Continuous Support in Labor: An Underused Evidence-Based Practice

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Continuous Support in Labor An Underused
Evidence-Based Practice

• Liza Goldman Huertas, MD
• Obstetrics Rotation
• Dept. of Family Social Medicine

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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

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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

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Infant Mortality Ranking
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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

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Expensive
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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

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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

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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

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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.

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Case Study

• 16yo P0 _at_40 and 6 undergoing IOL. No prenatal
  issues. No PMH.
• Pts 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.

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Case Study p2

• Initially coping well with contractions,
  surprising the nurses. Hoping to avoid epidural
  analgesia.
• Mother becomes Bs 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.

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Case Study p3

• Bs 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.

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Case Study p4

• 2nd stage complicated by poor maternal effort.
  Providers tell pt she isnt doing her job, needs
  to put in real effort. Fear, frustration turns to
  yelling.
• As B pushes her baby out, room goes quiet. The
  babys 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.

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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

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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

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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

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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.

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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

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Why Would Doula Care Help? Labor Physiology

• Intervene on stress response--gt increased epi--gt
  can effect FHR pattern, catecho-lamines decrease
  uterine contractility, prolong labors--gt lower
  APGARs
• Enhanced feto-pelvic relationships (mobility,
  gravity, preferred positions)

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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

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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.

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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

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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)

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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--gt Evidence of
  dose-response phenomenon

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Insufficient Data (Cochrane could not assess)

• Mothers and infants wellbeing postpartum
• Perineal trauma
• Relationship between woman and partner
• Urinary and fecal incontinence

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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

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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.

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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

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Implications for Family Physicians?
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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
  Feb25(1)28-33.
• Dundek LH. Establishment of a Somali doula
  program at a large metropolitan hospital. J
  Perinat Neonatal Nurs. 2006 Apr-Jun20(2)128-37.
• Schroeder C, Bell J. Doula birth support for
  incarcerated pregnant women. Public Health Nurs.
  2005 Jan-Feb22(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-Jun15(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 Jun24(3)195-8.
• www.dona.org, www.childbirthconnection.org