In Labor and Birth Care

Italian obstetricians report that replacing standard management of slow labor with a physiologic approach greatly reduced cesarean deliveries and the use of other medical interventions in 1st-time mothers. They conducted a before-and-after study in 419 1st-time mothers who had reached 37 weeks of pregnancy carrying one head-down baby and who either began labor on their own or were being induced for postdates (not defined). Let’s take a look at their study, comparing and contrasting with typical U.S. management as we go.

The Set-Up: Standard Management Vs. the Physiologic Approach

In the “before” phase, doctors collected statistics on 216 women having “standard” management. Elements of standard management were:

  • Women labor in bed mostly on their backs.
  • High-risk women and women having labor strengthened (augmented) by oxytocin (Pitocin, “Pit,” or Syntocinon) have continuous fetal heart rate monitoring while low-risk women have intermittent listening. [Continuous fetal monitoring is usually routine in the U.S. and is known to increase the likelihood of cesarean (Alfirevic 2013).]
  • Eating in labor is forbidden.
  • A diagnosis of active labor requires contractions and a cervix that has thinned (effaced) and dilated to at least 4 cm. Ineffective labor (dystocia) is diagnosed when the graphed dilation rate (partogram) falls behind the expected rate for 2 hours. [The current research-based recommendation is that the kick-over to active phase occurs around 6 cm dilation, not 4, and that active phase protraction or labor arrest should not be diagnosed before this point (ACOG/SMFM 2014); however, it is doubtful this threshold is widely used in the U.S.]
  • Ineffective labor is treated by rupturing membranes (amniotomy) and administering high-dose IV oxytocin. If labor progress continues to lag after 4 hours, a cesarean is performed. Slow descent or cessation of descent during the pushing phase is similarly treated with rupturing membranes, IV oxytocin, and cesarean if those fail. [Rupturing membranes is routine in many U.S. hospitals in the belief that it strengthens contractions thereby reducing cesareans, but not only does it not decrease cesareans, it probably increases them (Smythe 2013).]
  • Epidurals are discouraged. [Most women have epidurals in the U.S., and while current opinion is that they don’t increase cesareans, that is disputable (Bannister-Tyrrell 2014).]

(c) Springer with permission from author

 

In the “after” phase, 203 similar women were treated according to what doctors termed “comprehensive” management, which basically amounted to a physiologic approach, that is, start with physiologic care and move to judicious use of medical intervention only if necessary. Comprehensive management included:

  • Ultrasound scans used to ascertain the position of the baby’s head and trunk.
  • If the baby is facing the mother’s belly (occiput posterior), the head is tilted to one side (asynclitic), or the chin isn’t on the chest (deflexed), all of which make it more difficult for the baby to pass through the pelvic opening, doctors prescribe walking and trying different postures, especially upright and all fours, to shift the baby to a better position. If that doesn’t work, they try manipulating the baby’s head during a vaginal exam (manual rotation).
  • To enhance supportive care, midwives are assigned to work one-to-one with laboring women, and shifts are extended to 12 hours to increase continuity. A different midwife is assigned in cases of personality conflict. Women are encouraged to have a partner with them. [One-to-one continuous supportive care reduces cesareans (Hodnett 2017). Having a loved one is the norm in the U.S., but nursing care from the same person for a period hopefully spanning the entire labor is not. Doulas, women trained and experienced in providing one-to-one continuous labor support, are not mentioned here, and their use is uncommon in the U.S. (Declercq 2013); however, doula care specifically, that is, one-to-one continuous supportive care by someone who is not a staff member and not a member of the woman’s social network, increases the effect on cesareans and other interventions (Hodnett 2017).]
  • Women are encouraged to eat and drink, and snacks and water are provided.
  • The definition of active labor remains unchanged, but progress delay is now considered a symptom requiring diagnosis of possible underlying causes, and treatment is individualized based on that diagnosis.
  • Women have access to showers and warm baths and are encouraged to use non-drug pain coping strategies such as touch and massage. Epidurals are available on request and are recommended when doctors believe that fear of labor or of labor pain is holding back progress.
  • Rupturing membranes and IV oxytocin are used only when lesser measures fail to improve progress. Oxytocin is administered in low-level dosages more like those produced naturally.

The Physiologic Approach Wins in a Landslide

The results with “comprehensive” care were astonishing: The cesarean rate plummeted from 22% to 10%. [The U.S. cesarean rate in low-risk 1st-time mothers is 26% (Hamilton 2016), higher than the study’s baseline rate, possibly because of differences in policies and practices in the U.S.] The biggest difference was in rates for labor dystocia (2.5% vs. 9.3%), a difference that statistical calculation showed to be highly unlikely to be due to chance (statistical significance). Cesarean rates were reduced both in women who began labor on their own (7% vs. 15%) and women who were induced (21% vs. 44%), which, considering how much higher rates were with induction, makes one wonder what the overall cesarean rate would have been had fewer inductions been done. Fewer cesareans were performed for abnormal fetal heart rate as well (2.5% vs. 5.6%), although this difference didn’t achieve statistical significance, possibly because the population was too small (underpowered) to detect a difference in rates of uncommon events. As a bonus, the amniotomy rate fell from 42% to 7%, and IV oxytocin use declined from 33% to 14%. “Comprehensive” management also decreased incidence of 5-minute Apgar score < 7 (0.5% vs. 2.3%), although this difference, too, failed to achieve statistical significance, again, possibly because the population was too small to make the determination.

The Fly in the Ointment

For the first time, someone has tested a package of care, rather than bits and pieces in isolation, and the physiologic approach came up golden. So, what’s my beef? It’s that we’re still looking at medical-model thinking. The Italian OBs conceived of and presented their research as prescribed treatment for a labor complication, but the physiologic approach isn’t about fixing what is broken but about preventing it from breaking in the first place. Physiologic care should be the foundation of labor care to which medical intervention may sometimes need to be added. Even when intervention is needed, whatever can be preserved of physiologic care, should be. It isn’t a matter of “test-diagnose-apply appropriate treatment,” e.g., if labor is slow or stopped and ultrasound confirms a malpositioned baby, then get the woman up and moving. It’s that all women should labor in an environment conducive to mobility and position changes (access to a courtyard or garden, deep tubs for soaking, showers, rocking chairs, lounge chairs, pillows, birth balls, suspended straps to hang onto, and so forth); all women should be freed from routine practices and policies that inhibit mobility (continuous fetal monitoring, IVs, confinement to bed); and all women should be encouraged to take advantage of that environment and that freedom to discover what they find comfortable and effective.

“What’s the difference,” you might ask, “if the result is that women at this hospital now enjoy better care?” The problem is that if the physiologic approach hadn’t been shown to reduce cesareans, hospital staff would have no motivation to continue it. The problem is that the physiologic approach is presented as a treatment having to prove itself compared with the “gold standard” of what was already in place, in this case, “standard management,” A.K.A., medical management, when it should be the other way around. Medical management—the routine or liberal use of tests, drugs, procedures, and restrictions—has never been shown to be safe or effective and acknowledging that fact is long past due. The problem is that even progressive doctors such as these Italian obstetricians are so imbued with medical-model thinking that they couldn’t conceptualize care in any other way.

The Take-Away

The physiologic approach has significant benefits and no harms, and almost certainly improves outcomes because fewer mothers and babies are exposed to the potential harms of rupturing membranes, high-dose oxytocin, and cesarean surgery.

Whether you have a cesarean or other medical interventions depends largely on your care provider’s philosophy and practices, not on anything innate to you. For this reason, choose a care provider who practices physiologic care and avoids medical intervention whenever possible.

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*In the interest of full disclosure, this study isn’t “news from around the web.” I ran across it when I was searching the obstetric literature, and it was too good to pass up.

Learn more about the physiologic approach to care .

Learn more about preventing the preventable cesarean .

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