 Techniques to promote relaxation in labor

Introduction

Why relaxation?

Childbirth education

Promoting relaxation

Music

Progressive relaxation

Breathing techniques

Imagery

Heat and cold

Physical positioning

Hydrotherapy

Miscellaneous relaxation aides

Emotional relaxation

Mindfulness in relaxation

Summary

Chapter 8 Touch therapies in pregnancy and childbirth

Introduction

The role of touch in contemporary health care

The role of touch in midwifery, nursing, and medicine

Touch as metaphor for caring: Jean Watson’s science of caring

Use of touch therapies in promoting relaxation and reducing stress and pain

Overview of touch therapies

Reconceptualizing touch

Ethical considerations

Use of touch to provide support during labor/birth

Application of touch therapies to pregnancy and postpartum

Models of care

Summary and recommendations

Chapter 9 Water immersion for labor and birth

Introduction

History

Research

Theoretical risks to mother during water immersion and/or water birth

Risks to baby

Incorporating water birth into practice

Conclusion

Chapter 10 Aromatherapy in pregnancy and childbirth

Introduction

Brief history and definitions

Context of aromatherapy

Essential oils: Production and constituents

Methods of application

Toxicity, sensitization, and irritation

Aromatherapy in maternity care

Evidence for essential oils in pregnancy and postpartum

Incorporating aromatherapy in practice

Credentialing issues

Conclusion

Chapter 11 Acupressure and acupuncture in pregnancy and childbirth

Introduction

Definition of acupuncture and acupressure

Brief history

Mechanism of action: Eastern theories

Mechanism of action: Western perspective/theories

Safety

Incorporating acupuncture and acupressure into pregnancy

Specific care when treating pregnant women

Selected uses during pregnancy

Cost

Training, licensure, and certification: Acupuncture

Training, licensure, and certification: Acupressure

Section 3 Organizational approaches to supporting physiologic pregnancy and birth

Chapter 12 Rethinking care on the hospital labor unit

Introduction

Approaches to care

The change process

Picturing a transformed labor unit

Conclusion

Chapter 13 Out-of-hospital birth

Introduction

Background

Factors motivating clients to seek out-of-hospital birth—authority, centrality, and privacy

Enhancing empowerment of the birthing woman and family

Key considerations for safe out-of-hospital birth

System barriers to out-of-hospital birth

Conclusion

Chapter 14 Educating health professionals for collaborative practice in support of normal birth

Introduction

Background

National calls for interprofessional education

Health professions educational competencies

Barriers to interprofessional education

Call for interprofessional education in maternity care

Interprofessional education within collaborative practice models

Interprofessional education models

Interprofessional education for maternity care professionals

Summary

Chapter 15 Women’s health and maternity care policies: Current status and recommendations for change

Introduction

Policies for women’s health and maternity care providers

Hospital policies

Federal and state policies affecting women’s health and maternity care

Policies supporting breastfeeding

Summary

Resources for physiologic pregnancy and childbirth

Index

The optimal role of the attendant—whether physician or midwife—is to be ­vigilant without being meddlesome.

R. A. Rosenblatt, MD

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DedicationTo the women—for allowing us the privilege of being present with them during their special time.And to my husband—Randy Schnoes—who is always there for me.

Contributors

Cindy M. Anderson, PhD, RN, WHNP-BC, FAANAssociate ProfessorDepartment of NursingCollege of Nursing and Professional DisciplinesUniversity of North DakotaGrand Forks, North DakotaMelissa D. Avery, PhD, CNM, FACNM, FAANProfessorChair, Child and Family Health Co-operative UnitDirector, Nurse-Midwifery ProgramSchool of NursingUniversity of MinnesotaMinneapolis, MinnesotaAlice Bailes, CNM, MSN, FACNMCo-FounderBirth Care and Women’s HealthAlexandria, VirginiaRebeca Barroso, DNP, CNMFaculty, Frontier Nursing UniversityStaff Nurse-MidwifeHealthEast Nurse-MidwivesSt. Paul, MinnesotaHeidi Jean Bernard, RN, ADNStaff NurseDepartment of Labor and DeliveryUniversity of Iowa Hospitals and ClinicsIowa City, IowaHeather M. Bradford, MSN, CNM, ARNP, FACNMCertified Nurse-MidwifeEvergreen Health Midwifery CareKirkland, WashingtonAffiliate FacultyDepartment of Family and Child NursingUniversity of WashingtonSeattle, WashingtonMichelle R. Collins, PhD, CNMAssociate Professor of NursingDirector, Nurse-Midwifery ProgramVanderbilt University School of NursingNashville, TennesseeDawn M. Dahlgren-Roemmich, MS, CNMCertified Nurse-MidwifeJordan, MinnesotaLinda L. Halcón, PhD, MPH, RNAssociate ProfessorSchool of NursingUniversity of MinnesotaMinneapolis, MinnesotaEmily Higdon, RN, MSNPhD Student and Jonas ScholarStaff NurseDepartment of Labor and DeliveryUniversity of Iowa Hospitals and ClinicsIowa City, IowaMarsha E. Jackson, CNM, MSN, FACNMDirector and Co-FounderBirth Care and Women’s HealthAlexandria, VirginiaJohn C. Jennings, MDProfessor of Obstetrics and GynecologyTexas Tech University Health SciencesOdessa, TexasKathryn Leggitt, MS, CNMCertified Nurse-MidwifeHennepin County Medical CenterMinneapolis, MinnesotaLisa Kane Low, PhD, CNM, FACNMAssistant Professor and Director Nurse-Midwifery Education ProgramSchool of Nursing and Women’s Studies DepartmentUniversity of MichiganAnn Arbor, MichiganKatie Moriarty, PhD, CNM, CAFCI, RNClinical Assistant Professor Associate Director Nurse-Midwifery Education ProgramSchool of NursingUniversity of MichiganAnn Arbor, MichiganCertified Acupuncture Foundation of Canada InstituteCarrie E. Neerland, MS, CNMCertified Nurse-MidwifeWomen’s Health SpecialistsUniversity of Minnesota PhysiciansAdjunct FacultyUniversity of Minnesota School of NursingUniversity of Minnesota Medical SchoolMinneapolis, MinnesotaMichelle L. O’Brien, MD, MPH, IBCLCAdjunct FacultyAssistant ProfessorDepartment of Family Medicine and Community HealthUniversity of Minnesota Medical SchoolMinneapolis, MinnesotaDeborah Ringdahl, DNP, RN, CNMReiki MasterClinical Assistant ProfessorSchool of NursingUniversity of MinnesotaMinneapolis, MinnesotaKristin Rood, RNMaternal and Infant Staff NurseChildren and Women’s Services DivisionUniversity of Iowa Hospitals and ClinicsIowa City, IowaKennedy SharpLicensed AcupuncturistMasters in Oriental MedicineNCCAOM Certifiedsharpacupuncture.comMinneapolis, MinnesotaKerri D. Schuiling, PhD, CNM, FACNM, FAANDeanSchool of NursingOakland UniversityRochester, MichiganRachel Woodard, RN, BSN, RNC-OBObstetrical Nurse Specialist Staff Nurse Labor and DeliveryDepartments of Pediatrics and NursingUniversity of Iowa Hospitals and ClinicsIowa City, Iowa

Foreword

Birth is an event that carries our universe into the future. Each pregnancy and birth holds the promise of fresh life, renewed faith in our survival, and awe at the magnificence of human reproduction and the power of woman. Every birth is unique and every birth changes the person fortunate enough to witness the emergence of a new life.

Melissa Avery has brought together midwives, nurses, physicians, and other health practitioners in a collective, in-depth discussion of how to support a woman’s physiologic capacity to carry and birth her child. This long overdue book is founded on the premise that pregnancy and birth are normal physiologic processes. It takes a direction often missing in traditional texts—that birth is more than simple mechanical, physical processes that can be inherently controlled. Rather, it acknowledges that although there is much we fully understand, there is still much to be learned. Thus, she and her colleagues have expertly woven current scientific evidence and theory with practical clinical expertise for helping women and their families during this life-producing and life-changing event.

The first section grounds the reader in a woman’s physiology during pregnancy and birth. Avery starts the section off with a “real-life” scenario that clinicians who attend birth are often faced with each day. This is followed by an exquisite description of the physiologic intricacies of pregnancy and parturition that leaves us breathless in its detail and design and sets the stage for understanding how it all works. Prenatal care is emphasized as the place to work with the woman to establish her confidence in her body and its capabilities. The section closes with a stunning overview of how to keep the woman and her needs central during childbirth. The authors review the evidence on routine maternity care practices that can disrupt normal labor and birth and describe approaches to care that provide step-by-step support of a woman’s physiology. Taken together, these four chapters provide the essential elements of the book and lay the underpinning for the following sections, which explore specific techniques and policy.

The second section provides an overview of specific strategies in caring for ­childbearing women. Different theories and evidence for care strategies are presented, always returning to why and how they support normal physiologic birth. The section begins with an introduction to the theories of “comfort,” helping the reader understand how to meet each woman at the intersection of her life and her perception of pain and discomfort. The complexity of labor pain is disentangled through creative descriptions of pain modulation through the release of naturally occurring neuropeptides. The theoretical basis of comfort is extended by presence—the act by which the labor attendant creates a space in which the woman feels safe and thus her body’s physiology is supported to do the work of labor. Techniques of relaxation, healing touch, therapeutic use of water, aromatherapy, and ­acupressure/acupuncture round out the section. Each of the topics is carefully reviewed for current evidence and practical application. The end result of this portion of the book reveals the art and healing science of supporting physiologic birth.

The final section provides a welcome and practical discussion of the realities of change in childbearing care. Since childbirth moved into the hospital it has been regimented to institutional routines not always rooted in evidence. Although these routines were established in good faith and believed to be best for the mother and infant, that was not always the case. Over time routines became so conventional that changing them seemed insurmountable. The section begins by helping us rethink how care is provided in the hospital, where most women in the United States give birth. The challenges of creating a safe environment for the laboring woman within an institutional setting are creatively presented through case studies, principles from major advocacy organizations, and systematically decreasing the use of routine interventions. Complementary to the chapter on hospital birth is a thoughtful presentation on out-of-hospital birth. Both chapters discuss the essential desire of women to be respected for their needs during labor and birth and the right to make decisions about where and how they birth. The authors challenge the idea that medicine is the final word in health care and place the woman at the center of care and as the director. They propose that this change of roles might actually enhance the woman’ s physiologic ability to birth. These are hefty sea changes in how we think about the roles of providers and the women for whom they care. Avery, Jennings, and O’ Brien emphasize the need for careful nurturing of the professions’ young through interdisciplinary education in order to bring these changes about. By exploring issues together during the formative years of their professional identities, nurses, midwives, and physicians can learn together how to best work “with woman” during this profound moment of her life. The book closes by describing the need for policy to undergird the changes needed to best support women—through legislation, regulation, and institutional transformation.

If every clinician and institution that provides care to childbearing women instituted the recommendations in Supporting a Physiologic Approach to Pregnancy and Birth, we could truly see change in how women birth in the United States—and I believe improved outcomes. Perhaps the most important message in this book is the blending of our understanding of human birth physiology with human caring. In Proust Was a Neuroscientist (Houghton Mifflin, 2007), Jonah Lehrer explored the relationship of artists with concepts in neuroscience, noting, “scientists describe our brain in terms of its physical details . . . what science forgets is that this isn’t how we experience the world” (p. x)—artists help us to understand how the world is perceived and lived. Avery and her colleagues help us understand both the science and the art of supporting women’ s physiology, how that can actually make birth safer, and how artful presence and caring approaches enhance the woman’ s experience and create a powerful mother and healthy child and family in the process. This book is a passage to the future in childbearing care.

Holly Powell Kennedy, PhD, CNM, FACNM, FAANHelen Varney Professor of MidwiferyYale UniversityJanuary 1, 2013

Acknowledgments

This book would not have been possible without the dedication and hard work of each and every chapter author. Thank you so much for your contributions in providing the background information and practical advice to help maternity care clinicians in their efforts to promote a physiologic approach to pregnancy and childbirth. We have included the physiologic underpinnings, the normal aspects of pregnancy and labor care, multiple integrative therapies, and a focus on the care system including interprofessional education and policy. A special thank you to Deborah Ringdahl, DNP, RN, CNM. In addition to writing a wonderful chapter on touch therapies in pregnancy, her review of multiple chapters and advice on other aspects of the book were immensely helpful. Thank you to Lisa Summers, DrPH, CNM, FACNM, and Joanna King, JD, for their valuable contributions to the policy chapter.

Chapters on acupuncture and acupressure and touch therapies include photographs providing illustrations of the techniques described in the text. We thank Melissa Jackson, Aimee Flood, Beth Kuzma, and Lily Crutchfield for serving as models and helping bring the techniques to life. My research assistant, Colleen Quesnell, reviewed many sections and helped with so many other necessary details that are not evident in the final polished product. A special thanks to Kathe Grooms for expert advice along the way.

For more than three decades as a nurse and midwife, I have had the privilege of working with so many nurses, physicians, midwives, and others that have influenced my day-to-day work as well as broader career trajectory. The faculty and staff at the University of Minnesota, School of Nursing, and the students I have had the pleasure of teaching over the years deserve special thanks for their ongoing support.

Finally, my deepest gratitude to my daughter, Helen Avery Schnoes. Her helpful suggestions as a talented writer and her encouragement were invaluable all along the journey.

Section 1

Understanding a physiologic approach

Chapter 1

The case for a physiologic approach to birth: An overview

Melissa D. Avery

Childbirth is normal until proven otherwise.

Peggy Vincent

Picture yourself at a neighborhood clinic on a typical weekday. You are conducting a health care visit with a woman as her prenatal care provider; she is 32 weeks pregnant. You ask how she has been feeling—she is fine. Her fundal height is 33 cm, the baby feels vertex, fetal heart tones are 134 beats per minute, a 2-pound weight gain since her last visit. No, she has not experienced any bleeding or headaches, no contractions. Yes, she started prenatal classes this week and the instructor reviewed the signs of early labor. Transition to the hospital. You’re the nurse admitting a woman in labor to the birthing room with the bed centrally located, the fetal monitor in an attractive wood cabinet next to the bed. You ask when her contractions began, the current frequency and duration, and if her baby has been moving. Her membranes are intact, vital signs are normal, fetal heart rate 148. While you turn down the bedcovers, she changes into a hospital gown and asks if water birth is possible; she read about it on a pregnancy website and thought it might be a nice option.

On the face of it, the daily experiences of many maternity care clinicians and the women we care for seem pretty normal, routine, and positive to a degree. We talk about pregnancy as a normal life process, yet women enter our care system where problems are anticipated rather than emphasizing the normalcy of pregnancy. The number and ­frequency of technological interventions continue to increase while the outcomes of care have ­worsened, with some recent abatement. Substantial national resources are spent on what is supposed to be a normal process. From the clinic to the hospital, how do we as nurses, midwives, and physicians provide a safe and high-quality experience for the women we care for during pregnancy and birth? How are we helping women plan for and achieve their goals and desires for their birth experiences?

Cesarean section has become the most common operating room procedure in America [1]. The U.S. cesarean section rate is nearly 33%, appearing to at least stabilize in 2010 and 2011 after rising by 60% from 1996 to 2009 [2,3]. The Healthy People 2020 goal is a moderate 10% reduction in cesarean births to low-risk women (term, singleton, vertex) from a baseline of 26.5% in 2007 to 23.9% by 2020, as well as a 10% increase in vaginal births among women with a previous cesarean [4]. At the same time, infant mortality, a measure used worldwide to reflect care to mothers and families, is 6.05 deaths in the first year of life per 1,000 live births [5]. This is higher than all but three member countries of the Organisation for Economic Co-operation and Development (OECD), an organization of primarily developed countries including Europe, the United States, Canada, and others [6]. Infant mortality in the United States has declined from 6.71 per 1,000 live births in 2006 after remaining stable from 2000 to 2005 [7]. An 8% decline in premature births occurred from 12.80% in 2006 to 11.72% in 2011 [3], along with increased efforts at ­preventing early elective births such as the March of Dimes and the California Maternal Quality Care Collaborative [8,9]. Maternal mortality was 12.7 per 100,000 live births in 2007 [10], a number that may be increasing [11], with the U.S. rate behind forty-nine other developed nations in 2010 [12]. (See summary data in Table 1.1.)

Table 1.1 U.S. maternity care data.

Not readily apparent in these statistics are significant racial disparities. For example, infant mortality among African American women was 11.42 per 1,000 live births, 2.2 times greater than the 5.11 for White women [5]. Maternal mortality was approximately 3 times higher for African American women compared to White women [10,11]. These ­disparities are inexcusable in a country with such vast resources; we must reverse these trends by assuring access to continuous high-quality health care [13]. Returning to a more normal or physiologic approach to maternity care including access to ­comprehensive ­continuous care to all women in the United States is one step in that direction.

Spending and doing too much

Nearly 99% of U.S. births occur in hospitals [2], thus “liveborn infant” and “pregnancy and childbirth” are among the most common reasons for hospitalization [1], accounting for nearly a quarter of hospital discharges in 2008, and over $98 billion in hospital charges (amount hospitals bill for a stay). Medicaid payment covers the cost of care for over 40% of pregnancies and births [14]. Of “pregnancy and childbirth” and “liveborn infant” ­hospitalizations in 2008, $41 billion was paid by Medicaid and $50 billion was paid by private insurers [15]. The United States spent 17.6% of gross domestic product (GDP) on health care in 2010, more than any of the other OECD countries [6]. This phenomenon of doing more in perinatal care without a corresponding improvement in care outcomes was first referred to as the “perinatal paradox” more than 20 years ago [16]. Tremendous resources are allocated to maternal and infant care in the United States and yet our ­outcomes do not compare well with other developed countries. Although preterm birth has declined in recent years and the cesarean rate may have stabilized, there is much more work to be done.

The passage of the Affordable Care Act (ACA) in 2010 marked the first success in half a century of legislative attempts to change health care in the United States. When fully implemented, millions more Americans will have health care coverage. An important focus of the ACA is on improving health care and reducing costs by enhancing coordina­tion of care for individuals with chronic conditions, reducing medical errors, reducing ­hospital-acquired infections, and reducing waste in the system. Improving health care, improving care outcomes including client satisfaction, and providing care at lower cost, often referred to as the triple aim, are not only possible but necessary. In addition to improved access to health care, ACA improvements in care options for women include family planning and breast and cervical cancer screening without co-pays, coverage for maternity and newborn care, home-visiting services during pregnancy and early childhood, restricting insurance companies from charging women higher premiums than men, and enhanced support for breastfeeding mothers [17].

Concerns about the increased use of technology and medical intervention overuse in maternity care have been expressed by clinicians, scientists, educators, and others around the world. Multiple health professions and health-related organizations worldwide have issued statements calling for a more normal or physiologic approach to ­pregnancy and birth. Concerned with the rising rates of interventions in maternity care in the United Kingdom, the Maternity Care Working Party published a normal birth consensus ­statement in 2007, supported by the Royal College of Obstetricians and Gynecologists and the Royal College of Midwives, defining “normal delivery” as spontaneous labor, labor ­progression, and birth, without the use of interventions such as labor induction, epidural, cesarean section, and forceps. The statement proposes action steps to increase the proportion of normal births in the four UK countries [18]. Other statements, in some cases endorsed by multiple health professions organizations, have called for support of birth as a normal process, reduced intervention, use of best available evidence, and woman-­centered care [19–22]. More recently, in the United States, the American Academy of Family Physicians; American Academy of Pediatrics; American College of ­Nurse-Midwives; American College of Obstetricians and Gynecologists; American College of Osteopathic Obstetricians and Gynecologists; Association of Women’s Health, Obstetric and Neonatal Nurses; and Society for Maternal-Fetal Medicine endorsed a statement on quality patient care in labor and delivery identifying pregnancy and birth as normal processes requiring little if any intervention in most cases [23]. The authors called for effective communication, shared decision making, teamwork, and quality measurement in the provision of maternity care. Three U.S. midwifery ­organizations partnered in the development of a statement supporting physiologic birth—defining normal physiologic birth, identifying factors that disrupt and factors influencing normal birth, and proposing a set of actions to promote normal birth [24]. Reflecting the growing concern about the U.S. cesarean section rate, authors of a report summarizing a recent workshop held by the American Congress of Obstetricians and Gynecologists, the Society for Maternal-Fetal Medicine, and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, plus a similar commentary, recommended specific practices and actions for clinicians and health systems to prevent the first cesarean section [25,26]. At least on paper, it seems as if we all agree.

Internationally, a series of normal labor and birth conferences have been held beginning in England in 2002 and most recently in China in 2012 [27]. The conferences highlight current research and best practices in promoting normal birth. In the United States, authors of a key report on evidence-based maternity care have identified induction of labor and cesarean section as overused procedures. Additionally, midwives, family ­physicians, and prenatal vitamins were described as underused interventions [28]. Following that report, Childbirth Connection, a nonprofit organization focused on improving maternity care, held a multistakeholder meeting focused on just how the quality and value of maternity care could be improved in the United States. The resulting “Blueprint for Action: Steps toward a High-Quality, High-Value Maternity Care System” provides clinicians, payers, educators, and care systems with excellent proposals to improve our care to women [29]. Strong Start for Mothers and Newborns, a federally funded program under the Centers for Medicare and Medicaid Services (CMS) Center for Medicare and Medicaid Innovation, has provided funding to reduce early elective births and to test new models of enhanced prenatal care to meet the triple aim. The models include enhanced prenatal care in group prenatal settings, in birth centers, and in maternity care homes [30].

In order to improve quality, health systems need to measure and report on the care provided [29,31,32]. Maternity care measures are available for use to improve quality such as the Joint Commission, the National Quality Forum, and the American Medical Association (AMA). The AMA Physician Consortium for Performance Improvement measure set was developed by an interprofessional work group and includes measures related to overuse of certain care practices as well as a measure for spontaneous labor and birth [33]. These quality measure sets are available to health systems, clinicians, and payers to improve care and achieve better care outcomes. In addition to the national ­measure sets, a tool to examine the optimal processes and outcomes of normal ­pregnancies among groups of women has been developed and tested. The Optimality Index-US ­measures what is “optimal” or best possible care processes and outcomes—within a ­philosophy of aiming for the best outcome using the least number of interventions [34–36]. Higher Optimality scores in one setting over another may reflect an ­environment that supports a low intervention and physiologic approach to prenatal and labor care. Available as a research tool, clinicians can also use the index to examine institutional care processes and in peer review and other quality improvement processes [35].

Looking for something different

Women have signaled that they are beginning to look for something different, evidenced by the recent increase in out-of-hospital births [37]. After declining since 1990, home births increased by 29% from 2004 to 2009 [38]. In 2010, the increase in both home and free-standing birth center births was large enough to cross the “99% mark,” documenting more than 1% of births occurring outside the hospital [2]. While the absolute number may not seem impressive (47,000 of nearly 4 million), the change is a message that a ­segment of the U.S. childbearing population is looking for something else. Birth is ­important to women, often a transformative event that they remember clearly throughout their lives. Many women believe labor and birth should not be interfered with and women understand their right to full information and to accept or refuse specific care processes [39]. Women are asking for specific services in hospitals such as water immersion, ­aromatherapy, and acupressure as part of the support tools available for labor and birth. Although epidurals remain popular, women are increasingly planning for an unmedicated birth and express a desire to be in control of their birth process [40]. The author of the 2011 consumer book Natural Birth in the Hospital: The Best of Both Worlds [41] reaches out to the nearly 99% of women giving birth in hospitals, letting them know that they, too, can have a more normal experience in a hospital and how to get what they want.

Women’s partnerships with their care providers are of utmost importance. Return for a moment to your clinic—sit down for a few more minutes with your client. What is it that she and her birth support persons really hope for during her labor and birth? What does the best evidence suggest are the preferred care measures resulting in the least harm? Take a little more time to engage in meaningful discussions with her so she puts aside her fears about labor, forgets the anxiety she’s seen in births depicted in the media, and partners with you in understanding options and planning for her labor and birth. When you welcome her to the hospital birthing room, tell her that your goal is to accommodate her and her partner’s preferences. Although it sounds easy, and most likely what we are trying to provide, current data support an alternate story.

This book can help you—the clinician “at the bedside”—take a look into the clinic exam rooms and hospital labor units to see what else is possible. The various chapter authors are clinicians and educators just like you. Together we have worked to summarize recent research and other published information and provide some ideas, tools, and ­solutions to put into the hands of maternity care clinicians including midwives, nurses, physicians, and others. The authors herein argue for supporting and enhancing women’s confidence in their ability to give birth. At the same time we aim to increase the confidence of care providers to trust in the normal process and support women expecting a healthy outcome rather than looking for reasons to disrupt the process. It goes without saying that specific conditions warrant medical intervention and higher levels of care such as ­pre-existing diabetes, hypertension, and multifetal gestation, and yet even women with those conditions can still be supported as mothers, enhancing normal or physiologic processes as much as possible.

A word about language. We have chosen to talk about an approach to physiologic ­pregnancy and birth with a profound respect for the intricate changes that occur during both pregnancy and labor that result in what is commonly referred to as “the miracle of birth.” We use the word “birth” in most cases, to honor the work that women do in giving birth. “Delivery” is retained in some circumstances, primarily to refer to women ­delivering their newborns. “Normal” is meant to signify the usual process of being pregnant and giving birth without being disturbed by technology or other interventions that are not necessary in supporting the usual processes [42], with no intent to judge any woman’s pregnancy or birth experience [43]. Every woman is unique; her process is also unique. Physiologic or normal is not just one variety or type, but each woman’s individual ­experience to be supported, “managing” only when the experience is truly outside the range of normal and thus requiring additional intervention. Even then, aspects of a normal or physiologic approach can be retained, always remembering the unique woman giving birth. Finally, this book is based on a belief that it takes all types of maternity care ­providers working in partnership to improve maternity care. Thus we refer to providers and clinicians, and the authors represent midwives, nurses, physicians, and others.

A look inside

Section 1 begins with a review of the normal physiologic changes of pregnancy as well as the physiologic uterine phases through pregnancy, labor initiation, continuation, and birth. Although the exact mechanism of the initiation of labor is not completely ­understood, the known components of pregnancy and labor physiology are fascinating, with increasing understanding through research on the intricacies of the labor process. With the goal of a physiologic approach as the norm, how do we adapt routine prenatal care to enhance women’s confidence and understanding of pregnancy as normal and not an illness to be treated? In a woman-centered approach, women are supported to understand the range of tools for comfort in early labor, how to recognize active labor and the best time to transition to the birthing unit (if not the home), and mechanisms to support the process. We work to bring women’s knowledge and understanding of the process as close to ours as possible and respect the knowledge and expertise each woman brings to her pregnancy. Originally proposed as a description of exemplary midwifery care, “the art of doing ’nothing’ well” [44] is recommended here as an approach for all clinicians providing maternity care unless there is a compelling reason to do something more.

Section 2 begins with a theoretical perspective on promoting comfort for women in labor followed by chapters describing integrative therapies for pregnancy, labor, and birth. Maternity care clinicians may not have sufficient knowledge and understanding about integrative or complementary and alternative medicine (CAM) practices [45]. Midwives appear to have a more positive view of the effectiveness of alternative therapies and are less likely to believe that results of CAM are due to placebo effect than ­obstetricians [46]. Researchers investigating nurse-midwives’ experiences with CAM therapies ­demonstrated that a majority of certified nurse-midwife respondents reported CAM use. Herbal preparations, pharmacologic/biologic, mind-body interventions, and manual healing/bioelectromagnetic therapies were used most often. Diet and lifestyle therapies were also common [47]. Women have increased their use of CAM therapies during pregnancy, thus maternity care providers need to become knowledgeable about these practices and facilitate communication, cooperation, and respect among alternative and conventional providers [48].

Within the context of promoting comfort, chapters on relaxation, touch therapies, water immersion and water birth, acupuncture and acupressure, and aromatherapy are offered as adjuncts to “doing nothing” in support of women during pregnancy, labor, and birth. While not an exhaustive representation of possible integrative therapies, reviews of ­evidence and practical suggestions are offered as tools for maternity care clinicians to assist women in achieving their preferred birth experience. Authors aim to help clinicians understand these therapies better, including specific instructions on how to use certain techniques, as well as information on referring to providers of the therapy and how specific practices, such as acupuncture, are regulated.

Finally, section 3 focuses on the broader care and education systems. Individual clinicians can provide excellent one-on-one care and effect local change. In order to change maternity care in the United States, we must also work within our broader systems to shift to a more physiologic approach. Because nearly 99% of births occur in hospitals, the best opportunity to effect meaningful system change is to adjust the approach to care on labor units. Nurses are key in making that happen, and a group of labor nurses have proposed a possible solution after examining available evidence and related information. The other 1% of births occur outside the hospital; evidence supports the safety of this approach for carefully selected women when out-of-hospital practice is imbedded in a broader system of consultation and referral to more intensive care when needed. Respecting out-of-­hospital birth as a safe environment for low-risk women who desire that care is critical. When transfer to the hospital setting is required, the process of transfer and receiving the woman and her family can be more seamless and positive with enhanced understanding and respect among clinicians from both settings.

For the change we desire to be permanent and system-wide, we must promote ­interprofessional collaborative practices that are built on a foundation of mutual trust and respect, with care decisions made by informed women and their families [23,24,49,50]. Maternity care providers must be educated together so that they will provide the seamless quality care women deserve, with clinical education occurring in environments where students learn with interprofessional care teams. Policy changes to support clinicians practicing together to the full extent of their education and training, in an environment where all women have access to quality health care, is the final critical component to improving maternity care. Legislators and policy-makers need to hear from their constituent clinicians in making those necessary changes.

National attention is focused on maternity care in a way that has not been seen in recent history, providing an opportunity to be transformative [29]. This group of authors, representing committed clinicians, educators, and researchers from multiple ­professions, invites you to come along on a journey to serve women today to build ­tomorrow’s healthier families. Women and their families deserve the very best that we can collectively provide in an environment that respects pregnancy and birth as normal processes, that respects the women and their families/support networks to lead their care, and where we respect and trust each other as partners in providing excellent care. The change required is larger than any one clinician or profession can accomplish. Indeed, we are encouraged that health professionals are responding to calls for interprofessional ­practice and education. While we add our voices to the larger discussions in Congress, federal health-related agencies, educational settings, and corporate boardrooms, a more quiet yet powerful change can occur in our care settings through the ­conversations and plans we make with each other and with our clients every day—clinic by clinic, woman by woman, birth by birth.

References

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50. Avery MD, Montgomery O, & Brandl-Salutz E. (2012). Essential components of successful collaborative maternity care models: The ACOG-ACNM Project. Obstetrics and Gynecology Clinics of North America, 39, 423–434. DOI: 10.1016/j.ogc.2012.05.010.

Chapter 2

The physiology of pregnancy, labor, and birth

Cindy M. Anderson

Key points

The placenta is the interface between the mother and fetus supporting perfusion to meet fetal growth and development needs; transport is influenced by placental area, diffusing distance, permeability of placental barrier, and maternal-fetal blood flow in the intervillous spaces.