Alternative Birthing

Alternative Birthing

• System updates

• Medical director video• https

://www.youtube.com/watch?v=KHS6gVpT1_0&feature=youtu.be

Alternative Birth Movement

• Consumer reaction to medical obstetrical practices developed in the United States early in this century.

• Settings developed as single labor-delivery rooms in the hospital or as free standing birth centers

• Physician resistance based on maternal and infant safety• Physicians fear economic competition and loss of control

over obstetric practices

History

• Until the 1930s childbirth was truly dangerous• High percentages of women and infants died

during or soon after childbirth• Organized medicine began to take steps to lower

mortality rate• New medical specialty was founded called

Obstetrics• Prenatal care gained recognition for its benefits

in preventing death

History

• Childbirth moved from home to hospital with promise of more controlled conditions

• Improvements in public health, public sanitation, and control of chronic illness reduced dangers of childbirth

• 1940s advances in antibiotics and blood banks• 1950s routine maternity care became very rigid

in the hospital setting• 1960s the natural childbirth movement began to

gain momentum

History

• Mothers began to attend childbirth classes• Involved family members in birth process• Spent more time caring for their babies in the

hospital setting.• 1970s saw the reemergence of the midwife as

well as the use of alternative settings for birth• Hospitals began to offer more flexible family

centered care and more homelike rooms for birth

History

History

History

History

Current

Providers

• Obstetrician/Gynecologist• Medical physician (MD/DO) who has completed

residency in OB/GYN

• Certified Nurse Midwife• Registered nurse who has completed graduate

education/training in midwifery and is an APN

• Direct-Entry/Certified/Professional Midwife• Non RN who has completed education in midwifery• Not licensed to practice midwifery in Illinois

Providers• Doula• Lay person (non-

medical) who provides physical assistance and emotional support related to childbirth

• Advanced Practice Nurse• Registered Nurse

• Average of 2-4 years of nursing experience on OB/GYN, post partum, or related area

• Graduate education (master’s or doctorate) and training in nurse midwifery

• Certified by the American College of Nurse-Midwives Certification Council

• Licensed in Illinois as APN• Collaborate with OB-GYNs to care for women

Certified Nurse Midwife

Certified Nurse Midwife

• CNMs attend 10% of all spontaneous vaginal births in the United States• 7% of total births in United States

• 97% in hospitals• 1.8% in freestanding birth centers• 1% at home

• CNMs have been practicing in the United States since the 1920s

Certified Nurse Midwife

• Scope of practice• Primary healthcare for women (adolescence to

beyond menopause)• Gynecologic, family planning services• Preconception care• Care during pregnancy, childbirth, and postpartum

• Monitor fetal development• Manage acute and chronic illnesses of women

• Care of normal newborn during first 28 days of life• Treatment of male partners for STDs

Certified Nurse Midwife

• Scope of Practice• Conduct physical examinations• Prescribe medications• May admit, manage, discharge patients from the

hospital• Order, interpret laboratory and diagnostic tests• Order use of medical devices• Health promotion, disease prevention, wellness,

education/counseling

Certified Nurse Midwife

• Why nurse midwives?• Improved infant mortality rate in hospitals, birth

centers for women who are low risk• Fewer C-section births for low-risk women• Reduced use of unnecessary procedures• Reduced healthcare costs• Increases access to care• Provides care to underserved,• Rural areas, as well as urban

Certified Nurse Midwife

• Why nurse midwives?• Low risk pregnancies account for 60-80% of all

pregnancies• CNMs consult with and refer to obstetricians,

perinatologists and other healthcare professionals when patient is not low risk

• 20-40% could have potential complications• Complicated pregnancies are referred to

obstetricians or co-managed by physicians and CNMs in hospitals

Certified Nurse Midwife

• Referral from home to hospital• 7-18% antepartum for OB reasons

• Placenta previa, pregnancy-induced hypertension, pre-term, intrauterine growth restriction

• 8-12% intrapartum referrals• Failure to progress, prolonged rupture of

membranes, meconium staining, fetal distress, bleeding, hypertension

Certified Nurse Midwife

• 1-2% post-partum maternal referrals• Retained placenta, post partum hemorrhage,

laceration repair• 1-2% neonatal referrals

• Inability to establish normal respiration, congenital abnormality, low birth weight, low APGAR score, birth trauma, sepsis

• Urgent transfer 1/1000

Certified Nurse Midwife• What to expect for EMS

• Report• Vital signs• Description of reason for the call• Description of current patient condition• Description of all actions taken to stabilize patient

• History• Last menstrual period• Estimated due date/mother’s medical history• Gravida and para

Certified Nurse Midwife

• What to expect for EMS• CNM is an expert resource that can be utilized by

EMS to assist with patient care• CNM cannot ask EMS to administer medication

outside of their SOPs• CNM cannot ask EMS to perform any procedure

outside of their scope of practice• Usually will accompany patient to the hospital to

continue care• Also trained to provide newborn care

Certified Nurse Midwife

• Ensure that provider is a certified nurse midwife• Non-licensed individuals may refer to themselves

as “midwives”• If the situation is questionable, contact Medical

Control immediately

Doulas

• A doula, also known as a birth companion and post-birth supporter, is a non medical person who assists a woman before, during, and/or after childbirth, as well as her spouse and/or family, by providing physical assistance and emotional support

Doulas

Doulas

DO• Assist and coach

prior to, during, and after labor

• Provide emotional support

• Physical support and massage

• Assist with non-labor related needs

DO NOT• Physically aid in

delivering baby• Provide medical

advice• Examine, diagnosis,

or treat medically

Doulas

• Formal education not required• Can participate in a training program• May also learn through an apprenticeship or

mentorship• Certification highly recommended (Certified

Labor Doula (CLD))

Doulas

• CAPPA is an international certification organization for doulas

• The labor doula works with families during pregnancy, during labor, in the birth process and in the immediate post partum phase

• They can be found working in the community, in private practice, in cooperatives, as part of groups or agencies, as well as serving in various community programs

Childbirth

• Childbirth has not changed but many things associated with childbirth have• Women’s expectations• Pain management options• Economics of childbirth• Healthcare system• Technology used during pregnancy and birth

Birthing Methods

• Birth practices have changed in the past 100 years

• The Cesarean section rate is approaching 30% in the United States

• Labor induction is becoming more common. An estimate of 40% of all women are induced

Birthing Methods

• Vaginal birth• Most common method• Can be done with/without pain medication

• Cesarean section• Surgical method requiring incision in abdomen

and uterus• Longer recovery• Best for women at risk for complications, birth

defects, multiple fetuses, or women with certain health conditions

Birthing Methods

• Home birth• Allows for birth in familiar surroundings• Home birth not suitable for women with high

blood pressure, heart problems, or diabetes• Should be prepared for possible transfer to a

hospital should complications occur

Water Birth

• Process of giving birth in a tub of warm water• 25 U.S. hospitals and 70% of all birth centers

support water birth• Water birth said to reduce anxiety, relax muscles,

and speed up labor, more holistic experience• Reduces tearing of delicate tissues• Emerged as widespread practice in Europe in

1980s and 1990s

Water Birth

• Water immersion in labor • Water birth mother remains in the water during

the pushing phase and actual birth of baby• Risk of infection concern of physicians• Not recommended for breech births, twins or

pregnancies with risks of complications• In 2014 the American College of Obstetricians

and Gynecologists and the AAP released a statement rejecting water births

Water Birth• Breathing reflex in

healthy newborn babies does not kick in until the baby’s face, nose and mouth have been stimulated by exposure to air

Hypnobirth

Hypnobirthing

• Self hypnosis in childbirth has been around for centuries

• Birthing women and their support partners are taught non pharmacological strategies

Hypnobirth

• Hypnosis and self hypnosis during childbirth lead to:• Decreased average length of labor• Lower cesarean section rates• Decreased use of pain relief medication such as

epidurals• Increased ease and comfort of labor and birth• Babies born under hypnosis tend to be calmer,

more alert and better sleepers and eaters

Acupuncture

• Acupuncture and acupressure alternatives to medical intervention during labor

• Recommended to begin in the 36th or 37th week of pregnancy leading up to birth

• Treatments help prepare uterus, pelvis, cervix for birth encouraging efficient labor

• Pre-birth acupuncture found women 35% less likely to be induced and 31% less likely to have epidural

Acupuncture

Acupuncture

• Acupuncture can be used in labor as well• Helps to increase and sustain contractions• Stimulates cervical dilation• Increases endorphin release (body’s natural

coping mechanism for pain)• Acupressure can also be used to achieve similar

results during labor• Also utilized post partum to promote healing,

can decrease need for pain medication post- partum

Birth Centers

• Home like facility, existing within a healthcare system with a program of care designed in a wellness model of pregnancy and birth.

• Birth centers are guided by principles of prevention, sensitivity, safety, appropriate medical intervention and cost effectiveness

• They provide family centered care for healthy women before, during and after normal pregnancy

Birth Centers

• Offers gynecologic and maternity care in safe, comfortable environment

• Designed for healthy low risk mothers and healthy babies

• Involves the entire family in the pregnancy and birth

• Relaxed atmosphere• Offers privacy

Birth Centers

• Women are encouraged to drink instead of routine IVs

• Mothers are not tied to electronic fetal monitoring

• Baby’s heartbeats are checked with handheld dopplers at regular intervals

Birth Centers

• Nurse midwife is with mother throughout labor• Mother choses most comfortable position to

give birth• Birth centers promote breastfeeding• No separation of mother and baby• All infant care done in front of family

Birth Centers

• Birth center is part of a medical care system• If mother or baby develops a problem patient is

transported to the closest appropriate hospital • Nurse midwife may accompany mother to the

hospital• EMS should follow appropriate SOP’s

Birth Centers

• Low overall intrapartum and neonatal mortality rate

• Focus on creating healthy pregnancies and minimizing interventions during labor

• No maternal mortality• Neonatal mortality of 1.3/1000 births• C-section rate averages 4.4% compared to

national hospital average of 26%

OBSTETRICAL COMPLICATIONS

BLS/ALS 1. Initial Medical Care SOP, p. 4 2. HIGH FiO2 or VENTILATION

ALS: If altered mental status or signs of hypoperfusion, IV FLUID BOLUS IN 200 mL increments titrated to patient response.

Palpate abdomen to determine uterine tone and presence of contractions. Place mother on left side or raise right side of backboard 20-30°. Insert second

IV line if no response to initial fluids.

BLEEDING IN PREGNANCY 2. Note type, color and amount of bleeding and/or vaginal discharge. If tissue passes,

collect and bring to the hospital with the patient.

TOXEMIA IN PREGNANCY OR PREGNANCY INDUCED HYPERTENSION 2. HANDLE PATIENT GENTLY. Minimize CNS stimulation (avoid lights and siren).

DO NOT check pupil response. Seizure precautions. 3. ALS: If seizure occurs:

Administer VERSED (midazolam) 2 mg increments IV q 2 minutes up to 10 mg total as necessary, titrated to control seizures.

Labor and Delivery Complications

• Premature rupture of membranes (PROM)• Membranes rupture too early in pregnancy• Exposes baby to high risk of infection

• Umbilical cord prolapse• Cord can slip thru cervix after water breaks

preceding baby thru birth canal• Blood flow becomes blocked• Or stopped

Labor and Delivery Complications

• Cord stretches and is compressed during labor

• Leads to decrease in blood flow

• Can cause sudden drops in fetal heart rate

• Occurs 1 in 10 deliveries

Labor and Delivery Complications

• Amniotic fluid embolism• Most serious complication of labor and delivery• Small amount of amniotic fluid enters mothers

blood stream• Usually occurs during difficult labor or C-section• Fluid travels to lungs and causes arteries in lungs

to constrict• Widespread blood clotting a common

complication

EMERGENCY CHILDBIRTH

BLS/ALS PHASE I: UNCOMPLICATED LABOR 1. Obtain history and determine if there is adequate time to transport

a. Gravida (number of pregnancies) and Para (number of live births). b. Number of miscarriages, stillbirths, and multiple births. c. Due date (expected date of confinement, “EDC”) or date of LMP (last menstrual

period). d. Onset, duration, and frequency of contractions (time from beginning of one

contraction to beginning of the next). e. Length of previous labors in hours. f. Status of membranes, intact or ruptured. If ruptured, inspect for prolapsed cord

or evidence of meconium. g. HIGH RISK CONCERNS:

o maternal drug abuse o teenage pregnancy o history of diabetes/hypertension/cardiovascular disease/other pre-existing

diseases that may compromise mother and/or fetus o preterm labor (< 37 weeks) o previous breech or C-section.

2. Inspect for bulging perineum, crowning, or whether patient is involuntarily pushing

with contractions. If contractions are two minutes apart with crowning or any of the above are present, prepare for delivery. If delivery is not imminent, transport on left side. DO NOT ATTEMPT TO RESTRAIN OR DELAY DELIVERY UNLESS PROLAPSED CORD IS NOTED.

IF DELIVERY IS IMMINENT: 3. Initial Medical Care SOP, p. 4

a. If patient is hyperventilating, coach her to take slow deep breaths b. ALS: If patient becomes hypotensive or lightheaded at any time:

IV FLUID BOLUS in 200 mL increments HIGH FiO2 or VENTILATION

4. Position patient supine on a flat surface, if possible. Use standard precautions. 5. Open OB pack. Place drapes over the patient’s abdomen and beneath perineum.

EMERGENCY CHILDBIRTH (Continued)

PHASE II: DELIVERY 4. Control rate of delivery by placing palm of one hand over occiput. Protect perineum

with pressure from other hand. 5. If amniotic sac is still intact, gently twist or tear the membrane. Note presence or

absence of meconium. 6. Once the head is delivered, allow it to passively turn to one side. 7. Feel around the neck for the umbilical cord (nuchal cord). If present, attempt to gently

lift it over the head. If unsuccessful, double clamp and cut the cord between the clamps.

8. To facilitate delivery of the upper shoulder, gently guide to head downward. Once the upper shoulder is delivered, support and lift the head and neck slightly to deliver the lower shoulder. Allow head to deliver passively.

9. The rest of the newborn should deliver quickly with one contraction. Firmly grasp the newborn as it emerges. Newborn will be wet and slippery.

10. Keep newborn level with vagina until cord stops pulsating and is double clamped.

PHASE III: CARE OF THE NEWBORN NOTE: The majority of newborns require no resuscitation beyond maintenance of temperature, mild stimulation, and suctioning of the airway. Transport is indicated as soon as the airway is secured and resuscitative interventions, if needed, are initiated. If the APGAR score is < 6 at 1 minute or meconium is present, begin resuscitation. BLS / ALS 1. Pediatric Initial Medical Care SOP, p. 74 2. Deliver head and body 3. Clamp and cut cord 4. Assess neonatal risk factors:

Term gestation? Clear amniotic fluid? Breathing or crying? Good muscle tone?

5. Provide basic care: Provide warmth Position; clear airway as needed with bulb syringe or large bore suction catheter Dry the newborn, stimulate and reposition as needed

6. Check respirations: If apneic and meconium present, clear airway and provide deep suctioning of the

oropharynx. Begin positive pressure ventilation at rate of 40-60 per minute using neonatal BVM.

If apneic without signs of meconium, begin positive pressure ventilation at rate of 40-60 per minute using neonatal BVM.

7. Check heart rate: If heart rate > 100 BPM, check color If heart rate 60-100 BPM, continue ventilations for 1-2 minutes, reassess heart rate. If heart rate < 60 BPM, administer chest compressions for 30 seconds at a ratio of

3:1 with ventilations, reassess heart rate. If heart rate remains < 60 BPM, continue CPR.

Drug of the Month• The FDA has established five categories to indicate the

potential of a drug to cause birth defects if used during pregnancy

• Category A: failed to demonstrate a risk to the fetus in first trimester (levothyroxine, folic acid, magnesium sulfate)

• Category B: Animal studies have failed to demonstrate risk to fetus or pregnant woman (metformin, hydrochlorothiazide, cyclobenzaprine, amoxicillin)

• Category C: Studies have shown adverse effects on fetus but potential benefits may warrant use of drug in pregnant women despite risks (tramadol, gabapentin, prednisone)

Drug of the Month• Category D: Studies have shown fetal abnormalities and

positive evidence of human fetal risk, risks outweigh benefits of use in pregnant women ( lisinopril, alprazolam, lorazepam and losartan and most chemotherapy drugs)

• Category X: Studies demonstrated fetal abnormalities/fetal risks and use of drug in pregnancy outweighs potential benefits (atorvastatin, simvastatin, warfarin, methotrexate)

• Antibiotics: Drugs in the penicillin category are safe to take during pregnancy. Also most types of erythromycin and antibiotics in the cephalosporin category

Drug of the Month• Asthma medication: Pregnancy is an additional physiological

challenge that can impact severity of disease. Although uncontrolled asthma is rarely fatal, complications to the mother include high blood pressure, toxemia, and premature delivery

• Antidepressants: Excellent safety record in second and third trimesters

Cardiac

• Arrhythmias in pregnancy are common• Majority that occur are benign• Cardiovascular system undergoes significant

change• Increased heart rate• Increased cardiac output• Reduced systemic vascular resistance

Cardiac

• The decision to treat a pregnant woman’s arrhythmia depends upon:• Frequency• Duration• Tolerability of the arrhythmia

• Balance between benefit of arrhythmia reduction and maternal/fetal side effects of any drug treatment

• Palpitations most common symptom in pregnancy

Cardiac

• Potential factors that can promote arrhythmias in pregnancy and during labor and delivery include:

1. Electrophysiologic effects of hormones2. Changes in autonomic tone3. Hypokalemia in pregnancy4. Underlying heart disease

Torsades de pointes

• Torsades is a distinctive polymorphic ventricular tachycardia

• QRS amplitude varies• QRS complexes appear to twist around baseline• Associated with prolonged QT interval• May be congenital or acquired risk can increase

with pregnancy

Torsades de pointes

Cardiac

• Cardiac arrest during childbirth rare• Factors that can cause cardiac arrest include

• Preeclampsia• Excessive bleeding (45%)• Heart failure (13%)• Heart attack• Blood infection (11%)• Amniotic fluid embolism (13%)

Cardiac

• Researchers found that CPR was often successful in cases of cardiac arrest during childbirth and that survival rates rose from 52% in 1998 to 60% in 2011.

• Those who had cardiac arrests were older or had limited health care prior to or during their pregnancy.

State of IllinoisAbandoned NewbornInfant Protection Act

Background

• Safe Haven Laws• Statutes in the United States that decriminalize the leaving of

unharmed infants with statutorily designated private persons so that the child becomes the ward of the state• Also known in some states as:

• Baby Moses Law• Safe Place• Safe Surrender

Background• Texas was first state to enact a “Baby Moses Law” in 1999

• Safe place originates in Mobile, Alabama

• By 2008, all 50 states had a form of safe haven law

• As of 2013, no one has used the law in the state of Alaska

Summary of Act• The Abandoned Newborn Infant Protection Act allows the

parent or parents of unwanted infants, 30 days old or less to relinquish the newborn to a Safe Haven

• Regardless of the age of the child, If there are signs of abuse or neglect, proceed as if the child were abused or neglected with appropriate care and transport to a medical facility at which time a DCFS report must be filed

• If the child is obviously older than the 30 day-age covered in the Act, proceed as if the child is abused or neglected and proceed in accordance with the Act including filling a report with DCFS

Definitions

• Newborn• 30-days old or less

• Safe Haven • Any fire station, police station, hospital and emergency

medical care facility that is staffed 24-hours a day where the relinquishing parent may take an unwanted newborn

• This excludes free standing medical facilities• If a designated Safe Haven is not staffed 24-hours a day, the sign

must read “Only When Staff Are Present”

Immunity

• Receiving personnel are immune from criminal or civil liability for acting in good faith in accordance with this Act

Presumptions Allowed by the Act

• It is presumed that the relinquishing parent consents to the termination of his or her parental rights

• It is presumed that the relinquishing parent is the newborn infant’s biological parent

Consent and Treatment

• Consent for Medical Treatment of the Newborn• The act of relinquishing the newborn infant serves as

implied consent for medical treatment if necessary

• Treatment and Transport of the Newborn• Medical treatment will be provided as necessary• Any abandoned newborn or infant will be transported

to the hospital by ambulance

Relinquishing Parents’ Rights

• The relinquishing parent has the right to anonymity providing there is no evidence of abuse or neglect• If abuse or neglect is suspected at the time of relinquishment

notify law enforcement

• The relinquishing parent may return to the Safe Haven within 72 hours of relinquishment to reclaim the infant• Upon request by relinquishing parent, the name and location of

the hospital that the newborn was transferred to must be provided

• The relinquishing parent may petition the State within 60-days of the relinquishment to reclaim the infant

• As a designated Safe Haven, all employees are required to accept relinquished infants and newborns