Ep 190: Physiologic Birth

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I’m kicking off the new year with a really important episode about physiologic birth. I was inspired to cover this topic by our guest from episode 168, CNM Gianna Fay. She wrote to me asking if I would be willing to cover it and my response was - sure… but how?

It’s not a topic that OB/GYNs are taught much if anything about. The term gets used a lot in the online space but it’s not often defined. So I decided to roll up my sleeves and see what information I could find. I learned about it myself and I’m going to share that information with you today.

In this Episode, You’ll Learn About:

  • How normal physiologic birth is defined
  • Which factors disrupt physiologic childbirth
  • What are the benefits of normal physiologic birth
  • Whether any one position should be mandated or prescribed
  • What are the factors that influence physiologic birth
  • Why it’s vital for your medical team to support your wishes
  • What makes it necessary to intervene

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Dr. Nicole (00:00): In this episode, you are going to learn all about physiologic birth. Welcome to the All About Pregnancy & Birth podcast. I'm Dr. Nicole Calloway Rankins, a board certified OBGYN, who's been in practice for nearly 15 years. I've had the privilege of helping over 1000 babies into this world, and I'm here to help you be calm, confident, and empowered to have a beautiful pregnancy and birth. Quick note, this podcast is for educational purposes only and is not a substitute for medical advice. Check out the full disclaimer at drnicolerankins.com/disclaimer. Now let's get to it.

(00:51): Hello. Hello. Welcome to another episode of the podcast. This is episode number 190. I am so glad that you're spending some of your time with me today. I'm so excited for this episode. I'm kicking off the new year 2023 with a really important topic, and that is physiologic birth. I was inspired to do this episode by Gianna Faye. She is a certified nurse midwife. She was a guest on the podcast on episode 168 where we chatted about all things midwifery, and she sent me a message asking me if physiologic birth is a topic that I'd be willing to cover because it gets talked about a lot. And my response was, sure, but how do I talk about this? It's not a topic that OBGYNs are taught much if anything about. And quite honestly, we often scratch our heads at the term, what does that even mean?

(01:49): But as I said, the term gets used a lot in the online space, but it's not often defined. So I said, okay, let me roll up my sleeves, see what information I can find on physiologic birth so I can learn about it myself and also share that information with you. So I found two great documents that we're going to go through today. One is a document called Supporting Healthy and Normal Physiologic Childbirth, A Consensus Statement by A C N M M A N A and n a Ccpm. I'll tell you what those are in a minute. And in that statement, I'm going to walk you through their description of what is physiologic birth, things that influence physiologic birth and the recommendations for policy as well as benefits of physiologic birth. And then we'll talk about the ACOG, the American College of Obstetricians and Gynecologists Committee, opinion on approaches to limit intervention during labor and birth.

(02:50): And in that one we're going to talk more specifically about specific interventions like continuous support during labor, routine amniotomy, which is breaking the water, intermittent oscultation, which is listening to the fetal heart rate intermittently instead of continuously like is typically done, hydration and oral intake in labor, maternal position during labor, and second stage of labor pushing technique. There were a couple other things in that document that I chose not to include like what happens when your water breaks early and then when to start pushing. I just didn't feel like those were as effective. But if you're interested, I'll put the links to both of those documents in the show notes, and as I talk through the contents of those documents, I'm going to add in my own take or 2 cents or experience expertise based on what I know and what I've seen and comment on some of the things that are in the documents. This is going to be some great information. You're going to learn a lot. I did, and I know you are going to find it super duper useful.

(03:55): Now, before we get into the episode, I have some exciting news to share, and that is my birth plan class, Make A Birth Plan The Right Way, is back. My super popular class is back and better than ever, it is now exclusively a live class where I'll be teaching the content of the class live, of course, updated with the most helpful information. And I'm so excited about doing it live because we get to connect. You can ask me questions and you can learn in real time how to make a birth plan the right way because you know that a birth plan is important to help you have the birth that you want, especially in a system that can take a patriarchal approach to birth, can try and take away your power, can be racist. However, those templates and forms don't cut it. If you show up to the hospital with one of those filled out forms and think that that's going to really help you in terms of having the birth you want, you are sadly mistaken.

(04:52): Making a birth plan is a process that needs to start during the prenatal period where you ask the right questions. So whether or not the person who's going to be with you, the doctors who's going to be with you and the hospital where you give birth, actually support the things that you want for your birth. And you can make your wishes known early or make changes to your birth support team if needed so that you have the best chances of having that beautiful birth that you deserve. And just showing up on that day or even handing a form in the prenatal period is not going to cut it. It really needs to be a process that I teach you inside of this class, and it's one that literally thousands of women have found helpful. So the live class is Tuesday, January 17th. I'm teaching it twice that day, 1:00 PM Eastern Standard Time and 7:00 PM Eastern Standard Time.

(05:45): Now, I am only teaching this class live four times a year. Okay? So if you are due in January, February, March, or April of 2023, then you definitely need to go ahead and hop on this class in January. Even if you are due later, you can always go back and listen to the replay of the video because you'll have access to the replay forever. Now, not only will you have access to the replay, but you'll also still have the opportunity to ask me questions in real time because as a bonus, when you join the class, you also get to join the Pregnancy and Birth Inner Circle community. That is my private Facebook group where you will be able to connect with other pregnant mamas, receive support during your pregnancy, childbirth, and postpartum journey. The group has an amazing community manager who's a doula. She's also a mom of two.

(06:44): And this's just a place where it, it's not like there's no judgment, there's no shaming. Everyone is really accepted and welcoming and opening and helpful. If you like the evidence and the podcast, then the community in the Inner Circle community is very similar. And this is also the place where you will get the closest access to me. All right, in the group, I do live q and a sessions where I answer questions about pregnancy and birth people tag me, ask me questions, I respond. So this is the place where you can get the most access to me as well as you go through your pregnancy, childbirth, and postpartum journey. And that comes as a bonus when you sign up for the live class. Again, it's Tuesday, January 17th, 1:00 PM Eastern Standard time, 7:00 PM Eastern standard time, and registration is open now. Head to drnicolerankins.com/register and secure your spot today.

(07:41): All right, so let's get into the conversation about physiologic birth. So the first document that I wanna start with is something called Supporting healthy and normal Physiologic Childbirth, the Consensus Statement by A C N M, which is the American College of Nurse Midwives, M A N A, which is Midwives Alliance of North America, and N Acpm, which is National Association of Certified Professional Midwives. This statement was released in May of 2012, so that is what, 10 and a half years ago? Okay, 10 and a half years ago. And just a little bit of a background about this statement taken from the statement itself, this consis, this consensus statement represents the work of a task force comprised of representatives from three US member midwife free organizations whose members are experts on supporting women's innate capabilities to birth. It was extensively reviewed by maternity care organizations and leaders.

(08:43): And the aims of this statement are to provide a succinct definition of normal physiologic birth, identify measurable benchmarks to describe optimal processes and outcomes, reflective of normal physiologic birth, identify factors that facilitate or disrupt normal physiologic birth based on the best available evidence, create a template for system changes through clinical practice, education, research and health policy, and ultimately improve the health of mothers and infants while avoiding unnecessary and costly interventions. It goes on to further say that this statement is placed in the context of the current widespread application of technological interventions that lack scientific evidence to a primarily healthy birthing population. The use of obstetric interventions in labor and birth has become the norm in the United States. More than half of all pregnant women receive synthetic oxytocin to induce their augment labor that demands additional interventions to monitor, prevent, or treat side effects. And then nationally, one third of women deliver their babies via cesarean, which has potential for serious short and long-term health consequences.

(09:54): So that's the context in which this document was made informed, and keep in mind again that this is 10 years ago. I'm going to comment on that as well. All right. So let's start off with how normal physiology of childbirth is defined according to these organizations. So a normal physiologic labor and birth is one that is powered by the innate human capacity of the woman in fetus. The birth is more likely to be safe and healthy because there is no unnecessary intervention that disrupts normal physiologic processes. Push back on that a little bit. I do think birth can still be safe and healthy even if you intervene. So that part is a little tricky, but I get it where they're saying that physiologic birth is one that is powered by the innate human capacity of the woman and fetus. Like birth has been happening for millions of years.

(10:46): And so it can happen without intervention. It does go on to immediately say, some women and or fetuses will develop complications that warrant medical attention to assure safe and healthy outcomes. However, supporting the normal physiologic processes of labor and birth, even in the presence of such complications, has the potential to enhance best outcomes for the mother and infant. So what I see that as saying, which is really important is that yes, sometimes we do need to intervene to assure the safety and healthy of safe safety and health of the mom and baby. However, we can still adhere to the normal physiologic things that happen in labor and birth without us intervening even in that context. And I agree with that 100%.

(11:38): All right, so then it goes on to further say that normal physiologic birth is characterized, is, I'm just going to go through a list of things. It's characterized by spontaneous onset and progression of labor includes biological and psychological conditions that promote effective labor results in the vaginal birth of the infant. And placenta results in physiologic blood loss, although I'm not quite so sure what that means. It facilitates optimal newborn transition through skin to skin contact and keeping the mother and infant together during the postpartum period. And finally supports early initiation of breastfeeding. So that's what normal physiologic childbirth is. Now the following factors they report disrupt normal physiologic childbirth, induction or augmentation of labor, an unsupportive environment like with bright lights, cold, the room, lack of privacy, multiple providers, lack of supportive companions, time constraints, including those driven by institutional policy and or staffing, nutritional deprivation like depriving people of food and water, food and drink rather, opioids.

(12:58): Regional anesthesia and general anesthesia all disrupt normal physiologic childbirth as do episiotomy, operative vaginal birth with vacuum or forceps, or cesarean birth, immediate cord clamping, separation of mother and infant, and or any situation in which the mother feels threatened or unsupported. And as you can see, the things that disrupt normal physiologic childbirth are more likely to be features of hospital birth, for example, induction or augmentation of labor. Although that one I will push back a little bit on because certainly in the midwifery community or out of hospital community, there are lots of things that are done to attempt to induce or augment later labor that are considered natural like dates or castor oil or nipple stimulation. Okay. So yes, I would say medical augmentation or induction is more likely to be associated with hospital birth. But I wanna be clear that augmentation or induction are concepts that are not just limited to hospital birth.

(14:05): And then other things that are definitely more associated with hospital birth that are perceived as factors or that are factors that disrupt normal physiologic birth are an unsupportive environment like bright lights, cold room, people walking in and out of the room lack of privacy, multiple providers, all of those things happen in the hospital. Time constraints certainly happen in the hospital as well. Nutritional deprivation happens in the hospital. Opioids and epidurals, general anesthesia, those are all things that are in the hospital as are typically episiotomy, operative vaginal birth, and cesarean birth. Again, in the hospital, I think we've certainly gotten a lot better. We don't do immediate cord clamping or separate moms and babies like we used to, but there is certainly more of a possibility of a mom feeling threatened or unsupported in hospital birth. So the argument, or I don't wanna say argument cuz that makes it sound like it's contentious, but the data supports that things that disrupt normal physiologic childbirth are more likely to be present in the hospital.

(15:16): And then the final thing that it says that I thought that was really important in terms of just kind of the concept of physiologic birth is that regardless of intervention or outcome, childbearing care perceived by the woman as disrespectful or traumatic is more likely to be associated with maternal psychological morbidity and potential for disruptive mother infant attachment. I agree with that 100%. So often you will hear me say that when people are dissatisfied with their birth experience, it's not necessarily because of a specific outcome. It's often because of the way that they were treated or feeling like they weren't involved participant in their care. So I'm 100% agree with that statement. And the other thing that I will add, that not only may things happen that necessitate the interruption of physiologic birth, for example, if there are problems with the pregnancy and you need to be induced for whatever reason, but the person giving birth may also choose to interrupt physiologic birth.

(16:18): Maybe you want to be induced, maybe you want to get an epidural, maybe you want to have an elective cesarean birth. So my approach is that you don't have to have a physiologic birth, but you should know about it. You should know about potential benefits, and you should absolutely be supported in having a physiologic birth if that's what you choose. And that should be an option regardless of where you give birth, including in the hospital. Okay? So that's really important. You don't have to have a physiologic birth, but you should know what it is, no potential benefits and be supported in that if that is what you choose. So speaking of some of the benefits of physiologic birth, so according to the document, it says that optimal physiologic function of the neuroendocrine system enhances the release of exo endogenous oxytocin and beneficial what's called catecholamines in response to stress.

(17:21): And these hormones help promote effective labor patterns and protect protective physiologic responses, including enhanced endorphin levels, facilitation of cardio, respiratory transition, and thermal regulation of the newborn, successful lactation enhanced bonding behavior between the mother and infant. So that sounds a lot of scientificy, but basically it's saying you respond better to stress and the baby has a better chance or is better able to transition to newborn life. You also have better success with establishing lactation. It goes on to further say, when there's optimal physiologic functioning, women are less likely to require interventions to artificially augment labor, which can potentially interfere with their ability to cope with pain. So when you have things that augment labor like specifically Pitocin, yes, it can increase the pain and your challenges with coping with that pain. And then finally, it says, when labor progresses spontaneously, there's a reduced likelihood of fetal compromise or need for instrument surgical intervention. And that is true. There's a reduced issues of fetal heart rate abnormalities in spontaneous labor, and also reduced need for cesarean as well as a assisted vaginal birth.

(18:45): All right. So in terms of other benefits one of the things it says is the short term benefits of normal physiologic birth include emerging from childbirth, feeling physically and emotionally healthy and powerful as mothers. I will argue that that is not exclusively limited to physiologic birth. Lots of people feel that way regardless of whether or not they have a physiologic birth experience. So that is not unique, just to physiologic birth. However, I do acknowledge that many people do feel very empowered after having a physiologic birth experience. And then some other things that goes on to say is that their infants will benefit from the ability of their mothers to respond to their needs, and from the lack of exposure to medications that can affect neurological behavior. These are soft things and they don't really provide to me, I think really strong data for that also says long-term outcomes include beneficial effects for the women's physical and mental health and capacity to mother, enhanced infant growth and development, and potentially diminish incidents of chronic disease.

(19:53): And again, I wanna be clear that I do not think that these are things that are just related specifically or exclusively to if you have a physiologic birth experience, meaning if you don't have a physiologic birth that suddenly you're not going to be able to respond to your infants needs or because you've been exposed to medications that you're going to be reacting differently. So this part I don't agree as strongly with in terms of the benefits of physiologic birth because it's implying to me that you don't get those benefits if you don't have physiologic birth, which isn't true. So then let's go on to talk about factors that influence normal physiologic birth, and they divided up in terms of factors related to the woman have giving birth, the clinician, and then the birth setting and environment. So for the woman, the factors that influence the ability to have a physiologic birth or her individual health status and physical fitness, 100%, the healthier you are, the easier it's going to be to have a physiologic birth experience, autonomy and self-determination in childbirth.

(21:04): Absolutely. You have to be able to make choices about what happens in your own body and believe that this is something that you are able to do. Personal knowledge and confidence about birth, including cultural beliefs, norms and practices, and education about the value of normal physiologic birth. In this regard, it's important that you understand birth and what is happening in your body, period. In today's society, obviously birth on TV is depicted completely unlike reality. I think people are getting more realistic things about birth, but even those like 30 minute vlog stories that you see on YouTube aren't reflective of what birth can look like in the long term either. Obviously, birth stories are important to helping you understand as is childbirth education important to help you understand the normal physiology of birth. I think that that's important regardless of whether or not you have a or attempting a physiologic birth experience period.

(22:01): Everyone needs to know about what happens in childbirth, which is why I of course have the Birth Preparation Course, my childbirth education class. Also, the woman needs to be fully informed, have shared decision making, and have access to healthcare system settings and providers that are supportive of and skilled in normal physiologic birth. That last one can be tricky. Okay? Access to healthcare system settings and providers that are supportive of and skilled in normal physiologic birth, that is a challenge in hospital birth. Now, for the clinician, they need to have education, knowledge, competence, skill and confidence in supporting physiologic labor and birth, including helping women cope with pain. This is not something that I think obstetricians are particularly skilled in, and it is something that midwives are certainly more skilled in commitment to working with women through education to enhance their confidence in birth and diminish their fear of the process.

(22:58): Quite frankly, I don't think obstetricians have much time to do education, and that kind of gets relegated to being educated on your own, commitment to shared decision making, which is important. And then working within an infrastructure supportive of normal physiologic birth. And I don't wanna be clear that I'm not like poo-pooing or downplaying obstetricians. We obviously have our role and obviously many of us do embody these characteristics, but the reality is that it's not a routine part of how we are taught to provide care. And then for the birth setting and environment, access to midwifery care for each woman, that is not something that is going to happen anytime soon. All right? You can't just pluck midwives out of nowhere. It takes time to train them. I also don't think that as a field in the US that we're going to get to a model like it is in other countries where midwifery or midwives are responsible for most low risk care.

(23:58): It's just not a model that's going to happen anytime soon in the United States. Remember I said this document was written 10 and a half years ago, and we're still like saying, we need more midwives, we need more midwives. And then other things about the birth setting and environment that are needed are adequate time for shared decision making, freedom, freedom from coercion. Again, those are things that are not as likely to always happen in the hospital. No inductions or augmentations of labor without an evidence-based clinical indication, encouragement of nourishment, food, and drink during labor as the woman desires. That does not happen in the hospital very much. I'll talk about the ACOG recommendations regarding that in a moment. Freedom of movement in labor and the woman's choice of birth position also doesn't happen as much in the hospital. Intermittent oscultation of heart tones during labor and less continuous electronic monitoring is clearly clinically indicated.

(24:56): Maternity care providers, skilled and non-pharmacologic methods for coping with labor pain for all women, care that supports each woman's comfort, dignity, and privacy and respect for each woman's cultural needs. And again, I don't wanna poo poo hospitals, obviously I work in hospitals and I teach about hospital birth, but the reality is that this is not the standard of care across most hospitals. All right? It's just the reality is that it's just not. And we have some work to do in order to get to this point. And I would argue that these things should be especially care, that support supports each woman's comfort, dignity and privacy are things that should happen regardless of the type of birth that you have, physiologic birth or one that is not physiologic. And then as far as recommendations for policy, education, research to promote physiologic childbirth, they recommend the following introduction of policies into hospital settings as support normal physiologic birth, agree, comprehensive examination and dissemination of evidence and care practices that are supportive of normal physiologic birth.

(26:12): Midwifery care is a key strategy sup to support normal physiologic birth, increasing the midwife workforce and enhancing regulations and funding strategies to support their practice. Just to comment on those, I do think that we are making progress. Midwives are certainly more integrated into our care, but it is certainly not routine. And again, it's not going to be routine anytime soon because the opportunities just aren't there. The number of midwives aren't there, what needs to happen, and what I think is more feasible is that obstetricians learn to adopt pieces of midwifery care that are applicable for our low risk patients. That is something that we can do. That is something that we should do. That is something that I did as my own, as part of my own practice in becoming a better physician. And working around midwives and seeing the different things and strategies about supporting normal physiologic birth.

(27:09): We absolutely can and should do that. And then finally, recommendations about competent competency based interdisciplinary education programming for maternity healthcare clinicians and students on the application of care that promotes normal physiologic birth. Again, it's just not something that is routinely practiced or taught is how to support normal physiologic birth. Okay, just not. And then the last one is development of a future research agenda on short and long term long-term effects of normal physiologic birth. But I think that's important. If we look at more outcomes short and long term for when we don't intervene in birth, that'll be important to help us support physiologic birth for those who want it and desire it. All right, so let's move on and talk about the second document. This is from ACOG, the American College of Obstetricians and Gynecologists, and it's called Approaches to Limit Intervention during Labor and Birth.

(28:14): This was initially released in 2017, updated in 2019 and then reaffirmed in 2021. And ACOG is the organization that is kind of like the governing body for setting practice standards for OBGYN's physicians in particular. And here is the opening statement and some of the conclusion statements kind of combined from the document. I'm just going to read them. So obstetrician gynecologist and collaboration with midwives, nurses, patients, and those who support them in labor can help women meet their goals for labor and birth by using techniques that require minimal interventions and have high rates of patient satisfaction. Many common obstetric practices are of limited or uncertain benefit for low risk women in spontaneous labor. In addition, some women may seek to reduce medical interventions during labor and delivery. Therefore, obstetrician gynecologist and other obstetric care providers should be familiar with and consider using low interventional approaches when appropriate for the intrapartum management of low risk women in spontaneous labor.

(29:28): For women who is at term in spontaneous labor with the fetus and vertex presentation, that means with the head down, labor management may be individualized depending on maternal and fetal conditions, and risk to include techniques such as intermittent oscultation and non-pharmacologic methods of pain relief. All right, so a couple things that I think are really important about some of these statements before I go into a little bit more specific. Number one, it says, many common obstetric practices are of limited or uncertain benefit for low risk women in spontaneous labor. A lot of us just flat out don't believe this, okay? We just don't want to believe it. All right? And I think the hesitancy from the specialty as a culture is what leads to the further statements that I think are problematic where it says obstetrician gynecologists and other obstetric care providers should be familiar with and consider using low interventional approaches when appropriate.

(30:36): The end consider is problematic for me. So we just think about whether or not we should use it. No, we should use it. We should use low intervention approaches because the outcomes are better, and it more importantly, that's what people want. So the end consider is problematic to me. It should be strong, stronger, we should use them when appropriate. Okay? Period. Also, it said labor management may be individualized, may be individualized, is also not strong enough. Should be, it absolutely should be individualized for the person in front of you who's giving birth. All right? So not may be individualized. Should be individualized. So while I believe that this is a great start, I think there is room that I think I know there's room to significantly strengthen this statement and support the best interest of people who are giving birth. All right, so let's talk about more specific interventions and what those mean or what the evidence is, what the recommendations are according to ACOG.

(31:48): So one, it's continuous support during labor. So reading from the document, evidence suggests that in addition to regular nursing care, continuous one-to-one emotional support provided by support personnel such as a doula is associated with improved outcomes for women in labor benefits described in randomized trials. Keep in mind that randomized trials are the strongest form of evidence. Okay? Benefits described in randomized trials include shortened labor, decreased need for pain medication, fewer operative deliveries, and fewer reports of dissatisfaction with the experience of labor. In an evidence review, a woman who received continuous support was less likely to have a cesarean or a newborn with low five minute APGAR scores. And continuous support has a modest positive effect on shortening the duration of labor. Shorten it by, on average 0.69 hours, so less than an hour, so not much, but a little bit shorter, and a modest, modest effect on improving the rate of spontaneous vaginal birth.

(33:01): It also may be cost effective because of the associated lower cesarean rate. One analysis suggested that paying for such personnel might result in substantial cost savings annually. So given that these benefits and the absence of demonstrable risk patients, obstetrician gynecologists and other obstetric care providers and healthcare organizations may want to develop programs and policies to integrate trained support personnel into the interpartum care environment to provide continuous one-to-one emotional port emotional support to women undergoing labor. Again, that last statement I think is intentional that they say may want to develop, okay, they, ACOG, I believe, don't want to be too forceful with things and say should, even though the evidence is there. But really when we see the overwhelming support, this is something that we should support as well. And that is continuous labor support. This is why I support doulas, because the data's really clear that it helps.

(34:12): Okay? So routinely breaking your water, something called amniotomy. So statement says, for women with normally progressing labor, no evidence, the fetal compromise routine amniotomy need not be undertaken unless required to facilitate monitoring. So a review of 15 studies found that among women in spontaneous labor amniotomy alone did not shorten the duration of labor or lower the incidence of cesarean birth. Also, when compared with women who did not undergo amnio, amniotomy, those who did, they were similar in terms of patient satisfaction, frequency of five minute APGAR scores, umbilical cord prolapse, abnormal fetal heart rate patterns. So I think it's important there to say that it's not that people were less satisfied if they had amniotomy. So I think that's an important point to make. And another study showed that the combination of early, so breaking the water early with oxytocin augmentation, so adding pitocin. So another study evaluated combining early with oxytocin augmentation. And this study looking at 14 trials, found that that combination did result in a modest reduction in the first stage of labor. So from zero centimeters to completely dilated. So it reduced that time by 1.1 hours on average. So not a lot, and then also a little bit of a reduction in cesarean birth rate when compared to just rating waiting. So using amniotomy and oxytocin together did slightly reduce the duration of the first stage of labor and slightly reduce the cesarean birth rate.

(36:10): But the evidence wasn't considered so strong that it's something that we should do because it doesn't have a lot overwhelming benefits. So the takeaway is that it does not have to be undertaken unless it's required to facilitate monitoring. Okay, next is intermittent oscultation. So that's listening to the heart rate intermittently as opposed to continuously continuous electronic fetal monitoring was started in order to try and reduce the risk of perinatal death and cerebral pro palsy. And it was an alternative to intermittent oscultation, which had been the norm. It was adopted widely. However, it has not been shown to significantly impact perinatal death or cerebral palsy at all when used for women with low risk pregnancies and low risk has been defined in various ways, but in general, it means no meconium staining in the fluid, no bleeding during the labor, no abnormal fetal testing before giving birth. No increased risk of developing problems during labor. For example, if the baby is growth restricted, no maternal clinicians that may affect the baby's wellbeing like diabetes, hypertension no requirement for oxytocin or anything like that. Okay.

(37:39): And a review of 13 randomized trials found that, and again, randomized trials are the strongest level of evidence found that continuous monitoring was actually associated with an increase in cesarean birth, an increase in instrumental vaginal birth, okay, when compared with intermittent oscultation. So it doesn't reduce perinatal death, doesn't reduce cerebral palsy, it does increase cesarean births. It does increase instrumental vaginal births. And that kind of makes sense. Cause if you're looking and you see things, you're more likely to intervene. Continuous electronic fetal monitoring does have the rate of early neonatal seizures, but that rate is already very low. So it's 0.15% for continuous electronic fetal monitoring versus 0.29% for intermittent. So both numbers are very, very low to begin with. And this is when you have to be careful about data, cuz you can hear that, oh, continuous electronic fetal monitoring half the rate of early neonatal seizures, and you think that that's, wow, that's a big deal until you see that it's having it from 0.29 to 0.15.

(38:57): So both numbers are already really low. So the conclusion from ACOG is to facilitate the option of intermittent oscultation. Obstetrician gynecologists and other obstetric care providers and facilities should consider, again, there's that word, consider adopting protocols and training staff to use a handheld doppler device for low risk women who desire such monitoring during labor. I again, think it should be stronger that we should do not just should consider, we should adopt it for women who desire it during labor three more and to round out first hydration and oral intake in labor. So the statement is, women in spontaneously progressing labor may not require routine continuous infusion of intravenous fluids, although safe, intravenous hydration limits, freedom of movement and may not be necessary, there's no evidence that it helps at all. Oral hydration can be encouraged to meet hydration and caloric needs. So you can drink if you need to be hydrated, you can drink for calories.

(40:05): Arguments for limiting oral intake during labor center on concerns for aspiration and its sequelae. I talk about this inside the Birth Preparation Course, but in general, the thought is that if you have to go into general anesthesia, if you have solid foods or something heavy on your stomach, you can aspirate or that content comes up and gets into your lungs, and that can be bad. However, those restrictions have been questions because of the low incidence of aspiration with current obstetric anesthesia technique techniques is very rare that you need to be put to sleep for a C-section. Most of the time there's time to use an epidural or a spinal. So the recommendation there is that this information may inform ongoing review of recommendations regarding oral intake during labor. So not a strong stance one way or the other. Okay. My position is that you should be able to eat during labor if you're low risk. Most people are not hungry in the active part of labor. You're hungry in the early part. When you're active in the active part. You're so focused on getting through the labor. You're just generally not hungry or be careful about the things that you choose. And again, that's also something that I talk about more in depth inside the Birth Preparation Course.

(41:18): Okay. Maternal position during labor observational studies and maternal position during labor have found that women spontaneously assume many different positions during the course of labor. So it's like normal to move around during labor, and it further goes on to say there's little evidence that any one position is best. Moreover, this is really important. The traditional supine position, which is laying on your back during labor, has known adverse effects such as supine, hypotension, and more frequent fetal heart rate, dere deceleration. Therefore, for most women, no one position needs to be mandated or prescribed. Okay? This is something that unfortunately we do too frequently, is have people just only stay and lay on their backs.

(42:13): It goes on to further say that frequent position changes during labor to enhance maternal comfort and promote optimal fetal positioning can be supported as long as adoptive positions allow appropriate maternal and fetal monitoring and treatments are not contraindicated by maternal medical or obstetric complications. Again, so important is this can be supported, I think should be supported. And we look into some of the studies and data. One study showed that comparing upright positions like walking, sitting, standing, kneeling with recumbent, lateral recumbent is kind of sitting up slightly lateral on your side or supine lane all the way flat during the first stage of labor. That's the early part from zero to 10 centimeters, found that upright position shorten the duration of the first stage by about an hour and 22 minutes. But the key thing is that it shortens it by an hour and 22 minutes.

(43:10): But that is more than when labor is shortened by breaking the water artificially and oxytocin. So we can just change people's positions, let people move around and shorten that second st, that first stage of labor and not have to intervene. Okay? We have something that actually works better than intervening at shortening that first stage of labor. Women are also in upright. In upright positions are also less likely to have a cesarean birth. Another review of randomized control trials did show that upright or lateral positions compared with supine positions are associated with fewer abnormal, futile heart rate tracings, fewer AP episiotomies, decrease in operative vaginal birth. It is, however, associated with a increase in second degree tears. Okay? So second degree tears and an increase in blood loss greater than 500 ccs. Okay? Or 500 milliliters. All right? Also, interestingly, in a study of upright versus line positions during the pushing stage of labor among no leprous women, so women having their first baby with low dose epidurals, there were actually fewer spontaneous vaginal births among those who were assigned to the upright positioning.

(44:31): So that is also interesting. There were no evidence of other associated harms. So the general consensus, again, is that various positions should be supported. There's little evidence that one position is best. All right, and then the final thing I wanna talk about is the pushing techniques. We are often taught OB GYNs and other obstetric care providers, like nurses in the US, are often taught to encourage women to push with what's called a prolonged GLO closed glos effect. Valsalva maneuver like bearing down during each contraction. So hold your breath, bear down, count to 10. However, when not coached to breathe in a specific way, women will often push with an open glottis so they aren't bearing down and holding their breath while pushing. And a review of eight randomized trials that compared spontaneous to Valsalva pushing. So pushing however you felt was right in the moment versus our directed pushing, found no differences in the duration of the second stage.

(45:46): No differences in spontaneous vaginal birth, AP episiotomy, perineal lacerations, five minute APGAR scores less than seven, NICU admissions or the duration of pushing. All right? So it didn't make a difference. It didn't make a difference. So the consensus was that in consideration of the limited data regarding superiority of spontaneous versus Valsalva pushing, each woman should be encouraged to use her preferred and most effective technique. So I think it's interesting in some places where they say should be like here, they say should be encouraged, which is very true, and I think this is because this is a fairly easy thing to do. Whereas things like changing monitoring or amnio autotomy or continuous labor support are things that aren't necessarily as easy to do, so they don't get the stronger level of support. So just to recap and add a couple of Dr. Nicole's Notes on physiologic birth, normal physiologic childbirth is characterized by spontaneous onset and progression of labor includes biologic and psychological conditions that promote effective labor results in the vaginal birth of the infant and placenta results in physiologic blood loss facilitates optimal newborn transition through skin to skin contact and keeping the mother and infant together during the postpartum period and supports early initiation of breastfeeding.

(47:12): The following factors disrupt normal physiologic childbirth, induction or augmentation of labor, an unsupportive environment like bright lights, coldroom, lack of privacy, multiple providers, lack of supportive companions, time constraints, including those driven by institutional policy and or staffing, nutritional deprivation of food and drink opiates, regional anesthesia or general anesthesia, a episiotomy operative vaginal or abdominal birth, immediate cord clamping separation of mother infant in any situation in which the mother feels threatened or unsupported.

(47:52): ACOG summary, many common obstetric practices are of limited or uncertain benefit for low risk women in spontaneous labor. Evidence suggests that in addition to regular nursing care, continuous one-to-one emotional support provided by support personnel such as the doula is associated with improved outcomes for women in labor. Data suggests that for women with normally progressing labor, no evidence of fetal compromise, routine amn otomy routinely breaking the water need not be undertaken unless required to facilitate monitoring. The widespread use of continuous electronic fetal monitoring has not been shown to significantly affect such outcomes as perinatal death and cerebral palsy. When used for women with low risk pregnancies, women in spontaneously progressing labor may not require routine continuous infusion of intravenous fluids. And for most women, no one position needs to be mandated or prescribed. So my doctor Nicole's notes to add to this conversation, again, remember, you don't have to have a physiologic birth, okay?

(49:01): It's not something that you have to do, but you should know about it and you should know about potential benefits and you should be supported in having a physiologic birth if that is what you choose. And that should absolutely be able to happen in the hospital, but also know that sometimes physiologic birth isn't safe, it is not appropriate for everyone. There are times when we need to intervene for the health and safety of you or your baby. And if you don't have a physiologic birth, it doesn't mean that anything is wrong or that you've done something wrong or anything like that. It's not always going to be a possibility or a reality for everyone. Or again, may not be something that everyone necessarily wants, but again, you should have access to it if it's something that you do want and it's appropriate. Also, we have a cultural problem in obstetrics in the US that supports us doing things that are of no benefit or are even harmful or we don't actively support things that are of benefit.

(50:13): Some glaring examples of this, the arrived trial, which is labor induction versus expected management and low risk nolo risk women, okay? That's the title of the trial, and it's why so many people recommend labor induction because it showed a slight reduction in cesarean birth rate, 21% to about 19% for those who were induced because of that one trial induction is more and more frequently getting offered, even recommended, okay, from this randomized control trial. Yet we also have randomized controlled trials that demonstrate the effectiveness of doulas that demonstrate that we don't need to routinely break someone's water that demonstrate that we don't need to be doing continuous el electronic fetal monitoring for low risk risk pregnancies. Yet we don't support doulas. We pretty routinely will break someone's water. We still continuously do electronic fetal monitoring. So why is it that some things we do and some things we don't, despite all of the evidence that supports these things?

(51:30): Well, my thoughts are that doing things like working with doulas requires us to work with other people, and it requires that we acknowledge that our skills as obstetricians are not the only things that help improve outcomes. All right? We really have to do a collaborative approach in order to get the best outcomes. It's not just about medicine and obstetrics as it was portrayed way back in the day when obstetrics was brought into the hospital. It also requires us to not do things to not intervene. All right? And there's some thought, I think is, well, what are we doing if we as obstetricians aren't doing something? Our value culturally as a specialty is tied to doing something to intervening to try and make a difference in outcomes.

(52:41): So what I believe needs to happen is a shift in our mindset. Right now we have this sort of approach that yes, some people may be low risk, but birth is a disaster that is waiting to happen. Anything can happen at any moment like bleeding problems with the baby's heart rate, a shoulder dystocia. These are all terrible things that are possible at any time. So you absolutely need me and my expertise in the hospital in order to manage all of those disastrous things that can occur. Okay? So that too often is the typical mindset and approach towards birth, but here's where we need to shift our mindset. We need to say birth is a normal, natural thing. It's been happening for millions of years. Most often it goes well, but sometimes it really doesn't. And we will approach your birth expecting that things will go well, and we'll also do all of the evidence-based things that we know, support things going well in your birth.

(53:46): However, we're prepared if things don't go well, we're on the ready if things take a twist and turn to intervene and make sure you and your baby remain safe and healthy, both physically and emotionally. When you take that second approach, you're getting the best of both worlds. You're centering the needs of the pregnant person in their experience, both physically, both emotionally, and you are making your resources available, making our needed expertise available in case things don't go well. Okay? So I think that shift in mindset is really important in how we approach birth and is an important piece to making sure we provide better birth experiences for folks. And then the final thing I'll say is that the fastest way to help make change is for the people having babies, you all having babies to educate yourselves and do demand change. As I said, the first document by the nurse midwives was in 2012, so that's 10 and a half years ago. We're still talking about this, okay? The ACOG document was in 2017.

(54:59): Medicine is slow to change on its own. It needs a push, it needs a nudge, and the fastest way to help make changes for you to educate yourself and then demand that change. All right? Demand that change. Of course, one of the ways you can help educate yourself is to join my birth plan class. And I highly suggest if you are having your baby in January or February or March or April of 2023 that you had to drnicolerankins.com, and go ahead and sign up for that class today. All right? So there you have it. Do me a solid, share this podcast with the friend. Sharing is caring. It helps me to reach and serve more people. So I appreciate you helping me to do that. Also, subscribe to the podcast wherever you're listening to me right now. And if you feel so inclined, leave a review, an Apple Podcast. I'd love to hear what you think about the show, or shoot me a dm. Let me know what you think. You can find me on Instagram. I'm at Dr. Nicole Rankins on Instagram, where I also provide lots of great information on pregnancy and birth there as well. So that is it for this episode. Do come on back next week and remember that you deserve a beautiful pregnancy and birth.