- Email: [email protected]
A Nurse’s Guide to Supporting Physiologic Birth
CNE A Nurse’s Guide to Supporting Physiologic Birth Ellise D. Adams Mary Ann Stark Lisa Kane Low
Upon completion of this activity, the learner will be able to:
1. Define and list the benefits of physiologic birth. 2. L ist nursing care practices that support physiologic birth. 3. I dentify evidence-based resources that can aid nurses and other clinicians in supporting physiologic birth.
Continuing Nursing Education (CNE) Credit A total of 1.0 contact hour may be earned as CNE credit for reading “A Nurse’s Guide to Supporting Physiologic Birth” and for completing an online posttest and participant feedback form. To take the test and complete the participant feedback form, please visit http://awhonnjournals.org. Certificates of completion will be issued on receipt of the completed participant feedback form and processing fees. Association of Women’s Health, Obstetric and Neonatal Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. Accredited status does not imply endorsement by AWHONN or ANCC of any commercial products displayed or discussed in conjunction with an educational activity. AWHONN is approved by the California Board of Registered Nursing, provider #CEP580.
Ellise D. Adams, PhD, CNM, is an associate professor at the University of Alabama in Huntsville, AL. Mary Ann Stark, PhD, RNC, is a professor at Western Michigan University in Kalamazoo, MI. Lisa Kane Low, PhD, CNM, FACNM, FAAN, is an associate professor at the University of Michigan in Ann Arbor, MI. The authors and planners of this learning activity report no conflicts of interest or relevant financial relationships. No commercial support was received for this learning activity. Address correspondence to: [email protected].
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Physiologic birth, also called normal birth, has been defined as birth “that is powered by the innate human capacity of the woman and fetus” (American College of Nurse-Midwives [ACNM], 2012). According to several organizations, physiologic birth includes spontaneous vaginal birth at term, with minimal technologic and pharmacologic interventions, and is followed by skin-to-skin contact and immediate breastfeeding (International Confederation of Midwives, 2014; The Royal College of Midwives, The Royal College of Obstetricians and Gynaecologists, and National Childbirth Trust, 2007; Society of Obstetricians and Gynaecologists of Canada, 2008; World Health Organization & Maternal and Newborn Health/Safe Motherhood Unit, 1996). Physiologic birth is associated with many physical and emotional benefits to women and infants (Buckley, 2015), including the following: (a) decreased interference with the birth process; (b) decreased length of labor, including increased effectiveness of pushing; (c) decreased use of analgesia and anesthesia; (d) decreased operative birth; (e) increased maternal satisfaction and empowerment; (f) decreased newborn complications associated with elective inductions of labor and operative births; (g) enhanced bonding; and (h) enhanced breastfeeding (Dixon, Skinner, & Foureur, 2013; Sakala & Corry, 2008; Transforming Maternity Care Vision Team et al., 2010; Vogl et al., 2006). Despite the many potential health benefits of physiologic birth care practices, current maternity care includes the use of many perinatal interventions that are often overused, whereas care practices that promote physiologic birth are often underused (Sakala & Corry, 2008). National statistics reported in the Listening to Mothers III survey highlight this challenge (Declercq, Sakala, Corry, Applebaum, & Herrlick, 2013). In this survey of women who had given birth in the United States in the prior two years, more than 30% of women experienced an induction of labor, 67% reporting having an epidural, 62% received fluids intravenously, and 31% were given oxytocin to speed up labor. With regard to resources and practices that support physiologic birth, 46% of women surveyed reported access to supportive nursing care (e.g., helping to make women comfortable, Abstract: Physiologic birth promotes the practice of normal labor and birth, in which a woman’s innate power is supported and unnecessary interventions are avoided. Nurses are in a unique position to support physiologic birth because they attend almost all births. Several resources are available to assist nurses in promoting physiologic birth, including BirthTOOLS.org, a new online resource developed by the American College of Nurse-Midwives in collaboration with other organizations. By using resources such as BirthTOOLS.org and others, nurses can become familiar with the evidence surrounding physiologic birth and can contribute to improved patient safety and quality of care by supporting physiologic birth. http://dx.doi.org/10.1016/j.nwh.2015.12.009 Keywords: B irthTOOLS.org | intrapartum care | labor support | perinatal nursing | physiologic birth
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Opening photo © iStock Collection / thinkstockphotos.com
Objectives
Introduction
Physiologic birth can occur in a variety of settings, including hospitals, free-standing birth centers, or in the home. With the multiple benefits of physiologic birth, it is prudent to explore birth practices that promote and support this type of birth. In the United States in 2012, 98.6% of births occurred in a hospital setting (Martin, Hamilton, Osterman, Curtin, & Mathews, 2013). All of these hospital settings employ perinatal nurses. Perinatal nurses can have a profound influence on the labor and birth care provided in the hospital setting, thereby influencing birth outcomes (Adams, 2012). Ideally, a hospital perinatal nurse is usually present with a family for the entire labor and birth process. These nurses are responsible for assessing maternal and fetal well-being; administering procedures and monitoring their effectiveness; providing nursing interventions to assist with a laboring woman’s physical, emotional, and spiritual needs; rendering care related to the birth process, whether vaginal or cesarean; initiating newborn care; and providing care during the early postpartum period (Adams, 2012). Additional roles of perinatal nurses are advocacy and teaching for women during the birth process, communication with health care providers, and documentation. Nursing care implemented by perinatal nurses can affect the course of labor and birth. For example, upright positions for the second stage of labor reduce the length of time required for pushing (Sakala & Corry, 2008). A perinatal nurse who helps a laboring woman into a squatting, standing, or other gravity-assisted position can affect the timing of labor and birth. Implementation of upright positions for the second stage of labor can be categorized as one of many nonpharmacologic nursing interventions that are part of labor support (Adams & Bianchi, 2008).
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Despite the many potential health benefits of physiologic birth care practices, current maternity care includes the use of many perinatal interventions that are often overused, whereas care practices that promote physiologic birth are often underused standards can then provide guidelines for the work of perinatal nurses. Effective policies and standards lead to improved outcomes for women and their newborns; AWHONN (awhonn .org) provides numerous resources that are supportive of physiologic birth, including nursing care quality measures, position statements, clinical competencies, and protocol templates.
Resources for Supporting Physiologic Birth The emotional and physical support of women in labor is associated with positive outcomes, such as shorter labors, decreased use of analgesia and anesthesia, fewer operative births and cesareans, and increased incidence of breastfeeding (AWHONN, 2011). Many specific interventions provided by perinatal nurses can be called labor support and are associated with physiologic birth. Experts also agree that “increasing women’s access to nonmedical interventions during labor, such as continuous labor support, has been shown to reduce cesarean birth rates” (ACOG & SMFM, 2014, p. 180). Box 1 provides a list of these nursing interventions. In its position statement on “Nursing Support of Laboring Women,” AWHONN (2011) states, “Continuously available labor support from a registered nurse is a critical component to achieve improved birth outcomes” (p. 665). This position statement outlines a nurse’s role in providing labor support and supporting physiologic birth. It is not uncommon for perinatal nurses to seek additional training and resources to assist with labor support skills and other skills associated with physiologic birth. Selected resources can be found in Box 2. Many nursing interventions, such as labor support behaviors, are autonomous nursing actions. The Nursing Care
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The Vital Role of Nurses in Supporting Physiologic Birth
Labor support is a practice associated with physiologic birth and is defined as the intentional human interaction between a perinatal nurse and a laboring woman that assists with coping during labor and birth (Sauls, 2004). Specific institutional policies and nationally published standards need to be carefully examined and written to support physiologic birth and the positive benefits associated with this practice. These policies and
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providing emotional support, providing information), 6% reported access to doulas, and 10% reported access to midwives (Declercq et al., 2013). When taken together, these results give the impression that women generally experience technologically intense care. However, such care does not necessarily translate into improved health outcomes for women and their infants (Glantz, 2012). National quality initiatives have been launched by maternity care professional organizations to address high rates of cesarean birth, particularly primary cesareans (ACNM, 2012; American College of Obstetricians and Gynecologists [ACOG] and Society for Maternal-Fetal Medicine [SMFM], 2014; Association of Women’s Health, Obstetric and Neonatal Nurses [AWHONN], 2014a). The purpose of the article is twofold: (a) To outline opportunities for nurses to take a leadership role in promoting care practices that support physiologic birth through the use of resources such as the BirthTOOLS.org Web site and (b) to identify strategies for changing practice to promote physiologic birth.
Box 1 Nursing Care Practices That Support Physiologic Birth • Use recent guidelines (ACOG & SMFM, 2014) to assess the physiologic and psychological processes of labor. • Contribute to the diagnosis of active labor and progress during labor, using newer guidelines. • Provide continual support throughout the labor and birth process. • Encourage position changes and movement throughout labor, including upright positions, ambulation, and tools to promote movement such as birthing balls. • Provide access to and use of comfort measures such as hydrotherapy, ambulation, peanut balls, and emotional support. • Role-model comfort measures to encourage family participation and to assist in collaboration with members of the health care team. • Use intermittent auscultation for healthy, lowrisk women during labor. • Encourage spontaneous, self-directed physiologic approaches to pushing during secondstage labor. • Promote immediate skin-to-skin contact for newborns after birth. • Provide ongoing education and information to the woman and her family regarding the labor process. Sources: ACNM (2012); ACOG and SMFM (2014); AWHONN (2011).
Quality Measurement initiative seeks to measure independent nursing practice and show the impact that evidence-based care has on quality (AWHONN, 2014a). The Women’s Health and Perinatal Nursing Care Quality Measures (AWHONN, 2014b), currently under testing for reliability and validity, can provide evidence that interventions provided by perinatal nurses are able to facilitate physiologic birth and positive outcomes for women and their newborns.
BirthTOOLS.org: An Online Toolkit In 2012, ACNM, the Midwives Alliance of North America, and the National Association of Certified Professional Midwives collaborated to develop a consensus statement to define the practice of and barriers and facilitators related to physiologic birth. Many of these same practices were identified by ACOG
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and SMFM in a statement (ACOG & SMFM, 2014) promoting practices associated with the prevention of primary cesarean births. In an effort to transition these expert opinions into practice, ACNM developed the Healthy Birth Initiative. This initiative is a three-pronged approach to promote physiologic birth and to provide resources for consumers, clinicians, and policymakers. To address clinicians, including perinatal nurses at the point of care and in leadership positions, ACNM brought together the following stakeholders: ACNM, AWHONN, Childbirth Connections, Lamaze International, and the National Association of Certified Professional Midwives. Leaders from these organizations included clinicians, administrators, researchers, and academicians who were tasked with the job of developing and assembling resources to support, promote, and facilitate physiologic birth. The product of this collaborative effort is BirthTOOLS.org. (TOOLS stands for Tools for Optimizing the Outcomes of Labor Safely.) This Web site launched in 2014 and outlines the practices of physiologic birth, provides a synopsis of the evidence supporting the practice, and offers resources, protocols, and case examples to assist clinicians and health care systems in implementing best practices.
Elements of BirthTOOLS.org BirthTOOLS.org has many valuable suggestions for perinatal nurses on how to support physiologic birth. The site’s home page includes a brief introduction to the concept of physiologic birth; the rationale for supporting physiologic birth is presented in the “Focus on Physiologic Birth” section. This section contains a brief explanation of the value of physiologic birth and the benefit of providing care that supports the innate hormonally mediated physiology of childbearing. An additional resource is a link to Childbirth Connections, which provides the newly released and important work of Dr. Sarah Buckley (2015) on the hormonal physiology of childbearing. Of special interest to perinatal nurses is the section of the site titled “Menu of Change,” which describes specific areas for nursing activities to support physiologic birth (see Box 3). Resources in this part of the site include latest research evidence, consensus statements by professional organizations, systematic reviews and research reports, and educational materials and success stories. These resources can be used by individual perinatal nurses, journal clubs, and nurse educators. The content is useful for updating policies and procedures, having discussions with other clinicians, and educating women, administrators, and community groups. We believe BirthTOOLS.org should be introduced to all nursing students as part of their obstetric nursing course. Because BirthTOOLS.org was designed for all perinatal care providers, it provides all professionals with the same resources for changing practice to support physiologic birth. To meet the goal of improving care and changing practice, BirthTOOLS.org includes a quality improvement model with
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Box 2 Selected Resources for Supporting Physiologic Birth AWHONN Position Statement on Nursing Support of Laboring Women www.jognn.org/article/S0884-2175(15) 30584-0/abstract AWHONN Women’s Health and Perinatal Nursing Care Quality Draft Measures Specifications www.awhonn.org/awhonn/content.do?name=02_ practiceresources/02_perinatalqualitymeasures.htm
Consensus Statement of ACNM, Midwives Alliance of North America, and National Association of Certified Professional Midwives mana.org/pdfs/Physiological-Birth-ConsensusStatement.pdf
Optimal Care in Childbirth www.optimalcareinchildbirth.com Science & Sensibility Blog www.scienceandsensibility.org/the-roadmap-oflabor-a-framework-for-teaching-about-normal-labor Transforming Maternity Care transform.childbirthconnection.org/reports/physiology World Health Organization Safe motherhood care in normal birth: A practical guide whqlibdoc.who.int/hq/1996/WHO_FRH_ MSM_96.24.pdf?ua=1
Evidence-Based Birth evidencebasedbirth.com/start-here
frameworks for making practice changes and audit tools for documenting change. Clinicians who make changes in practice are invited to submit their success stories to the site. The site will continually be updated, and users can register to receive update notifications by e-mail.
Importance of Multidisciplinary Buy-In When Changing Practice In providing birth care, perinatal nurses practice collaboratively as part of the health care team within the unique cultures of each facility. Making changes in practice may require nurses to influence others within the health care team to first recognize the value of physiologic birth and then to obtain needed knowledge and skills. Nurses can influence peers, administrators, and consumers in their buy-in of the value of physiologic birth.
Nursing Colleagues Valuable partners in nursing practice are other nurses. Some perinatal nurses have experience, knowledge, and skills that make them comfortable supporting some aspects of physiologic labor and birth; others may not (Stark & Miller, 2009). To promote physiologic birth, nurses on maternity care units can join together to share resources and educational tools. For example, BirthTOOLS.org links to the National Institute for Health and Care Excellence (2014) in the United Kingdom, which provides an evidence-based guideline for nonpharmacologic painrelieving strategies. There are resources for helping women cope with labor (Roberts, Gulliver, Fisher, & Cloyes, 2010),
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which include suggestions for nonpharmacologic pain management interventions such as massage, application of heat and cold, and position changes. Two ACNM position statements for supporting comfort and coping during labor are available; one is for the use of nitrous oxide in labor (ACNM, 2010) and the other is for water birth (ACNM, 2014b). BirthTOOLS.org also links to Simkin’s (2014) “Road Map of Labor.” Nurses can use such resources in their nursing practice individually and can use the evidence-based information contained
Making changes in practice may require nurses to influence others within the health care team to first recognize the value of physiologic birth and then to obtain needed knowledge and skills in these resources to influence practice change among colleagues and other maternity care team members. Holding a journal club where BirthTOOLS.org is discussed is one way of introducing the evidence base for practice change to other nurses on the unit. Discussing some of the unit-specific barriers to physiologic birth in such a forum may lead to change. Common barriers to changing practice include limited knowledge of the evidence, lack of leadership and support for
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BirthTOOLs birthtools.org
National Institute for Health and Care Excellence (U.K.) www.nice.org.uk/guidance/cg190/chapter/ recommendations
practice changes, and limitations in staffing or access to resources such as peanut balls, showers, or tubs. Journal clubs can address questions about the evidence base for practice change as a first step. Another way to influence practice is to look for nurses who have skills that support physiologic birth. Ask them to mentor
to hospital education programs related to labor support. Seeking support from administration to provide education to support physiologic birth is also an opportunity. Collaborating with section and chapter meetings of national organizations, such as AWHONN, is another opportunity for education and training to support physiologic birth.
Hospitals and Organizations
Encouraging physiologic birth offers the opportunity to improve quality and safety of care as well as maternal and family satisfaction with the birth process other nurses on the unit or hold a labor support training program for nurses using community doulas, nurse-midwives, or other clinicians if there are not already nurses on the unit with these skills. Assessment of skills and understanding strengths and limitations as a first step can aid in supporting next steps in seeking new knowledge and mentorship, or in identifying an expert in promoting physiologic birth who can mentor others. Some birthing units designate nurses to serve as an onsite resource to colleagues. In-service education is required for perinatal nurses who provide care to women receiving intermittent or continuous electronic fetal monitoring. Albers (2007) suggests that, given the importance of providing labor support, BirthTOOLS. org could be used to provide labor support education for all perinatal nurses. The “Promoting Comfort in Labor” section of the site (birthtools.org/Promoting-Comfort-in-Labor) provides links
Box 3 BirthTOOLS.org “Menu of Change” 1. Promoting Spontaneous Onset of Labor 2. Promoting Progress in Labor • Promoting Progress in First Stage Labor • Transitioning Into the Birth Setting • Promoting Physiologic Pushing in Second Stage Labor 3. Promoting Comfort in Labor • Coping With Labor • Nutrition and Hydration 4. Assessment of Fetal Well-Being 5. Dyad Care in the Immediate Postpartum
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Although some changes can be made in individual nursing practice, there is increasing focus on hospitals and organizations to improve quality and safety. Encouraging physiologic birth offers the opportunity to improve quality and safety of care as well as maternal and family satisfaction with the birth process (ACNM, 2014a). Because physiologic birth is associated with reduced use of technology and unnecessary interventions, associated risks are likely to be reduced. Routine continuous electronic fetal monitoring is an example of unrestrained use of technology not supported by research evidence and associated with an increased rate of cesarean birth (Romano & Lothian, 2008; Zwelling, 2008). Recent efforts are aimed at reducing the rate of primary cesarean birth (ACOG & SMFM, 2014; Caughey, 2014). Use of evidence-based methods to support physiologic birth directly affects primary cesarean birth rates, a performance measure designated by the Joint Commission (2012). It is not just for accreditation that improved quality and safety is important. Since the release of the report To Err Is Human: Building a Safer Health System (Kohn et al., 2000), consumers, clinicians, and health care administrators have been alert to safety issues in health care. Supporting physiologic birth can help reduce routine unnecessary interventions and improve quality and safety during the childbearing process (Buckley, 2015). Satisfaction with the birth experience, another measure of importance to hospitals and administrators, may increase with physiologic birth. In a study of symptoms of posttraumatic stress disorder (PTSD) after childbirth, Beck, Gable, Sakala, and Declercq (2011) found that women who had symptoms of PTSD were more likely than others to have been pressured to have an induction, epidural, or a planned cesarean birth. These interventions may be avoided when physiologic birth is supported, potentially improving a woman’s experience and increasing maternal and family satisfaction while reducing PTSD symptoms. Finally, administrators, payers, and consumers are interested in reducing the cost of health care. Reducing use of routine unnecessary interventions is one way to reduce health care costs (James & Savitz, 2011). In addition, those interventions carry risks of iatrogenic complications that can increase costs and sometimes length of stay (ACNM, 2014a). Because hospitals are reporting more quality data to the public, consumers might choose hospitals with lower rates of complications and adverse events.
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A Call to Action Promoting physiologic birth in the hospital setting requires a philosophic shift in many cases. Nurses can lead the charge to change the philosophy of care and birth practices to make birth safer and more satisfying for families. Changing philosophies and, ultimately, practice requires education, time, and patience.
Contribute to a Culture of Change Practice changes are often associated with a culture of clinical inquiry. To lead change, nurses must be armed with evidence from current peer-reviewed journal articles and other reputable sources. One way to uncover evidence is to collaborate with nurse faculty or nurse researchers at local academic institutions. Another way to learn more about physiologic birth is to attend as many births as possible with no to low intervention or to shadow a certified nurse-midwife in a hospital supportive of physiologic birth, at a home birth, or in a free-standing birth center. A nursing model that is wellness-oriented is very compatible with the midwifery model when applied to care in childbirth. Another option is to provide labor support for a friend who plans to avoid an epidural during labor; this can provide firsthand experience from a different perspective that can be valuable when re-evaluating current care practices. Many agencies have courses for labor support or doula training tailored to nursing professionals. Alternatively, nurse-midwives, nurses, or other health care providers who are known to be particularly
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Engage Multiple Stakeholders Change often occurs when multiple stakeholders have similar visions. Developing a hospital task force composed of perinatal stakeholders allows for exploration of practice changes. BirthTOOLS.org is an appropriate resource to assist this process. Later these task forces can develop checklists, protocols, and bundles to assist with the implementation of practices associated with physiologic birth. Consumers and providers can be involved in these practice changes to improve the probability of success. New or varied practices within a birth environment are facilitated with the implementation of mentors and champions.
Changing philosophies and, ultimately, practice requires education, time, and patience Mentors and champions provide clinical guidance and support through the process of change.
Study Impact and Disseminate Results When practice changes are made, it is important to carefully study their impact and disseminate the results. The results of nurse-led quality improvement projects and research studies need to be presented to audiences of all maternity care stakeholders at the local, state, and national levels. In this way, changes in nurse-led practice may affect change in different birth environments. Publishing results in a peer-reviewed journal is another method of making a long-lasting impact on a larger group of birth stakeholders.
Conclusion Physiologic birth is associated with improved maternal and fetal health outcomes, as well as maternal and family satisfaction with the birth experience. Although physiologic birth is not yet considered routine in many hospitals, any practice that promotes physical and emotional health and improves maternal and family satisfaction is a worthy pursuit. Implementing a new or modified practice change is never simple or easy, yet the process can be greatly facilitated when evidence-based resources are accessible. BirthTOOLS.org was developed to provide resources related to physiologic birth in an easily accessible format. Perinatal nurses are well equipped and critical to affecting and sustaining birth practice changes, making them the perfect professionals to lead the charge for supporting physiologic birth. NWH
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Childbearing women and their families may or may not be aware of trends in childbirth, including prevalence of elective inductions, cesarean births, and use of epidural analgesia. They may lack knowledge of the risks and complications of these interventions (Glantz, 2012). For example, an elective induction may sound convenient to a pregnant woman at 38 weeks who has family coming from across the country to be present for her birth. She may not be aware of maternal and fetal alterations that are encountered when labor is induced rather than when it starts spontaneously. In a study in which education about elective induction was given to women attending prenatal classes, 27.9% of class attendees had elective inductions compared with 37% of the women who did not attend the classes (Simpson, Newman, & Chirino, 2010). This study underscores the need for informed, shared decision-making in health care. Consumers who are fully informed about their options before presenting to the maternity care unit have the opportunity to implement their desired choices for care during labor and birth. Resources to educate consumers prenatally about physiologic birth care practices include those that describe the evidence base for and benefits of physiologic birth, such as “Normal Healthy Childbirth for Women & Families: What You Need to Know” (ACNM, 2014c) and Lamaze International’s online presentation of “Healthy Birth Practices” (Lamaze International, 2015).
skilled in labor support can be invited to conduct a seminar for a local group of perinatal nurses and health care providers.
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References Adams, E. (2012). The psychometric properties of an instrument measuring the beliefs of intrapartum nurses related to birth practice (Doctoral dissertation). Retrieved from CINAHL Plus Full Text. (UMI Order AAI3538778) Adams, E. D., & Bianchi, A. L. (2008). A practical approach to labor support. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 37(1), 106–115. doi:10.1111/j.1552-6909.2007.00213.x Albers, L. L. (2007). The evidence for physiologic management of the active phase of the first stage of labor. Journal of Midwifery & Women’s Health, 52(3), 207–215. American College of Nurse-Midwives (ACNM). (2010). Nitrous oxide for labor analgesia. Journal of Midwifery & Women’s Health, 55(3), 292–296. doi:10.1016/j.jmwh.2010.03.003 American College of Nurse-Midwives (ACNM). (2012). Supporting healthy and normal physiologic childbirth: A consensus statement by the American College of Nurse-Midwives, Midwives Alliance of North America, and the National Association of Certified Professional Midwives. (5), 529–532. doi:10.1111/ j.1542-2011.2012.00218.x American College of Nurse-Midwives (ACNM). (2014a). Birth matters. Silver Spring, MD: Author. Retrieved from www.midwife .org/ACNM/files/ccLibraryFiles/FILENAME/000000004448/ HBI-BirthMatters-100314.pdf American College of Nurse-Midwives (ACNM). (2014b). Hydrotherapy during labor and birth. Position statement. Silver Spring, MD: Author. Retrieved from www.midwife.org/ACNM/files/ ccLibraryFiles/Filename/000000004048/Hydrotherapy-DuringLabor-and-Birth-April-2014.pdf American College of Nurse-Midwives (ACNM). (2014c). Normal, healthy childbirth for women & families: What you need to know. Silver Spring, MD: Author. Retrieved from www. ourmomentoftruth.com/omot/files/BirthToolFiles/FILENAME/000000000002/NormalBirthAndYou-031815.pdf American College of Obstetricians and Gynecologists (ACOG) & Society for Maternal-Fetal Medicine (SMFM). (2014). Obstetric care consensus no. 1: Safe prevention of the primary cesarean delivery. Obstetrics & Gynecology, 123(3), 693–711. doi:10.1097/01. AOG.0000444441.04111.1d Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). (2011). Nursing support of laboring women. An official position statement of the Association of Women’s Health, Obstetric & Neonatal Nursing. Journal of Obstetric, Gynecologic, & Neonatal Nursing 40(5), 665–666. doi:10.1111/j.15526909.2011.01288.x Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). (2014a). Nursing care quality measurement. Journal of Obstetric, Gynecologic, & Neonatal Nursing 43(1), 132–133. doi:10.1111/1552-6909.12276 Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). (2014b). Women’s health and perinatal nursing care quality draft measures specifications. Washington, DC: Author. Retrieved from www.awhonn.org/awhonn/content.do?name=02_ practiceresources/02_perinatalqualitymeasures.htm
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Beck, C. T., Gable, R. K., Sakala, C., & Declercq, E. R. (2011). Posttraumatic stress disorder in new mothers: Results from a twostage U.S. national survey. Birth, 38(3), 216–227. doi:10.1111/ j.1523-536X.2011.00475.x Buckley, S. (2015). Hormonal physiology of childbearing: Evidence and implications for women, babies, and maternity care. Washington, DC: Childbirth Connection Programs, National Partnership for Women & Families. Retrieved from childbirthconnection .org/pdfs/CC.NPWF.HPoC.Report.2015.pdf Caughey, A. (2014). Induction of labour: Does it increase the risk of cesarean delivery? BJOG: An International Journal of Obstetrics and Gynaecology, 121(6), 658–661. doi:10.1111/14710528.12329 Declercq, E. R, Sakala, C., Corry, M. P., Applebaum, S., & Herrlich, A. (2013). Listening to Mothers III: Pregnancy and birth. New York, NY: Childbirth Connection. Dixon, L., Skinner, J. P., & Foureur, M. (2013). The emotional and hormonal pathways of labour and birth: Integrating mind, body and behaviour. New Zealand College of Midwives Journal, 48, 15–23. doi:10.12784/nzcomjnl48.2013.3.15-23 Glantz, J. C. (2012). Obstetric variation, intervention, and outcomes: Doing more but accomplishing less. Birth, 39(4), 286– 290. doi:10.1111/birt.12002 International Confederation of Midwives. (2014). Position statement: Keeping birth normal. The Hague, The Netherlands: Author. Retrieved from www.internationalmidwives.org/assets/ uploads/documents/Position%20Statements%20-%20English/ Reviewed%20PS%20in%202014/PS2008_007%20V2014%20 Keeping%20Birth%20Normal%20ENG.pdf James, B. C., & Savitz, L. A. (2011). How Intermountain trimmed health care costs through robust quality improvement efforts. Health Affairs, 30(6), 1185–1191. doi:10.1377/hlthaff.2011.0358 Joint Commission. (2012). Specifications manual for Joint Commission national quality measures (v2013A1). Oak Brook, IL: Author. Retrieved from https://manual.jointcommission.org/ releases/TJC2013A/MIF0167.html Kohn, L. T., Corrigan, J. M., Donaldson, M. S., Committee on Health Care in American, & Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, DC: National Academies Press. Lamaze International. (2015). About Lamaze: Lamaze healthy birth practices. Washington, DC: Author. Retrieved from www .lamazeinternational.org/healthybirthpractices Martin, J. A., Hamilton, B. E., Osterman, M. J., Curtin, S. C., & Matthews, T. J. (2013). Birth: Final data for 2012. National Vital Statistics Reports, 62(9), 1–68. National Institute for Health and Care Excellence. (2014). Intrapartum care. Retrieved from www.nice.org.uk/guidance/cg55/ resources Roberts, L., Gulliver, B., Fisher, J., & Cloyes, K. G. (2010). The coping with labor algorithm: An alternate pain assessment tool for the laboring woman. Journal of Midwifery & Women’s Health, 55(2), 107–116. doi:10.1016/j.jmwh.2009.11.002
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Sakala, C., & Corry, M. P. (2008). Evidenced-based maternity care: What it is and what it can achieve. New York, NY: Childbirth Connection, the Reforming States Group, and the Milbank Memorial Fund. Retrieved from www.milbank.org/uploads/docum ents/0809MaternityCare/0809MaternityCare.html Sauls, D. J. (2004). The Labor Support Questionnaire: Development and psychometric analysis. Journal of Nursing Measurement, 12(2), 123–132.
Simpson, K. R., Newman, G., & Chirino, O. R. (2010). Patient education to reduce elective labor inductions. MCN: The American Journal of Maternal/Child Nursing, 35(4), 188–194. doi:10.1097/ NMC.0b013e3181d9c6d6 Society of Obstetricians and Gynaecologists of Canada. (2008). Joint policy statement on normal childbirth. Journal of the Society of Obstetricians and Gynecologists of Canada, 30(12), 1163–1165. Stark, M. A., & Miller, M. G. (2009). Barriers to the use of hydrotherapy in labor. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 38(6), 667–675. doi:10.1111/j.1552-6909.2009.01065.x
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Transforming Maternity Care Vision Team, Carter, M. C., Corry, M. C., Delbanco, S., Foster, T. C., . . . Simpson, K. R. (2010). 2020 vision for a high-quality, high-value maternity care system. Women’s Health Issues, 20(1 Suppl.), S7–S17. doi:10.1016/j. whi.2009.11.006 Vogl, S., Worda, C., Egarter, C., Bieglmayer, C., Szekeres, T., Huber, J., & Husslein, P. (2006). Mode of delivery is associated with maternal and fetal endocrine stress response. BJOG: An International Journal of Obstetrics and Gynaecology, 113(4), 441–445. doi:10.1111/j.1471-0528.2006.00865.x World Health Organization & Maternal and Newborn Health/ Safe Motherhood Unit. (1996). Care in normal birth: A practical guide. Geneva, Switzerland: World Health Organization. Retrieved from apps.who.int/iris/bitstream/10665/63167/1/WHO_ FRH_MSM_96.24.pdf Zwelling, E. (2008). The emergence of high-tech birthing. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 37(1), 85–93. doi:10.1111/j.1552-6909.2007.00211.x
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Simkin, P. (2014, September 2). The roadmap of labor: A framework for teaching about normal labor [Web log post]. Retrieved from www.scienceandsensibility.org/the-roadmap-of-labor-aframework-for-teaching-about-normal-labor/
The Royal College of Midwives, The Royal College of Obstetricians and Gynaecologists, & The National Childbirth Trust. (2007). Making normal birth a reality. Consensus statement from the Maternity Care Working Party: Our shared views about the need to recognise, facilitate and audit normal birth. United Kingdom: The National Childbirth Trust. Retrieved from https://www.rcm.org. uk/sites/default/files/NormalBirthConsensusStatement.pdf
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Romano, A. M., & Lothian, J. A. (2008). Promoting, protecting, and supporting normal birth: A look at the evidence. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 37(1), 94–104. doi:10.1111/j.1552-6909.2007.00210.x
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Post-test Questions Instructions: To access this CNE activity online, visit http://awhonnjournals.org. CNE for this activity is available online only; written tests submitted to AWHONN will not be accepted.
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Which of the following statements defines physiologic birth? a. Birth that is attended by a midwife. b. Birth that is powered by the innate human capacity of the woman and fetus. c. Birth that takes place outside the hospital setting.
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Which of the following is cited in this article as a common barrier to changing practice with regard to physiologic birth? a. Hospital budget cuts. b. Lack of training in skin-to-skin contact. c. Limitations in staffing resources.
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Which of the following benefits has been associated with physiologic birth? a. Greater ease in losing pregnancy weight gain. b. Less pain during labor. c. Shorter duration of labor.
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In the Listening to Mothers III survey, what percentage of women who had given birth in the prior 2 years reported having induction of labor? a. 10% b. 30% c. 67%
In a study in which education about elective induction was given to women attending prenatal classes, the elective induction rate among women attending these classes compared with the rate of those who did not attend differed by how many percentage points? a. 3.2 b. 9.1 c. 10.7
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Which of these statements do the authors suggest as helping to garner buy-in from both consumers and health care administrators regarding physiologic birth? a. Physiologic birth can reduce use of unnecessary interventions, thus lowering costs and possibly length of stay. b. Physiologic birth is a natural process in which a woman controls her birth experience. c. Physiologic birth is preferred by a majority of pregnant women.
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In the Listening to Mothers III survey, what percentage of women who had given birth in the prior 2 years reported having access to a midwife? a. 6% b. 10% c. 46%
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What is a nursing care action that can support physiologic birth? a. Encourage position changes and movement throughout labor, including upright positions. b. Monitor fetal heart tracings. c. Provide a referral to a lactation consultant.
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What is BirthTOOLS.org? a. An online site for maternity care medical instruments. b. An online site providing resources to aid clinicians in supporting physiologic birth. c. An online site where nurses and other clinicians can learn to become doulas.
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10. What is an important step to support nurse-led practice change that supports physiologic birth in different birth environments? a. Having obstetricians lead the practice change. b. Obtaining grants to fund the practice change. c. Studying the impact of the change in one setting and disseminating the results.
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Upon completion of this activity, the learner will be able to:
1. Define and list the benefits of physiologic birth. 2. L ist nursing care practices that support physiologic birth. 3. I dentify evidence-based resources that can aid nurses and other clinicians in supporting physiologic birth.
Continuing Nursing Education (CNE) Credit A total of 1.0 contact hour may be earned as CNE credit for reading “A Nurse’s Guide to Supporting Physiologic Birth” and for completing an online posttest and participant feedback form. To take the test and complete the participant feedback form, please visit http://awhonnjournals.org. Certificates of completion will be issued on receipt of the completed participant feedback form and processing fees. Association of Women’s Health, Obstetric and Neonatal Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. Accredited status does not imply endorsement by AWHONN or ANCC of any commercial products displayed or discussed in conjunction with an educational activity. AWHONN is approved by the California Board of Registered Nursing, provider #CEP580.
Ellise D. Adams, PhD, CNM, is an associate professor at the University of Alabama in Huntsville, AL. Mary Ann Stark, PhD, RNC, is a professor at Western Michigan University in Kalamazoo, MI. Lisa Kane Low, PhD, CNM, FACNM, FAAN, is an associate professor at the University of Michigan in Ann Arbor, MI. The authors and planners of this learning activity report no conflicts of interest or relevant financial relationships. No commercial support was received for this learning activity. Address correspondence to: [email protected].
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Physiologic birth, also called normal birth, has been defined as birth “that is powered by the innate human capacity of the woman and fetus” (American College of Nurse-Midwives [ACNM], 2012). According to several organizations, physiologic birth includes spontaneous vaginal birth at term, with minimal technologic and pharmacologic interventions, and is followed by skin-to-skin contact and immediate breastfeeding (International Confederation of Midwives, 2014; The Royal College of Midwives, The Royal College of Obstetricians and Gynaecologists, and National Childbirth Trust, 2007; Society of Obstetricians and Gynaecologists of Canada, 2008; World Health Organization & Maternal and Newborn Health/Safe Motherhood Unit, 1996). Physiologic birth is associated with many physical and emotional benefits to women and infants (Buckley, 2015), including the following: (a) decreased interference with the birth process; (b) decreased length of labor, including increased effectiveness of pushing; (c) decreased use of analgesia and anesthesia; (d) decreased operative birth; (e) increased maternal satisfaction and empowerment; (f) decreased newborn complications associated with elective inductions of labor and operative births; (g) enhanced bonding; and (h) enhanced breastfeeding (Dixon, Skinner, & Foureur, 2013; Sakala & Corry, 2008; Transforming Maternity Care Vision Team et al., 2010; Vogl et al., 2006). Despite the many potential health benefits of physiologic birth care practices, current maternity care includes the use of many perinatal interventions that are often overused, whereas care practices that promote physiologic birth are often underused (Sakala & Corry, 2008). National statistics reported in the Listening to Mothers III survey highlight this challenge (Declercq, Sakala, Corry, Applebaum, & Herrlick, 2013). In this survey of women who had given birth in the United States in the prior two years, more than 30% of women experienced an induction of labor, 67% reporting having an epidural, 62% received fluids intravenously, and 31% were given oxytocin to speed up labor. With regard to resources and practices that support physiologic birth, 46% of women surveyed reported access to supportive nursing care (e.g., helping to make women comfortable, Abstract: Physiologic birth promotes the practice of normal labor and birth, in which a woman’s innate power is supported and unnecessary interventions are avoided. Nurses are in a unique position to support physiologic birth because they attend almost all births. Several resources are available to assist nurses in promoting physiologic birth, including BirthTOOLS.org, a new online resource developed by the American College of Nurse-Midwives in collaboration with other organizations. By using resources such as BirthTOOLS.org and others, nurses can become familiar with the evidence surrounding physiologic birth and can contribute to improved patient safety and quality of care by supporting physiologic birth. http://dx.doi.org/10.1016/j.nwh.2015.12.009 Keywords: B irthTOOLS.org | intrapartum care | labor support | perinatal nursing | physiologic birth
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Opening photo © iStock Collection / thinkstockphotos.com
Objectives
Introduction
Physiologic birth can occur in a variety of settings, including hospitals, free-standing birth centers, or in the home. With the multiple benefits of physiologic birth, it is prudent to explore birth practices that promote and support this type of birth. In the United States in 2012, 98.6% of births occurred in a hospital setting (Martin, Hamilton, Osterman, Curtin, & Mathews, 2013). All of these hospital settings employ perinatal nurses. Perinatal nurses can have a profound influence on the labor and birth care provided in the hospital setting, thereby influencing birth outcomes (Adams, 2012). Ideally, a hospital perinatal nurse is usually present with a family for the entire labor and birth process. These nurses are responsible for assessing maternal and fetal well-being; administering procedures and monitoring their effectiveness; providing nursing interventions to assist with a laboring woman’s physical, emotional, and spiritual needs; rendering care related to the birth process, whether vaginal or cesarean; initiating newborn care; and providing care during the early postpartum period (Adams, 2012). Additional roles of perinatal nurses are advocacy and teaching for women during the birth process, communication with health care providers, and documentation. Nursing care implemented by perinatal nurses can affect the course of labor and birth. For example, upright positions for the second stage of labor reduce the length of time required for pushing (Sakala & Corry, 2008). A perinatal nurse who helps a laboring woman into a squatting, standing, or other gravity-assisted position can affect the timing of labor and birth. Implementation of upright positions for the second stage of labor can be categorized as one of many nonpharmacologic nursing interventions that are part of labor support (Adams & Bianchi, 2008).
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Despite the many potential health benefits of physiologic birth care practices, current maternity care includes the use of many perinatal interventions that are often overused, whereas care practices that promote physiologic birth are often underused standards can then provide guidelines for the work of perinatal nurses. Effective policies and standards lead to improved outcomes for women and their newborns; AWHONN (awhonn .org) provides numerous resources that are supportive of physiologic birth, including nursing care quality measures, position statements, clinical competencies, and protocol templates.
Resources for Supporting Physiologic Birth The emotional and physical support of women in labor is associated with positive outcomes, such as shorter labors, decreased use of analgesia and anesthesia, fewer operative births and cesareans, and increased incidence of breastfeeding (AWHONN, 2011). Many specific interventions provided by perinatal nurses can be called labor support and are associated with physiologic birth. Experts also agree that “increasing women’s access to nonmedical interventions during labor, such as continuous labor support, has been shown to reduce cesarean birth rates” (ACOG & SMFM, 2014, p. 180). Box 1 provides a list of these nursing interventions. In its position statement on “Nursing Support of Laboring Women,” AWHONN (2011) states, “Continuously available labor support from a registered nurse is a critical component to achieve improved birth outcomes” (p. 665). This position statement outlines a nurse’s role in providing labor support and supporting physiologic birth. It is not uncommon for perinatal nurses to seek additional training and resources to assist with labor support skills and other skills associated with physiologic birth. Selected resources can be found in Box 2. Many nursing interventions, such as labor support behaviors, are autonomous nursing actions. The Nursing Care
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The Vital Role of Nurses in Supporting Physiologic Birth
Labor support is a practice associated with physiologic birth and is defined as the intentional human interaction between a perinatal nurse and a laboring woman that assists with coping during labor and birth (Sauls, 2004). Specific institutional policies and nationally published standards need to be carefully examined and written to support physiologic birth and the positive benefits associated with this practice. These policies and
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providing emotional support, providing information), 6% reported access to doulas, and 10% reported access to midwives (Declercq et al., 2013). When taken together, these results give the impression that women generally experience technologically intense care. However, such care does not necessarily translate into improved health outcomes for women and their infants (Glantz, 2012). National quality initiatives have been launched by maternity care professional organizations to address high rates of cesarean birth, particularly primary cesareans (ACNM, 2012; American College of Obstetricians and Gynecologists [ACOG] and Society for Maternal-Fetal Medicine [SMFM], 2014; Association of Women’s Health, Obstetric and Neonatal Nurses [AWHONN], 2014a). The purpose of the article is twofold: (a) To outline opportunities for nurses to take a leadership role in promoting care practices that support physiologic birth through the use of resources such as the BirthTOOLS.org Web site and (b) to identify strategies for changing practice to promote physiologic birth.
Box 1 Nursing Care Practices That Support Physiologic Birth • Use recent guidelines (ACOG & SMFM, 2014) to assess the physiologic and psychological processes of labor. • Contribute to the diagnosis of active labor and progress during labor, using newer guidelines. • Provide continual support throughout the labor and birth process. • Encourage position changes and movement throughout labor, including upright positions, ambulation, and tools to promote movement such as birthing balls. • Provide access to and use of comfort measures such as hydrotherapy, ambulation, peanut balls, and emotional support. • Role-model comfort measures to encourage family participation and to assist in collaboration with members of the health care team. • Use intermittent auscultation for healthy, lowrisk women during labor. • Encourage spontaneous, self-directed physiologic approaches to pushing during secondstage labor. • Promote immediate skin-to-skin contact for newborns after birth. • Provide ongoing education and information to the woman and her family regarding the labor process. Sources: ACNM (2012); ACOG and SMFM (2014); AWHONN (2011).
Quality Measurement initiative seeks to measure independent nursing practice and show the impact that evidence-based care has on quality (AWHONN, 2014a). The Women’s Health and Perinatal Nursing Care Quality Measures (AWHONN, 2014b), currently under testing for reliability and validity, can provide evidence that interventions provided by perinatal nurses are able to facilitate physiologic birth and positive outcomes for women and their newborns.
BirthTOOLS.org: An Online Toolkit In 2012, ACNM, the Midwives Alliance of North America, and the National Association of Certified Professional Midwives collaborated to develop a consensus statement to define the practice of and barriers and facilitators related to physiologic birth. Many of these same practices were identified by ACOG
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and SMFM in a statement (ACOG & SMFM, 2014) promoting practices associated with the prevention of primary cesarean births. In an effort to transition these expert opinions into practice, ACNM developed the Healthy Birth Initiative. This initiative is a three-pronged approach to promote physiologic birth and to provide resources for consumers, clinicians, and policymakers. To address clinicians, including perinatal nurses at the point of care and in leadership positions, ACNM brought together the following stakeholders: ACNM, AWHONN, Childbirth Connections, Lamaze International, and the National Association of Certified Professional Midwives. Leaders from these organizations included clinicians, administrators, researchers, and academicians who were tasked with the job of developing and assembling resources to support, promote, and facilitate physiologic birth. The product of this collaborative effort is BirthTOOLS.org. (TOOLS stands for Tools for Optimizing the Outcomes of Labor Safely.) This Web site launched in 2014 and outlines the practices of physiologic birth, provides a synopsis of the evidence supporting the practice, and offers resources, protocols, and case examples to assist clinicians and health care systems in implementing best practices.
Elements of BirthTOOLS.org BirthTOOLS.org has many valuable suggestions for perinatal nurses on how to support physiologic birth. The site’s home page includes a brief introduction to the concept of physiologic birth; the rationale for supporting physiologic birth is presented in the “Focus on Physiologic Birth” section. This section contains a brief explanation of the value of physiologic birth and the benefit of providing care that supports the innate hormonally mediated physiology of childbearing. An additional resource is a link to Childbirth Connections, which provides the newly released and important work of Dr. Sarah Buckley (2015) on the hormonal physiology of childbearing. Of special interest to perinatal nurses is the section of the site titled “Menu of Change,” which describes specific areas for nursing activities to support physiologic birth (see Box 3). Resources in this part of the site include latest research evidence, consensus statements by professional organizations, systematic reviews and research reports, and educational materials and success stories. These resources can be used by individual perinatal nurses, journal clubs, and nurse educators. The content is useful for updating policies and procedures, having discussions with other clinicians, and educating women, administrators, and community groups. We believe BirthTOOLS.org should be introduced to all nursing students as part of their obstetric nursing course. Because BirthTOOLS.org was designed for all perinatal care providers, it provides all professionals with the same resources for changing practice to support physiologic birth. To meet the goal of improving care and changing practice, BirthTOOLS.org includes a quality improvement model with
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Box 2 Selected Resources for Supporting Physiologic Birth AWHONN Position Statement on Nursing Support of Laboring Women www.jognn.org/article/S0884-2175(15) 30584-0/abstract AWHONN Women’s Health and Perinatal Nursing Care Quality Draft Measures Specifications www.awhonn.org/awhonn/content.do?name=02_ practiceresources/02_perinatalqualitymeasures.htm
Consensus Statement of ACNM, Midwives Alliance of North America, and National Association of Certified Professional Midwives mana.org/pdfs/Physiological-Birth-ConsensusStatement.pdf
Optimal Care in Childbirth www.optimalcareinchildbirth.com Science & Sensibility Blog www.scienceandsensibility.org/the-roadmap-oflabor-a-framework-for-teaching-about-normal-labor Transforming Maternity Care transform.childbirthconnection.org/reports/physiology World Health Organization Safe motherhood care in normal birth: A practical guide whqlibdoc.who.int/hq/1996/WHO_FRH_ MSM_96.24.pdf?ua=1
Evidence-Based Birth evidencebasedbirth.com/start-here
frameworks for making practice changes and audit tools for documenting change. Clinicians who make changes in practice are invited to submit their success stories to the site. The site will continually be updated, and users can register to receive update notifications by e-mail.
Importance of Multidisciplinary Buy-In When Changing Practice In providing birth care, perinatal nurses practice collaboratively as part of the health care team within the unique cultures of each facility. Making changes in practice may require nurses to influence others within the health care team to first recognize the value of physiologic birth and then to obtain needed knowledge and skills. Nurses can influence peers, administrators, and consumers in their buy-in of the value of physiologic birth.
Nursing Colleagues Valuable partners in nursing practice are other nurses. Some perinatal nurses have experience, knowledge, and skills that make them comfortable supporting some aspects of physiologic labor and birth; others may not (Stark & Miller, 2009). To promote physiologic birth, nurses on maternity care units can join together to share resources and educational tools. For example, BirthTOOLS.org links to the National Institute for Health and Care Excellence (2014) in the United Kingdom, which provides an evidence-based guideline for nonpharmacologic painrelieving strategies. There are resources for helping women cope with labor (Roberts, Gulliver, Fisher, & Cloyes, 2010),
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which include suggestions for nonpharmacologic pain management interventions such as massage, application of heat and cold, and position changes. Two ACNM position statements for supporting comfort and coping during labor are available; one is for the use of nitrous oxide in labor (ACNM, 2010) and the other is for water birth (ACNM, 2014b). BirthTOOLS.org also links to Simkin’s (2014) “Road Map of Labor.” Nurses can use such resources in their nursing practice individually and can use the evidence-based information contained
Making changes in practice may require nurses to influence others within the health care team to first recognize the value of physiologic birth and then to obtain needed knowledge and skills in these resources to influence practice change among colleagues and other maternity care team members. Holding a journal club where BirthTOOLS.org is discussed is one way of introducing the evidence base for practice change to other nurses on the unit. Discussing some of the unit-specific barriers to physiologic birth in such a forum may lead to change. Common barriers to changing practice include limited knowledge of the evidence, lack of leadership and support for
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BirthTOOLs birthtools.org
National Institute for Health and Care Excellence (U.K.) www.nice.org.uk/guidance/cg190/chapter/ recommendations
practice changes, and limitations in staffing or access to resources such as peanut balls, showers, or tubs. Journal clubs can address questions about the evidence base for practice change as a first step. Another way to influence practice is to look for nurses who have skills that support physiologic birth. Ask them to mentor
to hospital education programs related to labor support. Seeking support from administration to provide education to support physiologic birth is also an opportunity. Collaborating with section and chapter meetings of national organizations, such as AWHONN, is another opportunity for education and training to support physiologic birth.
Hospitals and Organizations
Encouraging physiologic birth offers the opportunity to improve quality and safety of care as well as maternal and family satisfaction with the birth process other nurses on the unit or hold a labor support training program for nurses using community doulas, nurse-midwives, or other clinicians if there are not already nurses on the unit with these skills. Assessment of skills and understanding strengths and limitations as a first step can aid in supporting next steps in seeking new knowledge and mentorship, or in identifying an expert in promoting physiologic birth who can mentor others. Some birthing units designate nurses to serve as an onsite resource to colleagues. In-service education is required for perinatal nurses who provide care to women receiving intermittent or continuous electronic fetal monitoring. Albers (2007) suggests that, given the importance of providing labor support, BirthTOOLS. org could be used to provide labor support education for all perinatal nurses. The “Promoting Comfort in Labor” section of the site (birthtools.org/Promoting-Comfort-in-Labor) provides links
Box 3 BirthTOOLS.org “Menu of Change” 1. Promoting Spontaneous Onset of Labor 2. Promoting Progress in Labor • Promoting Progress in First Stage Labor • Transitioning Into the Birth Setting • Promoting Physiologic Pushing in Second Stage Labor 3. Promoting Comfort in Labor • Coping With Labor • Nutrition and Hydration 4. Assessment of Fetal Well-Being 5. Dyad Care in the Immediate Postpartum
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Although some changes can be made in individual nursing practice, there is increasing focus on hospitals and organizations to improve quality and safety. Encouraging physiologic birth offers the opportunity to improve quality and safety of care as well as maternal and family satisfaction with the birth process (ACNM, 2014a). Because physiologic birth is associated with reduced use of technology and unnecessary interventions, associated risks are likely to be reduced. Routine continuous electronic fetal monitoring is an example of unrestrained use of technology not supported by research evidence and associated with an increased rate of cesarean birth (Romano & Lothian, 2008; Zwelling, 2008). Recent efforts are aimed at reducing the rate of primary cesarean birth (ACOG & SMFM, 2014; Caughey, 2014). Use of evidence-based methods to support physiologic birth directly affects primary cesarean birth rates, a performance measure designated by the Joint Commission (2012). It is not just for accreditation that improved quality and safety is important. Since the release of the report To Err Is Human: Building a Safer Health System (Kohn et al., 2000), consumers, clinicians, and health care administrators have been alert to safety issues in health care. Supporting physiologic birth can help reduce routine unnecessary interventions and improve quality and safety during the childbearing process (Buckley, 2015). Satisfaction with the birth experience, another measure of importance to hospitals and administrators, may increase with physiologic birth. In a study of symptoms of posttraumatic stress disorder (PTSD) after childbirth, Beck, Gable, Sakala, and Declercq (2011) found that women who had symptoms of PTSD were more likely than others to have been pressured to have an induction, epidural, or a planned cesarean birth. These interventions may be avoided when physiologic birth is supported, potentially improving a woman’s experience and increasing maternal and family satisfaction while reducing PTSD symptoms. Finally, administrators, payers, and consumers are interested in reducing the cost of health care. Reducing use of routine unnecessary interventions is one way to reduce health care costs (James & Savitz, 2011). In addition, those interventions carry risks of iatrogenic complications that can increase costs and sometimes length of stay (ACNM, 2014a). Because hospitals are reporting more quality data to the public, consumers might choose hospitals with lower rates of complications and adverse events.
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A Call to Action Promoting physiologic birth in the hospital setting requires a philosophic shift in many cases. Nurses can lead the charge to change the philosophy of care and birth practices to make birth safer and more satisfying for families. Changing philosophies and, ultimately, practice requires education, time, and patience.
Contribute to a Culture of Change Practice changes are often associated with a culture of clinical inquiry. To lead change, nurses must be armed with evidence from current peer-reviewed journal articles and other reputable sources. One way to uncover evidence is to collaborate with nurse faculty or nurse researchers at local academic institutions. Another way to learn more about physiologic birth is to attend as many births as possible with no to low intervention or to shadow a certified nurse-midwife in a hospital supportive of physiologic birth, at a home birth, or in a free-standing birth center. A nursing model that is wellness-oriented is very compatible with the midwifery model when applied to care in childbirth. Another option is to provide labor support for a friend who plans to avoid an epidural during labor; this can provide firsthand experience from a different perspective that can be valuable when re-evaluating current care practices. Many agencies have courses for labor support or doula training tailored to nursing professionals. Alternatively, nurse-midwives, nurses, or other health care providers who are known to be particularly
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Engage Multiple Stakeholders Change often occurs when multiple stakeholders have similar visions. Developing a hospital task force composed of perinatal stakeholders allows for exploration of practice changes. BirthTOOLS.org is an appropriate resource to assist this process. Later these task forces can develop checklists, protocols, and bundles to assist with the implementation of practices associated with physiologic birth. Consumers and providers can be involved in these practice changes to improve the probability of success. New or varied practices within a birth environment are facilitated with the implementation of mentors and champions.
Changing philosophies and, ultimately, practice requires education, time, and patience Mentors and champions provide clinical guidance and support through the process of change.
Study Impact and Disseminate Results When practice changes are made, it is important to carefully study their impact and disseminate the results. The results of nurse-led quality improvement projects and research studies need to be presented to audiences of all maternity care stakeholders at the local, state, and national levels. In this way, changes in nurse-led practice may affect change in different birth environments. Publishing results in a peer-reviewed journal is another method of making a long-lasting impact on a larger group of birth stakeholders.
Conclusion Physiologic birth is associated with improved maternal and fetal health outcomes, as well as maternal and family satisfaction with the birth experience. Although physiologic birth is not yet considered routine in many hospitals, any practice that promotes physical and emotional health and improves maternal and family satisfaction is a worthy pursuit. Implementing a new or modified practice change is never simple or easy, yet the process can be greatly facilitated when evidence-based resources are accessible. BirthTOOLS.org was developed to provide resources related to physiologic birth in an easily accessible format. Perinatal nurses are well equipped and critical to affecting and sustaining birth practice changes, making them the perfect professionals to lead the charge for supporting physiologic birth. NWH
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Childbearing women and their families may or may not be aware of trends in childbirth, including prevalence of elective inductions, cesarean births, and use of epidural analgesia. They may lack knowledge of the risks and complications of these interventions (Glantz, 2012). For example, an elective induction may sound convenient to a pregnant woman at 38 weeks who has family coming from across the country to be present for her birth. She may not be aware of maternal and fetal alterations that are encountered when labor is induced rather than when it starts spontaneously. In a study in which education about elective induction was given to women attending prenatal classes, 27.9% of class attendees had elective inductions compared with 37% of the women who did not attend the classes (Simpson, Newman, & Chirino, 2010). This study underscores the need for informed, shared decision-making in health care. Consumers who are fully informed about their options before presenting to the maternity care unit have the opportunity to implement their desired choices for care during labor and birth. Resources to educate consumers prenatally about physiologic birth care practices include those that describe the evidence base for and benefits of physiologic birth, such as “Normal Healthy Childbirth for Women & Families: What You Need to Know” (ACNM, 2014c) and Lamaze International’s online presentation of “Healthy Birth Practices” (Lamaze International, 2015).
skilled in labor support can be invited to conduct a seminar for a local group of perinatal nurses and health care providers.
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References Adams, E. (2012). The psychometric properties of an instrument measuring the beliefs of intrapartum nurses related to birth practice (Doctoral dissertation). Retrieved from CINAHL Plus Full Text. (UMI Order AAI3538778) Adams, E. D., & Bianchi, A. L. (2008). A practical approach to labor support. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 37(1), 106–115. doi:10.1111/j.1552-6909.2007.00213.x Albers, L. L. (2007). The evidence for physiologic management of the active phase of the first stage of labor. Journal of Midwifery & Women’s Health, 52(3), 207–215. American College of Nurse-Midwives (ACNM). (2010). Nitrous oxide for labor analgesia. Journal of Midwifery & Women’s Health, 55(3), 292–296. doi:10.1016/j.jmwh.2010.03.003 American College of Nurse-Midwives (ACNM). (2012). Supporting healthy and normal physiologic childbirth: A consensus statement by the American College of Nurse-Midwives, Midwives Alliance of North America, and the National Association of Certified Professional Midwives. (5), 529–532. doi:10.1111/ j.1542-2011.2012.00218.x American College of Nurse-Midwives (ACNM). (2014a). Birth matters. Silver Spring, MD: Author. Retrieved from www.midwife .org/ACNM/files/ccLibraryFiles/FILENAME/000000004448/ HBI-BirthMatters-100314.pdf American College of Nurse-Midwives (ACNM). (2014b). Hydrotherapy during labor and birth. Position statement. Silver Spring, MD: Author. Retrieved from www.midwife.org/ACNM/files/ ccLibraryFiles/Filename/000000004048/Hydrotherapy-DuringLabor-and-Birth-April-2014.pdf American College of Nurse-Midwives (ACNM). (2014c). Normal, healthy childbirth for women & families: What you need to know. Silver Spring, MD: Author. Retrieved from www. ourmomentoftruth.com/omot/files/BirthToolFiles/FILENAME/000000000002/NormalBirthAndYou-031815.pdf American College of Obstetricians and Gynecologists (ACOG) & Society for Maternal-Fetal Medicine (SMFM). (2014). Obstetric care consensus no. 1: Safe prevention of the primary cesarean delivery. Obstetrics & Gynecology, 123(3), 693–711. doi:10.1097/01. AOG.0000444441.04111.1d Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). (2011). Nursing support of laboring women. An official position statement of the Association of Women’s Health, Obstetric & Neonatal Nursing. Journal of Obstetric, Gynecologic, & Neonatal Nursing 40(5), 665–666. doi:10.1111/j.15526909.2011.01288.x Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). (2014a). Nursing care quality measurement. Journal of Obstetric, Gynecologic, & Neonatal Nursing 43(1), 132–133. doi:10.1111/1552-6909.12276 Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). (2014b). Women’s health and perinatal nursing care quality draft measures specifications. Washington, DC: Author. Retrieved from www.awhonn.org/awhonn/content.do?name=02_ practiceresources/02_perinatalqualitymeasures.htm
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Beck, C. T., Gable, R. K., Sakala, C., & Declercq, E. R. (2011). Posttraumatic stress disorder in new mothers: Results from a twostage U.S. national survey. Birth, 38(3), 216–227. doi:10.1111/ j.1523-536X.2011.00475.x Buckley, S. (2015). Hormonal physiology of childbearing: Evidence and implications for women, babies, and maternity care. Washington, DC: Childbirth Connection Programs, National Partnership for Women & Families. Retrieved from childbirthconnection .org/pdfs/CC.NPWF.HPoC.Report.2015.pdf Caughey, A. (2014). Induction of labour: Does it increase the risk of cesarean delivery? BJOG: An International Journal of Obstetrics and Gynaecology, 121(6), 658–661. doi:10.1111/14710528.12329 Declercq, E. R, Sakala, C., Corry, M. P., Applebaum, S., & Herrlich, A. (2013). Listening to Mothers III: Pregnancy and birth. New York, NY: Childbirth Connection. Dixon, L., Skinner, J. P., & Foureur, M. (2013). The emotional and hormonal pathways of labour and birth: Integrating mind, body and behaviour. New Zealand College of Midwives Journal, 48, 15–23. doi:10.12784/nzcomjnl48.2013.3.15-23 Glantz, J. C. (2012). Obstetric variation, intervention, and outcomes: Doing more but accomplishing less. Birth, 39(4), 286– 290. doi:10.1111/birt.12002 International Confederation of Midwives. (2014). Position statement: Keeping birth normal. The Hague, The Netherlands: Author. Retrieved from www.internationalmidwives.org/assets/ uploads/documents/Position%20Statements%20-%20English/ Reviewed%20PS%20in%202014/PS2008_007%20V2014%20 Keeping%20Birth%20Normal%20ENG.pdf James, B. C., & Savitz, L. A. (2011). How Intermountain trimmed health care costs through robust quality improvement efforts. Health Affairs, 30(6), 1185–1191. doi:10.1377/hlthaff.2011.0358 Joint Commission. (2012). Specifications manual for Joint Commission national quality measures (v2013A1). Oak Brook, IL: Author. Retrieved from https://manual.jointcommission.org/ releases/TJC2013A/MIF0167.html Kohn, L. T., Corrigan, J. M., Donaldson, M. S., Committee on Health Care in American, & Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, DC: National Academies Press. Lamaze International. (2015). About Lamaze: Lamaze healthy birth practices. Washington, DC: Author. Retrieved from www .lamazeinternational.org/healthybirthpractices Martin, J. A., Hamilton, B. E., Osterman, M. J., Curtin, S. C., & Matthews, T. J. (2013). Birth: Final data for 2012. National Vital Statistics Reports, 62(9), 1–68. National Institute for Health and Care Excellence. (2014). Intrapartum care. Retrieved from www.nice.org.uk/guidance/cg55/ resources Roberts, L., Gulliver, B., Fisher, J., & Cloyes, K. G. (2010). The coping with labor algorithm: An alternate pain assessment tool for the laboring woman. Journal of Midwifery & Women’s Health, 55(2), 107–116. doi:10.1016/j.jmwh.2009.11.002
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Sakala, C., & Corry, M. P. (2008). Evidenced-based maternity care: What it is and what it can achieve. New York, NY: Childbirth Connection, the Reforming States Group, and the Milbank Memorial Fund. Retrieved from www.milbank.org/uploads/docum ents/0809MaternityCare/0809MaternityCare.html Sauls, D. J. (2004). The Labor Support Questionnaire: Development and psychometric analysis. Journal of Nursing Measurement, 12(2), 123–132.
Simpson, K. R., Newman, G., & Chirino, O. R. (2010). Patient education to reduce elective labor inductions. MCN: The American Journal of Maternal/Child Nursing, 35(4), 188–194. doi:10.1097/ NMC.0b013e3181d9c6d6 Society of Obstetricians and Gynaecologists of Canada. (2008). Joint policy statement on normal childbirth. Journal of the Society of Obstetricians and Gynecologists of Canada, 30(12), 1163–1165. Stark, M. A., & Miller, M. G. (2009). Barriers to the use of hydrotherapy in labor. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 38(6), 667–675. doi:10.1111/j.1552-6909.2009.01065.x
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Transforming Maternity Care Vision Team, Carter, M. C., Corry, M. C., Delbanco, S., Foster, T. C., . . . Simpson, K. R. (2010). 2020 vision for a high-quality, high-value maternity care system. Women’s Health Issues, 20(1 Suppl.), S7–S17. doi:10.1016/j. whi.2009.11.006 Vogl, S., Worda, C., Egarter, C., Bieglmayer, C., Szekeres, T., Huber, J., & Husslein, P. (2006). Mode of delivery is associated with maternal and fetal endocrine stress response. BJOG: An International Journal of Obstetrics and Gynaecology, 113(4), 441–445. doi:10.1111/j.1471-0528.2006.00865.x World Health Organization & Maternal and Newborn Health/ Safe Motherhood Unit. (1996). Care in normal birth: A practical guide. Geneva, Switzerland: World Health Organization. Retrieved from apps.who.int/iris/bitstream/10665/63167/1/WHO_ FRH_MSM_96.24.pdf Zwelling, E. (2008). The emergence of high-tech birthing. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 37(1), 85–93. doi:10.1111/j.1552-6909.2007.00211.x
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Simkin, P. (2014, September 2). The roadmap of labor: A framework for teaching about normal labor [Web log post]. Retrieved from www.scienceandsensibility.org/the-roadmap-of-labor-aframework-for-teaching-about-normal-labor/
The Royal College of Midwives, The Royal College of Obstetricians and Gynaecologists, & The National Childbirth Trust. (2007). Making normal birth a reality. Consensus statement from the Maternity Care Working Party: Our shared views about the need to recognise, facilitate and audit normal birth. United Kingdom: The National Childbirth Trust. Retrieved from https://www.rcm.org. uk/sites/default/files/NormalBirthConsensusStatement.pdf
CNE
Romano, A. M., & Lothian, J. A. (2008). Promoting, protecting, and supporting normal birth: A look at the evidence. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 37(1), 94–104. doi:10.1111/j.1552-6909.2007.00210.x
CNE
Post-test Questions Instructions: To access this CNE activity online, visit http://awhonnjournals.org. CNE for this activity is available online only; written tests submitted to AWHONN will not be accepted.
http://awhonnjournals.org
1.
Which of the following statements defines physiologic birth? a. Birth that is attended by a midwife. b. Birth that is powered by the innate human capacity of the woman and fetus. c. Birth that takes place outside the hospital setting.
7.
Which of the following is cited in this article as a common barrier to changing practice with regard to physiologic birth? a. Hospital budget cuts. b. Lack of training in skin-to-skin contact. c. Limitations in staffing resources.
2.
Which of the following benefits has been associated with physiologic birth? a. Greater ease in losing pregnancy weight gain. b. Less pain during labor. c. Shorter duration of labor.
8.
3.
In the Listening to Mothers III survey, what percentage of women who had given birth in the prior 2 years reported having induction of labor? a. 10% b. 30% c. 67%
In a study in which education about elective induction was given to women attending prenatal classes, the elective induction rate among women attending these classes compared with the rate of those who did not attend differed by how many percentage points? a. 3.2 b. 9.1 c. 10.7
9.
Which of these statements do the authors suggest as helping to garner buy-in from both consumers and health care administrators regarding physiologic birth? a. Physiologic birth can reduce use of unnecessary interventions, thus lowering costs and possibly length of stay. b. Physiologic birth is a natural process in which a woman controls her birth experience. c. Physiologic birth is preferred by a majority of pregnant women.
4.
In the Listening to Mothers III survey, what percentage of women who had given birth in the prior 2 years reported having access to a midwife? a. 6% b. 10% c. 46%
5.
What is a nursing care action that can support physiologic birth? a. Encourage position changes and movement throughout labor, including upright positions. b. Monitor fetal heart tracings. c. Provide a referral to a lactation consultant.
6.
What is BirthTOOLS.org? a. An online site for maternity care medical instruments. b. An online site providing resources to aid clinicians in supporting physiologic birth. c. An online site where nurses and other clinicians can learn to become doulas.
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10. What is an important step to support nurse-led practice change that supports physiologic birth in different birth environments? a. Having obstetricians lead the practice change. b. Obtaining grants to fund the practice change. c. Studying the impact of the change in one setting and disseminating the results.
Volume 20
Issue 1