Penny Simkin

The Nature and Management of Labor Pain: Executive summary

This report describes the background and process for a rigorous project to improve understanding of labor pain and its management, and summarizes the main results and their implications. Labor pain and methods to relieve it are major concerns of childbearing women, with considerable implications for the course, quality, outcome, and cost of intrapartum care. Although these issues affect many women and families and have major consequences for health care systems, both professional and public discourse reveal considerable uncertainty about many questions, including major areas of disagreement. An evidence-based framework, including commissioned papers prepared according to carefully specified scopes and guidelines for systematic review methods, was used to develop more definitive and authoritative answers to many questions in this field. The papers were presented at an invitational symposium jointly sponsored by the Maternity Center Association and the New York Academy of Medicine, were peer-reviewed, and are published in full in this issue of the journal. The results have implications for policy, practice, research, and the education of both health professionals and childbearing women.

The fetal occiput posterior position: state of the science and a new perspective.

BACKGROUND The fetal occiput posterior position poses challenges in every aspect of intrapartum care-prevention, diagnosis, correction, supportive care, labor management, and delivery. Maternal and newborn outcomes are often worse and both physical and psychological traumas are more common than with fetal occiput anterior positions. The purpose of this paper is to describe nine prevailing concepts that guide labor and birth management with an occiput posterior fetus, and summarize evidence to clarify the state of the science. METHODS A search was conducted of the databases of PubMed and the Cochrane Library. Additional valuable information was obtained from obstetric and midwifery textbooks, books and websites for the public, conversations with maternity care professionals, and years of experience as a doula. RESULTS Nine prevailing concepts are as follows: (1) prenatal maneuvers rotate the occiput posterior fetus to occiput anterior; (2) it is possible to detect the occiput posterior fetus prenatally; (3) a fetus who is occiput anterior at the onset of labor will remain in that position throughout labor; (4) back pain in labor is a reliable sign of an occiput posterior fetus; (5) the occiput posterior fetus can be identified during labor by digital vaginal examination; (6) an ultrasound scan is a reliable way to detect fetal position; (7) maternal positions facilitate rotation of the occiput posterior fetus; (8) epidural analgesia facilitates rotation; (9) manual rotation of the fetal head to occiput anterior improves the rate of occiput anterior deliveries. Concepts 1, 2, 3, 4, 5, and 8 have little scientific support whereas concepts 6, 7, and 9 are supported by promising evidence. CONCLUSIONS Many current obstetric practices with respect to the occiput posterior position are unsatisfactory, resulting in failure to identify and correct the problem and thus contributing to high surgical delivery rates and traumatic births. The use of ultrasound examination to identify fetal position is a method that is far superior to other methods, and has the potential to improve outcomes. Research studies are needed to examine the efficacy of midwifery methods of identification, and the effect of promising methods to rotate the fetus (simple positional methods and digital or manual rotation). Based on the findings of this review, a practical approach to care is suggested.

How birth doulas help clients adapt to changes in circumstances, clinical care, and client preferences during labor.

This study examined how doulas adapt to challenges in client’s labors. There were 104 Canadian and 92 American doulas who responded to a survey distributed at a doula conference. We report results from open-ended questions in which doulas describe how they manage changes deviating from the mother’s birth plan and how they navigate differences of opinion between themselves and providers. Four themes emerged: giving nonjudgmental support, assisting informed decision making, acting as a facilitator, and issues with advocacy. Although 30% of doulas said that advocacy and information giving could result in conflict with providers, doulas reported working within their scope of practice and striving to be part of the team. Issues in doula responsibility and patient advocacy remain, and ongoing role clarification is needed.

Moving Beyond the Debate: A Holistic Approach to Understanding and Treating Effects of Neuraxial Analgesia

Neuraxial analgesia is here to stay, yet, spirited debate continues over potential harms and the quality of research that fails to identify them. This paper proposes moving beyond the debate and examining holistically the impact of neuraxial analgesia on the psychophysiology of mother and baby. A review of alterations in functioning of many systems is followed by a suggested four-part protocol to partially restore normal physiology and emotional well-being, and improve outcomes of neuraxial analgesia.

The language of birth.

Our language both reflects and influences our attitudes and behavior. This Roundtable Discussion explores the language used in obstetrics and in the interactions between caregivers and women or their families: What do practitioners say to mothers and families during labor? At birth? In consultations? To describe what is happening? To encourage a womans efforts? To lighten the atmosphere? When advising about possible interventions? Medical terminology in perinatal care can often be deceptive or confusing, not only for mothers but for caregivers. The authors of this Roundtable, representing health professionals from different specialties and interests in the field, have examined some examples of such language use, misuse, and abuse in perinatal care. (BIRTH 39:2 June 2012).

Preventing Primary Cesareans: Implications for Laboring Women, Their Partners, Nurses, Educators, and Doulas

New evidence-based guidelines for Safe Prevention of the Primary Cesarean Delivery call for extensive modifications of many long-standing obstetric practices that have collectively contributed to large increases in cesarean rates and worsening outcomes (1). The document also calls for the resurrection of some skills and beneficial practices (such as external cephalic version and manual rotation of the fetal head) that have largely fallen out of favor. The most dramatic and revolutionary change, however, is the revision of long-held norms of labor progress that have guided obstetric management for many decades. The conclusion of recent extensive studies (2) of labor progress of tens of thousands of women who had normal healthy outcomes might be summed up in this catchy slogan: “6 is the new 4” (or “six centimeters is the new four centimeters”) (3). In other words, the threshold for the active phase, which until now had been defined as 4 centimeters may be as late as 6 centimeters (as it normally can require up to 6 hours to progress from 4 to 6 centimeters). Labor management should include a greater tolerance of longer labors and avoidance of a cesarean delivery for arrest of labor until there has been no cervical change for several hours, even with augmentation. The guidelines also recommend allowing nulliparas to push for 3 hours, and multiparas for 2 hours (plus another hour if an epidural is in place) before diagnosing second stage arrest. Many other “sacred cows” of obstetrics are challenged in this document, including current approaches to management of elective induction of labor, abnormal or indeterminate fetal heart rate tracings, fetal malpresentation and malposition, multiple gestation, suspected fetal macrosomia, and others (1). Such sweeping reforms will likely encounter resistance or may create a backlash among some clinicians. In a field where time limits and fear of litigation too often rule, all the players, including physicians, hospital administrators, nursing staff, third party payers, and risk managers, will have to make adjustments. As exciting and promising as these recommendations are, implementation will not only require buy-in from providers, but also from the childbearing public. Expectant parents will need quality education and support to address their fears and enhance their willingness to embrace longer labors. Ironically, as obstetricians steadily increased their use of cesarean delivery over the past two generations, women at first resisted (4, 5). They had to be convinced that this surgery was beneficial and safe. In an effort to reassure or convince women that a cesarean made sense, obstetric care providers emphasized the risks associated with labor and vaginal birth to both baby and mother. This emphasis is sometimes cynically referred to as “playing the dead baby card.” Even when those risks were not supported by scientific evidence or best practice models, the suggestions of harm were very powerful, especially when coming from the expert. But now all that is changing! Updated “best practice” models call for a reversal of management to include practices that were previously thought to be dangerous. Clinicians and expectant parents must now be persuaded that widespread use of cesareans or measures to speed early labor are no longer believed to be

Should ACOG support childbirth education as another means to improve obstetric outcomes? Response to ACOG Committee Opinion # 687: Approaches to limit intervention during labor and birth

The United States cesarean rate rose steadily from 1995, when it was 20.9% to a high of 32.9% in 2009; since then, it has declined to 32.0% in 2015.1 A similar pattern—decades of increasing cesarean rates followed in recent years by a leveling off—exists in most regions of the world. 2 Leading organizations in American mainstream maternity care—the American College of Obstetricians and Gynecologists (ACOG), Society for Maternal Fetal Medicine (SMFM), American College of NurseMidwives (ACNM), Association of Women’s Health, Obstetric and Neonatal Nursing (AWHONN), and others—have called for identification and implementation of evidencebased maternity care practices to further reduce cesarean rates, as well as mortality and morbidity among mothers and infants, ineffective interventions, and costs of care.3,4 I wrote a commentary in Birth on the earlier ACOG/SMFM document, “Safe Prevention of the Primary Cesarean Delivery,”5 in which I emphasized the need for public (not only professional) acceptance of the suggested reforms. In this commentary on ACOG Committee Opinion # 687, “Approaches to Limit Intervention During Labor and Birth,” I propose that the desired reforms will occur to a greater degree with active participation by educated expectant parents. The recommendations of the Committee Opinion are wide ranging and call for numerous changes and more flexibility in clinical management. Prominent among them is evidencebased advice for caregivers to slow down and wait before acting, before admitting women to hospital in latent labor; declaring prolonged pregnancy or arrested labor; intervening with induction, amniotomy, augmentation, instrumental delivery, or cesarean, etc. The passage of time plays an enormous role in most aspects of maternity care. In my opinion, the Committee seems a bit ambivalent with regard to the contributions that parents could make to improve the odds of success from the recommended measures. They also make questionable assumptions about what women want in their care. The Committee Opinion states, “The desire to avoid unnecessary interventions during labor and birth is shared by health care providers and pregnant women.” They also recommend “shared decisionmaking,”4 but it is tricky to implement these approaches. First, most women do not have a clear idea of what many interventions are, and whether they are likely to be harmful or beneficial.6 Not knowing the possible risks, many would be pleased to have labor induced early, because of their discomforts in late pregnancy; others might request or accept a planned cesarean because they see it as a quick and easy alternative to labor. Others, of course, simply trust and depend on their caregivers to make care decisions with little questioning. Listening to Mothers III,7 a nationwide survey of women’s childbearing experiences, found the following: