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Eco-Friendly

Birth“Downstream” Effects of Maternity Care

Practices & How to Optimize Them

Penny Simkin, PT, CD(DONA), CCE

Acknowledgments

• I gratefully acknowledge the following researchers, scholars, authors, and visionaries whose work has provided much background for this presentation:

– Sarah Buckley, Murray Enkin, Eileen Hutton, John Kennell, Marshall and Phyllis Klaus, Judith Mercer, Peter Nathanielsz, Michel Odent, Kirsten Uvnas-Moberg, Sandra Steingraber, and many others

Introduction

• Environmental science has much to teach us about birth

– Outcomes as “downstream effects“

– Importance of looking “upstream“ at prior events for explanations for healthy and less healthyoutcomes

• Parable: “The Village on the River”– As told by Sandra Steingraber in “Living Downstream”

• This presentation is a close look at common “upstream maternity care” practices.

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Habitat and Ecologyas They Apply to Birth

• Habitat – All the elements in a birthing woman’s or her fetus/newborn’s physical surroundings that have a direct bearing on their ability to survive, function and thrive.

• Birth Ecology -- The study of relationships among – mother-baby ecosystem, and

– support people,

– caregivers,

– physical environment for labor and birth (including hospital “culture” & treatments)

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Eco-Friendly Birth

• “Eco-friendly” practices maintain

– intactness of the habitats of the mother and her fetus/newborn,

– relationships of women with their support people and caregivers.

• At a biological level, “eco-friendly birth” fosters optimal hormonal balance, which results in labor progress, newborn adaptation, breastfeeding, and mother-infant bonding.

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The “Meconium Footprint”

• A measure of the negative impact of specific routine maternity care practices on the mother- baby habitat

• Based on the “carbon footprint” -- a measure of the impact of one’s actions on the environment.

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Meconium Footprint Scores for Routine Procedures

• 0 = a Perfect Score (no adverse impact on the mother/labor or fetus/newborn)

• 1 = Mother/labor, OR fetus/newborn is adversely affected

• 2 = Both mother/labor AND fetus/newborn are adversely affected

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How Specific Care Practices Disrupt the Delicate Feto-Maternal Ecology

• Inhibit maternal and fetal production of hormones that enhance labor and maternal/fetal well-being*

• Interfere with free movement and comfort-seeking behaviors by mother

• Disrupt contact and mutual adaptation by mother and infant after birth

• Hinder breastfeeding8

Downstream consequences of birth environment

• A “safe” undisturbed environment supports spontaneous behavior and encourages secretion of oxytocin (“love hormone”)

• A strange environment with invasive noisy equipment increases anxiety and catecholamine production

– Interferes with effects of oxytocin

– Slowed labor, adverse fetal response

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Downstream consequencesof caregiver

• Midwifery: – Fewer costly, risky interventions

– Attention to women’s psychosocial needs

– Better outcomes for selected populations

• Obstetrics:– A surgical specialty

– Appropriate for high risk situations

– Less personal care, more reliance on tests and technology

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Downstream consequencesof onset of labor

• Spontaneous – ensures fetus’s readiness for life outside mother’s uterus

• Elective induction increases – Late term prematurity

– NICU admissions, mother-baby separation

– Labor time in hospital

– Cesareans for fetal distress, failed induction in nullips

– Postpartum hemorrhage

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Downstream consequences of labor support

• Continuous doula support increases

– Spontaneous vaginal birth

– Maternal satisfaction with birth

– Psychological well-being

• Continuous doula support decreases

– Pain medications use

– Surgical delivery (cesareans, instruments)

– NICU admissions

• “Usual care” – just the opposite12

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Downstream consequences of hydration in labor

• Intravenous hydration may lead to—

– Inconvenience and discomfort for mother

– Fluid overload, foot and hand swelling that lasts for days

– Mother feeling deprived of basic comfort

• Drinking her choice of liquids

– Enhances sense of normalcy for mother

– Usually adequate in normal labor

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Downstream consequencesof monitoring in labor

• Electronic fetal monitoring assoc. with

– Differing interpretations by experts*

– More C/S for non-reassuring FH Tracings

– No improvements in newborn outcomes**

– Restrictions of mother’s activity

– Inability of cg to auscultate FHT

• Auscultation is less disturbing to the mother, and

• Ausc. has as good outcomes as EFM 14

Downstream consequencesof care of amniotic sac

• Artificial rupture of membranes (ROM)-

– May speed labor (by average 40 min.)

– May cause a pre-existing fetal malposition to become persistent

– Increases chance of infection

• Spontaneous ROM

– Usually occurs late in 1st stage or in 2nd

– May enhance chance of rotation to OA

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Downstream consequencesof pain management

• Suffering may increase likelihood of trauma and PTSD• Narcotics ineffective and unpleasant • Epidural reduces pain, but not suffering;• Is invasive and unsafe without precautions and

interventions, and• Side effects –

– low blood pressure, fever, fetal malposition and distress, urine retention, slow progress

•

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Downstream consequencesof pain management, continued

• Natural approaches reduce, not eliminate pain, and can…

– Reduce suffering (esp. with good support)

– Delay or eliminate need for pain meds

– Enhance maternal satisfaction

– Avoid many complications in normal labor

• That come with epidurals

– Reduce maternity care costs

Downstream consequences of positions and movement in labor

• Supine position or restriction of movement

– Increases dystocia, malposition, pain, fetal distress, maternal stress

• Freedom of movement and choice of position

– Increases comfort, decreases above effects

– Enhances maternal satisfaction

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Downstream consequencesof positions for pushing

• Supine position (most common in NA)– Narrows birth canal, increases effort needed

to birth baby

– Increases vacuum, forceps deliveries

– Increases pelvic floor damage, episiotomy

– Prolongs 2nd stage

• Non-supine positions & mother’s choice– Increase chance for spontaneous birth

– Reduce pelvic floor damage

– Increase mother’s satisfaction

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Pushing efforts

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“Hold your breath and push –1,2,3,4,5,6,7,8,9,10; Take another breath & push again – 1 to 10”

Directed “purple” pushing

Delayed, Spontaneous Bearing Down

“Push when you feel an urge as long and as hard as feels right in the position that feels right.”

Downstream consequencesof pushing techniques

• Prolonged breath holding & straining– Increases fetal distress

– Increases pelvic floor damage

– Increases long-term problems of pelvic floor relaxation

• Delayed or spontaneous bearing down– More intact perinea & spontaneous births

– Fewer 3rd & 4th degree tears

– Improved fetal well-being

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Downstream consequencesof clearing of newborn’s airway

• Bulb & deep suctioning cause gagging and abrasions of mucus membranes

• Doesn’t reduce respiratory problems or meconium aspiration in vigorous baby

• Vigorous newborn is able to expel the fluids, mucus, and handle meconium

• Self-clearing of secretions may improve early breastfeeding

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Downstream consequencesof timing of cord clamping

• Immediate clamping & cutting – Enables removal of baby to warmer,

– Doesn’t prevent jaundice, as believed

• Delaying clamping for 2 min. or more– Allows physiologic transfusion of blood between

baby and placenta

– Improves infant hematologic status at 2 and 6 months (i.e., less anemia)

– Encourages close mother-infant contact

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Downstream consequencesof immediate placement of baby & access for feeding

• Separation may interfere with mother-infant attachment, delay successful breastfeeding, and increase stress and crying time.

• Immediate, constant skin to skin and eye to eye contact improves newborn’s adaptation, temperature, breastfeeding, reduces crying, and promotes intuitive & affectionate care by

mother.

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Downstream consequencesof first days after birth

• Mother and baby together promotes

– Establishment of “on cue” breastfeeding

– Mutual regulation of temperature

– Maternal behavior

• Father-baby skin-to-skin contact in first day and after promotes protectiveness and closeness toward baby

• Separation increases newborn distress and maternal depression or detachment

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Meconium Footprint

• “Usual Care” practices include many adverse effects and to the meconium footprint!

Total meconium footprints for these procedures. . .

Drum roll, please!

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22 Meconium Footprints!

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How Do We Reduce Our Meconium Footprint?

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Adhere to The Precautionary Principle*

• If an action or policy might cause harm, the burden of proof falls on those who advocate the action.

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Consequences of Ignoring the Precautionary Principle

• The recent history of maternity care has demonstrated time and again that harm and lack of benefit from numerous “innovations” do not become evident until widespread use, much damage, and enormous costs have occurred.

– Elective deliveries (induction or cesarean)

– Episiotomy

– Cytotec (Misoprostol) inductions

– Continuous electronic fetal monitoring

– Routine suctioning of the newborn’s airway

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Precautionary principle applied to maternity care

• “The only justification for practices that restrict a woman’s autonomy, her freedom of choice, or her access to her baby, would be clear evidence that these restrictive practices do more good than harm.” – Murray Enkin*

How to Maintain Eco-Friendly Practice

• Besides playing the role proven to be effective in improving outcomes…

• Model confidence in the physiological process, not a sense of urgency or need to control it. Watch before acting.

– Patience and confidence: “Babies come out:” Help her accept her labor pattern. “Labor unfolds at its own pace.”

• Easier said than done. . .

How to Maintain Eco-Friendly Practice• Think of your own practice. Do you

– Feed or lead her desire to start labor?

– Urge her to keep moving, changing positions, to hasten a slow labor?

– Suggest bath to stop ctx that begin at night?

• Do you see yourself as one with lots of tricks who likes to “keep busy” in labor?

• Are you uncomfortable not “doing something?”

• We mustn’t rush the woman or the process, making her keep “doing” things.

How to Maintain Eco-Friendly Practice

• This does not mean that we never make suggestions or encourage activity

• It means we are relaxed and patient, because this reinforces her confidence

– We are not controlling or authoritative, unless we really need to be

– When there’s a deadline or a problem, then we act!

The Eco-Friendly Caregiver’s Motto

If it ain’t broke, don’t fix it!

Conclusions: Are Humans an Endangered Species?

• The meconium footprint is to birth as the carbon footprint is to earth.

• They are a simple way to assess the impact of common practices on earth’s most precious resources and birth’s most vulnerable participants.

• The “carbon footprint” inspires citizens to protect the earth; the “meconium footprint” can inspire us to protect birth.

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Conclusions

• Human birth is an endangered life process

• What will be the impact on the human species if giving birth and being born are removed from the life cycle?

• Does it matter?

Thank You!

On behalf of

Mothers, Babies, and FamiliesEverywhere