248249The Role of Birth Centers in Promoting Physiologic Birth

MELISSA D. AVERY

LEARNING OBJECTIVES

Upon completion of this chapter, the reader will be able to:

1.  Define birth center care as a physiologic approach to pregnancy, labor and birth, and postpartum/newborn care

2.  Describe common care practices and additional therapies/approaches to support physiologic labor and birth in the freestanding birth center care context

3.  Analyze the birth center as the ideal learning environment for physiologic pregnancy and birth

DEFINITIONS

Physiologic birth and birth center care are synonymous—two sides of the same coin. Physiologic birth refers to care in which the normalcy and state of health represented by pregnancy and birth is respected and supported; the freestanding birth center is the formal care location in which that approach is most appropriately implemented. In fact, the birth center standards defined by the American Association of Birth Centers (AABC) include that assertion in the definition of a birth center (AABC, 2016a). Birth center care has been shown to be a model that results in less use of medical interventions and fewer cesareans when compared with a risk-adjusted group of women, thus demonstrating it is the care approach, and not a low-risk designation contributing to outcomes (Jackson et al., 2003; Stapleton, Osborne, & Illuzzi, 2013). Common practices consistent 250with a physiologic approach to pregnancy, labor, and birth employed in birth centers are discussed in this chapter, and the birth center as the ideal location for learning about physiologic birth is explored.

BACKGROUND ON PHYSIOLOGIC BIRTH AND BIRTH CENTER CARE

Physiologic birth has received a good deal of attention in the past two decades as an ideal approach to maternity care for healthy women (American College of Nurse-Midwives [ACNM], Midwives Alliance of North America (NAMA), and National Association of Certified Professional Midwives (NACPM), 2012; International Confederation of Midwives [ICM], 2014; WHO, 1996). Current birth outcome statistics in the United States suggest that a modified maternity care model is needed to reverse current harmful and embarrassing trends. Maternal mortality has increased in the United States since 2000 (MacDorman, Declercq, Cabral, & Morton, 2016) and is greater than in most other industrialized countries (Save the Children, 2015). The United States spends 17.5% of gross domestic product (GDP) on health care, more than any other country (Healthcare Cost and Utilization Project [HCUP], 2016). “Live newborn” is the third most expensive reason for hospitalization when considering all payers (Medicare, Medicaid, private insurance); it ranks as the top condition billed to Medicaid (23% of stays) and was second for private insurance (16.2% of stays) in 2013 in the United States. The cesarean rate has declined slightly and was 32% in 2015 (Martin, Hamilton, Osterman, Driscoll, & Mathews, 2017) and 23% of women (with singletons) experienced induction of their labor, a number finally starting to slowly decline (Osterman & Martin, 2014). Defined initially by Rosenblatt (1989), we continue the perinatal paradox of spending more and getting less value for our health care dollars. Continued efforts to reduce the use of unnecessary interventions are needed to improve care outcomes and reduce expenditures.

Normal or physiologic birth has been defined by a number of groups, recognizing that pregnancy and birth are normal physiologic events for women, not an illness to be treated. In 1996, the World Health Organization defined a normal birth as “spontaneous in onset, low-risk at the start of labour and remaining so throughout labour and delivery. The infant is born spontaneously in the vertex position between 37 and 42 completed weeks of pregnancy. After birth mother and infant are in good condition” (WHO, 1996, p. 4). The ACNM, Midwives Alliance of North America (MANA), and National Association of Certified Professional Midwives (NACPM) issued a joint statement defining physiologic 251birth simply as “one that is powered by the innate human capacity of the woman and fetus” (ACNM, MANA, and NACPM, 2012, p. 2). The ICM defines normal birth as “where the woman commences, continues and completes labour with the infant being born spontaneously at term, in the vertex position at term, without any surgical, medical, or pharmaceutical intervention” (ICM, 2014, p. 1).

Research supports a physiologic approach to labor and birth for low-risk women (Romano & Lothian, 2008); physiologic approaches can also be incorporated into care for women who require a higher level of care and monitoring as appropriate to their situation. A recently published summary of the research on the physiology of the childbearing period supports the benefits of nonintervention unless needed. Buckley (2015) reviewed more than a thousand studies and suggested that interruptions to the normal hormonal physiology that occur in later pregnancy and labor may make labor more difficult, increase the likelihood of fetal distress requiring additional interventions, interrupt maternal–newborn bonding, and make breastfeeding more difficult. Newborns may experience disrupted thermoregulation and glycemic regulation. Disruptions to breastfeeding could have longer term effects on infant/child health. Additional research in many of these areas to further explain physiologic phenomena and the effects of intervening in normal processes is needed.

BIRTH CENTER APPROACH TO CARE

Birth center philosophy is consistent with promoting normal physiology during pregnancy, labor, and birth, which are considered normal family events unless the specific situation suggests otherwise (AABC, 2016b). Birth center care offers a model of a physiologic approach throughout pregnancy and birth, which is evident in preconception planning, antenatal care, intrapartum care, and the postpartum/newborn periods. The setting has been referred to as a maximized home setting, thus demonstrating the approach of woman-centered care, a focus on health and wellness, and links to an existing broader system of care (AABC, 2016c).

Preconception and Antenatal Care

Preconception and antenatal care set the stage for the focus on health promotion throughout pregnancy and planning for a physiologic birth. Although preconception care is not routinely sought by women, it provides 252an opportunity to plan in advance for a healthy pregnancy (Delissaint & McKyer, 2011). Women seeking a freestanding birth center experience for their pregnancy may be more likely to visit care settings and examine their options prior to pregnancy. In addition, some women will already be familiar with a birth center after receiving well-woman care there, and thus it is a natural extension to continue to receive prenatal and birth care during pregnancy. Prenatal care in a birth center is consistent with traditional care including baseline laboratory screening, ongoing risk assessment and measurement to assure safety for mother and fetus, and prenatal education related to healthy lifestyle and pregnancy-related topics. In addition, birth center care is specifically focused on helping women prepare for physiologic birth because labor and birth care in the freestanding birth center rely on human presence and nonpharmacological support techniques to achieve spontaneous labor and birth. Although the research on preparing women prenatally for physiologic birth is limited, the factors gleaned from a systematic review reflect the birth center approach to care including providing information to women and supporting their participation in care decisions in a relationship with a trusted care provider (Avery, Saftner, Larson, & Weinfurter, 2014).

Labor and Birth Care

Following an emphasis on healthy lifestyle and detailed planning for physiologic labor and birth during the pregnancy, supporting spontaneous onset and progression of labor becomes the focus with women’s preferences respected and modified as needed. Evidence-based resources highlighting physiologic care practices during labor are numerous (ACNM, n.d.; ACNM, 2014; Lamaze International, 2016). In addition, the Mother-Friendly Childbirth Initiative, built on the principles of normalcy of the birthing process, empowerment, autonomy, do no harm, and responsibility, includes 10 steps that birthing sites can follow to provide appropriate care (CIMS, 2015; Box 11.1). Admission to the birth center is planned to occur during active labor and thus communication and support in early labor while a woman remains at home is essential. Common approaches include encouraging adequate hydration and good intake with sufficient calories, ambulation to support labor progression balanced with rest as needed, presence of support persons, and being alert to ongoing fetal movement and signs of healthy labor progress. When planning to give birth in a hospital, women may need to include regular food and fluids, avoidance of an intravenous line, ambulation, intermittent auscultation of the fetal heart rate, and water immersion in their birth preferences. However, 253in the birth center these are the standard of care and methods employed to support physiologic labor.

BOX 11.1
Mother-Friendly Steps That Are Most Applicable to Birth Centers

These care principles and approaches continue when a woman is admitted to the birth center with her family and important support persons. Singata, Tranmer, and Gyte (2013) reviewed existing studies examining the restriction or use of food and fluids in labor. Neither harms nor benefits were found for restricting fluids and food in labor for women at low risk of needing general anesthesia; the authors recommended that women be allowed the flexibility to determine their intake in labor. Ambulation in labor, particularly upright positioning, has been well studied. Systematic reviews of both first- and second-stage labor have demonstrated that upright positions during first-stage labor result in shorter labor, less use of epidural analgesia, and fewer cesareans (Lawrence, Lewis, Hofmeyr, & Styles, 2013). During second-stage labor for women without epidurals (22 trials, more than 7,000 women), upright positions were associated with reduced assisted births, reduced episiotomies, an increase in second-degree lacerations, and a nonsignificant reduction in second-stage duration. An increase in the incidence of blood loss greater than 500 mL was also observed, and thus must be considered in caring for women using upright positions in second-stage labor (Gupta, Hofmeyr, & Shehmar, 2012). More and better research is needed in all of these areas to improve the evidence for practice.

254Intermittent auscultation of the fetal heart rate is standard in birth center care. Admission monitoring of the fetus by continuous cardiotocography (Devane, Lalor, Daly, McGuire, & Smith, 2012) and during labor (Alferivic, Devane, Gyte, & Cuthbert, 2017) has not been shown to improve outcomes and may increase cesarean and instrumental birth rates. Continuous cardiotocography in labor was associated with reduced neonatal seizures and no reduction in cerebral palsy or infant mortality, as well as an increase in cesarean and instrumental births (Alfirevic et al., 2017). The physiologic approach in birth centers of appropriate use of intermittent auscultation has been suggested as a way to reduce cesarean births (Cahill & Spain, 2015; Cox & King, 2015). Commission for the Accreditation of Birth Centers (CABC) accredited birth centers are required to demonstrate that they do not use continuous fetal monitoring once women are admitted in active labor (AABC, 2016a; CABC, 2016). ACNM (2015) provides a defined approach to intermittent auscultation that may be used in labor and birth settings.

Physiologic labor progress is supported while staying alert to any change in status that might indicate transfer to a hospital where higher levels of care are available. The most common reasons for transfer include lack of labor progress or need for pharmacological pain relief not available in the birth center (see Chapter 4).

Additional Care Practices to Promote Relaxation and Pain Relief in Labor

A number of integrative therapies have been used to support relaxation and thus improve coping and responses to labor pain for women who prefer to avoid pharmacological interventions. These care practices fit well with the woman-centered and physiologic approach to care in the birth center. Relaxation techniques were first formally taught to parents during childbirth education classes decades ago; Leggitt (2013) shares some simple techniques to promote relaxation during labor, such as appropriate use of language and focusing attention on the laboring woman as well as using music, progressive relaxation techniques, imagery, breathing, heat/cold, positioning, and more. These techniques along with ongoing presence of supportive persons are recommended. The research in these areas is not well developed and additional research is needed.

Intentional touch therapies including therapeutic touch, healing touch, reiki, and massage therapy are techniques that can be learned and may be useful during pregnancy or labor to aid relaxation and stress reduction, as well as reduce pain (Ringdahl, 2013). Smith, Levett, Collins, and Crowther (2011) conducted a systematic review of studies of relaxation 255methods (11 trials, 1,374 women) used to help women cope with labor pain. Relaxation techniques and yoga were shown to reduce pain in latent and active labor as well as increase satisfaction with the birth experience. These techniques may be helpful in labor; there was no evidence of effect for music or audio-analgesia.

Aromatherapy is another technique that may be utilized in labor to promote relaxation and stress reduction. Defined as “the intentional evidence-based application of plant essential oils for preventive or therapeutic purposes” (Halcon, 2013, p. 174), aromatherapy (excluding ingestion) is believed to be safe in appropriate doses in the second and third trimesters of pregnancy. Lavender, mandarin, frankincense, clary sage, and Roman chamomile are some essential oils that have been used. Research is limited and the few studies of aromatherapy for pain relief are not adequate to make clinical recommendations (Smith, Collins, & Crowther, 2011).

Water immersion is a common relaxation and pain relief technique used in birth centers and other birthing units. Water immersion during labor has been reviewed and shown to reduce the use of epidural analgesia and the duration of first-stage labor (Cluett & Burns, 2011). Water birth may also be requested by women for their childbirth experience. The majority of water immersion and water birth studies are descriptive or observational studies with small samples; few randomized controlled trials have been conducted. Authors of a recent integrative review of water birth studies concluded that although the research evidence has many limitations, outcomes are at least equivalent to conventional birth. Offering women a complete explanation of potential risks as well as benefits and considering the best information available along with their preferences is essential (Nutter, Meyer, Shaw-Batista, & Marowitz, 2014). Jones and colleagues (2012) conducted a review of systematic reviews of pain management techniques for women in labor, including 15 Cochrane reviews (255 trials) and three non-Cochrane systematic reviews (55 trials). Of therapies that could be used in a birth center, the authors concluded that water immersion, relaxation, massage, and acupuncture may relieve pain and increase satisfaction. Evidence was insufficient about the efficacy of hypnosis, biofeedback, transcutaneous electrical nerve stimulation (TENS), aromatherapy, and sterile water injections. Additional research is needed for most of these techniques to more fully assess efficacy.

Postpartum Care

Immediately following the birth, physiologic transition of the newborn and new mother continues. Mother and baby are encouraged to be skin to 256skin as the newborn is dried and breastfeeding is encouraged. Consistent with research demonstrating benefits of delayed cord clamping, this practice is standard in birth center care (McDonald, Middleton, Dowswell, & Morris, 2013). Commonly accepted baby-friendly principles are applied; some birth centers have achieved the baby-friendly designation (see Box 11.2). Maternal vital signs, bleeding, and newborn transition and vital signs are monitored carefully. Discharge from the birth center, to facilitate family transition to the home environment, occurs typically between 4 and 12 hours postpartum after assuring stability of mother and baby and initiation of breastfeeding. Birth center staff members stay in touch with the family to assure ongoing stable transition; home visits are made in the early days following the birth by most birth centers. Accredited birth centers are required to describe their plan for monitoring women and their newborns during the initial 48 to 72 hours post birth (AABC, 2016a; CABC, 2016).

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