CHAPTER 13. The medical approach to labour
Introduction
Most births include some form of medical intervention. Medicine saves lives and has other health benefits. However, there is a general agreement that healthy women and fetuses do not usually need much intervention and that birth has become overly medicalised in the past 50 years.
An example is the rising caesarean rate. This varies considerably from country to country, indicating that social and cultural factors play just as much of a role as medical factors in determining the use of medicine. In parts of some countries such as Brazil the rate is as high as 85–100% with rates of 47.7% not being uncommon (Ratner 1996).
Nationally in the UK the rate is 23% (in 2003–4; RCOG 2004), in Canada 25% (Anderson & Lomas 1984, but still approximately this rate), while in the Scandinavian countries the rate is 10% (Wagner 2000). In 1985, the WHO suggested that 10–15% should be the highest rate. In the work of Ina May Gaskin, an American lay midwife who specialises in supporting natural births, fewer than 2% of women needed a caesarean. No one knows what the optimal rate should be, although Mukherjee (2006) still feels that the rate should be kept between 10 and 15%.
There is increasing concern about rising rates in medical circles as well as among advocates of natural birth, as unnecessary caesareans carry health risks to both woman and fetus.
The reasons for the spiralling rate are multifactorial and include:
1. Patient choice (about 8%).
2. Increased incidence of twins, due to assisted reproductive technologies.
3. Reluctance to undergo trial of labour if there is scar from a previous caesarean because of potential risk of uterine rupture.
4. Medico-legal pressure on practitioners.
5. Increasing safety of procedure.
6. Increasing age of women having children.
7. Increasing obesity rates.
8. Use of caesarean for breech deliveries.
Even in what are recorded as ‘normal’ births there is a high degree of intervention. In a recent study in the Trent region of the UK in over 60% of the 956 deliveries recorded as ‘normal’ or ‘spontaneous’ (i.e. excluding instrumental or caesarean section deliveries) interventions had occurred. These included amniotomy, induction, augmentation of labour, episiotomy and epidural anaesthesia. In about a third, induction or augmentation of labour had taken place, while in 89% amniotomies were performed before the cervix was fully dilated (Downe et al 2001). There is current debate about how to ‘adopt the truly scientific approach of seeking the evidence base of all methods old and new’ (Henderson & Macdonald 2004: 1096).
Some practitioners argue that we are beginning to forget what ‘normal’ birth is and that anything which interferes with the natural process of birth can be considered an intervention. This includes vaginal examinations, telling the woman to push (or not to push if the obstetrician is not available), and monitoring the fetus (especially electronic fetal monitoring), because they rely on external sources for assessing and progressing labour and because they may interfere with the interaction between the woman and her baby.
While bodyworkers are not the professionals making the decisions about the use of medicine in labour, in this current climate they need to understand the implications of the different types of procedure in order that they can support their clients during labour and in the postnatal recovery period.
Bodywork during labour if there is medical intervention
The bodyworker must recognise that they are always secondary to the primary caregiver and should not interfere with their role. However, they may be able to continue to give emotional and physical support to their client in appropriate ways.
This may include:
Reducing stress for mother
This can include continuing to work with massage, holding techniques, breathing and visualisations.
Continuing to support the physiological process of labour as much as is possible
This may include:
• Supporting the mother to be in birth positions which support the process of labour.
• Using bodywork for a pain relief option to reduce the use of pharmacological pain relief which may lead to further interventions.
Including the baby
Doctors and midwives tend to communicate with the woman about what is going on. However, they often forget about the baby. The baby is aware and appreciates some form of communication. This could be through touch or sound. It is important to encourage the woman or her partner to talk to the baby and continue to touch the abdomen. If the woman and partner are too stressed then it may be appropriate for the bodyworker to touch the abdomen and communicate with the baby.
Bodywork to support postnatal recovery after intervention
Each intervention carries different effects which the bodyworker needs to take into account when working with women in the postnatal period. Some of the emotional effects of an intervention, particularly if it was a stressful time, or the mother felt disempowered during the process, may last for years, if unprocessed.
In understanding the implications of each intervention, the bodyworker must be careful not to make the client feel ‘guilty’ about not having achieved a natural birth. While interventions have effects on the body, without relevant interventions it must be remembered that sometimes mothers and babies might die or be severely injured.
13.1. The medical model of labour
Progress is determined by:
• Dilatation of the cervix.
• Descent of fetal head, measured in fifths palpable per abdomen above or below the ischial spines.
Assessments are made to check:
• The condition of the woman: pulse rate, temperature, blood pressure, urine output, urinary protein and ketones and psychological state.
• The condition of the fetus: auscultation of heart rate, meconium in amniotic fluids, cardiotocography and measurement of fetal scalp blood pH.
The partogram
Labour is usually charted on a ‘partograph’ where cervical dilatation is plotted against time.
The ‘normal’ parameters are often defined as such: 6 hours for latent phase and 6 hours for active phase, making a total of about 12 hours for the acceptable normal duration of the first stage of labour in a primipara; multiparas do not take this long.
When labour does not fit into these parameters a diagnosis of ‘prolonged labour’ is made.
Prolonged labour: ‘failure to progress’
A main cause given for failure to progress is cephalopelvic disproportion (CPD), when the fetal head seems too big for the birth canal. This is hard to be sure of as CPD is often relative and may be due to fetal position more than size.
Other causes include:
Fetal causes
• Fetal malposition (which can often be corrected).
• Fetal malformation (e.g. hydrocephaly). These days this is very rare and is often known prior to the onset of labour due to the prevalence of ultrasound as a routine part of antenatal care in developed countries.
• Macrosomia or a large fetus. This is often due to congenital or developmental abnormalities.
Maternal causes
• Contracted pelvis, e.g. deformed through rickets.
• Pelvic tumour.
• Stenosis or scarring of the cervix which means that the cervix may not dilate effectively.
• Septae or stenosis of the vagina.
• Uterine dysfunction; this could be due to many causes.
Medical treatment
Allow labour to continue with the goal of a vaginal delivery,
OR
Intervene with instrumental delivery.
Bodywork
This can be appropriate if labour is being allowed to continue.
The woman and baby are both likely to be exhausted. Work to relax the client wherever she is experiencing tension. Work to revitalise the client: this may include energy work with the leg meridians, supporting the Kidneys and the extraordinary vessels, especially the Conception Vessel.
13.2. Monitoring in labour
Assessing fetal condition
Different checks are regularly made on the fetus to monitor how they are coping with labour. If it is deemed that the fetus is not coping, then interventions may be made either to speed up labour or deliver the fetus instrumentally.
Status of amniotic fluid
This provides some indication of fetal well-being. If there is thick meconium (fetal faecal excretion) at the onset of labour there is a five- to sevenfold increase in risk of perinatal death (MacDonald et al 1985) as well as morbidity resulting from the risk of meconium aspiration. The recent passage of meconium will be indicated by dark greenish-black-coloured amniotic fluid. Old or stale meconium is a paler greenish-brown. If there is fresh meconium the fetal heart is checked more frequently.
Pinard/manual monitoring
This is a hollow instrument (Pinard fetal stethoscope) placed on the woman’s abdomen. It involves no ultrasound and is done intermittently. It is a traditional midwifery tool and often used in home births. Its accuracy depends on the skill of the individual caregiver. It is the least invasive form of fetal monitoring.
Electronic fetal monitoring
This can be hand held and intermittent or continuous.
An electronic fetal heart monitor or cardiotocograph (CTG), ultrasound, is placed over the woman’s abdomen near the fetus’s heart. It measures the fetal heart rate and gives a readout. It need not necessarily interfere with maternal position as the woman may still be able to utilise forward leaning or upright positions, although if she moves much the printout will be inaccurate. Some care providers prefer the woman to be semi-recumbent or side-lying. It cannot be used if the woman is in water.
Hand-held monitors, also called fetal Dopplers or sonicaids, which are not attached to a graphic record can be used. These can be used in the pool and the woman can remain more mobile than with the CTG.
The fetal heart rate is usually measured every 15–30 min in early labour and every 5 min in active labour. The normal rate is between 120 and 160 beats per minute.
Fetal scalp monitoring
This is done if more accurate monitoring is needed, which may be the case if there are risk factors present such as the use of oxytocin.
It involves inserting a spinal wire electrode through the cervix and attaching it to the fetal scalp. The heart rate is measured by calculating the intervals between R waves in the fetal electrocardiographic cycles. This method of monitoring is only possible when the waters have broken and if it is needed then the membranes need to be ruptured (ARM).
Fetal blood sampling (FBS)
When the fetal heart rate pattern is suspicious then FBS should be carried out (NICE 2001). The woman is placed in the left lateral position while a sample of blood is taken from the fetus’s skull. This is sent for analysis and gives a more accurate indication of fetal distress than monitoring heart rate as it assesses oxygen levels in the brain.
Drawbacks
• Continuous monitoring may interfere with the woman’s ability to move and remain comfortable, thus increasing the need for pharmacological pain relief.
• There is variation in the clinical interpretation of the data and altered heart rate does not necessarily mean fetal compromise.
• Increased monitoring is associated with an increase in the rate of caesarean section, especially if it is used without fetal blood sampling.
• Its increased use has not been linked with a decrease in maternal or fetal mortality or morbidity. Many clinicians believe that fetuses are just as safe if someone listens to the fetal heart just after a contraction has finished and in the interval between contractions with a Pinard stethoscope or hand-held Doppler machine.
• No one fully understands the effects of ultrasound monitoring on the fetus although some small studies have postulated possible adverse effects (American Institute of Ultrasound in Medicine 2000).
• Current NICE guidelines in the UK do not recommend continuous fetal monitoring in normal labour although many hospitals worldwide still employ it.
Bodywork implications
• The client may need more support to get into comfortable positions.
• The client may need emotional support as she may get worried about her baby.
13.3. Induction
Augmentation of labour often uses similar procedures to induction but they are made during a labour which has already begun, in order to strengthen uterine contractions.
Maternal indications for induction
1. Post-term pregnancy. In the Cochrane systematic review, trials demonstrated an effect of reducing perinatal mortality only for induction conducted after 42 weeks of gestation (Crowley 1999). There are, however, variations in different clinical opinions, with some clinicians inducing before 42 weeks.
2. Hypertension, primary or pregnancy-related, which may adversely affect the continuation of the pregnancy.
3. Renal and heart disease where there is concern about the pregnancy continuing.
4. Pre-labour at term spontaneous rupture of the membranes (PROM), due to increased risk of infection. There are variations: some hospitals induce after 24 hours whereas others allow up to 96 hours (RCOG 2001) if there are no other causes for concern such as raised temperature. Research (Savitz et al 1997) shows that 86% of women go into labour within 24 hours and 91% within 47 hours spontaneously.
5. Placental abruption or other placental issues.
Fetal indications
1. Fetal compromise.
2. Fetal death.
3. Rhesus iso-immunisation.
Contraindications
The following indicate that a caesarean section is needed rather than induction:
1. Placenta praevia – vaginal birth is too dangerous.
2. CPD (cephalopelvic disproportion).
3. Oblique or transverse lie of the fetus as normal labour is not able to proceed.
4. Severe fetal compromise necessitating immediate delivery.
5. VBAC (vaginal birth after caesarean section). Induction may cause excessive uterine contractions which could be too strong for the scar.
Methods
An assessment is made of how ripe the cervix is using the Bishop score. This is a way of grading softness and effacement.
Sweeping the membranes
The membranes are stripped from the lower uterine segment at term. The maternity care provider places a finger inside the cervix and makes a circular sweeping action to separate the membranes from the cervix. The theory behind this is that the localised prostaglandin production is increased (Mitchell et al 1977). It is not associated with an increase in infection but women may feel discomfort both during and after the procedure. It is routinely offered in the UK from 40 weeks of gestation.
Prostaglandin gel (PGE2)
The next method is to use prostaglandin (PGE2) gel/tablets to ripen the cervix. Gel is applied to the cervix in the form of a pessary. This is one of the most commonly used methods of induction worldwide. It is more likely than placebo to start labour and tends to reduce the need for induction with oxytocin (Enkin et al 2000).
Benefits
• It may be a fairly gentle way of getting labour started and then labour can proceed naturally.
• It may reduce the need for oxytocin.
• It is considered the most efficacious induction agent (Henderson & Macdonald 2004: 872).
Drawbacks and risks
• Side-effects include diarrhoea and nausea. Vomiting is less common. This affects LU/LI energy.
• Sometimes the uterus responds by producing excessive contractions. Contractions may be painful and emotionally difficult for the mother to process.
• The fetus may go into distress.
• There is a sudden onset of Yang energy affecting Yang Heel, Small Intestine, Heart, GV and CV.
• Sometimes there is maternal pyrexia due to the effect on the thermoregulating centre in the brain.
Rupturing the membranes (breaking the waters/amniotic sac) – amniotomy
This involves rupturing the membranes to accelerate or initiate labour. An amnio hook is introduced into the cervix and the amniotic sac is ruptured. This requires a firm commitment to delivery (Enkin et al 2000) as it increases the risk of intrauterine infection, early decelerations of the fetal heart rate, umbilical cord prolapse and bleeding from the cervix.
It is more usually done during labour to speed it up, often after prostaglandin gel when there are signs that labour is beginning, rather than to start labour off.
Benefits
This method does not introduce hormones into the body and if the woman is nearly ready to go into labour, may help speed up progress.
Drawbacks
• It may stimulate excessive contractions.
• The fetus is no longer protected by the amniotic sac and may show an increase in fetal heart rate decelerations.
• It may be unsuccessful in establishing labour, in which case the woman is on a time frame to deliver, which may in turn lead to more intervention.
Oxytocic drugs
This is the most common induction agent used worldwide. Intravenous infusion is the licensed and most common method of administration.
Synthetic oxytocin (syntocinon or pitocin)
This is a synthetic preparation of oxytocin administered through an electronic infusion pump. It is also used to augment labour and a version (Syntometrine) is given in the third stage of labour for the preventative treatment of postpartum haemorrhage.
Benefits
Usually labour will begin.
Drawbacks
1. Uterine hyperstimulation.
2. As the woman needs to be monitored continuously, her ability to move freely will be interfered with which may also affect her ability to cope with the pain.
3. It may produce strong contractions which are not able to effectively dilate the cervix, meaning that a LSCS becomes necessary (Bidgood & Steer 1987).
4. Water retention and hyponatraemia (low levels of sodium in blood) due to the antidiuretic effect of oxytocin. Symptoms are weakness and lethargy, muscle cramps and postural hypotension.
5. It may increase the risk of postpartum haemorrhage (Stones et al 1993).
6. It may affect the complex hormonal changes for the mother, affecting the energy of the Extraordinary Vessels, especially GV.
7. Some observational studies have shown a reduced rate of breastfeeding following induced labour even among women who intended to breastfeed and when controlled for low breastfeeding rates (Out et al 1988).
8. Neonatal hyperbilirubinaemia (jaundice).
Bodywork implications
Bodywork can often be continued. Many people assume that medical induction of labour happens quickly but it often involves a lot of waiting around and medical staff are reluctant to give any pain relief because they do not know how long it will take to get labour established.
Bodywork will not only help the woman be more relaxed while waiting, thus helping her to be more likely to go into labour, but this waiting time can also be used to work on the labour focus points as much as possible to try to get labour going naturally. Once the woman has started on whatever regimen she is having, it is still possible to continue to work the labour focus points.
Postnatally work with the effects of the drugs
Bodywork can also help with pain relief. Postnatally work with the effects of the drugs.
13.4. Pain relief
This is a key part of the medical approach to labour which assumes that women need help. Some practitioners believe that the hormones released naturally by women offer more effective pain relief without the potential side-effects of medical pain relief (Buckley 2005).
In the UK the obstetrician James Young Simpson was the first person to use chloroform for the relief of pain in labour in 1847. Dr John Snow administered it to Queen Victoria during the birth of her two youngest children and it became a popular analgesia. It was also introduced in the USA at around the same time.
Entonox (gas and air, nitrous oxide)
This is nitrous oxide inhaled through a mask. It provides partial relief of pain through its sedative effect. It is used fairly extensively in the UK but not so much worldwide, as in some countries such as Canada its use has been associated with an increase in abortion in caregivers.
Benefits
• It may take the edge off contractions by encouraging the woman to be less focused which can help her ‘let go’, relax and go with the contractions.
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