Continuous Support in Labor: Continuous Support in Labor: An Underused Evidence-Based An Underused Evidence-Based

PracticePractice

Liza Goldman Huertas, MD Liza Goldman Huertas, MD

Obstetrics RotationObstetrics Rotation

Dept. of Family & Social MedicineDept. of Family & Social Medicine

AgendaAgenda Review some overused harmful practices and Review some overused harmful practices and

underused beneficial practices in maternity care underused beneficial practices in maternity care in the U.S.in the U.S.

Case related to continuous support in laborCase related to continuous support in labor Define continuous support in laborDefine continuous support in labor Review evidence for doula careReview evidence for doula care Relate doula care to other aspects of evidence-Relate doula care to other aspects of evidence-

based maternity carebased maternity care Identify pts most likely to benefit from doula careIdentify pts most likely to benefit from doula care Discuss implications for our practiceDiscuss implications for our practice

Room for Improvement: Room for Improvement: Maternity Care in the U.S.Maternity Care in the U.S.

The U.S. has some of the highest infant The U.S. has some of the highest infant mortality rates among industrialized mortality rates among industrialized countries… and is falling in ranking: 29th countries… and is falling in ranking: 29th among countries, tied with Poland and among countries, tied with Poland and Slovakia (CDC)Slovakia (CDC)

In 2007, CDC reported an In 2007, CDC reported an increaseincrease in in U.S. maternal mortality ratesU.S. maternal mortality rates

Despite highest cost, best technologyDespite highest cost, best technology

Infant Mortality RankingInfant Mortality Ranking

Infant and Maternal MortalityInfant and Maternal Mortality

Complex social phenomena with many contributing Complex social phenomena with many contributing factors:factors:

Overall Socioeconomic wellbeing of societyOverall Socioeconomic wellbeing of society Social Status of women and subgroups of O+: Social Status of women and subgroups of O+:

economic opportunities, education, safetyeconomic opportunities, education, safety Nutrition, health status of vulnerable womenNutrition, health status of vulnerable women Obesity and DiabetesObesity and Diabetes Access to health care: 1°, prenatal, preventiveAccess to health care: 1°, prenatal, preventive Prematurity, LBW, C-section rate, IVF/multiples, Prematurity, LBW, C-section rate, IVF/multiples,

early inductionsearly inductions

ExpensiveExpensive

QuickTime™ and a decompressor

are needed to see this picture.

Evidence-Based Maternity Evidence-Based Maternity Care: The Millbank ReportCare: The Millbank Report

High rates of interventions with risks of High rates of interventions with risks of adverse effects (overused practices)adverse effects (overused practices)

Highlighted Overused Practices: Labor Highlighted Overused Practices: Labor Induction, Epidural & Spinal Analgesia, C-Induction, Epidural & Spinal Analgesia, C-Section, Continuous EFM, Rupture of Section, Continuous EFM, Rupture of Membranes, Episiotomy, Certain Routine Membranes, Episiotomy, Certain Routine Prenatal Screening PracticesPrenatal Screening Practices

Beneficial underused interventionsBeneficial underused interventions

Induction of LaborInduction of Labor

Theoretical concerns: pitocin may interfere with Theoretical concerns: pitocin may interfere with physiologic oxyctocin function in PPH, bonding, physiologic oxyctocin function in PPH, bonding, breastfeeding; iatrogenic prematurity in infant, ?breastfeeding; iatrogenic prematurity in infant, ?Effects on brain development in final 1-2 wks of Effects on brain development in final 1-2 wks of pregnancy (in-utero vs. ex-utero)pregnancy (in-utero vs. ex-utero)

Increased rates of C/S in 1st time mothersIncreased rates of C/S in 1st time mothers Increased EFMIncreased EFM More epidural analgesiaMore epidural analgesia More assisted deliveryMore assisted delivery Increases costIncreases cost

Epidural & Spinal AnalgesiaEpidural & Spinal Analgesia

Maternal effects: immobility, voiding difficulty, Maternal effects: immobility, voiding difficulty, sedation, fever, hypotension, longer 2nd stage, sedation, fever, hypotension, longer 2nd stage, perineal tearsperineal tears

Increased IVF, BP monitoring, EFM, bladder Increased IVF, BP monitoring, EFM, bladder cath, pitocin, meds for hypotension, forceps or cath, pitocin, meds for hypotension, forceps or vacuum delivery, episiotomyvacuum delivery, episiotomy

Under some conditions, likelihood of C/SUnder some conditions, likelihood of C/S Fetal /newborn risks: fetal tachycardia & Fetal /newborn risks: fetal tachycardia &

bradycardia, hyperbilirubinemia, sepsis workups, bradycardia, hyperbilirubinemia, sepsis workups, more abx, lower newborn assessment scoresmore abx, lower newborn assessment scores

Increased CostIncreased Cost

C-SectionC-Section Life-saving for absolute indications: cord pro-Life-saving for absolute indications: cord pro-

lapse, previa, abruption, persistant transverse. lapse, previa, abruption, persistant transverse. Increases risk of: maternal death, surgical injury, Increases risk of: maternal death, surgical injury,

PPH, emergent hyst, DVT, CVA, infection, pro-PPH, emergent hyst, DVT, CVA, infection, pro-longed hosp/rehosp, intense & prolonged pain, longed hosp/rehosp, intense & prolonged pain, bowel obstruction, poor birth experience, poor bowel obstruction, poor birth experience, poor mental health & overall functioning, abruption, mental health & overall functioning, abruption, previa, accreta, uterine rupture, infertility previa, accreta, uterine rupture, infertility

For infants: iatrogenic prematurity, LBW, For infants: iatrogenic prematurity, LBW, stillbirth, respiratory problems, failure to BFstillbirth, respiratory problems, failure to BF

Increased risk with repeat C/S. Increased risk with repeat C/S.

Case StudyCase Study

16yo P0 @40 and 6 undergoing IOL. No 16yo P0 @40 and 6 undergoing IOL. No prenatal issues. No PMH. prenatal issues. No PMH.

Pt’s mother & older sister present at bedside. Pt’s mother & older sister present at bedside. Older sister has scrubs on; bilingual, assertive, Older sister has scrubs on; bilingual, assertive, asks questions.asks questions.

FOB to be present . FOB and pt are not close FOB to be present . FOB and pt are not close but FOB is traveling from Boston to be present.but FOB is traveling from Boston to be present.

Nursing staff comes into conflict with family over Nursing staff comes into conflict with family over policy of 2 family members only.policy of 2 family members only.

Nursing staff increasingly annoyed. Nursing staff increasingly annoyed.

Case Study p2Case Study p2

Initially coping well with contractions, surprising Initially coping well with contractions, surprising the nurses. Hoping to avoid epidural analgesia.the nurses. Hoping to avoid epidural analgesia.

Mother becomes B’s only support. She speaks Mother becomes B’s only support. She speaks only Spanish. Anxious, distrusts staff & quiet only Spanish. Anxious, distrusts staff & quiet when staff present.when staff present.

B is increasingly frustrated. Wants to eat, go to B is increasingly frustrated. Wants to eat, go to the bathroom. Uncomfortable lying down. Does the bathroom. Uncomfortable lying down. Does not want FOB present for vaginal exams. not want FOB present for vaginal exams. Caregivers express annoyance outside room.Caregivers express annoyance outside room.

Frequency/intensity of contractions increase, B Frequency/intensity of contractions increase, B gets desperate and decides to get an epidural.gets desperate and decides to get an epidural.

Case Study p3Case Study p3

B’s mother upset because she feels B would be B’s mother upset because she feels B would be coping better with pain if her sister was present. coping better with pain if her sister was present. (Sister left because security was called earlier).(Sister left because security was called earlier).

Anesthesiology delayed in OR. Anesthesiology delayed in OR. B yells at mother & providers, demands epidural, B yells at mother & providers, demands epidural,

increasingly suffering & terrified. increasingly suffering & terrified. B eventually gets epidural, comfortable again.B eventually gets epidural, comfortable again. Epidural is dense and B can barely move her Epidural is dense and B can barely move her

legs. Progress slows. Pitocin is titrated up. legs. Progress slows. Pitocin is titrated up. FHR pattern becomes increasingly concerning. FHR pattern becomes increasingly concerning. C-section discussed.C-section discussed.

Case Study p4Case Study p4 2nd stage complicated by “poor maternal effort”. 2nd stage complicated by “poor maternal effort”.

Providers tell pt she isn’t doing her job, needs to Providers tell pt she isn’t doing her job, needs to put in real effort. Fear, frustration turns to yelling.put in real effort. Fear, frustration turns to yelling.

As B pushes her baby out, room goes quiet. The As B pushes her baby out, room goes quiet. The baby’s head is blueish.Tight nuchal cord x3. baby’s head is blueish.Tight nuchal cord x3.

No exclamations of joy as infant resuscitated. No exclamations of joy as infant resuscitated. Doctors complete their care of the mother.Doctors complete their care of the mother.

Infant improves quickly but pt & mother are not Infant improves quickly but pt & mother are not updated. Anxiety & grief are palpable.updated. Anxiety & grief are palpable.

An hour later, when doctors & nurses are An hour later, when doctors & nurses are finished taking care of her, B cries inconsolably. finished taking care of her, B cries inconsolably. She is not interested in holding her baby.She is not interested in holding her baby.

Selected Underused Selected Underused InterventionsInterventions

Midwives & Family PhysiciansMidwives & Family Physicians Smoking Cessation for Pregnant WomenSmoking Cessation for Pregnant Women Prematurity Prevention: Centering PregnancyPrematurity Prevention: Centering Pregnancy External Version to Turn Breech BabiesExternal Version to Turn Breech Babies Delayed and Spontaneous PushingDelayed and Spontaneous Pushing Non-pharmacologic measures to relieve pain, Non-pharmacologic measures to relieve pain,

promote comfort & labor progresspromote comfort & labor progress Non-supine positionsNon-supine positions

More Underused More Underused InterventionsInterventions

Early Skin to Skin ContactEarly Skin to Skin Contact Breastfeeding & BF Interventions (e.g. Breastfeeding & BF Interventions (e.g.

Baby Friendly Hospitals)Baby Friendly Hospitals) Psychosocial Interventions for Post-Psychosocial Interventions for Post-

partum Depressionpartum Depression Continuous Support in LaborContinuous Support in Labor

What is Continuous Support What is Continuous Support in Laborin Labor

Continuous presenceContinuous presence Emotional supportEmotional support Advice regarding comfort measures and Advice regarding comfort measures and

copingcoping Patient educationPatient education Advocacy on behalf of the laboring womanAdvocacy on behalf of the laboring woman

Doulas in the United StatesDoulas in the United States

Non-medical providers of labor supportNon-medical providers of labor support Ancient Greek meaning woman of serviceAncient Greek meaning woman of service Provide emotional support, physical comfort, Provide emotional support, physical comfort,

objective view, support informed decision-objective view, support informed decision-making, facilitate communication, advocacymaking, facilitate communication, advocacy

Provide support to partners and familyProvide support to partners and family May also be interpreters & cultural brokersMay also be interpreters & cultural brokers Several accreditation organizationsSeveral accreditation organizations Postpartum doulas, end of life doulas.Postpartum doulas, end of life doulas.

Why Would Doula Care Help? Why Would Doula Care Help? TheoriesTheories

May mediate effect of birth environment: May mediate effect of birth environment: Buffers to unfamiliar, stressful Buffers to unfamiliar, stressful environments.environments.

Enhancing maternal feelings of confidence Enhancing maternal feelings of confidence & control, reducing reliance on medical & control, reducing reliance on medical interventions. interventions.

Potential to limit “cascade of interventions” Potential to limit “cascade of interventions” by enhancing labor physiologyby enhancing labor physiology

Why Would Doula Care Help? Why Would Doula Care Help? Labor PhysiologyLabor Physiology

Intervene on stress response--> increased Intervene on stress response--> increased epi--> can effect FHR pattern, catecho-epi--> can effect FHR pattern, catecho-lamines decrease uterine contractility, lamines decrease uterine contractility, prolong labors--> lower APGARsprolong labors--> lower APGARs

Enhanced feto-pelvic relationships Enhanced feto-pelvic relationships (mobility, gravity, preferred positions)(mobility, gravity, preferred positions)

Why Would Doula Care Help? Why Would Doula Care Help? Possible Longterm ImpactPossible Longterm Impact

Adjustment to parenthood, self-image, Adjustment to parenthood, self-image, feelings of competence & confidencefeelings of competence & confidence

Mother-infant BondingMother-infant Bonding BreastfeedingBreastfeeding Postpartum depressionPostpartum depression Role modeling: nurturing mother, infant, Role modeling: nurturing mother, infant,

and family.and family. Encouraging healthy family relationships Encouraging healthy family relationships

Cochrane Intervention Cochrane Intervention Review: Use this practice! Review: Use this practice!

First Do No Harm: No evidence of harm from First Do No Harm: No evidence of harm from continuous support in labor has been reported.continuous support in labor has been reported.

Major Outcomes: increased chance of NSVD Major Outcomes: increased chance of NSVD

(decreased C/S, forceps and vacuum), less (decreased C/S, forceps and vacuum), less likely to use pain medications, greater likely to use pain medications, greater satisfaction with the childbirth experience, satisfaction with the childbirth experience, slightly shorter labors.slightly shorter labors.

Cochrane Intervention Review Cochrane Intervention Review (Meta-Analysis) 2007(Meta-Analysis) 2007

16 trials, 11 countries, 13,000 women16 trials, 11 countries, 13,000 women Controlled trials: support person could be Controlled trials: support person could be

certified professional or trained family membercertified professional or trained family member Outcomes included: pitocin, EFM, Outcomes included: pitocin, EFM,

pharmacologic analgesia, severe pain, labor pharmacologic analgesia, severe pain, labor length, SVD, C/S, episiotomy, perineal trauma, length, SVD, C/S, episiotomy, perineal trauma, low APGARS, low cord pH, NICU, anxiety during low APGARS, low cord pH, NICU, anxiety during labor, perception of low control, longer term labor, perception of low control, longer term maternal outcomesmaternal outcomes

Subgroup Analysis: effects of childbirth Subgroup Analysis: effects of childbirth environment, provider of care, timing of careenvironment, provider of care, timing of care

Cochrane: Cochrane: What doulas can doWhat doulas can do

Increase NSVDs (double in some cases)Increase NSVDs (double in some cases) Decrease regional analgesia, any Decrease regional analgesia, any

analgesiaanalgesia Decrease vacuum, forceps, C sectionsDecrease vacuum, forceps, C sections Fewer negative childbirth experiencesFewer negative childbirth experiences Slightly shorter labor length, less than 1 hr Slightly shorter labor length, less than 1 hr

difference (effect diluted by trials involving difference (effect diluted by trials involving staff doulas)staff doulas)

Subgroup Analysis: Care Subgroup Analysis: Care most effectivemost effective

When provided by person who was not a When provided by person who was not a member of the hospital staffmember of the hospital staff

In settings where epidural analgesia was In settings where epidural analgesia was not routinely usednot routinely used

When started early in labor--> Evidence of When started early in labor--> Evidence of dose-response phenomenondose-response phenomenon

Insufficient Data Insufficient Data (Cochrane could not assess)(Cochrane could not assess)

Mother’s and infants wellbeing postpartum Mother’s and infants wellbeing postpartum Perineal traumaPerineal trauma Relationship between woman and partnerRelationship between woman and partner Urinary and fecal incontinenceUrinary and fecal incontinence

Conclusions from Authors of Conclusions from Authors of Cochrane ReviewCochrane Review

Continuous support should be the norm Continuous support should be the norm not exception!not exception!

Birth environments should afford privacy, Birth environments should afford privacy, be empowering and non-stressfulbe empowering and non-stressful

Birth environments should not be Birth environments should not be characterized by routine interventions that characterized by routine interventions that add risk without clear benefitadd risk without clear benefit

Evidence of Longterm Benefit Evidence of Longterm Benefit in Smaller Trialsin Smaller Trials

Higher rates of breastfeeding at 6 weeks Higher rates of breastfeeding at 6 weeks Improved mother-infant bondingImproved mother-infant bonding Decreased rates of postpartum depressionDecreased rates of postpartum depression Increased confidence in & perception of Increased confidence in & perception of

ease of parentingease of parenting Positive maternal self-image and positive Positive maternal self-image and positive

perception of bodyperception of body Needs more study to corroborate.Needs more study to corroborate.

May have particular benefit May have particular benefit for certain groupsfor certain groups

Young women, especially teensYoung women, especially teens Low income womenLow income women Women of color, Black women & LatinasWomen of color, Black women & Latinas Doula programs for Spanish-, Doula programs for Spanish-,

Vietnamese-, and Somali-speaking Vietnamese-, and Somali-speaking immigrant womenimmigrant women

Incarcerated womenIncarcerated women Women laboring aloneWomen laboring alone

Implications for Family Implications for Family Physicians?Physicians?

ReferencesReferences Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during

childbirth. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: childbirth. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD003766.CD003766.

Stuebe, A. Continuous intrapartum support. In: UpToDate, Basow, DS (Ed), UpToDate, Stuebe, A. Continuous intrapartum support. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2009.Waltham, MA, 2009.

Sakala, C and Corry, MP. Sakala, C and Corry, MP. Evidence-Based Maternity Care: What It Is and What It Can AchieveEvidence-Based Maternity Care: What It Is and What It Can Achieve. 2008.. 2008.

Newton KN, Chaudhuri J, Grossman X, Merewood A. Factors associated with exclusive Newton KN, Chaudhuri J, Grossman X, Merewood A. Factors associated with exclusive breastfeeding among Latina women giving birth at an inner-city baby-friendly hospital. J breastfeeding among Latina women giving birth at an inner-city baby-friendly hospital. J Hum Lact. 2009 Feb;25(1):28-33.Hum Lact. 2009 Feb;25(1):28-33.

Dundek LH. Establishment of a Somali doula program at a large metropolitan hospital. J Dundek LH. Establishment of a Somali doula program at a large metropolitan hospital. J Perinat Neonatal Nurs. 2006 Apr-Jun;20(2):128-37.Perinat Neonatal Nurs. 2006 Apr-Jun;20(2):128-37.

Schroeder C, Bell J. Doula birth support for incarcerated pregnant women. Public Health Schroeder C, Bell J. Doula birth support for incarcerated pregnant women. Public Health Nurs. 2005 Jan-Feb;22(1):53-8.Nurs. 2005 Jan-Feb;22(1):53-8.

Lantz PM, Low LK, Varkey S, Watson RL. Doulas as childbirth paraprofessionals: results Lantz PM, Low LK, Varkey S, Watson RL. Doulas as childbirth paraprofessionals: results from a national survey. Womens Health Issues. 2005 May-Jun;15(3):109-16.from a national survey. Womens Health Issues. 2005 May-Jun;15(3):109-16.

Stein MT, Kennell JH, Fulcher A. Benefits of a doula present at the birth of a child. J Dev Stein MT, Kennell JH, Fulcher A. Benefits of a doula present at the birth of a child. J Dev Behav Pediatr. 2003 Jun;24(3):195-8.Behav Pediatr. 2003 Jun;24(3):195-8.

www.dona.www.dona.orgorg, , www.childbirthconnection.orgwww.childbirthconnection.org