for Normal Birth

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Thank you for your patience while we have updated the format of Research Summaries for Normal Birth. In response to subscriber feedback, we will now offer more concise summaries in this electronic publication. A comprehensive edition of each issue of Research Summaries for Normal Birth, including fuller discussions of research methods and results, will now appear in The Journal of Perinatal Education.

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Systematic Review Finds No Benefit to Routine Episiotomy

Hartmann, K., Viswanathan, M., Palmieri, R., Gartlehner, G., Thorp, J., Jr, & Lohr, K. N. (2005). Outcomes of routine episiotomy: a systematic review. JAMA, 293 (17), 2141-2148. [Abstract]

Summary: This systematic review, supported by the Agency for Healthcare Research and Quality (AHRQ), investigated the maternal outcomes of routine episiotomy versus restricted use of episiotomy. Outcome measures included perineal injury and suturing, perineal pain, urinary and rectal continence, and sexual function.

Seven randomized controlled trials (RCTs) with a combined 5,001 participants compared early postpartum outcomes of restricted versus routine use of episiotomy. The rates of episiotomy in each group varied widely across studies, and "restricted use" was poorly defined in several trials. The most restrictive definition was to avoid the procedure unless it was necessary for the well-being of the baby. The systematic review found that restrictive use of episiotomy was associated with increased likelihood of having an intact perineum, decreased risk of requiring sutures, and an increased risk of anterior lacerations (though the data suggested these were typically less severe than perineal tears and didn't always need suturing). The data on postpartum pain showed that restrictive use of episiotomy was associated with equivalent or better pain scores compared with routine episiotomy. Rates of infection and other healing complications were equivalent across groups.

 

The review of the evidence showed no benefit to routine use of episiotomy with respect to urinary or rectal continence or pelvic floor strength for up to 3 years following birth. Longer-term data were not available.

 

The review of the subset of studies that addressed sexual function showed that restrictive use of episiotomy was associated with earlier return to intercourse compared with routine use of episiotomy. No differences were found in women's reports of painful intercourse.

 

The reviewers concluded that there is no evidence that routine use of episiotomy results in improved maternal outcomes. They indict clinicians who "have been the primary agents to exercise choice to conduct or not conduct an episiotomy" as perpetuating a practice that has lacked an evidence base for decades. The authors strongly encourage clinicians, hospitals and birthing centers to work diligently to bring their rates of episiotomy below 8-10%, a rate that is possible when use is restricted to fetal indications.

Significance for Normal Birth: Routine episiotomy is an example of a care practice that continues unabated in many settings despite strong and consistent evidence that has failed to show that its use improves outcomes. As this review's authors point out, rates of episiotomy in different birth settings ranges from below 10% to as high as 85% of spontaneous term births. This discrepancy, they argue, "is heavily driven by local professional norms, experiences in training and individual practitioner preference." This is the strongest evidence to date that episiotomy is over-used and results in more harm than good. More research is needed to clarify and reinforce the specific medical indications for episiotomy (i.e., acute fetal distress) that prove to be beneficial. In the meantime, Lamaze educators, consumers and other normal birth advocates have the evidence necessary to demand an immediate reduction in episiotomy rates well below those currently achieved in most hospitals.

Epidural Analgesia Linked to Increased Risk of Occiput-  Posterior Babies

Lieberman, E., Davidson, K., Lee-Parritz, A., & Shearer, E. (2005). Changes in fetal position during labor and their association with epidural analgesia. Obstetrics & Gynecology, 105 (5, Part 1), 974-982. [Abstract]

Summary: This prospective cohort study used periodic ultrasound examinations during labor to evaluate changes in fetal position and their relationship with epidural analgesia. The researchers sought to determine whether epidural analgesia is responsible for higher rates of fetal malposition (occiput-posterior (OP) or occiput transverse (OT)) or whether women experiencing labor with a malpositioned baby have more painful labors and are therefore more likely to request epidural pain relief. A total of 1562 nulliparous, low-risk pregnant women were enrolled in the study.

The researchers found that the position of the baby (occiput anterior (OA), OP or OT) at the time of enrollment (in the early part of active labor) predicted position at birth poorly. For instance, of the women with an OP baby at birth, only 31% had a baby in the OP position at the initial ultrasound scan. Similarly, sonograms done later in labor were also poor predictors of position at birth. The data demonstrated that changes in fetal position were common during labor, with 36% of participants having an OP baby at the time of at least one scan. More than one-half of the women who gave birth to a baby in the OP position never had an OP baby at any ultrasound assessment in labor. Overall, 79.8% of babies were born in the OA position, 8.1% were OT, and 12.2% were OP at birth.

Epidural analgesia was strongly associated with delivery from the OP position: 12.9% of women with epidurals gave birth to babies in the OP position versus 3.3% of women without epidurals (relative risk 4.0, 95% CI 1.5-10.5). Transverse position was not related to epidural use. In a statistical model that controlled for various medical and obstetric factors that could affect outcomes, epidural use was still associated with a 4-fold increase in the risk of OP birth.

The data suggest that the association between epidurals and OP babies is not because women in labor with an OP baby are more likely to request an epidural. Women who received epidurals were no more likely to have OP babies at prior to or at the time that the epidural was administered. Furthermore, women with OP babies in labor or at birth reported the same degree of pain as those with OA or OT babies and were no more likely to report "back labor," which is commonly thought to be related to the OP position. Finally, women with OP or OT babies at birth were much more likely that those with babies in the OA position to give birth by cesarean section, with 6.3% of OA babies born by c-section versus 64.7% of OP and 73.8% of OT babies (p<.001).

Significance for Normal Birth: Epidural use increases the risk of instrumental (forceps or vacuum) delivery in first-time mothers. Experts have proposed various reasons for this association, including diminished urge to push and changes in the tone of the pelvic floor muscles that inhibit proper rotation of the fetal head. Letting the epidural "wear off" has been thought to increase the likelihood of unassisted vaginal birth, however, this systematic review calls into question that common practice.

In normal birth, there are complex hormonal shifts that help labor progress and facilitate delivery. The laboring woman produces natural endorphins that help her manage the pain of labor. Her ability to move freely and assume a variety of positions while pushing work in concert with these hormonal changes. Epidural analgesia numbs the sensations of birth, and the production of natural endorphins ceases as a result of the disruption of the hormonal feedback system. When the epidural is discontinued, the woman's pain returns but her natural endorphins may remain diminished and therefore her pain may be greater than if the epidural had not been given in the first place. Furthermore, when an epidural is administered, the woman is usually confined to bed and attached to fetal monitors and an intravenous line. The woman and provider may become accustomed to laboring in the bed attached to machines. When the epidural is discontinued the restrictions on her movement may persist. Under these conditions, it is likely that the impact of an epidural on normal birth may outlast the epidural itself.

Evidence-Based AAP Policy Emphasizes Link Between Normal Birth and Successful Breastfeeding

American Academy of Pediatrics. (2005). Breastfeeding and the use of human milk. Pediatrics, 115 (2), 496-506. [Full Text]

Summary: This policy statement, prepared by the American Academy of Pediatrics Section on Breastfeeding, provides evidence-based information to help pediatric health care professionals promote, protect and support breastfeeding. It replaces the 1997 AAP policy statement, providing an update of the literature on the benefits of human milk and recommendations for the promotion and clinical management of breastfeeding for both healthy term infants and high-risk infants.

The AAP's recommendations reflect a strong stance in favor of normal birth. Routine or unnecessary use of interventions that have been shown to interfere with breastfeeding, such as suctioning of the infant's nose and mouth, are discouraged. The authors recommend minimizing the use of maternal medications that affect feeding behavior. They also advise delaying newborn routines such as the first bath and administration of medications until after the first successful feeding, with skin-to-skin contact maintained from the time of birth whenever possible.

 

Significance for Normal Birth: The new policy statement definitively positions exclusive breastfeeding as the "normative model against which all alternative feeding methods must be measured." (p. 496). Similarly, normal birth should be the reference model for maternity care, with interventions and deviations only occurring with sound medical rationale and after consideration of potential risks and adverse outcomes. When birth and breastfeeding are seen as a continuum, it is easier to understand how promoting normalcy in maternity care improves the likelihood of successful lactation. Conversely, care practices that disturb the normal physiologic events of labor and birth may have the effect of disrupting the breastfeeding relationship.

 

This revised policy statement from the American Academy of Pediatrics, which cites more than 200 scientific articles, is an important evidence-based resource for all maternity care professionals, as well as those working exclusively with pediatric populations.  

First National Survey of Doulas Describes Their Background and Practice Characteristics

Lantz, P. M., Low, L. K., Varkey, S., & Watson, R. L. (2005). Doula s as childbirth paraprofessionals: results from a national survey. Women's Health Issues, 15 (3), 109-116. [Abstract]

Summary: This study describes the socioeconomic characteristics, practice patterns, beliefs and attitudes of a representative sample of doulas practicing in the United States. It is the first national survey to provide a descriptive analysis of this growing profession. The researchers surveyed a random sample of all doulas who were certified or in the process of being certified by the five major doula certifying associations. Surveys were completed by 626 participants, 471 of whom were certified doulas and 155 of whom were in the certification process.

The respondents were primarily white (93.8%) and had a mean age of 40.3 years. They tended to be married (81%) and to have given birth (87.8%). High levels of household income and formal education were common, and many respondents had training as nurses, midwives, childbirth educators or massage therapists. More than one in four respondents reported that they were planning to become midwives.

Almost 80% of doulas were in solo practice, with only 3.6% working in hospital- or clinic-based practices. The doulas served an average of 11.3 prenatal clients, 9.3 labor/delivery clients and 4.1 postpartum clients within the previous year. These clients also tended to be white (84%) and married (84%) and about half were giving birth for the first time.

The respondents generally found doula work to be emotionally and personally rewarding, citing the supportive, nurturing and empowering nature of their work and helping women have positive birth experiences as among the most satisfying aspects of their jobs. Lack of support or respect from other members of the medical team and balancing doula work with other jobs and family obligations were considered the biggest challenges. Furthermore, few doulas gained significant financial rewards for their work, with the average gross income from doula work being $3,645. Almost 90% of doulas believed that there should be third-party reimbursement for their work, but only 10% reported they had received such payment.

 

Significance for Normal Birth: Continuous support throughout labor and birth promotes progress and comfort in labor and minimizes the need for certain medical interventions. Doula s are trained to provide this support and their presence during labor and birth has been proven beneficial in randomized controlled trials. Until now, no research has looked at a representative sample of all certified doulas in the U.S. to determine who they are, how they practice and what challenges they face. The results of this survey suggest that doulas are a relatively homogeneous population who serve a slightly more diverse clientele. The lack of financial reward for doulas and the related limited third-party reimbursement for their services limits the accessibility of doulas to an even broader population of pregnant women who would benefit from their support. Despite this, doulas remain very dedicated to their work and perceive substantial emotional rewards from their interactions with childbearing families.