5 contraction patterns of labour
TRANSCRIPT
Contraction Patterns of LabourHow do they influence our management of care to support the normal process of labour?
Know the normalWork with the abnormal to make it normal
In the past quarter century, advances in medical
technologyhave been accompanied by an
increase inintervention-intensive labour
and birth ( Hamilton, Martin, & Ventura, 2006 ).
Nature ’ s simpleplan for birth has been replaced by
a maternity caresystem that routinely interferes
with the normal physiologicalprocess and in doing so introduces
unnecessaryrisks for mother and baby.
Women no longer have confi -dence in their ability to give birth without technologic intervention.
The physiological mechanisms of labour and
childbirthare NOT completely
understood.
Intrinsic factors within the uterine muscle affect contractions and
progressive cervical dilation. Thus,spontaneous onset of term labour
signifies the baby’sreadiness to be born as well as the
mother ’s physiologicalreceptiveness to the process.
Don’t pick a plum before it is ripe
The Cervix needs to be soft
With good observation applied anatomy and physiology, and
critical thinking during the birthing process it is possible
to achieve normal vaginal birth.
One of my failings as a midwife is my inability to assess the strength and effectiveness of uterine contractions. I am often asked
How strong are her contractions?
How effective are her contractions
Can we measure the effectiveness of contractions?
Failure to understand labour
Early interventions Pain relief Epidurals Artificial rupture of membranes Oxytocinon/Syntocinon/Pitocin C section
There are Many theories
Friedmann defined the three stages of labour
Latent and active Second stage Third stage
These theories do not have any application to anatomy
and physiology or to the contraction patterns of
labourthey merely measure time
frames.
Failure to diagnose labour
In 2013, researchers published a report of 38,484 first-time C-sections that occurred among a national sample of women. The overall C-section rate among first-time mothers was 30.8%. More than 1 in 3 (35%) of these C-Sections were due to a diagnosis of “failure to progress,” or slow progress in labour. This means that 10%, or 1 in 10, of all first-time mothers in the U.S. had a C- Section for failure to progress during the years 2002-2008 (Boyle, Reddy et al. 2013).
More than 4 in 10 of these women who had C-sections for failure to progress had not even reached 5 cm dilation before they were taken to surgery. This means that many of these women were still in very early labour when they were told that they weren’t dilating fast enough (Boyle, Reddy et al. 2013).
Progress and Time A substantial number of women have unplanned
C- Sections for failure to progress during a medical induction. In a 2010 study that included 233,844 new-borns born between 2002 and 2008, researchers found that about half of all induced women who had C-sections for failure to progress had not reached 6 cm yet (53%)– indicating that they were still in very early labour when their inductions were labelled as “failed”
(Zhang et al., 2010b).
The baby is the passenger presentation is important
Power of uterine contractions are they doing the Job
The Pelvis
Outdated 3 P’s
Passenger
Power
PassageFriedmann 1955
Midwives perspective to look at the bigger picture and plan care to support the normal physiological process of child birth
The 5 P’s• Passenger• Power• Passage• Psyche• Preparation
The Art of Midwifery Consider the Five P’s Observe contraction
patterns Apply anatomy and
physiology to the six stages of labour
Know the birthing hormones and applied anatomy and physiology
Look at the bigger picture then plan yourcare/advice
And education to get the best outcomes for the individual woman
Labour contractions can increase and decrease in
frequency following admission to hospital. This
may be associated with dilatation and posture
rather than anxietyMidwifery 2009 June 25: (3)242-52 Epub2007 july 12
Missing from the statementNo reference to applied anatomy and physiology
What is really Happening?
Clock watching and timing
X
Lack of understanding leads to
Contractions are slow
Augmentation that is in apropriatley managed
Need to know latent and active phase
Lets augment the process
Foetal distress Caesarean Neonatal units
Are there 6 stages of Labour? Descent
Effacement
Active Transition Second Stage Third stage
Descent• The transverse
muscles of the uterus contract to facilitate the descent of the head into the pelvis
Oestrogen levels begin to fall and go over a few weeks
Descent
The transverse muscles continue to assist the head to descend into the pelvis. At some stage prostaglandin is released. The cervix softens. The longitudinal muscle begins to contract from the fundus to pull back the cervix over the head. This gives a picture of variable contractions. The rounded contractions giving height as the longitudinal muscles do their job. Short and sharp contractions as the head continues to descend into the pelvisEffacement
and early dilation
Effacement
Regular coordinated contractions as oxytocin is released
The longitudinal muscles pull s the cervix back over the baby’s head
Usually greater than 5cm on admission
Can stop for 1-2 hours prior to transition
Endorphins are released to assist with maternal pain management.
Active Phase
Dilation
Contraction patterns may change
The body knows what to do. If the baby is in posterior position there will be more
descent patterns of contractions with back pain. Babies sometimes rotate in and out of posterior
position as the baby corkscrews down into the pelvis If baby is moving from ROA to LOA. The mother needs to move position to help her baby
turn. Augmentation may drive down the Op baby and
cause obstruction if forced. In my experience forcing a baby down in the OP
position may weaken the uterus.
Can’t do it Won’t do it Cut it out Give me an
epidural Get me out of
here It’s all your fault I hate you
TransitionUsually occurs around 7-8cm
Adrenaline is released the flight and fight hormone
Can last around 20 minutes
Amy and Jo Worlds Apart
Jo in a large tertiary Hospital
Opinions for child birth
No choices Not ambulant Augmentation Fetal Distress LSCS
Amy in a midwifery led unit
Ambulant Choices Positioning Squatting Well informed Normal delivery Elated about her
experience
Case scenarios Mary home birth
Rajeshri- induction Jo- Posterior birth Kshama -
Unprepared Noha- Waterbirth
Picture perfect
Tough love and bargaining
Positioning
Tough love/positioning Tough love
Early admission leads to intervention
Burnt out midwives More midwifery staff for one to one care. High intervention rates Increases the risk of LSCS Increased risk babies requiring intensive care Affects on breastfeeding Postnatal depression Increased staffing levels Exhausted obstetricians
The Birthing Environmentwarmsafeprivatequietdark
Active Birth
Hospital Walking Garden
Understand the contraction patterns of labour
Understand and apply anatomy and physiology of the uterus
Take into account the Five P’s when making decisions
Understand the roles of birthing hormones
Midwife’s Role
To support the normal physiological process of childbirth
My intervention rate was much higher.
I did not understand the normal physiological process of labourI did not know how to manage the contraction patterns of labouror manage care applied to the 5P’s with a midwifery perspective
I did not know how to educate and empower my womenI was not strong enough to provide tough love
In the beginning I spent many of 16 hours with women on delivery unit.
Now I can drink tea. Usually only two to fours hours on Delivery unit.
Thanks to the continuity of care, reflection of practice, use of
complementary therapies, my vaginal birth rate is around 95%.
My epidural rate is around 4%
“Very few women spend a long time in hospital and have faith in childbirth. When midwives learn
from reflection, share knowledge and work as a team the future for our families will be sound”
Irene Chain Midwife
Your Decisions Affect the woman for life Take into consideration the professional team If not sure Ask If you don’t apply the anatomy physiology,
mental state you will have longer times on delivery maternal exhaustion and burnt out colleagues
We are a team with a wealth of knowledge and experience
Recommendations Support the natural process Tough love where necessary Better antenatal education Ambient Rooms and acceptance for women who
have little support Support your colleagues/and better communications On call sleep room for health professionals with
facilities. Empower women to take charge No CTG monitoring for low risk women