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