Safe Childbirth Practice for Healthy Women ~ critical difference btw obstetrics & physiologically-based childbirth practices

by faithgibson on January 26, 2015

by faith gibson, LM, CPM, former L&D nurse, mother & grandmother

~ What everybody needs to know but is afraid to ask:

  • Question: Why the routine use of medical interventions and obstetrical technologies is not the right answer for healthy childbearing women, and the high level of medical and surgical interventions and unproductive expenses is a burden to the economy
  • Answer: Obstetrical interventions disturb and disrupt the normal physiology of labor and birth. These disturbances frequently trigger the need for additional medical or surgical interventions. Unfortunately this sometimes results in complications that require operative delivery (forceps,  vacuum extraction or Cesarean surgery) that otherwise would have not been necessary.
  • Question: Why midwifery care is a safe and sensible choice for cost-effective maternity care within a functional, accessible and affordable healthcare system.
  • Answer: Read the following essay, click on links to supporting documents and read companion files.

LINK to original & longer document, with discussion of studies and citations that are the background resources for the conclusion state in the following essay.

*This is a companion document to the “Political History of Midwifery in California 1850 to 2014”, and “The Healing Arts ~ A Short History of California Medical Practice Act


 Identifying the safest forms of care for normal childbirth in healthy women

Any contemporary discussion about childbirth safety for healthy women must start by identifying the four crucial elements that together create a reliable and cost-effective ‘safety net’ for mothers and babies.

The first of these essentials is a functional, accessible and affordable healthcare system. Physical wellbeing in all areas of life, including childbearing and raising a family, require unfettered access to healthcare and medical services whenever necessary. Not having access to comprehensive healthcare that includes medical and emergency services makes daily life order-of-magnitude more dangerous. One of the privileges of living in modern times and in a wealthy, developed country is the ability to correct minor health problems before they become life-threatening or cause irreparable damage or chronic pain.

Access to a working healthcare system impacts all aspect of our lives – traveling in vehicles, participating in sports and vacation activities, jobs and schooling, the hazards of daily life such as climbing up and down stairs and frequent illness and accidents that children are prone to (accidents are the 5th leading cause injury-related fatalities in the US). Imagine how many more people would suffer unbearable chronic pain, be come permanently disabled or die of treatable illness and injuries if we had no functional health system to provide emergency medical care and follow-up services?

While such services are not frequently used by the average person, that they available and used when needed prevents untimely deaths and disability when compared to places that, for any reason or any period of time, lack a functional healthcare system.

How this applies to safety for childbearing women

Again we have to start with the central role of a functional, accessible and affordable healthcare system. Quality maternity care is a primary function of healthcare. According to Egyptian hieroglyphics, maternity care by trained midwives was the very first example of healthcare as an organized system.

The basic safety of normal childbirth in healthy women with normal pregnancies is like-wise dependent on having access to necessary medical services prior to pregnancy, and receiving maternity care services during pregnancy, childbirth and the postpartum-neonatal period in conjunction with the use of medical services as needed. According to a review of the scientific literature, the best outcomes for healthy mothers and babies are consistently associated with three healthcare-related circumstances. In combination, these basic elements are equally advantageous to industrialized countries as well as developing countries.

In addition to a functional healthcare system, the folioing three elements are critical:

(1) Initial risk-screening and on-going prenatal care, with use of medical services as indicated

(2) Birth attendant(s) educated and skilled in physiologic care*, aseptic technique and emergency response who are physically present during active labor, birth & immediate postpartum-neonatal period

(3) Appropriate use of comprehensive and emergent medical services as the need arises

The type of practitioner doesn’t matter — family practice physicians, obstetricians, professional midwives and even empirically-trained lay midwives. This is no statistically significant difference in maternal and perinatal outcomes regardless of the type of trained birth attendant. [Link to “Real Data Identifies Real Risks and Gives Us Real answers” on CCM website]

In countries with a functional healthcare system, effective maternity care makes an order-of-magnitude difference in the safety of normal childbirth. In areas of the world without a functional healthcare system, and places (including the US) where individuals or groups failure to use them for economic, religious or personal reasons (ex. lack of trust based on prior traumatic experience), the maternal and perinatal mortality rate is similar to that of a hundred years age or current rates in Afghanistan and sub-Sahara Africa .

Basic Purpose and Goals of Maternity Care

The basic purpose of maternity care is to protect and preserve the health of already healthy women. Its basic goal is a safe and cost-effective model that is able to preserve health and effectively prevent or successfully treat complications during pregnancy and childbirth, while also meeting the needs of maternity care service providers, professionals and institutions.

  • The ideal maternity care system integrates the time-tested principles of physiologically-based care, with the best advances in obstetrical medicine to create a single, evidence-based standard for all healthy women.
  • As a scientific model, it requires that the type of care be determined by the health status of the childbearing woman and her unborn baby, in conjunction with the mother’s stated preferences, rather than by the occupational status of the care provider (physician, obstetrician, midwife).

Mastery in normal childbirth services for healthy women with normal pregnancies means bringing about a good outcome without introducing any unnecessary harm or unproductive expense.

The ideal maternity care system seeks out the point of balance where the skillful use of physiological management and adroit use of necessary medical interventions provides the best outcome with the fewest number of medical/surgical procedures and least expense to the health care system.

The definitions of safety and cost-effectiveness must factor in the full spectrum of reproductive mortality and morbidity over the course of a woman’s entire reproductive life, including the prevention of delayed and downstream problems, complications in subsequent pregnancies, future fetal or neonatal loss and over-all cost of care to individuals and society.

Ultimately, all maternity care is judged by its results — the number of mothers and babies who graduate from its ministration as healthy, or healthier, than when they started.

Safest and most cost-effective model of maternity care

Safe and cost-effective maternity care systems are based on physiological management rather than a medical model that includes routine interventions. ‘Physiologic’ is defined as “in accord with, or characteristic of the normal functioning of a living organism”.

The primary role of the care provider is like that of a lifeguard at the beach – an educated observer with emergency response capacity. Maternity care for healthy women with normal pregnancies uses risk-screening throughout the months of care, from the first encounter early in pregnancy to the last postpartum visit. Its underpinning are an assumption that childbirth is a normal biological process that rarely needs intervention but almost always needs careful watching and physical, emotional and social support during the events of labor, birth and the postpartum and neonatal period.

In many parts of the world, including the five countries with the best maternal-infant outcomes, this supportive model is routinely provided by midwives and family practice physicians. These birth attendants are aware that complications, while infrequent, can occur in any pregnancy or labor, no matter how healthy the mother or normal the pregnancy. For this reason, access to and appropriate use of obstetrical interventions is an integral part of physiologically-based care, to be called on when needed to treat complications or if requested by the mother.

While the practice of obstetrics as a surgical specialty is a part of the maternity care system, its role, its relationship to healthy childbearing women and its practices are a subset of the services required to achieve the basic goals of a maternity care system.

Because we enjoy a high standard of living in North America and generally have access to routine maternity care and comprehensive obstetrical services for complications, healthy childbearing women can expect a good outcome for themselves and their babies. In the US, over 70% of childbearing women are healthy, have normal pregnancies and give birth to healthy babies.

The special role of the obstetrical profession in modern maternity care

The practice of obstetrics and gynecology is a surgical discipline that specializes in the treatment of reproductive problems (such as infertility and miscarriages) and many of the complications of associated with pregnancy and childbirth. As a result, the obstetrical profession is vitally important part of any maternity care model.

Unfortunately the training and practices of a surgical specialty is not a good match for most healthy childbearing women. The reason is very straightforward: the typical needs of healthy women during pregnancies and normal childbirths are neither medical or surgical. Ideally obstetrics should not consider itself a replacement for the physiologically supportive model of care, but instead would functions as resource within the larger maternity care system.

However, in 1910 doctors in the US began using obstetrical management as the standard of care for normal childbirth in healthy women early. This represented the most profound change in childbirth practices in the history of the human species. These obstetrical policies and practices are still the norm for almost labors and births, resulting a 2 to 10-fold increase in medical interventions, and invasive and surgical procedures compared to physiologically-based maternity care.

In contrast to the physiologic model of maternity care, the modern standard for obstetrics treats labor as a medical event and birth as a surgical procedure. Despite this strict model of obstetrics, with its many policies and protocols designed to make childbirth safer, and despite spending more on maternity care than any country in world, the US has always ranked near the bottom of the developed world in the most important quality measures. Currently the US ranks 39th in maternal mortality and 50th in neonatal outcomes. When it comes to rates of operative delivery, we also have a poor showing — a 32.8 % Cesarean section rate, which is among the highest in the world.

Under obstetrical management, there is a 2 to 10-fold difference in the use of medical interventions, invasive and surgical procedures between obstetrically-based and physiologically-based care. While the mortality rate (i.e. death) is the same for all categories of birth attendants, the morbidity (short and long-term complications) is far greater when the labors and births of healthy women were medicalized. In regard to childbirth, morbidity also includes medical situation that require hospitalization, re-hospitalization and/or the use of major medical and surgical interventions. Accounting for sub-optimal outcome and complications relative to childbirth applies to the baby’s wellbeing as well as the mother’.

If maternity care is to be judged by its results, this model of care as applied to a healthy population of childbearing women is failing to meet the intrapartum needs of laboring women and failing to meet the needs of society for a safe and cost-effective model of maternity care.

The measure of quality of maternity care must be comprehensive

In modern times, the childbirth-related mortality rate is the statistically-equivalent same for all categories of trained birth attendants and all childbirth settings, but morbidity is greatly increased under two polar-opposite circumstances — when healthy women with normal pregnancies a routinely medicalizes and when the childbearing family reject the use of medical services in an emergency.

Childbirth-related morbidity includes short and long-term complications, medical situations that require hospitalization, re-hospitalization and/or the use of major medical and surgical interventions. As already identified, morbidity is greatly increased when childbirth of healthy women is routinely medicalized, which is the current norm of obstetrical management.

In these situations, morbidity and sub-optimal outcomes and iatrogenic complications are increased for babies as well as childbearing women. Relative-safety for a healthy population is most appropriately measured by both mortality and morbidity, which means includes all relevant factors and outcomes.

When comprehensive data is used to judge the safety of childbirth practice, the model identified as having statistically more optimal outcomes is maternity care by practitioners trained and skilled in physiologic (i.e. non-medical) care.

While the discipline of midwifery has historically been the primary provider of physiologically-based maternity care, it also includes many general practice (or family practice) physicians. The use of physiological management by obstetricians is legally difficult, as they are required to practice under the policies, practices and protocols of their surgical specialty, which currently would define the use of physiologic childbirth practices by a Board-certifed obstetricians to be a sub-standard, or negligent care and thus open them and the hospital up to malpractice litigation.

According to Stedman’s Medical Dictionary “physiological” means “…in accord with or characteristic of the normal functioning of a living organism” (1995). Technically ‘physiologic care’ belongs to a healthcare category known as “non-allopathic”. This describes any form of healthcare that does not depend on the use of drug therapies, invasive diagnostic procedures, and medical and surgical interventions.These practitioners are physical present or immediately available at the mother’s request during active labor, as well as the birth and following 2 hours (or longer when if needed).

Midwives, who are members of a non-allopathic discipline, freely consult with physicians as needed and refer women to be evaluated to medical services if there are unanswered questions. If a complication should occur they transfer mother or baby to obstetrical or pediatric specialists. Midwives are also authorized to use a limited number of emergency drugs and medical interventions in urgent or emergent situations.

While non-allopathic care is generally associated with midwifery, you don’t have to be a midwife to use physiologic principles. Family practice physicians may also use very non-interventive forms of care during labor and birth.

The critical issue is the contrasting nature of the care provided during the intrapartum (active labor, birth, postpartum-neonatal). The medicalized model relies on technologies to indirectly monitor the status of the fetus during labor, while the nursing staff provides physical care to it’s laboring mother.

By contrast, physiologic care providers are personally present during all the active stages of the intrapartum. Its practitioners specifically strive to not to disturb the normal biology of labor and birth while also effectively supporting the mother-to-be, a strategy statistically associated with optimal outcomes.

What makes “physiologic” care unique?

Physiologic care requires its practitioners to first and foremost be experienced observers. As labor and birth attendants, they are carefully watching and listening for subtle signs of that indicate progress, looking for physical and emotional issues that may need attention, always attuned to early signs and symptoms of possible complications that may call for intervention.

Physiological management is a fundamentally subtle system that relies on practical, person and interactive methods rather than technological ones. By being physically present to directly monitor the pregnant woman and her unborn-newborn baby, subtle diminutions of well-being can be dealt with immediately as part of a strategy of prevention.

As students of the physiological management of labor, the mnemonic taught is that small deviations precede abnormalities which precede complications, which in turn precede emergencies that, if not properly dealt with, can result in disabilities or death. The best way to prevent emergencies is to deal with issues while they are still small and the course of events can be positively influenced. This kind of safety net is implement by gathering visual and auditory information and periodically monitoring vital signs for mother and baby. This is a binary sampling process in which normalcy is either confirmed (no intervention necessary) or the need for the medical care is indicated.

Observation as a purposeful activity is attuned to see and respond to ‘subtle’ emotional and biological signs. Watching for subtle indicators is what the parents of babies and young children do all the time. The most dramatic example is how an experienced parent knows about 1.5 seconds before their child up-chucks. That tiny, brief, almost invisible gag-reflex triggers mom or dad to springs into action like a cork. Non-parents watching this little vignette often attribute this spritely response to a mystical form of pre-cognition. Not so. It is simply the consequence of careful and ‘experienced’ observation. Likewise providers of physiologic childbirth services are educated observers with emergency-response capacity.

As with effective parenting, observation requires the practitioner to be awake, in the room and paying attention. In a physiologically managed labor and birth, this period of time is occupied by providing non-interventive support that facilitates the normal and spontaneous biology of labor and birth and protects the mother as much as possible from being disturbed by interruptions and unnecessary conversation.

One of the reasons physiological care has such dependable outcomes is that a majority of laboring women don’t require narcotics or anesthesia during labor. As a result, they are able to walk around, change positions and activities, get in and out the shower or a deep water tub, and generally spend little or no time lying down in bed.

Being upright and mobile makes for the right use of gravity. This helps the unborn baby to fit more favorably into the mother’s pelvis, which in turn reduces the likelihood of fetal distress and the need to use forceps, vacuum extraction or Cesarean delivery. The mother’s physical mobility also makes it easier to for her tolerate the normal pain and natural stress of an unmedicated labor. Because their newborns don’t have drugs their blood stream that can cause respiratory depression they are much less likely to suffer this serious complication after being born.

What is different about a medicalized model of care?

In the medical model of care, the primary birth attendant is never continuously present in the room. Most obstetricians arrive just a few minutes just prior to the baby’s birth, which is very near end of the pushing phase. Typically the total time being present before, during and after the baby’s birth is about 10 to 30 minutes.

Within the medical model, management of 1st and 2nd stage labor, as well as postpartum care of the newly delivered mother and baby, is all considered to be a nursing function. However, the primary job of a nursing staff in any hospital is to carry out the orders of the attending physician. In this military-type hierarchy, physicians are the commanding officers and nurses are members of the enlisted ranks that carry out the orders of higher-ups. With no independent decision-making authority, the primary duty of L&D nurses is to provide standard obstetrical care. If she veers off from that standard she will be reprimanded, reassigned or even fired.

As an ‘allopathic’ discipline, obstetrics primarily depends on the use of drugs, medical treatments and surgical procedures. Drastic as this The majority of its patients expect medical treatments, and members of the profession are legally judged by whether they used medical and surgical interventions in a timely manner. Equally compelling, the use of physiologic policies and practices would legally be defined as a “substandard” form of care if used within the standard practice of obstetrics, which is a surgical specialty.

In the US, nursing schools do not teach the principles of physiological management. Nurses cannot decline that the principles and practices of physiological management are more appropriate for a particular labor patient. Their orders are to carry out obstetrical department protocols even if they unnecessarily interrupt or disturb the biological process of normal labor.

The practicalities of being an institutional employee in a busy, often short-staffed hospital is also an issue. L&D nurses are often responsible for 2 or even more labor patients at the same time. They fill in for other nurses during meal breaks, circulate in the OR during Cesarean surgeries, and have bureaucratic and other non-patient duties. Because they work in 8-hour shifts, each laboring woman is often cared for by 2 to 6 different nurses before their baby is born.

The job of L&D nurses consists of checking each of their assigned labor patients, admitting new patients and discharged those already delivered, answering call-bells, periodically taking blood pressures, checking on IV fluid levels, adjusting and re-adjusting fetal monitor belts dozens and dozens of different times, providing water, juice and clean bed linens as needed and asking laboring women if they is feeling any rectal pressure or pushing sensations so the doctor can be notified in time to arrive before the baby.

While electronic medical records was suppose to make the healthcare system run better, nurses spend an inordinate amount of the time they are in the room with the patient looking at a computer screen and charting the tedious details of the laboring woman or new mother’s medical status.

Labor room nurses frequently tell to me that they no longer feel like caregivers. Instead they have become technicians whose real job is to attend to the needs of the electronic and medical devices and performing additional medical procedures made necessary by the use of obstetrical technology. Instead of observing the labor patient, their time and expertize is spent watching and fiddling with continuous electronic fetal monitors, IV infusion pump, anesthesia infusion device, intra-uterine pressure catheter (IUPCs), Foley catheter, continuous automatic blood pressure machine and the pulse oximetry equipment.

For the work they do and the abuse they incur if a mother should deliver quickly, before the doctor arrives, L&D nurses are overworked and under paid. I can vouch for this myself after working as an L&N nurse for more than a decade before cross-training into midwifery.

Even if an individual L&D nurse is able to stay with a laboring woman during her entire 8-hour shift, she can’t provide any form of care that is not part of the hospital’s approved protocols with first getting a written or verbal “order” from the patient’s doctor. Usually the opinion of the obstetrician, who is not in the room, trumps those of the nurse.

All L&D protocols were developed by the chief of the obstetrical department and reflect standard obstetrical management, which does not include physiologic practices. According to a study published in the Journal of American Medicine (JAMA), one-on-one care by L&D nurses did not reduce the number of major medical and surgical interventions.

These researchers were looking for a way to reduce an escalating Cesarean rate, but concluded that one-on-one nursing care in a highly medicalized hospital unit made no appreciable difference in the rate of medical interventions and surgical deliveries. The conclusion to be drawn was that a high-tech, highly-interventive hospital environment front-load the outcomes towards the routine use of medical and surgical interventions and a higher level of side-effects and associated complications.

Using comprehensive data to compare the two models

A comprehensive comparison of the two models is based on numbers that factor in the full spectrum of reproductive mortality and morbidity over the course of a woman’s entire reproductive life, including delayed and downstream problems, complications in subsequent pregnancies, future fetal or neonatal loss and over-all cost of care to individuals and society.

When this comprehensive data is used, physiologic childbirth practices turn out to be the best choice whenever possible.

While medicalized childbirth in a healthy population has some specific advantages, these benefits are almost always offset by a specific downside. Unfortunately many of these side effects are extremely detrimental, and a few are associated with iatrogenic (medical provider) and nosocomial (hospital-related) mortality and morbidity.

Based on a consensus of the scientific literature, childbirth services based on physiological principles are the evidence-based standard of care for healthy women with normal pregnancies. Recent scientific research on this topic has provided valuable new information on the hormonal physiology of normal labor and birth. Naturally-produced hormones in the body and brain of the mother-to-be are produced during the last weeks of pregnancy and during labor and birth. At just the right time and right circumstances (when the mother-to-be feels safe) these endogenous (internal) hormones will trigger and maintain a normal and progressive labor, spontaneous birth, mother-baby bonding, initiation of breastfeeding and its continued success in the following weeks and months.

The conclusions of this body of scientific evidence cautions against the use of any medical intervention unless there is an immediate and demonstrated need. Recent publications are characterizing this as “The Precautionary Principle”, which put the burden of proof for the safe use of each intervention and surgical procedure on those that are promoting their use. This in the reverse of the frequently repeated obstetrical axiom “When in doubt, cut it out”, which refers to the very liberal use of Cesarean surgery anytime the labor was something other than perfect.

“According to the evidence …, the innate hormonal physiology of mothers and babies – when promoted, supported, and protected – has significant benefits for both during the critical transitions of labor, birth, and the early postpartum and newborn periods, ……. extending into the future by optimizing breastfeeding and attachment. While beneficial in selected circumstances, maternity care interventions may disrupt these beneficial processes.

Because of the possibility of enduring effects, including via epigenetics, the Precautionary Principle suggests caution in deviating from these healthy physiologic processes in childbearing.” Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies and Maternity Care;” Dr. Sarah Buckley

In contrast to this physiologic model, the standard obstetrical care in America currently treats labor as a potential medical emergency, and birth as a necessary surgical procedure. Despite this strict model of obstetrics, with its many policies and protocols designed to make childbirth safer, despite spending more on maternity care than any country in world, the US has always ranked near the bottom of the developed world in the most important quality measures: 39th in maternal mortality and 50th in neonatal outcomes. When it comes to rates of operative delivery, we also have a poor showing — a 32% Cesarean section rate, which is among the highest in the world.

According to a review of the scientific literature, the best outcomes for healthy mothers and babies are consistently associated with three healthcare-related circumstances. In combination, these three basic elements are equally advantageous to industrialized countries as well as developing countries.

In country with a functional healthcare system, effective maternity care must include these three critical elements:

(1) Initial risk-screening, on-going prenatal care, and use of medical services as indicated

(2) Birth attendant(s) educated and skilled in physiologic care, aseptic technique and emergency response who are present during the intrapartum & postpartum-neonatal period

(3) Appropriate use of comprehensive and emergent medical services as necessary

The safest and most cost-effective the care for healthy women with normal pregnancies is a model of maternity care that uses risk-screening from the first encounter early in pregnancy to the last postpartum visit. Its underpinning are an assumption that childbirth is a normal biological process that rarely needs intervention but almost always needs careful watching and physical, emotional and social support during the events of labor, birth and the postpartum and neonatal period.

Because complications, while infrequent, can occur in any pregnancy or labor, no matter how healthy the mother or normal the pregnancy, access to and appropriate use of obstetrical interventions is an integral part of physiologically-based care, and are used whenever needed to treat complications, or if the mother requests medical care.

Recap ~ Optimal maternity care is based on the principles of physiological management

  • The ideal maternity care system integrates the time-tested principles of physiologically-based care, with the best advances in obstetrical medicine to create a single, evidence-based standard for all healthy women.
  • The type of care is determined by the health status of the childbearing woman and her unborn baby, in conjunction with the mother’s stated preferences, rather than by the occupational status of the care provider (physician, obstetrician, midwife).
  • Mastery in normal childbirth services for healthy women with normal pregnancies means bringing about a good outcome without introducing any unnecessary harm or unproductive expense.
  • Maternity care providers seek out the point of balance where the skillful use of physiological management and adroit use of necessary medical interventions provides the best outcome with the fewest number of medical/surgical procedures and least expense to the health care system.

Ultimately, all maternity care is judged by its results — the number of mothers and babies who graduate from its ministration as healthy, or healthier, than when they started.

Based on ethical grounds, full information on these two models of management (obstetrical and physiologic) and evidence-based childbirth options should never be withheld from informed and consenting consumers.

Note: this is a companion document to the “Political History of Midwifery in California 1850 to 2014”, and “The Healing Arts ~ A Short History of California Medical Practice Act”