Continuous Support in Labor: An Underused Evidence-Based Practice

1. Continuous Support in Labor: An Underused Evidence-Based Practice Liza Goldman Huertas, MD Obstetrics Rotation Dept. of Family & Social Medicine

3. Agenda • Review some overused harmful practices and underused beneficial practices in maternity care in the U.S. • Case related to continuous support in labor • Define continuous support in labor • Review evidence for doula care • Relate doula care to other aspects of evidence-based maternity care • Identify pts most likely to benefit from doula care • Discuss implications for our practice

4. Room for Improvement: Maternity Care in the U.S. • The U.S. has some of the highest infant mortality rates among industrialized countries… and is falling in ranking: 29th among countries, tied with Poland and Slovakia (CDC) • In 2007, CDC reported an increase in U.S. maternal mortality rates • Despite highest cost, best technology

5. Infant Mortality Ranking

6. Infant and Maternal Mortality Complex social phenomena with many contributing factors: • Overall Socioeconomic wellbeing of society • Social Status of women and subgroups of O+: economic opportunities, education, safety • Nutrition, health status of vulnerable women • Obesity and Diabetes • Access to health care: 1°, prenatal, preventive • Prematurity, LBW, C-section rate, IVF/multiples, early inductions

7. Expensive

8. Evidence-Based Maternity Care: The Millbank Report • High rates of interventions with risks of adverse effects (overused practices) • Highlighted Overused Practices: Labor Induction, Epidural & Spinal Analgesia, C-Section, Continuous EFM, Rupture of Membranes, Episiotomy, Certain Routine Prenatal Screening Practices • Beneficial underused interventions

9. Induction of Labor • Theoretical concerns: pitocin may interfere with physiologic oxyctocin function in PPH, bonding, breastfeeding; iatrogenic prematurity in infant, ?Effects on brain development in final 1-2 wks of pregnancy (in-utero vs. ex-utero) • Increased rates of C/S in 1st time mothers • Increased EFM • More epidural analgesia • More assisted delivery • Increases cost

10. Epidural & Spinal Analgesia • Maternal effects: immobility, voiding difficulty, sedation, fever, hypotension, longer 2nd stage, perineal tears • Increased IVF, BP monitoring, EFM, bladder cath, pitocin, meds for hypotension, forceps or vacuum delivery, episiotomy • Under some conditions, likelihood of C/S • Fetal /newborn risks: fetal tachycardia & bradycardia, hyperbilirubinemia, sepsis workups, more abx, lower newborn assessment scores • Increased Cost

11. C-Section • Life-saving for absolute indications: cord pro-lapse, previa, abruption, persistant transverse. • Increases risk of: maternal death, surgical injury, PPH, emergent hyst, DVT, CVA, infection, pro-longed hosp/rehosp, intense & prolonged pain, bowel obstruction, poor birth experience, poor mental health & overall functioning, abruption, previa, accreta, uterine rupture, infertility • For infants: iatrogenic prematurity, LBW, stillbirth, respiratory problems, failure to BF • Increased risk with repeat C/S.

12. Case Study • 16yo P0 @40 and 6 undergoing IOL. No prenatal issues. No PMH. • Pt’s mother & older sister present at bedside. Older sister has scrubs on; bilingual, assertive, asks questions. • FOB to be present . FOB and pt are not close but FOB is traveling from Boston to be present. • Nursing staff comes into conflict with family over policy of 2 family members only. • Nursing staff increasingly annoyed.

13. Case Study p2 • Initially coping well with contractions, surprising the nurses. Hoping to avoid epidural analgesia. • Mother becomes B’s only support. She speaks only Spanish. Anxious, distrusts staff & quiet when staff present. • B is increasingly frustrated. Wants to eat, go to the bathroom. Uncomfortable lying down. Does not want FOB present for vaginal exams. Caregivers express annoyance outside room. • Frequency/intensity of contractions increase, B gets desperate and decides to get an epidural.

14. Case Study p3 • B’s mother upset because she feels B would be coping better with pain if her sister was present. (Sister left because security was called earlier). • Anesthesiology delayed in OR. • B yells at mother & providers, demands epidural, increasingly suffering & terrified. • B eventually gets epidural, comfortable again. • Epidural is dense and B can barely move her legs. Progress slows. Pitocin is titrated up. • FHR pattern becomes increasingly concerning. • C-section discussed.

15. Case Study p4 • 2nd stage complicated by “poor maternal effort”. Providers tell pt she isn’t doing her job, needs to put in real effort. Fear, frustration turns to yelling. • As B pushes her baby out, room goes quiet. The baby’s head is blueish.Tight nuchal cord x3. • No exclamations of joy as infant resuscitated. Doctors complete their care of the mother. • Infant improves quickly but pt & mother are not updated. Anxiety & grief are palpable. • An hour later, when doctors & nurses are finished taking care of her, B cries inconsolably. She is not interested in holding her baby.

16. Selected Underused Interventions • Midwives & Family Physicians • Smoking Cessation for Pregnant Women • Prematurity Prevention: Centering Pregnancy • External Version to Turn Breech Babies • Delayed and Spontaneous Pushing • Non-pharmacologic measures to relieve pain, promote comfort & labor progress • Non-supine positions

17. More Underused Interventions • Early Skin to Skin Contact • Breastfeeding & BF Interventions (e.g. Baby Friendly Hospitals) • Psychosocial Interventions for Post-partum Depression • Continuous Support in Labor

18. What is Continuous Support in Labor • Continuous presence • Emotional support • Advice regarding comfort measures and coping • Patient education • Advocacy on behalf of the laboring woman

19. Doulas in the United States • Non-medical providers of labor support • Ancient Greek meaning woman of service • Provide emotional support, physical comfort, objective view, support informed decision-making, facilitate communication, advocacy • Provide support to partners and family • May also be interpreters & cultural brokers • Several accreditation organizations • Postpartum doulas, end of life doulas.

21. Why Would Doula Care Help? Theories • May mediate effect of birth environment: Buffers to unfamiliar, stressful environments. • Enhancing maternal feelings of confidence & control, reducing reliance on medical interventions. • Potential to limit “cascade of interventions” by enhancing labor physiology

22. Why Would Doula Care Help? Labor Physiology • Intervene on stress response--> increased epi--> can effect FHR pattern, catecho-lamines decrease uterine contractility, prolong labors--> lower APGARs • Enhanced feto-pelvic relationships (mobility, gravity, preferred positions)

23. Why Would Doula Care Help? Possible Longterm Impact • Adjustment to parenthood, self-image, feelings of competence & confidence • Mother-infant Bonding • Breastfeeding • Postpartum depression • Role modeling: nurturing mother, infant, and family. • Encouraging healthy family relationships

25. Cochrane Intervention Review: Use this practice! • First Do No Harm: No evidence of harm from continuous support in labor has been reported. • Major Outcomes: increased chance of NSVD (decreased C/S, forceps and vacuum), less likely to use pain medications, greater satisfaction with the childbirth experience, slightly shorter labors.

26. Cochrane Intervention Review (Meta-Analysis) 2007 • 16 trials, 11 countries, 13,000 women • Controlled trials: support person could be certified professional or trained family member • Outcomes included: pitocin, EFM, pharmacologic analgesia, severe pain, labor length, SVD, C/S, episiotomy, perineal trauma, low APGARS, low cord pH, NICU, anxiety during labor, perception of low control, longer term maternal outcomes • Subgroup Analysis: effects of childbirth environment, provider of care, timing of care

27. Cochrane: What doulas can do • Increase NSVDs (double in some cases) • Decrease regional analgesia, any analgesia • Decrease vacuum, forceps, C sections • Fewer negative childbirth experiences • Slightly shorter labor length, less than 1 hr difference (effect diluted by trials involving staff doulas)

28. Subgroup Analysis: Care most effective • When provided by person who was not a member of the hospital staff • In settings where epidural analgesia was not routinely used • When started early in labor--> Evidence of dose-response phenomenon

29. Insufficient Data (Cochrane could not assess) • Mother’s and infants wellbeing postpartum • Perineal trauma • Relationship between woman and partner • Urinary and fecal incontinence

30. Conclusions from Authors of Cochrane Review • Continuous support should be the norm not exception! • Birth environments should afford privacy, be empowering and non-stressful • Birth environments should not be characterized by routine interventions that add risk without clear benefit

31. Evidence of Longterm Benefit in Smaller Trials • Higher rates of breastfeeding at 6 weeks • Improved mother-infant bonding • Decreased rates of postpartum depression • Increased confidence in & perception of ease of parenting • Positive maternal self-image and positive perception of body • Needs more study to corroborate.

33. May have particular benefit for certain groups • Young women, especially teens • Low income women • Women of color, Black women & Latinas • Doula programs for Spanish-, Vietnamese-, and Somali-speaking immigrant women • Incarcerated women • Women laboring alone

34. Implications for Family Physicians?

36. References • Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD003766. • Stuebe, A. Continuous intrapartum support. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2009. • Sakala, C and Corry, MP. Evidence-Based Maternity Care: What It Is and What It Can Achieve. 2008. • Newton KN, Chaudhuri J, Grossman X, Merewood A. Factors associated with exclusive breastfeeding among Latina women giving birth at an inner-city baby-friendly hospital. J Hum Lact. 2009 Feb;25(1):28-33. • Dundek LH. Establishment of a Somali doula program at a large metropolitan hospital. J Perinat Neonatal Nurs. 2006 Apr-Jun;20(2):128-37. • Schroeder C, Bell J. Doula birth support for incarcerated pregnant women. Public Health Nurs. 2005 Jan-Feb;22(1):53-8. • Lantz PM, Low LK, Varkey S, Watson RL. Doulas as childbirth paraprofessionals: results from a national survey. Womens Health Issues. 2005 May-Jun;15(3):109-16. • Stein MT, Kennell JH, Fulcher A. Benefits of a doula present at the birth of a child. J Dev Behav Pediatr. 2003 Jun;24(3):195-8. • www.dona.org, www.childbirthconnection.org