Look at that! That’s me with baby #1 at about 7 centimeters when I had just arrived at the hospital after laboring at home for 12 hours. I got my 20 minute non-stress test and got straight in the shower.
Not everyone gets that same supportive care for low risk pregnancy.
That’s why, for part 4 of the 2023 State of Midwifery series, I’m highlighting physiologic birth.
Why? Because there are many barriers to physiologic birth across the healthcare system.
If you missed the other posts in the series, catch up below:
- 2023 State of Midwifery: The 10,000 Foot View of the Profession
- 2023 State of Midwifery: The Key to Making More Midwives
- 2023 State of Midwifery: Become A Postpartum Warrior
I’m not saying there aren’t people promoting physiologic birth across the nation – they are on the front lines and they are fighting the battle with tooth and nail.
I’m much more concerned that now is the moment, more than ever, that we rally to encourage, support and educate everything to do with physiologic birth.
I’m seeing more and more that labor and delivery nurses and OBGYNs don’t know how to support physiologic birth.
We should be hearing these things every day on labor units:
“After a reactive NST, let’s do intermittent monitoring to allow her to move freely until she desires her epidural.”
“We can help you move into a hands and knees position in preparation for the birth the baby.”
“Would you like a snack and a drink?” (To a laboring woman at 5 centimeters).
“Out of bed birth is totally an option here!”
The reality is, these aren’t the standard of care. And if these aren’t the foundation of care for low risk birth I only fear that maternal mortality is going to get worse.
These are some ideas that I have. But I’d love to know what you all think as well!
To start, what is physiologic birth?
This is the definition of physiologic birth from the 2013 Supporting Healthy and Normal Physiologic Childbirth: A Consensus Statement by ACNM, MANA, and NACPM:
Seems simple right?
Ah, but obstetrics makes this simple definition a train wreck sometimes!
Read on for 10 tips to help promote physiologic birth.
Ramp up education about physiologic birth.
Here are a few comments I have on the education of physiologic birth.
One, most people haven’t seen a laboring woman before or experienced the intensity of labor pain. Because of this fact in out society, I think we need to provide education about normal labor and birth as the standard during pregnancy care.
I don’t think that education is happening in the clinic. (Please see influences from the ARRIVE trial from 2018 that has resulted in a slew of elective/risk-reducing inductions, as well as a global pandemic that stripped all visitors and support systems away from birthing people.) And I see childbirth classes focusing less on the value and importance of physiologic birth and more on the 10,000 foot view of labor, birth and the postpartum unit.
It’s great to go over options for pain management but what about how to labor at home before coming to the hospital??
There’s really no one better to speak to this topic than midwives or doulas. But not everyone has access to one or the other.
And you might think that it’s the patient’s responsibility to complete their own education; I don’t disagree, but I see a lot of bad content offering false education (i.e. social media…).
What can we do then?
For anyone in the clinic, I would start the conversation with:
“What do you know about physiologic birth?”
It’s a different question than “What is your birth plan?”
Although, the two questions definitely have overlap.
The first question allows you to see what the patient and family know about birth and the interventions they have learned about and planned for. It also allows for the provider to comment on what your hospital, birth center, or home birth team offer to support physiologic birth. This is a great place in the conversation to review the benefits of physiologic birth.
In the clinics, we need to talk more about the different interventions of induction and augmentation and the alternatives, risks and benefits of each intervention. I think traumatic birth is on the rise because so many people go into labor and birth without the proper education and preparation. It’s not surprising then, when you don’t know what things are, why they are being done, and you’re in pain, that things spiral out of control mentally or physically.
This infographic offers some of the risks associated with interventions:
Think about what other education you can offer in the clinic – or, offer an infographic for your patients to review with the provider sometime in the third trimester!
Delay admission until 6cm.
Back in 2014, the American College of Obstetricians published a consensus on the Safe Prevention of Primary Delivery that stated, active labor should not be diagnosed until 6 centimeters dilation.
In 2018, the Listening to Mothers study from California noted that…
I spend a lot of time counseling that admission at 6 centimeters rather than 4 centimeters is associated with fewer interventions in labor. For those that have worked in labor and delivery, it’s common to see a patient admitted at 4-5 centimeters dilation that receives an epidural and has contractions slow down after the epidural is placed. Often times, this requires either an amniotomy or pitocin to augment the labor further. And once you start one intervention, a slew of interventions usually follows.
It doesn’t take a lot of time to explain the benefits of waiting for admission until active labor. But I think that a lot of the education could start in the clinic. And triages that are run by labor nurses need the same education. If a nurse tells me the patient is 5-6 centimeters, I usually ask them to pick 5 or 6. If they’re 5 centimeters, I recommend walking for an hour before admission as long as mother and baby are reassuring.
I’ve posted this before on instagram, but it deserves revisiting here.
People should have the option to birth in the position of their choice.
And you should be able to decline stirrups for pushing (outside of needs for a vacuum/forceps assisted birth or a vaginal laceration repair).
This doesn’t have to be reviewed in the office, but it can be. Be sure you’re offering choice.
Beware of standing order sets.
This is a goodie. If your standing order sets are a clear diet and IV fluids at 125cc/hour, it’s time to revamp those to support physiologic birth.
This seems really simple, but orders are orders.
I find the same is true of unit protocols.
The more outdated the protocol, the less evidence-based it is.
Stop doing things that aren’t evidence based.
NSTs (non-stress tests) once an hour.
Continuous monitoring when it’s not indicated.
Continuous IV fluids when a person can drink normally.
These things are not evidence-based but are routine on labor and delivery units.
Be educated. Stay educated. Question everything. Advocate for yourself or your patient.
Post reminders about physiologic birth in the patient rooms, the break rooms, the nurse’s station and my favorite place – the bathroom.
Sometimes we all need a good reminder. This infographic does a great job of illustrating what takes labor closer or father away from a physiologic birth.
It’s easy to read for patients, nurses, families, and…providers.
I’ve seen posters of how to use the peanut balls during labor in labor rooms – also a great idea.
However it looks for your unit, find your poster and get them up ASAP!
Fully counsel patients and families on induction of labor.
Whether medical or elective induction of labor, let’s just ensure that we’re actually counseling on what an induction of labor is and what it may entail.
In my experience, patients and families are not counseled fully in the clinic.
They are tired of being pregnant, offered an induction date, and show up with very little education about what the entire process involves. Then I see patients that are frustrated 2-3 days into their induction when they are still pregnant and their baby has not arrived yet and they have had every intervention obstetrics has to offer during their inpatient course.
I really believe this education starts in the clinic. I also believe it’s not the labor and delivery staff or provider on call’s responsibility to fully counsel on induction of labor at the time of admission, because I think the education should be done in the clinic as much as possible. I believe this sets realistic expectations for the induction and allows for questions and concerns to be addressed. The admission team is responsible for setting out the induction plan and ensuring understanding of alternatives, risks and benefits.
But I don’t see this done. Hardly ever.
For inductions without a medical reason, there is a lot of evidence that supports waiting for physiologic birth and labor but this evidence has been placed by the wayside because of the ARRIVE trial.
In response to the trial, New Zealand published two flyers detailing the importance of shared decision-making around inductions and the ARRIVE trial. Although pertinent to New Zealand, there are many notable facts about the ARRIVE trial that are never included in the counseling for elective inductions.
My favorite is the very bottom where the flyer states: There are many ways to prevent a cesarean section.
My last comment is this: I see far more people that regret how an induction of labor went versus people that were happy with the induction process. It’s a good litmus test for if we’re doing something the right way or not, but that’s my opinion.
Make labor lounges the standard.
Evidence supports that labor lounges support latent labor until it’s time for admission at 6 centimeters dilation. Although these are not standardized across the United States, the trend appears to be gaining traction among a handful of units. The idea stems from lowering the cesarean rate by delaying admission until active labor, or at 6 centimerters dilated.
By making small changes to a triage unit, a laboring person can have support and comfort of the staff without limitations of IV fluids, continuous monitoring, or dietary restrictions. It’s a win win for the whole team.
This is another simple one but obstetrics misses this every day. If we prevent pre-eclampsia from occurring, supporting physiologic birth is much easier. Get people on aspirin at 12 weeks of pregnancy that need to be on aspirin so they’re able to ambulate during labor instead of being in the bed hooked up to a magnesium sulfate drip.
Turn off the lights.
Oh bless my nurses I work with all the time. I am CONSTANTLY turning off the bright hospital lights. I almost can’t talk to people until the lights are adjusted to a calmer setting. I also can’t talked to people that don’t have a pillow behind their head in be. Oh vey.
Don’t discount the use of low lighting to help support labor. For alternative light sources, I like to use the light on the baby warmer, the frog lights for laceration repairs, or the light in the bathroom with the door cracked open.
There is a new trend to bring LED fairy lights to the hospital – I’m loving it.
That’s the wrap! I hope this was helpful and the tips are actionable for those on the front lines.
For the pregnant people, mamabears, and families out there, be cautious of units that are not supporting physiologic birth.
Ask about primary cesarean rates in the practice you are thinking about getting care from.
Look out for you and your baby. Get educated.
Here are some other resources about physiologic birth:
Birth Matters: Understanding How Physiologic, Healthy Birth Benefits Hospitals and Organizations (American College of Nurse-Midwives)
Consensus Statement of Physiologic Birth (Midwives Alliance North America)
Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies, and Maternity Care (Childbirth Connection)
- Pathway to a Healthy Birth (Childbirth Connection)
- The Overmedicalization of Childbirth (Listening to Mothers California, 2018)
Physiologic Birth (International Childbirth Education Association)
Top 5 Tips For Physiologic Birth From A Midwife (Buffalo Doula Services)
What is Physiologic Birth? (BirthTOOLS.org)
Hugs until the next post… the last post for the 2023 State of Midwifery series publishes next week!
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