CHILDBIRTH

Supporting the Physiological Process

What is physiologic?

The Study of normal biological function as opposed to pathologic . . . as well as how the organism as a whole accomplishes particular

tasks essential to life.

What is pathologic?

A specialty concerned with the nature and cause of disease as expressed by changes in cellular or tissue structure and function caused by the

disease process

What is Physiologic Birth?

• Starts on it’s own– Baby is mature (brown fat, mature brain and

lungs), transfer of maternal antibodies, fetal descent

• Progresses on it’s own – Optimal neuro-endocrine function allows for

natural hormonal cascade• Results in vaginal delivery

– Baby transitions normally, successful breastfeeding (AWHONN 2012)

CONSENSUS STATEMENT

“Normal Physiologic labor and birth is one that is powered by the innate human capacity of the

woman and fetus. This birth is more likely to be safe and healthy because there is no unnecessary

intervention that disrupts the physiologic processes. Some women/babies will develop complications,

however, supporting the normal physiologic process, even in the presence of complications, has the

potential to enhance best outcomes for the mother and infant”

(ACNM, MANA, and NACPM*)

What Drives the Physiologic Process of Birth?

“The main lesson of modern physiology is that the process of parturition is an

involuntary process related to the activity of archaic brain structures”

(Odent 2007)

The Thinking Brain

The cerebral cortex is the part of the brain that functions to make human beings unique from

other mammals. Distinctly human traits including higher thought, language and human

consciousness as well as the ability to think, reason and imagine all originate in the

cerebral cortex.

IT’S ALL HAPPENING IN THE BRAIN

we want to decrease activation of the ‘thinking’ brain

and optimize the activity of the ‘non-thinking’ brain (the archaic structure)

HOW DO WE DO THIS?

Optimize Neuro-Endocrine Function!

Laboring women mostly need “protection against any factor that might increase the levels of

adrenaline or stimulate the neocortex.”(Odent 2007)

The Relaxation Response

Take a Deep Breath

HORMONES of BIRTH

• Produced primarily in the limbic system – the area of the brain that regulates instinctual behavior – the hypothalamus and pituitary

• Optimal function of this system facilitates the progress of labor, boosts both mom and baby’s ability to cope with the process, and enhances attachment and breastfeeding success

THE MAJOR PLAYERS

oxytocin endorphin

es

catecholamines

OXYTOCIN

“whatever the facet of love we

consider….

…OXYTOCIN is involved.”

(Beckley, 2002)

THE HORMONE OF LOVE

• Made in the hypothalamus, stored in the pituitary and released in pulses.

• Responsible for the ‘ejection reflexes’ of reproduction: orgasm, fetal ejection reflex, placental ejection, milk ejection and let down reflex.

• Secreted in social situations such as friendly gatherings, sharing meals, etc.

• In other words: ENHANCES HUMAN BONDING

OXYTOCIN – before birth • Secreted during pregnancy and breastfeeding period to

enhance nutrient absorption – helps formulation of intestinal villi.

• Plays a role in the inhibition of the brain regions associated with behavioral control, fear, and anxiety; thereby decreasing stress and enhancing relaxation.

• Also produced by baby – this secretion may play role in initiation of labor.

• Baby’s head pushes on cervix creating a positive feedback loop.

POSITIVE FEEDBACK LOOP

HOW CAN WE HELP… DURING LABORHelp mom stay calm,

comfortable and confident

oxytocin

HOW CAN WE HELP?…

Advocate to avoid

disturbances such as

unwelcome people or noise

and uncomfortable

procedures (these will

stimulate the neo-cortex)

POSITIONING

Encourage upright and forward leaning positions

that help baby’s head push against cervix

POSITIONING

POSITIONING

Maximize pelvic diameter as much as possible. Side-lying is good for pushing and delivery if pt has an epidural and can’t squat.

OXYTOCIN – after delivery

• Levels remain high after birth as the baby nuzzles and licks the breast, which helps the uterus contract.

• Immediate and uninterrupted skin to skin contact helps facilitate this process, secreted by both mom and babe, bathing both in an ‘ecstatic cocktail’ of love and bonding… also enhanced by eye contact.

• Evokes feelings of contentment, reduces anxiety, and increases feelings of calmness and security.

• Protects against stress and promotes wound healing.

POSITIVE FEEDBACK LOOP

HOW CAN WE HELP… After Delivery

Provide opportunity for skin-to-skin and eye-to-eye contact, nipple stimulation

and privacy

HOW CAN WE HELP …AFTER DELIVERY

PROVIDE PRIVACY FOR FAMILY BONDING

Inhale… Exhale…

ENDORPHINES

ENDORPHINES IN LABOR

• CREATE FEELINGS OF EUPHORIA AND PLEASURE… increase tolerance to pain.

• Levels increase during labor, peaking at the time of birth and subsiding slowly over 1-3 days.

• Endorphins can create a ‘hazy’ effect (just like opiates), which help soften the memory of the pain of labor.

• The body produces endorphines in relationship to length of labor.

HOW CAN WE HELP?Help mom stay calm,

comfortable and confident

endorphines

HOW CAN WE HELP?…

Advocate to avoid

disturbances such as

unwelcome people or noise

and uncomfortable

procedures

HOW CAN WE HELP?Encourage mom’s natural efforts!

You Can Do It!

Good Job!

Keep it up!

You’re doing Awesome

ENDORPHINES

“Birth is not only about making babies. Birth is about making mothers – strong, competent, capable mothers who trust themselves and

know their inner strength.” ~Barbara Katz Rothman, PhD

CATECHOLAMINES

CATECHOLAMINES before birth

• Stimulate the nervous system for fight or flight. High levels during the active phase of labor can block oxytocin (a protective mechanism so that labor can be halted temporarily if danger is present).

• When birth is imminent, an increase in adrenaline activates the ‘fetal ejection reflex’ (urge to push), which facilitates quick delivery.

• Emotional response is varied and can produce excitement, fear, anger, and anxiety, nausea, panic – even if pt has an epidural.

HOW CAN WE HELP?Help mom stay calm,

comfortable and relaxed

HOW CAN WE HELP?…

Advocate to avoid

disturbances such as

unwelcome people or noise

and uncomfortable

procedures (these will

stimulate the stress response)

HOW CAN WE HELP?

Educate and explain – proven to decrease anxiety

Promote feelings of trust and confidence in her ability to give birth – and in yourself as caregiver – feelings of trust and confidence decrease the stress response

Avoid the turtle on it’s back position as much as possible

HOW CAN WE HELP?

Take advantage of the fetal ejection reflex by allowing

physiologic second stage (laboring

down, waiting for an urge to push, allowing mom to

push as she wants).

DO NOT DISTURB!!

• Like all mammals, humans need to feel safe and protected for labor to proceed. When catecholamine levels rise, labor slows or stops.

• Hospital environment (bright lights, invasive procedures, interruptions by strangers, etc) provokes the release of catecholamines (stress response).

• Stress response interferes with oxytocin and endorphine release leading to prolonged labor, increased fear and pain.

• Statistics don’t lie….rise in C/S rates, increased use of interventions, induction, augmentation and instrument deliveries.

CATECHOLAMINES after delivery

• Levels drop quickly which contribute to a cold, ‘shocky’ feeling (shivering).

• Important to keep mom warm (skin to skin also helps regulate maternal temp) because cold stress can keep catecholamine levels high, which inhibits oxytocin production.

• The fetus also secretes these hormones which helps it’s response to the stress of labor (intermittent decreases in oxygen) and adaptation at birth.

• Keeps mom and baby alert after birth for feeding and bonding.

HOW CAN WE HELP?

We don’t want this! We want this!

Do whatever you can to decrease the stress response

HOW CAN WE HELP?

Promote immediate skin-to-skin, cover mom with warm

blankets after delivery, if she is having pain with placenta or repair, speak reassuringly,

bring attention to baby

SUPPORTING OXYTOCIN AND ENDORPHINE RELEASE WILL INHIBIT CATECHOLAMINE RELEASE

Breathing in… Breathing out…

BREATH AND RELAXATION

• Slow deep breathing• Inhaling through nose, exhaling through

mouth• Adapt techniques as needed – each labor is

unique• Encourage relaxation in the shoulders and

pelvis/hips/thighs

VOCALIZATION AND RELAXATION

• Same concept as breath patterns: promotes relaxation and provides distraction

• Keep tone low: moans, groans, humming, deep breathing, chanting or sighing. Low tones come from relaxed throat and jaw

• High pitched screeching, does not come from a relaxed body, nor does it create a relaxing environment for mother or baby…

…or the nurse!

HOW CAN WE HELP?

• Encourage her own spontaneous vocalizations as long as they’re conducive to relaxation

• Keep your own voice calm and relaxed

• Direct mom in between contractions, not during them

IN SUMMARY – HOW CAN WE HELP the PHYSIOLOGIC PROCESS OF BIRTH?

• Optimize function of birth hormones– Positioning – Support and encouragement – create a trusting

relationship, reinforce her ability to give birth– Education and explanation – especially before any

procedures– Relaxation techniques – soft, calm demeanor– Allow/support bonding after birth

CREATE A BUBBLE OF PRIVACY

“…continuously supported, protected and cared for, but not disturbed the laboring woman can let

go of fear…within this bubble, privacy is protected: Strangers are kept away, information is filtered, questions interruptions and intrusions

are kept to a minimum” (Beckley 2002)

Give the body a chance to do it’s job of birthing!

RESOURCESCalais-Germain, B. (2003). The female pelvis: anatomy and exercises. Eastland Press, Inc.Gaskin, I. (2011). Birth matters: a midwife’s manifesta. Seven Stories Press.Hansen, R. (2009). Buddha's brain; the practical neuroscience of happiness, love and wisdom. (1st ed.). New Harbinger Publications.Kabat-Zinn, J. (2013). Full catastrophe living: using the wisdom of your body and mind to face stress, pain and illness. (2nd ed.). Bantam.Odent, M. (2008). Birth and breastfeeding: rediscovering the needs of women during pregnancy and childbirth. (2nd ed.). Rudolph SteinerSimpson, K. (2013). Awhonn's Perinatal Nursing. (4th Ed.). Lippincott, Williams and Wilkins. Walsh, D. (2013). Evidence and skills for normal labour and birth: a guide for midwives. (2nd ed.) Routledge.Buckley, S. (2003). Undisturbed birth: nature's blueprint for ease and ecstasy. Journal of Perinatal Psychology

and Health, 17(4), Simpkin, P. (2007). How to use comfort measures to manage pain and prevent suffering in labor. AWHONN 2012 Position Statement. Nursing support of laboring women. AWHONN 2012 Webinar. The importance of physiologic birthAWHONN 2013 Women’s Health and Perinatal Nursing Care Quality Draft Measures Specifications acnm, mana, and nacpm*, (2012). Supporting healthy and normal physiologic childbirth - a consensus

statement.Normal Birth: A Thing of the Past? JOGNN examines a trend toward high-tech, high-intervention birth; suggests care practices to return to normal birth. NEWS RELEASE: January 8, 2008 CONTACT: Jackie C