Objectives. How do we support spontaneous labor and birth? Disclosures: I have no conflicts of interest. Care for women in spontaneous labor:

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Disclosures: I have no conflicts of interest Care for women in spontaneous labor: Evidence-based management Holly Powell Kennedy, PhD, FACNM, FAAN Helen Varney Professor of Midwifery

1 Disclosures: I have no conflicts of interest Care for women in spontaneous labor: Evidence-based management Holly Powell Kennedy, PhD, FACNM, FAAN Helen Varney Professor of Midwifery Acknowledgements: The UK/US Fulbright Commission The Burdett Trust for Nursing ACNM Foundation Childbirth Connection UCSF Academic Senate The New Hampshire Charitable Trust TriService Nursing Research Program The Renfield Trust The women, clinicians, & leaders who have participated in my research Objectives Examine the evidence to support spontaneous labor and birth How do we support spontaneous labor and birth? Review specific care practices supportive of spontaneous labor and birth Identify critical resources to help units adapt practices supportive of spontaneous labor and birth 1

2 How do we support spontaneous labor and birth? WHO states that childbirth interventions should be based on best evidence for the mother and optimal level of intervention should be to achieve best outcomes World Health Organization (2015) Are we really using evidence to the mother s and infant s advantage? Photo courtesy B. Reid what evidence and outcomes matter? 2

(where less is more) Optimal health of the mother and baby in the given situation Optimal health of the mother and baby in the given situation Kennedy HP. (2000).

3 Salutogenic Birth... that which creates health The examination of how we care for women during labor and birth Photo courtesy B. Reid Belief in the normalcy of pregnancy and birth Belief in the normalcy of pregnancy and birth The art of doing nothing well (where less is more) The art of doing nothing well (where less is more) Optimal health of the mother and baby in the given situation Optimal health of the mother and baby in the given situation Kennedy HP. (2000). A model of exemplary midwifery care. Results of a Delphi study. Journal of Midwifery and Women s Health, 45(1), 4-19 Kennedy HP. (2000). A model of exemplary midwifery care. Results of a Delphi study. Journal of Midwifery and Women s Health, 45(1),

Return to the basics http://transform.childbirthconnection.

Activation of spinal-cord pain relief pathways Onset of labor

4 Return to the basics Upregulation of OTRs Electrical connection of muscle cells for coordinated CTX Cervical ripening Shift from PG receptors to increasing uterine stimulants Inflammation Activation of spinal-cord pain relief pathways Onset of labor David N. Figlio DN; Guryan J; Karbownik K; Roth, J. (2016). JAMA Pediatrics (online). 4

We are also learning that the window of the puerperium can have life long effects for the mother and the child Normal physiology of labor & birth Oxytocin endogenous v.

Eye-to-eye contact C. Diet restriction D. Diminished sensory stimulation 1% 49% 0% 49% Buckley, S. J. (2015).

5 We are also learning that the window of the puerperium can have life long effects for the mother and the child Normal physiology of labor & birth Oxytocin endogenous v. exogenous Beta-endorphins Catecholamines Cortisol (Eustress) Prolactin Prostaglandins What factors support the release of maternal endogenous oxytocin in labor? A. Continuous fetal monitoring B. Eye-to-eye contact C. Diet restriction D. Diminished sensory stimulation 1% 49% 0% 49% Buckley, S. J. (2015). Hormonal physiology of childbearing: evidence and implications for women, babies, and maternity care. Washington, D.C.: Childbirth Connection Programs, National Partnership for Women & Families. C o n t i n u o u s f e t a l m o n i t o r i n g E y e - t o - e y e c o n t a c t D i e t r e s t r i c t i o n D i m i n i s h e d s e n s o r y s t i m u... 5

Oxytocin release sensory stimulation eye-to-eye contact acupressure eating suckling warmth water immersion companions pleasing sounds pleasing views Ferguson reflex sexual activity

, Peterson, N., Lagrew, D., Main, E. (Eds). (2016). Toolkit to Support Vaginal Birth and Reduce Primary Cesareans.: A Quality Improvement Toolkit.

6 Oxytocin release sensory stimulation eye-to-eye contact acupressure eating suckling warmth water immersion companions pleasing sounds pleasing views Ferguson reflex sexual activity smiling (muscle) relaxation nor-adrenaline love Photo by Michelle Wellborne; courtesy Y. Neumann... we are the instruments Oxytocin release sensory stimulation eye-to-eye contact acupressure eating suckling warmth water immersion companions pleasing sounds pleasing views Ferguson reflex sexual activity smiling (muscle) relaxation nor-adrenaline love Smith, H., Peterson, N., Lagrew, D., Main, E. (Eds). (2016). Toolkit to Support Vaginal Birth and Reduce Primary Cesareans.: A Quality Improvement Toolkit. Stanford, CA: California Maternal Quality Care 6

7 CMQCC Recommendations Readiness (improving the culture of care, awareness, and education) Recognition & prevention (supporting intended vaginal birth) Response (managing labor abnormalities) Reporting (using data to drive improvement) CMQCC Recommendations Readiness (improving the culture of care, awareness, and education) Recognition & prevention (supporting intended vaginal birth) Response (managing labor abnormalities) Reporting (using data to drive improvement) Improving the culture of care, awareness, and education 1. Improve quality of & access to childbirth education 2. Improve communication through shared decision-making at critical points in care 3. Bridge the provider knowledge gap 4. Improve support from senior hospital leadership and harness the power of clinical champions 5. Transition from paying for volume to paying for value Do you know what the women in your care are reading? Where are they getting their information? 7

Kennedy, Nardini, Mcleod-Waldo, Ennis. (2009). A discourse analysis of top selling childbirth advice books.

Pain has a purpose; different from suffering If you are birthing in a hospital you automatically become part that system.

Pain Pain has no purpose and is unacceptable Keep this in mind: Those of us who took a little nip from the epidural tap are

8 Kennedy, Nardini, Mcleod-Waldo, Ennis. (2009). A discourse analysis of top selling childbirth advice books. BIRTH, 36(4), 318. Pain has a purpose; different from suffering If you are birthing in a hospital you automatically become part that system. A woman's intolerance of labor pain may not be to pain, but to other people's response to it. Pain Pain has no purpose and is unacceptable Keep this in mind: Those of us who took a little nip from the epidural tap are usually the life of the champagne celebration in our rooms after the baby is born, while our American Gothic counterparts are sound asleep with every capillary in their cheeks broken. Becoming a mother minimal messages about women s strength or values of childbearing processes 8

a 6/10/2016 http://ourmomentoftruth.com/omot/files/birthtoolfiles/filename/00 0000000002/NormalBirthAndYou-031815.pdf Improving the culture of care, awareness, and education 1.

Improve support from senior hospital leadership and harness the power of clinical champions 5.

9 a 6/10/ /NormalBirthAndYou pdf Improving the culture of care, awareness, and education 1. Improve quality of & access to childbirth education 2. Improve communication through shared decision-making at critical points in care 3. Bridge the provider knowledge gap 4. Improve support from senior hospital leadership and harness the power of clinical champions 5. Transition from paying for volume to paying for value Evidence-based practice includes which of the following: A. a A. The best available scientific evidence B. The clinician s skill and judgment C. The desires of the patient B. a & b C. a & c D. a, b, & c 25% a & b 8% 11% a & c 56% a, b, & c Smith, H., Peterson, N., Lagrew, D., Main, E. (Eds). (2016). Toolkit to Support Vaginal Birth and Reduce Primary Cesareans.: A Quality Improvement Toolkit. Stanford, CA: California Maternal Quality Care 9

Antenatal Guidelines 2nd Edition Oct 2007 (Notes) Institutional ethnography Understand how women are supported in the achievement of physiologic normal birth or optimal birth in the presence of

, Grant, J., Walton, C., Shaw-Battista, J., Sandall, J. (2010). Normalizing birth in England: a qualitative study. Journal of Midwifery and Women s Health, 55(3), 262-269.

10 Antenatal Guidelines 2nd Edition Oct 2007 (Notes) Institutional ethnography Understand how women are supported in the achievement of physiologic normal birth or optimal birth in the presence of social/medical/obstetric complexity in 2 NHS Trusts (London 2008) Following the initial booking appointment the women will be given their notes to carry throughout their pregnancy. Kennedy, H.P., Grant, J., Walton, C., Shaw-Battista, J., Sandall, J. (2010). Normalizing birth in England: a qualitative study. Journal of Midwifery and Women s Health, 55(3), When is a prenatal record more likely to be lost? A. When the hospital retains it? B. When the woman retains it? W h e n t h e h o s p i t a l r e t a i n s... 78% W h e n t h e w o m a n r e t a i n s... 22% Improving the culture of care, awareness, and education 1. Improve quality of & access to childbirth education 2. Improve communication through shared decision-making at critical points in care 3. Bridge the provider knowledge gap 4. Improve support from senior hospital leadership and harness the power of clinical champions 5. Transition from paying for volume to paying for value 10

Resources American College of Nurse-Midwives http://www.birthtools.

The Case for a Physiologic Approach (Romano & Goer, 2013)

11 Resources American College of Nurse-Midwives National Institutes of Clinical Excellence (NICE) Intrapartum Guidelines Resources Resources Optimal Care in Childbirth: The Case for a Physiologic Approach (Romano & Goer, 2013) Normal Childbirth: Evidence and Debate (Downe, 2008) (Available at Amazon.com) 11

12 Resources Dixon, L., Fullerton, J.T., Begley, C. Kennedy, H.P., & Guilliland. (2011) International Journal of Childbirth, 1(3), 179. Improving the culture of care, awareness, and education 1. Improve quality of & access to childbirth education 2. Improve communication through shared decision-making at critical points in care 3. Bridge the provider knowledge gap 4. Improve support from senior hospital leadership and harness the power of clinical champions 5. Transition from paying for volume to paying for value Our leaders are visible and vocal: the workforce There is an open culture in which staff are supported and challenged in their decision making Lets talk Kennedy, H.P., Grant, J., Walton, C., Shaw-Battista, J., Sandall, J. (2010). Normalizing birth in England: a qualitative study. Journal of Midwifery and Women s Health, 55(3), Improving the culture of care, awareness, and education 1. Improve quality of & access to childbirth education 2. Improve communication through shared decision-making at critical points in care 3. Bridge the provider knowledge gap 4. Improve support from senior hospital leadership and harness the power of clinical champions 5. Transition from paying for volume to paying for value 12

Implement early labor supportive care policies and establish criteria for active labor admission 3. Improve the support infrastructure and supportive care during labor Photo courtesy B.

13 The New Normal: Redesigning Maternity Care for Low-Risk Women Key strategies for supporting intended vaginal birth 1. Implement institutional policies that uphold best practices safely reduce routine intervention in low risk women 2. Implement early labor supportive care policies and establish criteria for active labor admission 3. Improve the support infrastructure and supportive care during labor Photo courtesy B. Reid Nourishing women (body) In cases of normal, low risk labours, women should be encouraged to eat and drink as their appetite dictates. With progression of labour the amount that women will take decreases and therefore should not be forced upon them. It is important to let women choose and decide. Kennedy, H.P., Grant, J., Walton, C., Shaw-Battista, J., Sandall, J. (2010). Normalizing birth in England: a qualitative study. Journal of Midwifery and Women s Health, 55(3),

Key strategies for supporting intended vaginal birth 1. Implement institutional policies that uphold best practices safely reduce reduce routine intervention in low risk women 2.

Improve the support infrastructure and supportive care during labor Helping women stay home in early labor I think sometimes they admit them too early.

14 Key strategies for supporting intended vaginal birth 1. Implement institutional policies that uphold best practices safely reduce reduce routine intervention in low risk women 2. Implement early labor supportive care policies and establish criteria for active labor admission 3. Improve the support infrastructure and supportive care during labor Helping women stay home in early labor I think sometimes they admit them too early. Like women come in at you know, 1 to 2 cm and they admit them very early and give them epidurals right off the bat. I feel like they re not really in good labor on their own, and that kind of impedes the process (nurse). Key strategies for supporting intended vaginal birth 1. Implement institutional policies that uphold best practices safely reduce reduce routine intervention in low risk women 2. Implement early labor supportive care policies and establish criteria for active labor admission 3. Improve the support infrastructure and supportive care during labor Unit design 14

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16 ... and it was like a haven... Key strategies for supporting intended vaginal birth Photo courtesy B. Reid 4. Encourage the use of doulas and work collaboratively to provide labor support 5. Utilize best practice recommendations for laboring women with regional anesthesia 6. Implement intermittent monitoring policies for low risk women 7. Implement current treatment and prevention guidelines for potentially modifiable conditions 16

Key strategies for supporting intended vaginal birth Photo courtesy B. Reid 4. Encourage the use of doulas and work collaboratively to provide labor support 5.

Implement current treatment and prevention guidelines for potentially modifiable conditions Key strategies for supporting intended vaginal birth 4.

17 Key strategies for supporting intended vaginal birth Photo courtesy B. Reid 4. Encourage the use of doulas and work collaboratively to provide labor support 5. Utilize best practice recommendations for laboring women with regional anesthesia 6. Implement intermittent monitoring policies for low risk women 7. Implement current treatment and prevention guidelines for potentially modifiable conditions Key strategies for supporting intended vaginal birth 4. Encourage the use of doulas and work collaboratively to provide labor support 5. Utilize best practice recommendations for laboring women with regional anesthesia 6. Implement intermittent monitoring policies for low risk women 7. Implement current treatment and prevention guidelines for potentially modifiable conditions Photo courtesy E. Knobf 17

... we ask the question, why was she put on the monitor? Kennedy, H.P., Grant, J., Walton, C., Shaw-Battista, J., Sandall, J. (2010). Normalizing birth in England: a qualitative study.

Utilize best practice recommendations for laboring women with regional anesthesia 6. Implement intermittent monitoring policies for low risk women 7.

18 ... we ask the question, why was she put on the monitor? Kennedy, H.P., Grant, J., Walton, C., Shaw-Battista, J., Sandall, J. (2010). Normalizing birth in England: a qualitative study. Journal of Midwifery and Women s Health, 55(3), Key strategies for supporting intended vaginal birth 4. Encourage the use of doulas and work collaboratively to provide labor support 5. Utilize best practice recommendations for laboring women with regional anesthesia 6. Implement intermittent monitoring policies for low risk women 7. Implement current treatment and prevention guidelines for potentially modifiable conditions Successful models Trust in women Trust in birth Use of evidence Teamwork & respect Integrated systems of care Kennedy, H.P., Grant, J., Walton, C., Shaw-Battista, J., Sandall, J. (2010). Normalizing birth in England: a qualitative study. Journal of Midwifery and Women s Health, 55(3),

Critical steps Personal & institutional commitment to keeping low risk women, low risk Use the evidence and the physiology always question if intervening is the best option Bring in experts to help

19 Critical steps Personal & institutional commitment to keeping low risk women, low risk Use the evidence and the physiology always question if intervening is the best option Bring in experts to help change takes careful thought & strategy All stakeholders must engage (including women) it has to be a team approach Critical steps Small steps with team development, training, & evaluation Childbirth education think about completely different approaches and make it available to all women Branding & marketing how to present it to women Track, evaluate, & disseminate Keep that oxytocin flowing Photo courtesy B. Reid 19

20 Thank you for the invitation to join you in this dialogue Photo courtesy B. Reid 20

THE INTRAPARTUM NURSE S BELIEFS RELATED TO BIRTH PRACTICE

THE INTRAPARTUM NURSE S BELIEFS RELATED TO BIRTH PRACTICE Ellise D. Adams PhD, CNM All Rights Reserved Contact author for permission to use The Intrapartum Nurse s Beliefs Related to Birth Practice (IPNBBP)