Download - Keeping the ‘Normal’ in Normal Birth Interdisciplinary Panel Discussion November 30 th, 2006
Keeping the ‘Normal’ in Keeping the ‘Normal’ in Normal BirthNormal Birth
Interdisciplinary Panel Interdisciplinary Panel DiscussionDiscussion
November 30November 30thth, 2006, 2006
‘‘Normal’ Birth: Normal’ Birth: A Problematic A Problematic NotionNotion
Wide range of Wide range of normalnormal amongst labouring womenamongst labouring women
Notion of normal has Notion of normal has different meanings in different meanings in different contextsdifferent contexts– WHO DefinitionWHO Definition– Obstetric Obstetric NormalityNormality in Active in Active
Management of Labour Management of Labour Intervention has become the Intervention has become the
normnorm in contemporary in contemporary cultureculture
WHO Definition of Normal WHO Definition of Normal Birth:Birth:
Spontaneous in its onsetSpontaneous in its onset low-risk at the start and throughout low-risk at the start and throughout
labour and delivery. labour and delivery. Baby is born spontaneously in the vertex Baby is born spontaneously in the vertex
position between 37 and 42 gestationposition between 37 and 42 gestation Following birth both mother and infant Following birth both mother and infant
are in good condition. are in good condition.
Normal Progression in Active Normal Progression in Active Management of LabourManagement of Labour
1.1. Strict diagnostic criteria for Strict diagnostic criteria for labour onset labour onset
2.2. Artificial Rupture of the Artificial Rupture of the Membranes (ARM) if dilatation Membranes (ARM) if dilatation not maintained at rate of l cm/ not maintained at rate of l cm/ hr hr
3.3. Augmentation with synthetic Augmentation with synthetic oxytocin if dilatation not oxytocin if dilatation not increasing at this same rateincreasing at this same rate
4.4. Charting of labour progress– Charting of labour progress– the partogram.the partogram.
5.5. The provision of customized The provision of customized childbirth education & childbirth education & continuous 1 on 1 supportcontinuous 1 on 1 support**
Intervention As Normal:Intervention As Normal:
Physiologic Birth:Physiologic Birth: The The spontaneous head-first spontaneous head-first delivery of a single baby delivery of a single baby without employment of without employment of narcotics, entinox or narcotics, entinox or epidurals, synthetic epidurals, synthetic hormones-induction or hormones-induction or augmentation of labor, augmentation of labor, artificial rupture of the artificial rupture of the membranes or membranes or episiotomy. (episiotomy. (MidwiferyMidwifery))
Physiologic birthrate Physiologic birthrate in Nova Scotia:in Nova Scotia:4
1.75%1.75% for first time for first time mothersmothers
5%5% for women for women having their having their second or second or subsequent babysubsequent baby
Birth Intervention MenuBirth Intervention Menu
Continuous Electronic Fetal Continuous Electronic Fetal MonitoringMonitoring
IV DripIV Drip CatheterizationCatheterization Epidurals, Narcotics, EntinoxEpidurals, Narcotics, Entinox Labour Induction Labour Induction Artificial Rupture of MembranesArtificial Rupture of Membranes Labour Augmentation Labour Augmentation Operative Assisted DeliveryOperative Assisted Delivery Caesarean SectionsCaesarean Sections
Intervention Menu: The Intervention Menu: The GapsGaps
1 to 1 Continuous caregiver support (Midwife/ 1 to 1 Continuous caregiver support (Midwife/ Douala/ Other trained birth attendant)Douala/ Other trained birth attendant)
Consistent Information, Education and Support Consistent Information, Education and Support re Non-pharmacological Pain Relief Methodsre Non-pharmacological Pain Relief Methods
NourishmentNourishment
Interventions: The Cascade Interventions: The Cascade EffectEffect
Cascade:Cascade: A succession of A succession of
things…each of which things…each of which activates, effects, or activates, effects, or determines the nextdetermines the next
Understanding Understanding the Cascade of the Cascade of InterventionsInterventions
The Cascade The Cascade of of InterventionIntervention6
Directional Directional Relationships Relationships highlighted in this highlighted in this diagram have all diagram have all been established in been established in scientific literature.scientific literature.
To interpret the To interpret the diagram begin with diagram begin with an intervention of an intervention of interest and follow interest and follow arrows from that arrows from that point.point.
Select Birth Indicators Select Birth Indicators (2001)(2001)7
IndicatorIndicatorCanadiaCanadian n
Nfld *Nfld * ProvincialProvincial
RangeRangeNationalNational
RangeRangeC/SectionC/Section 22.5%22.5% 26.6%26.6% 24.8 - 24.8 -
31.5%31.5%9.2-31.5%9.2-31.5%
VBACVBAC 26.7%26.7% 12.5%12.5% 7.0 - 14.4%7.0 - 14.4% 7.0-60.7%7.0-60.7%
Vaginal Vaginal AssistedAssisted
16.2%16.2% 18.6%18.6% 17.1 - 17.1 - 28.2%28.2%
2.5-28.2%2.5-28.2%
VaginalVaginal
UnassistedUnassisted61.3%61.3% 54.8% 54.8%
InductionsInductions 20%20% 13%13%
EpiduralsEpidurals 45.4%45.4% 34.4%34.4% 8.3-50.5%8.3-50.5% 3.9-74.6%3.9-74.6%
NL Intervention Rates By NL Intervention Rates By RegionRegion(2005)(2005)8
IndicatoIndicatorr
EasternEastern CentralCentral WesterWesternn
LabradoLabradorr
GrenfellGrenfell
ProvincProvincee
ChangChangee
(01-05)(01-05)
C/SectionC/Section 31.1%31.1% 29.4%29.4% 26.5%26.5% 26.5%26.5% 29.8%29.8% +3.3+3.3%%
C/S – 1C/S – 1stst time time momsmoms
31.6%31.6% 30.6%30.6% 25.0%25.0% 30.7%30.7% 30.5%30.5% N/AN/A
Vaginal Vaginal AssistedAssisted
12.4%12.4% 12.4%12.4% 11.6%11.6% 5.6%5.6% 11.7%11.7% - - 6.9%6.9%
VaginalVaginal
UnassisteUnassistedd
56.5%56.5% 58.3%58.3% 61.9%61.9% 67.8%67.8% 58.5%58.5% +3.7+3.7%%
InducedInduced 26.3%26.3% 28.8%28.8% 17.8%17.8% 19.7%19.7% 25.0%25.0% +12%+12%EpiduralsEpidurals 39.7%39.7% 7.9%7.9% 43.7%43.7% 5.9%5.9% 32.9%32.9% -1.5%-1.5%
Why Should We Be Why Should We Be Concerned?Concerned?
Birth Intervention
Trends
ImpactHealth Outcomes(women and baby)
Carry SignificantFinancial
Implications
Contravene Best Practice
Guidelines
Caesarean Caesarean
SectionsSections
Infant Risks:Infant Risks: Breathing ProblemsBreathing Problems Low Apgar ScoresLow Apgar Scores Fetal InjuryFetal Injury Increased Neonatal Increased Neonatal
Deaths & NICU AdmissionsDeaths & NICU Admissions Premature BirthPremature Birth Lower Breastfeeding Lower Breastfeeding
InitiationInitiation Increased Asthma Increased Asthma
IncidenceIncidence Higher Stillbirth Rate Higher Stillbirth Rate
amongst women with amongst women with previous C/Sprevious C/S
Maternal Risks:Maternal Risks: Operative & Post-Op Operative & Post-Op
complications: e.g. bleeding, complications: e.g. bleeding, clots, infections, transfusionsclots, infections, transfusions
Increased pain, length of Increased pain, length of recovery, hospital stay and re-recovery, hospital stay and re-admissionadmission
Respiratory complications Respiratory complications Secondary infertilitySecondary infertility Ectopic pregnancyEctopic pregnancy Placental abruption/ adherence Placental abruption/ adherence
problemsproblems uterine rupture before and uterine rupture before and
during laborduring labor Need for further surgeries (e.g. Need for further surgeries (e.g.
Hysterectomy, bladder repairs) Hysterectomy, bladder repairs)
Caesarean Sections:Caesarean Sections: The Financial CostsThe Financial Costs 9
Average Cost of Vaginal Average Cost of Vaginal Delivery Without Delivery Without Complications in Complications in 2002/20032002/2003::
$2700$2700
Average Cost of Average Cost of Caesarean Delivery Caesarean Delivery Without Complications Without Complications in 2002/2003in 2002/2003::
$4600$4600
Best Practice GuidelinesBest Practice Guidelines
The World Health The World Health Organization Organization (WHO) states that (WHO) states that no region in the no region in the world is justified in world is justified in having a cesarean having a cesarean rate greater than rate greater than 10 to 15 percent.10 to 15 percent.10
Explaining The TrendExplaining The Trend
Maternally Derived Factors
Socio-Cultural FactorsCaregiver Derived Factors
ReferencesReferences1. 1. Kaufman KJ, Kaufman KJ, Effective control or effective careEffective control or effective care, (roundtable debate: active , (roundtable debate: active
management part 2) Birth, 1993; 20(3): 150-61 management part 2) Birth, 1993; 20(3): 150-61 2. World Health Organisation (1996). Care in Normal Birth: A practical guide. 2. World Health Organisation (1996). Care in Normal Birth: A practical guide.
www.who.int/reproductive-health/publications/MSM_96_24/MSM_96_24_Chawww.who.int/reproductive-health/publications/MSM_96_24/MSM_96_24_Chapter1.en.htmlpter1.en.html
3. Thornton, J.G (1996). Active management of labour. BMJ, 313: 378. 3. Thornton, J.G (1996). Active management of labour. BMJ, 313: 378. http://www.bmj.com/cgi/content/full /313/7054/378http://www.bmj.com/cgi/content/full /313/7054/378
4. Source: The Reproductive Care Program of NS 4. Source: The Reproductive Care Program of NS 5. The second national U.S. 5. The second national U.S. Listening to MothersListening to Mothers® survey (2006). ® survey (2006).
http://www.marketwire.com/mw/release_html_b1?release_id=175714http://www.marketwire.com/mw/release_html_b1?release_id=1757146. Cascade of Intervention: 6. Cascade of Intervention:
http://www.acegraphics.com.au/parents/obstetric/diagram.htmlhttp://www.acegraphics.com.au/parents/obstetric/diagram.html7. Canadian Institute for Health Information (2004) Giving Birth In Canada: A 7. Canadian Institute for Health Information (2004) Giving Birth In Canada: A
Regional Profile. Regional Profile. http://secure.cihi.ca/cihiweb/products/GBC2004_regional_e.pdfhttp://secure.cihi.ca/cihiweb/products/GBC2004_regional_e.pdf
8. Prepared By the NL Centre for health Information, November 88. Prepared By the NL Centre for health Information, November 8thth, 2006 , 2006 9. Canadian Institute For Health Information (2006) Giving Birth in Canada: 9. Canadian Institute For Health Information (2006) Giving Birth in Canada:
The Costs. The Costs. http://secure.cihi.ca/cihiweb/products/Costs_Report_06_Eng.pdfhttp://secure.cihi.ca/cihiweb/products/Costs_Report_06_Eng.pdf 10. WHO Guidelines for Caesarean Sections - 10. WHO Guidelines for Caesarean Sections -
http://www.childbirth.org/section/CSFact.htmlhttp://www.childbirth.org/section/CSFact.html